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Gastric adenomyoma is a rare, benign neoplasm, often mistaken as a gastrointestinal stromal tumor and not properly identified until after surgical excision. The importance of defining the diagnosis in this entity is highlighted by the fact that these tumors do not require surgical excision. General knowledge of this neoplasm is lacking among physicians. In case reports, this tumor was either incidentally discovered and removed or found during workup for nonspecific GI symptoms and removed because of suspicion for gastrointestinal stromal tumor (GIST). Multiple papers state that surgical excision is necessary for diagnostic clarity. We present an updated review of the modern literature and a case of gastric adenomyoma, as well as define an algorithm using histology and immunohistochemical (IHC) stains (desmin, CKIT, DOG1, PDGF and CK7) for the diagnosis of gastric adenomyoma in a noninvasive manner in order to potentially avoid unnecessary surgery.

Transcatheter aortic valve implantation (TAVI) is approved for treatment of symptomatic aortic stenosis in patients at increased risk for surgical valve replacement, but outcomes data in patients with severe native aortic regurgitation (AR) treated with TAVI remain limited. The objective of this analysis was to evaluate outcomes among patients identified in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry who underwent TAVI for native AR with a commercially available self-expanding valve system. From January 2014 to December 2017, 230 patients in the TVT Registry underwent TAVI for primary severe native AR using a commercially available self-expanding valve (n = 81, CoreValve; n = 149, Evolut R). For inclusion, AR was either pure or mixed with predominantly moderate/severe AR and mean aortic valve gradient ≤20 mm Hg. Thirty-day outcomes were evaluated using time-to-event methods. Device success was reported in 81.7% of patients (CoreValve, 72.2%; Evolut R, 86.9%; p = 0.0.01). Thirty-day all-cause mortality was 13.3%. All patients presented with moderate/severe AR at baseline; at 30 days, 9.1% of implanted patients with data continued to have moderate and 1.4% severe AR. There was a significant reduction in residual moderate/severe AR from the CoreValve to Evolut R device (19.1% vs 6.3%, p = 0.02). Multivariable analysis revealed factors associated with 30-day all-cause mortality include number of valves used (hazard ratio [HR] 2.361, 1.643 to 3.391, p0.001), albumin3.3 mg/dL (HR 3.358, 1.551 to 7.273, p=0.002), and left ventricular ejection fraction (HR 0.978, 0.957 to 1.000, p = 0.047). Despite higher 30-day all-cause mortality, self-expanding TAVI may be an option in selected patients with AR who have no surgical options.

Objective We sought to characterize differences in operative management and surgical outcomes after coronary artery bypass grafting associated with the socioeconomic context in which a patient lives. Methods We used a validated index of 17 variables derived from the US Census Bureau to assign socioeconomic status at the block group level to patients who underwent isolated coronary artery bypass grafting at a single institution over a 16-year period. Operative mortality, stroke, renal failure, prolonged ventilation, sternal wound infection, reoperation, composite morbidity or mortality, long-term survival, and use of arterial conduits were the outcomes assessed. Results This study was composed of 6751 patients. Lower socioeconomic status was significantly associated with increased rates of stroke, renal failure, prolonged ventilation, and composite morbidity or mortality in a multivariable analysis. Low socioeconomic status was significantly associated with poorer long-term adjusted survival (hazard ratio, 1.26; 95% confidence interval, 1.03-1.55). Finally, lower socioeconomic status was significantly associated with decreased use of more than 1 arterial conduits in a multivariable analysis. Conclusions The socioeconomic context in which a patient lives is significantly associated with short- and long-term outcomes after coronary artery bypass grafting. There may also be variation in operative management, demonstrated by decreased use of arterial conduits. Lower rates of arterial revascularization among socioeconomically disadvantaged patients who undergo coronary artery revascularization may provide a target for intervention.

The purpose of this study is to evaluate the association of tricuspid regurgitation (TR) severity with outcomes after transcatheter aortic valve replacement (TAVR).We analyzed data from 34,576 patients who underwent TAVR at 365 US hospitals from November 2011 through March 2015 submitted to The Society of Thoracic Surgeon/American College of Cardiology Transcatheter Valve Therapy Registry. We examined unadjusted mortality and heart failure readmission stratified by degree of preoperative TR and used multivariable models for 1-year mortality and heart failure readmission.Tricuspid regurgitation was present in 80% (n = 27,804) of TAVR patients, with mild TR in 56% (n = 19,393), moderate TR in 19% (n = 6687), and severe TR in 5% (n = 1,724). Increasing TR severity was associated with a number of comorbidities and The Society of Thoracic Surgeons predicted risk of mortality increased (p0.001): no TR (7.3 ± 5.4); mild TR (8.0 ± 5.7); moderate TR (9.6 ± 6.8); and severe TR (10.7 ± 7.4). In unadjusted analysis, moderate and severe TR were associated with increased use of cardiopulmonary bypass, longer intensive care unit and hospital stays, new dialysis, inhospital major adverse cardiac event, inhospital mortality, observed-to-expected inhospital mortality ratio, long-term heart failure readmission, and mortality (p0.001). Adjusted mortality at 1 year was significantly worse for patients with severe TR when left ventricular ejection fraction greater than 30% (hazard ratio 1.29, 95% confidence interval: 1.11 to 1.50) as was heart failure readmission (hazard ratio 1.27, 95% confidence interval: 1.04 to 1.54).Tricuspid regurgitation was common among patients undergoing TAVR. Increasing TR severity was associated with higher risk patients and increased mortality and readmission-particularly for patients with severe TR and left ventricular ejection fraction greater than 30%. The effectiveness of TAVR alone in patients with aortic stenosis and concomitant severe TR may warrant further consideration, particularly for lower risk patients.

Background: Conscious sedation is used during transcatheter aortic valve replacement (TAVR) with limited evidence as to the safety and efficacy of this practice. Methods: The National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry was used to characterize the anesthesia choice and clinical outcomes of all US patients undergoing elective percutaneous transfemoral TAVR between April 1, 2014, and June 30, 2015. Raw and inverse probability of treatment-weighted analyses were performed to compare patients undergoing TAVR with general anesthesia with patients undergoing TAVR with conscious sedation on an intention-to-treat basis for the primary outcome of in-hospital mortality, and secondary outcomes including 30-day mortality, in-hospital and 30-day death/stroke, procedural success, intensive care unit and hospital length-of-stay, and rates of discharge to home. Post hoc falsification end point analyses were performed to evaluate for residual confounding. Results: Conscious sedation was used in 1737/10 997 (15.8%) cases with a significant trend of increasing usage over the time period studied ( P for trendP =0.31). The conscious sedation group was less likely to experience in-hospital (1.6% versus 2.5%, P =0.03) and 30-day death (2.9% versus 4.1%, P =0.03). Conversion from conscious sedation to general anesthesia was noted in 102 of 1737 (5.9%) of conscious sedation cases. After inverse probability of treatment-weighted adjustment for 51 covariates, conscious sedation was associated with lower procedural success (97.9% versus 98.6%, P P P P P Conclusions: In US practice, conscious sedation is associated with briefer length of stay and lower in-hospital and 30-day mortality in comparison with TAVR with general anesthesia in both unadjusted and adjusted analyses. These results suggest the safety of conscious sedation in this population, although comparative effectiveness analyses using observational data cannot definitively establish the superiority of one technique over another.

We here describe a complex case of a 75-year-old man presenting with contained rupture of an aortic arch aneurysm in the presence of a second thoracic aortic aneurysm. He was managed with emergent total arch replacement with frozen elephant trunk. Another stent-graft was used to achieve hemostasis at the distal anastomosis. He later underwent TEVAR extension to manage his second aneurysm in a staged fashion. This case demonstrates a number of important concepts in the evolving interaction between open and endovascular therapies of the aortic arch, particularly in the emergent setting.

Since United States Food and Drug Administration approval in 2005, thoracic endovascular aneurysm repair (TEVAR) has replaced open surgery to become the preferred treatment for descending thoracic aneurysms (DTAs). This study investigated TEVAR trends during the previous 15 years regarding patient and hospital characteristics and their effect on survival.Between 2000 and 2014, 27,079 Medicare patients underwent TEVAR for DTA. We analyzed TEVAR trends during this period and stratified hospitals based on the number of cases completed during the previous 5 years: low (0-19 cases), medium (20-99 cases), and high (≥100 cases) volume. Trends over time were calculated using Poisson regression to determine the average annual percentage changes (aAPC). Survival was calculated using a multivariate Cox regression and adjusted logistic regression with a restricted cubic spline.TEVAR volume significantly increased from 81 cases in 2000 to 3478 cases in 2014 (aAPC, 16.2%; P .001). During the study period, the proportion of cases performed at medium-volume centers increased (aAPC, 5.2%; P.001). Thirty-day mortality after TEVAR increased in the recent period (2013-2014) to 8.8% as compared with 6.6% in the early years (2004-2006) of TEVAR (P.001), and a significant contribution was due to increased patient comorbidity score (aAPC, 1.6%; P.001). Lastly, TEVAR center volume was significantly associated with 30-day survival when fewer than 33 cases were done in the prior 5 years.From 2000 to 2014, TEVAR volume accelerated, and centers are gaining more experience. TEVAR patients have become more acute, and mortality has increased over this period. Patient selection and procedural experience are critical to improving outcomes.

Objective Patients undergoing emergency peripheral arteriovenous extracorporeal life support were evaluated for lower-extremity complications on the basis of the ipsilateral limb perfusion strategy. Methods In a retrospective review of patients receiving extracorporeal life support (2008-2013), 105 of 250 underwent femoral extracorporeal life support. For ipsilateral lower-extremity perfusion, patients underwent no superficial femoral artery cannulation (n = 35), percutaneous superficial femoral artery cannulation (n = 23), or open superficial femoral artery cannulation (n = 47). Results Patients' mean age was 50 ± 16 years, and 63% (n = 67) were male. A total of 92 patients (88%) had primary cardiac emergency, and 13 patients (12%) had cardiopulmonary emergency. The 30-day in-hospital mortality was 65% (n = 68), with an overall lower-extremity complication rate of 13% (n = 14). Lower-extremity complications were highest in the percutaneous superficial femoral artery (n = 6, 26%) and no superficial femoral artery (n = 7, 20%) groups (n = 1 [2%] in open superficial femoral artery group). In 2 group comparisons, the open superficial femoral artery group had significantly lower lower-extremity complications than the no superficial femoral artery ( P = .02) and percutaneous superficial femoral artery ( P = .004) groups. There was no difference between the no superficial femoral artery and percutaneous superficial femoral artery groups ( P = .7). In the no superficial femoral artery group, emergency thromboembolectomy (n = 2), fasciotomy (n = 3), and emergency superficial femoral artery cannula placement (n = 2) were required. In the percutaneous superficial femoral artery group, thromboembolectomy with superficial femoral artery repair (n = 2), fasciotomy (n = 1), below-knee amputation (n = 1), open superficial femoral artery cannula revision (n = 1), and loss of distal signals from multiorgan failure (n = 1) were noted. In the open superficial femoral artery group, 1 patient had loss of signals from multiorgan failure. Conclusions No superficial femoral artery perfusion strategy is associated with a high lower-extremity complication rate. If percutaneous cannulation is performed, then angiographic confirmation of superficial femoral artery run-off is highly recommended. The open superficial femoral artery approach remains a safe alternative to the other strategies.

When clinicians consider extracorporeal life support (ECLS) for acute respiratory distress syndrome (ARDS) patients with hemodynamic instability, both veno-arterial (VA) and veno-venous (VV) ECLS are therapeutic possibilities. We analyzed 17 patients with ARDS on inotropic or vasopressor support requiring ECLS for refractory hypoxemia. After implementing VV ECLS, pressor requirements (based on norepinephrine equivalents) were significantly lower in all patients (P = .0001 for overall comparison across time points). None of the 17 patients required conversion from VV ECLS to VA ECLS (95% confidence interval 0%-20.0%). In this sample of 17 patients with substantial baseline vasopressor support and hypoxemic respiratory failure, initiation of VV ECLS was associated with reduced pressor requirements. Such a strategy may help avoid complications of VA ECLS in patients with both respiratory and hemodynamic failure.

Socioeconomic status (SES) has been associated with adverse outcomes after cardiac surgery, but is not included in commonly applied risk adjustment models. This study evaluates whether inclusion of SES improves aortic valve replacement (AVR) risk prediction models, as this is the most common elective operation performed at our institution during the study period. All patients who underwent AVR at a single institution from 2005 to 2015 were evaluated. SES measures included unemployment, poverty, household income, home value, educational attainment, housing density, and a validated SES index score. The risk scores for mortality, complications, and increased length of stay were generated using models published by the Society for Thoracic Surgeons. Univariate models were fitted for each SES covariate and multivariable models for mortality, any complication, and prolonged length of stay (PLOS). A total of 1,386 patients underwent AVR with a 2.7% mortality, 15.1% complication rate, and 9.7% PLOS. In univariate models, higher education was associated with decreased mortality (odds ratio [OR] 0.96, p = 0.04) and complications (OR 0.97, p < 0.01). Poverty was associated with increased length of stay (OR 1.02, p = 0.02). In the multivariable models, the inclusion of SES covariates increased the area under the curve for mortality (0.735 to 0.750, p = 0.14), for any complications (0.663 to 0.680, p < 0.01), and for PLOS (0.749 to 0.751, p = 0.12). The inclusion of census-tract-level socioeconomic factors into the the Society of Thoracic Surgeons risk predication models is new and shows potential to improve risk prediction for outcomes after cardiac surgery. With the possibility of reimbursement and institutional ranking based on these outcomes, this study represents an improvement in risk prediction model.

Due to the scarcity of donor hearts to meet recipient demands, more than 40% of heart transplants are performed in patients bridged to transplant (BTT) with a left ventricular assist device (LVAD). The objective of this study was to determine the effect of BTT duration with an LVAD on posttransplant outcomes.From 2009 to 2014, we identified 2639 fee-for-service Medicare patients who underwent a primary heart transplants with 1186 (45%) patients BTT with an LVAD. The LVAD patients were stratified as BTT ≤31 days (n = 28 [2.4%]), BTT 31-365 days (n = 748 [63.1%]), and BTT365 days (n = 409 [34.5%]). Patients went directly to heart transplantation and were not bridged in 1453 cases (55%). LVAD duration was analyzed dichotomously and as a continuous variable with adjusted overall survival as the primary end point.All-cause mortality was significantly worse in patients who were BTT31 days. Survival at 30 days was 81.5% for BTT31 days, 94% for BTT 31 to 365 days, 95% for BTT365 days, and 94% for no BTT. At 1 year, survival was 74% for BTT31 days, 85% for BTT 31 to 365 days, 88% for BTT365 days, and 89% for no BTT (P = .018). When LVAD duration was analyzed as a continuous variable, patients BTT with an LVAD34 days had significantly increased mortality.Patients who underwent heart transplantation within the first month of BTT with an LVAD had significantly increased mortality. However, there was no survival difference among patients who were BTT with an LVAD longer than 31 days.

Rapid growth in the provision of cardiac imaging tests has led to concerns about overuse. Little is known about the degree to which health care delivery system characteristics influence use and variation in echocardiography.We analyzed administrative claims of veterans with heart failure older than 65 years from 2007 to 2010 across 34 metropolitan service areas (MSAs). We compared overall rates and geographic variation in use of transthoracic echocardiography (TTE) between veterans who used the Veterans Health Administration (VA) and propensity-matched veterans who used Medicare. "Dual users" were excluded.There were no significant differences in clinical characteristics or mortality between the propensity-matched cohorts (overall n = 30,404 veterans, mean age 76 years, mortality rate 52%). The Medicare cohort had a significantly higher overall rate of TTE use compared with the VA cohort (1.25 vs 0.38 TTEs per person-year, incidence rate ratio 2.89 [95% CI 2.80-3.00], both P.001), but a similar coefficient of variation across MSAs (0.36 [95% CI 0.27-0.45] vs 0.48 [95% CI 0.37-0.59]). There was a moderate to strong correlation in variation at the MSA level between cohorts (Spearman r = 0.58, P.001).Overall rates of TTE use were significantly higher in a Medicare cohort compared with a propensity score-matched VA cohort of veterans with heart failure living in urban areas, with similar relative degrees of geographic variation and moderate to strong regional correlation. Rates of TTE use may be strongly influenced by health care system characteristics, but local practice styles influence echocardiography rates irrespective of health system.

This study evaluates contemporary trends in the use and outcomes of adult patients undergoing extracorporeal membrane oxygenation (ECMO) in U.S. hospitals. All adult discharges in the Nationwide Inpatient Sample database during the years 2002-2012 that included ECMO were used to estimate the total number of U.S. ECMO hospitalizations (n = 12,407). Diagnostic codes were used to group patients by indication for ECMO use into postcardiotomy, heart transplant, lung transplant, cardiogenic shock, respiratory failure, and cardiopulmonary failure. A Mann-Kendall test was used to examine trends over time using standard statistical techniques for survey data. We found that ECMO use increased significantly from 2002-2012 (P = 0.003), whereas in-hospital mortality rate fluctuated without a significant difference in trend over time. No significant trend was observed in overall ECMO use from 2002-2007, but the use did demonstrate a statistically significant increase from 2007-2012 (P = 0.0028). The highest in-hospital mortality rates were found in the postcardiotomy (57.2%) and respiratory failure (59.2%) groups. Lung and heart transplant groups had the lowest in-hospital mortality rates (44.10% and 45.31%, respectively). The proportion of ECMO use for postcardiotomy decreased from 56.9% in 2002 to 37.9% in 2012 (P = 0.026) and increased for cardiopulmonary failure from 3.9% to 11.1% (P = 0.026). We concluded that ECMO use in the United States increased between 2002 and 2012, driven primarily by increase in national ECMO use beginning in 2007. Mortality rates remained high but stable during this time period. Though there were shifts in relative ECMO use among patient groups, absolute ECMO use increased for all indications over the study period.

Objective: Low socioeconomic status (SES) is associated with worse surgical outcomes. Current risk adjustment models for aortic valve replacement (AVR) surgery do not include (SES), and therefore centers that treat large numbers of low-SES patients may be disadvantaged in hospital outcomes comparisons. This study evaluates whether inclusion of SES improves AVR risk prediction models. Methods: All patients undergoing isolated aortic valve replacement (AVR) at a single institution from 2005-2015 were evaluated. We estimated patients’ SES using census-tract-level data, which are more precise than ZIP-code-level data. We excluded patients (~5%) with addresses that could not be geolocated to census tracts. SES covariates were available for 95% of the study population. SES measures included mean rates of unemployment, poverty, household income, home value, educational attainment, and housing density. The risk scores for mortality, complications and increased length of stay were generated using models published by the Society for Thoracic Surgeons. Univariate models were fitted for each SE covariate with a cut-off of p Results: Amongst the 1,386 patients undergoing AVR included in the study, the overall mortality was 2.8%, any complication rate was 15.1% and PLOS was 9.7%. In univariate models, higher education quartile was associated with decreased mortality (OR 0.96, p = 0.04) and complications (OR 0.97, p Conclusions: The inclusion of census-tract-level socioeconomic factors into the STS risk predication models is new and shows potential to improve risk prediction for outcomes following AVR, particularly for predictions of any complications following AVR. With the possibility of reimbursement and institutional ranking based on these outcomes, this study represents an improvement in risk predication model even when limited to census tracts and a single institution’s experience.

The introduction of transcatheter aortic valve replacement (TAVR) as an alternative to open surgery in high-risk patients has been increasing steadily across the United States since the Food and Drug Administration approval of the Edwards Lifesciences SAPIEN device (Edwards Lifesciences, Irvine

Background Extracorporeal life support (ECLS) has been utilized as a rescue strategy for patients with cardiac arrest unresponsive to conventional cardiopulmonary resuscitation. Objective We sought to describe our institution's experience with implementation of ECLS for out-of-hospital and emergency department (ED) cardiac arrests. Our primary outcome was survival to hospital discharge. Methods Consecutive patients placed on ECLS in the ED or within one hour of admission after out-of-hospital or ED cardiac arrest were enrolled at two urban academic medical centers in the United States from July 2007–April 2014. Results During the study period, 26 patients were included. Average age was 40 ± 15 years, 54% were male, and 42% were white. Initial cardiac rhythms were ventricular fibrillation or pulseless ventricular tachycardia in 42%. The average time from initial cardiac arrest to initiation of ECLS was 77 ± 51 min (range 12–180 min). ECLS cannulation was unsuccessful in two patients. Eighteen (69%) had complications related to ECLS, most commonly bleeding and ischemic events. Four patients (15%) survived to discharge, three of whom were neurologically intact at 6 months. Conclusion ECLS shows promise as a rescue strategy for refractory out-of-hospital or ED cardiac arrest but is not without challenges. Further investigations are necessary to refine the technique, patient selection, and ancillary therapeutics.

ObjectivesPatients often present for aortic root replacement surgery with concomitant mitral valve pathology. Moderate mitral regurgitation is the point of clinical equipoise where the benefits of intervention compared with observation are currently unknown. This study compares outcomes in patients undergoing aortic root replacement surgery who did or did not receive a mitral valve repair for their preoperative moderate mitral regurgitation.MethodsA total of 1316 patients who underwent aortic root replacement surgery between 2000 and 2011 were evaluated, with 104 patients meeting the inclusion criteria by presenting with moderate preoperative mitral regurgitation. A total of 73 patients (70%) received no mitral intervention, and 31 patients (30%) received a mitral repair. Patients underwent preoperative, postoperative, and greater than 6-month follow-up echocardiograms. Average clinical follow-up was 6.5 years.ResultsThe mitral repair group had increased preoperative New York Heart Association III/IV and heart failure, longer crossclamp times, and more postoperative renal failure (P = .0003, P = .04, P

After a period of rapid growth, use of cardiac stress testing has recently decreased among Medicare beneficiaries and in a large integrated health system. However, it is not known whether declines in cardiac stress testing are universal or are confined to certain populations.To determine trends in rates of cardiac stress testing among a large and diverse cohort of commercially insured patients.A serial cross-sectional study with time trends was conducted using administrative claims from all members aged 25 to 64 years belonging to a large, national managed care company from January 1, 2005, to December 31, 2012. Linear trends in rates were determined using negative binomial regression models with procedure count as the dependent variable, calendar quarter as the key independent variable, and the size of the population as a logged offset term. Data analysis was performed from January 1, 2005, to December 31, 2012.Age- and sex-adjusted rates of cardiac stress tests per calendar quarter (reported as number of tests per 100 000 person-years).A total of 2 085 591 cardiac stress tests were performed among 32 921 838 persons (mean [SD] age, 43.2 [10.9] years; 16 625 528 women [50.5%] and 16 296 310 [49.5%] men; 7 604 945 nonwhite [23.1%]). There was a 3.0% increase in rates of cardiac stress testing from 2005 (3486 tests; 95% CI, 3458-3514) to 2012 (3589 tests; 95% CI, 3559-3619; P = .01 for linear trend). Use of nuclear single-photon emission computed tomography decreased by 14.9% from 2005 (1907 tests; 95% CI, 1888-1926) to 2012 (1623 tests; 95% CI, 1603-1643; P = .03). Use of stress echocardiography increased by 27.8% from 2005 (709 tests; 95% CI, 697-721) to 2012 (906 tests; 95% CI, 894 to 920; P .001). Use of exercise electrocardiography increased by 12.5% from 2005 (861 tests; 95% CI, 847-873) to 2012 (969 tests; 95% CI, 953-985; P .001). Use of other stress testing modalities increased 65.5% from 2006 (55 tests; 95% CI, 51-59) to 2012 (91 tests; 95% CI, 87-95; P .001). For individuals aged 25 to 34 years, rates of cardiac stress testing increased 59.1% from 2005 (543 tests; 95% CI, 532-554) to 2012 (864 tests; 95% CI, 852-876; P .001). For individuals aged 55 to 64 years, rates of cardiac stress testing decreased by 12.3% from 2005 (7894 tests; 95% CI, 7820-7968) to 2012 (6923 tests; 95% CI, 6853-6993; P .001).In contrast to declines in the use of cardiac stress testing in some health care systems, we observed a small increase in its use among a nationally representative cohort of commercially insured patients. Our findings suggest that observed trends in the use of cardiac stress testing may have been driven more by unique characteristics of populations and health systems than national efforts to reduce the overuse of testing.