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Objective: We created and validated a low-cost simulation model for robotic internal mammary artery (IMA) takedown., Methods: The simulation model utilized a calf fetus thorax cavity stented open internally and secured to a table. The simulation model was validated at a 2-day robotic cardiac surgery workshop. Each participant harvested one IMA using the da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA, USA). We compared participant self-reported confidence at robotic IMA harvest before and after using the simulator., Results: Our novel thorax-securing strategy resulted in a stable structure and allowed access to both IMAs from the same 3 ports. The cost to set up the first simulation model was $176 and $133 for every subsequent model. Fifty participants used the simulation model: 42 cardiothoracic surgery attendings and 8 fellows or residents. The feedback form response rate was 78% ( n = 39). On the Likert scale, participants rated realism of the calf model to simulate robotic IMA harvesting (0 = not realistic , 10 = highly realistic ) with a median of 8 out of 10 (interquartile range [IQR] 7 to 9). Participant confidence (0 = not at all confident , 10 = very confident ) in robotic IMA harvesting before and after using the simulator increased ( P = 0.001) from a median of 5 (IQR 1 to 7) to 9 (IQR 7 to 10)., Conclusions: This robotic IMA harvest simulation model is affordable, realistic, and improved participant confidence in robotic IMA harvest. It may provide a valuable training tool for surgeons learning robotic coronary bypass surgery and allows for training frequency necessary to pass basic learning curves., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: T.S.G. is a consultant for Edwards Lifesciences and Medtronic and case observation site and proctor for Intuitive Surgical.

Background: We present a case series of right ventricle (RV) rehabilitation after the Starnes procedure in patients with Ebstein anomaly (EA), applying the Cone repair of the tricuspid valve (TV) to achieve 2-ventricle or 1.5-ventricle physiology., Methods: This is a retrospective database analysis from 2 institutions in North America. We included all consecutive cases of Cone repair after the Starnes procedure. The data are expressed as median and interquartile range (IQR)., Results: Eleven patients underwent RV rehabilitation between 2019 and 2023 after initial Starnes palliation at a median age of 27 months (IQR, 20.5 months). All patients were critically ill before their Starnes procedure, and 4 were on extracorporeal membrane oxygenation. Before the Cone repair, the median preoperative regurgitant velocity at the Starnes patch was 1.65 m/s (IQR, 1.3 m/s). During the Cone procedure, 9 patients required a concomitant pulmonary valve repair, of whom 3 needed a transannular monocusp patch. Four patients were successfully rerouted to a 2-ventricle repair, and 7 patients with a previous Glenn achieved 1.5-ventricle circulation. There were no cases of heart block and no deaths. Seven patients had trivial, 3 patients had mild, and 1 patient had moderate tricuspid regurgitation (TR) at a median follow-up of 11 months (IQR, 21.5 months). There was no significant TV stenosis; all patients had good functional status at the last follow-up despite severe RV dysfunction in 1 patient., Conclusions: After the Starnes procedure, the Cone repair allowed RV rehabilitation, resulting in trivial or mild TR at a midterm follow-up. The Starnes procedure is a reproducible technique that no longer commits patients to lifetime single-ventricle physiology., 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 © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Studies that have assessed the Rastelli and Nikaidoh operations for transposition of the great arteries (TGA) with obstructed left ventricular outflow tract obstruction (LVOTO) have not fully evaluated the anatomic drivers that may contribute to surgical selection. We present our procedural selection process for optimizing outcomes of complex TGA in the modern era., Methods: This is a single-center, retrospective study that included pediatric patients who underwent either a Nikaidoh or Rastelli operation for the treatment of TGA-LVOTO, congenitally corrected TGA-LVOTO, or double-outlet right ventricle TGA type-LVOTO from June 2004 to June 2021., Results: There were 34 patients stratified by Nikaidoh (n = 16) or Rastelli (n = 18) operation. The incidence of all postoperative complications and mortality was low, and the incidence of complications between the groups was similar. Patients were more likely to have undergone a Nikaidoh than a Rastelli if they had a pulmonary annulus >5 mm (87.5% vs 11.1%), anteriorly/posteriorly oriented great vessels (88% vs 8%), remote (80% vs 11%) or restrictive (75% vs 6%) ventricular septal defect, and right ventricular hypoplasia (50% vs 0%; all, P < .05). The resulting rates of reoperation were similar between the groups (44.0% vs 37.5%; P = .24) and largely composed of conduit replacements in the Rastelli patients and valvular repairs or replacements in the Nikaidoh group. Rates of catheter-based interventions were also similar., Conclusions: These findings suggest that for the optimal treatment of conotruncal anomalies with discordant ventriculoarterial connections, procedural selection should be based on pathoanatomic criteria that can ensure patients undergo the operation most suited to their anatomy., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

This review article addresses the history, morphology, anatomy, medical management, and different surgical options for patients with double outlet right ventricle., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Bell-Cheddar, Devine, Diaz-Castrillon, Seese, Castro-Medina, Morales, Follansbee, Alsaied and Lin.)

Objective: This study sought to identify the optimal temperature for moderate hypothermic circulatory arrest in patients undergoing elective hemiarch replacement with antegrade brain perfusion., Methods: The Society of Thoracic Surgeons adult cardiac surgery database was queried for elective hemiarch replacements using antegrade brain perfusion for aneurysmal disease (2014-2019). Generalized estimating equations and restricted cubic splines were used to determine the risk-adjusted relationships between temperature as a continuous variable and outcomes., Results: Elective hemiarch replacement with antegrade brain perfusion occurred in 3898 patients at 374 centers with a median nadir temperature of 24.9°C (first quartile, third quartile = 22.0°C, 27.5°C) and median circulatory arrest time of 19 minutes (first quartile, third quartile = 14.0 minutes, 27.0 minutes). After adjustment for comorbidities, circulatory arrest time, and individual surgeon, patients cooled between 25 and 28°C had an early survival advantage compared with 24°C, whereas those cooled between 21 and 23°C had higher risks of mortality compared with 24°C. A nadir temperature of 27°C was associated with the lowest risk-adjusted odds of mortality (odds ratio, 0.62; 95% confidence interval, 0.42-0.91). A nadir temperature of 21°C had the highest risk of mortality (odds ratio, 1.4; 95% confidence interval, 1.13-1.73). Risk of experiencing a major morbidity was elevated in patients cooled between 21 and 23°C, with the highest risk occurring in patients cooled to 21°C (odds ratio, 1.12; 95% confidence interval, 1.01-1.24)., Conclusions: For patients with aneurysmal disease undergoing elective hemiarch with antegrade brain perfusion, circulatory arrest with a nadir temperature of 27°C confers the greatest early survival benefit and smallest risk of postoperative morbidity., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Although randomized trial data exist for 2-y outcomes comparing isolated coronary artery bypass grafting (CABG) versus CABG with concomitant mitral valve repair (CABG + MVr) for the treatment of moderate ischemic mitral regurgitation (IMR), longer term outcomes are unclear. This study evaluated the longitudinal outcomes of isolated CABG for moderate IMR., Methods: Patients with moderate IMR undergoing isolated CABG from January 2010 to February 2018 at a single institution were included. Outcomes included longitudinal freedom from heart failure readmission, survival, rates of persistent mitral regurgitation (MR), and freedom from mitral valve reinterventions. A subanalysis was conducted comparing CABG versus CABG + MVr. Multivariable Cox regression was used for risk adjustment., Results: A total of 528 patients with moderate IMR underwent isolated CABG. Postoperatively, 26% of patients had at least moderate MR at 1-mo follow-up, although at 5 y progression to severe MR was rare (2.2%) as were mitral valve reinterventions (0.2%). Survival at 30 d (95.8%), 1 y (89.6%), and 5 y (76.6%) was acceptable. Furthermore, the freedom from readmission for heart failure was also acceptable at 30 d (92.6%), 1 y (79.9%), and 5 y (65.0%) postoperatively. In a subanalysis comparing CABG versus CABG + MVr, unadjusted and risk-adjusted survival, freedom from heart failure readmissions, mitral valve reinterventions, and degrees of MR were comparable between the groups at all intervals (all P > 0.05)., Conclusions: The majority of patients with moderate IMR can undergo isolated CABG with acceptable rates of heart failure readmissions, survival, progression to severe MR, and the need for subsequent mitral interventions. These data support the use of isolated CABG in patients with moderate IMR., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Aortic root translocation (Nikaidoh), Rastelli, and réparation à l'etage ventriculaire (REV) are repair options for transposition of the great arteries (TGA) with ventricular septal defects and left ventricular outflow tract obstruction (VSD-LVOTO) or double outlet right ventricle TGA type (DORV-TGA)., Methods: This retrospective study using The Society of Thoracic Surgeons Congenital Heart Surgery Database evaluates surgical procedure utilization and outcomes of patients undergoing repair of TGA-VSD-LVOTO and DORV-TGA with a Nikaidoh, Rastelli, or REV procedure., Results: A total of 293 patients underwent repair at 82 centers (January 2010 to June 2019). Most patients underwent a Rastelli (n = 165, 56.3%) or a Nikaidoh (n = 119, 40.6%) operation; only 3.1% (n = 9) underwent a REV. High-volume centers performed the majority of the repairs. Fewer Nikaidoh than Rastelli patients had prior cardiac operations (n = 57 [48.7%] vs n = 102 [63.0%]; P = .004). Nikaidohs had longer median cardiopulmonary bypass time (227 [interquartile range (IQR), 167-299] minutes vs 175 [IQR, 133-225] minutes; P < .001) and median aortic cross-clamp times (131 [IQR, 91-175] minutes vs 105 [IQR, 82-141] minutes; P = .0015). Operative mortality was 3.1% (95% confidence interval [CI], 1.0%-7.0%; n = 5) for Rastelli, 4.4% (95% CI, 1.4%-9.9%; n = 5) for Nikaidoh, and 11.1% (95% CI, 0.3%-48.3%, n = 1) for REV. The rates of cardiac arrest, unplanned reoperation, mechanical circulatory support, prolonged ventilation, and permanent pacemaker placement were higher in the Nikaidoh population but with 95% CIs overlapping those of the other procedures., Conclusions: Rastelli and Nikaidoh procedures are the prevalent repair strategies for patients with DORV-TGA and TGA-VSD-LVOTO. Most are performed at high-volume institutions, and early outcomes are similar., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The US adult heart allocation policy was changed on October 18, 2018. This study aims to evaluate its impact on orthotopic heart transplantation (OHT) for adults with congenital heart disease (ACHD)., Methods: The United Network for Organ Sharing database was used to perform 2 comparisons: waitlist outcomes among listed ACHD candidates, and post-transplant outcomes in those transplanted. Waitlisted candidates were stratified by date of waitlisting: Period 1: 2010 to 2013; Period 2: 2014 to October 17, 2018 and Period 3: October 18, 2018 to March 20, 2020. Transplanted ACHD patients were similarly stratified but by date of transplantation. Competing risk regression for waitlist outcomes was performed. Post-transplant survival was analyzed using the Kaplan-Meier method and multivariable Cox regression., Results: Nine hundred and seventy-six patients with ACHD were waitlisted for OHT in our study: 343(35.1%), 466(47.8%), and 167(17.1%) in periods 1, 2, and 3. Post-policy change, 1-year cumulative incidence of waitlist mortality or deterioration decreased (p = 0.02). Six hundred and forty-eight patients were transplanted: 221(34.1%), 329(50.8%) and 98(15.1%) respectively. In those transplanted, post-policy median waitlist time (174, 161 and 38 days, p < 0.001) decreased and the use of intra-aortic balloon pumps increased (1.4%, 4.9% and 19.4%, p < 0.001). Compared to periods 1 and 2, risk-adjusted post-transplant 1-year mortality was similar to period 3 (HR 1.10, 95% CI 0.52-2.32; p = 0.81) (HR 1.19, 95% CI 0.58-2.46, p = 0.63)., Conclusions: The recent US allocation policy change may have resulted in reduced waitlist times and 1-year waitlist mortality for OHTs in ACHD patients. Early post-transplant outcomes appear comparable post-policy change., (Copyright © 2021 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Available aortic prosthesis replacement options present a challenge to achieving low perioperative morbidity, low pressure gradients, and prolonged durability. Trileaflet aortic valve reconstruction using autologous pericardium offers an alternative treatment option with excellent postoperative gradients, large effective orifice areas, and the avoidance of long-term anticoagulation. The modified Bentall procedure with either tissue xenograft valved conduit or mechanical valved conduit is considered the gold standard for patients with aortic root pathology requiring surgical replacement. We report a novel adaptation of the modified Bentall procedure with a self-fabricated valved conduit with trileaflet aortic valve neocuspidization using autologous pericardium., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

This study evaluates the impact of the recent United Network for Organ Sharing (UNOS) allocation policy change on outcomes of patients bridged with durable left ventricular assist devices (LVADs) to orthotopic heart transplantation (OHT). Adults bridged to OHT with durable LVADs between 2010 and 2019 were included. Patients were stratified based on the temporal relationship of their OHT to the UNOS policy change on October 18, 2018. The primary outcome was early post-OHT survival. In total, 9,628 OHTs were bridged with durable LVADs, including 701 (7.3%) under the new policy. Of all OHTs performed during the study period, the proportion occurring following durable LVAD bridging decreased from 45% to 34% (p < 0.001). The more recent cohort was higher risk, including more extracorporeal membrane oxygenation bridging (2.6% vs. 0.3%, p < 0.001), more mechanical right ventricular support (9.7% vs. 1.4%, p < 0.001), greater pretransplant ICU admission (22.8% vs. 8.7%, p < 0.001) more need for total functional assistance (62.8% vs. 53.0%, p < 0.001), older donor age (33.3 vs. 31.7 years, p < 0.001), and longer ischemic times (3.38 vs. 3.13 hours, p < 0.001). Despite this, early post-OHT survival was comparable at 30 days (96.1% vs. 96.0%, p = 0.89), 90 days (93.7% vs. 94.0%, p = 0.76), and 6 months (91.0% vs. 93.0%, p = 0.96), findings that persisted after risk-adjustment. In this early analysis, OHT following bridging with durable LVADs is performed less frequently and in higher risk recipients under the new allocation policy. Despite this, short-term posttransplant outcomes appear to be unaffected in this patient cohort in the current era., (Copyright © ASAIO 2021.)

Background: This study evaluated operative mortalities following adult cardiac surgical operations to determine if this metric remains appropriate for the modern era., Methods: This was a retrospective review of Society of Thoracic Surgeons (STS) indexed adult cardiac operations that included coronary artery bypass grafting (CABG), aortic valve replacement (AVR), CABG + AVR, mitral valve repair (MVr), CABG + MVr, mitral valve replacement (MVR) and CABG + MVR, performed at a single institution between 2011 and 2017. The primary outcome was the timing and relatedness of operation mortality, as defined by the STS as mortality within 30-day or during the index hospitalization, compared to the index operation. The secondary outcomes evaluated cause of death and the rates of postoperative complications., Results: A total of 11,190 index cardiac operations were performed during the study period and operative mortality occurred in 246 (2.2%) of patients. The distribution of operative mortalities included 83.7% (n=206) who expired within 30-day while an inpatient, 6.9% (n=17) died within 30-day as an outpatient, 11.2% (n=23) expired after 30-day. The most common causes of operative mortality were cardiac (38.7%, n=92), renal failure (15.6%, n=37), and strokes (13.9%, n=33). Furthermore, 98.4% (n=242) of deaths were attributable to the index operation. Postoperative complications occurred frequently in those with operative mortality, with blood transfusions (80.1%), reoperations (65.0%) and prolonged ventilation (62.2%) being most common., Conclusions: Most of the operative mortalities seemed to be attributable to the index cardiac operation. We believe that the current definition of mortality remains appropriate in the modern era., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/jtd-20-2213). TGG reports that he is on the Medical Advisory Board at Abbott, but this does not pose a potential conflicts of interest. AK reports that he is on the Medical Advisory Board at Medtronic, but this does not pose a potential conflicts of interest. The other authors have no conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

Background: This study employed machine learning approaches to analyze sequences of adverse events (AEs) after left ventricular assist device (LVAD) implantation., Methods: Data on patients implanted with the HeartWare HVAD durable LVAD were extracted from the ENDURANCE and ENDURANCE Supplemental clinical trials, with follow-up through 5 years. Major AEs included device malfunction, major bleeding, major infection, neurological dysfunction, renal dysfunction, respiratory dysfunction, and right heart failure (RHF). Time interval and transition probability analyses were performed. We created a Sankey diagram to visualize transitions between AEs. Hierarchical clustering was applied to dissimilarity matrices based on the longest common subsequence to identify clusters of patients with similar AE profiles., Results: A total of 568 patients underwent HVAD implantation with 3590 AEs. Bleeding and RHF comprised the highest proportion of early AEs after surgery whereas infection and bleeding accounted for most AEs occurring after 3 months. The highest transition probabilities were observed with infection to infection (0.34), bleeding to bleeding (0.31), RHF to bleeding (0.31), RHF to infection (0.28), and bleeding to infection (0.26). Five distinct clusters of patients were generated, each with different patterns of time intervals between AEs, transition rates between AEs, and clinical outcomes., Conclusions: Machine learning approaches allow for improved visualization and understanding of AE burden after LVAD implantation. Distinct patterns and relationships provide insights that may be important for quality improvement efforts., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Left ventricular dimension has the potential to impact clinical outcomes following implantation of left ventricular assist devices (LVAD). We investigated the effect of pre-implant left ventricular end-diastolic diameter (LVEDD) on outcomes following LVAD implantation., Methods: Patients implanted with a continuous-flow LVAD between 2004 and 2018 at a single institution were included. The primary outcome was death while on LVAD support. Secondary outcomes included adverse event rates such as renal failure requiring dialysis, device thrombosis, and right ventricular failure. The LVEDD measurements were dichotomized using restricted cubic splines and threshold regression. Survival was determined using Kaplan-Meier estimates. Multivariable logistic regression was used to determine risk-adjusted mortality based on LVEDD., Results: A total of 344 patients underwent implantation of a continuous flow LVAD during the study period. The optimal cut point for LVEDD was 65 mm, with 126 (36.6%) subjects in the <65 mm group and 165 (48.0%) in the >65 mm group. The LVEDD <65 mm group was older, had more females, higher incidence of diabetes, more pre-implant mechanical ventilation, and more admissions for acute myocardial infarctions (all, P<0.05). Importantly, post-implant adverse events were similar between the groups (all, P>0.05). Risk-adjusted survival at 1-year (OR 1.3, 95% CI: 0.6-2.5, P=0.53) was also comparable between the groups. Furthermore, incremental increases in LVEDD when modeled as a continuous variable did not impact overall mortality (OR 0.98, 95% CI: 0.9-1.0, P=0.09)., Conclusions: Preoperative LVEDD was not associated with rates of major morbidities or mortality following LVAD implantation., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/jtd-20-2778). AK reports that he is on the medical advisory board for Medtronic, Inc. The other authors have no conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

Background: Racial disparities exist between Black and White patients with coronary artery disease with regard to access to revascularization, preprocedural comorbidities, and postprocedural outcomes. This study investigated the differences in the treatment of multivessel coronary artery disease (MVCAD) and long-term outcomes between Black and White patients., Methods: This was a propensity-matched retrospective analysis that utilized pooled institutional data from a large, multihospital health care system. It included Black and White patients who underwent coronary revascularization for MVCAD between 2011 and 2018., Results: A total of 6005 patients were included (5689 White and 316 Black). In the unmatched cohort, Black patients had a higher incidence of preexisting comorbidities such as diabetes, dialysis dependence, peripheral arterial disease, heart failure, and underwent percutaneous coronary intervention (PCI) more frequently. Five-year overall survival was similar, but Black patients experienced higher rates of major adverse cardiac and cerebrovascular events and repeat revascularization. Propensity matching resulted in a sample of 926 (312 Black, 614 White) patients that were well matched. In the matched analysis, Black patients underwent PCI more frequently and a had higher rate of stoke. Five-year survival, major adverse cardiac and cerebrovascular events and repeat revascularization rates were comparable., Conclusions: Black patients with MVCAD have a higher comorbidity burden and undergo PCI at higher rates. After adjusting for baseline differences, Black patients still had higher rates of PCI utilization and long-term stroke. It is possible that a significant portion of racial disparities in MVCAD are driven by differences in baseline risk; however, there is evidence of possible racial bias with regard to revascularization strategies., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study derived and validated a risk score for 1-year mortality in patients with adult congenital heart disease (ACHD) undergoing orthotopic heart transplantation (OHT)., Methods: The United Network for Organ Sharing registry identified patients with ACHD (≥18 years of age) who underwent OHT between 1987 and 2018. The primary outcome was 1-year mortality. Associated covariates (univariate P < .2) were entered into a multivariable logistic regression model. Variable inclusion in the model was assessed by improvement in the McFadden pseudo-R 2 , likelihood ratio test, and C-index. A risk score was created using the absolute magnitude of the odds ratios from the derivation cohort, and its ability to predict 1-year mortality was tested in the validation cohort., Results: A total of 1388 recipients were randomly divided into derivation (66.7%, n = 950) and validation (33.3%, n = 438) cohorts. A 13-point risk score incorporating 4 pretransplant variables (age, dialysis dependence, serum bilirubin level, and mechanical ventilation) was created. The predicted 1-year mortality ranged from 14.6% (0 points) to 49.9% (13 points) (P < .001). In weighted regression analysis, there was a strong correlation between predicted 1-year mortality and observed 1-year mortality in the validation cohort (r = 0.85, P < .001). Logistic regression also demonstrated a significant association (odds ratio, 1.18; 95% confidence interval, 1.1-1.3; P = .004). The Brier score of the composite score in the validation cohort was 0.14. Kaplan-Meier analysis demonstrated that risk scores of 4 points or higher portended worse survival at 1-year posttransplant (P < .001)., Conclusions: This 13-point risk score for ACHD is predictive of mortality within 1 year after OHT and has potential utilization in improving recipient selection for OHT in adult patients with CHD., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study evaluated the impact of the heart allocation policy change in 2018 on the characteristics and outcomes of multiorgan transplants involving heart allografts., Methods: Adults undergoing multiorgan heart transplantation from 2010 to 2020 were identified from the United Network for Organ Sharing (UNOS) registry. Transplants were stratified into occurring before versus after the October 2018 heart allocation change. The primary outcome was 1-year survival following transplantation. A Cox proportional hazards model was used to evaluate the risk-adjusted effect of the allocation policy change on outcomes between cohorts., Results: A total of 1832 patients underwent multiorgan heart transplantation during the study period with 245 (13.37%) undergoing heart-lung transplantation, 244 (13.32%) undergoing heart-liver transplantation, and 1343 (73.31%) undergoing heart-kidney transplantation. There was a higher utilization of temporary MCSDs as well as longer ischemic times for all three types of transplantation following the policy change. Heart-lung and heart-liver recipients had a similar 1-year survival before and after the policy change (each p > .05). Renal failure requiring dialysis (29.5% vs. 39.4%, p = .001) as well as 1-year survival (88% vs. 82%; log-rank p = .01) were worse in the heart-kidney cohort after the organ allocation system modification., Conclusions: This study demonstrates similar trends in multiorgan transplants as has been observed in isolated heart transplants following the allocation change, including more frequent utilization of temporary mechanical support and longer ischemic times. Although outcomes have remained comparable in the new allocation era with heart-lung and heart-liver transplants, heart-kidney recipients have a worse 1-year survival following the change., (© 2021 Wiley Periodicals LLC.)

Background: This study delineates the sequences of adverse events (AEs) preceding mortality attributed to multisystem organ failure (MSOF) in patients with a left ventricular assist device (LVAD)., Methods: We analyzed 3765 AEs after 536 LVAD implants recorded in The Society of Thoracic Surgeons Intermacs data registry between 2006 and 2015 that resulted in MSOF death. Hierarchical clustering identified and visualized quantitatively unique clusters of patients with similar AE profiles. Markov modeling was used to illustrate the AE sequences that led to MSOF death within the clusters. Cox proportional hazard models determined the risk-adjusted, preimplant predictors of MSOF., Results: We identified 2 distinct MSOF clusters based on their proportion of AE types and survival time. The early-death cluster (418 patients, 2304 AEs) had a median survival of 1 month (interquartile range, 3-6 months), whereas the late-death cluster (118 patients, 1,461 AEs) had a median survival of 11 months (interquartile range, 6-22 months). The predominant AE sequences in the early-death and late-death clusters were renal failure, to respiratory failure, to death (62%) and bleeding, to infection, to respiratory failure, to death (45%), respectively. Significant risk-adjusted preimplant predictors of MSOF included line sepsis (hazard ratio [HR] 3.0; 95% confidence interval [CI], 1.1-8.2), extracorporeal membrane oxygenation (HR, 2.2; 95% CI, 1.2-3.9), and dialysis or ultrafiltration (HR, 2.1; 95% CI, 1.5-3.0)., Conclusions: This analysis identified 2 AE clusters and the predominant sequences that result in MSOF-associated mortality. MSOF develops in 1 cluster of patients after chronic bleeding and repeated infections but has prolonged survival, while another group dies early after renal and respiratory complications., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study evaluated the impact of very early hospital discharge after coronary artery bypass grafting (CABG) on subsequent readmission and survival., Methods: Adults undergoing isolated CABG from 2011 to 2018 at a single institution were included. Patients were stratified on the basis of their postoperative length of hospital stay: short stay (≤4 days) and nonshort stay (>4 days). The primary outcomes were longitudinal survival and freedom from hospital readmission. Secondary outcomes included rates of postoperative complications. Propensity score matching with a 1:1 ratio was performed to generate cohorts with comparable baseline characteristics., Results: A total of 6327 patients underwent CABG during the study period, and a matched cohort of 2286 patients was identified. In matched analysis, the average Society of Thoracic Surgeons predicted risk of operative mortality was low in both groups (average, 0.7%). Rates of postoperative complications were low and several complication rates were even lower in the short-stay cohort: stroke (1.14% vs 0.26%; P = .01), renal failure (0.87% vs 0.09%; P = .007), reoperations (1.84% vs 0.26%; P < .001), and new-onset atrial fibrillation (34.21% vs 13.04%; P < .001). Survival was similar between the matched groups at 30 days (99.56% vs 99.21%), 1 year (97.73% vs 97.46%), and 5 years (91.15% vs 92.48%) (all P > .05). Readmission rates were also comparable at all time intervals, and there were no differences in cardiac-related or heart failure-specific readmissions (all P > .05). Risk-adjusted analyses confirmed these findings., Conclusions: This study demonstrates that very early discharge within 4 days of isolated CABG is safe and has no substantial impact on subsequent mortality or readmission risk., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: With septuagenarians undergoing orthotopic heart transplantation (OHT) more frequently, we aimed to develop a risk score for 1-year mortality in this population., Methods: Septuagenarian OHT recipients were identified from the UNOS registry between 1987 and 2018. The primary outcome was 1-year post-OHT mortality. Patients were randomly divided into derivation and validation cohorts. Associated covariates were entered into a multivariable logistic regression model. A risk score was created using the magnitudes of the odds ratios from the derivation cohort, and its 1-year post-OHT mortality prediction capacity was tested in the validation cohort., Results: A total of 1156 septuagenarians were included, and they were randomly divided into derivation (66.7%, n = 771) and validation (33.3%, n = 385) cohorts. An 11-point risk score incorporating 4 variables was created, which included mechanical ventilation, serum bilirubin, serum creatinine, and donor age. The predicted 1-year mortality ranged from 4.2% (0 points) to 48.1% (11-points) (p < .001). After cross-validation, the c-index was 0.67 with a Brier score of 0.10. Risk scores above 3 points portended a survival disadvantage at 1-year follow-up (p < .001)., Conclusions: This 11-point risk score for septuagenarians is predictive of mortality within 1-year of OHT and has potential utilization in improving recipient evaluation and selection of elderly patients., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: This study evaluates the impact of secondary functional tricuspid regurgitation (TR) and concomitant tricuspid valve repair (TVr) at the time of left-sided valve operations., Methods: Adults undergoing left-sided valve operations between 2010 and 2019 at a multihospital academic institution were included. Patients were stratified into three groups: less-than-moderate TR without TVr (Group 1), moderate-or-greater TR without TVr (Group 2), and moderate-or-greater TR with TVr (Group 3). Primary outcomes included survival and hospital readmissions. Secondary outcomes included major postoperative morbidities. Multivariable logistic regression evaluated risk-adjusted mortality and readmission., Results: About 3444 patients were included in the analysis and were stratified into Group 1 (n = 2612, 75.8%), Group 2 (n = 563, 16.3%), and Group 3 (n = 269, 7.8%). Patients with moderate or greater TR (Groups 2 and 3) had higher rates of mortality, hospital readmissions and major postoperative complications including reoperations, renal failure requiring dialysis, blood transfusions, and prolonged ventilation (all, p < .05). When assessed individually, the Group 3 had substantially higher rates of renal failure requiring dialysis, prolonged ventilation, and reoperations, although the Group 2 had higher rates of 30-day mortality (all, p < .05). These findings persisted in risk-adjusted analysis with the highest hazards for mortality (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.7-2.2) and readmission (HR 1.3, 95% CI 1.2-1.5) appreciated in the Group 2., Conclusions: In this analysis of 3444 patients, those with moderate-to-severe TR who did not undergo a TVr at the time of their left-sided valve operation had substantially higher risks of mortality and hospital readmissions compared with those who did undergo TV surgery., (© 2021 Wiley Periodicals LLC.)

Background: Donors with drowning or asphyxiation (DA) as a mechanism of death (MOD) are considered high risk in pediatric lung transplantation. We sought to evaluate whether recipients of DA donors had negatively impacted outcomes., Methods: Pediatric recipients recorded in the United Network for Organ Sharing registry between 2000 and 2019 were included. Primary stratification was donor MOD. Propensity matching with a 1:1 ratio was performed to balance the DA and non-DA MOD donor cohorts. Cox multivariable regression was used to determine the risk-adjusted impact of donor MOD. A subanalysis of the effect of lung allocation score was also evaluated., Results: A total of 1016 patients underwent bilateral lung transplantation during the study period, including 888 (85.6%) from non-DA donors and 128 (14.4%) from DA donors. Survival at 90 days, 1 year, and 2 years were similar in the matched and unmatched cohorts regardless of the donor MOD. Moreover, separate risk-adjusted analysis of drowning and asphyxiated donors was similar to other MOD donors at 30 days, 1 year, and 5 years. Similar survival findings persisted regardless of pretransplant lung allocation score. Although the rates of posttransplant stroke (1.0% versus 3.1%, P = 0.04) and the length of hospital stay (19 versus 22 d, P = 0.004) were elevated in the unmatched DA MOD recipients, these differences were mitigated after propensity matching., Conclusions: This study evaluated the impact of DA MOD donors in pediatric lung transplant recipients and found similar rates of complications and survival in a propensity-matched cohort. These data collectively support the consideration of DA MOD donors for use in pediatric lung transplantation., Competing Interests: A.K. received research funds from Medical Advisory Board, Medtronic, Inc. The other authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Although frailty has been previously shown to negatively influence postoperative outcomes, frailty measurements remain undefined and underused for patients undergoing orthotopic heart transplantation (OHT). This study aims to derive and validate an OHT frailty screening tool., Methods: The United Network for Organ Sharing database was queried for adults undergoing OHT between 2000 and 2018. The total population was randomly divided into derivation (80%) and validation (20%) cohorts. The primary outcome was mortality. Secondary outcomes included rates of major morbidities and hospital length of stay. Variables that were constructs within preexisting frailty tools and that were predictive of a composite frailty outcome within the derivation cohort were incorporated into a multivariable regression model (exploratory, P < .2). Independent predictors of frailty were included in the OHT frailty screening tool., Results: A total of 36,790 OHT recipients met the criteria for inclusion. Twelve variables were identified as independent predictors of frailty and included as OHT frailty screening tool constructs. Recipients in the validation cohort were stratified as nonfrail (72.9%, n = 5363), prefrail (24.4%, n = 1795), and frail (2.7%, n = 200). Frail patients had significantly higher rates of posttransplant stroke, renal failure, and mortality at all time intervals as well as longer length of stay (all P < .001). The risk model's predictive rates of mortality strongly correlated with the observed rates of mortality (r 2  = 0.97, P < .001). The c-index of the OHT frailty score was 0.74., Conclusions: The OHT frailty screening tool is highly predictive of adverse posttransplant outcomes. This screening tool may provide a framework to enhance existing risk stratification tools and improve overall resource utilization., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A 50-year-old male with a history of nonischemic dilated cardiomyopathy presented in cardiogenic shock and ultimately underwent durable left ventricular assist device implantation. He recovered well initially but developed persistent bacteremia. His indwelling pacemaker leads were extracted due to evidence of vegetation. Shortly thereafter, around 3 months post-left ventricular assist device, he succumbed to a massive intracranial hemorrhage due to ruptured cerebral mycotic aneurysm. This case highlights the potential importance of brain imaging in left ventricular assist device patients with persistent bacteremia to avoid this likely catastrophic complication.

Background: This study compares the postoperative outcomes, 30-day readmission rates, and incidence of sternal wound infection-related readmissions between patients receiving bilateral internal mammary arteries (BIMA) and single internal mammary artery (SIMA) grafting during coronary artery bypass graft (CABG) surgery., Methods: We utilized the weighted 2013-2014 National Readmission Database claims to identify all US adult patients who underwent CABG utilizing SIMA (n = 279,891) or BIMA (n = 11,651). Thirty-day overall and wound-related readmissions, in-hospital outcomes, costs, lengths of stay (LOS) at readmissions were compared between the two groups. Predictors of 30-day readmission were assessed using multivariable Cox proportional hazards analysis., Results: After propensity matching (n = 10,339 pairs), there were no significant differences between the two groups during the index hospitalization, except for higher total hospital costs in the BIMA group (p = .02). The incidence of wound infections was also comparable between BIMA and SIMA (1.1% vs. 1.2%; p = .50). At 30-days, the overall readmission rate was elevated in SIMA patients (9.5% vs. 8.8%; p < .01), primarily impacted by cardiovascular causes. While the proportion of 30-day readmissions due to infections was significantly higher among BIMA versus SIMA patients (20.4% vs. 15.9%; p < .01), wound infections during the index hospitalization did not predict all-cause 30-day readmission among BIMA patients (p = .24) in the risk-adjusted analysis. Among the readmitted patients, LOS (6.4 vs. 6.2 days), costs ($14,440 vs. $16,461), and in-hospital mortality (2.4% vs. 1.7%) were comparable between the two groups (all p > .05)., Conclusions: BIMA grafting is not an independent predictor of all-cause 30-day readmissions. Cardiovascular causes remain the primary driver of 30-day readmissions among SIMA and BIMA patients after CABG., (© 2020 Wiley Periodicals LLC.)

Background: This study reports a single-center experience with thrombolytics for left ventricular assist device (LVAD) pump thrombosis., Methods: Adults undergoing continuous-flow LVAD implantation between 2004 and 2018 at a single center were reviewed and those with pump thrombosis were identified. Primary outcomes included 1-year survival and success rates of thrombolytic therapy. Secondary outcomes included posttreatment adverse events, freedom from major bleeding at 1 year, and freedom from stroke at 1-year follow-up., Results: A total of 341 patients underwent LVAD implantation and 10.8% (n = 37) developed pump thrombosis. Of those 37, 26 received initial thrombolytic therapy (70.2%), 5 underwent direct pump exchange (13.5%), and 6 received only intravenous heparin owing to presentation with acute stroke or severe multiorgan failure (16.2%). Successful treatment was achieved in 11.5% of patients receiving thrombolytics (n = 3). Early adverse events after thrombolytic therapy included major bleeding in 11.5% (n = 3) and new stroke in 7.7% (n = 2). Most patients undergoing thrombolytic therapy underwent subsequent device exchange (69.2%; n = 18). Overall survival in patients with pump thrombosis after treatment was 96.8% at 30 days, 78.9% at 90 days, and 63.1% at 1 year. Freedom from major bleeding and stroke at 1 year was 74.2% and 87.2%, respectively., Conclusions: In this single-center experience of thrombolytics for pump thrombosis in LVAD patients, there was limited efficacy; most patients required subsequent pump exchange. Combined with the risk for major bleeding or stroke with thrombolysis, this underscores the importance of further refining patient selection for direct pump exchange in those presenting with pump thrombosis., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Institutional factors have been shown to impact outcomes following orthotopic heart transplantation (OHT). This study evaluated center variability in the utilization of induction therapy for OHT and its implications on clinical outcomes., Methods: Adult OHT patients between 2010 and 2018 were identified from the United Network for Organ Sharing registry. Transplant centers were stratified based on their rates of induction therapy utilization. Mixed-effects logistic regression models were created with drug-treated rejection within 1 year as primary endpoint and individual centers as a random parameter. Risk-adjusted Cox regression was used to evaluate patient-level mortality outcomes., Results: In 17,524 OHTs performed at 100 centers, induction therapy was utilized in 48.6% (n = 8411) with substantial variability between centers (interquartile range, 21.4%-79.1%). There were 36, 30, and 34 centers in the low (<29%), intermediate (29%-66%), and high (>67%) induction utilization terciles groups, respectively. Induction therapy did not account for the observed variability in the treated rejection rate at 1 year among centers after adjusting for donor and recipient factors (p = .20). No differences were observed in postoperative outcomes among induction utilization centers groups (all, p > .05). Furthermore, there was a weak correlation between the percentage of induction therapy utilization at the center-level and recipients found to have moderate (r = .03) or high (r = .04) baseline risks for acute rejection at 1 year., Conclusions: This analysis demonstrates that there is substantial variability in the use of induction therapy among OHT centers. In addition, there was a minimal correlation with baseline recipient risk or 1-year rejection rates, suggesting a need for better-standardized practices for induction therapy use in OHT., (© 2020 Wiley Periodicals LLC.)

Background: The aim of this study was to evaluate outcomes of left ventricular assist devices (LVADs) in patients who tested positive for hypercoagulable hematologic disorders., Methods: Adults undergoing continuous-flow LVAD implantation with preoperative hypercoagulability testing between 2004 and 2018 at a single center were reviewed. Hypercoagulability was defined as testing positive for antiphospholipid antibody, anticardiolipin antibody, lupus anticoagulant, protein C, protein S, factor V Leiden, and/or heparin-induced thrombocytopenia. The primary outcome was survival on the original LVAD. Secondary outcomes included rates of thromboembolic complications and readmission for intravenous heparin treatment., Results: A total of 270 LVAD patients with pre-implant hypercoagulability testing were included, and 157 (58%) tested positive for a hypercoagulable disorder. Of those testing positive, 10 (6.4%) had a clinical pre-LVAD history of thromboembolic events. Survival was comparable between hypercoagulable and non-hypercoagulable patients (1 year: 73.3% vs 78.9%, P = .2195, 2-year: 60.7% vs 62.8%, P = .3627). Rates of pump thrombosis (14.0% vs 13.3%, P = .8618), hemolysis (4.5% vs 3.5%, P = .3536), stroke (18.5% vs 14.2%, P = .3483) and readmission for IV heparin therapy (87.3% (n = 137) vs 77.9% (n = 88), P = .7560) were similar. Outcomes were comparable in patients with positive hypercoagulable tests when stratified by pre-implant clinical history of hypercoagulability as well as stratified by recent preoperative exposure to heparin or warfarin., Conclusions: In this series, positive laboratory tests for hypercoagulability were common amongst patients undergoing LVAD implantation although few had positive clinical histories. Survival and freedom from thromboembolic complications were comparable to non-hypercoagulable patients. Hypercoagulability alone should therefore not serve as a contraindication to LVAD implantation., (© 2020 Wiley Periodicals LLC.)

Background: This study evaluates the impact of a history of malignancy on outcomes of left ventricular assist device (LVAD) implantation., Methods: Adult patients with a preimplant history of malignancy who underwent LVAD implantation between 2006 and 2018 were included. The primary outcome was post-LVAD survival., Results: A total of 250 patients underwent LVAD implant during the study period, including 37 (14.8%) patients with a history of malignancy. Of these 37 patients, five (13.5%) had active malignancy at the time of LVAD implantation, and seven had more than one type of cancer. The median disease-free duration before LVAD was 3.5 years (interquartile range [IQR] 1.0-7.75 years). The most common types of malignancy included urologic (n = 20; 45.5%), skin (n = 7, 15.9%), and leukemia or lymphoma (n = 6; 13.6%). Median follow-up was 244 (IQR, 126-571) days and 313 (IQR 127-738) days for those with and without a history of malignancy, respectively (P = .49). Unadjusted post-LVAD survival was reduced in those with a malignancy history (2-year survival 53.4% vs 66.9%; P = .01), a finding that persisted after risk-adjustment (hazard ratio 1.89, 95% confidence interval, 1.13-3.14; P = .01). Only one (2.7%) patient died post-LVAD from their cancer., Conclusions: Although a history of malignancy is associated with reduced survival after LVAD implantation, more than half of the patients are alive at 2 years. This combined with the fact that most do not die from causes directly related to their cancer suggest that LVAD implantation is reasonable to perform in carefully selected patients with a history of malignancy., (© 2020 Wiley Periodicals LLC.)

Background: This study evaluates the longitudinal impacts of off-pump coronary artery bypass (OPCAB) surgery in patients with reduced left ventricular ejection fraction (LVEF)., Methods: Adults with LVEF ≤ 30% undergoing coronary artery bypass grafting between 2011 and 2020 were included. Patients were stratified based on the utilization of cardiopulmonary bypass into OPCAB or on-pump coronary artery bypass (ONCAB) groups. Primary outcomes included survival and hospital readmissions. Secondary outcomes evaluated postoperative morbidities. Multivariable regression evaluated risk-adjusted mortality and readmission. Propensity score matching was utilized to reduce bias., Results: A total of 660 low LVEF patients were included, of which 28.5% (n = 188) were OPCAB and 71.5% (n = 472) were ONCAB. The rates of complete revascularization were similar between the groups (80.3% vs 82.0%; P = .67). Early survival between the unmatched groups was similar at 1-year follow-up (86.2% vs 87.9%; P = .53); however, at 5 years OPCABs had significantly worse survival compared with ONCABs (71.5% vs 64.2%; P = .02). These findings persisted in the matched cohort where survival at 1 year was comparable (86.8% vs 85.7%; P = .80), but 5-year survival was better for ONCABs (64.1% vs 69.9%; P = .03). The rates of readmission were similar between the unmatched and matched groups at all time intervals, including readmissions for cardiac-related and heart failure-related events (all, P > .05)., Conclusions: In contemporary patients with reduced LVEF, survival after OPCAB was similar at 1 year but lower at 5-year follow-up compared with ONCAB, despite similar rates of complete revascularization. These findings suggest that there may be other factors influencing longitudinal mortality in the low LVEF cohort, beyond the use of cardiopulmonary bypass., (© 2020 Wiley Periodicals LLC.)

Left ventricular assist devices (LVADs) are an increasingly common therapy for patients with advanced heart failure. However, implantation of the LVAD increases the risk of stroke, infection, bleeding, and other serious adverse events (AEs). Most post-LVAD AEs studies have focused on individual AEs in isolation, neglecting the possible interrelation, or causality between AEs. This study is the first to conduct an exploratory analysis to discover common sequential chains of AEs following LVAD implantation that are correlated with important clinical outcomes. This analysis was derived from 58,575 recorded AEs for 13,192 patients in International Registry for Mechanical Circulatory Support (INTERMACS) who received a continuous-flow LVAD between 2006 and 2015. The pattern mining procedure involved three main steps: (1) creating a bank of AE sequences by converting the AEs for each patient into a single, chronologically sequenced record, (2) grouping patients with similar AE sequences using hierarchical clustering, and (3) extracting temporal chains of AEs for each group of patients using Markov modeling. The mined results indicate the existence of seven groups of sequential chains of AEs, characterized by common types of AEs that occurred in a unique order. The groups were identified as: GRP1: Recurrent bleeding, GRP2: Trajectory of device malfunction & explant, GRP3: Infection, GRP4: Trajectories to transplant, GRP5: Cardiac arrhythmia, GRP6: Trajectory of neurological dysfunction & death, and GRP7: Trajectory of respiratory failure, renal dysfunction & death. These patterns of sequential post-LVAD AEs disclose potential interdependence between AEs and may aid prediction, and prevention, of subsequent AEs in future studies.

Background: This study evaluated the impact of postoperative complications on long-term survival after cardiac surgery., Methods: Adults undergoing an index cardiac operation from January 2010 to December 2017 were included. Patients were stratified by the number and type of major complications as defined by The Society of Thoracic Surgeons. Failure to rescue was defined as mortality after a complication that occurred before hospital discharge. Long-term mortality among patients with complications was defined as a postcomplication death occurring after hospital discharge. Multivariable Cox regression was used for risk adjustment., Results: In all, 9532 patients were included in the study, and 16.8% (n = 1600) had a major postoperative complication. Operative mortality was 0.8% for patients with no complications. Early failure to rescue increased as the number of complications increased (7.5%, 28.1%, and 51.5% for one, two, and three or more complications, respectively; P < .0001). Median length of intensive care unit and hospital stay ranged, respectively, from 38 hours and 7 days for patients with no complications to 359 hours and 23 days for patients with three or more complications (P < .0001). The adverse impact of complications on survival persisted at 1-year follow-up (3.5%, 18.8%, 52.1%, and 77.9%; P < .0001) and 5-year follow-up (10.8%, 33%, 61.8%, and 77.9%; P < .0001) for patients with no complications or one, two, or three or more complications, respectively. Risk-adjusted analysis confirmed these findings (P < .0001). Furthermore, 5-year survival conditional on 30-day survival ranged from 85.1% to 41.5% for patients with no complications versus three or more complications (P < .0001)., Conclusions: Postoperative complications after cardiac surgery, particularly when occurring in combination, have a profound impact on long-term survival, even after excluding early postoperative deaths., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

While elective cardiac surgeries have been postponed to prevent coronavirus disease 2019 (COVID-19) transmission and to reduce resource utilization, patients with urgent indications necessitating surgery may still be at risk of contracting the disease throughout their postoperative recovery. We present a case of an 81-year-old female who underwent urgent coronary artery bypass grafting and was readmitted following discharge to a nursing facility with a cluster of COVID-19 cases. Despite symptomatology and imaging concerning for COVID-19, two initial reverse transcription polymerase chain reaction (RT-PCR) tests were negative but a third test was positive. This case emphasizes the risks of discharge location in the COVID-19 era as well as the importance of clinical suspicion, early isolation practices for those presumed positive, and repeat testing, given the marginal sensitivity of available COVID-19 RT-PCR., (© 2020 Wiley Periodicals LLC.)

Background: This study evaluates the outcomes of conventional cardiac surgery in patients with a left ventricular ejection fraction (LVEF) of 25% or less., Methods: Patients with preoperative low LVEF (25% or less) undergoing The Society of Thoracic Surgeons (STS) indexed cardiac operations from 2010 to 2018 were included. The primary outcome was survival. Secondary outcomes included major postoperative complications and readmission rates. Multivariable Cox regression was utilized for risk adjustment. Subanalyses evaluated the effect of preoperative inotropes as well as the impact of low LVEF on survival and readmission compared with propensity matched patients with LVEF greater than 25%., Results: In all, 9467 patients underwent STS-indexed cardiac operations during the study period, including 588 with LVEF of 25% or less. The low LVEF group included 397 (67.5%) isolated coronary artery bypass graft, 51 (8.67%) isolated valve, and 140 (23.8%) concomitant coronary artery bypass graft and valve operations. Survival of low LVEF patients was not affected by operative procedure but instead by traditional risk factors such as advanced age and medical comorbidities. Freedom from hospital readmission for heart failure was 57.2% at 5-year follow-up. Patients receiving preoperative inotropes had reduced survival, although the majority were still alive at 5 years (53.1% vs 64.9%, P = .002). In addition, propensity matched patients with LVEF 25% or less and LVEF greater than 25% had similar survival and hazards for mortality at 30-day, 1-year, and 5-year follow-up., Conclusions: Despite a high-risk profile, patients with reduced preoperative LVEF can undergo conventional cardiac surgery with acceptable outcomes. The majority of patients, including those receiving preoperative inotropes, were alive and free from heart failure readmissions at 5 years., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This single-center, the retrospective study evaluates the impact of preoperative serum prealbumin levels on outcomes after left ventricular assist device (LVAD) implantation., Methods: Adults undergoing LVAD implantation, with a recorded preoperative prealbumin level, between 2004 to 2018 were included. Primary outcomes included rates of 1-year survival and secondary outcomes included rates of postimplant adverse events. Threshold regression and restricted cubic splines were utilized to identify a cut-point to dichotomize prealbumin level. Prealbumin was also evaluated as a continuous variable. Multivariable logistic regression was used for risk-adjustment., Results: A total of 333 patients were included. Patients were dichotomized according to an optimal prealbumin threshold of 15 mg/dL: 47.4% (n = 158) had levels below and 52.6% (n = 175) had levels above this threshold, respectively. The rates of postimplant adverse events, including bleeding, infection, stroke, renal failure, and right heart failure, were similar between the groups (all P > .05). Furthermore, the rates of cardiac transplantation and device explantation were also similar (all P > .05). Unadjusted survival was comparable between the groups at 30-days, 90-days, and 1-year following LVAD implantation (all P > .05). In addition, lower prealbumin did not impact risk-adjusted 1-year mortality when modeled either as a categorical (OR, 1.08; 95% CI, 0.48-2.12; P = .82) or continuous variable (OR, 1.99; 95% CI, 0.73-2.34; P = .96)., Conclusions: This study demonstrates that lower prealbumin levels were not predictive of increased post-LVAD morbidity or mortality. Although an established marker of nutritional and inflammatory status, the role of prealbumin in patient selection or prognostication appears limited in LVAD patients., (© 2020 Wiley Periodicals, Inc.)