Search

Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome. [ABSTRACT FROM AUTHOR]

Goal: For decades, hospitals performing cardiac surgery have carried the cost of implementing quality improvement activities and reporting quality outcomes. However, the financial return of such investments is unclear, which weakens the incentive for hospitals to invest in quality improvement activities. This study explored the relationship between a hospital's measured quality and its financial performance. Methods: Using data from the American Hospital Association and Hospital Compare from 2014 to 2018, we performed an observational study of hospitals performing cardiac surgery. We used mixed-effects regression models with fixed-year effects and random intercepts to explore associations between measured quality and hospital financial performance. Our dependent variables were margins (profit divided by revenue) and financial distress; our independent variables included Patient Safety Indicator 90 (PSI-90) and hospital characteristics. Principal Findings: Our sample included 4,927 hospital-years from 1,209 unique hospitals. Hospitals in the worst-performing PSI-90 score quartile experienced a lower operating margin (−1.26%, 95% CI [−2.10 to −0.41], p =.004), a lower total margin (−0.92%, 95% CI [−1.66 to −0.17], p =.016), and an increased odds of financial distress in the next year (OR: 2.12, 95% CI [1.36–3.30], p =.001) when compared with the best-performing hospitals. Practical Applications: Our exploration into financial distress provides managers with a better understanding of the relationship between a hospital's measured quality and its financial position. In reflecting on our findings, hospital leaders may consider viewing patient safety as a modifiable factor that can improve their organization's overall financial health. Our findings suggest that excellent safety performance may be both financially and clinically beneficial to hospitals. [ABSTRACT FROM AUTHOR]

Background: Despite recent guideline statements, there is still wide practice variation in the use of multiple arterial grafts (MAGs) versus single arterial grafts (SAGs) for patients with multivessel disease undergoing coronary artery bypass graft surgery. This may be related to differences in findings between observational and randomized controlled studies.Objectives: This study sought to compare intermediate-term MAG and SAG outcomes with enhanced matching to reduce selection bias.Methods: New York's cardiac registry identified 63,402 multivessel disease patients undergoing coronary artery bypass graft surgery between January 1, 2005, and December 31, 2014, to compare outcomes (median follow-up 6.5 years) for patients receiving SAGs and MAGs. SAG and MAG patients were propensity matched using 38 baseline characteristics to reduce selection bias. The primary endpoint was mortality, and secondary endpoints included repeat revascularization and a composite endpoint of mortality, acute myocardial infarction, and stroke.Results: Before matching, 20% of procedures employed MAG. At 1 year, there was no mortality difference between matched MAG and SAG patients (2.4% vs. 2.2%, adjusted hazard ratio [AHR]: 1.11; 95% confidence interval [CI]: 0.93 to 1.32). At 7 years, MAG patients had lower mortality (12.7% vs. 14.3%, AHR: 0.86; 95% CI: 0.79 to 0.93), a lower composite outcome (20.2% vs. 22.8%, AHR: 0.88; 95% CI: 0.83 to 0.93), and a lower repeat revascularization rate (11.7% vs. 14.6%, AHR: 0.80; 95% CI: 0.74 to 0.87). At 7 years, the subgroups for which MAG did not have a lower mortality rate included patients with off-pump surgery, 2-vessel disease with right coronary artery disease, recent acute myocardial infarction, renal dysfunction, and patient ≥70 years of age.Conclusions: Mortality and the composite outcome were similar between MAG and SAG patients at 1 year, but lower for MAG after 7 years. Patients of higher volume MAG surgeons experienced lower MAG mortality. [ABSTRACT FROM AUTHOR]

Background: Reduced risk of paraplegia is argued as an advantage of endovascular repair of descending thoracic aortic aneurysms (DTA) and thoracoabdominal aortic aneurysms (TAAA); however, paraplegia rates with open repair vary widely. Study Design: We identified consecutive patients undergoing open repair of TAAA or DTA with or without arch replacement using profound hypothermia and circulatory arrest as a spinal cord protection strategy on a single surgical service between June 1, 2001 and September 20, 2010. Results: Ninety-nine procedures were performed in 94 patients with a mean age of 59 years (range 19 to 84 years), 56 of whom were male (60%). The extent of repair was TAAA in 37 (Crawford extent I in 6, extent II in 28, and extent III in 3), DTA in 37, and DTA plus arch in 25. Surgery was urgent or emergent in 25 patients (25%). Operative mortality (30-day) was 10% (10 of 99), including a mortality of 12% for arch DTA (3 of 26), 11% for TAAA (4 of 25), and 5% for isolated DTA (2 of 37). There were 11 (11%) strokes and 11 patients experienced renal failure (7 with dialysis). There were 15 late deaths and survival at 5 years was 74% (95% CI, 62.4−88.2%). No patients experienced paraplegia, although one had delayed paraparesis thought to be secondary to refractory hypotension postoperatively. Conclusions: Although the mortality and stroke risks for patients undergoing repair of DTA or TAAA using profound hypothermia and circulatory arrest are substantial, the risk for paraplegia is low. In appropriately selected patients, profound hypothermia and circulatory arrest should be the preferred technique for spinal cord protection for DTA and TAAA. [ABSTRACT FROM AUTHOR]

Awareness of the clinical significance of thoracic aortic aneurismal disease has increased in recent years. As diagnostic tools have improved our ability to identify aortic pathology, surgical outcomes have also improved, making intervention a life-saving option in the majority of cases. Here, we aim to examine the indications for surgical intervention on the dilated aorta, particularly the ascending segment. Studies of the natural history of ascending aortic aneurysms indicate that aneurysms exceeding 6 cm in maximum diameter are associated with a particularly high risk of complications. In the interest of providing some margin of safety, most surgeons would agree that intervention is indicated with an aortic diameter of 5.5 cm. Many would intervene even earlier (at 5.0 cm) for patients at low surgical risk, or for those with known connective tissue disorders such as Marfan's syndrome. In some cases, only the ascending aortic segment needs to be treated, while in others full root replacement is required. Reduction aortoplasty has been superseded largely by interposition graft replacement. The standard procedure involves replacement of the valve and root with a composite mechanical conduit or tissue root prosthesis, and results are excellent. Recently developed valve-sparing root reconstructive options, however, are promising and have encouraged an even more aggressive surgical stance. [ABSTRACT FROM AUTHOR]

Background and Aim: Aneurysmal dilatation of the aortic arch is uncommon, and the complex anatomy involved imposes unique technical challenges. The results of surgical intervention reported from large centers are improving; however, the degree to which these results are reproducible by other surgeons is less clear. We therefore reviewed our recent experience with total aortic arch replacement. Methods: Between July 1, 1997 and July 1, 2001 19 patients underwent complete aortic arch replacement, with or without concomitant procedures. We retrospectively reviewed perioperative results retrieved from the computerized database and clinical records. Results: The mean age of the study population was 68 ± 8.3 years (range 52 to 82), with women predominating (11 women, 8 men). All patients had hypertension. Patient history indicated active or past tobacco abuse in 16 patients (80%); cerebrovascular disease in 3, and peripheral vascular disease in 7 patients. Associated procedures included an elephant trunk in 12 (63%), replacement of the upper descending thoracic aorta in 5 (26%), concomitant coronary artery bypass in 5 (26%), and aortic root replacement in 3 (16%). One patient underwent replacement of the entire aorta from sinotubular ridge to iliac bifurcation in a single procedure. Brachiocephalic reconstruction with a "Y-graft" permitting early antegrade cerebral perfursion was performed in 12 patients. Retrograde cerebral perfusion was performed in ten patients (53%). Perioperatively, death occurred in two patients (11%) and stroke in two (11%). Conclusions: With cautious application, techniques developed in high-volume centers can also achieve satisfactory results when used at centers with a more modest case volume. [ABSTRACT FROM AUTHOR]

The article presents an editorial regarding the treatment of patients with atrial fibrillation. Some evidence suggests that the impact of a treatment strategy may vary among patients. The editorial discusses a clinical trial by Doukas and colleagues found in the November 9, 2005 issue of the journal. This trial looked at a surgical approach for patients with severe valvular heart disease. The trial used a maze procedure to restore sinus rhythm in patients. The procedure is supposed to address three consequences of atrial fibrillation, including irregular rhythm, risk of thromboembolism, and loss of atrioventricular synchronization. It is important to identify which patients will benefit from the maze procedure. Doukas and colleagues showed that a concomitant maze procedure should be considered during mitral valve surgery among patients with atrial fibrillation.

Background: Previous meta‐analyses combining randomized and observational evidence in cardiac surgery have shown positive impact of enhanced recovery protocols after surgery (ERAS) on postoperative outcomes. However, definitive data based on randomized studies are missing, and the entirety of the ERAS measures and pathway, as recently systematized in guidelines and consensus statements, have not been captured in the published studies. The available literature actually focuses on "ERAS‐like" protocols or only limited number of ERAS measures. This study aims at analyzing all randomized studies applying ERAS‐like protocols in cardiac surgery for perioperative outcomes. Methods: A meta‐analysis of randomized controlled trials (RCTs) comparing ERAS‐like with standard protocols of perioperative care was performed (PROSPERO registration CRD42021283765). PRISMA guidelines were used for abstracting and assessing data. Results: Thirteen single center RCTs (N = 1704, 850 in ERAS‐like protocol and 854 in the standard care group) were selected. The most common procedures were surgical revascularization (66.3%) and valvular surgery (24.9%). No difference was found in the incidence of inhospital mortality between the ERAS and standard treatment group (risk ratio [RR] 0.61 [0.31; 1.20], p = 0.15). ERAS was associated with reduced intensive care unit (standardized mean difference [SMD] −0.57, p < 0.01) and hospital stay (SMD −0.23, p < 0.01) and reduced rates of overall complications when compared to the standard protocol (RR 0.60, p < 0.01) driven by the reduction in stroke (RR 0.29 [0.13; 0.62], p < 0.01). A significant heterogeneity in terms of the elements of the ERAS protocol included in the studies was observed. Conclusions: ERAS‐like protocols have no impact on short‐term survival after cardiac surgery but allows for a faster hospital discharge while potentially reducing surgical complications. However, this study highlights a significant nonadherence and heterogeneity to the entirety of ERAS protocols warranting further RCTs in this field including a greater number of elements of the framework. [ABSTRACT FROM AUTHOR]

The article presents a case report of a 55-year-old man who experienced cardiac arrest, cardiogenic shock, and hypoxemia. Topics include the patient's presentation after out-of-hospital cardiac arrest, initial management including defibrillation and intravenous medications, and subsequent complications such as acute respiratory failure and the need for mechanical ventilation and percutaneous left ventricular assist device (LVAD) support.

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Kommerell diverticulum (KD) is a rare congenital vascular anomaly often associated with an aberrant subclavian artery (ASCA). Definitive indications for intervention remain unclear. We present open and endovascular (EV) operative outcomes in a large contemporary series and propose a management algorithm. METHODS Between 2004 and 2020, 224 patients presented with ASCA and associated KD to our institution. Of the 43 (19.2%) patients who underwent operative repair, 31 (72.1%) had open surgical (OS) repair via thoracotomy and 12 (27.9%) had EV repair. Univariable and bivariable statistical analyses were conducted stratified by approach. The median follow-up time was 5.4 years (IQR, 2.9–9.7). RESULTS Patients in EV group were older (68 years vs 47 years, P  < 0.001) and had larger aneurysms (base diameter 3.2 cm vs 21.5 cm, P  = 0.007). All patients with dysphagia lusoria were treated with open surgery (n  = 20). Asymptomatic patients with incidentally detected KD (50% vs 16.1%), those with chest or back pain (50% vs 19.4%) and patients who presented with an aortic emergency (25% vs 6.5%) were more likely to be treated endovascularly (P  = 0.001). Carotid-to-subclavian bypass was used in 38 (88.4%) patients. There were no operative mortalities. In-hospital mortality was similar between groups (3.2% vs 16.7%, P  = 0.121). Mid-term mortality was higher in the EV group [4 (33.8%) vs 0, P  < 0.001]. There were 2 (15.4%) postoperative strokes in the EV group. There were no statistically significant differences in other postoperative complications or hospital length of stay between groups. CONCLUSIONS KD can be managed using open or EV approaches with low morbidity and mortality. Treatment strategy should depend on clinical presentation and patient factors. [ABSTRACT FROM AUTHOR]

Background: Transcatheter edge-to-edge (TEER) mitral repair may be complicated by residual or recurrent mitral regurgitation. An increasing need for surgical reintervention has been reported, but operative outcomes are ill defined.Objectives: This study evaluated national outcomes of mitral surgery after TEER.Methods: The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify 524 adults who underwent mitral surgery after TEER between July 2014 and June 2020. Emergencies (5.0%; n = 26), previous mitral surgery (5.3%; n = 28), or open implantation of transcatheter prostheses (1.5%; n = 8) were excluded. The primary outcome was 30-day or in-hospital mortality.Results: In the study cohort of 463 patients, the median age was 76 years (interquartile range [IQR]: 67 to 81 years), median left ventricular ejection fraction was 57% (IQR: 48% to 62%), and 177 (38.2%) patients had degenerative disease. Major concomitant cardiac surgery was performed in 137 (29.4%) patients: in patients undergoing isolated mitral surgery, the median STS-predicted mortality was 6.5% (IQR: 3.9% to 10.5%), the observed mortality was 10.2% (n = 23 of 225), and the ratio of observed to expected mortality was 1.2 (95% confidence interval [CI]: 0.8 to 1.9). Predictors of mortality included urgent surgery (odds ratio [OR]: 2.4; 95% CI: 1.3 to 4.6), nondegenerative/unknown etiology (OR: 2.2; 95% CI: 1.1 to 4.5), creatinine of >2.0 mg/dl (OR: 3.8; 95% CI: 1.9 to 7.9) and age of >80 years (OR: 2.1; 95% CI: 1.1 to 4.4). In a volume outcomes analysis in an expanded cohort of 591 patients at 227 hospitals, operative mortality was 2.6% (n = 2 of 76) in 4 centers that performed >10 cases versus 12.4% (n = 64 of 515) in centers performing fewer (p = 0.01). The surgical repair rate after failed TEER was 4.8% (n = 22) and was 6.8% (n = 12) in degenerative disease.Conclusions: This study indicates that mitral repair is infrequently achieved after failed TEER, which may have implications for treatment choice in lower-risk and younger patients with degenerative disease. These findings should inform patient consent for TEER, clinical trial design, and clinical performance measures. [ABSTRACT FROM AUTHOR]

The global pandemic of coronavirus 2019 (COVID‐19) caused by coronavirus has had a profound impact on the delivery of health care in the United States and globally. Boston was among the earliest hit cities in the United States, and within Boston, the Massachusetts General Hospital provided care for more patients with COVID‐19 than any other hospital in the region. This necessitated a massive reallocation of resources and priorities, with a near doubling of intensive care bed capacity and a halt in all deferrable surgical cases. During this crisis, the Division of Cardiac Surgery responded in a unified manner, dealing honestly with the necessity to reduce Intensive Care Unit resource utilization for the benefit of both the institution and our community by deferring nonemergent cases while also continuing to efficiently care for those patients in urgent or emergent need of surgery. Many of the interventions that we instituted have continued to support teamwork as we adapt to the remarkably fluid changes in resource availability during the recovery phase. We believe that the culture of our division and the structure of our practice facilitated our ability to contribute to the mission of our hospital to support the community in this crisis, and now to its recovery. We describe here the challenge we faced in Boston and some of the details of the structure and function of our division. [ABSTRACT FROM AUTHOR]

The article presents the reports of Theodore Roosevelt on the evolution with modifications to improve long-term performance. Topics discussed include perioperative mortality for a young adult calculated from the Society of Thoracic Surgeons (STS) database Risk Calculator; mechanical valves failed to demonstrate superiority of the former valve; and the implantation of xenografts in a patient.

The article offers information on a clinical study to compare the efficacy of coronary artery bypass grafting (CABF) with CABF combined with mitral valve annuloplasty regurgitation (MVAR) in the management of ischemic mitral regurgitation (IMR) associated with coronary heart disease. Topics covered include the symptoms and recurrence of IMR, reduction of distortion in the mitral valves and explanation of the efficacy of CABG with MVAR therapy.

Background: Patients with isolated tricuspid regurgitation (TR) in the absence of left-sided valvular dysfunction are often managed nonoperatively.Objectives: The purpose of this study was to assess the impact of surgery for isolated TR, comparing survival for isolated severe TR patients who underwent surgery with those who did not.Methods: A longitudinal echocardiography database was used to perform a retrospective analysis of 3,276 adult patients with isolated severe TR from November 2001 to March 2016. All-cause mortality for patients who underwent surgery versus those who did not was analyzed in the entire cohort and in a propensity-matched sample. To assess the possibility of immortal time bias, the analysis was performed considering time from diagnosis to surgery as a time-dependent covariate.Results: Of 3,276 patients with isolated severe TR, 171 (5%) underwent tricuspid valve surgery, including 143 (84%) repairs and 28 (16%) replacements. The remaining 3,105 (95%) patients were medically managed. When considering surgery as a time-dependent covariate in a propensity-matched sample, there was no difference in overall survival between patients who received medical versus surgical therapy (hazard ratio: 1.34; 95% confidence interval: 0.78 to 2.30; p = 0.288). In the subgroup that underwent surgery, there was no difference in survival between tricuspid repair versus replacement (hazard ratio: 1.53; 95% confidence interval: 0.74 to 3.17; p = 0.254).Conclusions: In patients with isolated severe TR, surgery is not associated with improved long-term survival compared to medical management alone after accounting for immortal time bias. [ABSTRACT FROM AUTHOR]

A response by Chan B. Park and Thoralf M. Sundt III to a letter to the editor about their article "What is the optimal myocardial preservation strategy at re-operation for aortic valve replacement in the presence of a patent internal thoracic artery?" in the 2011 issue is presented.

The article examines whether aortic valve replacement (AVR) is indicated in the management of asymptomatic severe aortic stenosis (AS). The authors discuss the risks associated with asymptomatic AS, as the developments in the risks linked with surgical intervention. They also express their belief that AVR should be considered in all asymptomatic patients with severe AS. They note that the decision on whether to proceed with AVR, particularly in an elderly patient, is taken on a case-by-case basis.

Background. Intraoperative team turnover is necessary given the duration of many cardiac surgical procedures, despite being an established risk factor for harm. We sought to determine if there was an association between intraoperative anesthesia handoff (AH) and patient morbidity and/or mortality after cardiac surgery. Methods. All adult cardiac surgery procedures from November 2016 through November 2021 were retrospectively interrogated for AH. These results were merged with postoperative patient outcomes data and analyzed for morbidity and mortality. Results. A single AH occurred in 1,087/5,937 (18.3%) procedures, and two or more AHs occurred in 224 (3.8%) procedures. Baseline characteristics show that AH is more frequently associated with higher complexity patients and operations. The primary outcome of operative mortality occurred in 113 (2.4%), 54 (5.0%), and 7 (3.1%) patients in the no AH, single AH, and multiple AH cohorts. After multivariable adjustment, the odds ratio for mortality was 1.15 (95% CI 0.79–1.67 and P = 0.46) for a single AH and 0.83 (95% CI 0.36–1.90 and P = 0.66) for multiple AH. There were no significant differences in readmission, length of stay, or a composite complication outcome between the cohorts after adjustment. Conclusions. In a large single-center experience, intraoperative anesthesia handoffs were not associated with adverse outcomes after cardiac surgery. [ABSTRACT FROM AUTHOR]

Heart and lung transplant recipients require care provided by clinicians from multiple different specialties, each contributing unique expertise and perspective. The period the patient spends in the intensive care unit is one of the most critical times in the perioperative trajectory. Various organizational models of intensive care exist, including those led by intensivists, surgeons, transplant cardiologists, and pulmonologists. Coordinating timely efficient intensive care is an essential and logistically difficult goal. The present work product of the American Society of Transplantation's Thoracic and Critical Care Community of Practice, Critical Care Task Force outlines operational guidelines and principles that may be applied in different organizational models to optimize the delivery of intensive care for the cardiothoracic organ recipient. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Patients undergoing surgical mitral valve repair (MVr) for degenerative mitral regurgitation are at risk of even late postoperative atrial fibrillation (AF). Left atrial (LA) function has been shown superior to LA volume in evaluating the risk of AF in diverse cardiac conditions. We therefore investigated the prognostic value of LA function and volume in predicting mid-to-late postoperative AF after MVr (>30 days postoperatively). METHODS We retrospectively identified all patients who underwent MVr for degenerative mitral regurgitation between 2012 and 2019 at our institution. Exclusion criteria were preoperative AF, concomitant procedures, re-operations, missing or insufficiently processable preoperative echocardiograms and missing follow-up. LA function and volume measurements were conducted using speckle-tracking strain echocardiographic analysis. Postoperative LA function was measured in a subgroup with sufficient postoperative echocardiograms. RESULTS We included 251 patients, of whom 39 (15.5%) experienced AF in the mid-to-late postoperative period. Reduced LA strain parameters and more than mild preoperative tricuspid regurgitation were independently associated with mid-to-late postoperative AF. LA volume index had no association with mid-to-late postoperative AF in univariable analysis and did not improve the performance of multivariable models. Patients with mid-to-late AF exhibited diminished improvement in LA function after surgery. CONCLUSIONS In MVr patients, LA function (but not volume) showed independent predictive value for mid-to-late postoperative AF. Including LA function into surgical decision-making and approach may identify patients who will benefit from earlier intervention with the aim to prevent irreversible LA damage with consequent risk of postoperative AF. [ABSTRACT FROM AUTHOR]

The author reflects on a study related to postoperative glucose control which shows a disciplined approach to the "Plan-Do-Check-Act" cycle in glucose management.

The article presents a case study of a 38-year-old man with exertional chest discomfort. Topics include food related exercise-induced anaphylaxis with reactions to soybeans, chickpeas, and tahini; and review of systems being negative for dyspnea, recent syncope, orthopnea, edema, cough, hemoptysis, and recent allergic symptoms.

Two guidelines from the American College of Cardiology (ACC), the American Heart Association (AHA), and collaborating societies address the risk of aortic dissection in patients with bicuspid aortic valves and severe aortic enlargement: the "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease" (J Am Coll Cardiol 2010;55:e27-130) and the "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease" (J Am Coll Cardiol 2014;63:e57-185). However, the 2 guidelines differ with regard to the recommended threshold of aortic root or ascending aortic dilatation that would justify surgical intervention in patients with bicuspid aortic valves. The ACC and AHA therefore convened a subcommittee representing members of the 2 guideline writing committees to review the evidence, reach consensus, and draft a statement of clarification for both guidelines. This statement of clarification uses the ACC/AHA revised structure for delineating the Class of Recommendation and Level of Evidence to provide recommendations that replace those contained in Section 9.2.2.1 of the thoracic aortic disease guideline and Section 5.1.3 of the valvular heart disease guideline. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Prosthetic heart valves," by W. Vongpatanasin, L. D. Hillis, and R. A. Lange in the August 8, 1996 issue.

Open in new tab Download slide Open in new tab Download slide OBJECTIVES We sought to examine management and outcomes of (Stanford) type A aortic dissection (TAAAD) in patients aged >70 years. METHODS All patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection database (1996–2018) were studied (n  = 5553). Patients were stratified by age and therapeutic strategy. Outcomes for octogenarians were compared with those for septuagenarians. Variables associated with in-hospital mortality were identified by multivariable logistic regression. RESULTS In-hospital mortality for all patients (all ages) was 19.7% (1167 deaths), 16.1% after surgical intervention vs 52.1% for medical management (P  <   0.001). Of the study population, 1281 patients (21.6%) were aged 71–80 years and 475 (8.0%) were >80 years. Fewer octogenarians underwent surgery versus septuagenarians (68.1% vs 85.9%, P  <   0.001). Overall mortality was higher for octogenarians versus septuagenarians (32.0% vs 25.6%, P  =   0.008); however, surgical mortality was similar (25.1% vs 21.7%, P  =   0.205). Postoperative complications were comparable between surgically managed cohorts, although reoperation for bleeding was more common in septuagenarians (8.1% vs 3.2%, P  =   0.033). Kaplan–Meier 5-year survival was significantly superior after surgical repair in all age groups, including septuagenarians (57.0% vs 13.7%, P  <   0.001) and octogenarians (35.5% vs 22.6%, P  < 0.001). CONCLUSIONS When compared with septuagenarians, a smaller percentage of octogenarians undergo surgical repair for TAAAD, even though postoperative outcomes are similar. Age alone should not preclude consideration for surgery in appropriately selected patients with TAAAD. [ABSTRACT FROM AUTHOR]

Background Consensus guidelines recommend multidisciplinary models to manage infective endocarditis, yet often do not address the unique challenges of treating people with drug use–associated infective endocarditis (DUA-IE). Our center is among the first to convene a Drug Use Endocarditis Treatment (DUET) team composed of specialists from Infectious Disease, Cardiothoracic Surgery, Cardiology, and Addiction Medicine. Methods The objective of this study was to describe the demographics, infectious characteristics, and clinical outcomes of the first cohort of patients cared for by the DUET team. This was a retrospective chart review of patients referred to the DUET team between August 2018 and May 2020 with DUA-IE. Results Fifty-seven patients were presented to the DUET team between August 2018 and May 2020. The cohort was young, with a median age of 35, and injected primarily opioids (82.5% heroin/fentanyl), cocaine (52.6%), and methamphetamine (15.8%). Overall, 14 individuals (24.6%) received cardiac surgery, and the remainder (75.4%) were managed with antimicrobial therapy alone. Nearly 65% of individuals were discharged on medication for opioid use disorder, though less than half (36.8%) were discharged with naloxone and only 1 patient was initiated on HIV pre-exposure prophylaxis. Overall, the cohort had a high rate of readmission (42.1%) within 90 days of discharge. Conclusions Multidisciplinary care models such as the DUET team can help integrate nuanced decision-making from numerous subspecialties. They can also increase the uptake of addiction medicine and harm reduction tools, but further efforts are needed to integrate harm reduction strategies and improve follow-up in future iterations of the DUET team model. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular procedural volumes can serve as metrics of hospital infrastructure and quality, and are the basis for thresholds for initiating transcatheter mitral valve repair (TMVr) programs. Whether hospital volumes of TMVr, surgical mitral valve replacement or repair (SMVRr), and percutaneous coronary intervention (PCI) are indicators of TMVr quality of care is not known.Methods: We used the 2017 Nationwide Readmissions Database to identify hospitals that performed at least 5 TMVr procedures. Hospitals were divided into quartiles of TMVr volume. Associations of hospital TMVr, SMVRr, and PCI volumes, as well as SMVRr and PCI outcomes with TMVr outcomes were examined. Outcomes studied were risk-standardized in-hospital mortality rate (RSMR) and 30-day readmission rate (RSRR).Results: The study included 3404 TMVr procedures performed across 150 hospitals in the US. The median hospital TMVr volume was 17 (IQR 10, 28). The mean hospital-level RSMR and RSRR for TMVr were 3.0% (95% CI 2.5%, 3.4%) and 14.8% (95% CI 14.5%, 15.0%), respectively. There was no significant association between hospital TMVr volume (as quartiles or as a continuous variable) and TMVr RSMR or RSRR (P > 0.05). Similarly, there was weak or no correlation between hospital SMVRr and PCI volumes and outcomes with TMVr RSMR or RSRR (Pearson correlation coefficients, r = -0.199 to 0.269).Conclusion: In this study, we found no relationship between hospital TMVr, SMVRr, and PCI volume and TMVr outcomes. Further studies are needed to determine more appropriate structure and process measures to assess the performance of established and new TMVr centers. [ABSTRACT FROM AUTHOR]

Objective: Aortic valve disease is a risk factor for atrial fibrillation (AF), and AF is associated with increased late mortality and morbidity after cardiac surgery. The evolution of alternative approaches to AF prophylaxis, including less invasive technologies and medical therapies, has altered the balance between risk and potential benefit for prophylactic intervention at the time of surgical aortic valve replacement (SAVR). Such interventions impose incremental risk, however, making an understanding of predictors of new onset AF that persists beyond the perioperative episode relevant. Methods: We conducted a retrospective single‐institution cohort analysis of patients undergoing SAVR with no history of preoperative AF (n = 1014). These patients were cross‐referenced against an institutional electrocardiogram (ECG) database to identify those with ECGs 3–12 months after surgery. Logistic regression was used to identify predictors of late AF. Results: Among the 401 patients (40%), who had ECGs in our institution 3–12 months after surgery, 16 (4%) had late AF. Patients with late AF were older than patients without late AF (73 vs. 65, p =.025), and underwent procedures that were more urgent/emergent (38% vs. 15%, p =.015), with higher predicted risk of mortality (2.2% vs. 1.3%, p =.012). Predictors associated with the development of late AF were advanced age, higher preoperative creatinine level and urgent/emergent surgery. Conclusions: The incidence of late AF 3–12 months after SAVR, is low. Prophylactic AF interventions at the time of SAVR may not be warranted. [ABSTRACT FROM AUTHOR]

Obstructive thrombosed prosthetic heart valve (OTPHV) is a serious complication of heart valve replacement. There are no generally accepted criteria for management of these patients. Therefore, in September 2012, a literature survey of studies published after 1995 was performed to analyze the data regarding clinical outcomes of patients with OTPHV treated with thrombolytic agents and with surgery since 1996. The search yielded appropriate and relevant studies, which included 17 studies comprising 756 patients who had received thrombolytic therapy and 13 studies comprising 662 patients who had received surgery. The data on these 2 groups was analyzed in detail relating to frequency of use of the diagnostic studies, baseline patient data, and on the rate of complete success, outcomes, and complications of the therapy they had received, and the limitations of the studies. We have then developed a strategy for therapy of OTPHV. [ABSTRACT FROM AUTHOR]

Objectives: We sought to examine temporal trends in the utilization of coronary revascularization in a geographically defined population. Background: Earlier reports on revascularization utilization focused on inpatient settings and did not distinguish incident from recurrent procedures. Furthermore, little is known on age- and gender-specific trends. Finally, longitudinal data on the utilization and results of coronary angiography as explanatory factors for the changing revascularization practice are lacking. Methods: Data integrating diagnostic and therapeutic coronary procedures performed in Olmsted County (Minnesota) between 1990 and 2004 were analyzed. Standardized rates were calculated applying the direct method and temporal trends compared using Poisson regression models. Results: Revascularization utilization increased by 24% during the study (95% confidence interval [CI] 5% to 46%), but the trends diverged by procedure type, with a sustained increase (69%, 95% CI 43% to 101%) for percutaneous coronary interventions (PCI) contrasting with a stabilization, then decline (−33%, 95% CI −16% to −47%) for coronary artery bypass grafting (CABG). For PCI, although the use increased in all categories, greater increases were noted in the elderly, in women, and for recurrent procedures. No such patterns were detected for CABG. Angiography use remained stable, and the rate of 3-vessel and/or left main disease declined (−22%, 95% CI −8% to −33%). Conclusions: Over the 15-year period, revascularization increased in the community with a large increase in PCI partially offset by a decrease in CABG. More PCIs are performed in women and the elderly and for recurrent disease. These changes occurred within the context of a decline in multivessel disease and thus likely reflect the natural history of coronary artery disease. [Copyright &y& Elsevier]

Aim: This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.Methods: A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines. [ABSTRACT FROM AUTHOR]

Duration of Secondary Prophylaxis for Rheumatic Fever Type Duration After Last Attack* Rheumatic fever with carditis and residual heart disease (persistent VHD†) 10 y or until patient is 40 y of age (whichever is longer) Rheumatic fever with carditis but no residual heart disease (no valvular disease†) 10 y or until patient is 21 y of age (whichever is longer) Rheumatic fever without carditis 5 y or until patient is 21 y of age (whichever is longer) *Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Systemic Fibrinolysis Versus Surgery for Prosthetic Valve Thrombosis Favor Surgery Favor Fibrinolysis Readily available surgical expertise No surgical expertise available Low surgical risk High surgical risk Contraindication to fibrinolysis No contraindication to fibrinolysis Recurrent valve thrombosis First-time episode of valve thrombosis NYHA class IV NYHA class I, II, or III Large clot (>0.8 cm 2) Small clot (<=0.8 cm 2) LA thrombus No LA thrombus Concomitant CAD in need of revascularization No or mild CAD Other valve disease No other valve disease Possible pannus Thrombus visualized Patient choice Patient choice CAD indicates coronary artery disease; The threshold for valve operation for valve regurgitation is higher in the asymptomatic patient who might ever become pregnant than in patients who will not become pregnant because there always is the possibility that valve repair will not be successful and a prosthetic valve will be needed. Consultation with or referral to a Primary or Comprehensive Heart Valve Center is reasonable when treatment options are being discussed for 1) asymptomatic patients with severe VHD, 2) patients who may benefit from valve repair versus valve replacement, or 3) patients with multiple comorbidities for whom valve intervention is considered. [Extracted from the article]

Aim: This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.Methods: A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline.Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines. [ABSTRACT FROM AUTHOR]

Background: In this study, we compare the clinical characteristics, intraoperative management, and postoperative outcomes of patients with acute type A aortic dissection (ATAAD) between two academic medical hospitals in the United States and China.Methods: From January 2011 to December 2017, 641 and 150 patients from Nanjing Drum Tower Hospital (NDTH) and Massachusetts General Hospital (MGH) were enrolled. Patient demographics, clinical features, surgical techniques, and postoperative outcomes were compared.Results: The annual number of patients presenting with ATAAD at MGH remained relatively stable, while the number at NDTH increased significantly over the study period. The average age was 51 years at NDTH and 61 years at MGH (P < .001). The percentage of patients with known hypertension at the two centers was similar. The time interval from onset of symptoms to diagnosis was significantly longer at NDTH than MGH (11 vs 3.5 hours; P < .001). Associated complications at presentation were more common at NDTH than MGH. More than 90% of patients (91% NDTH and 92% MGH) underwent surgery. The postoperative stroke rate was higher at MGH (12% vs 4%; P < .001); however, the 30-day mortality rate was lower (7% vs 16%; P = .006).Conclusions: There was a significant increase in the number of ATAAD at NDTH during the study period while the number at MGH remained stable. Hypertension was a common major risk factor; however, the onset of ATAAD at NDTH was nearly one decade earlier than MGH. Chinese patients tended to have more complicated preoperative pathophysiology at presentation and underwent more extensive surgical repair. [ABSTRACT FROM AUTHOR]

Introduction: Intra-Aortic Balloon Pumps (IABPs) can be utilized to provide hemodynamic support in high risk patients awaiting coronary artery bypass grafting (CABG). There are many indications for IABP and institutional practice patterns regarding the placement of IABPs is variable. As a result, the preoperative placement of an IABP in a patient awaiting CABG is not standardized and may vary according to non-clinical factors. We hypothesize that the rate of IABP placement varies by day of the week.Methods: A retrospective cohort analysis of the Office of Statewide Health Planning and Development database from 2006 to 2010 was performed. All patients admitted for CABG were included. Patients who died within 24 h of admission and those who had absolute contraindications to IABP placement were excluded. The primary outcome was preoperative IABP placement versus non-placement. A multivariable logistic regression analysis to identify predictors of IABP placement was performed, adjusting for patient demographics, clinical factors, and system variables.Results: A total of 46,347 patients underwent CABG, of which 7695 (16.60%) had an IABP placed preoperatively. On unadjusted analysis, IABP rates were significantly higher on weekends versus weekdays (20.83% vs. 15.70%, p < 0.001). On adjusted analysis, patients awaiting CABG were 1.30 times more likely to have an IABP placed on weekends than on weekdays (OR: 1.30, 95% CI 1.20-1.40, p < 0.001).Conclusion: The odds of preoperative IABP placement prior to CABG is significantly increased on weekends compared to weekdays, even when controlling for clinical factors. Further exploration of this phenomenon and its associations are warranted. [ABSTRACT FROM AUTHOR]

Background: Structural valve deterioration (SVD) is a known limitation of bioprosthetic valves. Recent reports have suggested a concerning rate of early SVD in patients receiving a Mitroflow aortic bioprosthesis. We therefore compared the incidence of SVD and SVD requiring reoperation among patients receiving a Mitroflow versus a common contemporary bioprosthesis.Methods: A retrospective cohort analysis was performed on 592 patients receiving a Mitroflow aortic bioprosthesis at our institution between 2010 and 2014. Patients were matched 1:1 using a coarsened exact matching algorithm with patients receiving a Carpentier-Edwards Magna Ease aortic bioprosthesis (Edwards Lifesciences, Irvine, CA) during the same period. The incidence of SVD (defined as a mean transprosthetic gradient ≥30 mmHg or moderate to severe intraprosthetic regurgitation), reoperation for SVD, and cumulative survival were compared between prosthesis types.Results: The cumulative incidence of SVD at 5 years for all patients receiving a Mitroflow aortic bioprosthesis was 16% (13-21%) and 5% underwent reoperation for SVD. Implantation of a Mitroflow valve was associated with an increased risk of SVD compared to the comparator valve (hazard ratio [HR] 2.59 [1.69-3.98], P < 0.01). Older age had a protective effect against SVD (HR 0.95 [0.93-0.96], P < 0.01). Patients who received a Mitroflow valve had reduced long-term survival compared to those who received a comparator valve (P = 0.03).Conclusion: The Mitroflow aortic bioprosthesis is associated with increased rates of early SVD and reoperation for valvular dysfunction as well as reduced survival compared to a contemporary valve. Enhanced clinical and echocardiographic follow-up is advisable after Mitroflow implantation. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this research is to analyze factors associated with delays to surgical management of Type A acute aortic dissection patients.Methods: Time from diagnosis to surgery and associated factors were evaluated in 1880 surgically managed Type A dissection patients enrolled in the International Registry of Acute Aortic Dissection.Results: The majority of patients were transferred (75.7% vs 24.3%). Patients who were transferred had a median delay from diagnosis to surgery of 4.0 hours (interquartile range 2.5-7.2 hours), compared with 2.3 hours (interquartile range 1.1-4.2 hours; P < .001) in nontransferred patients. Among patients who were transferred, those with worst-ever, posterior, or tearing chest pain those with severe complications, and those receiving transthoracic echocardiogram prior to a transesophageal echocardiogram or as the only echocardiogram were treated more quickly. Those undergoing magnetic resonance imaging, or who had prior cardiac surgery, had longer delays to surgery. Among nontransferred patients, those with coma were treated more quickly. In both groups, patients presenting with emergent conditions such as cardiac tamponade, hypotension, or shock had more rapid treatment. Among transferred patients, surviving patients had longer delays (4.1 [2.6-7.8] hours vs 3.3 [2.0-6.0] hours, P = .001). Overall mortality did not differ between patients who were transferred vs not (19.3% vs 21.1%, P = .416).Conclusion: Simply being transferred added significantly to the delay to surgery for Type A acute aortic dissection patients, but a number of factors affected its extent. Overall, signs and symptoms leading to a definitive diagnosis or indicating immediate life threat reduced time to surgery, while factors suggesting other diagnoses correlated with delays. [ABSTRACT FROM AUTHOR]

The article presents an update of the "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease" report of the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Clinical Practice Guidelines. It discusses basic principles of medical therapy for infective endocarditis, aortic stenosis and mitral regurgitation, among other valvular heart diseases. It also explains the term "guideline-directed management and therapy."

Background: Recent studies have demonstrated that many patients with acute type A aortic dissection (AD) have aortic diameters of <55 mm at presentation, prompting discussion of lowering the prophylactic surgical guidelines. However, risk of dissection at these smaller diameters is poorly defined.Objectives: The purpose of this study is to understand the risk of AD in moderately dilated ascending aortas using a large echocardiographic data set.Methods: Using an institutional echocardiography database, we identified 4,654 nonsyndromic adults (age: 68.6 ± 13.1 years; 1,003 women) with maximal ascending aortic diameters of 40 to 55 mm. We performed competing risk analysis to determine the independent risk factors of AD or aortic rupture.Results: Five hundred eighty-six individuals (12.6%) had bicuspid aortic valves (BAVs). During follow-up (14,431.5 patient-years), AD and rupture occurred in 13 and 1 patients, respectively, which demonstrated a linearized incidence of AD and/or rupture of 0.1% per patient-year. Elective ascending aortic repair was performed in 176 individuals. On multivariable analyses, independent predictors of AD and/or rupture were age (hazard ratio [HR]: 1.06; 95% confidence interval [CI]: 1.01 to 1.12; p= 0.024) and baseline aortic diameters (HR: 1.20; 95% CI: 1.05 to 1.36; p = 0.006). The presence of a BAV was not a significant factor (HR: 0.94; 95% CI: 0.10 to 8.40; p = 0.95). Estimated risks of AD and/or rupture within 5 years were 0.4%, 1.1%, and 2.9% at baseline aortic diameters of 45, 50, and 55 mm, respectively.Conclusions: Risks of AD and/or rupture were significantly correlated with the aortic diameter and age in patients with moderately dilated ascending aortas. However, the risks were low for diameters <5.0 cm when timely elective aortic repair was performed, regardless of the morphology of the aortic valve. [ABSTRACT FROM AUTHOR]

Thoracic aortic aneurysms (TAs) occur in reproducible patterns, but etiologic factors determining the anatomic distribution of these aneurysms are not well understood. This study sought to gain insight into etiologic differences and clinical outcomes associated with repetitive anatomic distributions of TAs. From 3,247 patients registered in an institutional Thoracic Aortic Center database from July 1992 to August 2013, we identified 844 patients with full aortic dimensional imaging by computerized axial tomography or magnetic resonance imaging scan (mean age 62.8 ± 14 years, 37% women, median follow-up 40 months) with TA diameter >4.0 cm and without evidence of previous aortic dissection. Patient demographic and imaging data were analyzed in 3 groups: isolated ascending thoracic aortic aneurysms (AAs; n = 628), isolated descending TAs (DTAs; n = 130), and combined AA and DTA (mixed thoracic aortic aneurysm, MTA; n = 86). Patients with DTA had more hypertension (82% vs 59%, p <0.001) and a higher burden of atherosclerosis (88% vs 9%, p <0.001) than AA. Conversely, patients with isolated AA were younger (59.5 ± 13.5 vs 71.0 ± 11.8 years, p <0.001) and contained almost every case of overt, genetically triggered TA. Patients with isolated DTA were demographically indistinguishable from patients with MTA. In follow-up, patients with DTA/MTA experienced more aortic events (aortic dissection/rupture) and had higher mortality than patients with isolated AA. In multivariate analysis, aneurysm size (odds ratio 1.1, 95% CI 1.07 to 1.16, p <0.001) and the presence of atherosclerosis (odds ratio 5.7, 95% CI 2.02 to 16.15, p <0.001) independently predicted adverse aortic events. We find that DTA with or without associated AA appears to be a disease more highly associated with atherosclerosis, hypertension, and advanced age. In contrast, isolated AA appears to be a clinically distinct entity with a greater burden of genetically triggered disease. [ABSTRACT FROM AUTHOR]

Background: Current practice guidelines recommend surgical repair of large thoracic aortic aneurysms to prevent fatal aortic dissection or rupture, but limited natural history data exist to support clinical criteria for timely intervention.Methods and Results: Of 3247 patients with thoracic aortic aneurysm registered in our institutional Thoracic Aortic Center Database, we identified and reviewed 257 nonsyndromic patients (age, 72.4±10.5 years; 143 female) with descending thoracic or thoracoabdominal aortic aneurysm without a history of aortic dissection in whom surgical intervention was not undertaken. The primary end point was a composite of aortic dissection/rupture and sudden death. Baseline mean maximal aortic diameter was 52.4±10.8 mm, with 103 patients having diameters ≥55 mm. During a median follow-up of 25.1 months (quartiles 1-3, 8.3-56.4 months), definite and possible aortic events occurred in 19 (7.4%) and 31 (12.1%) patients, respectively. On multivariable analyses, maximal aortic diameter at baseline emerged as the only significant predictor of aortic events (hazard ratio=1.12; 95% confidence interval, 1.08-1.15). Estimated rates of definite aortic events within 1 year were 5.5%, 7.2%, and 9.3% for aortic diameters of 50, 55, and 60 mm, respectively. Receiver-operating characteristic curves for discriminating aortic events were higher for indexed aortic sizes referenced by body size (area under the curve=0.832-0.889) but not significantly different from absolute maximal aortic diameter (area under the curve=0.805).Conclusions: Aortic size was the principal factor related to aortic events in unrepaired descending thoracic or thoracoabdominal aortic aneurysm. Although the risk of aortic events started to increase with a diameter >5.0 to 5.5 cm, it is uncertain whether repair of thoracic aortic aneurysms in this range leads to overall benefit, and the threshold for repair requires further evaluation. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Markers of operation room (OR) efficiency in cardiac surgery are focused on 'knife to skin' and 'start time tardiness.' These do not evaluate the middle and later parts of the cardiac surgical pathway. The purpose of this analysis was to evaluate knife to skin time as an efficiency marker in cardiac surgery. Methods We looked at knife to skin time, procedure time, and transfer times in the cardiac operational pathway for their correlation with predefined indices of operational efficiency (Index of Operation Efficiency - InOE, Surgical Index of Operational Efficiency - sInOE). A regression analysis was performed to test the goodness of fit of the regression curves estimated for InOE relative to the times on the operational pathway. Results The mean knife to skin time was 90.6 ± 13 minutes (23% of total OR time). The mean procedure time was 282 ± 123 minutes (71% of total OR time). Utilization efficiencies were highest for aortic valve replacement and coronary artery bypass grafting and least for complex aortic procedures. There were no significant procedure-specific or team-specific differences for standard procedures. Procedure times correlated the strongest with InOE (r = −0.98, p < 0.01). Compared to procedure times, knife to skin is not as strong an indicator of efficiency. A statistically significant linear dependence on InOE was observed with 'procedure times' only. Conclusions Procedure times are a better marker of OR efficiency than knife to skin in cardiac cases. Strategies to increase OR utilization and efficiency should address procedure times in addition to knife to skin times. doi: 10.1111/jocs.12528 (J Card Surg 2015;30:477-487) [ABSTRACT FROM AUTHOR]

Septic coronary embolization in a patient with endocarditis is a rare and can be a devastating complication. The management of this clinical problem in the current era may be best served with a multi-modality approach. We present an interesting case of a patient with septic coronary embolization managed with the combined use of aspiration thrombectomy followed by surgical management of the infected valve. [ABSTRACT FROM AUTHOR]