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Importance: In patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited.Objective: To report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial.Design, setting, and participants: SURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021.Intervention: Patients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis.Main outcomes and measures: The prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years.Results: A total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm2 vs 1.8 [0.6] cm2; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention.Conclusions and relevance: Among intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.

The aim of this study was to determine whether specific three-dimensional aortic shape features, extracted via statistical shape analysis (SSA), correlate with the development of thoracic ascending aortic dissection (TAAD) risk and associated aortic hemodynamics. Thirty-one patients followed prospectively with ascending thoracic aortic aneurysm (ATAA), who either did (12 patients) or did not (19 patients) develop TAAD, were included in the study, with aortic arch geometries extracted from computed tomographic angiography (CTA) imaging. Arch geometries were analyzed with SSA, and unsupervised and supervised (linked to dissection outcome) shape features were extracted with principal component analysis (PCA) and partial least squares discriminant analysis (PLS-DA), respectively. We determined PLS-DA to be effective at separating dissection and no-dissection patients (p=0.0010), with decreased tortuosity and more equal ascending and descending aortic diameters associated with higher dissection risk. In contrast, neither PCA nor traditional morphometric parameters (maximum diameter, tortuosity, or arch volume) were effective at separating dissection and no-dissection patients. The arch shapes associated with higher dissection probability were supported with hemodynamic insight. Computational fluid dynamics (CFD) simulations revealed a correlation between the PLS-DA shape features and wall shear stress (WSS), with higher maximum WSS in the ascending aorta associated with increased risk of dissection occurrence. Our work highlights the potential importance of incorporating higher dimensional geometric assessment of aortic arch anatomy in TAAD risk assessment, and in considering the interdependent influences of arch shape and hemodynamics as mechanistic contributors to TAAD occurrence.

Randomized clinical trials have shown that transcatheter aortic valve replacement is noninferior to surgery in low surgical risk patients. We compared outcomes in patients treated with a sutured (stented or stentless) or sutureless surgical valve from the Evolut Low Risk Trial.The Evolut Low Risk Trial enrolled patients with severe aortic stenosis and low surgical risk. Patients were randomized to self-expanding transcatheter aortic valve replacement or surgery. Use of sutureless or sutured valves was at the surgeons' discretion.Six hundred eighty patients underwent surgical aortic valve implantation (205 sutureless, 475 sutured). The Valve Academic Research Consortium-2 30-day safety composite endpoint was similar in the sutureless and sutured group (10.8% vs 11.0%, P = .93). All-cause mortality between groups was similar at 30 days (0.5% vs 1.5%, P = .28) and 1 year (3.3% vs 2.6%, P = .74). Disabling stroke was also similar at 30 days (2.0% vs 1.5%, P = .65) and 1 year (2.6% vs 2.2%, P = .76). Permanent pacemaker implantation at 30 days was significantly higher in the sutureless compared with the sutured group (14.4% vs 2.9%, P.001). Aortic valve-related hospitalizations occurred more often at 1 year with sutureless valves (9.1% vs 5.1%, P = .04). Mean gradients 1 year after sutureless and sutured aortic valve replacement were 9.9 ± 4.2 versus 11.7 ± 4.7 mm Hg (P.001).Among low-risk patients, sutureless versus sutured valve use did not demonstrate a benefit in terms of 30-day complications and produced marginally better hemodynamics but with an increased rate of pacemaker implantation and valve-related hospitalizations.

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 80 years. Fewer octogenarians underwent surgery versus septuagenarians (68.1% vs 85.9%, P 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.

Aortic valve replacement (AVR) is common in the setting of type A aortic dissection (TAAD) repair. Here, we evaluated the association between prosthesis choice and patient outcomes in an international patient cohort. We reviewed data from the International Registry of Acute Aortic Dissection (IRAD) interventional cohort to examine the relationship between valve choice and short- and mid-term patient outcomes. Between January 1996 and March 2016, 1290 surgically treated patients with TAAD were entered into the IRAD interventional cohort. Of those, 364 patients undergoing TAAD repair underwent aortic valve replacement (AVR; mean age, 57 years). The mechanical valve cohort consisted of 189 patients, of which 151 (79.9%) had a root replacement. The nonmechanical valve cohort consisted of 5 patients who received homografts and 160 patients who received a biologic AVR, with a total of 118 (71.5%) patients who underwent root replacements. The mean follow-up time was 2.92 ± 1.75 years overall (2.46 ± 1.69 years for the mechanical valve cohort and 3.48 ± 1.8 years for the nonmechanical valve cohort). After propensity matching, Kaplan-Meier estimates of 4-year survival rates after surgery were 64.8% in the mechanical valve group compared with 74.7% in the nonmechanical valve group (p = 0.921). A stratified Cox model for 4-year mortality showed no difference in hazard between valve types after adjusting for the propensity score (p = 0.854). A biologic valve is a reasonable option in patients with TAAD who require AVR. Although this option avoids the potential risks of anticoagulation, long-term follow up is necessary to assess the effect of reoperations or transcatheter interventions for structural valve degeneration.

Our aim was to analyze outcomes of patients aged 70 years or above presenting with type A acute aortic dissection (TAAAD) and cerebrovascular accident (CVA). A retrospective analysis of the International Registry of Acute Aortic Dissection (IRAD) was conducted. Patients aged 70 years or above (n = 1449) were stratified according to presence or absence of CVA before surgery (CVA: n = 110, 7.6%). In-hospital outcomes and mortality up to 5 years were analyzed. Additionally, in-hospital outcomes of patients who received medical management were described. No patient presenting with CVA over the age of 87 years underwent surgery. The rates of in-hospital mortality and post-operative CVA were significantly higher in patients presenting with CVA (in-hospital mortality: 32.7% vs 21.7%, P = 0.008; post-operative CVA: 23.4% vs 8.3%, P0.001). Presence of CVA was independently associated with significantly increased in-hospital mortality (odds ratio 2.99, 95% confidence interval 1.35 - 6.60, P = 0.007). In survivors of the hospital stay, presenting CVA had no independent influence on mortality up to 5 years (hazard ratio 1.52, 95% confidence interval 0.99 - 2.31, P = 0.54). In medically managed patients, exceedingly high rates of in-hospital mortality (71.4%) and CVA (90.9%) were noted. Patients presenting with TAAAD and CVA at ≥ 70 years of age are at significantly increased risk of in-hospital mortality, although long-term mortality is not affected in hospital survivors. Medical management is associated with poor outcomes. We believe that surgical management should be offered after critical assessment of comorbidities.

Data for nearly all patients undergoing transcatheter edge-to-edge repair (TEER) and transcatheter mitral valve replacement (TMVR) with an approved device in the United States is captured in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. All data submitted for TEER or TMVR between 2014 and March 31, 2020, are reported. A total of 37,475 patients underwent a mitral transcatheter procedure, including 33,878 TEER and 3,597 TMVR. Annual procedure volumes for TEER have increased from 1,152 per year in 2014 to 10,460 per year in 2019 at 403 sites and for TMVR from 84 per year to 1,120 per year at 301 centers. Mortality rates have decreased for TEER at 30 days (5.6%-4.1%) and 1 year (27.4%-22.0%). Early off-label use data on TMVR in mitral valve-in-valve therapy led to approval by the U.S. Food and Drug Administration in 2017, and the 2019 30-day mortality rate was 3.9%. Overall improvements in outcomes over the last 6 years are apparent. (STS/ACC TVT Registry Mitral Module; NCT02245763 )

PURPOSE: To describe the design and methodological approach of a multicenter, retrospective study to externally validate a clinical and imaging-based model for predicting the risk of late adverse events in patients with initially uncomplicated type B aortic dissection (uTBAD).MATERIALS AND METHODS: The Registry of Aortic Diseases to Model Adverse Events and Progression (ROADMAP) is a collaboration between 10 academic aortic centers in North America and Europe. Two centers have previously developed and internally validated a recently developed risk prediction model. Clinical and imaging data from eight ROADMAP centers will be used for external validation. Patients with uTBAD who survived the initial hospitalization between January 1, 2001, and December 31, 2013, with follow-up until 2020, will be retrospectively identified. Clinical and imaging data from the index hospitalization and all follow-up encounters will be collected at each center and transferred to the coordinating center for analysis. Baseline and follow-up CT scans will be evaluated by cardiovascular imaging experts using a standardized technique.RESULTS: The primary end point is the occurrence of late adverse events, defined as aneurysm formation (≥6 cm), rapid expansion of the aorta (≥1 cm/y), fatal or nonfatal aortic rupture, new refractory pain, uncontrollable hypertension, and organ or limb malperfusion. The previously derived multivariable model will be externally validated by using Cox proportional hazards regression modeling.CONCLUSION: This study will show whether a recent clinical and imaging-based risk prediction model for patients with uTBAD can be generalized to a larger population, which is an important step toward individualized risk stratification and therapy.Keywords: CT Angiography, Vascular, Aorta, Dissection, Outcomes Analysis, Aortic Dissection, MRI, TEVAR© RSNA, 2022See also the commentary by Rajiah in this issue.

Background Atrial fibrillation (AF) is the most common arrhythmia observed with concomitant cardiac surgery. Surgical options include a cut-and-sew technique Maze (CAS) and a cryoablation/bipolar technique Maze (CB). There are limited data comparing the long-term outcomes of these 2 techniques. Methods All patients who underwent either CAS or CB Maze between 2011 and 2018 were included in the study. Chi-square test and Fisher’s exact test or Student’s t test were used to compare differences between baseline characteristics. Kaplan-Meier survival curves were generated for each group. Cumulative incidence functions were generated for AF recurrence and Fine-Gray competing-risk regression was used to determine predictors for AF recurrence. Results A total of 482 patients underwent open surgical ablation. Of those, 287 had CAS and 198 had CB. All procedures were concomitant with cardiac surgery. There was similar long-term mortality between the CAS and CB cohorts (22.3% vs 17.4%; log-rank P = .91). There was no difference in pacemaker implantation (11.1% vs 11.3%; P = .813) or long-term freedom from AF recurrence (73.3% vs 78.2%; P = .294). On Fine-Gray competing-risk regression, New York Heart Association functional class IV (hazard ratio [HR], 2.07; P = .03), concomitant aortic valve replacement (HR, 3.02; P = .01), and concomitant CABG + valve (HR, 2.36; P = .02) were significant independent predictors for AF recurrence; Maze type was not a predictor. Conclusions These data indicate no difference between the CAS vs CB with respect to freedom from long-term AF. Both techniques may be appropriate based on surgeon experience and patient characteristics.

Cerebral malperfusion and carotid artery dissection in patients with acute type A aortic dissections (TAAD) carry high morbidity and mortality. There are limited data on outcomes of concomitant carotid artery replacement with total arch replacement in the setting of TAAD.All patients with acute TAAD who underwent a total arch replacement between 2007 and 2018 were included. Data were retrospectively collected from a prospectively maintained database. Baselines variables were compared, and Kaplan-Meier estimates were used for long-term survival. Cox multivariable regression analysis was used to identify predictors of mortality.A total of 161 patients underwent total arch replacement for acute TAAD. Of these, 111 underwent conventional total arch reconstruction, and 50 had a concomitant carotid artery replacement. Baseline characteristics were similar between both cohorts apart from the carotid replacement cohort having a higher rate of preoperative cerebral malperfusion (48% vs 10.81%, P.01) and preoperative stroke (28% vs 11.71%, P = .02). There was no difference in (operative) 30-day mortality between the carotid replacement and conventional total arch replacement groups (22% vs 18.9%, P = .81), 1-year mortality (28% vs 27.9%, P = .99), or 5-year mortality (32% vs 29.7%, P = .917). Postoperative stroke was 0% vs 4.5% (P = .301) for the carotid vs conventional total arch replacement cohort.Concomitant carotid artery replacement is a feasible and safe technique to address perioperative cerebral malperfusion, carotid dissection, and neurologic dysfunction associated with carotid artery dissection, with no difference in long-term survival or postoperative stroke when compared with conventional total arch replacement.

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.

INTRODUCTION This study aimed to determine the ability of multimodality intraoperative neurophysiologic monitoring, including somatosensory evoked potentials (SSEP) and EEG, to predict perioperative clinical stroke and stroke-related mortality after open-heart surgery in high-risk patients. METHODS The records of all consecutive patients who underwent coronary artery bypass grafting, and cardiac valve repair/replacement with high risk for stroke who underwent both SSEP and EEG recording at the University of Pittsburgh Medical Center between 2009 and 2015 were reviewed. Sensitivity and specificity of these modalities to predict in-hospital clinical strokes and stroke-related mortality were calculated. RESULTS A total of 531 patients underwent open cardiac procedures monitored using SSEP and EEG. One hundred thirty-one patients (24.67%) experienced significant changes in either modality. Fourteen patients (2.64%) suffered clinical strokes within 24 hours after surgery, and eight patients (1.50%) died during their hospitalization. The incidence of in-hospital clinical stroke and stroke-related mortality among patients who experienced a significant change in monitoring compared with those with no significant change was 11.45% versus 1.75%. The sensitivity and specificity of significant changes in either SSEP or EEG to predict in-hospital major stroke and stroke-related mortality were 0.93 and 0.77, respectively. CONCLUSIONS Intraoperative neurophysiologic monitoring with SSEP and EEG has high sensitivity and specificity in predicting perioperative stroke and stroke-related mortality after open cardiac procedures. These results support the benefits of multimodality neuromonitoring during cardiac surgery.

In this prospective US investigational device exemption trial, we assessed the safety and 1-year clinical outcomes of the Thoraflex Hybrid device (Terumo Aortic) for the frozen elephant trunk technique to repair the ascending aorta, aortic arch, and descending thoracic aorta.For the trial, which involved 12 US sites, 65 patients without rupture were recruited into the primary study group, and 9 patients were recruited into the rupture group. All patients underwent open surgical repair of the ascending aorta, aortic arch, and descending thoracic aorta in cases of aneurysm and/or dissection. The primary end point was freedom from major adverse events (MAE), defined as permanent stroke, permanent paraplegia/paraparesis, unanticipated aortic-related reoperation (excluding reoperation for bleeding), or all-cause mortality.In the primary study group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 81% (51/63). Seven patients (11%) died (including 2 before 30 days or discharge), 3 patients (5%) suffered permanent stroke, and 3 (5%) developed permanent paraplegia/paraparesis. Twenty-six patients (41%) underwent planned extension procedures, including 22 endovascular procedures within a median of 122 (interquartile range, 64-156) days. In the aortic rupture group, 2 patients were lost to follow-up at 1 year. Freedom from MAE at 1 year was 71% (5/7). One patient (14%) died, 2 patients (29%) had permanent stroke, and none had permanent paraplegia/paraparesis. No extension procedures were performed in the rupture group.One-year results with the Thoraflex Hybrid device are acceptable. Long-term data are necessary to assess the durability of these repairs.

To evaluate the ability of intraoperative neurophysiologic monitoring (IONM) during aortic arch reconstruction with hypothermic circulatory arrest (HCA) to predict early (48 hours) adverse neurologic events (ANE; stroke or transient ischemic attack) and operative mortality.This was an observational study of aortic arch surgeries requiring HCA from 2010 to 2018. Patients were monitored with electroencephalogram (EEG) and somatosensory evoked potentials (SSEP). Baseline characteristics and postoperative outcomes were compared according to presence or absence of IONM changes, which were defined as any acute variation in SSEP or EEG, compared with baseline. Multivariable logistic regression analysis was used to assess the association of IONM changes with operative mortality and early ANE.A total of 563 patients underwent aortic arch reconstruction with HCA and IONM. Of these, 119 (21.1%) patients had an IONM change, whereas 444 (78.9%) did not. Patients with IONM changes had increased operative mortality (22.7% vs 4.3%) and increased early ANE (10.9% vs 2.9%). In multivariable analysis, SSEP changes were correlated with early ANE (odds ratio [OR], 4.68; 95% confidence interval [CI], 1.51-14.56; P = .008), whereas EEG changes were not (P = .532). Permanent SSEP changes were correlated with early ANE (OR, 4.56; 95% CI, 1.51-13.77; P = .007), whereas temperature-related SSEP changes were not (P = .997). Finally, any IONM change (either SSEP or EEG) was correlated with operative mortality (OR, 5.82; 95% CI, 2.72-12.49; P .001).Abnormal IONM events during aortic arch reconstruction with HCA portend worse neurologic outcomes and operative mortality and have a negative predictive value of 97.1%. SSEP might be more sensitive than EEG for predicting early ANE, especially when SSEP changes are permanent.

There is a known association between need for transfusion and short-term outcomes in patients undergoing cardiac surgery. However long-term data are lacking in the contemporary literature.All patients who underwent open cardiac surgery from 2010 to 2018 were included, except those undergoing transplant, with a ventricular-assist device, and requiring circulatory arrest. Primary outcome included short- and long-term mortality. Secondary outcomes included postoperative complications and hospital readmissions.The total patient population included 14,281 patients with a median follow-up of 4.03 years (range, 2.25-6.1). Outcomes were stratified into patients with (n = 6239) or without (n = 8042) packed red blood cell (PRBC) use. Patients with PRBC transfusions had significantly (P.001) worse postoperative outcomes compared with those without PRBC use, including higher operative mortality (6.89% vs 0.98%), return to the operating room (17.8% vs 1.61%), pneumonia (7.84% vs 0.98%), stroke (3.22% vs 1.51%), sepsis (2.66% vs 0.20%), renal failure (8.42% vs 1.12%), and dialysis (5.74% vs 0.42%). On multivariate analysis PRBC transfusion was an independent predictor of mortality (hazard ratio [[HR], 2.39; 95% confidence interval [CI], 2.08-2.64; P.001) and hospital readmission (HR, 1.15; 95% CI, 1.09-1.21; P.001). Total units of PRBCs were directly associated with mortality (HR, 1.09; 95% CI, 1.08-1.09; P.001) and hospital readmissions (HR, 1.02; 95% CI, 1.01-1.03; P.005).Patients with perioperative PRBC transfusions have increased operative and long-term mortality and hospital readmissions. Total units of PRBCs transfused were directly associated with mortality and readmissions.

Objectives The aim of this study was to examine real-world experience with repeat transcatheter aortic valve replacement (TAVR) in a population-based national database. Background Repeat TAVR is a growing option in patients requiring reintervention for TAVR. However, large-scale studies with longitudinal follow-up are limited. Methods All Medicare beneficiaries who underwent TAVR from 2012 to 2017 were included. Outcomes included 30-day and longitudinal mortality and major adverse cardiovascular events, defined as death, stroke, pacemaker insertion, major bleeding, acute kidney injury, or cardiac arrest. Outcomes of repeat TAVR were compared with surgical explantation after TAVR (TAVR explantation) in a matched analysis. Results Of 133,250 patients who underwent TAVR, 617 (0.46%) underwent subsequent repeat TAVR at a median interval of 154 days (interquartile range: 58-537 days). Mortality at 30 days and 1 year was 6.0% and 22.0%, respectively. Rates of 30-day stroke and pacemaker insertion were 1.8% and 4.2%. Mortality at 30 days was lower in those who underwent their first TAVR during the later era (2015-2017) compared with earlier years (2012-2014) (4.6% vs 8.7%; P = 0.049). Repeat TAVR was associated with lower 30-day mortality compared with a matched group undergoing TAVR explantation (6.2% vs 12.3%; P = 0.05), although 1-year mortality was similar (21.0% vs 20.8%; P = 1.000). The incidence of 30-day major adverse cardiovascular events was higher with TAVR explantation compared with repeat TAVR (risk ratio: 2.92; 95% CI: 1.88-4.99; P ≤ 0.001). Conclusions Repeat TAVR was performed with acceptable 30-day mortality in this high-risk population. Short-term outcomes were superior to surgical explantation, but 1-year outcomes were similar. Repeat TAVR will likely be an important option for aortic valve reintervention after TAVR.

Background Readmissions following transcatheter aortic valve replacement (TAVR) are common but detailed analysis of cardiac and non-cardiac inpatient readmissions beyond thirty days to different levels of care are limited. Methods Our study population was 1,037 consecutive patients who underwent TAVR between 2011-2017 within a multi-hospital quaternary health system. A retrospective chart review was performed and readmissions were adjudicated and classified based on primary readmission diagnosis (cardiac versus noncardiac) and level of care [intensive care unit (ICU) admission vs. non-ICU admission]. Incidence, causes, and outcomes of readmissions to up to three years post procedure were evaluated. Results Of the 1,017 patients who survived their index hospitalization, there were readmissions due to noncardiac causes in 350 (34.4%) and cardiac causes in 208 (20.5%) during a mean 1.96 years of follow-up. The most common non-cardiac causes of readmission were sepsis/infection (14.3%), gastrointestinal (8.3%), and respiratory (4.8%), whereas heart failure (14.0%) and arrhythmias (4.6%) were the most common cardiac causes of readmission. A total of 191 (18.8%) patients were readmitted to the ICU and 372 patients (36.6%) were non-ICU readmissions. The risk of a noncardiac readmission was highest in the period immediately following TAVR (~4.5% per month) with an early high hazard phase that gradually declined over months. However, the risk of cardiac readmission remained stable at ~1% per month throughout. TAVR patients that were readmitted for any cause had markedly increased mortality; this was especially true for patients readmitted to an ICU. Conclusions In TAVR patients who survived their index hospitalization, non-cardiac readmissions were more prevalent than cardiac. The risk of readmission and subsequent mortality was highest immediately post-procedure and declined thereafter. Readmission to ICU portends the highest risk of subsequent death in this cohort. Patient baseline co-morbidities are an important consideration for TAVR patients and play a significant role in readmissions and outcomes.

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.

BackgroundCalcific aortic valve disease (CAVD) is the pathological remodeling of the valve leaflets which leads to heart failure and high stroke risk. While several mechanisms are known to drive cardiovascular calcification, the initial steps orchestrating the osteogenic reprogramming of cells are not fully understood. Non-canonical functions of telomerase reverse transcriptase (TERT) include service as a cofactor to stimulate gene transcription, and TERT overexpression primes mesenchymal stem cells to differentiate into osteoblasts. We investigated whether TERT contributes to osteogenic reprogramming of valve interstitial cells.MethodsBaseline transcription of TERT and osteogenic markers, senescence, DNA damage, and telomere length in valve tissue and primary aortic valve interstitial cells (VICs) from control and CAVD patients were assessed. TERT expression was depleted in cells using lentiviral vectors. Cells from Tert+/+ and Tert-/- mice were used to validate human findings. Immunofluorescence staining, proximity ligation assay, and chromatin immunoprecipitation assay were used in mechanistic experiments.ResultsTERT protein was highly expressed in calcified valve leaflets, without changes in telomere length, DNA damage, or senescence. These phenotypic features were retained in primary VICs isolated and cultured from those diseased tissues. TERT levels were increased with osteogenic or inflammatory stimuli, and genetic deletion or reduction of TERT prevented calcification of VICs isolated from humans and mice. Similar results were seen in smooth muscle cells (SMCs) and mesenchymal stem cells (MSCs). TERT and Signal Transducer and Activator of Transcription 5A/B (STAT5) colocalize and bind to the Runt-Related Transcription Factor 2 (RUNX2) gene promoter, and TERT and STAT5 co-localized in calcified valve tissues. Pharmacological inhibition of STAT5A prevented calcification in vitro.ConclusionsThese data show that non-canonical TERT activity is required for the calcification of VICs. TERT partners with STAT5A to bind to and activate the RUNX2 gene promoter. These data identify a novel therapeutic target to abate vascular calcification.Novelty and SignificanceWhat Is Known?Calcific aortic valve disease (CAVD) is the most prevalent form of aortic valve pathology. CAVD strongly correlates with age and leads to heart failure and a high risk of stroke. Currently, the only therapeutic option is valve replacement, which comes with significant healthcare costs and additional risks to patients.Runt-related transcription factor 2 (RUNX2) is the master transcription factor required for osteogenic differentiation of osteoblasts and osteogenic reprogramming of vascular cells, yet the early events driving its transcription in valve cells are not well defined.Overexpression of TERT primes mesenchymal stem cells to differentiate down the osteoblast lineage, suggesting that TERT signaling plays an important role in cell differentiation and phenotype.What New Information Does This Article Contribute?TERT protein is highly expressed in calcified aortic leaflets and valve interstitial cells, independent of changes in telomere length.Genetic loss or depletion of TERT blocks calcification in valve interstitial cells, coronary smooth muscle cells, and mesenchymal stem cells.TERT co-localizes with STAT5 in the cytosol and on the RUNX2 gene promoter, the master regulator of osteogenic transcriptional programs.Pharmacological inhibition of STAT5 prevents calcification of human valve interstitial cells, coronary smooth muscle cells, and mesenchymal stem cells.What are the clinical implications?We have identified TERT/STAT5 as novel signaling axis that promotes the early transcriptional reprogramming in cardiovascular cells. Inhibiting TERT and STAT5 interaction and activity can be leveraged for the development of pharmacological or biological therapeutic strategies to halt or prevent calcification in the aortic valve and perhaps other cardiovascular tissues.Surgical procedures are currently the only treatment option for patients with CAVD. Discovering the early events driving vascular calcification identifies novel and druggable targets for the development of non-surgical therapies.

Aortic stenosis is the most common valvular disease requiring valve replacement. Valve replacement therapies have undergone progressive evolution since the 1960s. Over the last 20 years, transcatheter aortic valve replacement has radically transformed the care of aortic stenosis, such that it is now the treatment of choice for many, particularly elderly, patients. This review provides an overview of the pathophysiology, presentation, diagnosis, indications for intervention, and current therapeutic options for aortic stenosis.

This study sought to identify the optimal temperature for moderate hypothermic circulatory arrest in patients undergoing elective hemiarch replacement with antegrade brain perfusion.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.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).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.

The STS-ACC TVT Registry (Society of Thoracic Surgeons–American College of Cardiology Transcatheter Valve Therapy Registry) from 2011 to 2019 has collected data on 276,316 patients undergoing transcatheter aortic valve replacement (TAVR) at sites in all U.S. states. Volumes have increased every year, exceeding surgical aortic valve replacement in 2019 (72,991 vs. 57,626), and it is now performed in all U.S. states. TAVR now extends from extreme- to low-risk patients. This is the first presentation on 8,395 low-risk patients treated in 2019. In 2019, for the entire cohort, femoral access increased to 95.3%, hospital stay was 2 days, and 90.3% were discharged home. Since 2011, the 30-day mortality rate has decreased (7.2% to 2.5%), stroke has started to decrease (2.75% to 2.3%), but pacemaker need is unchanged (10.9% to 10.8%). Alive with acceptable patient-reported outcomes is achieved in 8 of 10 patients at 1 year. The Registry is a national resource to improve care and analyze TAVR’s evolution. Real-world outcomes, site performance, and the impact of coronavirus disease 2019 will be subsequently studied. (STS/ACC Transcatheter Valve Therapy Registry [TVT Registry]; NCT01737528 )

Social determinants of health, including neighborhood socioeconomic status (NSES), are increasingly being associated with disparate outcomes in those undergoing cardiac procedures. The objective of this study was to determine the effect of NSES on outcomes after coronary artery bypass grafting (CABG).Adults undergoing isolated CABG between July 2011 and December 2017 were retrospectively reviewed. Neighborhood median household income (NMI) and neighborhood high school graduation rate (NHS) were obtained by individual patient ZIP code from the American FactFinder Database. Primary outcome was 5-year all-cause mortality stratified by NMI quartile. Secondary end points included mortality risk by NHS, freedom and frequency of readmission, and mortality and readmission predictors.During the study period, 5243 patients underwent CABG. Increasing NMI quartile was associated with increasing age, male sex, white race, decreased diabetes prevalence, decreased active smoker status, and decreased lung disease (all P.05). Although no difference in 30-day mortality was observed, lower NMI quartiles were associated with increased longitudinal mortality through 5 years (log-rank P.01). Lower NMI quartile was associated with increased blood transfusions and sternal wound infections. Multivariable modeling demonstrated multiple complex associations between socioeconomic status variables (race, sex, age, NMI, and NHS) for mortality and readmission.NSES affects longer-term outcomes after CABG. Patient-focused NSES interventions and incorporation of NSES variables into prediction models may improve prediction and outcomes after CABG.

Background This study evaluated the performance of a machine learning (ML) algorithm in predicting outcomes of surgical aortic valve replacement (SAVR). Methods Adult patients undergoing isolated SAVR in The Society of Thoracic Surgeons (STS) National Database between 2007 and 2017 (n = 243,142) were randomly split 4:1 into training and validation sets. Outcomes that were evaluated were those for which STS models exist. The ML algorithm extreme gradient boosting (XGBoost) was used. Model calibration was measured by the ratio of observed to expected risk, calibration-in-the-large, and slope of calibration curve, and model discrimination was measured by the c-index. Results XGBoost demonstrated excellent calibration, with an average observed-to-expected ratio of 0.985, calibration-in-the-large of −0.017, and slope of calibration curve of 0.944. The c-index of XGBoost was significantly improved compared with STS models for 5 of 7 outcomes: operative mortality (77.1% [95% confidence interval {CI}, 75.8% to 78.4%] vs 76.2% [95% CI, 75.0% to 77.6%]; P = .007), prolonged ventilation (73.9% [95% CI, 73.1% to 74.6%] vs 72.6% [95% CI, 71.9% to 73.4%]; P Conclusions The ML algorithm XGBoost demonstrated excellent calibration and modest improvements in discriminatory ability compared with existing STS models in this study of isolated SAVR.

The aim of the current study was to assess the impact of hospital readmissions within 30-days of discharge, on long-term postoperative outcomes. All patients who underwent cardiac surgery from 2011 - 2018 were included. Patients who had transcatheter procedures, VAD, and transplant were excluded. Inverse probability of treatment weighting (IPTW) propensity scoring was used for population risk adjustment. Multivariable analysis was performed to identify association with long-term mortality and readmission. The total risk adjusted (propensity scoring with IPTW) patient population consisted of 14,538 patients divided into those who were not readmitted in 30-days (nonreadmitted) (n = 12,627) and patients who were readmitted within 30-days (30-day readmitted) (n = 1911). Following IPTW, all baseline characteristics and postoperative complications were equivalent between cohorts (SMD0.10). Patients who required intraoperative [OR 1.178 (1.05, 1.32); P = 0.006] and postoperative [1.32 (1.18, 1.48); P0.001] blood transfusions were at greater risk for 30-day readmission. Median follow-up period was 4.19 years (2.45 - 6.10). The 30-day readmission cohort had a significantly higher mortality risk during early (6 months) follow-up [HR 2.49 (2.01-3.10); P0.001] and late (60 months) follow-up [HR 1.30 (1.16-1.47); P0.001]. After risk adjustment, the 30-day readmission cohort was significantly associated with increased mortality over the study follow-up period [HR 1.62 (1.48, 1.78); P0.001]. 30-day readmissions were an independent predictor of subsequent long-term hospital readmission [HR 1.61 (1.50, 1.73); P0.001]. Patients who require 30-day readmissions following cardiac surgery are at increased risk of long-term mortality and repeat readmissions. Early postoperative hospital readmission may be a marker for worse long-term outcomes in cardiac surgery.

Reoperative coronary artery bypass grafting (CABG) surgery has an established increased operative risk with worse perioperative morbidity and mortality. However, contemporary propensity-matched outcomes are limited in the existing literature.All patients who underwent CABG from 2011 to 2017 at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania were included. Propensity matching yielded risk-adjusted patient populations. Cox regression analysis was performed to identify independent predictors of 30-day, 1-year, and 5-year mortality and readmission.The total population consisted of 7615 patients who underwent CABG; 7265 of these patients had first-time CABG, and 350 patients had reoperative CABG. After propensity score matching, blood product transfusion (45.5% vs 56.4%; P = .002) and delayed sternal closure (0.2% vs 2.5%; P.001) remained significantly higher for reoperative CABG. There was no difference in 30-day (5.3% vs 7.5%; P = .19) or 1-year (12.1% vs 14.8%; P = .23) mortality for first-time vs reoperative CABG. Five-year mortality was significantly higher for the reoperative cohort (28.5% vs 38.3%; P = .03). There was no difference in 30-day, 1-year, or 5-year hospital readmissions. On Cox multivariable regression analysis, reoperative CABG was not a predictor of mortality or readmission at 30 days, 1 year, or 5 years.After propensity score matching, there was no difference in postoperative mortality or readmission for reoperative CABG up to 1-year. This trend continued for 5-year readmissions; however, 5-year mortality was higher for the reoperative cohort. Risk adjustment did not identify reoperative CABG as a risk factor for long-term mortality.

Background Prior reports of mitral valve surgery (MVS) for ischemic papillary muscle rupture (PMR) have been limited in patient numbers. This study evaluated national outcomes of MVS for PMR using the Society of Thoracic Surgeons (STS) National Database. Methods The study cohort was comprised of patients undergoing MVS for ischemic PMR between 2011 to 2018 in the STS registry. Concomitant procedures were included. The primary outcome was operative mortality. Secondary outcomes included STS major morbidities. Multivariable logistic regression was used for risk-adjustment using clinically important variables as well as those predictive in univariate analysis. Results 1,342 patients underwent MVS for PMR during the study period. The majority of these were mitral valve replacements (79.8%; n=1,071) and were performed emergently (52.0%; n=698). Concomitant coronary artery bypass grafting (CABG) was performed in 59.3% (n=796). Mechanical circulatory assistance prior to MVS included intra-aortic balloon pump (56.9%; n=764), Impella (4.1%; n=55), and extracorporeal membrane oxygenation (3.1%; n=41). STS predicted risk of mortality was 16.9% ± 15.4%. Operative mortality was 20.0%. Blood products were transfused in 70.7% (n=949). Major morbidity rates included prolonged ventilation (61.8%; n=829), acute renal failure (15.4%; n=206), reoperation (10.2%; n=137), and stroke (5.2%; n=70). Multivariable predictors of operative mortality included mitral valve replacement, older age, lower albumin, cardiogenic shock, ejection fraction Conclusions These data provide a national overview of outcomes following MVS for PMR. Rates of mortality and morbidity are high but the majority of patients survive operative intervention in this high-risk and otherwise lethal condition.

Background Coronary artery disease has historically been responsible for more deaths among women than men, and previous studies have suggested sex differences in revascularization approaches and outcomes. We sought to compare sex-specific adverse events in patients who underwent percutaneous or surgical revascularization for multivessel coronary artery disease. Methods All patients at a single institution undergoing percutaneous coronary intervention or coronary artery bypass graft surgery for multivessel coronary artery disease between 2011 and 2018 were included. Propensity score matching was utilized to compare patients with similar baseline characteristics. Outcomes included death, major adverse cardiac and cerebrovascular events (MACCE), repeat revascularization, and readmissions. Results Of the 6163 patients, 1679 (27.2%) were female. Male patients were more likely to have three-vessel disease (71.9% vs 68.6%, P = .002) and to undergo complete revascularization (69.9% vs 66.4%, P = .008). Female sex was associated with an increased hazard for death (hazard ratio 1.16, P = .03) and MACCE (hazard ratio 1.16, P = .02) but not repeat revascularization (hazard ratio 1.23, P = .16). In the matched cohorts, female sex was associated with lower survival at 1 year (90.63% vs 93.12%, P = .01) but not at 5 years (76.64% vs 77.33%, P = .20). Similarly, freedom from MACCE was lower for female patients at 1 year (87.79% vs 90.19%, P = .03) but was comparable at 5 years (73.22% vs 74.3%, P = .10). Conclusions In a matched analysis pooling percutaneous and surgical revascularization, female sex was associated with worse outcomes at 1 year although there were no sex differences at 5 years of follow-up. Increasing coronary artery bypass graft surgery utilization and the completeness of revascularization in female patients may be targets for improving 1-year survival and freedom from MACCE.

Objective Long-term outcomes after cardiac surgery in solid organ transplant recipients are limited in the contemporary literature. The objective of this study is to evaluate postoperative outcomes in these patients, including variables associated with mortality and readmissions. Methods All adults undergoing isolated coronary artery bypass grafting, isolated valve, or coronary artery bypass grafting + valve cardiac surgical procedures from 2011 to 2018 were included in this study. Patients with solid organ transplants undergoing cardiac surgery were studied. Primary outcomes included operative (30-day) and 5-year mortality. Results A total of 11,190 patients underwent isolated coronary artery bypass grafting, isolated valve, or coronary artery bypass grafting + valve operations at our institution from 2011 to 2018. Of these, 129 patients (1%) had solid organ transplants and underwent isolated coronary artery bypass grafting (n = 84), isolated valve (n = 30), or coronary artery bypass grafting + valve (n = 15). Type of organ transplant included 84 patients (65%) with kidney, 27 patients (21%) with liver, 9 patients (7%) with heart, and 9 patients (7%) with lung transplants. The median Society of Thoracic Surgeons Predicted Risk Of Mortality for the cohort was 2.73 (Q1-Q3: 1.67-6.33). Three patients (2%) had an operative (30-day) mortality. Significant variables associated with 5-year mortality on multivariable Cox regression analysis included chronic obstructive pulmonary disease (hazard ratio, 2.44; 1.01-5.90; P = .048) and congestive heart failure (hazard ratio, 4.45; 1.81-10.9; P = .001). Significant variables associated with 5-year readmissions included chronic obstructive pulmonary disease, dialysis dependence, and concomittant valve surgery with coronary artery bypass grafting. Five-year readmission rate was 88%, and patients with valve operations (± coronary artery bypass grafting) had significantly lower (P = .009) freedom from readmission (6%). Conclusions Cardiac surgery can be performed with low operative mortality and good long-term survival in patients with solid organ transplants. Five-year hospital readmissions are common, with significantly more readmissions in patients who had valve procedures.

Introduction Large institutional and administrative datasets that have compared on pump versus off pump first time coronary artery bypass grafting (CABG). However, comparison of off-pump vs on-pump outcomes in patients undergoing redo CABG are limited in current literature. Methods All patients who underwent redo CABG for coronary artery disease from 2011 to 2017 at our institution were included in the study. Cox regression analysis was performed to identify variables associated with 5-year mortality and readmission. Results Three hundred and fifty patients underwent redo CABG; of which, 309 underwent on-pump CABG and 41 underwent off-pump CABG. Blood product transfusion (31.7% vs 58.9%; p = 0.001) and new onset atrial fibrillation (17.1% vs 35.6%; p = 0.018) were higher in the on-pump cohort. There was no difference in 30-day (2.4% vs 8.1%; p = 0.209), 1-year (4.9% vs 16.5%; p = 0.074), or 5-year mortality (31.7% vs 35.6%; p = 0.213) for off vs on pump redo CABG. There was no difference in 30-day or 1- hospital readmissions between groups. Five-year all cause readmissions (76.9% vs 55.3%; p = 0.037) was significantly higher in the off-pump redo CABG group. On multivariable analysis, on vs. off pump CABG was not significantly associated with mortality or readmission at 5 years. Conclusion There was no short or long-term survival advantage for on-pump vs off-pump CABG despite risk adjustment. Hospital readmissions at 5-years were higher in the off-pump group.

BACKGROUND: The optimal revascularization approach for patients with multivessel coronary artery disease (MVCAD) is controversial. We sought to investigate outcomes in patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for non-ST elevation myocardial infarction (NSTEMI). METHODS: Adult patients with MVCAD and NSTEMI undergoing either CABG or PCI at a single institution between 2011 and 2018 were included. Multivariable analysis was utilized to determine independent predictors of death, major adverse cardiac and cerebrovascular events (MACCE), and readmissions. A subanalysis examined patients undergoing complete revascularization. RESULTS: A total of 2001 patients were included, of whom 1480 (74.0%) underwent CABG. CABG was associated with a lower risk-adjusted hazard for death (hazard ratio, 0.59, P < .001) and with improved survival at 1 year (92.0 vs 81.8%, P < .001) and 5 years (80.7 vs 63.3%, P < .001). Additionally, freedom from MACCE (P < .001) was greater in the CABG group and cumulative readmission, rates of MI, and rates of repeat revascularization were lower with CABG (each P < .001). Among patients undergoing complete revascularization, overall survival (1 year: 92.7 vs 83.9%, P = .010; 5 years: 81.1 vs 69.4%, P < .001) and freedom from MACCE (1 year: 92.3 vs 75.2%, P < .001; 5 years: 81.7 vs 61.4%, P < .001) remained higher for the CABG group; cumulative incidence of readmission was also decreased in those undergoing CABG (P < .001). CONCLUSIONS: In this real-world analysis of patients with MVCAD presenting with NSTEMI, revascularization with CABG resulted in improved survival with lower rates of MACCE and readmission as compared to PCI, which persisted when accounting for complete revascularization.

Objectives Recruiting medical students to cardiothoracic surgery is critical given new training paradigms and projected cardiothoracic surgeon shortages. This study characterizes current perceptions and exposure to cardiothoracic surgery among all levels of medical students. Methods Currently active medical students at all levels at a US allopathic medical school were sent an invitation to complete an online survey. Baseline demographics, medical specialty interest, interest and exposure to cardiac surgery specifically, and awareness of procedures performed by cardiothoracic surgeons were evaluated. Five-point Likert scales were used to evaluate attitudes toward facets of the field of cardiothoracic surgery. Only complete surveys over the 4-week enrollment period were used for analysis. Results There were 126 surveys (22%) completed during the study period. Interest in cardiothoracic surgery at any point was indicated by 37% of students, but only 13% indicated an interest at the time of the survey. Interest among first-year students was greater than all other classes (30% vs Conclusions Although medical students report early interest in cardiothoracic surgery because of intellectual stimulation and patient care attributes, lack of early exposure and perceived poor lifestyle negatively affect interest in the field. Early interaction between students and cardiothoracic faculty/trainees along with early exposure opportunities may increase recruitment.

Background Data on primary cardiac malignancies are limited to small single-center studies. Objectives The aim of the current study was to provide detailed outcomes for treatment of primary cardiac malignancies from a multi-institutional database. Methods Outcomes were acquired from the National Cancer Database for all solid primary cardiac malignancies from 2004 to 2016. The primary outcome was long-term survival. Logistic regression was used to determine factors associated with mortality. Results A total of 100,317 cardiac tumors were identified, of which 826 (0.8%) were primary malignant tumors. After exclusion criteria, the cohort consisted of 747 patients (median age 53 years, 47.5% women). Most tumors were primary sarcomas (88.5%), the majority of which were hemangiosarcoma (40.4%). A total of 136 patients received no therapy, 113 received just chemotherapy, and 20 received just radiation. Surgery was performed in 442 (59.2%) patients including 255 patients undergoing multimodal therapy (surgery with chemotherapy, radiation, or chemoradiation). With surgery alone, 90-day mortality was 29.4%. Overall 30-day, 1-year, and 5-year survival rates were 81.2%, 45.3%, and 11.5%, respectively. The surgery group as compared with the no surgery groups had significantly better long-term survival (p Conclusions Primary cardiac malignancies are rare cancers with dismal long-term survival despite mode of treatment. Patients who underwent surgery and those with stage III disease who received peri-operative chemotherapy had better survival compared with those who did not. However, there was likely a significant selection bias in patients chosen for surgical or medical therapy.

Background This study evaluated outcomes of mitral valve surgery (MVS) in the elderly. Methods Patients 75 years or older undergoing MVS at a single center between 2010 and 2018 were included. Patients were stratified into mitral valve repair (MVr) or replacement (MVR). The primary outcome was mortality. Secondary outcomes included postoperative complications, readmissions, and freedom from at least moderate mitral regurgitation. Multivariable Cox regression was used for risk adjustment. A subanalysis of isolated, non-reoperative MVS for degenerative disease was also performed. Results Elderly patients (n = 472) underwent MVS, 301 (64%) with MVr and 171 (36%) with MVR. The majority of cases (68%) were performed for degenerative etiologic process. Survival was similar between MVr and MVR at 1 year (84% versus 86%; P = .40) and 5 years (64% versus 64%; P = .59). Postoperative complications were also comparable. Freedom from readmission was lower in the MVR cohort at 1 year (57% versus 68%; P = .02) and 5 years (33% versus 43%; P = .02). In isolated MVS for degenerative etiologic process, there was no difference in early or late mortality between MVr and MVR, although readmissions were lower with MVr. Overall, freedom from mitral valve reoperation was comparable, and the freedom from at least moderate regurgitation was 86% at 5 years in the MVr group. Conclusions This study indicates that the outcomes of elderly patients undergoing MVS are acceptable with approximately 64% survival at 5 years. Our data suggest that MVr in the elderly may not confer a survival advantage but can be performed with durable results.

Background Left subclavian revascularization has become an integral part of thoracic endovascular aortic repair to extend the proximal landing zone. This is most commonly achieved via carotid-subclavian bypass; however, this can be achieved via vessel transposition. Methods All patients who had zone 2 thoracic endovascular aortic repairs without branched grafts from 2007 to 2018 were included in the study. The primary outcomes were adverse events, including operative mortality, paraplegia, left arm ischemia, and stroke. Multivariable regression analysis was performed for baseline characteristics associated with adverse events. Results A total of 58 patients underwent left subclavian artery transposition for zone 2 thoracic endovascular aortic repair coverage. Operative (30-day) mortality occurred in 3 patients (5.2%). The majority of patients were operated on under urgent (N = 25; 43.1%) or emergency (N = 12; 20.7%) status. Indications for thoracic endovascular aortic repair included aneurysmal disease (34.5%) and type B aortic dissection (chronic [13.8%]; acute [51.7%]). Major adverse events included paraplegia (N = 1; 1.7%), transient paraparesis (N = 3; 5.2%), and stroke (N = 2; 3.4%). Over a mean follow-up of 2.8 years, there were 5 deaths (8.6%). On multivariable analysis, prior stroke (odds ratio, 31.4; 1.95-506.72; P = .02) was an independent predictor of adverse events. Conclusions Carotid-subclavian transposition offers patients a safe and effective method for left subclavian artery revascularization during thoracic endovascular aortic repair with zone 2 coverage with no increased operative risk and a low complication rate.