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Background: Little attention is given to development of mitral regurgitation (MR) in adults with atrial septal defect (ASD). The aim of the study was to determine the associated factors of MR in ASD adults before surgical repair and the fate of moderate to severe MR after surgery. Methods: We examined 71 consecutive patients with secundum ASD (47 ± 16 years) who underwent surgical repair. Clinical and echocardiographic variables including size of left and right heart systems and severity of MR and tricuspid regurgitation (TR) were investigated before and early after surgery. Results: Before ASD closure, 14 patients (20%) had moderate to severe MR and 25 patients (35%) showed mitral valve (MV) prolapse. The ASD patients with moderate to severe MR showed worse cardiovascular symptoms, increased occurrence of atrial fibrillation and MV prolapse, and greater left ventricular (LV) end-diastolic volume, left atrial area, and TR severity than those with none to mild MR (all P < 0.05). Among preoperative variables, TR severity, left atrial area, LV end-diastolic volume, and MV prolapse were associated with preoperative MR severity in all the patients (all P < 0.03). Isolated ASD closure (n= 46) decreased MV prolapse (P= 0.008). Preoperative moderate to severe MR decreased after ASD closure with and without MV surgery (n= 9 and 5, respectively; both P < 0.05). Conclusions: Preoperative MR severity was associated with TR severity, dilated left heart chambers, and MV prolapse. MR decreased after ASD closure with and even without MV surgery. [ABSTRACT FROM AUTHOR]

Objective: The study objective was to identify the effects of surgeon experience and age, in the context of cumulative institutional experience, on risk-adjusted hospital mortality after cardiac reoperations., Methods: From 1951 to 2020, 36 surgeons performed 160,338 cardiac operations, including 32,871 reoperations. Hospital death was modeled using a novel tree-bagged, generalized varying-coefficient method with 6 variables reflecting cumulative surgeon and institutional experience up to each cardiac operation: (1) number of total and (2) reoperative cardiac operations performed by a surgeon, (3) cumulative institutional number of total and (4) reoperative cardiac operations, (5) year of surgery, and (6) surgeon age at each operation. These were adjusted for 46 patient characteristics and surgical components., Results: There were 1470 hospital deaths after cardiac reoperations (4.5%). At the institutional level, hospital death decreased exponentially and became less variable, leveling at 1.2% after approximately 14,000 cardiac reoperations. For all surgeons as a group, hospital death decreased rapidly over the first 750 reoperations and then gradually decreased with increasing experience to less than 1% after approximately 4000 reoperations. Surgeon age up to 75 years was associated with ever-decreasing hospital death., Conclusions: Surgeon age and experience have been implicated in adverse surgical outcomes, particularly after complex cardiac operations, with young surgeons being novices and older surgeons having declining ability. However, at Cleveland Clinic, outcomes of cardiac reoperations improved with increasing primary surgeon experience, without any suggestion to mid-70s of an age cutoff. Patients were protected by the cumulative background of institutional experience that created a culture of safety and teamwork that mitigated adverse events after cardiac surgery., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate outcomes after aortic root allograft reoperation, identify risk factors for morbidity and mortality, and describe practice evolution since publication of our 2006 allograft reoperation study., Methods: From January 1987 to July 2020, 602 patients underwent 632 allograft-related reoperations at Cleveland Clinic: 144 before 2006 (early era, which suggested radical explant was superior to aortic-valve-replacement-within-allograft [AVR-only]), and 488 from 2006 to present (recent era). Indications for reoperation were structural valve deterioration in 502 (79%), infective endocarditis in 90 (14%), and nonstructural valve deterioration/noninfective endocarditis in 40 (6.3%). Reoperative techniques included radical allograft explant in 372 (59%), AVR-only in 248 (39%), and allograft preservation in 12 (1.9%). Perioperative events and survival were assessed among indications, techniques, and eras., Results: Operative mortality by indication was 2.2% (n = 11) for structural valve deterioration, 7.8% (n = 7) in those with infective endocarditis, and 7.5% (n = 3) for nonstructural valve deterioration/noninfective endocarditis, and by surgical approach 2.4% (n = 9) after radical explant, 4.0% (n = 10) for AVR-only, and 17% (n = 2) for allograft preservation. Operative adverse events occurred in 4.9% (n = 18) of radical explants and 2.8% (n = 7) of AVR-only procedures (P = .2). Patients undergoing radical explants received larger valves than those undergoing AVR-only (median, 25 vs 23 mm)., Conclusions: Aortic root allograft reoperations present a technical challenge but can be performed with low mortality and morbidity. Radical explant offers outcomes similar to AVR-only while allowing for implant of larger prostheses. Increasing experience with allograft reoperations has permitted excellent outcomes; thus, risk of reoperation should not dissuade surgeons from using allografts for invasive aortic valve infective endocarditis and other indications., (Copyright © 2023. Published by Elsevier Inc.)

Competing Interests: The authors have no financial conflicts of interest.

In this invited expert review, we focus on evolving lifetime management strategies for adolescents and young adults with congenital aortic valve disease, acknowledging that these patients often require multiple interventions during their lifetime. Our goal is to preserve the native aortic valve when feasible. Leveraging advanced multimodality imaging, a detailed assessment of the aortic valve and root complex can be obtained, and a surgically approach tailored to an individual patient's anatomy and pathology can be used. In turn, aortic valve repair and reconstruction can be offered to a greater number of patients, either as a definitive strategy or as a component of a staged strategy to delay the need for aortic valve replacement until later in life when more options are available., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

This focused review highlights the latest issues in native valve infective endocarditis. Native valve disease moderately increases the risk of developing infective endocarditis. In 2023, new diagnostic criteria were published by the Duke-International Society of Cardiovascular Infectious Diseases group. New pathogens were designated as typical, and findings on computed tomography imaging were included as diagnostic criteria. It is now recognized that a multidisciplinary approach to care is vital, and the role of an "endocarditis team" is highlighted. Recent studies have suggested that a transition from intravenous to oral antibiotics in selected patients may be reasonable, and the role of long-acting antibiotics is discussed. It is also now clear that an aggressive surgical approach can be life-saving in some patients. Finally, results of several recent studies have suggested there is an association between dental and other invasive procedures and an increased risk of developing infective endocarditis. Moreover, data indicate that antibiotic prophylaxis may be effective in some scenarios., Competing Interests: Funding Support and Author Disclosures Dr Dayer has received payment for expert testimony from Bevan Brittan. Dr Thornhill has received grant support from the National Institutes for Health, Delta Dental of Michigan Research and Data Institute’s Research Committee, and Renaissance Health Service Corporation. Dr Baddour has received consulting fees from Boston Scientific and Roivant Sciences; and has received royalty payments from UpToDate, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. All rights reserved.)

Background: Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death., Objectives: The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors., Methods: From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE)., Results: Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse., Conclusions: Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue., Competing Interests: Funding Support and Author Disclosures Support was provided by the Drs Sidney and Becca Fleischer Heart and Vascular Education Chair (to Dr Blackstone), The Peter and Elizabeth C. Tower Family Endowed Chair in Cardiothoracic Research (to Dr Unai), James and Sharon Kennedy, The Slosburg Family Charitable Trust, and The Stephen and Saundra Spencer Fund for Cardiothoracic Research. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The objectives of this study were to investigate patient characteristics, valve pathology, bacteriology, and surgical techniques related to outcome of patients who underwent surgery for isolated native (NVE) or prosthetic (PVE) mitral valve endocarditis., Methods: From January 2002 to January 2020, 447 isolated mitral endocarditis operations were performed, 326 for NVE and 121 for PVE. Multivariable analysis of time-related outcomes used random forest machine learning., Results: Staphylococcus aureus was the most common causative organism. Of 326 patients with NVE, 88 (27%) underwent standard mitral valve repair, 43 (13%) extended repair, and 195 (60%) valve replacement. Compared with NVE with standard repair, patients who underwent all other operations were older, had more comorbidities, worse cardiac function, and more invasive disease. Hospital mortality was 3.8% (n = 17); 0 (0%) after standard valve repair, 3 (7.0%) after extended repair, 8 (4.1%) after NVE replacement, and 6 (5.0%) after PVE re-replacement. Survival at 1, 5, and 10 years was 91%, 75%, and 62% after any repair and 86%, 62%, and 44% after replacement, respectively. The most important risk factor for mortality was renal failure. Risk-adjusted outcomes, including survival, were similar in all groups. Unadjusted extended repair outcomes, particularly early, were similar or worse than replacement in terms of reinfection, reintervention, regurgitation, gradient, and survival., Conclusions: A patient- and pathology-tailored approach to surgery for isolated mitral valve endocarditis has low mortality and excellent results. Apparent superiority of standard valve repair is related to patient characteristics and pathology. Renal failure is the most powerful risk factor. In case of extensive destruction, extended repair shows no benefit over replacement., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Patient characteristics, risks, and outcomes associated with reoperative multivalve cardiac surgery are poorly characterized. Effect of patient variables and surgical components of each reoperation were evaluated with regard to operative mortality., Methods: From January 2008 to January 2022, 2324 patients with previous cardiac surgery underwent 2352 reoperations involving repair or replacement of multiple cardiac valves at Cleveland Clinic. Mean age was 66 ± 14 years. Number of surgical components representing surgical complexity (valve procedures, aortic surgery, coronary artery bypass grafting, and atrial fibrillation procedures) ranged from 2 to 6. Random forest for imbalanced data was used to identify risk factors for operative mortality., Results: Surgery was elective in 1327 (56%), urgent in 1006 (43%), and emergency in 19 (0.8%). First-time reoperations were performed in 1796 (76%) and 556 (24%) had 2 or more previous operations. Isolated multivalve operations comprised 54% (1265) of cases; 1087 incorporated additional surgical components. Two valves were operated on in 80% (1889) of cases, 3 in 20% (461), and 4 in 0.09% (2). Operative mortality was 4.2% (98 out of 2352), with 1.7% (12 out of 704) for elective, isolated multivalve reoperations. For each added surgical component, operative mortality incrementally increased, from 2.4% for 2 components (24 out of 1009) to 17% for ≥5 (5 out of 30). Predictors of operative mortality included coronary artery bypass grafting, surgical urgency, cardiac, renal dysfunction, peripheral artery disease, New York Heart Association functional class, and anemia., Conclusions: Elective, isolated reoperative multivalve surgery can be performed with low mortality. Surgical complexity coupled with key physiologic factors can be used to inform surgical risk and decision making., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements., Methods: From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs)., Results: Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P  = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P  = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P  = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% ( P  = .33) and 87% versus 100% ( P  = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P  = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively ( P  = .47)., Conclusions: The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach., Competing Interests: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2023 The Author(s).)

Infective endocarditis (IE) describes the infection of native and prosthetic cardiac valves as well as cardiac implantable electronic devices. Echocardiography is the most widely used imaging technique for evaluation of IE. Due to its reduced sensitivity in detection of prosthetic valve IE and cardiac implantable electronic device related IE and related complications, complementary techniques such as cardiac computed tomography (CT) and 18-flurodeoxyglucose positron emission tomography/CT play an emerging role. Therefore, multiple guidelines recommend the use of multimodality imaging in the diagnosis and management of IE. In this review, we aim to compare the various guidelines and to discuss the role of imaging in the diagnosis, detection of complications, monitoring of treatment response, and prognostication of IE., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023. Published by Elsevier Inc.)

Background: The Ozaki procedure using autologous pericardium is an interesting but complex alternative for aortic valve replacement. We present a standardized approach to minimize the learning curve and confirm reproducibility., Methods: After careful preparation, from May 2015 to February 2021, an Ozaki procedure was performed on 46 patients age 51 ± 14 years. Seven had unicuspid (15%), 29 bicuspid (63%), and 10 tricuspid (22%) aortic valves, and 2 patients had endocarditis. Endpoints were operative learning curves, perioperative outcomes, intermediate-term valve hemodynamics, reintervention, health-related quality of life (MacNew Heart Disease Health-Related Quality of Life questionnaire), and mortality., Results: Cardiopulmonary bypass and aortic clamp times decreased from 145 to 125 ​minutes and 120 to 100 ​minutes, respectively, over the first 20 cases, reflecting the learning curve. There was no major perioperative morbidity or mortality. Median postoperative stay was 6.9 days. Aortic regurgitation was mild or less in all but 2 patients who developed moderate aortic regurgitation. Mean aortic valve gradient was 7.9 mmHg postoperatively, 9.2 mmHg by 6 months, and constant thereafter. Left ventricular ejection fraction was 58% preoperatively, 60% at 6 months, and remained stable thereafter. One patient developed infective endocarditis 7 months postoperatively, failed medical management, and underwent valve replacement at 14 months. Two-year survival was 96%, with 1 noncardiac death at 16 months. Health-related quality of life in mental, physical, and emotional domains was better than matched norms, global 6.2 vs. 5.0 ( p < 0.0001)., Conclusions: Using a well-prepared standardized approach, the Ozaki procedure is reproducible with a short learning curve, excellent hemodynamic performance, and good quality of life., Competing Interests: Dr Blackstone had statistical consultation related to valve trials with Edwards Lifesciences and Abiomed. The other authors had no conflicts to declare., (© 2023 The Author(s).)

Competing Interests: Dr Elgharably has a financial relationship with Edwards Lifesciences and Dr Witten has a financial relationship with LifeNet Health. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Objective: To characterize patients with right heart failure undergoing isolated tricuspid valve surgery, focusing on right heart morphology and function., Patients and Methods: From January 2007 to January 2014, 62 patients underwent isolated tricuspid valve surgery. Forty-five patients (73%) had undergone previous heart operations. Right heart morphology and function variables were measured de novo from stored echocardiographic images, and clinical and hemodynamic data were extracted from patient registries and records. Cluster analysis was performed and outcomes assessed., Results: On average, the right ventricle was dilated (diastolic area 32 cm 2 ), but its function was preserved (free-wall strain -17% ± 5.8%) and right heart failure manifestations were moderate, with 40 (65%) having congested neck veins, 35 (56%) dependent edema, and 15 (24%) ascites. Average model for end-stage liver disease with sodium score was 11 ± 4.4, but individual values varied widely. Tricuspid valve variables split patients into 2 equal clusters: those with functional tricuspid regurgitation (TR) and those with structural TR. These groups had similar right ventricular function, but the functional TR group had worse right ventricular morphology and more severe manifestations of right heart failure, including greater model for end-stage liver disease with sodium scores (12 ± 44 vs 9.1 ± 3.9; P = .008). Both groups survived operation with low morbidity, but patients with functional TR had worse long-term survival, 48% versus 73% at 10 years after surgery., Conclusions: The cluster analysis of patients with right heart failure undergoing isolated tricuspid valve surgery separated functional and structural tricuspid valve disease. Good early outcomes suggest expanding criteria for tricuspid valve surgery and earlier intervention for functional TR with right heart failure., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Isolated tricuspid valve (TV) surgery has higher mortality compared with other single-valve operations. The optimal timing and indications remain controversial, and earlier surgery before the development of class I surgical indications may improve outcomes. We aimed to compare the characteristics and outcomes of surgery for isolated tricuspid regurgitation (TR), based on class I indication versus an earlier operation., Methods: Consecutive patients undergoing isolated TV surgery for TR without other concomitant valve surgery at our center during 2004 to 2018 were studied. Indications were divided into class I versus earlier surgery (asymptomatic severe TR with right ventricular dilation and/or dysfunction) for comparative analyses of characteristics and outcomes. The primary outcome was mortality., Results: The study included 159 patients (91 females [57.2%]; 115 for class I, 44 for early surgery), with a mean age of 59.7 ± 15.6 years, 119 (74.8%) with surgical repairs, and a mean follow-up of 5.1 ± 4.0 years. Overall operative mortality was 5.1% (8 patients) (class I, 7.0%; early surgery, 0.0%; P = .107), and class I had a higher composite morbidity than early surgery (35.7% [n = 41] vs 18.2% [n = 8]; P = .036). On Cox proportional hazard model analysis, class I versus early surgery (hazard ratio [HR], 4.62; 95% confidence interval [CI], 1.09-19.7; P = .04), age (HR, 1.03; 95% CI, 1.00-1.07; P = .046), and diabetes (HR, 2.50; 95% CI, 1.13-5.55; P = .024) were independently associated with higher mortality during follow-up., Conclusions: Patients with class I indication for isolated TV surgery had worse survival compared with those undergoing earlier surgery before reaching class I indication. Earlier surgery may improve outcomes in these high-risk patients., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Intrinsic risk of infection of cryopreserved allograft aortic root replacements remains poorly understood despite their long history of use. The objective of this study was to determine this intrinsic risk of allograft infection and its risk factors when allografts are implanted for both nonendocarditis indications and infective endocarditis., Methods: From January 1987 to January 2017, 2042 patients received 2110 allograft aortic valves at a quaternary medical center, 1124 (53%) for nonendocarditis indications and 986 (47%) for endocarditis indications (670 [68%] prosthetic valve endocarditis). Staphylococcus aureus caused 193 of 949 cases of endocarditis (20%), 71 (7.3%) in persons who injected drugs. Periodic surveillance and cross-sectional follow-up achieved 85% of possible follow-up time. The primary end point was allograft infection in patients with nonendocarditis and endocarditis indications. Risk factors were identified by hazard function decomposition and machine learning., Results: During follow-up, 30 allografts (26 explanted) became infected in patients in the nonendocarditis group and 49 (41 explanted) in patients with endocarditis. At 20 years, the probability of allograft infection was 5.6% in patients in the nonendocarditis group and 14% in patients with endocarditis. Risk factors for allograft infection in patients in the nonendocarditis group were younger patient age and older donor age. Risk factors for allograft infection in patients with endocarditis were earlier implant year, injection drug use, and younger age. In patients with endocarditis, 18% of allograft infections were caused by the original organism., Conclusions: The low infection rates, both in patients without and with endocarditis, support continued use of allografts in the modern era, in particular for the treatment of invasive endocarditis of the aortic root., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

The objective of the study was to construct a multi-parametric mitral annular calcification (MAC) score using computed tomography (CT) features for prediction of outcomes in patients undergoing mitral valve surgery. We constructed a multi-parametric MAC score, which ranges between 2 and 12, and consists of Agatston calcium score (1 point: <1000 Agatston units (AU); 2 points: 1000-<3000 AU; 3 points: 3000-5000 AU; 4 points: >5000 AU), quantitative MAC circumferential angle (1 point: <90°; 2 points: 90-<180°; 3 points: 180-<270°; 4 points: 270-360°), involvement of trigones (1 point: 1 trigone; 2 points: both trigones), and 1 point each for myocardial infiltration and left ventricular outflow tract extension/involvement of aorto-mitral curtain. The association between MAC score and clinical outcomes was evaluated. The study cohort consisted of 334 patients undergoing mitral valve surgery (128 mitral valve repairs, 206 mitral valve replacements) between January 2011 and September 2019, who had both non-contrast gated CT scan and evidence of MAC. The mean age was 72 ± 11 years, with 58% of subjects being female. MAC score was a statistically significant predictor of total operation time (P<0.001), cross-clamp time (P = 0.001) and in-hospital complications (P = 0.003). Additionally, MAC score was a significant predictor of time to all-cause death (P = 0.046). A novel multi-parametric score based on CT features allowed systematic assessment of MAC, and predicted clinical outcomes in patients with mitral valve dysfunction undergoing mitral valve surgery., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background We assessed the Ozaki procedure, aortic valve reconstruction using autologous pericardium, with respect to its learning curve, hemodynamic performance, and durability compared with a stented bioprosthesis. Methods and Results From January 2007 to January 2016, 776 patients underwent an Ozaki procedure at Toho University Ohashi Medical Center. Learning curves, aortic regurgitation (AR), and peak gradient, assessed by serial echocardiograms, valve rereplacement, and survival were investigated. Valve performance and durability were compared with 627 1:1 propensity-matched patients receiving stented bovine pericardial valves implanted from 1982 to 2011 at Cleveland Clinic. Learning curves were observed for aortic clamp and cardiopulmonary bypass times, AR prevalence, and early mortality. Decreased aortic clamp time was observed over the first 300 cases. New surgeons performing parts of the procedure after case 400 resulted in a slight increase in aortic clamp and cardiopulmonary bypass times. Among matched patients, the Ozaki cohort had more AR than the PERIMOUNT cohort (severe AR at 1 and 6 years, 0.58% and 3.6% versus 0.45% and 1.0%, respectively; P [trend]=0.006), although with a steep learning curve. Peak gradient showed the opposite trend: 14 and 17 mm Hg for Ozaki and 24 and 28 mm Hg for PERIMOUNT at these times ( P [trend] < 0.001). Freedom from rereplacement was similar ( P =0.491). Survival of the Ozaki cohort was 85% at 6 years. Conclusions Patients undergoing the Ozaki procedure had lower gradients but more recurrent AR than those receiving PERIMOUNT bioprostheses. Although recurrent AR is concerning, results confirm low risk and good midterm performance of the Ozaki procedure, supporting its continued use.

Background: Significant tricuspid regurgitation (TR) is associated with poor outcome and high operative mortality resulting from late presentation. Yet, the optimal timing for intervention is unknown., Objectives: The purpose of this study was to evaluate the prognostic value of echocardiographic parameters to inform early intervention in asymptomatic TR., Methods: Using the Cleveland Clinic echocardiography database 2004 to 2018, the authors identified a consecutive cohort of asymptomatic patients with moderate to severe (3+) or severe (4+) TR. Quantitative TR and right heart parameters were retrospectively determined, and their prognostic utility for all-cause mortality was assessed., Results: In 325 asymptomatic patients (mean age: 67.9 years; 79.4% female) with at least 3+ TR, there were 132 deaths (40.6%), with a median survival time of 9.9 years (95% CI: 7.9-12.7 years). By contrast, the median survival time in an age- and sex-matched cohort of symptomatic TR patients was 4.4 years (95% CI: 2.8-5.9 years). Among all the echocardiographic parameters evaluated, right ventricle free wall strain (RVFWS) and tricuspid regurgitant volume (RVol) were the strongest predictors of mortality in asymptomatic TR. The optimal discriminatory thresholds for these parameters were RVFWS <-19% and RVol >45 mL. The 5-year survival rates by number of risk factors (RF) were 93% (95% CI: 86%-96%), 65% (95% CI: 55%-74%), and 38% (95% CI: 26%-49%) for no RF, 1 RF, and both RFs, respectively. Compared with symptomatic TR, mortality was lower for asymptomatic TR with no RF (HR: 0.10; 95% CI: 0.04-0.29) or 1 RF (HR: 0.29; 95% CI: 0.14-0.58), but similar for asymptomatic TR with both RFs (HR: 1.11; 95% CI: 0.56-2.19)., Conclusions: RVFWS and RVol are key prognostic markers that can be serially monitored to inform optimal timing of intervention for severe asymptomatic TR., Competing Interests: Funding Support and Author Disclosures Dr Gillinov has served as a consultant to AtriCure, Medtronic, Edwards Lifesciences, CryoLife, Abbott, and ClearFlow; and has rights to equity in ClearFlow. Dr Desai has been supported by the Haslam Family endowed chair in cardiovascular medicine at the Cleveland Clinic. The current research was supported by a philanthropic gift from the Haslam family, Bailey family, and Khouri family. Dr Desai has research and consulting agreements with Bristol Myers Squibb, Medtronic, and Caristo Diagnostics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2021. Published by Elsevier Inc.)

Background: The American Heart Association has sponsored both guidelines and scientific statements that address the diagnosis, management, and prevention of infective endocarditis. As a result of the unprecedented and increasing incidence of infective endocarditis cases among people who inject drugs, the American Heart Association sponsored this original scientific statement. It provides a more in-depth focus on the management of infective endocarditis among this unique population than what has been provided in prior American Heart Association infective endocarditis-related documents., Methods: A writing group was named and consisted of recognized experts in the fields of infectious diseases, cardiology, addiction medicine, and cardiovascular surgery in October 2021. A literature search was conducted in Embase on November 19, 2021, and multiple terms were used, with 1345 English-language articles identified after removal of duplicates., Conclusions: Management of infective endocarditis in people who inject drugs is complex and requires a unique approach in all aspects of care. Clinicians must appreciate that it requires involvement of a variety of specialists and that consultation by addiction-trained clinicians is as important as that of more traditional members of the endocarditis team to improve infective endocarditis outcomes. Preventive measures are critical in people who inject drugs and are cured of an initial bout of infective endocarditis because they remain at extremely high risk for subsequent bouts of infective endocarditis, regardless of whether injection drug use is continued.

There are limited data regarding the impact of mitral annular calcium (MAC) on the outcomes of patients who underwent transcatheter aortic valve implantation (TAVI). We performed a retrospective analysis of patients who underwent TAVI in 2018 and divided them into 2 groups based on the presence or absence of MAC, using a validated MAC computed tomography-based scoring system. Among 468 patients who underwent TAVI in 2018, 271 patients (58%) had MAC present compared with 197 patients (42%) without MAC. Compared with patients without MAC, patients in the MAC group were older (81 vs 79, p = 0.012), had a higher body mass index (29.30 vs 28.05, p = 0.031), lower left ventricular end-diastolic diameter (4.47 vs 4.80, p &lt;0.001), higher mitral valve mean gradient (4.54 vs 3.01, p = 0.031), and a higher Society of Thoracic Surgeons risk score (5.69 vs 4.91, p = 0.127). There was no significant difference in the with versus without MAC groups in the all-cause mortality (at 1 year: 9% vs 6%, p = 0.8; at 2 years: 15% vs 13%, p = 0.47), incidence of myocardial infarction (1% vs 2%, p = 0.417), stroke (1% vs 3%, p = 0.4), and major adverse cardiac and cerebrovascular events (17% vs 19%, p = 0.53) at 1 year. Although the rate of new-onset left bundle branch block was higher in patients with MAC, there was no significant difference between the 2 groups in the rates of complete atrioventricular block (5% vs 3%, p = 0.483) or the need for pacemaker implantation (6% vs 3%, p = 0.168). The post-TAVI peak aortic valve gradient was comparable between the groups with and without MAC (22.52 vs 22.60, p = 0.931). In conclusion, TAVI is a safe alternative for patients with severe aortic stenosis and concomitant MAC, with comparable outcomes to patients without MAC., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Reoperative cardiac surgery in patients with patent bilateral internal thoracic artery (ITA) grafts is technically challenging., Methods: From 2008 to 2017, of 7640 patients undergoing reoperative cardiac surgery, 116 (1.5%) had patent bilateral ITA grafts, including 28 with a right ITA crossing the midline. Mean age was 70 ± 9.6 years, and 111 patients (96%) were men. Reoperations included isolated coronary artery bypass grafting (n = 11), isolated valve (n = 55), valve + coronary artery bypass grafting (n = 26), and other procedures (n = 24). Clinical details, intraoperative management, and perioperative outcomes were analyzed., Results: Aortic cannulation was central in 64 patients (56%) and through the femoral or axillary artery in 50 (44%). Four patients (3.4%) had planned transection and reattachment of ITAs crossing the midline, and 4 (3.4%) had ITA injuries, all right ITAs, 3 crossing the midline; 3 were repaired with an interposition vein graft, and 1 was managed by translocating the right ITA as a Y-graft off another graft. Patent ITAs were managed by atraumatic occlusion during aortic clamping in 90 patients (78%) and by systemic cooling without ITA occlusion in 19. There were 6 operative deaths, all due to low cardiac output syndrome (5.2%); 4 strokes (3.4%); and 5 cases of new postoperative dialysis (4.3%)., Conclusions: Risk of injury to bilateral ITA grafts during reoperation is high, and right ITAs crossing the midline present a particular risk of injury and should inform planning for primary coronary artery bypass grafting. Risk of low cardiac output syndrome underscores the challenge of ensuring adequate myocardial protection., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although coronary artery bypass grafting using bilateral internal thoracic arteries (ITA) maximizes long-term survival, knowledge of the effect of different right ITA (RITA) inflow configurations on graft patency is limited. We have compared RITA occlusion among these configurations and identified its risk factors while adjusting for outflow coronary target location., Methods: From January 1972 to January 2016, of 7092 patients undergoing bilateral ITA grafting at a single center, 1331 received one ITA to the left anterior descending coronary artery and had one or more evaluable postoperative coronary angiograms: 835 (63%) in situ, 496 free RITA grafts (311 [63%] originating from aorta; 98 [20%] left ITA [LITA], 76 [15%] saphenous vein graft, 11 [2%] radial graft). RITA occlusion reported on 1983 angiograms performed a median of 5.8 years later was estimated using nonlinear mixed-effects longitudinal modeling., Results: RITA patency was 90% at 1 year, 87% at 5 years, and 86% at 10 and 15 years. At 15 years, in situ RITA patency was 91% and free RITA patency from aorta was 91%, LITA 89%, and saphenous vein graft 77%. After adjusting for coronary target location and degree of stenosis, occlusion was similar in free RITAs from aorta (P = .15), LITA (P = .4), saphenous vein grafts (P = .13), and in situ RITAs. However, RITAs grafted to the left anterior descending coronary artery had fewer occlusions (P < .001), with patency similar to LITAs., Conclusions: Among patients with bilateral ITA grafting requiring interval coronary angiography, long-term RITA patency was high and independent of its inflow configuration. Therefore, priority should be a RITA configuration optimizing its reach to important coronary targets, including the left anterior descending coronary artery., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Perioperative right ventricular function is a significant predictor of patient outcomes after cardiac surgery. This prospective study aimed to identify perioperative factors associated with reduced intraoperative right ventricular function., Methods: Right ventricular function was assessed at the beginning and end of surgery by standardized transesophageal echocardiographic measurements, including tricuspid annular plane systolic excursion, peak systolic longitudinal right ventricular strain, and fractional area change, in 109 adult patients undergoing cardiac surgery at Cleveland Clinic. Associations between right ventricular function and 33 patient characteristics and perioperative factors were analyzed by random forest machine learning. The relative importance of each variable in predicting right ventricular function at the end of surgery was determined., Results: Longer aortic clamp duration and lower baseline right ventricular function were highly important variables for predicting worse right ventricular function measured by tricuspid annular plane systolic excursion, right ventricular strain, and fractional area change at the end of surgery. For example, right ventricular function after longer aortic clamp times of 100-120 minutes was worse (median [Q1, Q3] tricuspid annular plane systolic excursion 1.0 [0.9, 1.1] cm) compared with right ventricular function after shorter aortic clamp times of 50 to 70 minutes (tricuspid annular plane systolic excursion 1.5 [1.3, 1.7]; P = .001). Right ventricular strain at the end of surgery was reduced in patients with worse baseline right ventricular function compared with those with higher baseline right ventricular function (end of surgery right ventricular strain in lowest quartile -13.7 [-16.6, -12.4]% vs highest quartile -17.7 [-18.6, -15.3]% of baseline right ventricular function; P = .043)., Conclusions: Intraoperative decline in right ventricular function is associated with longer aortic clamp time and worse baseline right ventricular function. Efforts to optimize these factors, including better myocardial protection strategies, may improve perioperative right ventricular function., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Bacterial pathogens have evolved virulence factors to colonize, replicate, and disseminate within the vertebrate host. Although there is an expanding body of literature describing how bacterial pathogens regulate their virulence repertoire in response to environmental signals, it is challenging to directly visualize virulence response within the host tissue microenvironment. Multimodal imaging approaches enable visualization of host-pathogen molecular interactions. Here we demonstrate multimodal integration of high spatial resolution imaging mass spectrometry and microscopy to visualize Staphylococcus aureus envelope modifications within infected murine and human tissues. Data-driven image fusion of fluorescent bacterial reporters and matrix-assisted laser desorption/ionization Fourier transform ion cyclotron resonance imaging mass spectrometry uncovered S. aureus lysyl-phosphatidylglycerol lipids, localizing to select bacterial communities within infected tissue. Absence of lysyl-phosphatidylglycerols is associated with decreased pathogenicity during vertebrate colonization as these lipids provide protection against the innate immune system. The presence of distinct staphylococcal lysyl-phosphatidylglycerol distributions within murine and human infections suggests a heterogeneous, spatially oriented microbial response to host defenses., Competing Interests: Declaration of interests The authors declare no interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Transcatheter aortic valve replacement (TAVR) is now frequently performed for severe aortic stenosis. Data regarding cardiac operations after TAVR are limited, however. Therefore, we investigated patient characteristics, operative timing and indications, and outcomes of these operations in a single-center experience., Methods: From January 2012 to July 2020, 59 patients (median age, 70 years) underwent cardiac operations after TAVR, 38 (64%) of which were performed in other centers. The Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was calculated at the time of prior TAVRs and at applicable index cardiac operations., Results: From 2012 to 2018, fewer than 10 operations were performed after TAVR, but 18 were performed in 2019. The interval between prior TAVR and cardiac surgery decreased exponentially from 7 years to less than 1 year over the experience. In applicable cases (19 of 59 operations [32%]), the median STS-PROM was 5.5% (15th-85th percentiles, 3.1%-25%), and 40 (68%) were complex operations with no calculable STS-PROM. The TAVR valve was explanted in 46 (78%); 5 were isolated surgical aortic valve replacements. TAVR valve stenosis/regurgitation (34 [58%]) was the leading indication, followed by paravalvular leak in 14 (24%) and endocarditis in 10 (17%). When the TAVR valve was not explanted, mitral regurgitation was the leading indication for operation. Operative death occurred in 5 (8.5%), postoperative stroke in 2 (3.4%), and postoperative dialysis in 6 (10%)., Conclusions: Cardiac operations after TAVR are increasing, and the interval between TAVR and operation is decreasing. Most cardiac operations are complex, high-risk reoperations, and isolated aortic valve replacement is rare. These findings should be considered when TAVR is selected for low- to intermediate-risk patients, particularly with multiple cardiac pathologies not addressed by TAVR., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Reoperation for structural valve deterioration (SVD) of bioprosthetic mitral valves carries a presumed high operative risk, and transcatheter mitral valve-in-valve implantation has emerged as an alternative. However, surgical risk and long-term outcome following mitral valve re-replacement in these patients remain ill-defined. Hence, we sought to evaluate outcomes and long-term survival following surgical mitral valve re-replacement and to identify risk factors for mortality., Methods: From January 1990 to January 2017, 525 patients underwent surgical mitral valve re-replacement at Cleveland Clinic for bioprosthetic SVD: 133 (25%) isolated operations and 392 (75%) with concomitant procedures. Surgical complications and modes of death were compiled, long-term mortality assessed, and risk factors identified using a multivariable nonproportional hazards model and random forest analysis., Results: SVD was characterized by bioprosthetic regurgitation in 81% (425 out of 525) and stenosis in 44% (231 out of 525). One in-hospital death occurred after isolated valve re-replacement (0.75%) and 28 deaths occurred (7.1%; P = .003) after nonisolated re-replacement, 19 (68%) of which were from coagulopathy, vasoplegia, and multisystem organ failure. In the nonisolated group, incremental risk factors for time-related death after re-replacement included New York Heart Association functional class IV symptoms, concomitant coronary artery bypass grafting, prolonged cardiopulmonary bypass time, and transfusions., Conclusions: Mitral valve re-replacement for bioprosthetic SVD was associated with low surgical risk and excellent long-term survival. Isolated mitral valve re-replacement for bioprosthetic SVD had near-zero surgical risk. Excessive cardiopulmonary bypass duration and multiple transfusions correlated with increased early mortality in nonisolated procedures, as did preoperative severe heart failure. Optimal surgical plan and timing of surgery are keys to success., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The authors report etiologies and outcomes and devise a risk model in a large contemporary cohort of patients with isolated tricuspid regurgitation (TR)., Background: Isolated TR is a challenging clinical entity with heterogeneous etiology and often poor outcomes, with a paucity of recent research regarding the epidemiology of isolated TR., Methods: Consecutive patients with isolated TR graded at least moderate to severe on echocardiography from January 2004 to December 2018 (n = 9,045, mean age 70.4 ± 15.4 years, 60.3% women) were studied. TR etiologies were individually adjudicated as secondary or primary, with subcategories. All-cause death during follow-up was the primary endpoint, with associations between etiology and outcomes analyzed and a risk model created., Results: Primary and secondary TR etiologies were present in 470 (5.2%) and 8,575 (94.8%) patients, respectively. The main secondary etiologies were left heart disease in 4,664 (54.4%), atrial functional in 2,086 (24.3%), and pulmonary disease in 1,454 (17.0%), and the main primary etiologies were endocarditis in 222 (47.2%), degenerative or prolapse in 86 (18.3%), and prosthetic valve failure in 79 (16.8%). There were 3,987 deaths (44.0%) over a mean follow-up period of 2.6 ± 3.3 years. In unadjusted analyses, patients with secondary TR had worse survival than those with primary TR (HR: 1.56; 95% CI: 1.32-1.85), but this result was not statistically significant in multivariable analysis. The authors devised and internally validated a risk score for predicting 1-year mortality in these patients., Conclusions: Secondary TR constituted 95% of isolated significant TR and conferred worse survival than primary TR in unadjusted but not adjusted analyses. The present novel risk score stratifies the risk for 1-year death and may influence decision making for management in these high-risk patients., Competing Interests: Funding Support and Author Disclosures Dr Wang is supported by the National Heart Foundation of New Zealand Overseas Clinical and Research Fellowship (grant 1775). Dr Desai is supported by the Haslam Family endowed chair in cardiovascular medicine at the Cleveland Clinic, a generous philanthropic gift from the Haslam family, Bailey family, and Khouri family. Dr Desai has research and consulting agreements with Myokardia, Medtronic, and Silence Therapeutics. Dr Gillinov is a consultant to AtriCure, Medtronic, Edwards Lifesciences, CryoLife, Abbott, Johnson & Johnson, and ClearFlow; and has rights to equity in ClearFlow. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Infective endocarditis due to Bartonella species is rare. The clinical and echocardiographic characteristics are not well defined. We aimed to investigate the clinical and echocardiographic findings of Bartonella endocarditis in the contemporary era., Methods: The infective endocarditis (IE) registry and echocardiographic database at our institution were retrospectively analysed to evaluate the clinical and echocardiographic features of Bartonella endocarditis., Results: Between January 2008 and December 2015, there were 11 patients with Bartonella IE (0.84% among a total of 1,308 cases of definite IE): median age 54 (30-69) years, all male, 9 Caucasian, 10 had a history of cat exposure, 10 had a pre-existing valvulopathy including 6 patients with a prosthetic valve with prosthesis age range between 3 to 5 years and 1 patient with implantable cardioverter defibrillator (ICD). Bartonella henselae was responsible for all the cases. Echocardiographic evidence of IE was found in 6 of 11 patients on transthoracic echocardiography (TTE), and 6 of 8 on transoesophageal echocardiography (TEE). Bartonella IE was associated with significant valvular destruction and dysfunction on echocardiography. Nine (9) patients were managed surgically with excellent outcomes, including two patients who failed initial medical therapy. Two (2) patients who were managed medically had progression of valvular dysfunction. At a median follow-up of 6 months, there were no deaths attributable to IE or other cardiovascular causes., Conclusion: In a contemporary single-centre cohort in the United States, Bartonella IE remains rare, but should be considered when pathogen could not be identified in patients with suspected IE, especially those with prosthetic valves or bicuspid aortic valve (BAV). The vast majority of patients with Bartonella IE were managed surgically with excellent outcomes., (Copyright © 2021 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objectives: Anomalous aortic origin of the right coronary artery (AAORCA) may cause ischemia and sudden death. However, the specific anatomic indications for surgery are unclear, so dobutamine-stress instantaneous wave-free ratio (iFR) is increasingly used. Meanwhile, advances in fluid-structure interaction (FSI) modeling can simulate the pulsatile hemodynamics and tissue deformation. We sought to evaluate the feasibility of simulating the resting and dobutamine-stress iFR in AAORCA using patient-specific FSI models and to visualize the mechanism of ischemia within the intramural geometry and associated lumen narrowing., Methods: We developed 6 patient-specific FSI models of AAORCA using SimVascular software. Three-dimensional geometries were segmented from coronary computed tomography angiography. Vascular outlets were coupled to lumped-parameter networks that included dynamic compression of the coronary microvasculature and were tuned to each patient's vitals and cardiac output., Results: All cases were interarterial, and 5 of 6 had an intramural course. Measured iFRs ranged from 0.95 to 0.98 at rest and 0.80 to 0.95 under dobutamine stress. After we tuned the distal coronary resistances to achieve a stress flow rate triple that at rest, the simulations adequately matched the measured iFRs (r = 0.85, root-mean-square error = 0.04). The intramural lumen remained narrowed with simulated stress and resulted in lower iFRs without needing external compression from the pulmonary root., Conclusions: Patient-specific FSI modeling of AAORCA is a promising, noninvasive method to assess the iFR reduction caused by intramural geometries and inform surgical intervention. However, the models' sensitivity to distal coronary resistance suggests that quantitative stress-perfusion imaging may augment virtual and invasive iFR studies., (© 2022 The Author(s).)

Mitral annular calcification (MAC) refers to calcium deposition in the fibrous skeleton of the mitral valve. It has many cardiovascular associations, including mitral valve dysfunction, elevated cardiovascular risk, arrhythmias, and endocarditis. Echocardiography conventionally is the first-line imaging modality for anatomic assessment, and evaluation of mitral valve function. Cardiac computed tomography (CT) has demonstrated importance as an imaging modality for the evaluation and planning of related procedures. It also holds promise in quantitative grading of MAC. Currently, there is no universally accepted definition or classification system of MAC severity. We review the multimodality imaging evaluation of MAC and associated valvular dysfunction and propose a novel classification system based on qualitative and quantitative measurements derived from echocardiography and cardiac CT., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Background: Advanced aortic valve infective endocarditis (IE) with progression and destruction beyond the valve cusps-invasive IE-is incompletely characterized. This study aimed to characterize further the invasive disease extent, location, and stage and correlate macroscopic operative findings with microscopic disease patterns and progression., Methods: A total of 43 patients with invasive aortic valve IE were prospectively enrolled from August 2017 to July 2018. Of these patients, 23 (53%) had prosthetic valve IE, 2 (5%) had allograft IE, and 18 (42%) had native aortic valve IE. Surgical findings and intraoperative photography were analyzed for invasion location, extent, and stage. Surgical samples were formalin fixed and analyzed histologically. The time course of disease and management were evaluated., Results: Pathogens included Staphylococcus aureus in 17 patients (40%). Invasion predominantly affected the non-left coronary commissure (76%) and was circumferential in 15 patients (35%) (14 had prosthetic valves). Extraaortic cellulitis was present in 29 patients (67%), abscess in 13 (30%), abscess cavity in 29 (67%), and pseudoaneurysm in 8 (19%); 7 (16%) had fistulas. Histopathologic examination revealed acute inflammation, abscess formation, and lysis of connective tissue but not of myocardium or elastic tissue. Median time from onset of symptoms to antibiotics was 5 days, invasion confirmation 15 days, and surgery 37 days. Patients with S aureus had a 21-day shorter time course than patients non-S aureus. New or worsening heart block developed in 8 patients., Conclusions: Advanced invasive aortic valve IE demonstrates consistent gross patterns and stages correlating with histopathologic findings. Invasion results from a confluence of factors, including pathogen, time, and host immune response, and primarily affects the fibrous skeleton of the heart and expands to low-pressure regions., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Controversies remain in the management strategy for isolated tricuspid regurgitation (TR) because of adverse prognosis and uncertainties regarding the benefits of tricuspid valve surgery. We compared the characteristics and outcomes of a large cohort of patients with isolated TR, based on downstream tricuspid valve surgery versus medical management. Consecutive patients with isolated TR graded at least moderate-to-severe by echocardiography identified between January 2004 and December 2018 (n = 9,031, age 70 ± 15 years, 60% women) were retrospectively studied. The primary end point was time to all-cause mortality during follow-up. Outcomes were compared by management strategy using unadjusted and adjusted survival and multivariable regression analyses. Tricuspid valve surgery was performed in 632 of 9,031 of the cohort (7%), including 514 valve repairs and 118 valve replacements, with in-hospital mortality in 19 patients (2.9%). Overall, there were 3,985 all-cause deaths (44%) over mean follow-up of 2.6 ± 3.3 years. Tricuspid valve surgery was independently associated with lower mortality rate during follow-up, with hazard ratios (HRs) of 0.53 (95% confidence interval [CI] 0.45 to 0.64), and the association persisted in both primary and secondary TR subgroups. Tricuspid valve surgery also had a significantly higher rate of infective endocarditis and heart failure hospitalizations rates during follow-up, at HRs of 5.55 (95% CI 4.00 to 7.71) and 1.29 (95% CI 1.16 to 1.43), respectively. In conclusion, tricuspid valve surgery is rarely performed in isolated TR, but it is independently associated with greater survival for the overall cohort and both primary and secondary etiology subgroups. Increasing the utilization of this surgery at specialized centers is encouraged to try to improve the clinical outcomes for this challenging clinical entity., Competing Interests: Disclosures Dr. Desai has research and consultant agreements with Myokardia Inc, Medtronic, Silence therapeutics, and Caristo Diagnostics. Dr. Gillinov is consultant to AtriCure, Medtronic, Edwards, CryoLife, Abbott, Johnson and Johnson, and ClearFlow and has right to equity for ClearFlow. The other authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Risk models play important roles in stratification and decision-making towards cardiac surgery. Isolated tricuspid valve surgery is a high risk but increasingly performed the operation, however, the performance of risk models has not been externally evaluated in these patients. We compared the prognostic utility of contemporary risk scores for isolated tricuspid valve surgery., Methods: Consecutive patients undergoing isolated tricuspid valve surgery at Cleveland Clinic during 2004-2018 were evaluated in this cohort study. EuroSCORE II, Society of Thoracic Surgeon's tricuspid (STS-TVS) score, and the Model for End-stage Liver Disease (MELD) score were retrospectively calculated, and their performance for predicting operative mortality, postoperative complications, and mortality during follow-up was assessed., Results: Amongst 207 patients studied, the mean age was 54.1 ± 17.9 years, 116 (56.0%) were female, 92 (44.4%) had secondary tricuspid regurgitation, and 151 (72.9%) had a surgical repair. Mean EuroSCORE II, STS-TVS, and MELD scores were 6.3 ± 6.6%, 5.5 ± 6.2%, and 9.8 ± 4.7, respectively. C-statistics (95% confidence intervals) for operative mortality were 0.83 (0.74-0.93) for EuroSCORE II, 0.60 (0.45-0.75) for STS-TVS score, and 0.74 (0.58-0.89) for MELD score, while observed/expected ratios were 0.78 and 0.89 for the first two scores. All three scores were associated with mortality during follow-up and discriminated most postoperative complications., Conclusion: EuroSCORE II was superior to STS-tricuspid score for isolated TVS risk assessment. Although surgical risk scores traditionally underestimated operative mortality after isolated tricuspid valve surgery, they did not in our cohort, reflecting the excellent surgical results. The simple MELD score performed similarly to the EuroSCORE II, especially for discriminating morbidities., (© 2021 Wiley Periodicals LLC.)

Background: Lung transplantation (LTx) is a definitive treatment for end-stage lung disease. Herein, we reviewed our center experience over 3 decades to examine the evolution of recipient characteristics and contemporary predictors of survival for LTx., Methods: We retrospectively reviewed the data of LTx procedures performed at our institution from January 1990 to January 2019 (n = 1819). The cohort is divided into 3 eras; I: 1990-1998 (n = 152), II: 1999-2008 (n = 521), and III: 2009-2018 (n = 1146). Univariate and multivariate analyses of survival in era III were performed., Results: Pulmonary fibrosis has become the leading indication for LTx (13% in era I, 57% in era III). Median recipient age increased (era I: 46 y-era III: 61 y) as well as intraoperative mechanical circulatory support (era I: 0%-era III: 6%). Higher lung allocation score was associated with primary graft dysfunction (P < 0.0001), postoperative extracorporeal mechanical support (P < 0.0001), and in-hospital mortality (P = 0.002). In era III, hypoalbuminemia, thrombocytopenia, and high primary graft dysfunction grade were multivariate predictors of early mortality. The 5-y survival in eras II (55%) and III (55%) were superior to era I (40%, P < 0.001). Risk factors for late mortality in era III included recipient age, chronic allograft dysfunction, renal dysfunction, high model for end-stage liver disease score, and single LTx., Conclusions: In this longitudinal single-center study, recipient characteristics have evolved to include sicker patients with greater complexity of procedures and risk for postoperative complications but without significant impact on hospital mortality or long-term survival. With advancing surgical techniques and perioperative management, there is room for further progress in the field., Competing Interests: K.R.M. is a consultant to Lung Bioengineering and Breethe. The other authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

We sought to evaluate the outcomes of patients with severe mitral stenosis (MS) resulting from mitral annular calcification and assessed the prognostic impact of co-morbidities and frailty in guiding management. Among 6,915 patients with calcific MS who underwent echocardiography between January 2011 and March 2020, a total of 283 patients with severe calcific MS were retrospectively enrolled. We calculated the Charlson co-morbidity index (CCI). Frailty was scored from 0 to 3 points, with 1 point each assigned for reduced hemoglobin, reduced albumin, and inactivity. The primary end point was all-cause death. The mean age was 72 ± 11 years. The mean mitral valve (MV) area was 1.1 ± 0.4 cm 2 , and the mean transmitral gradient was 12 ± 4 mm Hg. Although 33% of the patients underwent MV intervention, 67% were conservatively managed. During a median follow-up of 360 days, 35% died. Patients who underwent MV intervention had an improved prognosis compared with those who were treated conservatively, even after propensity score matching. On multivariate Cox regression analysis, higher CCI (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.04 to 1.38, p = 0.011) and frailty score (HR 1.58, 95% CI 1.12 to 2.23, p = 0.01) were predictors of all-cause mortality, and MV intervention (HR 0.45, 95% CI 0.25 to 0.83, p = 0.011) and angiotensin converting enzyme inhibitor/angiotensin receptor blocker use (HR 0.39, 95% CI 0.20 to 0.79, p = 0.009) were associated with an improved prognosis. In conclusion, patients with severe calcific MS were often frail with multiple co-morbidities and were often managed conservatively. Higher CCI and worse frailty were associated with worse prognosis, regardless of the treatment strategy. MV intervention for select patients was associated with improved prognosis., Competing Interests: Disclosures Dr. Gillinov receives fees of ≥$5,000 per year as a paid consultant, speaker, or member of an advisory committee for Clear Catheter Systems, Inc., AtriCure, Inc., (Copyright © 2021 Elsevier Inc. All rights reserved.)