Search

Studies have demonstrated the devastating effects of coronavirus disease 2019 (COVID-19) on vulnerable populations. Although they receive close follow-up, heart transplant recipients represent a particularly vulnerable population, given long-term immunosuppression and comorbid conditions. We sought to investigate the association between race/ethnicity and the probability of death due to COVID-19 in adult heart transplant recipients in the United States.Adult isolated heart transplant recipients were identified using the Organ Procurement and Transplantation Network database. Recipients who were described as deceased or lost to follow-up before January 2020 were excluded. Recipients were stratified into 4 cohorts by race/ethnicity. The primary outcome of interest was death due to COVID-19.A total of 22 157 adult recipients were identified. During the course of follow-up, 153 recipients had COVID-19 reported as the primary cause of death. COVID-19 mortality was significantly different between race/ethnicity cohorts (Black, n = 34 [0.79%]; Hispanic, n = 23 [1.33%]; White, n = 92 [0.60%]; other, n = 4 [0.44%]; P = .007). COVID-19 was listed as a contributing cause of mortality in 0.12% of Black, 0.23% of Hispanic, 0.04% of White, and 0.33% of other recipients (P = .002). No significant difference in non-COVID mortality or all-cause mortality was observed. After multivariable adjustment, Black (hazard ratio, 2.78 [1.40-5.52]; P = .003) and Hispanic (hazard ratio, 3.92 [1.88-8.16]; P.001) recipients were at higher risk of death due to COVID-19 compared with White recipients.Compared with White recipients, Black and Hispanic recipients experienced higher rates of COVID-19 mortality after transplantation. These findings suggest that racial/ethnic disparities of COVID-19 mortality in the general population persist in adult heart transplant recipients.

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.

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.

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.

This study aims to compare treatments and outcomes of mechanical complications of acute myocardial infarction (MI) during the Covid-19 and in the pre-Covid-19 era. Electronic databases have been searched for MI mechanical complications during the Covid-19 era and in the previous period from January 1998 to January 2020 (pre-Covid-19 era), until October 2021. To perform a quantitative analysis of non-comparative series, a meta-analysis of proportion has been conducted. Early mortality after surgical treatment was 15.0% while it was significantly higher after conservative treatment (62.4%) (P = 0.026). Early mortality after surgical treatment was seemingly higher in the pre-Covid-19 era but the difference did not reach statistical significance (15.0% vs 38.9%; P = 0.13). Mortality in patients treated conservatively, or turned down for surgery, was lower during the Covid-19 pandemic (62.4% vs 97.7%; P = 0.001). The crude mean prevalence of the use rate of conservative or surgical treatment across the studies during Covid-19 and in the pre-Covid-19 era was comparable. The current increased incidence of MI mechanical complications might be a consequence of delayed presentation or restricted access to hospital facilities. Despite the general negative impact of Covid-19 on cardiac surgery volumes and outcomes and the apparent increase of the incidence of MI complications, the outcomes of their surgical and clinical treatment seem not to have been affected during the pandemic.

Background Historically, a glomerular filtration rate (GFR) of less than 50 mL/min per 1.73 m2 has been considered a contraindication to lung transplantation. Combined or sequential lung–kidney transplantation is an option for those with a GFR less than 30 mL/min per 1.73 m2. Patients with a GFR of 30 to 50 mL/min per 1.73 m2 are provided with no options for transplantation. This study explores factors associated with improved survival in patients who undergo isolated lung transplantation with a GFR of 30 to 50 mL/min per 1.73 m2. Methods The United Network for Organ Sharing database was queried for adult patients undergoing primary isolated lung transplantation between January 2007 and March 2018. Regression models were used to identify factors associated with improved survival in lung recipients with a preoperative GFR of 30 to 50 mL/min per 1.73 m2. The propensity score method was used to match highly performing patients (outpatient recipients aged less than 60 years) with a GFR of 30 to 50 mL/min per 1.73 m2 with patients who had a GFR greater than 50 mL/min per 1.73 m2. Kaplan-Meier, Cox, and logistic regression analyses compared outcomes in matched populations. Results A total of 21,282 lung transplantations were performed during the study period. Compared with patients with a GFR greater than 50 mL/min per 1.73 m2, survival was significantly worse for patients with a GFR of 30 to 50 mL/min per 1.73 m2. Multivariate analysis of patients with a GFR of 30 to 50 mL/min per 1.73 m2 demonstrated outpatient status and age less than 60 years to be predictive of superior survival. After propensity matching, survival of this highly performing subset with a GFR of 30 to 50 mL/min per 1.73 m2 was no different from that of patients with a normal GFR. Conclusions Outpatient recipients aged less than 60 years represent an optimal subset of patients with a GFR of 30 to 50 mL/min per 1.73 m2. Lung transplant listing should not be declined based only on a GFR less than 50 mL/min per 1.73 m2.

Background Treatment guidelines for nonvalvular atrial fibrillation (AF) recommend use of non–vitamin K antagonist oral anticoagulants (NOACs) over warfarin, yet clinical trials excluded individuals with post cardiac surgery AF. We sought to compare outcomes with NOACs vs warfarin for new onset post cardiac surgery AF. Methods We examined 26,522 patients from The Society of Thoracic Surgeons’ database with post cardiac surgery AF who were discharged on oral anticoagulation from July 2017–December 2018. Three primary outcomes were evaluated: 30-day mortality, major bleeding complications, and stroke/transient ischemic attack. Secondary outcomes included postoperative length of stay, 30-day myocardial infarction, venous thromboembolism, and pericardial effusion/tamponade. Results A total of 9769 (36.8%) participants were prescribed NOACs and 16,753 (63.2%) warfarin. In multivariable analysis, there was no association between type of anticoagulant and 30-day major bleeding complications (odds ratio [OR]NOAC/warfarin 0.76, 95% confidence interval [CI] 0.49-1.18), stroke/transient ischemic attack (ORNOAC/warfarin 0.94, 95% CI 0.53-1.67) or mortality (ORNOAC/warfarin 1.08, 95% CI 0.80-1.45). After stratification by renal function or isolated coronary bypass vs valve surgery, there remained no difference in the primary outcomes. Additionally, there was no difference in 30-day myocardial infarction (ORNOAC/warfarin 1.17, 95% CI 0.62-2.22), venous thromboembolism (ORNOAC/warfarin 0.91, 95% CI 0.47-1.78), or pericardial effusion/tamponade (ORNOAC/warfarin 1.09, 95% CI 0.80-1.47) between the 2 groups. NOAC therapy was associated with a half-day reduction in postoperative length of stay (βNOAC/warfarin –0.47, 95% CI –0.62 to –0.33). Conclusions NOACs are associated with a reduction in postoperative length of stay, without excess bleeding or other short-term complications, compared with warfarin. These findings support the broader use of NOACs as a safe alternative to warfarin in patients with post cardiac surgery AF at elevated stroke risk and acceptable bleeding risk.

Background Most studies of patients with isolated proximal left anterior descending (PLAD) coronary artery disease do not include all 3 procedural options: percutaneous coronary intervention (PCI), conventional coronary artery bypass graft (CABG) surgery, or minimally invasive CABG. Methods New York’s cardiac registries were used to identify patients who underwent revascularization for isolated PLAD disease between January 1, 2010, and November 30, 2016, in New York State. After exclusions, 14,327 patients, of whom 13,115 received PCI, 1001 of whom underwent CABG surgery, and 211 of whom underwent minimally invasive CABG were monitored through the end of 2017 to compare outcomes. Registry data were matched to vital statistics data to obtain deaths occurring after discharge and matched to claims data to obtain subsequent admissions for myocardial infarction and stroke. Results There were no significant differences in mortality or in mortality/myocardial infarction/stroke after 7 years (with median follow-up times in excess of 4 years) among the 3 procedures after adjusting for differences in patient risk factors. However, conventional CABG surgery was associated with a lower subsequent revascularization rate than PCI (adjusted hazard ratio, 0.45; 95% confidence interval, 0.35-0.58) and minimally invasive CABG surgery (adjusted hazard ratio, 0.46; 95% confidence interval, 0.32-0.66). Conclusions Among patients with isolated PLAD disease undergoing any of 3 revascularization options (PCI, conventional CABG surgery, or minimally invasive CABG surgery), conventional CABG surgery was associated with lower subsequent revascularization rates, but there were no differences in mortality or mortality/myocardial infarction/stroke rates.

Approximately one-quarter of patients with acute type A aortic dissection (TAAD) present with concomitant malperfusion of coronary arteries, mesenteric circulation, lower extremities, kidneys, brain, and/or coma. It is generally accepted that TAAD patients who present with malperfusion experience higher mortality rates than patients without, although how specific malperfusion syndromes, alone or in combination, affect mortality is not well described.The International Registry of Acute Aortic Dissection database was queried for patients who underwent surgical repair of TAAD. Patients were stratified according to the presence/absence of malperfusion at presentation. Multivariable logistic regression was used to evaluate in-hospital mortality according to malperfusion type. Kaplan-Meier estimates were used to estimate 30-day postoperative survival.Six thousand four hundred thirty-seven patients underwent surgical repair of acute TAAD, of whom 2642 (41%) had 1 or more preoperative malperfusion syndromes. Mesenteric malperfusion (adjusted odds ratio [AOR], 4.84; P .001) was associated with the highest odds of in-hospital mortality, followed by coma (AOR, 1.88; P = .007), limb ischemia (AOR, 1.73; P = .008), and coronary malperfusion (AOR, 1.51; P = .02). Renal malperfusion (AOR, 1.37; P = .24) and neurologic deficit (AOR, 1.35; P = .28) were not associated with increased in-hospital mortality. In patients who survived to discharge, there was no difference in 1-year postdischarge survival in the malperfusion and no malperfusion cohorts (P = .36).Survival during the index admission after TAAD repair varies according to the presence and type of malperfusion syndromes, with mesenteric malperfusion being associated with the highest odds of in-hospital death. Not only the presence of malperfusion but rather specific malperfusion syndromes should be considered when assessing a patient's risk of undergoing TAAD repair.

The objective of this study was to compare midterm outcomes of aortic valve-replacing root replacement (AVR) and aortic valve-sparing root replacement (AVS) operations in patients with Marfan syndrome.Patients who met strict Ghent diagnostic criteria for Marfan syndrome and who underwent either AVR or AVS between March 1, 2005 and December 31, 2010 were enrolled in a 3-year follow-up prospective, multicenter, international registry study; the study was subsequently amended to include 20-year follow-up. Enrollees were followed clinically and echocardiographically.Of the 316 patients enrolled, 77 underwent AVR and 239 underwent AVS; 214 gave reconsent for 20-year follow-up. The median clinical follow-up time for surviving patients was 64 months (interquartile range, 42-66 months). Survival rates for the AVR and AVS groups were similar at 88.2% ± 4.4% and 95.0% ± 1.5%, respectively (P = .1). Propensity score-adjusted competing risk modeling showed associations between AVS and higher cumulative incidences of major adverse valve-related events, valve-related morbidity, combined structural valve deterioration and nonstructural valve dysfunction, and aortic regurgitation ≥2+ (all P .01). No differences were found for reintervention (P = .7), bleeding (P = .2), embolism (P = .3), or valve-related mortality (P = .8).Five years postoperatively, major adverse valve-related events and valve-related morbidity were more frequent after AVS than after AVR procedures, primarily because of more frequent aortic valve dysfunction. No between-group differences were found in rates of survival, valve-related mortality, reintervention on the aortic valve, or bleeding. We plan to follow this homogenous cohort for 20 years after aortic root replacement.

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.

Item does not contain fulltext BACKGROUND: Acute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details. METHODS: Patients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI. RESULTS: A total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001). CONCLUSIONS: AKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI. 01 april 2023

Objective Current cardiac surgery risk models do not address a substantial fraction of procedures. We sought to create models to predict the risk of operative mortality for an expanded set of cases. Methods Four supervised machine learning models were trained using preoperative variables present in the Society of Thoracic Surgeons (STS) data set of the Massachusetts General Hospital to predict and classify operative mortality in procedures without STS risk scores. A total of 424 (5.5%) mortality events occurred out of 7745 cases. Models included logistic regression with elastic net regularization (LogReg), support vector machine, random forest (RF), and extreme gradient boosted trees (XGBoost). Model discrimination was assessed via area under the receiver operating characteristic curve (AUC), and calibration was assessed via calibration slope and expected-to-observed event ratio. External validation was performed using STS data sets from Brigham and Women's Hospital (BWH) and the Johns Hopkins Hospital (JHH). Results Models performed comparably with the highest mean AUC of 0.83 (RF) and expected-to-observed event ratio of 1.00. On external validation, the AUC was 0.81 in BWH (RF) and 0.79 in JHH (LogReg/RF). Models trained and applied on the same institution's data achieved AUCs of 0.81 (BWH: LogReg/RF/XGBoost) and 0.82 (JHH: LogReg/RF/XGBoost). Conclusions Machine learning models trained on preoperative patient data can predict operative mortality at a high level of accuracy for cardiac surgical procedures without established risk scores. Such procedures comprise 23% of all cardiac surgical procedures nationwide. This work also highlights the value of using local institutional data to train new prediction models that account for institution-specific practices.

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.

The current management of acute complicated type B aortic dissection is a combination of medical therapy and endovascular repair. Endovascular repair is not feasible when the dissection extends into the aortic arch. We describe 3 patients with acute type B aortic dissection complicated by retrograde arch extension and visceral malperfusion who were successfully treated with a total arch replacement and frozen elephant trunk.

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

Background Operative mortality (in-hospital during the index admission or within 30 days of the procedure after discharge) is commonly used as a quality of care measure for public reporting of cardiac surgery outcomes, but the ability to capture out-of-hospital deaths accurately remains undetermined. The objective of the study was to estimate the impact of incomplete reporting of out-of-hospital deaths on hospital risk-adjusted mortality and outlier status. Methods New York State’s 2014 to 2016 cardiac registry data were used to compare the capture of 30-day postprocedure deaths after discharge with and without the use of national and state-level vital statistics data for all 54,442 patients undergoing isolated coronary artery bypass graft, cardiac valve surgery, or both. Hospital risk-adjusted operative mortality rates and mortality outliers were compared based on statistical models that were developed with and without the use of vital statistics data. Results Thirty-day deaths postprocedure after discharge ranged from 10% to 39% of all operative deaths among cardiac surgical procedures. More than 30% of these deaths were missing without vital statistics confirmation for 7 of the 10 cardiac procedures examined, and more than 40% were missing for 5 of the procedures examined. When vital statistics data were used to confirm 30-day postprocedure deaths after discharge, an additional high outlier for valve surgery was identified. Conclusions Operative mortality after cardiac surgery is often underreported owing to a considerable percentage of out-of-hospital cardiac surgery deaths that are missed by reporting centers. This can adversely affect the assessment of hospital risk-adjusted mortality in public reports.

Summary and Background Data: VV ECMO can be utilized as an advanced therapy in select patients with COVID-19 respiratory failure refractory to traditional critical care management and optimal mechanical ventilation. Anticipating a need for such therapies during the pandemic, our center created a targeted protocol for ECMO therapy in COVID-19 patients that allows us to provide this life-saving therapy to our sickest patients without overburdening already stretched resources or excessively exposing healthcare staff to infection risk. Methods: As a major regional referral program, we used the framework of our well-established ECMO service-line to outline specific team structures, modified patient eligibility criteria, cannulation strategies, and management protocols for the COVID-19 ECMO program. Results: During the first month of the COVID-19 outbreak in Massachusetts, 6 patients were placed on VV ECMO for refractory hypoxemic respiratory failure. The median (interquartile range) age was 47 years (43–53) with most patients being male (83%) and obese (67%). All cannulations were performed at the bedside in the intensive care unit in patients who had undergone a trial of rescue therapies for acute respiratory distress syndrome including lung protective ventilation, paralysis, prone positioning, and inhaled nitric oxide. At the time of this report, 83% (5/6) of the patients are still alive with 1 death on ECMO, attributed to hemorrhagic stroke. 67% of patients (4/6) have been successfully decannulated, including 2 that have been successfully extubated and one who was discharged from the hospital. The median duration of VV ECMO therapy for patients who have been decannulated is 12 days (4–18 days). Conclusions: This is 1 the first case series describing VV ECMO outcomes in COVID-19 patients. Our initial data suggest that VV ECMO can be successfully utilized in appropriately selected COVID-19 patients with advanced respiratory failure.

Background To review the efficacy of a minimally invasive surgical technique for mitral valve (MV) repair, we analyzed a nonresectional technique for degenerative mitral regurgitation. Methods A retrospective analysis was performed on 101 consecutive patients who underwent a minimally invasive MV repair for severe degenerative mitral regurgitation between 2014 and 2017. All patients underwent a right lateral minithoracotomy and femoral cannulation and were repaired by a nonresectional technique using neochord loop implantation and ring annuloplasty. Patients were followed with longitudinal echocardiograms. Results The median age was 58 years (interquartile range [IQR], 49-64), and 31% were women. The procedure was successfully performed using a right minithoracotomy in all patients except for 1 who required an extended thoracotomy. A median of 4 neochords were placed. The median length was 16 mm (IQR, 14-18), and ring size was 34 mm (IQR, 32-36). Concomitant procedures included left atrial appendage exclusion in 10 patients (10%) and patent foramen ovale closure in 13 (13%). Median cardiopulmonary bypass time was 152 minutes (IQR, 142-164), and aortic cross-clamp time was 90 minutes (IQR, 81-98). Operative mortality was 0% and 1-year survival 100%. At 3 years freedom from recurrent at least moderate mitral regurgitation was 100%, and no patient required a valve-related reoperation. At 1 year the median left atrial diameter decreased by 15% (44 vs 37 mm, P Conclusions Minimally invasive MV repair using a nonresectional technique can be performed for severe degenerative mitral regurgitation with a low complication rate, excellent durability, and promising left ventricular reverse remodeling.