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We conducted a retrospective study using the NIS database from 2008 to 2018 to examine the most contemporary national hospitalization trends of transcatheter (TAVR) and surgical (SAVR) aortic valve replacement regarding volume, patient and hospital demographics and economics, resource utilization, total cost of stay, and in-hospital mortality. We demonstrate that TAVR procedures have been performed on a slow by steadily diversifying patient population while volume has grown significantly, while in-hospital mortality, length of stay, discharge home, and costs have improved, whereas these metrics have generally remained stable for SAVR. These trends will likely drive continued TAVR adoption, greatly expanding the overall aortic stenosis patient population eligible for AVR.

Background and aim In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted the first-year residents' duty-hour to less than 16-hour shifts, decreased the maximum shift duration for senior residents, and increased minimum time off after on-call duties. Whether these changes may have impacted the outcomes in cardiac surgery remains unclear. Methods We performed a difference-in-difference analysis of the New York State Cardiac Surgery Reporting System data in 2004-2006 (before the duty-hour policies change) and 2014-2016 (after the change). We evaluated differences in 30-day risk-adjusted mortality rates (RAMR) in coronary artery bypass grafting (CABG) and valve surgeries, stratifying data by hospital type: teaching hospitals (TH) versus nonteaching hospitals (NTH). NTH served as the control not affected by the duty-hour policies. Results (1) The overall surgical volume for CABG surgery has decreased over time (37,645-24,991), while the volume for valve surgery remained similar (20,969-21,532); (2) TH had better short-term outcomes for CABG procedures during 2014-2016 (median RAMR: 1.01% vs. 1.55% in TH vs. NTH, respectively; p = .025) as well as for valve procedures during both 2004-2006 (5.16% vs. 7.49%, p = .020) and 2014-2016 (2.59% vs. 4.09%, p = .033); (3) at difference-in-difference analysis, trainees' duty-hour regulations were not associated with worsening short-term outcomes in both CABG (p = .296) and valve (p = .651) procedures performed in TH. Conclusion The introduction of the 2011 trainees' duty-hour regulations was not associated with worse short-term outcomes for CABG and valve surgery performed in the State of NY by TH.

Objectives The goal of this study was to describe outcomes of patients with bridge to heart transplantation (BTT) after changes were made to the donor heart allocation system. Background Left ventricular assist devices (LVADs) have been used as a BTT. On October 18, 2018, the donor heart allocation system in the United States was updated. Methods This study identified adults in the United Network for Organ Sharing database with durable, continuous-flow LVAD at listing or implanted while listed between April 2017 and April 2020. Baseline recipient and donor characteristics, waitlist survival, and post-transplantation outcomes were compared pre- and post-allocation system change. Results A total of 1,794 patients met inclusion criteria: 983 in the pre-change period and 814 afterward. The number of patients listed with LVAD decreased nationally over time from 102 in April 2017 to 12 in April 2020 (p Conclusions The number of patients with BTT on the transplant list decreased steadily and dramatically after the allocation system change. Although time to transplant decreased, there was an increase in post-transplant mortality. These data suggest that the risks and benefits of LVAD implantation as a BTT have changed under the new allocation system and that the appropriate indication for this treatment strategy warrants a re-evaluation.

BACKGROUND As the symptoms for both chronic lung disease (CLD) and aortic stenosis (AS) frequently overlap, it may be challenging to determine the degree of symptomatic improvement expected for a patient with CLD after correction of AS. Our aim was to determine if patients with CLD have the same degree of quality-of-life improvement following transcatheter aortic valve replacement (TAVR) as patients without CLD. METHODS A retrospective review of 238 TAVR patients from January 2017 to November 2018 who underwent preoperative pulmonary function tests and completed 30-day follow-up was performed. Patients were identified as having CLD with FEV1 more than 75% predicted. Postoperative outcomes and changes in Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) were compared between groups. RESULTS Of the 238 patients identified, 143 (60.0%) had CLD, 50 (35.0%) of whom had an obstructive disease pattern. Patients with CLD were more likely to be male, had higher rates of peripheral artery disease, and had lower baseline ejection fraction. There was no difference in STS Predicted Risk of Mortality, but patients with CLD were more likely to be designated as high-risk by surgeon evaluation. While initial and follow-up KCCQ-12 was lower for patients with CLD, there was no significant difference in degree of improvement (p = .900). When comparing patients with obstructive lung disease (FEV1/FVC

Tricuspid regurgitation (TR) is common in patients with end-stage heart failure receiving left ventricular assist devices (LVADs), but the benefit of concomitant tricuspid valve procedures (TVPs) remains uncertain. This study examined the impact of TVP at the time of LVAD implantation on clinical outcomes and quality of life (QOL) metrics.We included adult patients in the Interagency Registry for Mechanical Circulatory Support database with various degrees of TR who received continuous-flow LVADs from 2008 to 2017. Patients undergoing concomitant TVP were compared with those without the intervention in a stratified analysis. Descriptive analyses, survival analyses, and Andersen‒Gill hazard models were used as appropriate to examine associations with clinical and patient-centered QOL outcomes.Our analysis included 8,263 (53.1%) mild, 4,252 (33.3%) moderate, and 2,100 (13.5%) severe TR cases. TVP rate increased with severity: 8.6% of mild, 18.0% of moderate, and 43.9% of severe cases. TVP was not associated with survival benefit in cases of mild (adjusted hazard ratio [aHR]: 0.97, 95% CI: 0.79-1.19, p = 0.75), moderate (aHR: 1.03, 95% CI: 0.88-1.20, p = 0.72), or severe (aHR: 1.20, 95% CI: 0.98-1.48, p = 0.08) TR. For patients with combined moderate or severe TR, TVP was associated with increased mortality (log-rank p0.01, aHR: 1.13, 95% CI: 1.00-1.27, p = 0.04). After adjusting for TR severity, TVP was associated with increased risk of bleeding, arrhythmia, and stroke (p0.01 each) and no improvements in QOL (p0.05).TVP at the time of LVAD implantation was not associated with either improved survival or QOL, and there were associations with increased risk of adverse events among patients with moderate and severe TR.

This study sought to use INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) results to evaluate sex differences in the use and clinical outcomes of left ventricular assist devices (LVAD).Despite a similar incidence of heart failure in men and women, prior studies have highlighted potential underuse of LVADs in women, and studies of clinical outcomes have yielded conflicting results.Patients were enrolled from the INTERMACS study who underwent implantation of their first continuous-flow LVAD between 2008 and 2017, and survival analyses stratified by sex were conducted.Among the 18,868 patients, 3,984 (21.1%) were women. At 1 year, women were less likely to undergo heart transplantation than men (17.9% vs. 20.0%, respectively; p = 0.003). After multivariable adjustments, women had a higher risk of death (hazard ratio [HR]: 1.15; 95% confidence interval [CI]: 1.07 to 1.23; p 0.001) and were more likely to incur post-implantation adverse events, including rehospitalization, bleeding, stroke, and pump thrombosis or device malfunction. Although women younger than 50 years of age had an increased risk of death compared to men of the same age (HR: 1.34; 95% CI: 1.12 to 1.6), men and women 65 years of age and older had a similar risk of death (HR: 1.09; 95% CI: 0.95 to 1.24).This study found that women had a higher risk of mortality and adverse events after LVAD. Only 1 in 5 LVADs were implanted in women, and women were less likely to receive a heart transplant than men. Further investigation is needed to understand the causes of adverse events and potential underuse of advanced treatment options in women.

BACKGROUND Comorbidity profiles of cardiac surgery patients are known to have changed over time, but modern national trends in these comorbidities and outcomes are not described. This study describes comorbidity trends over time for common adult cardiac surgery procedures. METHODS A retrospective, cross-sectional analysis of the National Inpatient Sample was conducted for years 2005-2014. Hospitalizations with coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and mitral valve repair/replacement (MVRR), as well as combined CABG/valve operations, were identified by ICD-9 procedure codes. Comorbidities were defined based on ICD-9 codes to discriminate between comorbidities and complications. Surgical volume, patient age, in-hospital mortality, and length of stay trends over time were evaluated by linear regression. RESULTS Incidence increased for AVR, MVRR, and CABG + AVR and declined for CABG and CABG + MVRR (P

Psychiatric comorbidities play a key role in patient selection for left ventricular assist devices (LVADs), but their impact on clinical outcomes is unknown.The goal of this study was to examine the clinical impact of psychiatric illness on outcomes in patients receiving LVADs for end-stage heart failure (HF).The study identified adults in the Interagency Registry for Mechanically Assisted Circulatory Support with psychiatric comorbidities (history of alcohol abuse, drug use, narcotic dependence, depression, and other major psychiatric diagnoses) receiving continuous-flow LVADs from 2008 to 2017. Demographic characteristics, survival, adverse events, and quality of life scores were compared for patients with and without each psychiatric comorbidity.Over the study period, the prevalence of psychiatric comorbidities was low: alcohol abuse, n = 1,093 (5.5%); drug use, n = 1,077 (5.4%); narcotic dependence, n = 96 (0.5%); depression, n = 401 (2.0%); and other major psychiatric illnesses, n = 265 (1.4%). Narcotic dependence (adjusted hazard ratio: 1.9; 95% confidence interval: 1.2 to 3.0; p = 0.004) and other major psychiatric illnesses (adjusted hazard ratio: 1.4; 95% confidence interval: 1.0 to 1.9; p = 0.02) were associated with increased risk of mortality, whereas alcohol abuse, drug use, and depression were not. All comorbidities except narcotic dependence were associated with increased risk of rehospitalization and device-related infection (both p 0.05). Kansas City Cardiomyopathy Questionnaire scores were lower from 6 to 24 months' post-implantation among patients with psychiatric comorbidities (p 0.05).Despite a low prevalence of psychiatric comorbidities among LVAD recipients, these conditions were associated with mortality risk, adverse events, and poorer quality of life. Further study is needed to understand how specific psychiatric conditions affect outcomes and how to best manage this vulnerable patient population.

OBJECTIVES The effectiveness of proximal thoracic aortic aneurysm (TAA) surgery in preventing acute aortic syndromes, such as dissection and rupture, is unknown at the populational level. This study evaluated trends in acute aortic syndrome operation incidence relative to proximal aortic surgical volume in the USA. METHODS A retrospective analysis of the National Inpatient Sample in 2005–2014 was performed. Acute aortic syndrome and TAA were identified with International Classification of Diseases, 9th edition diagnosis codes. Proximal aortic surgery was defined as the diagnosis of acute aortic syndrome or TAA with an aortic procedure and either cardioplegia, cardiopulmonary bypass or other cardiac operation. Annual rates of acute aortic syndrome surgery and proximal thoracic aneurysm surgery were adjusted for US population. Trends were evaluated using linear regression. RESULTS We identified 38 442 operations for acute aortic diagnoses and 74 953 operations for TAAs. Case volume for acute aortic syndromes increased from 0.93 to 1.63 per 100 000 (P = 0.001), and aneurysm surgery increased from 1.75 to 3.19 per 100 000 (P CONCLUSIONS Acute aortic syndrome operative volume increased from 2005 to 2014 despite increasing rates of proximal aortic aneurysm surgery. Patient characteristic discrepancies were observed between the 2 groups of hospitalizations, highlighting the need for continued efforts to minimize sociodemographic disparities.

There is limited clinical evidence on when to address tricuspid regurgitation in patients with aortic and mitral valve disease requiring surgical intervention. In this study, we aimed to investigate the potential added value of performing a tricuspid valve repair concomitantly in patients requiring double valve surgery (DVS) of the aortic and mitral valves. We reviewed 223 cases of multivalve surgery from 2011 to 2016. In this single-institution series, 190 underwent DVS in aortic and mitral positions and 33 had triple valve surgery in aortic, mitral, and tricuspid positions. Preoperative and postoperative echocardiograms were evaluated to determine changes in valve function. A logistic regression model was performed to assess relationship of patient comorbidities and type of valve operations to perioperative adverse events. Mid-term survival was similar between the 2 groups (P = 0.541). Compared to DVS, TVS was not associated with an increased risk of perioperative adverse events, including need for pacemaker or mortality on multivariable analysis. Within the DVS subgroup, 19.8% of patients experienced improvement in tricuspid valve function with decrease in the degree of tricuspid regurgitation within a 6-month postoperative follow-up. Our study indicates that repairing the tricuspid valve while addressing the aortic and mitral valves does not pose significant additional risk. The observed improvement of the degree of tricuspid regurgitation without tricuspid operation suggests the need to further define subpopulations of patients with multivalvular disease.

Objectives The purpose of this study was to examine outcomes after left ventricular assist device (LVAD) implantation in older adults (>75 years of age). Background An aging heart failure population together with improvements in mechanical circulatory support (MCS) technology have led to increasing LVAD implantations in older adults. However, data presenting age-specific outcomes are limited. Methods Adult patients in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) who required durable MCS between 2008 and 2017 were included. Patients were stratified by 4 age groups: 75 years of age. Kaplan-Meier survival estimates were used to assess post-LVAD outcomes, with log-rank testing used to compare groups. Univariate and multivariate cox proportional hazard regression models were used to determine predictors of survival and complications. Results A total of 20,939 individuals received an LVAD during the study period: 7,743 (37.0%) were Conclusions Despite careful selection of older adults for LVAD implantation, age remains a significant predictor of mortality. Higher bleeding and lower clotting risk in elderly patients with LVADs support the use of a less intense antithrombotic regimen in this unique population.

Background Patients with obesity and advanced heart failure face unique challenges on the path to heart transplantation. There are limited data on waitlist and transplantation outcomes in this population. We aimed to evaluate the impact of obesity on heart transplantation outcomes, and to investigate the effects of the new organ procurement and transplantation network allocation system in this population. Methods and Results This cohort study of adult patients listed for heart transplant used the United Network for Organ Sharing database from January 2006 to June 2020. Patients were stratified by body mass index (BMI) (18.5–24.9, 25–29.9, 30–34.9, 35–39.9, and 40–55 kg/m 2 ). Recipient characteristics and donor characteristics were analyzed. Outcomes analyzed included transplantation, waitlist death, and posttransplant death. BMI 18.5 to 24.9 kg/m 2 was used as the reference compared with progressive BMI categories. There were 46 645 patients listed for transplantation. Patients in higher BMI categories were less likely to be transplanted. The lowest likelihood of transplantation was in the highest BMI category, 40 to 55 kg/m 2 (hazard ratio [HR], 0.19 [0.05–0.76]; P =0.02). Patients within the 2 highest BMI categories had higher risk of posttransplantation death (HR, 1.29; P P P 2 : HR, 1.31 [1.18–1.46], P 2 : HR, 1.29 [1.06–1.58]; P =0.01). Conclusions There was an inverse relationship between BMI and likelihood of heart transplantation. Higher BMI was associated with increased risk of posttransplant mortality. Patients with obesity were more likely to undergo transplantation under the revised allocation system.

Background Because of discrepancies between donor supply and recipient demand, the cardiac transplantation process aims to prioritize the most medically urgent patients. It remains unknown how recipients with the lowest medical urgency compare to others in the allocation process. We aimed to examine differences in clinical characteristics, organ allocation patterns, and outcomes between cardiac transplantation candidates with the lowest and highest medical urgency. Methods and Results We performed a retrospective analysis of the United Network for Organ Sharing database. Patients listed for cardiac transplantation between January 2011 and May 2020 were stratified according to status at time of transplantation. Baseline recipient and donor characteristics, waitlist survival, and posttransplantation outcomes were compared in the years before and after the 2018 allocation system change. Lower urgency patients in the old system were older (58.5 versus 56 years) and more likely female (54.4% versus 23.8%) compared with the highest urgency patients, and these trends persisted in the new system ( P P P P Conclusions Patients transplanted as lower urgency receive hearts from donors with additional comorbidities compared with higher urgency patients, but outcomes are similar at 1 year.

Background T2D is an increasingly common disease that is associated with worse outcomes in patients with heart failure. Despite this, no contemporary study has assessed its impact on heart transplantation outcomes. This paper examines the demographics and outcomes of patients with type 2 diabetes (T2D) undergoing heart transplantation. Methods Using the United Network for Organ Sharing (UNOS) database, patients listed for transplant were separated into cohorts based on history of T2D. Demographics and comorbidities were compared, and cox regressions were used to examine outcomes. Results Between January 1st, 2011 and June 12th, 2020, we identified 9,086 patients with T2D and 23,676 without T2D listed for transplant. The proportion of patients with T2D increased from 25.2% to 27.9% between 2011 and 2020. Patients with T2D were older, more likely to be male, less likely to be White, and more likely to pay with public insurance (p Conclusions Over the last ten years, the proportion of heart transplant recipients with T2D has increased. These patients are more likely to be from traditionally underserved populations. Patients with T2D have a lower likelihood of transplantation and a higher likelihood of post-transplant mortality. After the allocation system change, likelihood of transplantation has improved for patients with T2D.

Background Racial and ethnic disparities contribute to differences in access and outcomes for patients undergoing heart transplantation. We evaluated contemporary outcomes for heart transplantation stratified by race and ethnicity as well as the new 2018 allocation system. Methods and Results Adult heart recipients from 2011 to 2020 were identified in the United Network for Organ Sharing database and stratified into 3 groups: Black, Hispanic, and White. We analyzed recipient and donor characteristics, and outcomes. Among 32 353 patients (25% Black, 9% Hispanic, 66% White), Black and Hispanic patients were younger, more likely to be women and have diabetes mellitus or renal disease (all, P P =0.003) and 7.7% to 9.0% ( P =0.002), respectively. Compared with White patients, Black patients were less likely to undergo transplantation (adjusted hazard ratio [aHR], 0.87; CI, 0.84–0.90; P P =0.004). There were no differences in transplantation likelihood or post‐transplant mortality between Hispanic and White patients. Following the allocation system change, transplantation rates increased for all groups ( P P =0.024). Conclusions Although the proportion of Black and Hispanic patients listed for cardiac transplantation have increased, significant disparities remain. Compared with White patients, Black patients were less likely to be transplanted, even with the new allocation system, and had a higher risk of post‐transplantation death.

Aims The impact of mechanical ventilation (MV) at the time of heart transplantation is not well understood. In addition, MV was recently removed as a criterion from the new US heart transplantation allocation system. We sought to assess for the association between MV at transplantation and 1-year mortality. Methods and results We utilized the United Network for Organ Sharing database and included all adult, single organ heart transplantations from 1990 to 2019. We utilized multivariable logistic regression adjusting for demographics, comorbidities, and markers of clinical acuity. We identified 60 980 patients who underwent heart transplantation, 2.4% (n = 1431) of which required MV at transplantation. Ventilated patients were more likely to require temporary mechanical support, previous dialysis, and had a shorter median waitlist time (21 vs. 95 days, P Conclusion We found a strong association between the presence of MV at heart transplantation and 90-day and 1-year mortality. Future studies are needed to identify which patients requiring MV have reasonable outcomes, and which are associated with substantially poorer outcomes.

BACKGROUND: Recent clinical evidence suggests an association between warfarin use and calcification of the aortic valve. We sought to determine the effect of warfarin on aortic valve interstitial cell (AVIC) osteogenic protein expression and the signaling pathways by which this effect is mediated. METHODS: Human AVICs were isolated from normal aortic valves of patients undergoing cardiac transplantation, whereas diseased AVICs were isolated from patients undergoing aortic valve replacement for aortic stenosis. AVICs were treated with various anticoagulants, and osteogenic protein expression was evaluated using immunoblotting. Phosphorylation of lipoprotein receptor-related protein 6 (LRP6) and extracellular signal-regulated kinase 1/2 (ERK1/2) was evaluated after treatment with warfarin. AVICs were pretreated with LRP6 inhibitor dkk1 and ERK1/2 inhibitor PD98059 followed by treatment with warfarin, and osteogenic protein expression was evaluated. RESULTS: Warfarin, but not heparin or dabigatran, significantly increased Runx-2 and Osx expression in both normal and diseased human AVICs. Upregulation of β-catenin protein expression and nuclear translocation occurred in diseased AVICs but not normal AVICs after warfarin treatment. Warfarin induced phosphorylation of LRP6 in diseased AVICs only and phosphorylation of ERK1/2 in both normal and diseased AVICs. LRP6 inhibition attenuated warfarin-induced Runx-2 expression in diseased AVICs. ERK1/2 inhibition attenuated warfarin-induced Runx-2 expression in both normal and diseased AVICs. CONCLUSIONS: Warfarin induces osteogenic activity in normal and diseased isolated human AVICs. This effect is mediated by ERK1/2 in both diseased and normal AVICs, but in diseased AVICs β-catenin signaling also plays a role. These results implicate the role of warfarin in aortic valve calcification and highlight potential mechanisms for warfarin-induced aortic stenosis.

It remains unclear why depression is associated with adverse outcomes in patients with heart failure (HF). We examine the relationship between depression and clinical outcomes among patients with HF with reduced ejection fraction managed with guideline-directed medical therapy (GDMT).Using the GUIDE-IT trial, 894 patients with HF with reduced ejection fraction were stratified according to a history of depression, and Cox proportional hazards regression modeling was used to examine the association with outcomes. There were 140 patients (16%) in the overall cohort who had depression. They tended to be female (29% vs 46%, P.001) and White (67% vs 53%, P = .002). There were no differences in GDMT rates at baseline or at 90 days; nor were there differences in target doses of these therapies achieved at 90 days (NS, all). amino-terminal pro-B-type natriuretic peptide levels at all time points were similar between the cohorts (P.05, all). After adjustment, depression was associated with all-cause hospitalizations (hazard ratio, 1.42, 95% confidence interval 1.11-1.81, P.01), cardiovascular death (hazard ratio, 1.69, 95% confidence interval 1.07-2.68, P = .025), and all-cause mortality (hazard ratio, 1.54, 95% confidence interval 1.03-2.32, P = .039).Depression impacts clinical outcomes in HF regardless of GDMT intensity and amino-terminal pro-B-type natriuretic peptide levels. This finding underscores the need for a focus on mental health in parallel to achievement of optimal GDMT in these patients.NCT01685840, https://clinicaltrials.gov/ct2/show/NCT01685840.

Background. Query a single institution computed tomography (CT) database to assess the prevalence of aortic arch anomalies in general adult population and their potential association with thoracic aortopathies. Methods. CT chest scan reports of patients aged 50-85 years old performed for any indication at a single health system between 2013 and 2016 were included in the analysis. Characteristics of patients with and without aortic arch anomalies were compared by t-test and Fisher exact tests. Logistic regression analysis was performed to assess for independent risk factors of thoracic aortic aneurysm. Results. Of 21,336 CT scans, 603 (2.8%) described arch anomalies. Bovine arch (n=354, 58.7%) was the most common diagnosis. Patients with arch anomalies were more likely to be female (p

Background Patients with restrictive or hypertrophic cardiomyopathy (RCM/HCM) and congenital heart disease (CHD) do not derive clinical benefit from inotropes and mechanical circulatory support. Concerns were expressed that the new heart allocation system implemented in October 2018 would disadvantage these patients. This paper aimed to examine the impact of the new adult heart allocation system on transplantation and outcomes among patients with RCM/HCM/CHD. Methods We identified adult patients with RCM/HCM/CHD in the United Network for Organ Sharing (UNOS) database who were listed for or received a cardiac transplant from April 2017-June 2020. The cohort was separated into those listed before and after allocation system changes. Demographics and recipient characteristics, donor characteristics, waitlist survival, and post-transplantation outcomes were analyzed. Results The number of patients listed for RCM/HCM/CHD increased after the allocation system change from 429 to 517. Prior to the change, the majority RCM/HCM/CHD patients were Status 1A at time of transplantation; afterwards, most were Status 2. Wait times decreased significantly for all: RCM (41 days vs 27 days; P Conclusions The new allocation system has had a positive impact on time to transplantation of patients with RCM, HCM, and CHD without negatively influencing survival.

Objective: To assess the impact of surgeon experience on the outcomes of degenerative mitral valve disease. Methods: We reviewed all patients who had surgery for degenerative mitral valve disease between 2011-2016. Experienced surgeon was defined as performing  25 mitral valve operations/year. Patient characteristics and outcomes were compared. Multivariable analysis was performed to identify factors associated with MR recurrence. Survival analysis for mortality was done using Kaplan Meier curve and Cox proportional Hazard method. Results: There were 575 patients treated by 9 surgeons for severe mitral regurgitation caused by degenerative mitral valve disease between 2011-2016. Three experienced surgeons performed 77.2% of the operations. Patients treated by less experienced surgeons had worse comorbidity profile and were more likely to have an urgent or emergent operation (P=0.001). Experienced surgeons were more likely to attempt repair (P=0.024), to succeed in repair (94.7% vs 87%, P=0.001), had shorter cross-clamp times (P=0.001), and achieved higher repair rate (81.3% vs 69.7%, P=0.005). Experienced surgeons were more likely to use neochordae (P=0.001) and less likely to use chordae transfer (P=0.001). Surgeon experience was not associated with recurrence (moderate or higher MR) within the first two years after surgery but was an independent risk factor for mortality (HR= 2.64, P=0.002). Conclusions: Techniques of degenerative mitral valve surgery differ with surgeon experience, with higher rates of repair and better outcomes associated with more experienced surgeons.

Importance Patient outcomes in heart failure clinical trials are generally better than those observed in real-world settings. This may be related to stricter inclusion and exclusion criteria in clinical trials. Objective We study sought to characterize the clinical implications of differences between patients in clinical trials and those in a real-world registry of patients receiving left ventricular assist devices (LVADs). Design, setting, and participants This retrospective cohort study included all patients in INTERMACS (the Interagency Registry for Mechanically Assisted Circulatory Support) who were implanted with an axial flow LVAD from 2010 to 2015 to allow for equivalent comparisons. Main outcomes and measures Differences in patient characteristics and 2-year rates of adverse outcomes with those reported in the ENDURANCE and MOMENTUM 3 clinical trials. Survival analyses were used to assess the relationships between prespecified patient factors and clinical outcomes. Results Of the 10,937 LVAD recipients identified in INTERMACS between 2010–2015, 44% met at least 1 clinical trial exclusion criterion. The 2-year incidence of stroke and death amongst LVAD recipients in INTERMACS and the landmark clinical trials differed significantly (P Conclusions and relevance Most exclusion criteria used in LVAD clinical trials did not afford a substantially greater risk to patients in the real-world setting. In the relatively infrequent cases of end stage renal disease, thrombocytopenia, respiratory failure, and need for ECMO, the risks and benefits of LVAD therapy need careful weighting and further study.

Background and aim We report a case of intravenous drug use associated tricuspid valve endocarditis in a 28-year-old pregnant female at 26-week gestation. Methods Patient management required a multidisciplinary collaboration between cardiac surgery, obstetrics and gynecology, and neonatal critical care. Results Despite appropriate intravenous antibiotics, the patient developed life-threatening complications and underwent planned cesarean delivery at 28 weeks 6 days gestation followed by interval tricuspid valve replacement 1 week later. Conclusions Both the patient and her infant were successfully managed through the perioperative period.

Although the use of extracorporeal membrane oxygenation (ECMO) continues to increase, very little is known about how age influences the transition to definitive advanced therapies.Using the National Inpatient Sample database from 2008 to 2017, we analyzed patients supported by ECMO for cardiogenic shock and separated patients into 2 age cohorts:65 years and ≥ 65 years. Primary outcomes of interest included the proportion of patients undergoing orthotopic cardiac transplantation (OHT) and left ventricular assist device (LVAD) implantation.Over the study period, we identified 16,132 hospitalizations of people with cardiogenic shock requiring ECMO support. Significantly fewer patients in the older group underwent OHT compared to the younger group (0.4% vs 1.2%, P0.001). Compared to the younger group, a lower proportion of those ≥ 65 years received an LVAD (3.7% vs 5.8%, P0.001). LVAD implantation increased over the study period in both age cohorts, whereas OHT increased only in the65 group (P0.05, all). After multivariable adjustment, patients in the oldest age group were still less likely to receive an LVAD (odds ratio 0.54; confidence interval: 0.43-0.69, P0.001) and continued to have the highest odds of in-hospital mortality (odds ratio 1.53; confidence interval : 1.39-1.69, P0.001).Survival of patients ≥ 65 years requiring ECMO for cardiogenic shock is poor and less commonly includes transition to definitive advanced therapies. Although we must stress that no patient should be denied ECMO based solely on age, we believe our results may be helpful for providers when counseling patients and their families.

Aortic arch surgery is a technical challenge, and cerebral protection during distal anastomosis is a continued topic of controversy and discussion. The physiologic effects of hypothermic arrest and adjunctive cerebral perfusion have yet to be fully defined, and the optimal strategies are still undetermined. This review highlights the historical context, physiological rationale, and clinical efficacy of various neuroprotective strategies during arch operations.

Background In the United States, both cannabis use disorder (CUD) and opioid use disorder (OUD) have increased in prevalence. The prevalence, demographics, and costs of CUD and OUD are not well known in heart failure (HF) admissions. This study aimed to use a national database to examine the prevalence, demographics, and costs associated with CUD and OUD in HF. Methods This study used the National Inpatient Sample from 2008 to 2018 to identify all primary HF admissions with and without the co-diagnosis of OUD or CUD using International Classification for Diagnosis, diagnosis codes. Demographics, costs, and trends were examined. Results Between 2008 and 2018, we identified 11,692,995 admissions for HF of which 84,796 (0.8%) had a co-diagnosis of CUD only, and 67,137 (0.6%) had a co-diagnosis of OUD only. The proportion of HF admissions with CUD significantly increased from 0.3% in 2008 to 1.3% in 2018 (p Conclusions Among discharge records for HF, CUD and OUD are increasing in prevalence, significantly affect underserved populations and are associated with higher costs of stay. Future research is essential to better delineate the cause of these increased costs and create interventions, particularly in underserved populations.

Purpose The clinical impact of mitral valve procedures (MVP) at time of left ventricular assist device (LVAD) is not well understood. We examined the association of MVP, according to severity of MR, with long term survival and quality of life metrics. Methods Continuous-flow LVAD recipients with MR from the 2008-2017 INTERMACS registry were included in the analysis. Patients with concomitant MVP were compared to those without intervention, stratified by severity of MR. Descriptive analyses, hazard modeling, and Kaplan-Meier analyses were used to examine associations between intervention and clinical outcomes. Results 6360 (40.0%) mild, 5592 (35.2%) moderate, and 3936 (24.8%) severe MR cases were included. MVP was not associated with improved survival for mild (median: 80.7 months for MVP vs. 55.0 months for non-MVP, P=0.49, HR 0.65 [95%:0.34-1.23]), moderate (58.8 vs. 49.3 months, P=0.31, HR 0.90 [0.57-1.42]), or severe MR (76.8 vs 49.7 months, P=0.15, HR 1.08 [0.73-1.59]). MVP was not associated with differential risk for device failure, bleeding, arrhythmia, thrombotic, right heart failure, or renal failure. There were no differences in Kansas City Cardiomyopathy Questionnaire with or without MVP for mild, moderate, or severe MR at 1- or 2-years after implantation. Conclusion Concomitant MVP with LVAD implantation was not associated with mortality, adverse events, or objective quality of life metrics. The role of concomitant MVP with LVAD implantation must be carefully considered.

Background Pulmonary embolism is common, but the benefit of surgical embolectomy remains unclear. National trends in embolectomy have been described to 2008. Recent data are lacking. We characterized the national trends in incidence, management, and outcomes of pulmonary embolisms, along with the population-level outcomes. Methods The National Inpatient Sample was queried by International Classification of Diseases-9th Revision codes for pulmonary embolisms from 2011 to 2014. Saddle embolisms, shock, and interventions, including systemic thrombolysis, catheter-directed therapy, extracorporeal membrane oxygenation, and pulmonary embolectomy, were identified. Predictors of in-hospital death were identified by logistic regression. Results We identified 1,283,063 embolism records, including 34,040 (2.6%) with saddle embolism, 31,057 (2.4%) with shock, and 1768 (0.14%) had saddle embolism with shock. Embolectomy and catheter-directed therapies were associated with reduced death in saddle embolism with shock (n = 1768; embolectomy: odds ratio [OR], 0.30; 95% confidence interval [CI], 0.19-0.48; catheter-directed therapies: OR, 0.68; 95% CI, 0.49-0.96). Systemic thrombolytics were not associated with a in-hospital death difference (OR, 1.10; 95% CI, 60.87-1.38). Extracorporeal membrane oxygenation was associated with increased death (OR, 2.07; 95% CI, 1.09-3.92). The number needed to treat for in-hospital death of saddle embolisms with shock was 4.7 (95% CI, 3.9-6.9). Conclusions In this contemporary nationally representative sample, surgical embolectomy and catheter-directed therapies were associated reduced in-hospital death for saddle pulmonary embolism with shock, and systemic thrombolytics were not associated with in-hospital death.

OBJECTIVES Evidence of an association between postoperative survival and the presenting syndrome following coronary artery bypass grafting (CABG) is limited. Our goal was to evaluate whether the presenting symptoms of acute coronary syndrome (ACS) or stable ischaemic heart disease were associated with mid-term survival in patients undergoing CABG. METHODS We performed a single-centre retrospective study involving consecutive CABG operations from 2011 to 2016. Post-discharge survival was ascertained via patient-level data linkage with the State of Connecticut vital statistics. Baseline and postoperative variables were compared between the two groups. The multivariate Cox proportional hazard model, adjusted for demographics and comorbidity, was used to show whether the presenting syndrome category was independently associated with mid-term survival. RESULTS A total of 1631 patients were included: 794 with stable ischaemic heart disease and 837 with ACS. Patients with ACS who underwent CABG showed more comorbidities. The overall 30-day mortality rate was 1.8% (ACS 2.3% vs stable ischaemic heart disease 1.3%; P = 0.12). In-hospital, postoperative outcomes revealed higher rates of prolonged ventilation (11.7% vs 4.8%; P CONCLUSIONS The presenting syndrome was not an independent predictor of the mid-term mortality rate. The results indicate that the classification of the presenting syndrome may be fluid and that clinical decision-making for postoperative care of patients who have CABG directed by category of presenting syndrome needs careful consideration. These data should be interpreted in the context of the limitations of this study.

Patient characteristics, trends in the management strategy, and outcomes of patients with constrictive pericarditis have not been characterized at the national scale.Annual trends of patients admitted to hospitals in the United States with constrictive pericarditis were evaluated using the National Inpatient Sample dataset between 2005 and 2014. Poisson regression models adjusting for the US census population estimate were fitted to evaluate trends in the incidence of constrictive pericarditis, isolated pericardiectomy, and cardiopulmonary bypass (CPB) use. Descriptive analyses were performed to compare patient characteristics and in-hospital mortality rates between surgically and medically managed cohorts.During 2005-2014, 29,487 patients were admitted with constrictive pericarditis. Sixteen percent underwent isolated pericardiectomy. The prevalence of constrictive pericarditis remained stable between 2005 and 2014 at 9-10 cases per million, but proportion of patients undergoing isolated pericardiectomy decreased from 18% in 2005 to 15% in 2014 (P = 0.001 for trend). CPB use increased from 15% to 29% (P0.001). Compared with medically managed patients, the pericardiectomy cohort was younger (age 57 vs 61 years, P0.001), less likely to be female (25% vs 41%, P 0.001), and harboured fewer comorbidities. In-hospital mortality was 7.3% for those undergoing pericardiectomy and 6.8% for a medically managed cohort (P = 0.58) and operative mortality was stable across years (P = 0.99 for trend).The prevalence of constrictive pericarditis remained stable between 2005 and 2014 at 9-10 cases per million. Surgical management was infrequent, with younger and less comorbid patients being more likely to be managed operatively. Increasing use of CPB without a change in operative mortality highlights the persisting challenge of this complex disease.

We evaluated whether volume-based, rather than time-based, annual reporting of center outcomes for coronary artery bypass grafting may improve inference of quality, assuming that large center-level year-to-year outcome variability is related to statistical noise.We analyzed 2012 to 2016 data on isolated coronary artery bypass grafting using statewide outcome reports from New York and California. Annual changes in center-level observed-to-expected mortality ratio represented stability of year-to-year outcomes. Cubic spline fit related the annual observed-to-expected ratio change and center volume. Volume above the inflection point of the spline curve indicated centers with low year-to-year change in outcome. We compared observed-to-expected ratio changes between centers below and above the volume threshold and observed-to-expected ratio changes between consecutive annual and biennial measurements.There were 155 centers with median annual volume of 89 (interquartile range, 55-160) for isolated coronary artery bypass grafting. The inflection point of observed-to-expected ratio variability was observed at 111 cases/year. Median year-to-year observed-to-expected ratio change for centers performing less than 111 cases (62 centers) was greater at 0.83 (0.26-1.59) compared with centers performing 111 cases or more (93 centers) at 0.49 (022-0.87) (P .001). By aggregating the outcome over 2 years, centers above the 111-case threshold increased from 93 centers (60%) to 118 centers (76%), but the median observed-to-expected change for all centers was similar between annual aggregates at 0.70 (0.26-1.22) compared with observed-to-expected change between biennial aggregates at 0.54 (0.23-1.02) (P = .095).Center-level, risk-adjusted coronary artery bypass grafting mortality varies significantly from one year to the next. Reporting outcomes by specific case volume may complement annual reports.

Purpose Tricuspid regurgitation (TR) is common in end stage heart failure patients receiving left ventricular assist devices (LVADs), but the value of intervention is uncertain. This study examined the impact of tricuspid valve procedures (TVP) at time of LVAD implantation on clinical outcomes and quality of life metrics. Methods We included patients in the INTERMACS database with TR who received continuous-flow LVADs from the 2008 to 2017. TR was stratified by severity. Patients receiving concomitant TVP were compared to those without intervention in a stratified analysis. Survival analyses and Andersen-Gill hazard models were used to examine associations with clinical outcomes. Results Our analysis included 8263 (53.1%) mild, 4252 (33.3%) moderate, and 2100 (13.5%) severe TR cases. TVP rate increased with severity: 13.0% of mild cases underwent TVP versus 55.2% of severe cases. TVP was not associated with survival difference for mild (median 57.8 months for TVP vs. 55.6 months for non-TVP, P=0.69, HR 1.10 [95%: 0.87-1.50]), moderate (47.5 vs. 51.1 months, P=0.23, HR 1.20 [0.99-1.50]), or severe TR (43.3 vs 46.3 months, P=0.09, HR 1.30 [0.99-1.60]). TVP was associated with increased risk of bleeding, arrhythmia, stroke, renal failure, and respiratory failure (P Conclusion TVP at time of LVAD implantation was not associated with differences in survival or KCCQ scores. However, there were associations with increased risk of adverse events. Further studies are needed to understand appropriateness criteria for TVP with LVAD implantation.

Outcomes in heart failure clinical trials are generally better than those in the real-world. This may be due to stricter inclusion criteria. We compared patient characteristics and clinical outcomes in clinical trial patients and those in a real-world registry who received an axial flow left