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Perioperative stroke remains one of the most dreaded complications following coronary artery bypass grafting. In this review, we highlight the significant advances in understanding and preventing stroke in patients undergoing bypass surgery and offer our center's current best-practice recommendations to help avoid this debilitating outcome.The incidence of stroke has significantly reduced since the advent of coronary artery bypass graft surgery. Improvements in our understanding of the cause, mechanisms, risk factors, and diagnosis of stroke as well as refinements in medical optimization, surgical technique, and perioperative care all have contributed to making coronary artery bypass grafting safer even as patients have become increasingly complex.The field of cardiothoracic surgery endures in its quest to eliminate the risk of perioperative stroke. By incorporating the lessons of the past into our innovations of the future, cardiac surgeons will continue to strive for safer coronary artery bypass grafting and afford patients to not only live longer but better as well.

Titania (anatase) nanoparticles were anisotropically functionalized in water-toluene Pickering emulsions to self-assemble into nanoshells with diameters from 500 nm to 3 μm as candidates for encapsulation of drugs and other compounds. The water-phase contained a hydrophilic ligand, glucose-6-phosphate, while the toluene-phase contained a hydrophobic ligand, n-dodecylphosphonic acid. The addition of a dilute sodium alginate suspension that provided electrostatic charge was essential for the self-limited assembly of the nanoshells. The self-assembled spheres were characterized by scanning electron microscopy, elemental mapping, and atomic force microscopy. Drug release studies using tetracycline suggest a rapid release dominated by surface desorption.

Background SARS-CoV-2 enters cells by binding of its spike protein to angiotensin-converting enzyme 2 (ACE2). Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) have been reported to increase ACE2 expression in animal models, and worse outcomes are reported in patients with co-morbidities commonly treated with these agents, leading to controversy during the COVID-19 pandemic over whether these drugs might be helpful or harmful. Methods : Animal, in vitro and clinical data relevant to the biology of the renin-angiotensin system (RAS), its interaction with the kallikrein-kinin system (KKS) and SARS-CoV-2, and clinical studies were reviewed. Findings and Interpretation SARS-CoV-2 hijacks ACE2to invade and damage cells, downregulating ACE2, reducing its protective effects and exacerbating injurious Ang II effects. However, retrospective observational studies do not show higher risk of infection with ACEI or ARB use. Nevertheless, study of the RAS and KKS in the setting of coronaviral infection may yield therapeutic targets.

The COVID-19 pandemic has dramatically impacted healthcare delivery worldwide. In hotspot areas such as Wuhan, Lombardy, and New York City, the disease has forced hospitals to focus on COVID-19 patients. Anecdotal reports have suggested that the pandemic has led to a decrease in patients presenting to these hospitals with serious cardiovascular and neurologic diseases such as ST-elevation myocardial infarction (STEMI) and stroke. We sought to measure the impact of the COVID-19 pandemic on emergency transfers for STEMI, stroke, and acute aortic emergencies within our regional health system.

Background There is a paucity of data regarding the optimum timing of PCI in relation to TAVR. Objective We compared the major adverse cardiovascular and cerebrovascular events (MACCE) rates among patients who underwent percutaneous coronary intervention (PCI) before transcatheter aortic valve replacement (TAVR) with those who received PCI with/after TAVR. Methods In this multicenter study, we pooled all consecutive patients who underwent TAVR at three high volume centers. Results Among 3,982 patients who underwent TAVR, 327 (8%) patients underwent PCI within 1 year before TAVR, 38 (1%) had PCI the same day as TAVR and 15 (0.5%) had PCI within 2 months after TAVR. Overall, among patients who received both PCI and TAVR (n = 380), history of previous CABG (HR:0.501; p = .001), higher BMI at TAVR (HR:0.970; p = .038), and statin therapy after TAVR (HR:0.660, p = .037) were independently associated with lower MACCE while warfarin therapy after TAVR was associated with a higher risk of MACCE (HR:1.779, p = .017). Patients who received PCI within 1 year before TAVR had similar baseline demographics, STS scores, clinical risk factors when compared to patients receiving PCI with/after TAVR. Both groups were similar in PCI (Syntax Score, ACC/AHA lesion class) and TAVR (valve types, access) related variables. There were no significant differences in terms of MACCE (log rank p = .550), all-cause mortality (log rank p = .433), strokes (log rank p = .153), and repeat PCI (log rank p = .054) in patients who underwent PCI with/after TAVR when compared to patients who received PCI before TAVR. Conclusion Among patients who underwent both PCI and TAVR, history of CABG, higher BMI, and statin therapy had lower, while those discharged on warfarin, had higher adverse event rates. Adverse events rates were similar regardless of timing of PCI.

As the use of transcatheter aortic valve implantation (TAVI) expands to varying patient populations, impacting the landscape of surgical aortic valve replacement (SAVR), this study sought to assess volume and performance trends of aortic valve replacement (AVR) in the United States during 2012–2017. The Nationwide Readmissions Database was queried for patients who underwent endovascular/transapical TAVI, isolated SAVR, or complex aortic valve surgery between 2012 and 2017. Temporal trends in annual case volume, admission costs, in-hospital outcomes, and 30-day readmission were evaluated. Of 624,303 patients (median age 72 years) who received AVR, 387,011 (62%) were men. Among these patients, 170,521 (27%) underwent TAVI and 453,782 (73%) underwent SAVR with 299,398 isolated and 154,384 complex aortic valve surgery. TAVI patients were significantly older and higher risk compared with SAVR patients. From 2012 to 2017, the annual number of TAVI increased from 8,295 to 55,168 whereas SAVR volume remained remarkably stable. Patients who underwent AVR demonstrated significant improvements in mortality, stroke, duration of hospitalization, and 30-day readmission. In conclusion, this large contemporary analysis reports the considerable growth of AVR in the United States. It remains unequivocal that the treatment of aortic stenosis is improving overall with reduced mortality following AVR, highlighting the effectiveness of various process improvements such as newer valves, enhanced patient selection, and the interdisciplinary Heart Team approach.

Patient selection for robotically assisted mitral valve repair remains controversial. We assessed outcomes of a conservative screening algorithm developed to select patients with degenerative mitral valve disease for robotic surgery.From January 2014 to January 2019, a screening algorithm that included transthoracic echocardiography and computed tomography scanning was rigorously applied by 3 surgeons to assess candidacy of 1000 consecutive patients with isolated degenerative mitral valve disease (age 58 ± 11 years, 67% male) for robotic surgery. Screening results and hospital outcomes of those selected for robotic versus sternotomy approaches were compared.With application of the screening algorithm, 605 patients were selected for robotic surgery. Common reasons for sternotomy (n = 395) were aortoiliac atherosclerosis (n = 74/292, 25%), femoral artery diameter7 mm (n = 60/292, 20%), mitral annular calcification (n = 83/390, 21%), aortic regurgitation (n = 100/391, 26%), and reduced left ventricular function (n = 126/391, 32%). Mitral valve repair was accomplished in 996. Compared with sternotomy, patients undergoing robotic surgery had less new-onset atrial fibrillation (n = 144/582, 25% vs n = 125/373, 34%; P = .002), fewer red blood cell transfusions (n = 61/601, 10% vs 69/395, 17%; P .001), and shorter hospital stay (5.2 ± 2.9 days vs 5.9 ± 2.1 days; P .001). No hospital deaths occurred, and occurrence of postoperative stroke in the robotic (n = 3/605, 0.50%) and sternotomy (n = 4/395, 1.0%; P = .3) groups was similar.This conservative screening algorithm qualified 60% of patients with isolated degenerative mitral valve disease for robotic surgery. Outcomes were comparable with those obtained with sternotomy, validating this as an approach to select patients for robotic mitral valve surgery.

To evaluate the temporal relations of cardiovascular disease in oncology patients referred to cardio-oncology and describe the impact of cardiovascular disease and cardiovascular risk factors on outcomes. All adult oncology patients referred to the cardio-oncology service at the Cleveland Clinic from January 2011 to June 2018 were included in the study. Comprehensive clinical information were collected. The impact on survival of temporal trends of cardiovascular disease in oncology patients were assessed with a Cox proportional hazards model and time-varying covariate adjustment for confounders. In total, 6,754 patients were included in the study (median age, 57 years; [interquartile range, 47 to 65 years]; 3,898 women [58%]; oncology history [60% - breast cancer, lymphoma, and leukemia]). Mortality and diagnosis of clinical cardiac disease peaked around the time of chemotherapy. 2,293 patients (34%) were diagnosed with a new cardiovascular risk factor after chemotherapy, over half of which were identified in the first year after cancer diagnosis. Patients with preexisting and post-chemotherapy cardiovascular disease had significantly worse outcomes than patients that did not develop any cardiovascular disease (p < 0.0001). The highest 1-year hazard ratios (HR) of post-chemotherapy cardiovascular disease were significantly associated with male (HR 1.81; 95% confidence interval 1.55 to 2.11; p < 0.001] and diabetes [HR 1.51; 95% confidence interval 1.26 to 1.81; p < 0.001]. In conclusion, patients referred to cardio-oncology, first diagnosis of cardiac events peaked around the time of chemotherapy. Those with preexisting or post-chemotherapy cardiovascular disease had worse survival. In addition to a high rate of cardiovascular risk factors at baseline, risk factor profile worsened over course of follow-up.

Objectives To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest. Methods From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect. Results Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2). Conclusions Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.

The congenital bicuspid aortic valve (BAV) is a heterogeneous condition that is better understood considering 3 types of valvulo-aortopathy presentations: A typical-presentation valvulo-aortopathy, a complex-presentation valvulo-aortopathy and an uncomplicated/undiagnosed-presentation. The burden of BAV-related complications has been elucidated in patients with the typical-presentation valvulo-aortopathy and is discussed in this review. These patients enjoy an overall normal expected long-term survival as long as complications are identified and treated in a timely manner. This notion and the fact that the most dreaded complications (infective endocarditis and aortic dissection) are infrequent, represent important reassuring points for the BAV patient. Common complications such as valve dysfunction and aorta dilatation must be the subject of focused research in prevention and treatment. Conversely, BAV patients with complex-presentation valvulo-artopathy, as well as typical valvulo-aortopathy BAV patients who are older, with advanced valvular dysfunction, and possible late-referral to specialized care, may incur a survival penalty as compared to the general population. An evidence-based discussion of these concepts is provided in this review. (c) 2020 Elsevier Inc. All rights reserved.

Background The effect of transcatheter aortic valve replacement (TAVR) on kidney function stage in patients with aortic stenosis remains poorly understood. We hypothesized that in some patients, TAVR results in improved kidney function by alleviating cardiorenal syndrome. Objectives The purpose of this study was to assess change in chronic kidney disease (CKD) stage following TAVR, identify variables associated with pre- and post-TAVR estimated glomerular filtration rate (eGFR), and assess association of post-TAVR eGFR with mortality. Methods Patients (n = 5,190) receiving TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) 1, 2, and PARTNER 2 S3 trials between April 2007 and October 2014 were included. Pre-TAVR and procedural variables associated with post-TAVR eGFR, change in CKD stage at ≤7 days post-TAVR, and association of post-TAVR eGFR on intermediate-term mortality were assessed. Results At baseline, CKD stage ≥2 was present in 91% of patients. CKD stage either improved or was unchanged following TAVR in the majority of patients (77% stage 1, 90% stage 2, 89% stage 3A, 94% stage 3B, and 99% stage 4). Progression to CKD stage 5 occurred in 1 (0.035%) of 2,892 patients within 7 days post-TAVR. Of 3,546 patients in whom data were available, 70 (2.0%) underwent post-TAVR dialysis. Higher pre-TAVR eGFR and transfemoral approach were strongly associated with higher post-TAVR eGFR. Lower baseline and longitudinal post-TAVR eGFR were associated with lower intermediate-term survival. Conclusions In patients with severe aortic stenosis undergoing TAVR, even with baseline impaired eGFR, CKD stage is more likely to stay the same or improve than worsen. Aortic stenosis may contribute to cardiorenal syndrome that improves with TAVR.

BACKGROUND The use of transcatheter aortic valve replacement (TAVR) has expanded to patient populations of varying surgical risk in light of recent clinical trials, yet its role in patients with aortic stenosis and coexisting thoracic aortic aneurysm (TAA) is not well-delineated. We aimed to evaluate whether risk factors and in-hospital outcomes vary between TAVR patients with and without an unruptured TAA. METHODS The Nationwide Readmissions Database was queried for patients hospitalized between January 2012 and December 2017 who underwent TAVR with and without an unruptured TAA. In-hospital outcomes were compared between cohorts after adjusting for sex, comorbidities, and TAVR approach, and in a subgroup analysis that excluded those with bicuspid aortic valves. RESULTS Among 171,011 TAVR patients, 1,677 (1%) presented with TAA. Patients with TAA were younger (median age 80 vs. 82 years, p

Background Concurrent presence of aortic stenosis and aortic regurgitation is termed mixed aortic valve disease ( MAVD ). Although multiple articles have addressed patients with “isolated” aortic stenosis or aortic regurgitation, the natural history, impact, and outcomes of MAVD are not well defined. Here, we evaluate long‐term outcomes in patients with MAVD and cardiovascular adaptations to chronic MAVD . Methods and Results This observational cohort study evaluated 862 adult patients (56.8% male) with preserved left ventricular ejection fraction and at least moderate aortic regurgitation and moderate aortic stenosis. Primary outcome was all‐cause mortality. Subgroup analysis was based on treatment modality (aortic valve replacement [ AVR ] versus medical management). A regression analysis of longitudinal echocardiographic parameters was performed to assess the natural history of MAVD . Mean age was 68±15 years, and mean left ventricular ejection fraction was 58±5%. At 4.6 years (25th–75th percentile range, 1.0–8.7), 58.6% of patients underwent an AVR and 48.8% patients died. In both unadjusted and adjusted Cox survival analysis, AVR was associated with improved survival (hazard ratio, 0.41; 95% CI , 0.34–0.51, P AVR persisted when stratifying the cohort by symptom status and baseline aortic valve area (log rank, P CI , 0.32–0.50; P P P P P Conclusions MAVD confers a high risk of all‐cause mortality. However, AVR significantly reduces this risk independent of aortic valve area, symptom status, and after controlling for confounding variables.

Severe gastrointestinal (GI) complications (GICs) after cardiac surgery are associated with poor outcomes. Herein, we characterize the severe forms of GICs and associated risk factors of mortality.We retrospectively analyzed the clinically significant postoperative GICs after cardiac surgical procedures performed at our institution from January 2010 to April 2017. Multivariable analysis was used to identify predictors for in-hospital mortality.Of 29,909 cardiac surgical procedures, GICs occurred in 1037 patients (3.5% incidence), with overall in-hospital mortality of 14% compared with 1.6% in those without GICs. GICs were encountered in older patients with multiple comorbidities who underwent complex prolonged procedures. The most lethal GICs were mesenteric ischemia (n = 104), hepatopancreatobiliary (HPB) dysfunction (n = 139), and GI bleeding (n = 259), with mortality rates of 45%, 27%, and 17%, respectively. In the mesenteric ischemia subset, coronary artery disease (odds ratio [OR], 4.57; P = .002], coronary bypass grafting (OR, 6.50; P = .005), reoperation for bleeding/tamponade (OR, 12.07; P = .01), and vasopressin use (OR, 11.27; P.001) were predictors of in-hospital mortality. In the HPB complications subset, hepatic complications occurred in 101 patients (73%), pancreatitis in 38 (27%), and biliary disease in 31 (22%). GI bleeding occurred in 20 patients (31%) with HPB dysfunction. In the GI bleeding subset, HPB disease (OR, 10.99; P.001) and bivalirudin therapy (OR, 12.84; P = .01) were predictors for in-hospital mortality.Although relatively uncommon, severe forms of GICs are associated with high mortality. Early recognition and aggressive treatment are mandatory to improve outcomes.

OBJECTIVE: Current guidelines for elective surgery of ascending thoracic aortic aneurysms (aTAAs) use aneurysm size as primary determinant for risk stratification of adverse events. Biomechanically, dissection may occur when wall stress exceeds wall strength. Determining patient-specific aTAA wall stresses by finite element analysis (FEA) can potentially predict patient-specific risk of dissection. This study compared peak wall stresses in patients with ≥5.0cm vs

BACKGROUND Open repair is the standard of care for patients with descending thoracic and thoracoabdominal aortic aneurysms. Although effective, surgery carries a high risk of morbidity and mortality. Endovascular stent grafts were introduced to treat these aneurysms in patients considered too high risk for open repair. Early results are promising, but later results are incompletely known. Therefore, we sought to compare short- and intermediate-term outcomes of open vs endovascular repair for these aneurysms. METHODS From 2000 to 2010, 1053 patients underwent open (n = 457) or endovascular (n = 596) repair of descending thoracic and thoracoabdominal aortic aneurysms at Cleveland Clinic. To balance patient characteristics between these groups, propensity score matching was performed, yielding 278 well-matched pairs (61% of possible pairs). End points included short- and long-term outcomes. RESULTS In matched patients, compared with endovascular stenting, open repair achieved similar in-hospital death (n = 23 [8.3%] vs n = 21 [7.6%], P = .80) and occurrence of paralysis and stroke (n = 10 [3.6%] vs n = 6 [2.2%], P = .30), despite a longer postoperative stay (median 11 vs 6 days), more dialysis-dependent acute renal failure (n = 24 [8.6%] vs n = 9 [3.3%], P = .008), and prolonged ventilation (n = 106 [46%] vs n = 17 [6.3%], P < .0001). Open repair resulted in better 10-year survival than endovascular repair (52% vs 33%, P < .0001), and aortic reintervention was less frequent (4% vs 21%, P < .0001). Despite a decrease in the first postoperative year, average aneurysm size did not recover to normal range after endovascular stenting. CONCLUSIONS Open repair of descending thoracic and thoracoabdominal aneurysms can achieve acceptable short-term outcomes with better intermediate-term outcomes than endovascular repair.

Background Early coronary ischemic events are uncommon after cardiac surgery, with little known about their management or associated outcomes. We evaluated clinical outcomes of patients undergoing coronary angiography ± percutaneous coronary intervention or redo coronary artery bypass grafting for suspected coronary ischemia within 3 weeks after index cardiac surgery. Methods This is a retrospective observational study based on data from 53,287 patients who underwent cardiac surgery at our institution (1996-2017); 180 patients (0.34%) satisfied the inclusion criteria. The primary outcome was 1-year all-cause mortality. Statistical evaluation involved χ2, analysis of variance, Kaplan-Meier, and receiver operating characteristic curve analyses. Results Most coronary angiography ± percutaneous coronary intervention and redo coronary artery bypass grafting procedures occurred in the first 2 weeks after index cardiac surgery. Patients presenting with ST elevation myocardial infarction (STEMI)/non-STEMI had the lowest 1-year mortality (13.5%), followed by patients with ventricular tachycardia/fibrillation (28.1%), and patients with non–ventricular tachycardia/fibrillation arrest or hemodynamic instability alone the worst (38.6%) (χ2 = 17.3, P = .001). Peak troponin T level after cardiac surgery was strongly predictive of 1-year mortality (area under the curve, 0.74; 95% confidence interval, 0.65-0.84; P Conclusions Although suspected myocardial ischemia requiring coronary angiography or intervention early after cardiac surgery was rare, mortality was high, particularly in presentations other than STEMI/non-STEMI. In patients with overt signs and symptoms of myocardial ischemia after index cardiac surgery, troponin T was not a reliable marker of underlying coronary or graft obstruction but was a robust predictor of 1-year mortality.

Major advances in aortic arch surgery have generally occurred through refinement of technique. The elephant trunk is a concept originally devised by Borst. This involves leaving a piece of tube graft floating in the descending aorta while repairing the ascending aorta and aortic arch. Over time, the concept was expanded to include inverting the graft within itself. The elephant trunk procedure has proven to be reliably successful and become the mainstay of treatment in aortic arch disease. Despite this relatively simple algorithm, the inconsistent and variable anatomy of the aortic arch and its neighboring aorta, coupled with brain protection issues, result in surgery being highly complex and challenging. Successful management of aortic arch disease requires appropriate patient selection, preoperative assessment, and tailoring the treatment for the individual patient with close posttreatment surveillance. Globally, endovascular modalities are also leveraged to expand the therapeutic window of the elephant trunk procedure. The inherent advantages of endovascular therapies are especially appealing when treating patients unable to tolerate conventional surgery. Significant progress has been made in both open and interventional treatment for aortic arch disease. If the elephant trunk procedure is undertaken, consideration of aortic arch principles, understanding brain protection, and the limitations of available surgical corridors is essential. This chapter focuses on the techniques of the elephant trunk in terms of the unique fundamentals and describes a contemporary approach to the management of patients with complex aortic arch pathology.

Coronavirus disease-2019 (COVID-19) caused by SARS-CoV-2 is an ongoing viral pandemic marked by increased risk of thrombotic events. However, the role of platelets in the elevated observed thrombotic risk in COVID-19 and utility of anti-platelet agents in attenuating thrombosis is unknown. We aimed to determine if human platelets express the known SARS-CoV-2 receptor-protease axis on their cell surface and assess whether the anti-platelet effect of aspirin may mitigate risk of myocardial infarction (MI), cerebrovascular accident (CVA), and venous thromboembolism (VTE) in COVID-19. Expression of ACE2 and TMPRSS2 on human platelets were detected by immunoblotting and confirmed by confocal microscopy. We evaluated 22,072 symptomatic patients tested for COVID-19. Propensity-matched analyses were performed to determine if treatment with aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) affected thrombotic outcomes in COVID-19. Neither aspirin nor NSAIDs affected mortality in COVID-19. However, both aspirin and NSAID therapies were associated with increased risk of the combined thrombotic endpoint of (MI), (CVA), and (VTE). Thus, while platelets clearly express ACE2-TMPRSS2 receptor-protease axis for SARS-CoV-2 infection, aspirin does not prevent thrombosis and death in COVID-19. The mechanisms of thrombosis in COVID-19, therefore, appears distinct and the role of platelets as direct mediators of SARS-CoV-2-mediated thrombosis warrants further investigation.

Background: Readmission for acute decompensated heart failure (ADHF) following transcatheter aortic valve replacement (TAVR) is common and linked with mortality. However, time course of ADHF readmissions, their risk factors, and their association with long-term outcomes are not well understood. Our objectives were to identify the temporal pattern of readmission for ADHF following TAVR, which patients are at high risk, and the association of readmission for ADHF and subsequent mortality. Methods: We evaluated 2467 patients successfully treated and discharged in the PARTNER-1 trial, and followed for 5 years. Baseline and discharge clinical, pharmacologic, procedure, and echocardiographic characteristics were considered. The likelihood and temporal pattern of ADHF readmission after accounting for the competing risk of death were assessed using nested competing-risk methodology for repeating time-related events. Risk factors were identified by unsupervised bootstrap-aggregation machine learning. Results: Admission for ADHF following TAVR was associated with an increased risk of subsequent readmission. Accounting for baseline, procedure, and discharge characteristics, we identified greater severity of post-procedure mitral and aortic regurgitation, both lower- and higher-gradient aortic stenosis, oxygen-dependent COPD, baseline calcium channel blocker and long-acting nitrate use, and longer index hospitalization length of stay as risk factors for readmission for ADHF. Conclusion: Early readmission for ADHF following TAVR was associated with clinical, pharmacologic, and echocardiographic characteristics. The resulting models may be used to identify patients at high risk for early readmission following TAVR and to suggest future prospective trials, particularly to treat combined mitral regurgitation associated with aortic stenosis.

Objectives The aim of this study was to further evaluate clinical outcomes in patients with and without PCS. Background Prior cardiac surgery (PCS) is associated with increased surgical risk and post-operative complications following surgical aortic valve replacement (SAVR), but whether this risk is similar in transcatheter aortic valve replacement (TAVR) is unclear. Methods In the PARTNER 2A (Placement of Aortic Transcatheter Valve) trial, 2,032 patients with severe aortic stenosis at intermediate surgical risk were randomized to TAVR with the SAPIEN XT valve or SAVR. Adverse clinical outcomes at 30 days and 2 years were compared using Kaplan-Meier event rates and multivariate Cox proportional hazards regression models. The primary endpoint of the PARTNER 2 trial was all-cause death and disabling stroke. Results Five hundred nine patients (25.1%) had PCS, mostly (98.2%) coronary artery bypass grafting. There were no significant differences between TAVR and SAVR in patients with or without PCS in the rates of the primary endpoint at 30 days or 2 years. Nevertheless, an interaction was observed between PCS and treatment arm; whereas no-PCS patients treated with TAVR had higher rates of 30-day major vascular complications than patients treated with SAVR (adjusted hazard ratio: 2.66; 95% confidence interval: 1.68 to 4.22), the opposite was true for patients with PCS (adjusted hazard ratio: 0.27; 95% confidence interval: 0.11 to 0.66) (pinteraction Conclusions In the PARTNER 2A trial of intermediate-risk patients with severe aortic stenosis undergoing SAVR versus TAVR, the relative risk for 2-year adverse clinical outcomes was similar between TAVR and SAVR in patients with or without PCS.

OBJECTIVES We investigated the hemodynamic durability of the transcatheter aortic valves (TAVs) using the updated Valve Academic Research Consortium-2 (VARC-2) criteria. BACKGROUND The updated VARC-2 consensus criteria combine flow-dependent and flow-independent echocardiographic parameters for hemodynamic assessment of TAVR. Data on the hemodynamic durability of TAV and clinical risk factors associated with valve hemodynamic deterioration (VHD) are lacking. METHODS All patients (n = 276) who received TAV between 2006 and 2012 and had ≥2 follow-up echocardiograms were studied. RESULTS During a median follow up period of 3.3 (1.8-4.4) years, 8 patients (3%) developed moderate to severe valve stenosis per the VARC-2 criteria, while 20 had mild stenosis. In a Cox proportional hazards model analysis, moderate to severe stenosis by VARC-2 criteria was associated with younger age (P = 0.03, HR 0.94), absence of dual antiplatelet therapy (DAPT) (P = 0.026, HR 0.18), and lower baseline left ventricular ejection fraction (LVEF) (P = 0.006, HR 0.94). Longitudinal analysis using a mixed effect model showed that presence of stenosis by VARC-2 criteria was associated with an increase in aortic valve mean gradient (P

There is a recent rise in percutaneous therapies for the tricuspid valve. Due to the innovative nature of these procedures and the complex anatomy of the tricuspid valve, procedural planning often relies on 3-dimensional (3D) printing. Whereas contrast-enhanced 4-dimensional (4D) computed tomography

Background Stroke after transcatheter aortic valve replacement (TAVR) occurs with an incidence of 4–11% and is a particularly devastating adverse event associated with the procedure. Several cerebral protection devices (CPD) have been developed to prevent cerebrovascular events during TAVR. While most studies have shown CPD to be associated with decreased number and volume of lesions on diffusion weighted magnetic resonance imaging , the clinical benefit of these devices remains uncertain. Methods We aimed to use meta-analysis techniques to study the clinical safety and efficacy of these CPD in prospective randomized and non-randomized studies. Data was summarized as Mantel-Haenszel relative risk (RR) and 95% confidence intervals (CI). We used the Higgins' I2 statistic to evaluate heterogeneity. Results We found no evidence of difference between patients with and without CPD [RR 0.70 (95% CI 0.40–1.21)] for the primary composite outcome of stroke and mortality at 30 days. The two groups were also comparable in peri-procedural strokes [RR 0.53 (95% CI 0.27–1.07)], stroke at 30 days [RR 0.69(95% CI 0.38–1.26)], mortality [RR 0.59 (95% CI 0.22–1.59) at 30 days, AKI [RR 0.68(95% CI 0.28–1.62)], major bleeding [RR 0.56 (95% CI 0.26–1.18)], life threating bleeding [0.54 (95% CI 0.19–1.53)] and major vascular complications [RR 0.80 (95% CI 0.52–1.24)]. The risk of strokes within the first week of TAVR was significantly lower in the CPD group [0.56(95% CI 0.33–0.96)]. Conclusion CPD are associated with a decreased incidence of strokes within 1 week of follow-up without showing any evidence of increased risk of other peri-procedural adverse events.

Background Postoperative brain injury is a cause of mortality and morbidity in patients who undergo thoracic aortic replacement. Chronic microvascular white matter ischemic change (WMIC) has been shown to be associated with acute brain infarction in the general population. WMIC has also been shown to be an independent predictor of non-focal neurocognitive changes, generalized seizures, and temporary neurologic dysfunction in patients who undergo thoracic aortic replacement. The aim of this study is to determine if WMIC is a risk factor for acute brain infarction in patients who undergo thoracic aortic replacement. Methods A case-control study of patients who underwent thoracic aortic replacement between 2001 and 2014 were reviewed for neurological changes after surgery and acute brain infarction on postoperative diffusion-weighted imaging (DWI) magnetic resonance imaging (MRI). Patients with neurological changes were matched with control patients who underwent thoracic aortic replacement and had postoperative neurological symptoms without acute brain infarctions. Acute infarction was re-assessed by reviewing DWI sequences on postoperative MRI. WMIC was assessed on FLAIR and T2WI sequences on both preoperative and postoperative MRI. Logistic regression was performed assessing the relationship of WMIC and acute ischemic infarction. Results 5171 patients underwent thoracic aortic replacement; 179 had postoperative neurological changes, and of those 53 patients had acute brain infarction on postoperative DWI. Patients with deep WMIC were more likely to have acute DWI infarctions after thoracic aortic replacement (P = 0.023). Conclusion Our matched retrospective case-controlled study shows deep WMIC to be a predictor of acute brain infarction on DWI after thoracic aortic replacement.

Objectives: The aim of this study was to study differences in progression of aortic stenosis (AS) in patients with mediastinal radiotherapy (XRT)-associated moderate AS versus a matched coh...

Background: Despite preserved left ventricular ejection fraction (LVEF), patients with significant primary mitral regurgitation (MR) often have reduced exercise capacity. In asymptomatic patients with ≥3+ primary MR undergoing rest-stress echocardiography (RSE), we sought to evaluate the incremental impact of left ventricular global longitudinal strain (LV-GLS) on exercise capacity. Methods: A total of 660 asymptomatic patients with ≥3+ primary MR, non-dilated LV and LVEF ≥60% (mean age, 57±14 years, 66% men, body mass index or BMI 25±4 kg/m 2 ) who underwent RSE at our center between 2001 and 2013 were included. Standard RSE data were obtained. Average resting LV-GLS was measured using Velocity Vector Imaging. Results: Mean mitral effective regurgitant orifice, resting right ventricular systolic pressure (RVSP) and LV-GLS were 0.45±0.2 cm 2 , 31±12 mmHg and −21.7%±2%, respectively; 28% had flail mitral leaflet. Mean metabolic equivalents (METs) and post-stress RVSP were 9.9±3, and 46±17 mmHg; 28% achieved

Balloon predilation (BPD) has been an integral part of transcatheter aortic valve implantation (TAVI) since inception. We sought to investigate the effect of avoiding BPD on outcomes of TAVI across different valve types. Articles were included if outcomes of TAVI without BPD were reported. Pooled meta-analysis used a random effects model and reported odds ratios (ORs). Twenty-one studies with 10,752 patients were pooled for analysis. Age and gender were well matched between NoBPD and BPD groups. There was no difference in mortality, stroke, bleeding, and acute kidney injury. NoBPD showed lower pacemaker rates (OR 0.84, 95% confidence interval [CI] 0.72 to 0.97), vascular complications (OR 0.77, 95% CI 0.62 to 0.95), and early safety at 30 days (OR 0.81, 95% CI 0.66 to 0.99). For balloon-expandable valves, lower rates of aortic regurgitation (OR 0.73, 95% CI 0.53 to 0.99) and early safety (OR 0.68, 95% CI 0.55 to 0.85) were seen. Self-expanding valves showed lower pacemaker (OR 0.80, 95% CI 0.66 to 0.97) and vascular complications (OR 0.70, 95% CI 0.50 to 0.99), with a trend toward higher postdilation (OR 1.51, 95% CI 0.85 to 2.67). TAVI without BPD is safe and effective. NoBPD is associated with fewer vascular complications, less aortic regurgitation, and fewer pacemaker requirements and composite early safety end points.

Background: Preoperative mitral regurgitation (MR) in patients undergoing transcatheter (TAVR) and surgical aortic valve replacement (SAVR) has been studied in high-risk cohorts. This study examines the outcomes of preoperative MR (≥ moderate) in a larger, intermediate-risk cohort. Methods: The Placement of Aortic Transcatheter Valves (PARTNER) 2A Trial randomized 2032 intermediate-risk patients with severe, symptomatic aortic stenosis to TAVR or SAVR. An ad-hoc analysis was performed on 1738 patients with baseline MR echocardiographic data. Patients were analyzed according to the degree of preoperative MR (≥ moderate versus ≤ mild). Results: At baseline, ≥ moderate MR was reported in 300 patients (17%). At 30 days, ≥ moderate MR had improved in 47% to ≤ mild. Thirty-day mortality was higher in SAVR patients with ≥ moderate MR (8.0 versus 3.5%; p = 0.01), but this difference was not seen in TAVR (2.7 vs. 3.1%; p = 0.78). At 2-years, the combined outcome of death (20.5 vs. 16.3%; p = 0.07), stroke (12.9 vs. 9.0%; p = 0.06), and rehospitalization (22.0 versus 17.4%; p = 0.06) was higher in the ≥ moderate MR (40.4 vs. 32.6%; p = 0.009), and similar between SAVR and TAVR (39.8 vs. 41.0%; p = 0.89). Conclusions: Significant MR is prevalent in patients with severe AS and affects clinical outcomes after both TAVR and SAVR. SAVR patients with MR have high early risk, but the increased risk of death/stroke/rehospitalization becomes similar in both groups over time. Improvement in MR is common, especially in patients with lower ejection fraction and larger left-ventricular dimensions.

Background: Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has been shown to be feasible, yet the safety and efficacy in relation to native valve (NV) TAVR are not known...

The ability of Sport for Development and Peace (SDP) organizations to achieve desired outcomes depends on the ability of leaders to develop and utilize a set of organizational capacities. This study provides insight into the current state of capacity in the SDP landscape and the relationship between capacity and key phases of the life of an organization. A sample of 165 organizations from across all six continents rated 65 capacity-related elements. We employ a multilevel analysis to explain variation in capacity within and across SDP organizations. This allows us to identify the probabilities of having low capacity across five different capacity dimensions (human resources, finance, partnership, infrastructure, and planning and development capacities). Results indicate critical capacity strengths and challenges across organizational life stages, the positive influence of size, foundation and government funding, the role of geographical location, and the insignificant or limited effect of earned revenues ...

Stroke has long been a devastating complication of any cardiovascular procedure that unfavorably affects survival and quality of life. Over time, strategies have been developed to substantially reduce the incidence of stroke after traditional cardiovascular procedures such as coronary artery bypass grafting, isolated valve surgery, and carotid endarterectomy. Subsequently, with the advent of minimally invasive technologies including percutaneous coronary intervention, carotid artery stenting, and transcatheter valve therapies, operators were faced with a new host of procedural risk factors, and efforts again turned toward identifying novel ways to reduce the risk of stroke. Fortunately, by understanding the procedural factors unique to these new techniques and applying many of the lessons learned from prior experiences, we are seeing significant improvements in the safety of these new technologies. In this review, the authors: 1) carefully analyze data from different cardiac procedural experiences ranging from traditional open heart surgery to percutaneous coronary intervention and transcatheter valve therapies; 2) explore the unique risk factors for stroke in each of these areas; and 3) describe how these risks can be mitigated with improved patient selection, adjuvant pharmacotherapy, procedural improvements, and novel technological advancements.

Background The Placement of Aortic Transcatheter Valves 2A (PARTNER-2A) randomized trial compared outcomes of transfemoral transcatheter and surgical aortic valve replacement (SAVR) in intermediate-risk patients with severe aortic stenosis. The purpose of the present study was to perform an in-depth analysis of outcomes after SAVR in the PARTNER-2A trial. Methods From January 2012 to January 2014, 937 patients underwent SAVR at 57 centers. Mean age was 82 ± 6.7 years and 55% were men. Less-invasive operations were performed in 140 patients (15%) and concomitant procedures in 198 patients (21%). Major outcomes and echocardiograms were adjudicated by an independent events committee. Follow-up was 94% complete to 2 years. Results Operative mortality was 4.1% (n = 38, Society of Thoracic Surgeons predicted risk of mortality: 5.2% ± 2.3%), observed to expected ratio (O/E) was 0.8, and in-hospital stroke was 5.4% (n = 51), twice expected. Aortic clamp and bypass times were 75 ± 30 minutes and 104 ± 46 minutes, respectively. Patients having severe prosthesis–patient mismatch (n = 260, 33%) had similar survival to patients without ( p > 0.9), as did patients undergoing less-invasive SAVR ( p = 0.3). Risk factors for death included cachexia ( p = 0.004), tricuspid regurgitation ( p = 0.01), coronary artery disease ( p = 0.02), preoperative atrial fibrillation ( p = 0.001), higher white blood cell count ( p p = 0.0002). Conclusions In this adjudicated prospective study, SAVR in intermediate-risk patients had excellent results at 2 years. However, there were more in-hospital strokes than expected, most likely attributable to mandatory neurologic assessment after the procedure. No pronounced structural valve deterioration was found during 2-year follow-up. Continued long-term surveillance remains important.

Transcatheter aortic valve replacement has become an accepted alternative to surgery for patients with severe, symptomatic aortic stenosis who are inoperable or are at high surgical risk. Recent trials support the use of transcatheter aortic valve replacement also in patients at intermediate risk, and ongoing trials are assessing appropriateness in other patient groups. The authors review the key anatomic features integral to the transcatheter aortic valve replacement procedure and the echocardiographic imaging required for preprocedural, intraprocedural, and postprocedural assessment.

Purpose Management of acute type A aortic dissection (AAAD) is challenging and operative strategies are varied. We used the STS Adult Cardiac Surgery Database (STS ACSD) to describe contemporary surgical strategies and outcomes for AAAD. Methods Between July 2011 and September 2012, 2982 patients with AAAD underwent operations at 640 centers in North America. Results In this cohort, median age was 60 years old, 66% were male, and 80% had hypertension. The most common arterial cannulation strategies included femoral (36%), axillary (27%), and direct aortic (19%). The median perfusion and cross-clamp times were 181 and 102 min, respectively. The lowest temperature on bypass showed significant variation. Hypothermic circulatory arrest (HCA) was used in 78% of cases. Among those undergoing HCA, brain protection strategies included antegrade cerebral perfusion (31%), retrograde cerebral perfusion (25%), both (4%), and none (40%). Median HCA plus cerebral perfusion time was 40 min. Major complications included prolonged ventilation (53%), reoperation (19%), renal failure (18%), permanent stroke (11%), and paralysis (3%). Operative mortality was 17%. The median intensive care unit and hospital length of stays were 4.7 and 9.0 days, respectively. Among 640 centers, the median number of cases performed during the study period was three. Resuscitation, unresponsive state, cardiogenic shock, inotrope use, age >70, diabetes, and female sex were found to be independent predictors of mortality. Conclusions These data describe contemporary patient characteristics, operative strategies, and outcomes for AAAD in North America. Mortality and morbidity for AAAD remain high.

Objectives The purpose of this study was to identify sex-specific outcomes of intermediate risk patients undergoing transcatheter aortic valve replacement with the SAPIEN 3 valve. Background A survival difference has been observed in women as compared with men in inoperable and high-risk patients receiving early-generation balloon-expandable valves for transcatheter aortic valve replacement (TAVR). Whether a sex-specific outcome difference persists with newer-generation valves and in lower-risk patients is unknown. Methods The PARTNER (Placement of Aortic Transcatheter Valves) II S3 trial included high-risk (HR) (Society of Thoracic Surgeons risk score >8% or heart team determination) and intermediate-risk (IR) (Society of Thoracic Surgeons risk score 4% to 8% or heart team determination) patients with severe symptomatic aortic stenosis who were treated with TAVR with the SAPIEN 3 valve. Patient characteristics and clinical outcomes at 30 days and 1 year were compared by sex. Results Between October 2013 and December 2014, 1,661 patients were enrolled: 583 were HR (338 men, 245 women) and 1,078 were IR (666 men, 412 women). In both cohorts, women were more likely than men to be frail (22% vs. 13%; p Conclusions The study found no apparent sex-specific differences in survival or stroke in this trial of TAVR. This may reflect the changing demographic of patients enrolled, use of newer-generation valves with more sizes available, and more accurate valve sizing techniques.

Phosphotungstic acid (POM) was crystallized together with the neurotransmitter γ-aminobutyric acid (GABA) in acidic medium to form [(HGABA)3PW12O40], compound 1. The latter would only crystalize in the presence of dopamine, while dopamine itself did not become a part of the complex, but crystallized separately as [(Hdopamine)2HPW12O40], compound 2, as previously reported. GABA interacts with POM via hydrogen bonding between the protonated amino group and a terminal oxygen on POM and also via protonated carboxylic acid group. Based on structural information from the crystal structures of 1 and 2 together with complementary studies using other catechols we attempted to provide molecular insight into the well-known structure-directing effect of dopamine. Strong hydrogen bonding between dopamine and POM, together with formation of “dopamine dimers” in the packed structure by interactions between the aromatic rings and intermolecular hydrogen bonding might be important factors for them in directing the self-assembly of polyoxometalates into complex hierarchal structures. Interaction between dopamine and GABA in solution was investigated by diffusion ordered spectrometry (DOSY) NMR in MilliQ-water and in 0.1 M HCl.