Immobile Leaflets at Time of Bioprosthetic Valve Implantation: A Novel Risk Factor for Early Bioprosthetic Failure: A Novel Risk Factor for Early Bioprosthetic Failure

OBJECTIVES

The clinical implications of finding immobile leaflet(s) at the time of bioprosthetic valve implantation but with acceptable prosthetic haemodynamics are uncertain. We sought to determine the characteristics of such patients and their impact on outcome.

METHODS

Patients with immobile leaflet at the time of surgical bioprosthetic valve implantation were identified retrospectively by a systematic search of an institutional echocardiography database (2010-2020). Intraoperative echocardiograms were reviewed de-novo to confirm immobile leaflet(s) at the time of implantation. Cases were matched 1:2 to controls with normal bioprosthetic leaflets motion for age, sex, prosthesis position, prosthesis model, size, year of implantation, and pre-implantation left ventricular ejection fraction. Proportional hazards method was used to analyse the composite endpoint of stroke, valve thrombosis or re-intervention.

RESULTS

Immobile leaflet at the time of bioprosthetic valve implantation were found in 26 patients (median age 71 ys 39% males) following tricuspid (n=13), mitral (n=11) and aortic (n=2) valve replacements; 96% received porcine prostheses; prosthesis size was 27 mm or larger in 92%. Immobile leaflet were recorded on intraoperative reports in 16 (62%) cases. It resulted in elevated gradient or mild-moderate prosthetic regurgitation in three (12%), but none led to immediate corrective action intraoperatively. At median follow-up of 21 (4-50) months, presence of immobile leaflet was associated with composite clinical endpoint of stroke, valve thrombosis or re-intervention (hazard ratio 6.8 95% CI 1.8-25.2 p<0.01) compared to controls.

CONCLUSION

Immobile leaflet immediately post-bioprosthetic valve implantation is frequently under-recognised intraoperatively and appears to be associated with early bioprosthetic dysfunction and worse clinical outcome.

Prevalence and risk of progressive aortic aneurysm and dissection in adults with conotruncal anomalies

AIMS

Conotruncal anomalies share common embryogenic defects of the outflow tracts and great arteries, which result in a predisposition to aortic aneurysms. The purpose of this study was to describe the prevalence and risk of progressive aortic aneurysms in adults with conotruncal anomalies.

METHODS AND RESULTS

Retrospective study of adults with conotruncal anomalies that underwent cross-sectional imaging 2003-20. Aneurysm was defined as aortic root/mid-ascending aorta >2.1 mm/m2/>1.9 mm/m2, progressive aneurysm as increase by >2 mm, and severe aneurysm as dimension >50 mm. Of 2261 patients (38 ± 12 years; male 58%), 1167 (52%) had an aortic aneurysm, and 205 (14%) had a severe aortic aneurysm. Mean annual increase in aortic root/mid-ascending aorta was 0.3 ± 0.1 mm/0.2 ± 0.1 mm. The 3-, 5-, and 7-year cumulative incidence of the progressive aortic aneurysm was 4%, 7%, and 9%, respectively. The rate of aneurysm growth decreased with age, with no significant growth after age 40 years. There was an excellent correlation between aortic indices from cross-sectional imaging and echocardiography. Of 950 females, 184 had ≥1 pregnancy, and 81 (44%) of the 184 patients had aortic aneurysm prior to pregnancy. There was no aortic dissection or progression of the aortic aneurysm during pregnancy. Overall, there was no aortic dissection during 7984 patient-years of follow-up.

CONCLUSIONS

Aortic aneurysm was common in patients with conotruncal anomalies. However, the risk of progressive aneurysm or dissection was low. Collectively, these data suggest a benign natural history and perhaps a less frequent need for cross-sectional imaging. Further studies are required to determine the optimal timing for surgical intervention in this population.

Robotic Mitral Valve Repair: A Decade of Experience with Echocardiographic Follow-up

BACKGROUND

Surgical approaches for mitral valve (MV) disease have evolved with the aim of developing minimally invasive techniques. While the safety of robotic procedures has been documented, there are limited data on long-term echocardiographic follow-up. This review demonstrates outcomes of 11 years of robotic MV repair at a single, tertiary institution.

METHODS

From 2008 to 2019, 843 patients underwent robotic MV repair at our institution. Repeated measures generalized least squares (GLS) modelling was used to assess the echocardiographic changes over time.

RESULTS

The median age was 58 years (IQR 50.8, 65.5) (591 males, 70.1%). Mechanism of MR was posterior leaflet prolapse in 479 (56.8%), bileaflet prolapse in 325 (38.6%), and anterior leaflet prolapse in 36 (4.3%). There were 3 early deaths (0.4%) and 24 early reoperations (2.8%). Echocardiographic follow up demonstrated left ventricular end systolic and diastolic dimensions, left atrial volume index and pulmonary pressure all continuously improvement up to 2 years postoperatively. Ejection fraction immediately declined postoperatively but then gradually improved to near normal over 2 years. Survival and freedom from reoperation at 10 years were 93% and 92.6%, respectively. When surveyed after dismissal, 93.4% reported their activity level at or above their peers and 93.3% reported no activity limitation from cardiac symptoms.

CONCLUSIONS

Robotic MV repair is safe and effective with excellent long-term results, including echocardiographic parameters that demonstrated early improvement in cardiac chamber size and maintenance of postoperative cardiac function. Exceedingly low mortality rates and freedom from reoperation are comparable to those of the standard open repair.

Aortic Stenosis and Coronary Artery Disease: Cost of Transcatheter versus Surgical Management

BACKGROUND

Surgical aortic valve replacement with coronary artery bypass grafting (SAVR+CABG) is the recommended treatment for aortic stenosis (AS) and coronary artery disease (CAD), however percutaneous coronary intervention at the time of transcatheter aortic valve replacement (TAVR+PCI) is used with increasing frequency.

METHODS

Using the National Inpatient Sample, we identified all adult admissions with a diagnosis of AS. Sub-groups of SAVR+CABG and TAVR+PCI formed the study group. Outcomes of interest included total hospitalization charges, temporal trends, in-hospital mortality, and complications.

RESULTS

Between 2012 and 2017, a total of 97,955 (95.9%) admissions received SAVR+CABG, and 4240 (4.1%) received TAVR+PCI; the proportion of TAVR+PCI increased from 1.0% in 2012 to 9.2% in 2017 (p<0.001). Compared to those receiving TAVR+PCI, admissions receiving SAVR+CABG were younger, more likely to be male, and had lower comorbidity (all p<0.001). Adjusted in-hospital mortality was comparable in both groups (OR 0.94, 95% CI 0.79-1.11, p=0.45). Higher rates of pacemaker implantation, cardiac arrest, and vascular complications were seen in the TAVR+PCI group, while SAVR+CABG was associated with a greater requirement of prolonged ventilation. Admissions receiving TAVR+PCI had shorter lengths of hospital stay and were more likely to be discharged home. Nevertheless, TAVR+PCI had higher hospitalization charges compared to SAVR+CABG group (all p<0.001).

CONCLUSIONS

There has been a steady increase in the utilization of percutaneous strategies for AS and CAD management. In-hospital mortality was comparable in SAVR+CABG and TAVR+PCI groups, but despite shorter in-hospital stays, TAVR+PCI was associated with higher cardiac and vascular complication rates and hospitalization charges.

Doppler Mean Gradient Is Discordant to Aortic Valve Calcium Scores in Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Doppler mean gradient (MG) may underestimate aortic stenosis (AS) severity when obtained during atrial fibrillation (AF) because of lower forward flow compared with sinus rhythm (SR). Whether AS is more advanced at the time of referral for aortic valve intervention in AF compared with SR is unknown. The aim of this study was to examine flow-independent computed tomographic aortic valve calcium scores (AVCS) and their concordance to MG in AF versus SR in patients undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Patients who underwent TAVR from 2016 to 2020 for native valve severe AS with left ventricular ejection fraction ≥ 50% were identified from an institutional TAVR database. MGs during AF and SR in high-gradient AS (HGAS) and low-gradient AS (LGAS) were compared with AVCS (AVCS/MG ratio). AVCS were obtained within 90 days of pre-TAVR echocardiography.

RESULTS

Six hundred thirty-three patients were included; median age was 82 years (interquartile range [IQR], 76-86 years), and 46% were women. AF was present in 109 (17%) and SR in 524 (83%) patients during echocardiography. Aortic valve area index was slightly smaller in AF versus SR (0.43 cm²/m² [IQR, 0.39-0.47 cm²/m²] vs 0.46 cm²/m² [IQR, 0.41-0.51 cm²/m²], P = .0003). Stroke volume index, transaortic flow rate, and MG were lower in AF (P < .0001 for all). AVCS were higher in men with AF compared with SR (3,510 Agatston units [AU] [IQR, 2,803-4,030 AU] vs 2,722 AU [IQR, 2,180-3,467 AU], P < .0001) in HGAS but not in LGAS. AVCS were not different in women with AF versus SR. Overall AVCS/MG ratios were higher in AF versus SR in HGAS and LGAS (P < .03 for all), except in women with LGAS.

CONCLUSIONS

AVCS were higher than expected by MG in AF compared with SR. The very high AVCS in men with AF and HGAS at the time of TAVR suggests late diagnosis of severe AS because of underestimated AS severity during progressive AS and/or late referral to TAVR. Additional studies are needed to examine the extent to which echocardiography may be underestimating AS severity in AF.

Effect of eliminating pre-discharge transthoracic echocardiogram on outcomes after TAVR

OBJECTIVES

The aim of this study was to determine the safety of eliminating the pre-discharge transthoracic echocardiogram (TTE) on 30-day outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).

BACKGROUND

TTE is utilized before, during, and after TAVR. Post-procedural, pre-discharge TTE assists in assessment of prosthesis function and detection of clinically significant paravalvular leak (PVL) after TAVR.

METHODS

Patients who underwent TAVR at Mayo Clinic from July 2018 to July 2019 were included in a prospective institutional registry. Patients undergoing TAVR prior to February 2019 received a pre-discharge TTE, while those undergoing TAVR after February 2019 did not. Both cohorts were evaluated with TTE at 30 days post-TAVR.

RESULTS

A total of 330 consecutive patients were included. Of these, 160 patients (age 81.1 ± 7.6) had routine pre-discharge TTE, while 170 patients (age 78.9 ± 7.5) were dismissed without routine pre-discharge TTE. Mortality at 30 days was similar between the two groups (0% and 1.2%, respectively). One episode of PVL requiring intervention (0.6%) occurred in the pre-discharge TTE group and none in the group without pre-discharge TTE at 30-day follow-up. There was a similar incidence of total composite primary and secondary adverse events between the cohort receiving a pre-discharge TTE and those without (28.1% vs. 25.3%, P = 0.56) at 30 days. The most common event was need for permanent pacemaker or ICD implantation in both groups (13.1% vs. 11.8%, P = 0.71).

CONCLUSIONS

Elimination of the pre-discharge TTE is safe and associated with comparable 30-day outcomes to routine pre-discharge TTE. These findings have implication for TAVR practice cost-efficiency and health care utilization.

Outcomes and Echocardiographic Follow-up After Surgical Management of Tricuspid Regurgitation in Patients With Transvenous Right Ventricular Leads

OBJECTIVE

To evaluate outcomes of elective surgical management of tricuspid regurgitation (TR) in patients with transvenous right ventricular leads, and compare results between non-lead-induced and lead-induced TR patients.

PATIENTS AND METHODS

We studied patients with right ventricular leads who underwent tricuspid valve surgery from January 1, 1993, through December 31, 2015, and categorized them as non-lead-induced and lead-induced TR. Propensity score (PS) for the tendency to have lead-induced TR was estimated from logistic regression and was used to adjust for group differences.

RESULTS

From the initial cohort of 470 patients, 444 were included in PS-adjustment analyses (174 non-lead-induced TRs [123 repairs, 51 replacements], 270 lead-induced TRs [129 repairs, 141 replacements]). In PS-adjusted multivariable analysis, lead-induced TR was not associated with mortality (P=.73), but tricuspid valve replacement was (hazard ratio, 1.59; 95% CI, 1.13 to 2.25; P=.008). Five-year freedom from tricuspid valve re-intervention was 100% for non-lead-induced TR and 92.3% for lead-induced TR; rates adjusted for PS differed between groups (P=.005). There was significant improvement in TR postoperatively in each group (P<.001). In patients having tricuspid valve repair, TR grades tended to worsen over time, but the difference in trends was not significantly different between groups.

CONCLUSION

Lead-induced TR did not affect long-term survival after elective tricuspid valve surgery. In patients with lead-induced TR, tricuspid valve re-intervention was more common. Improvement in TR was achieved in both groups after surgery; however, severity of TR tended to increase over follow-up after tricuspid valve repair.

The Effect of COVID-19 on Adult Cardiac Surgery in the United States in 717 103 Patients

Background

COVID-19 has changed the world as we know it, and the United States continues to accumulate the largest number of COVID-related deaths worldwide. There exists a paucity of data regarding the effect of COVID-19 on adult cardiac surgery trends and outcomes on regional and national levels.

Methods

The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried from January 1, 2018, to June 30, 2020. The Johns Hopkins COVID-19 database was queried from February 1, 2020, to January 1, 2021. Surgical and COVID-19 volumes, trends, and outcomes were analyzed on a national and regional level. Observed-to-expected ratios were used to analyze risk-adjustable mortality.

Results

The study analyzed 717 103 adult cardiac surgery patients and more than 20 million COVID-19 patients. Nationally, there was a 52.7% reduction in adult cardiac surgery volume and a 65.5% reduction in elective cases. The Mid-Atlantic region was most affected by the first COVID-19 surge, with 69.7% reduction in overall case volume and 80.0% reduction in elective cases. In the Mid-Atlantic and New England regions, the observed-to-expected mortality for isolated coronary bypass increased as much as 1.48 times (148% increase) pre-COVID rates. After the first COVID-19 surge, nationwide cardiac surgical case volumes did not return to baseline, indicating a COVID-19–associated deficit of cardiac surgery patients.

Conclusions

This large analysis of COVID-19–related impact on adult cardiac surgery volume, trends, and outcomes found that during the pandemic, cardiac surgery volume suffered dramatically, particularly in the Mid-Atlantic and New England regions during the first COVID-19 surge, with a concurrent increase in observed-to-expected 30-day mortality.

Differences in the characteristics and outcomes of isolated tricuspid and mitral valve surgery for valvular regurgitation

BACKGROUND

Isolated tricuspid valve (TV) surgery is associated with markedly worse outcomes than isolated mitral valve (MV) surgery. We hypothesized that this is related to late referral of patients with isolated TV disease.

METHODS

Adult patients who underwent isolated TV or MV surgery in 2016-2017 were identified in the National-Readmission-Database. We compared the outcomes of isolated TV and MV surgery before and after adjustment for surrogates of late referral.

RESULTS

A total of 21,446 patients who had isolated MV (n = 19,933), or TV surgery (n = 1153) were included. Patients in the TV group were younger (55.7 ± 16.6 vs. 63.4 ± 12.3 years), had lower socioeconomic status, but higher prevalence of surrogates for late referral [acute HF 41.0% vs. 22.0%, advanced liver disease 16.8% vs. 2.6%, non-elective surgery status 44.3% vs. 23.5%, need for peri-operative mechanical circulatory support 27.7% vs. 4.7%, and unplanned admissions in the 90 days before surgery 31.0% vs. 18.8%, (P < 0.001 for all)]. Surgery was performed on day 0/1 of the admission in 80% of patients in the MV group and 52% in the TV group, P < 0.001. Repair rate was 63.5% in the TV group and 56.3% in the MV group (P < 0.001). In-hospital mortality was 3-folds higher after TV surgery (8.7% vs. 2.5%; OR = 3.41, 95%CI 2.73-4.25, p < 0.001). However, this difference became non-significant after adjusting for baseline characteristics including surrogates for late referral (OR = 1.24, 95%CI 0.85-1.82, p = 0.27).

CONCLUSION

The poor outcomes of isolated TV surgery compared with isolated MV surgery may be largely explained by the late referral for intervention in patients with isolated TR.

Temporal Incidence and Predictors of High-Grade Atrioventricular Block After Transcatheter Aortic Valve Replacement

Background

The temporal incidence of high‐grade atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR) is uncertain. As a result, periprocedural monitoring and pacing strategies remain controversial. This study aimed to describe the temporal incidence of initial episode of HAVB stratified by pre‐ and post‐TAVR conduction and identify predictors of delayed events.

Methods and Results

Consecutive patients undergoing TAVR at a single center between February 2012 and June 2019 were retrospectively assessed for HAVB within 30 days. Patients with prior aortic valve replacement, permanent pacemaker (PPM), or conversion to surgical replacement were excluded. Multivariable logistic regression was performed to assess predictors of delayed HAVB (initial event >24 hours post‐TAVR). A total of 953 patients were included in this study. HAVB occurred in 153 (16.1%). After exclusion of those with prophylactic PPM placed post‐TAVR, the incidence of delayed HAVB was 33/882 (3.7%). Variables independently associated with delayed HAVB included baseline first‐degree atrioventricular block or right bundle‐branch block, self‐expanding valve, and new left bundle‐branch block. Forty patients had intraprocedural transient HAVB, including 16 who developed HAVB recurrence and 6 who had PPM implantation without recurrence. PPM was placed for HAVB in 130 (13.6%) (self‐expanding valve, 23.7% versus balloon‐expandable valve, 11.9%; P<0.001). Eight (0.8%) patients died by 30 days, including 1 unexplained without PPM present.

Conclusions

Delayed HAVB occurs with higher frequency in patients with baseline first‐degree atrioventricular block or right bundle‐branch block, new left bundle‐branch block, and self‐expanding valve. These findings provide insight into optimal monitoring and pacing strategies based on periprocedural ECG findings.

Transcarotid Versus Transaxillary/Subclavian Transcatheter Aortic Valve Replacement (TAVR): Analysis of Outcomes

Transcatheter aortic valve replacement (TAVR) has revolutionized the percutaneous management of valvular heart disease and has evolved to progressively minimalist techniques over the past decade. This review discusses the impact of minimalist TAVR, explores the alternative approaches when transfemoral (TF) TAVR is not possible, and analyzes the current outcomes of transcarotid (TC) versus transaxillary/subclavian (TAx) TAVR, which are the two leading nonfemoral (NF) approaches emerging as the preferred alternatives to TF TAVR.

Natural history and outcomes of non-replaced aortic sinuses in patients with bicuspid aortic valves

BACKGROUND

Enlargement of the sinus of Valsalva (SOV) is common in patients with bicuspid aortic valves (BAV), and management at the time of aortic valve replacement (AVR) and concomitant ascending aorta replacement/repair is controversial.

METHODS

Between January 2000 and July 2017, 400 patients with BAV underwent AVR and concomitant ascending aorta repair (79%, graft replacement; 21%, aortoplasty). To assess the impact of the initial SOV dimension on future dilatation and outcomes, patients were stratified into two groups: SOV<40mm (n=209) and SOV≥40mm (n=191).

RESULTS

Patients with SOV≥40 mm were older, and more often male. At a median follow-up of 8.1 years (IQR 7.4-9.1), 6 patients underwent reoperations on the ascending or sinus portion of the aorta due to aneurysmal dilatation; enlargement of the sinus was the primary indication for operation in one patient. Adjusted analysis showed that baseline SOV and SOV dimension over time were not associated with late outcomes. A gradual increase in SOV diameter over time was identified (P=0.004). Patients with smaller baseline SOV diameters showed an initial early decrease in diameter followed by gradual increase, while those with larger baseline diameters had a stable early phase followed by gradual dilatation.

CONCLUSIONS

Ascending aorta replacement may lead to an initial remodeling/stabilizing effect on the spared bicuspid aortic root, which is more pronounced in patients with lower SOV diameters. In addition, our data demonstrate that the retained aortic sinuses enlarge slowly, and within the limited follow-up of our study, SOV diameter was not a risk factor for survival or reoperation.

Surgical aortic valve replacement in the setting of anomalous circumflex coronary artery

BACKGROUND

The anomalous circumflex coronary artery (ACCA) from the right coronary artery or sinus of Valsalva lies in proximity to the aortic valve annulus. We sought to determine the prevalence of injury to the ACCA during surgical aortic valve replacement (SAVR).

METHODS

We queried the Cardiac Surgery and Cardiology databases for all patients who received SAVR in the setting of an ACCA. We identified 31 patients operated from September 2002 through December 2018. The endpoint was myocardial ischemia in the distribution of the ACCA.

RESULTS

The patient mean age was 69 ± 11 years, sex was female in 8 patients (26%), and ejection fraction was 62% (interquartile range 59-68). No patient received exploration of the ACCA, but 6 (19%) received a coronary artery bypass graft (CABG) to the ACCA. No patient demonstrated myocardial infarction or received perioperative intervention on the ACCA; however, discharge echocardiography demonstrated new lateral wall motion abnormality in 5 (16%) patients which was associated with a reduction in ejection fraction of -11% from baseline (P=0.007). CABG to the ACCA was not protective of new lateral wall motion abnormality (P=0.968). Mortality was 34 ± 10% at 10 years and was not associated with new lateral wall motion abnormality (Log rank test P=0.183).

CONCLUSIONS

Clinically apparent myocardial infarction was not identified following SAVR, but echocardiography evidence of myocardial ischemia in the distribution of the ACCA was identified in 16% of patients. Protective adjuvant intervention on the ACCA may be indicated. Further study is warranted.

Association of Transcatheter Mitral Valve Repair Availability With Outcomes of Mitral Valve Surgery

Background

Transcatheter mitral valve repair (TMVr) is currently offered at selected centers that meet certain operator and institutional requirements. We sought to explore the hypothesis that the availability of TMVr is associated with improved outcomes of MV surgery.

Methods and Results

We used the Nationwide Readmissions Database to identify patients who underwent MV surgery at centers with or without TMVr capabilities between January 1 and December 31, 2017. The primary end point was in‐hospital mortality. Secondary end points were postoperative complications, resource use, and 30‐day readmissions. A total of 24 477 patients from 595 centers (446 TMVr, 149 non‐TMVr) were included. There were modest but statistically significant differences in the prevalence of comorbidities between the groups. Patients at non‐TMVr centers had higher unadjusted in‐hospital mortality than those at TMVr centers (5.6% versus 3.6%, P<0.001). They also had higher rates of postoperative complications, longer hospitalizations, higher cost, and fewer home discharges but similar 30‐day readmission rates. After propensity matching, mortality remained higher at non‐TMVr centers (5.5% versus 4.0%, P<0.001). Rates of postoperative complications, prolonged hospitalizations, and nonhome discharges also remained higher. Postoperative mortality was consistently higher at non‐TMVr centers in multiple risk‐adjustment analyses incrementally accounting for differences in risk factors, surgical volume, availability of surgical repair, and excluding concomitant procedures. In the most comprehensive model, surgery at non‐TMVr centers was associated with higher odds of death (odds ratio, 1.41; 95% CI, 1.14–1.73; P=0.002).

Conclusions

Mitral valve surgery at TMVr centers is associated with improved in‐hospital outcomes compared with non‐TMVr centers.

Outcomes of Primary vs Secondary Delayed Sternal Closure in Pediatric Cardiac Surgery

BACKGROUND

Delayed sternal closure (DSC) is a management strategy for hemodynamic instability and severe coagulopathy after complex congenital heart surgery. We hypothesized that DSC results in better outcomes than perioperative sternal reopening.

METHODS

We reviewed patients aged <18 years old undergoing cardiac surgery 2007-2017 at our institution. A total of 179 patients (3.8%) had primary DSC (PDSC, sternum left open after initial operation) and 45 patients (0.9%) had secondary DSC (SDSC, sternum closed primarily and reopened perioperatively). Perioperative characteristics and outcomes among PDSC ≤2 days (98 patients), PDSC >2 days (81 patients), and SDSC (45 patients) were analyzed.

RESULTS

Median age was 120 days (range, 3-6553 days) and median DSC duration was 2 days (range, 1-60 days). The PDSC >2 days group was the youngest group, and the distribution of procedures was different between groups. Indications for DSC were hemodynamic instability in 152 patients (67.9%) and severe coagulopathy in 33 patients (14.7%), with no difference between groups (P = .141). Extracorporeal membrane oxygenation use was higher in the PDSC >2 days group than the other groups (47.5% vs 7.1%, P < .01 and 47.5% vs 28.9%, P = .02), respectively. Operative mortality was higher in SDSC compared to the other groups (17.8% vs 0% for PDSC ≤2 and 6.2% for PDSC >2 days, P < .01). Hospital stay was longer in SDSC (57 ± 7 days) than PDSC ≤2 days (22 ± 5 days) and PDSC >2 days (44 ± 6, P = .01). Survival was better in PDSC regardless of duration than SDSC.

CONCLUSIONS

PDSC demonstrated better outcomes than SDSC. Sternal reopening can be life-saving, but, when anticipated, PDSC can yield better outcomes.

Determinants of Morbidity and Mortality Associated With Isolated Tricuspid Valve Surgery

Background

Whether the poor outcomes of isolated tricuspid valve surgery are related to the operation itself or to certain patient characteristics including late referral is unknown.

Methods and Results

Adult patients who underwent isolated tricuspid valve surgery were identified in the Nationwide Readmissions Database (2016–2017). Patients who had redo tricuspid valve surgery, endocarditis, or congenital heart disease were excluded. Multivariable logistic regression was performed to identify contributors to postoperative mortality. A total of 1513 patients were included (mean age 55.7±16.6 years, 49.6% women). Surrogates of late referral were frequent: 41% of patients were admitted with decompensated heart failure, 44.3% had a nonelective surgery status, 16.8% had advanced liver disease, and 31% had an unplanned hospitalization in the prior 90 days. The operation was performed on day 0 to 1 of the hospitalization in only 50% of patients, and beyond day 10 in 22% of patients. In‐hospital mortality occurred in 8.7% of patients. Median length of stay was 14 days (7–35 days), and median cost was $87 223 ($43 122–$200 872). In multivariable logistic regression analysis, surrogates for late referrals (acute heart failure decompensation, nonelective surgery status, or advanced liver disease) were the strongest predictors of in‐hospital mortality (odds ratio [OR], 4.75; 95% CI, 2.74–8.25 [P<0.001]). This was also consistent in a second model incorporating unplanned hospitalizations in the 90 days before surgery as a surrogate for late referral (OR, 5.50; 95% CI, 2.28–10.71 [P<0.001]).

Conclusions

The poor outcomes of isolated tricuspid valve surgery may be largely explained by the late referral for intervention. Studies are needed to determine the role of early intervention for severe isolated tricuspid regurgitation.

Temporal Trends in Resource Use, Cost, and Outcomes of Transcatheter Aortic Valve Replacement in the United States

OBJECTIVE

To evaluate the contemporary trends in outcomes and resource use associated with transcatheter aortic valve replacement (TAVR) in the United States.

METHODS

We identified patients who underwent TAVR between January 1, 2012, and December 31, 2017, in the National Readmission Database. We assessed temporal trends in clinical outcomes, length-of-stay, non-home discharges, and cost of the index TAVR hospitalization. We also evaluated the changes in the burden of hospitalizations before and after TAVR.

RESULTS

A total of 89,202 patients were included. In-hospital mortality decreased from 5.3% (188) in 2012 to 1.6% (484) in 2017 (adjusted odds ratio: 0.37, 95% CI: 0.30 to 0.46). Risk-adjusted incidences of new dialysis, vascular complications, blood transfusion, and mechanical ventilation decreased, but strokes and pacemaker implantations remained unchanged. Length of stay decreased from median of 7 (interquartile range [IQR]: 4 to 11) to 2 (IQR: 2 to 5) days (P<.001). Risk-adjusted non-home discharges decreased from 32.2% (1134) to 15.5% (386) (P<.001). Median cost of the TAVR hospitalization decreased from $56,022 (IQR: $43,690 to $75,174) to $46,101 (IQR: $36,083 to $59,752) (P<.001). Pre-TAVR admissions at 30, 90, and 180 days decreased from 21.6% (713), 39.5% (1160), and 50.5% (1009) in 2012 to 15.5% (4451), 30.2% (7186), and 36.8% (5928) in 2017, respectively (P<.001). Similarly, re-hospitalizations at 30, 90, and 180 days post-TAVR decreased from 17.5% (531), 27.9% (657), and 34.2% (521) to 12.4% (3486), 21.1% (4783), and 29.1% (4306), respectively (P<.001). The expenditure on index, pre-, and post-TAVR hospitalizations increased from $0.53 to $2.8 billion between 2012 and 2017.

CONCLUSION

This study reflects the changes in the characteristics and outcomes of TAVR in the United States between 2012 and 2017. It also shows the temporal decrease in resource use, cost, and burden of hospitalizations among patients undergoing TAVR in the United States, but an increase in the overall expenditure on TAVR-related hospitalizations.

Causes and mechanisms of isolated mitral regurgitation in the community: clinical context and outcome

AIMS

To define the hitherto unknown aetiology/mechanism distributions of mitral regurgitation (MR) in the community and the linked clinical characteristics/outcomes.

METHODS AND RESULTS

We identified all isolated, moderate/severe MR diagnosed in our community (Olmsted County, MN, USA) between 2000 and 2010 and classified MR aetiology/mechanisms. Eligible patients (n = 727) were 73 ± 18 years, 51% females, with ejection fraction (EF) 49 ± 17%. MR was functional (FMR) in 65%, organic (OMR) in 32% and 2% mixed. Functional MR was linked to left ventricular remodelling (FMR-v) 38% and isolated atrial dilatation (FMR-a) 27%. At diagnosis FMR-v vs. FMR-a, vs. OMR displayed profound differences (all P < 0.0001) in age (73 ± 14, 80 ± 10, 68 ± 21years), male-sex (59, 33, 51%), atrial-fibrillation (28, 54, 13%), EF (33 ± 14, 57 ± 11, 61 ± 10%), and regurgitant-volume (38 ± 13, 37 ± 11, 51 ± 24 mL/beat). Dominant MR mechanism was Type I (normal valve-movement) 38%, Type II (excessive valve-movement) 25%, Type IIIa (diastolic movement-restriction) 3%, and Type IIIb (systolic movement-restriction) 34%. Outcomes were mediocre with excess-mortality vs. general-population in FMR-v [risk ratio 3.45 (2.98-3.99), P < 0.0001] but also FMR-a [risk ratio 1.88 (1.52-2.25), P < 0.0001] and OMR [risk ratio 1.83 (1.50-2.22), P < 0.0001]. Heart failure was frequent, particularly in FMR-v (5-year 83 ± 3% vs. 59 ± 4% FMR-a, 40 ± 3% OMR, P < 0.0001). Mitral surgery during patients' lifetime was performed in 4% of FMR-v, 3% of FMR-a, and 37% of OMR.

CONCLUSION

Moderate/severe isolated MR in the community displays considerable aetiology/mechanism heterogeneity. Functional MR dominates, mostly FMR-v but FMR-a is frequent and degenerative MR dominates OMR. Outcomes are mediocre with excess-mortality particularly with FMR-v but FMR-a, despite normal EF incurs notable excess-mortality and frequent heart failure. Pervasive undertreatment warrants clinical trials of therapies tailored to specific MR cause/mechanisms.

Hyponatremia: An Overlooked Risk Factor Associated With Adverse Outcomes After Cardiac Surgery

BACKGROUND

Hyponatremia is an unrecognized risk factor for adverse outcomes after cardiac surgery. We sought to study the prevalence of preoperative hyponatremia and its impact on short-term and long-term outcomes after cardiac surgery.

METHODS

Patients who had coronary artery bypass graft, valve, or coronary artery bypass graft and valve procedures from 2000 to 2016 and available preoperative serum sodium values within 30 days of the index procedure were included in the study. The effect of preoperative sodium on short-term and long-term outcomes was analyzed as a continuous and binary (hyponatremia [Na+ <135 mEq/L] versus no hyponatremia) predictor variable in multivariable regression models.

RESULTS

Preoperative hyponatremia was present in 9.9% of 16,238 patients with available sodium levels. Comorbidities were more common in patients with hyponatremia. Hyponatremia was independently associated with operative mortality (odds ratio [OR] = 1.80; 95% confidence interval [CI], 1.38-2.34; P < .001), long-term mortality (hazard ratio = 1.31; 95% CI, 1.21-1.40; P < .001), longer postoperative length of stay (hazard ratio = 1.35; 95% CI, 1.28-1.43; P < .001), renal failure (OR = 1.52; 95% CI, 1.20-1.93; P < .001), prolonged ventilation use (OR = 1.52; 95% CI, 1.30-1.78; P < .001), and stroke or transient ischemic attack (OR = 1.48; 95% CI, 1.09-2.02; P = .013). Severity of hyponatremia, as measured by sodium level, was similarly associated with increased risk for death and postoperative complications.

CONCLUSIONS

Preoperative hyponatremia is relatively common and is associated with adverse short-term and long-term outcomes after cardiac surgery. Preoperative hyponatremia can be used independently from standard risk factors to identify high-risk patients for cardiac surgery.

Effect of a fourth-generation transcatheter valve enhanced skirt on paravalvular leak

OBJECTIVES

The aim of this study was to assess the 30 day incidence of paravalvular leak (PVL) and need for aortic valve reintervention of a fourth generation balloon expandable transcatheter valve with enhanced skirt (4G-BEV) (SAPIEN 3 Ultra) compared with a third generation balloon expandable transcatheter valve (3G-BEV) (SAPIEN 3).

BACKGROUND

The incidence of PVL has steadily declined with iterative improvements in transcatheter aortic valve replacement (TAVR) technology and implantation strategies.

METHODS

Patients who underwent TAVR at Mayo Clinic from 7/2018 to 7/2019 were included in a prospective institutional registry. 4G-BEV has been utilized since 2/2019, and, after this date, 3G-BEV and 4G-BEV were simultaneously used. 4G-BEV had three sizes (20, 23, and 26 mm) while 3G-BEV included four sizes (20, 23, 26, and 29 mm). Both cohorts were evaluated at 30 days post-TAVR with a transthoracic echocardiogram to assess for PVL.

RESULTS

A total of 260 consecutive patients were included. Of these, 101 patients received a 4G-BEV and 159 patients received a 3G-BEV. There were more females (p = .0005) and a lower aortic valve calcium score (p = .02) in the 4G-BEV cohort at baseline. Age, STS risk score, NYHA Class, and aortic valve mean gradient did not differ between groups. 4G-BEV was associated with a lower incidence of mild PVL (10.8 vs. 36.5%; p < .0001) and moderate PVL (0 vs. 5.8%) compared to the 3G-BEV at 30 days. There was no association between PVL and valve size in either cohort.

CONCLUSIONS

Utilization of 4G-BEV is associated with reduced PVL at 30 days post-TAVR compared with 3G-BEV.

Impact of Hematologic Malignancies on Outcome of Cardiac Surgery

BACKGROUND

Previous studies suggest that patients with prior or current hematologic malignancy are at increased risk of intraoperative and postoperative complications when undergoing cardiac surgery. The aim of this review was to compare clinical outcomes of patients with a history of hematologic malignancy to those of similar patients with no known blood dyscrasia.

METHODS

From January 1993 to June 2017, 37,839 patients underwent elective cardiac surgery at Mayo Clinic. We matched 612 patients (1.6%) with a history of hematologic malignancy to 612 controls, and compared operative details, early postoperative complications, and late survival.

RESULTS

The median age of matched patients with hematologic malignancy was 71 years (interquartile range [IQR], 62 to 77) and 71 years (IQR, 62 to 77) for patients without cancer. Patients with prior diagnosis of malignancy had lower hemoglobin levels, 12.8 (IQR, 11.5 to 13.8) vs 13.5 (IQR, 12.2 to 14.6; P < .001), but similar platelet counts, 195 (IQR, 147 to 263) vs 203 (IQR, 170 to 245; P = .533). Patients with malignancy were at greater risk of receiving postoperative blood transfusions (47.4% vs 35.6%, P < .001). However, reoperations for postoperative bleeding (4.7% vs 3.3%, P = .253) and stroke (1.3% vs 1.3%, P > .999) were similar. Thirty-day mortality was 3.3% among patients with hematologic malignancy and 1.5% among matched controls (P = .061). Overall survival among patients with cancer was reduced (P < .0001).

CONCLUSIONS

Although late survival is reduced in patients with hematologic malignancies, early outcomes are generally similar to those of matched controls. Therefore, surgery should not be withheld from patients with a diagnosis of hematologic malignancy who would benefit from cardiac procedures.

Acute Myocardial Infarction Due to Fixed Coronary Artery Stenosis From Myocardial Bridging

Myocardial bridging is a common coronary abnormality often associated with left ventricular hypertrophy. It can be noted incidentally on coronary angiography by findings of systolic narrowing of the involved coronary artery. We present the case of a 59-year-old woman that presented with a non-ST elevation myocardial infarction. She had a history of angina and workup 9-months prior with CT coronary angiography that revealed an intra-myocardial course of the left anterior descending coronary artery (LAD) with minimal stenosis and no concomitant coronary artery disease. Invasive coronary angiography now demonstrated apparent myocardial bridging associated with a severe fixed stenosis of the LAD without change in diameter with nitroglycerin injection. Due to persistent symptoms, surgical myotomy was attempted and then aborted because of difficulty unroofing the LAD due to surrounding fibrosis. Coronary artery bypass grafting (CABG) was then successfully performed using a left internal mammary artery graft. The patient had complete resolution of her chest pain and was without functional limitation at 3-month follow-up. This case highlights possible sequelae of myocardial bridging and suggests that, in rare cases, fixed obstruction of the involved coronary artery may occur in the setting of fibrosis of the bridged segment. In such cases, surgical myotomy may not be feasible and CABG may be required.

Functional tricuspid regurgitation of degenerative mitral valve disease: a crucial determinant of survival

Aims 

To assess functional tricuspid regurgitation (FTR) determinants, consequences, and independent impact on outcome in degenerative mitral regurgitation (DMR).

Methods and results 

All patients diagnosed with isolated DMR 2003–2011, with structurally normal tricuspid leaflets, prospective FTR grading and systolic pulmonary artery pressure (sPAP) estimation by Doppler echocardiography at diagnosis were identified and long-term outcome analysed. The 5083 DMR eligible patients [63 ± 16 years, 47% female, ejection fraction (EF) 63 ± 7%, and sPAP 35 ± 13 mmHg] presented with FTR graded trivial in 45%, mild in 37%, moderate in 15%, and severe in 3%. While pulmonary hypertension (PHTN-sPAP ≥ 50 mmHg) was the most powerful FTR severity determinant, other strong FTR determinants were older age, female sex, lower left ventricle EF, DMR, and particularly atrial fibrillation (AFib) (all P ≤ 0.002). Functional tricuspid regurgitation moderate/severe was independently linked to more severe clinical presentation, more oedema, lower stroke volume, and impaired renal function (P ≤ 0.01). Survival (95% confidence interval) throughout follow-up [70% (69–72%) at 10 years] was strongly associated with FTR severity [82% (80–84%) for trivial, 69% (66–71%) for mild, 51% (47–57%) for moderate, and 26% (19–35%) for severe, P &lt; 0.0001]. Excess mortality persisted after comprehensive adjustment [adjusted hazard ratio 1.40 (1.18–1.67) for moderate FTR and 2.10 (1.63–2.70) for severe FTR, P ≤ 0.01]. Excess mortality persisted adjusting for sPAP/right ventricular function (P &lt; 0.0001), by matching [adjusted hazard ratios 2.08 (1.50–2.89), P &lt; 0.0001] and vs. expected survival [risk ratio 1.79 (1.48–2.16), P &lt; 0.0001]. Within 5-year of diagnosis valve surgery was performed in 73% (70–75%) and 15% (13–17%) of severe and moderate DMR and in only 26% (19–34%) and 6% (4–8%) of severe and moderate FTR. Valvular surgery improved outcome without alleviating completely higher mortality associated with FTR (P &lt; 0.0001).

Conclusion 

In this large DMR cohort, FTR was frequent and causally, not only linked to PHTN but also to other factors, particularly AFib. Higher FTR severity is associated at diagnosis with more severe clinical presentation. Long term, FTR is independently of all confounders, associated with considerably worse mortality. Functional tricuspid regurgitation moderate and even severe is profoundly undertreated. Thus careful assessment, consideration for tricuspid surgery, and testing of new transcatheter therapy is warranted.

Impact of Aortic Valve Replacement for Severe Aortic Stenosis on Perioperative Outcomes Following Major Noncardiac Surgery

OBJECTIVE

To compare the incidence of major adverse cardiac events and death among severe aortic stenosis patients with and without aortic valve replacement (AVR) before noncardiac surgery.

PATIENTS AND METHODS

We retrospectively evaluated 491 severe aortic stenosis patients undergoing non-emergency/non-urgent elevated-risk noncardiac surgery between January 1, 2000, and December 31, 2013, including 203 patients (mean age, 74±10 years, 63.5% men) with previous AVR and 288 patients (mean age, 77±12 years, 55.6% men) without prior AVR.

RESULTS

The incidence of major adverse cardiac events was significantly lower in the AVR group (5.4% vs 20.5%; P<.001), primarily because of the lower incidence of new or worsening heart failure (2.5% vs 17.7%; P<.001), compared with the non-AVR group. No significant differences were observed between the groups with and without AVR in the incidence of death (2.5% vs 3.5%; P=.56), myocardial infarction (0.5% vs 1.4%; P=.48), ventricular arrhythmia (0.0% vs 0.7%; P=.51), or stroke (0.0% vs 0.7%; P=.51) at 30-days. At a median follow-up of 4.2 (interquartile range,1.3-7.5) years, overall mortality was significantly worse in patients without versus with AVR (5-year rate: 57.0% vs 32.7%; P<.001). Symptomatic patients without AVR (n=35) had the worst outcomes overall, including increased 30-day and overall mortality rates, compared with the AVR-group and asymptomatic non-AVR patients.

CONCLUSION

In patients with severe aortic stenosis, AVR before noncardiac surgery was associated with decreased incidence of heart failure after noncardiac surgery and improved overall survival without differences in 30-day survival, myocardial infarction, ventricular arrhythmia, or stroke. Preoperative AVR should be considered in symptomatic patients for whom the benefit of AVR is greatest.

Open hemiarch versus clamped ascending aorta replacement for aortopathy during initial bicuspid aortic valve replacement

BACKGROUND

There is controversy regarding the extent of aortic resection necessary in patients with aortopathy related to bicuspid aortic valve disease. To address this issue, we reviewed our experience in patients undergoing ascending aorta replacement during bicuspid aortic valve replacement.

METHODS

We reviewed 702 patients who underwent ascending aorta replacement at the time of initial nonemergent native bicuspid aortic valve replacement at our institution between January 2000 and June 2017. Treatment cohorts included an open hemiarch replacement group (n = 225; 32%) and a clamped ascending aorta replacement group (n = 477; 68%).

RESULTS

Median patient age was 60 years (interquartile range [IQR], 51-67 years), female sex was present in 113 patients 16%, ejection fraction was 62% (IQR, 56%-66%), and aortic arch diameter was 33 mm (IQR, 29-36 mm). Cardiopulmonary bypass time was longer in the hemiarch replacement group (188 minutes vs 97 minutes; P < .001). Procedure-related complications (36%) and mortality (<1%) were similar in the 2 groups; however, the hemiarch group had an increased odds of blood transfusion (odds ratio, 1.62; 95% confidence interval [CI], 1.15-2.28; P = .006). The median duration of follow-up was 6.0 years (95% CI, 5.3-6.8 years). Overall survival was 94 ± 1% at 5 years and 80 ± 2% at 10 years. Multivariable analysis demonstrated similar survival in the 2 groups (hazard ratio, 0.83; 95% CI, 0.51-1.33; P = .439). No repeat aortic arch operations were done for aortopathy over the duration of clinical follow-up.

CONCLUSIONS

Compared with patients in the clamped ascending aorta replacement group, patients in the hemi-arch replacement group had longer cardiopulmonary bypass and aortic cross-clamp times, along with an increased risk of blood transfusion, but similar freedom from repeat aortic arch operation and survival. We identified no advantage of performing hemiarch replacement in the absence of aortic arch dilation.