1
|
Goldstein DJ, Chang HL, Mack MJ, Voisine P, Gammie JS, Marks ME, Iribarne A, Vengrenyuk Y, Raymond S, Taylor BS, Dagenais F, Ailawadi G, Chu MWA, DiMaio JM, Narula J, Moquete EG, O'Sullivan K, Williams JB, Crestanello JA, Scavo V, Puskas JD, Acker MA, Gillinov M, Gelijns AC, O'Gara PT, Moskowitz AJ, Alexander JH, Bagiella E. Intimal hyperplasia, saphenous vein graft disease, and clinical outcomes: Insights from the CTSN VEST randomized trial. J Thorac Cardiovasc Surg 2024; 167:1782-1792.e5. [PMID: 36494209 PMCID: PMC10148927 DOI: 10.1016/j.jtcvs.2022.10.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Diffuse intimal hyperplasia and graft irregularity adversely affect the long-term patency of saphenous vein grafts (SVGs) and clinical outcomes of patients undergoing coronary artery bypass grafting (CABG). The VEST trial evaluated the efficacy of external graft support in limiting the development of intimal hyperplasia (IH) at 1 year postsurgery. In the present secondary analysis, we explored the associations between graft disease and IH and clinical events. We also examined risk factors for early graft occlusion. METHODS VEST is a within-patient randomized, multicenter trial that enrolled 224 patients with multivessel coronary disease undergoing CABG surgery, of whom 203 were evaluated by 1 year postsurgery. Intimal hyperplasia, lumen uniformity, graft stenosis, and graft perfusion were measured by intravascular ultrasound and angiography. Major cardiac and cerebrovascular events (MACCE; including death, myocardial infarction, stroke, and revascularization) were recorded over a median follow-up of 3 years. RESULTS Worse lumen uniformity, greater stenosis, and worse graft perfusion were associated with higher IH values and an increased incidence of clinical events. Consistent with previous findings, we identified endoscopic vein harvesting, female sex, and transit time flow measurement of pulsatility index and flow as risk factors for SVG occlusion during the first year postsurgery. CONCLUSIONS In this secondary analysis of the VEST trial, we observed an association between intimal hyperplasia area and clinical measures of SVG disease at 1 year postsurgery. More severe SVG disease and larger areas of IH were associated with a higher incidence of 3-year MACCE. Ongoing follow-up to 5 years will further elucidate the impact of SVG disease on long-term clinical outcomes of CABG.
Collapse
Affiliation(s)
- Daniel J Goldstein
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, NY
| | - Helena L Chang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael J Mack
- Cardiothoracic Surgery, Baylor Scott & White Health, Plano, Tex
| | - Pierre Voisine
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec City, Québec, Canada
| | - James S Gammie
- Johns Hopkins Heart and Vascular Institute, Johns Hopkins Health System, Baltimore, Md
| | - Mary E Marks
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander Iribarne
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Yuliya Vengrenyuk
- Division of Cardiology, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Samantha Raymond
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bradley S Taylor
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
| | - François Dagenais
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec City, Québec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Michael W A Chu
- Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
| | | | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ellen G Moquete
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Karen O'Sullivan
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Vincent Scavo
- Cardiovascular and Thoracic Surgery, Lutheran Medical Group, Fort Wayne, Ind
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY
| | - Michael A Acker
- Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Patrick T O'Gara
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Mass
| | - Alan J Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John H Alexander
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
2
|
Hosseini M, Griffeth EM, Schaff HV, Klompas AM, Warner MA, Stulak JM, Dearani JA, Lee AT, Lahr BD, Crestanello JA. Analysis of Anemia, Transfusions, and CABG Outcomes in The Society of Thoracic Surgeons National Database. Ann Thorac Surg 2024; 117:1053-1060. [PMID: 38286201 DOI: 10.1016/j.athoracsur.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND This study characterized the association of preoperative anemia and intraoperative red blood cell (RBC) transfusion on outcomes of elective coronary artery bypass grafting (CABG). METHODS Data from 53,856 patients who underwent CABG included in The Society of Thoracic Surgeons (STS) Adult Cardiac Database in 2019 were used. The primary outcome was operative mortality. Secondary outcomes were postoperative complications. The association of anemia with outcomes was analyzed with multivariable regression models. The influence of intraoperative RBC transfusion on the effect of preoperative anemia on outcomes was studied using mediation analysis. RESULTS Anemia was present in 25% of patients. Anemic patients had a higher STS Predicted Risk of Operative Mortality (1.2% vs 0.7%; P < .001). Anemia was associated with operative mortality (odds ratio [OR], 1.27; 99.5% CI, 1.00-1.61; P = .047), postoperative RBC transfusion (OR, 2.28; 99.5% CI, 2.12-2.44; P < .001), dialysis (OR, 1.58; 99.5% CI, 1.19-2.11; P < .001), and prolonged intensive care unit and hospital length of stay. Intraoperative RBC transfusion largely mediated the effects of anemia on mortality (76%), intensive care unit stay (99%), and hospital stay, but it only partially mediated the association with dialysis (34.9%). CONCLUSIONS Preoperative anemia is common in patients who undergo CABG and is associated with increased postoperative risks of mortality, complications, and RBC transfusion. However, most of the effect of anemia on mortality is mediated through intraoperative RBC transfusion.
Collapse
Affiliation(s)
- Motahar Hosseini
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Elaine M Griffeth
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alexander T Lee
- Department of Quantitative Health Sciences; Mayo Clinic, Rochester, Minnesota
| | - Brian D Lahr
- Department of Quantitative Health Sciences; Mayo Clinic, Rochester, Minnesota
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
3
|
Ergi DG, Rowse PG, Daly RC, Crestanello JA, Schaff HV, Dearani JA, Todd A, Arghami A. Single Center Prospective Study of Cross-Clamp versus Balloon Occlusion in Robotic Mitral Surgery. Ann Thorac Surg 2024:S0003-4975(24)00291-1. [PMID: 38657703 DOI: 10.1016/j.athoracsur.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/08/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Both transthoracic aortic cross-clamp and endoaortic balloon occlusion have been shown to have comparable safety profiles for aortic occlusion. Since most surgeons use only one technique, we sought to compare the outcomes when a homogeneous group of surgeons changed their occlusion technique from aortic cross-clamp to balloon occlusion. METHODS We changed our technique from aortic cross-clamp to balloon occlusion in November 2022. This allowed us to conduct a prospective treatment comparison study in the same group of surgeons. Propensity score matching (PSM) was used to match cases(balloon occlusion) 1:3 to controls (aortic cross-clamp) based on age, gender, body mass index, concomitant maze, and tricuspid valve repair. RESULTS Total of 411 patients underwent robotic mitral surgery from 2020 through 2023. Using PSM, 56 balloon occlusion patients were matched to 168 aortic cross-clamp patients. Median age was 65 years (interquartile range[IQR],55.6-70.0) and the majority were males(n=119,53%). All valves were successfully repaired. Balloon occlusion had a shorter median cardiopulmonary bypass (CPB) time compared to aortic cross-clamp (84.0 vs. 94.5 min,p=0.006). Median cross-clamp time (64.0 vs. 64.0 min,p=0.483) and total surgery time (5.9 vs. 6.1 hours,p=0.495) did not differ between groups. There was no in hospital death. There were five surgeons who performed various combinations of console and bedside roles. CPB, cross-clamp, and surgery durations were not significantly affected by the different surgeon combinations. CONCLUSIONS Compared to aortic cross-clamp, balloon occlusion has similar perioperative and early postoperative outcomes. Additionally, it likely introduces a 10-minute reduction in total CPB time.
Collapse
Affiliation(s)
- Defne Gunes Ergi
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Austin Todd
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
4
|
Nguyen A, Schaff HV, Crestanello JA, Luis SA, Halfdanarson TR, Connolly HM. Outcome of selective pulmonary valve management in patients undergoing surgery for carcinoid heart disease. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00291-5. [PMID: 38588975 DOI: 10.1016/j.jtcvs.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/28/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Affiliation(s)
- Anita Nguyen
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | | | - S Allen Luis
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | | | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| |
Collapse
|
5
|
Warner MA, Hanson AC, Schulte PJ, Sanz JR, Smith MM, Kauss ML, Crestanello JA, Kor DJ. Preoperative Anemia and Postoperative Outcomes in Cardiac Surgery: A Mediation Analysis Evaluating Intraoperative Transfusion Exposures. Anesth Analg 2024; 138:728-737. [PMID: 38335136 PMCID: PMC10949062 DOI: 10.1213/ane.0000000000006765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND Preoperative anemia is associated with adverse outcomes in cardiac surgery, yet it remains unclear what proportion of this association is mediated through red blood cell (RBC) transfusions. METHODS This is a historical observational cohort study of adults undergoing coronary artery bypass grafting or valve surgery on cardiopulmonary bypass at an academic medical center between May 1, 2008, and May 1, 2018. A mediation analysis framework was used to evaluate the associations between preoperative anemia and postoperative outcomes, including a primary outcome of acute kidney injury (AKI). Intraoperative RBC transfusions were evaluated as mediators of preoperative anemia and outcome relationships. The estimated total effect, average direct effect of preoperative anemia, and percent of the total effect mediated through transfusions are presented with 95% confidence intervals and P -values. RESULTS A total of 4117 patients were included, including 1234 (30%) with preoperative anemia. Overall, 437 of 4117 (11%) patients went on to develop AKI, with a greater proportion of patients having preoperative anemia (219 of 1234 [18%] vs 218 of 2883 [8%]). In multivariable analyses, the presence of preoperative anemia was associated with increased postoperative AKI (6.4% [4.2%-8.7%] absolute difference in percent with AKI, P < .001), with incremental decreases in preoperative hemoglobin concentrations displaying greater AKI risk (eg, 11.9% [6.9%-17.5%] absolute increase in probability of AKI for preoperative hemoglobin of 9 g/dL compared to a reference of 14 g/dL, P < .001). The association between preoperative anemia and postoperative AKI was primarily due to direct effects of preoperative anemia (5.9% [3.6%-8.3%] absolute difference, P < .001) rather than mediated through intraoperative RBC transfusions (7.5% [-4.3% to 21.1%] of the total effect mediated by transfusions, P = .220). Preoperative anemia was also associated with longer hospital durations (1.07 [1.05-1.10] ratio of geometric mean length of stay, P < .001). Of this total effect, 38% (22%, 62%; P < .001) was estimated to be mediated through subsequent intraoperative RBC transfusion. Preoperative anemia was not associated with reoperation or vascular complications. CONCLUSIONS Preoperative anemia was associated with higher odds of AKI and longer hospitalizations in cardiac surgery. The attributable effects of anemia and transfusion on postoperative complications are likely to differ across outcomes. Future studies are necessary to further evaluate mechanisms of anemia-associated postoperative organ injury and treatment strategies.
Collapse
Affiliation(s)
- Matthew A Warner
- From the Departments of Anesthesiology and Perioperative Medicine
| | | | | | - Juan Ripoll Sanz
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Mark M Smith
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Marissa L Kauss
- From the Departments of Anesthesiology and Perioperative Medicine
| | | | - Daryl J Kor
- From the Departments of Anesthesiology and Perioperative Medicine
| |
Collapse
|
6
|
Mazur P, Kurmann R, Klarich KW, Dearani JA, Arghami A, Daly RC, Greason K, Schaff HV, Ahmad A, El-Am E, Sorour A, Bois MC, Viehman J, King KS, Maleszewski JJ, Crestanello JA. Operative management of cardiac papillary fibroelastomas. J Thorac Cardiovasc Surg 2024; 167:1088-1097.e2. [PMID: 35989118 DOI: 10.1016/j.jtcvs.2022.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Papillary fibroelastomas are associated with an increased risk of embolic strokes. Excision of papillary fibroelastomas may be the primary indication for surgery (primary) or performed during other cardiac operations (secondary). The present study summarizes our experience with primary and secondary fibroelastoma surgery. METHODS We analyzed the medical records of patients who underwent surgical excision of papillary fibroelastoma between January 1998 and February 2020. Patient characteristics, indications for operation, tumor size and location, and operative and long-term outcomes were evaluated. RESULTS Among the 294 patients (median age: 66 years, 62% female), papillary fibroelastoma was the primary indication for surgery in 136 patients (46%), and 51% of patients had a history of stroke or transient ischemic attack. When papillary fibroelastoma was a secondary indication for surgery (158 patients, 54%), the lesion was identified preoperatively in 39%. Papillary fibroelastomas were located most commonly on the aortic valve and least commonly in the right side of the heart. For valvular papillary fibroelastoma resected from a normal valve, valve shave was sufficient in 96% (196/205). Operative mortality was low in both groups (primary, 0% vs secondary, 2.5%, P = .13), and early neurologic events occurred in 1.3%. Recurrence rate was 15.8% at 10 years. The estimated survival for patients with primary papillary fibroelastoma at 10 years was 78.4%, whereas for secondary papillary fibroelastoma removal it was 53.6% (log rank, P = .003). CONCLUSIONS Resection of papillary fibroelastomas can be performed safely, with preservation of the native valve, and with low rates of neurologic events. Operative and long-term outcomes after fibroelastoma resection are excellent.
Collapse
Affiliation(s)
- Piotr Mazur
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Reto Kurmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Kyle W Klarich
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Edward El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Ahmed Sorour
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minn
| | - Melanie C Bois
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minn
| | - Jason Viehman
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minn
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minn
| | - Joseph J Maleszewski
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn; Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minn
| | | |
Collapse
|
7
|
Alkhouli M, Crestanello JA, Rihal CS. Universal Mastery in Valve Disease Treatment: Myth or Attainable Goal? JACC Cardiovasc Interv 2024; 17:516-519. [PMID: 38340103 DOI: 10.1016/j.jcin.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/04/2023] [Indexed: 02/12/2024]
Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
8
|
Reddy P, Anand V, Rajiah P, Larson NB, Bird J, Williams JM, Williamson EE, Nishimura RA, Crestanello JA, Arghami A, Collins JD, Bratt A. Predicting postoperative systolic dysfunction in mitral regurgitation: CT vs. echocardiography. Front Cardiovasc Med 2024; 11:1297304. [PMID: 38464845 PMCID: PMC10920321 DOI: 10.3389/fcvm.2024.1297304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/07/2024] [Indexed: 03/12/2024] Open
Abstract
Introduction Volume overload from mitral regurgitation can result in left ventricular systolic dysfunction. To prevent this, it is essential to operate before irreversible dysfunction occurs, but the optimal timing of intervention remains unclear. Current echocardiographic guidelines are based on 2D linear measurement thresholds only. We compared volumetric CT-based and 2D echocardiographic indices of LV size and function as predictors of post-operative systolic dysfunction following mitral repair. Methods We retrospectively identified patients with primary mitral valve regurgitation who underwent repair between 2005 and 2021. Several indices of LV size and function measured on preoperative cardiac CT were compared with 2D echocardiography in predicting post-operative LV systolic dysfunction (LVEFecho <50%). Area under the curve (AUC) was the primary metric of predictive performance. Results A total of 243 patients were included (mean age 57 ± 12 years; 65 females). The most effective CT-based predictors of post-operative LV systolic dysfunction were ejection fraction [LVEFCT; AUC 0.84 (95% CI: 0.77-0.92)] and LV end systolic volume indexed to body surface area [LVESViCT; AUC 0.88 (0.82-0.95)]. The best echocardiographic predictors were LVEFecho [AUC 0.70 (0.58-0.82)] and LVESDecho [AUC 0.79 (0.70-0.89)]. LVEFCT was a significantly better predictor of post-operative LV systolic dysfunction than LVEFecho (p = 0.02) and LVESViCT was a significantly better predictor than LVESDecho (p = 0.03). Ejection fraction measured by CT demonstrated significantly greater reproducibility than echocardiography. Discussion CT-based volumetric measurements may be superior to established 2D echocardiographic parameters for predicting LV systolic dysfunction following mitral valve repair. Validation with prospective study is warranted.
Collapse
Affiliation(s)
- Prajwal Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Prabhakar Rajiah
- Department of Radiology, Division of Cardiovascular Imaging, Mayo Clinic, Rochester, MN, United States
| | - Nicholas B. Larson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, United States
| | - Jared Bird
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - James M. Williams
- Department of Radiology, Division of Cardiovascular Imaging, Mayo Clinic, Rochester, MN, United States
| | - Eric E. Williamson
- Department of Radiology, Division of Cardiovascular Imaging, Mayo Clinic, Rochester, MN, United States
| | - Rick A. Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jeremy D. Collins
- Department of Radiology, Division of Cardiovascular Imaging, Mayo Clinic, Rochester, MN, United States
| | - Alex Bratt
- Department of Radiology, Division of Cardiovascular Imaging, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
9
|
Lo Russo GV, Alarouri HS, Al‐Abcha A, Vogl B, Mahayni A, Sularz A, Hatoum H, Collins J, Crestanello JA, Alkhouli M. Association of Bovine Arch Anatomy With Incident Stroke After Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2024; 13:e032963. [PMID: 38348804 PMCID: PMC11010090 DOI: 10.1161/jaha.123.032963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/11/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Acute ischemic stroke complicates 2% to 3% of transcatheter aortic valve replacements (TAVRs). This study aimed to identify the aortic anatomic correlates in patients after TAVR stroke. METHODS AND RESULTS This is a single-center, retrospective study of patients who underwent TAVR at the Mayo Clinic between 2012 and 2022. The aortic arch morphology was determined via a manual review of the pre-TAVR computed tomography images. An "a priori" approach was used to select the covariates for the following: (1) the logistic regression model assessing the association between a bovine arch and periprocedural stroke (defined as stroke within 7 days after TAVR); and (2) the Cox proportional hazards regression model assessing the association between a bovine arch and long-term stroke after TAVR. A total of 2775 patients were included (59.6% men; 97.8% White race; mean±SD age, 79.3±8.4 years), of whom 495 (17.8%) had a bovine arch morphology. Fifty-seven patients (1.7%) experienced a periprocedural stroke. The incidence of acute stroke was significantly higher among patients with a bovine arch compared with those with a nonbovine arch (3.6% versus 1.7%; P=0.01). After adjustment, a bovine arch was independently associated with increased periprocedural strokes (adjusted odds ratio, 2.16 [95% CI, 1.22-3.83]). At a median follow-up of 2.7 years, the overall incidence of post-TAVR stroke was 6.0% and was significantly higher in patients with a bovine arch even after adjusting for potential confounders (10.5% versus 5.0%; adjusted hazard ratio, 2.11 [95% CI, 1.51-2.93]; P<0.001). CONCLUSIONS A bovine arch anatomy is associated with a significantly higher risk of periprocedural and long-term stroke after TAVR.
Collapse
Affiliation(s)
| | | | | | - Brennan Vogl
- Department of Biomedical EngineeringMichigan Technological UniversityHoughtonMI
| | | | - Agata Sularz
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | - Hoda Hatoum
- Department of Biomedical EngineeringMichigan Technological UniversityHoughtonMI
| | | | | | | |
Collapse
|
10
|
Ergi DG, Schaff HV, Pochettino A, Hurst PD, Greason KL, Daly RC, Crestanello JA, Dearani JA, Todd A, Saran N. Outcomes of aortic surgery in patients with Takayasu arteritis. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00099-0. [PMID: 38325517 DOI: 10.1016/j.jtcvs.2024.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/26/2024] [Accepted: 01/27/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE To investigate the presentation, aortic involvement, and surgical outcomes in patients with Takayasu arteritis undergoing aortic surgery. METHODS We queried our surgical database for patients with Takayasu arteritis who underwent aortic surgery from 1994 to 2022. RESULTS There were a total of 31 patients with Takayasu arteritis who underwent aortic surgery. Patients' median age at the time of diagnosis was 35.0 years (interquartile range, 25.0-42.0). The majority were female (n = 27, 87.0%). Most patients (n = 28, 90.3%) were diagnosed before surgery, and 3 patients (9.6%) were diagnosed perioperatively. The median time interval from diagnosis to surgery was 2.8 years (interquartile range, 0.5-13.9). The most common presentation was ascending aorta aneurysm (n = 22, 70.9%), and severe aortic regurgitation was the most common valve insufficiency (n = 17, 54.8%). The most common operation was ascending aorta replacement (n = 20, 64.5%), and aortic valve replacement was the most common valve intervention (n = 17, 54.8%). Active vasculitis was identified in 2 (11.7%) aortic valve specimens. Early mortality was 6.5% (n = 2). A total of 6 deaths occurred over a median follow-up of 13.1 years (interquartile range, 6.1-25.2). Survival at 10 years was 86.7% (95% CI, 75.4-99.7). A total of 5 patients (16.1%) required a subsequent operation in a median of 1.9 years (interquartile range, 0.2-7.4). Freedom from reoperation was 96.9% (95% CI, 90.1-100) at 1 year, 89.4% (95% CI, 78.7-100.0) at 5 years, and 77.5% (95% CI, 61.2-98.1) at 10 and 15 years. CONCLUSIONS Ascending aorta aneurysm and aortic valve regurgitation are the most frequent presentations in patients with Takayasu arteritis requiring aortic surgery. Surgery in these individuals is safe, with acceptable short- and long-term results.
Collapse
Affiliation(s)
- Defne Gunes Ergi
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | | | - Philip D Hurst
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Austin Todd
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| |
Collapse
|
11
|
Karadzha A, Schaff HV, Frye RL, Bois MC, Crestanello JA, Bagameri G, Greason KL, Shrestha ML. Post-mortem examination of fatal acute type A aortic dissection: what does it teach us? Eur J Cardiothorac Surg 2024; 65:ezad432. [PMID: 38175790 DOI: 10.1093/ejcts/ezad432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/06/2023] [Indexed: 01/06/2024] Open
Abstract
OBJECTIVES Acute type A aortic dissection (ATAAD) remains a highly life-threatening condition. This study investigates factors associated with fatal ATAAD prior to surgical treatment. METHODS We reviewed autopsy reports of ATAAD decedents who died before surgical intervention and underwent postmortem examination at our clinic from 1994 to 2022. RESULTS Among 94 eligible cases, 50 (53.2%) decedents had DeBakey type I dissection, and 44 (46.8%) had DeBakey type II dissection. Most were males, 63 (67%), and 72 (77%) had a history of hypertension. The median age was 70.5 years, and the type II group was a decade older than the type I group (P < 0.001). Decedents in the type II group predominantly died during the first hour after symptoms onset 16 (52%), while in the type I group, fatalities occurred between 1 h and 1 day, 27 (66%). The most common site of the intimal tear was the midportion of the ascending aorta, 45 (48%). The median ascending aorta size was 5 cm for the entire cohort, 5.2 cm for type I and 4.6 cm for type II (P < 0.045). CONCLUSIONS In this autopsy study of fatal acute aortic dissection, the median aortic size was below the current guideline threshold for elective repair. Type II acute aortic dissections were found more frequently than expected and were characterized by older age, advanced aortic atherosclerosis, smaller aortic size, a shorter interval from symptom onset to death and a higher frequency of syncope compared to type I dissection.
Collapse
Affiliation(s)
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Robert L Frye
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Melanie C Bois
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Malakh L Shrestha
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
12
|
Naser JA, Luis SA, Pislaru SV, Michelena HI, Kennedy AM, Eleid MF, Crestanello JA, Chebib FT, Pellikka PA, Nkomo VT. Impact on Kidney Function and Medium-Term Outcomes of Transcatheter Aortic Valve Replacement in Patients With Chronic Kidney Disease. Am J Cardiol 2024; 210:163-171. [PMID: 37863302 DOI: 10.1016/j.amjcard.2023.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 09/26/2023] [Accepted: 10/05/2023] [Indexed: 10/22/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is now widely approved for the treatment of aortic stenosis, regardless of the patients' surgical risk. However, the outcomes of TAVR and their determinants in patients with chronic kidney disease (CKD) beyond 1 year of follow-up are unknown. We aimed to assess the medium-term outcomes of TAVR in CKD, develop a risk score to estimate the 2-year mortality in patients with CKD, and evaluate the changes in kidney function at discharge after TAVR. Adults who underwent TAVR were retrospectively identified. The CKD stage was determined using the Chronic Kidney Disease Epidemiology 2021 creatinine formula. Improved kidney function was defined as post-TAVR creatinine ≤50% of pre-TAVR creatinine or decrease in creatinine of ≥0.3 mg/100 ml compared with pre-TAVR creatinine. Overall, 1,523 patients (median age 82 years; 59% men; 735 with CKD stage II or less, 661 with CKD III, 83 with CKD IV, and 44 with CKD V [of whom 40 were on dialysis]) were included. The all-cause mortality was higher in CKD stages IV and V on the multivariable analysis (p <0.001) at median follow-up of 2.9 (interquartile range 2.0 to 4.2) years. Moderate or severe tricuspid regurgitation, anemia, right ventricular systolic pressure >40 mm Hg and CKD stages IV and V were independent predictors of 2-year mortality and were used to develop a risk score. At hospital discharge, persisting acute kidney injury after TAVR occurred in 88 of 1,466 patients (6%), whereas improved kidney function occurred in 170 of 1,466 patients (12%). In conclusion, CKD stage was an independent determinant of mortality beyond 2 years after TAVR. Kidney function was more likely to improve than worsen at the time of hospital discharge after TAVR.
Collapse
Affiliation(s)
- Jwan A Naser
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sushil Allen Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Austin M Kennedy
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Fouad T Chebib
- Department of Nephrology and Hypertension Division, Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
13
|
Ergi DG, Klarich KW, Dearani JA, Crestanello JA, Maleszewski JJ, Morris JM, Young PM, Callaghan CM, Pitot HC, Arghami A. Resection of a Solitary Right Ventricular Metastasis in Oligorecurrent Hepatocellular Carcinoma. J Clin Med 2023; 12:7530. [PMID: 38137599 PMCID: PMC10743666 DOI: 10.3390/jcm12247530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
Hepatocellular carcinoma (HCC), constituting the predominant manifestation of liver cancer, stands as a formidable medical challenge. The prognosis subsequent to surgical intervention, particularly for individuals presenting with a solitary tumor, relies heavily on the degree of invasiveness. The decision-making process surrounding therapeutic modalities in such cases assumes paramount importance. This case report illuminates a rather unusual clinical scenario. Here, we encounter a patient who, following a disease-free interval, manifested an atypical presentation of HCC, specifically, a solitary cardiac metastasis. The temporal interval of remission adds an additional layer of complexity to the case. Through a multidisciplinary planning process, the decision was made for surgical removal of the metastatic tumor.
Collapse
Affiliation(s)
- Defne Gunes Ergi
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55901, USA; (D.G.E.); (J.A.D.); (J.A.C.)
| | - Kyle W. Klarich
- Department of Cardiology, Mayo Clinic, Rochester, MN 55901, USA;
| | - Joseph A. Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55901, USA; (D.G.E.); (J.A.D.); (J.A.C.)
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55901, USA; (D.G.E.); (J.A.D.); (J.A.C.)
| | - Joseph J. Maleszewski
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55901, USA;
| | - Jonathan M. Morris
- Department of Radiology, Mayo Clinic, Rochester, MN 55901, USA; (J.M.M.); (P.M.Y.)
| | - Phillip M. Young
- Department of Radiology, Mayo Clinic, Rochester, MN 55901, USA; (J.M.M.); (P.M.Y.)
| | | | - Henry C. Pitot
- Department of Medical Oncology, Mayo Clinic, Rochester, MN 55901, USA;
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55901, USA; (D.G.E.); (J.A.D.); (J.A.C.)
| |
Collapse
|
14
|
Huang Y, Schaff HV, Swarna KS, Sangaralingham LR, Nishimura RA, Dearani JA, Crestanello JA, Greason KL. Benefit of Anticoagulation Early After Surgical Aortic Valve Replacement Using Bioprosthetic Valves. Mayo Clin Proc 2023; 98:1797-1808. [PMID: 38043997 DOI: 10.1016/j.mayocp.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE To compare all-cause mortality and thromboembolic events in patients undergoing surgical aortic valve replacement (sAVR) receiving anticoagulation with warfarin versus patients with no systemic anticoagulation. PATIENTS AND METHODS Using data from the OptumLabs Data Warehouse, we investigated adult patients having bioprosthetic sAVR with or without coronary artery bypass from January 1, 2007, through December 31, 2019. Patients were classified into groups of nonwarfarin or warfarin (≥30 days of continuous prescription coverage after sAVR). One-to-one propensity score (PS) matching was used to adjust for group differences. RESULTS Of 10,589 patients having sAVR, 7659 (72.3%) were in the nonwarfarin group and 2930 (27.7%) were in the warfarin group. After PS matching, 2930 pairs of patients were analyzed. Median follow-up was 4.1 months (interquartile range [IQR], 2.6-7.4 months) for the warfarin group and 21.3 months (IQR, 7.8-24.0 months) for the nonwarfarin group. Overall mortality was lower for the warfarin group than for the nonwarfarin group (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.47 to 1.00; P=.047), and there was a trend toward decreased cumulative incidence of thromboembolic events (subdistribution HR [SHR], 0.62; 95% CI, 0.35 to 1.07; P=.09). Cumulative incidence of major bleeding events was higher for the warfarin group vs the nonwarfarin group (SHR, 1.94; 95% CI, 1.28 to 2.94; P=.002). Results were similar in a subgroup analysis of patients undergoing isolated sAVR. CONCLUSION During the prescription coverage period, warfarin use after bioprosthetic sAVR was associated with lower all-cause mortality and decreased risk of thromboembolism compared with not receiving warfarin. However, warfarin use was associated with an increased risk of major bleeding events.
Collapse
Affiliation(s)
- Ying Huang
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Kavya S Swarna
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
15
|
Deb B, Scott C, Pislaru SV, Nkomo VT, Kane GC, Alkhouli M, Crestanello JA, Arruda-Olson A, Pellikka PA, Anand V. Machine learning facilitates the prediction of long-term mortality in patients with tricuspid regurgitation. Open Heart 2023; 10:e002417. [PMID: 38011995 PMCID: PMC10685925 DOI: 10.1136/openhrt-2023-002417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/31/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVE Tricuspid regurgitation (TR) is a prevalent valve disease associated with significant morbidity and mortality. We aimed to apply machine learning (ML) to assess risk stratification in patients with ≥moderate TR. METHODS Patients with ≥moderate TR on echocardiogram between January 2005 and December 2016 were retrospectively included. We used 70% of data to train ML-based survival models including 27 clinical and echocardiographic features to predict mortality over a 3-year period on an independent test set (30%). To account for differences in baseline comorbidities, prediction was performed in groups stratified by increasing Charlson Comorbidity Index (CCI). Permutation feature importance was calculated using the best-performing model separately in these groups. RESULTS Of 13 312 patients, mean age 72 ± 13 years and 7406 (55%) women, 7409 (56%) had moderate, 2646 (20%) had moderate-severe and 3257 (24%) had severe TR. The overall performance for 1-year mortality by 3 ML models was good, c-statistic 0.74-0.75. Interestingly, performance varied between CCI groups, (c-statistic = 0.774 in lowest CCI group and 0.661 in highest CCI group). The performance decreased over 3-year follow-up (average c-index 0.78). Furthermore, the top 10 features contributing to these predictions varied slightly with the CCI group, the top features included heart rate, right ventricular systolic pressure, blood pressure, diuretic use and age. CONCLUSIONS Machine learning of common clinical and echocardiographic features can evaluate mortality risk in patients with TR. Further refinement of models and validation in prospective studies are needed before incorporation into the clinical practice.
Collapse
Affiliation(s)
- Brototo Deb
- Internal Medicine, Georgetown University, Washington, District of Columbia, USA
| | | | - Sorin V Pislaru
- Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | | | | | | | - Vidhu Anand
- Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Cardiovascular Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin, USA
| |
Collapse
|
16
|
Cangut B, Greason KL, Todd A, Arghami A, Krishnan P, Crestanello JA, Stulak JM, Dearani JA, Schaff HV. Aortic root replacement in the setting of a mildly dilated nonsyndromic ascending aorta. J Thorac Cardiovasc Surg 2023; 166:983-993. [PMID: 35863966 DOI: 10.1016/j.jtcvs.2022.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 03/18/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE There is controversy on how to address mild aortic root dilation during concomitant aortic valve replacement: composite aortic valve conduit replacement or separate ascending aorta and aortic valve replacement. We reviewed our experience to address the issue. METHODS We retrospectively reviewed 778 adult nonsyndromic patients with aortic root diameter 55 mm or less who received replacement of the ascending aorta and aortic valve from January 1994 to June 2017. Patients were divided into 2 groups based on the type of aortic root intervention: composite aortic valve conduit replacement in 406 patients (52%) and separate ascending aorta and aortic valve replacement in 372 patients (48%). Propensity matching was used to mitigate differences in baseline patient characteristics and produced 188 matched pairs. RESULTS Sinus of Valsalva diameter was 43 mm (39-47). Operative mortality occurred in 3 patients (2%) in the composite aortic valve conduit replacement group and in 5 patients (3%) in the separate ascending aorta and aortic valve replacement group (P = .470). Median follow-up was 9.6 years (8.4-10.1). Long-term mortality was similar in the 2 groups (P = .083). Repeat operation was performed in 13 patients (7%) in the composite aortic valve conduit replacement group and in 19 patients (10%) in the separate ascending aorta and aortic valve replacement group (P = .365). Sinus of Valsalva diameter decreased 2 mm (-4-0; median follow-up 41 months) in the propensity-matched separate ascending aorta and aortic valve replacement group. CONCLUSIONS In patients with mild aortic root dilation, separate ascending aorta and aortic valve replacement results in a similar risk of repeat operation and mortality in comparison with composite aortic valve replacement. Separate ascending aorta and aortic valve replacement is not associated with subsequent aortic root dilation on medium-term echocardiography follow-up.
Collapse
Affiliation(s)
- Busra Cangut
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| | - Austin Todd
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minn
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Prasad Krishnan
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | |
Collapse
|
17
|
Juarez-Casso FM, Castro-Varela A, Nguyen A, Stulak JM, Greason KL, Crestanello JA, Schaff HV. Having a successful dedicated research time in cardiothoracic surgery. JTCVS Open 2023; 15:355-358. [PMID: 37808052 PMCID: PMC10556928 DOI: 10.1016/j.xjon.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 10/10/2023]
Affiliation(s)
| | | | - Anita Nguyen
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - John M. Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin L. Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | | |
Collapse
|
18
|
Juarez-Casso FM, Crestanello JA. The Evolving Role of Surgical Aortic Valve Replacement in the Era of Transcatheter Valvular Procedures. J Clin Med 2023; 12:5299. [PMID: 37629341 PMCID: PMC10455383 DOI: 10.3390/jcm12165299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/11/2023] [Accepted: 07/19/2023] [Indexed: 08/27/2023] Open
Abstract
Surgical aortic valve replacement (SAVR) has long been the standard treatment for severe symptomatic aortic stenosis (AS). However, transcatheter aortic valve replacement (TAVR) has emerged as a minimally invasive alternative; it was initially intended for high-risk patients and has now expanded its use to patients of all risk groups. While TAVR has demonstrated promising outcomes in diverse patient populations, uncertainties persist regarding its long-term durability and potential complications, raising the issue of the ideal lifetime management strategy for patients with AS. Therefore, SAVR continues to play an important role in clinical practice, particularly in younger patients with longer life expectancies, those with complex aortic anatomy who are unsuitable for TAVR, and those requiring concomitant surgical procedures. The choice between TAVR and SAVR warrants personalized decision-making, considering patient characteristics, comorbidities, anatomical considerations, and overall life expectancy. A multidisciplinary approach involving an experienced heart team is crucial in the preoperative evaluation process. In this review, we aimed to explore the current role of surgical management in addressing aortic valve stenosis amidst the expanding utilization of less invasive transcatheter procedures.
Collapse
Affiliation(s)
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA;
| |
Collapse
|
19
|
Kaneyuki D, Villarraga HR, Gallego-Navarro CA, Todd A, Pislaru SV, Crestanello JA, Dearani JA, Greason KL, Schaff HV, Arghami A. Fate of concomitant tricuspid regurgitation in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00649-9. [PMID: 37541574 DOI: 10.1016/j.jtcvs.2023.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/09/2023] [Accepted: 07/26/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE Owing to a lack of supportive data, tricuspid regurgitation (TR) is usually not addressed in patients undergoing coronary artery bypass grafting (CABG). Here we evaluated changes in TR degrees over time and its impact on survival in patients undergoing CABG. METHODS We reviewed the data of 9726 patients who underwent isolated CABG between January 2000 and January 2021. According to preoperative TR severity, patients were stratified into nonsignificant (none to trivial, mild) and significant (moderate to severe) TR groups. We excluded patients who had undergone previous tricuspid valve surgery, pacemaker placement, and concomitant valve or ablative surgery. Propensity score matching and Cox proportional hazards models were used to identify associations between TR grade and the primary outcome of all-cause mortality. The secondary outcome was change in TR severity on the last echocardiogram. RESULTS After propensity score matching, 380 patients in each group were identified. At baseline, 359 patients had moderate TR (94.5%) and 21 (5.5%) had severe TR. On the last follow-up echocardiogram, TR had improved in 40.5% of the patients in the significant TR group. Kaplan-Meier survival curves showed significantly lower survival in patients with significant preoperative TR compared to those with nonsignificant TR (P < .001). After adjusting for other confounders, survival was no worse in the patients with significant TR group (hazard ratio, 1.05; 95% confidence interval, 0.80-1.38; P = .70). CONCLUSIONS Significant preoperative TR improved in 40.5% of patients after isolated CABG. After adjusting for other factors, significant TR did not affect long-term survival.
Collapse
Affiliation(s)
- Daisuke Kaneyuki
- Department of Cardiac Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa
| | | | | | - Austin Todd
- Department of Biostatistics, Mayo Clinic, Rochester, Minn
| | - Sorin V Pislaru
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minn
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.
| |
Collapse
|
20
|
Oguz D, Huntley GD, El-Am EA, Scott CG, Thaden JJ, Pislaru SV, Fabre KL, Singh M, Greason KL, Crestanello JA, Pellikka PA, Oh JK, Nkomo VT. Impact of atrial fibrillation on outcomes in asymptomatic severe aortic stenosis: a propensity-matched analysis. Front Cardiovasc Med 2023; 10:1195123. [PMID: 37408654 PMCID: PMC10318187 DOI: 10.3389/fcvm.2023.1195123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
Background Atrial fibrillation (AF) portends poor prognosis in patients with aortic stenosis (AS). Objectives This study aimed to study the association of AF vs. sinus rhythm (SR) with outcomes in asymptomatic severe AS during routine clinical practice. Methods We identified 909 asymptomatic patients from 3,208 consecutive patients with aortic valve area ≤1.0 cm2 and left ventricular ejection fraction ≥50% at a tertiary academic center. Patients were grouped by rhythm at the time of transthoracic echocardiogram [SR: 820/909 (90%) and AF: 89/909 (10%)]. Propensity-matched analyses (2 SR:1 AF) matching 174 SR to 89 AF patients by age, sex, and clinical comorbidities were used to compare outcomes. Results In the propensity-matched cohort, median age (82 ± 8 vs. 81 ± 9 years, p = 0.31), sex distribution (male 58% vs. 52%, p = 0.30), and Charlson comorbidity index (4.0 vs. 3.0, p = 0.26) were not different in AF vs. SR. Median follow-up duration was 2.6 (IQR: 1.0-4.4) years. The 1-year rate of aortic valve replacement (AVR) was not different (AF: 32% vs. SR: 37%, p = 0.31). All-cause mortality was higher in AF [hazard ratio (HR): 1.68 (1.13-2.50), p = 0.009]. Independent predictors of mortality were age [HR: 1.92 (1.40-2.62), p < 0.001], Charlson comorbidity index [1.09 (1.03-1.15), p = 0.002], aortic valve peak velocity [HR: 1.87 (1.20-2.94), p = 0.006], stroke volume index [HR: 0.75 (0.60-0.93), p = 0.01], moderate or more mitral regurgitation [HR: 2.97 (1.43-6.19), p = 0.004], right ventricular systolic dysfunction [HR: 2.39 (1.29-4.43), p = 0.006], and time-dependent AVR [HR: 0.36 (0.19-0.65), p = 0.0008]. There was no significant interaction of AVR and rhythm (p = 0.57). Conclusions Lower forward flow, right ventricular systolic dysfunction, and mitral regurgitation identified increased risk of subsequent mortality in asymptomatic patients with AF and AS. Additional studies of risk stratification of asymptomatic AS in AF vs. SR are needed.
Collapse
Affiliation(s)
- Didem Oguz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Geoffrey D. Huntley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Edward A. El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Christopher G. Scott
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Jeremy J. Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Sorin V. Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Katarina L. Fabre
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kevin L. Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Patricia A. Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jae K. Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Vuyisile T. Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
21
|
Castro-Varela A, Schaff HV, Oh JK, Ghoniem K, Crestanello JA, Daly RC, Dearani JA, King KS, Greason KL. Diagnosis and Surgical Management of Pericardial Constriction after Cardiac Surgery. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00457-9. [PMID: 37295645 DOI: 10.1016/j.jtcvs.2023.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/12/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Prior cardiac surgery is an increasingly common etiology of constrictive pericarditis, but there is a paucity of data on clinical presentation and outcome of surgical treatment. METHODS We reviewed data of 263 patients who underwent pericardiectomy for postoperative constriction from January 1, 1993, through July 1, 2017. Outcomes of interest were early and late mortality, as well as features of clinical presentation. RESULTS Median patient age was 64 (56-72) years, and the median interval between prior operation and pericardiectomy was 2.7 years (range: 0-54 years). Previous operations included CABG 114 (43%), valve surgery 85 (32%), combined CABG and valve surgery 33 (13%), and other procedures in 31 (12%). Common presentations were symptoms of right heart failure in 221 (84%) or dyspnea in 42 (16%). Moderate to severe tricuspid valve regurgitation was present in 108 (41%) patients. There were 14 (5.5%) deaths within 30 days postoperatively, and survival at 5 and 10 years postoperatively was 61% and 44%. On multivariate analysis, older age (P= 0.013), diabetes (P=0.019), and non-elective pericardiectomy within two years of cardiac surgery (P<0.001) were associated with decreased long-term survival. CONCLUSIONS Pericardial constriction after cardiac surgery can present at any interval postoperatively. Symptoms and signs of right heart failure in patients with previous cardiac surgery should alert physicians to the possibility of pericardial constriction followed by a correct diagnosis. Pericardiectomy performed urgently following cardiac operation has poor long-term outcomes.
Collapse
Affiliation(s)
| | | | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Khaled Ghoniem
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | | | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
22
|
Hosseini M, Lahr BD, Greason KL, Arghami A, Gulati R, Eleid MF, Crestanello JA. Obesity and vascular complication in percutaneous transfemoral transcatheter aortic valve insertion. Catheter Cardiovasc Interv 2023; 101:1221-1228. [PMID: 37036273 DOI: 10.1002/ccd.30658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 02/01/2023] [Accepted: 03/19/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Obesity has been associated with an increased risk of vascular complication during percutaneous coronary intervention, but there are no data on the risk of vascular complication during percutaneous transfemoral transcatheter aortic valve insertion (TAVI). OBJECTIVES We hypothesized there would be a similar increased risk associated with TAVI. METHODS We reviewed the records of 1176 patients who received percutaneous transfemoral transcatheter aortic valve insertion from September 2015 to September 2020. All patients received 1) preoperative computed tomoraphy angiography assessment of the abdomen and pelvis to delineate iliofemoral artery anatomy, 2) ultrasound-guided percutaneous femoral arterial access, and 3) pre-closure of the delivery sheath femoral access site. Vascular complication was recorded based on definitions set forth by Valve Academic Research Consortium 3. RESULTS The median age of patients was 81 years, and 60% were men. The median body mass index (BMI) was 29 kg/m2 (range, 11-67), and 91 (8%) patients had a value ≥40 kg/m2 (i.e., morbid obesity). Delivery sheath size was 14-French in 859 (73%) patients, 16-French in 311 (26%), and 18-French in 6 (1%). Vascular complication occurred in 53 (5%) patients, including 39 (7%) among the first half of procedures and 14 (2%) among the second half (p < 0.001). When stratified by obesity status (BMI < or ≥30 kg/m2 , p < 0.001), the complication rate was 4% in nonobese patients and 5% in obese patients. Multivariable analysis showed no overall association between risk of vascular complication and BMI categories (p = 0.583)BMI continuous values (p = 0.529), or sheath size (p = 0.217). CONCLUSIONS Obesity is not associated with a vascular complication during percutaneous transfemoral transcatheter aortic valve insertion. The operation should not be denied in obese patients.
Collapse
Affiliation(s)
- Motahar Hosseini
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian D Lahr
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F Eleid
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
23
|
Naser JA, Kucuk HO, Gochanour BR, Scott CG, Kennedy AM, Luis SA, Pislaru C, Greason KL, Crestanello JA, Gulati R, Eleid MF, Nkomo VT, Pislaru SV. Medium-Term Outcomes of the Different Antithrombotic Regimens After Transcatheter Aortic Valve Implantation. Am J Cardiol 2023:S0002-9149(23)00214-X. [PMID: 37202327 DOI: 10.1016/j.amjcard.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/20/2023]
Abstract
Bioprosthetic valve thrombosis is associated with accelerated bioprosthesis degeneration and valve re-replacement. Whether 3-month warfarin use after transcatheter aortic valve implantation (TAVI) protects against such consequences is unknown. We aimed to investigate if 3-month warfarin treatment after TAVI is associated with better outcomes than dual antiplatelet therapy (DAPT) and single antiplatelet therapy (SAPT) at medium-term follow-up. Adults who underwent TAVI were identified retrospectively (n = 1,501) and classified into warfarin, DAPT, and SAPT groups based on antithrombotic regimen received. Patients with atrial fibrillation were excluded. Outcomes and valve hemodynamics were compared between the groups. Annualized change from baseline in mean gradients and effective orifice area at last follow-up echocardiography was calculated. Overall, 844 patients were included (mean age: 80 ± 9 years, 43% women; 633 receiving warfarin, 164 DAPT, and 47 SAPT). Median time to follow-up was 2.5 (interquartile range 1.2 to 3.9) years. There were no differences in the adjusted outcome end points of ischemic stroke, death, valve re-replacement/intervention, structural valve degeneration, or their composite end point at follow-up. Annualized change in aortic valve area was significantly higher in DAPT (-0.11 [0.19] cm2/year) than warfarin (-0.06 [0.25] cm2/y, p = 0.03), but annualized change in mean gradients was not different (p >0.05). In conclusion, antithrombotic regimen, including warfarin, after TAVI was associated with marginally lower decrease in aortic valve area but no difference in medium-term clinical outcomes compared with DAPT and SAPT.
Collapse
|
24
|
Cangut B, Schaff HV, Suri RM, Greason KL, Stulak JM, Lahr BD, Michelena HI, Daly RC, Dearani JA, Crestanello JA. Excess Reintervention With Mitroflow Prosthesis for Aortic Valve Replacement: Ten-Year Outcomes of a Randomized Trial. Ann Thorac Surg 2023; 115:949-956. [PMID: 36183748 DOI: 10.1016/j.athoracsur.2022.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/09/2022] [Accepted: 09/19/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Current bioprostheses are considered to have improved durability and better hemodynamic performance compared with previous designs, but there are limited comparative data on late outcomes. METHODS From 2009 through 2011, 300 adults with severe aortic valve stenosis undergoing aortic valve replacement (AVR) were randomly assigned to receive Edwards Magna, St Jude Epic, or Sorin Mitroflow bioprostheses (n = 100, n = 101, n = 99, respectively). Overall survival was analyzed using Kaplan-Meier and Cox proportional hazards methods, whereas competing risk analysis was used for all time-to-event outcomes. Serial echocardiographic data were fitted with longitudinal models stratified by implant valve size. RESULTS During median follow-up of 9.8 years (interquartile range, 8.7-10.2), 10-year survival was 50% for the Magna group, 42% for the Epic group, and 41% for the Mitroflow group (P = .415). Cumulative risk of stroke was 9% at 10 years, and rates were comparable for the three groups. Indexed aortic valve area and mean gradients were similar among the three groups receiving 19 mm and 21 mm valves, but in larger (23 mm or more) prostheses, gradients were lower (P < .001) and indexed aortic valve areas were higher in the Magna group (P < .001). The 10-year risk of endocarditis differed by group (P = .033), with higher incidence in the Mitroflow vs the Magna group (7% vs 0%, P = .019). Late risk of reinterventions in the Mitroflow group was 22%, compared with 0% in the Magna group (P < .001) and 5% in the Epic group (P = .008). CONCLUSIONS The Magna valve had the lowest gradients and largest indexed aortic valve area with larger implant sizes. The Mitroflow bioprosthesis is associated with an increased rate of reintervention and possible increased risk of infection compared with Magna and Epic valves.
Collapse
Affiliation(s)
- Busra Cangut
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Rakesh M Suri
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Hector I Michelena
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
25
|
Mazur PK, Arghami A, Macielak SA, Nei SD, Viehman JK, King KS, Daly RC, Crestanello JA, Schaff HV, Dearani JA. Apixaban for Anticoagulation After Robotic Mitral Valve Repair. Ann Thorac Surg 2023; 115:966-973. [PMID: 35973484 DOI: 10.1016/j.athoracsur.2022.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 06/04/2022] [Accepted: 07/25/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is no consensus regarding postoperative anticoagulation after mitral valve repair (MVRep). We compared the outcomes of post-MVRep anticoagulation with apixaban compared to warfarin. METHODS We reviewed data of 666 patients who underwent isolated robotic MVRep between January 2008 and October 2019. We excluded patients who had conversion to sternotomy and those discharged without anticoagulation or on clopidogrel (n = 40). Baseline and intraoperative characteristics and antiplatelet/anticoagulation records were collected. In-hospital and post-discharge complications and overall survival were compared. RESULTS Among the 626 studied patients the median age was 58 years (interquartile range, 51-66), 71% were male, and 1% (n = 9) had atrial fibrillation. Eighty percent (n = 499) were discharged on warfarin and 20% on apixaban (n = 127). Almost all patients (126 of 127, 99%) in the apixaban group were also on aspirin at discharge, whereas in the warfarin group only 79% (n = 395) were also on aspirin at discharge. Baseline characteristics were similar, except that the apixaban group had more female patients (46 of 127, 36% vs 136 of 499, 27%, P = .047). There were no differences in in-hospital complications, including stroke. Readmission rate was higher in the apixaban group (15 of 127, 12% vs 30 of 499, 6%, P = .02), driven mostly by postoperative atrial fibrillation (6 of 127 [5%] vs 5 of 499 [1%], respectively; P = .01). There was no difference in other complications (including bleeding and thromboembolic events), or overall mortality within 3 years. Exclusion of patients who did not receive aspirin at discharge did not affect the results. CONCLUSIONS Anticoagulation with apixaban after minimally invasive robotic MVRep is safe and has similar rates of bleeding and thromboembolism compared to patients treated with warfarin.
Collapse
Affiliation(s)
- Piotr K Mazur
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Scott D Nei
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
| | - Jason K Viehman
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
26
|
Huntley GD, Michelena HI, Thaden JJ, Alkurashi AK, Pislaru SV, Pochettino A, Crestanello JA, Maleszewski JJ, Brown RD, Nkomo VT. Cerebral and Retinal Infarction in Bicuspid Aortic Valve. J Am Heart Assoc 2023; 12:e028789. [PMID: 36942747 PMCID: PMC10122894 DOI: 10.1161/jaha.122.028789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Background Description of cerebral and retinal infarction in patients with bicuspid aortic valve (BAV) is limited to case reports. We aimed to characterize cerebral and retinal infarction and examine outcomes in patients with BAV. Methods and Results Consecutive patients from 1975 to 2015 with BAV (n=5401) were retrospectively identified from the institutional database; those with confirmed cerebral or retinal infarction were analyzed. Infarction occurring after aortic valve replacement was not included. Patients were grouped according to infarction pathogenesis: embolism from a degenerative calcific BAV (BAVi); non-BAV, large artery atherosclerotic or lacunar infarction (LAi); and non-BAV, non-large artery embolic infarction (nLAi). There were 83/5401 (1.5%) patients, mean age 54±12 years and 28% female, with confirmed cerebral or retinal infarction (LAi 23/83 [28%]; nLAi 30/83 [36%]; BAVi 26/83 [31%]; other 4/83 [5%]). Infarction was embolic in 72/83 (87%), and 35/72 (49%) were cardioembolic. CHA2DS2-VASc score was 1.4±1.2 in BAVi (P=0.188 versus nLAi) and 2.3±1.2 in LAi (P=0.005). Recurrent infarction occurred in 41% overall (50% BAVi, P=0.164 and 0.803 versus LAi and nLAi). BAVi was more commonly retinal (39% BAVi versus 13% LAi, P=0.044 versus 0% nLAi, P=0.002). Patients with BAVi and LAi were more likely to have moderate-to-severe aortic stenosis and undergo aortic valve replacement compared with patients with nLAi. Conclusions Cardioembolism, often from degenerative calcification of the aortic valve, is a predominant cause of cerebral and retinal infarction in patients with BAV and is frequently recurrent. Cerebral and retinal infarction should be regarded as a complication of BAV.
Collapse
Affiliation(s)
| | | | - Jeremy J Thaden
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Sorin V Pislaru
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | | | | | | | | |
Collapse
|
27
|
Deb B, Scott C, Pislaru S, Nkomo VT, Kane GC, Alkhouli MA, Saran N, Crestanello JA, Pellikka PA, Anand V. MACHINE-LEARNING OF CLINICAL FEATURES PREDICTS MORTALITY IN MODERATE-SEVERE TRICUSPID REGURGITATION: A LARGE REGISTRY STUDY. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02452-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
|
28
|
Huang Y, Schaff HV, Swarna KS, Sangaralingham LR, Nishimura RA, Dearani JA, Crestanello JA, Greason KL. Anticoagulation After Bioprosthetic Aortic Valve Replacement: Are We Following the Guidelines? Ann Thorac Surg 2023; 115:619-625. [PMID: 35779595 DOI: 10.1016/j.athoracsur.2022.05.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/22/2022] [Accepted: 05/09/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Guideline-directed medication adherence is considered an important quality measure after cardiac surgery. We evaluated compliance with the American College of Cardiology/American Heart Association guidelines for warfarin use after surgical aortic valve replacement (sAVR) using bioprostheses and examined potential variations in anticoagulation practice over time. METHODS Using the OptumLabs Data Warehouse, we investigated adult patients having bioprosthetic sAVR with or without coronary artery bypass (2007-2019). Early postoperative warfarin use was defined as ≥30 days of continuous prescription coverage after sAVR. RESULTS Among 10 730 adult patients having sAVR, 3071 (28.6%) received warfarin early postoperatively. Median length of warfarin prescription coverage was 4.5 months (interquartile range, 3.0-8.9 months). However, only 11.1% (736/6634) had warfarin prescription coverage of 3 to 6 months in compliance with the most recent guidelines. Yearly warfarin prescription rate did not change significantly during the 13-year period (P = .386). Compared with patients from the non-warfarin group, those receiving warfarin prescriptions were older and more likely to be male and to have atrial fibrillation, congestive heart failure, chronic pulmonary disease, and CHA2DS2-VASc score ≥2; warfarin use was also greater in patients receiving prescriptions for other cardiac medications (P < .05). CONCLUSIONS Anticoagulation after sAVR as reflected by warfarin prescriptions may be underused; the rates of warfarin use have not changed in the last decade. Although additional studies are needed to confirm the benefit of early anticoagulation after sAVR, these results indicate that guideline recommendations are not followed by most clinicians. The findings highlight a potentially important area for quality improvement.
Collapse
Affiliation(s)
- Ying Huang
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Kavya S Swarna
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Rick A Nishimura
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
29
|
Crestanello JA, Greason K, Elsisy M, Lahr B, Bagameri G, Daly R, Stulak J, Dearani J, Schaff H. Impact of time to chest closure on early and late survival in adults with delayed sternal closure. Eur J Cardiothorac Surg 2023; 63:7030692. [PMID: 36749008 DOI: 10.1093/ejcts/ezad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/10/2023] [Accepted: 02/06/2023] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Delayed sternal closure (DSC) after cardiac surgery is a temporizing measure to address coagulopathy or haemodynamic instability after cardiac surgery. We sought to study: (i) indications and temporal trends for DSC, (ii) factors associated with time to chest closure and (iii) its impact on short-term and long-term outcomes. METHODS From January 2007 to December 2017, 494 patients (median age 67 years, 66% males) required DSC after cardiac surgery. Medical records were reviewed for indications, risk factors, time to DSC and outcomes. Multivariable Cox regression via landmark analysis of 486 5-day survivors was used to investigate the impact of time to chest closure on early and late survival. RESULTS Coagulopathy and haemodynamic instability were the most common indications. Median time to chest closure was 2 days. Pre-/intraoperative extracorporeal membranous oxygenation, severe right ventricular dysfunction and diabetes mellitus were associated with longer time to chest closure. Longer time to closure was associated with increased risk of operative complications and operative mortality, but did not have a statistically significant association with late mortality. Increasing age, pulmonary hypertension and a greater number of prior sternotomies were also found to be associated with overall mortality. CONCLUSIONS While longer time to chest closure was associated with increased rates of operative complications and operative mortality, it did not reveal a statistically significant association with long-term survival.
Collapse
Affiliation(s)
| | - Kevin Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohamed Elsisy
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Brian Lahr
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Richard Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - John Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joseph Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
30
|
Crestanello JA, Greason KL, Mathew J, Eleid MF, Nkomo VT, Rihal CS, Bagameri G, Holmes DR, Pislaru SV, Sandhu GS, Lee AT, King KS, Alkhouli M. The Interaction of FEV1 and NT-Pro-BNP with Outcomes after Transcatheter Aortic Valve Replacement. Eur J Cardiothorac Surg 2023; 63:6988033. [PMID: 36645236 DOI: 10.1093/ejcts/ezad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/29/2022] [Accepted: 01/14/2023] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Low forced expiratory volume in 1 second (FEV1) and elevated N-terminal Pro form B-type natriuretic peptide (NT-Pro-BNP) have been individually associated with poor outcomes after transcatheter aortic valve replacement (TAVR). We hypothesized a combination of the two would provide prognostic indication after TAVR. METHODS We categorized 871 patients who received TAVR from 2008 to 2018 into 4 groups according to baseline FEV1 (< or ≥ 60% predicted) and NT-Pro-BNP (< or ≥ 1601 pg/ml): group A (n = 312, high FEV1, low NT-Pro-BNP), group B (n = 275, high FEV1, high NT-Pro-BNP), group C (n = 123 low FEV1, low NT-Pro-BNP), and group D (n = 161, low FEV1, high NT-Pro-BNP). The primary endpoint was survival at 1 and 5 years. RESULTS Patients in group A had more severe aortic stenosis and achieved the best long-term survival at 1- (93% (95% CI: 90-96) and 5- years (45.3% (95% CI: 35.4-58). Low FEV1 and high NT-Pro-BNP (group D) patients had more severe symptoms, higher Society of Thoracic Surgeons predicted risk of operative mortality, lower ejection fraction and aortic valve gradient at baseline. They had the worst survival at 1- (76% (95% CI: 69-83) and at 5-years (13.1% (95% CI: 7-25), Hazard Ratio compared to group A: 2.29 (95% CI: 1.6-3.2, p < 0.001) with 25.7% of patients in NYHA class III-IV. Patients in groups B and C had intermediate outcomes. CONCLUSIONS The combination of FEV1 and NT-Pro-BNP stratify patients into 4 groups with distinct risk profiles and clinical outcomes. Patients with low FEV1 and high NT-Pro-BNP have increased comorbidities, poor functional outcomes, and decreased long term survival after TAVR.
Collapse
Affiliation(s)
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jessey Mathew
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Alexander T Lee
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Katherine S King
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
31
|
Hosseini M, Crestanello JA. Commentary: It Is All About the Skirt: Length and Material. JTCVS Tech 2023; 18:51-52. [PMID: 37096091 PMCID: PMC10122139 DOI: 10.1016/j.xjtc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Affiliation(s)
| | - Juan A. Crestanello
- Address for reprints: Juan A. Crestanello, MD, Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
| |
Collapse
|
32
|
Egbe AC, Miranda WR, Jain CC, Anderson JH, Stephens EH, Andi K, Goda A, Abozied O, Ramachandran D, Crestanello JA, Francois C, Connolly HM. Risk of pulmonary artery dissection in adults with congenital heart disease. Int J Cardiol 2023; 370:186-190. [PMID: 36216090 DOI: 10.1016/j.ijcard.2022.09.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/07/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND There are limited data about the risk of pulmonary artery (PA) dissection in adults with congenital heart disease (CHD), and the purpose of this study was to estimate the incidence of PA dissection in this population. METHODS Retrospective cohort study of adults with CHD that underwent cross-sectional imaging (2003-2020). PA aneurysm was defined as main or branch PA diameter > 40 mm or > 30 mm respectively, and severe PA aneurysm was defined as main or branch PA diameter > 50 mm. RESULTS Of 1, 673 patients (41 ± 10 years; male 58%), 493 (24%), 286 (19%), and 306 (20%) had aneurysms of the main, right, and left PA respectively, while 66 (4%) had severe PA aneurysm. During a median follow-up of 8.2 (interquartile range 3.7-10.3) years, there was one PA dissection in a patient with Eisenmenger syndrome, thus the incidence of PA dissection was 14 per 100,000 patient-years. Of 779 females, 163 had one or more pregnancies during follow-up, and 41 (25%) of these patients had known PA aneurysm at the time of conception. There was no PA dissection during pregnancy. Of the 163 patients, 91 (56%) had cross-sectional imaging before and after pregnancy, there was no significant difference in PA dimension before versus after pregnancy (main PA 35 ± 5 versus 36 ± 4 mm, p = 0.6; right PA 21 ± 3 versus 33 ± 4 mm, p = 0.1; and left PA 23 ± 4 versus 22 ± 4 mm, p = 0.4). CONCLUSIONS The risk of PA dissection was extremely low even in patients with severe PA aneurysm, or in patients with PA aneurysm that became pregnant. Collectively, these data suggest a benign natural history for patients without severe pulmonary hypertension and encourage and a conservative approach in managing patients with PA aneurysm.
Collapse
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Kartik Andi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Ahmed Goda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Dhanya Ramachandran
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| |
Collapse
|
33
|
Mazur P, Marin-Cuartas M, Arghami A, Noack T, Crestanello JA, Borger MA. Operative management after transcatheter aortic valve replacement. Kardiol Pol 2023; 81:107-114. [PMID: 36706263 DOI: 10.33963/kp.a2023.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 01/29/2023]
Abstract
With broadening applications of transcatheter aortic valve replacement (TAVR) and increasing use in intermediate- and low-risk patients, the incidence of surgical re-interventions after TAVR is growing. Transcatheter heart valves suffer from similar long-term complications as surgical heart valve prostheses that require surgical re-intervention, including endocarditis and structural valve deterioration. Catastrophic periprocedural complications - such as annular or aortic rupture requiring urgent surgical intervention - may also occur during TAVR procedures. This review summarizes the current knowledge on indications, methods, and outcomes of cardiac operations after TAVR, with a focus on how to improve results in a rapidly growing patient population.
Collapse
Affiliation(s)
- Piotr Mazur
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany. .,Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States.
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Thilo Noack
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Michael A Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| |
Collapse
|
34
|
Jahanian S, Arghami A, Wittwer ED, King KS, Daly RC, Dearani JA, Rowse PG, Crestanello JA, Schaff HV. Does Minimally Invasive Mitral Valve Repair Mean Less Postoperative Pain? Ann Thorac Surg 2022; 115:1172-1178. [PMID: 36395877 DOI: 10.1016/j.athoracsur.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 10/21/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Rapid recovery after minimally invasive mitral valve (MV) repair has been demonstrated in many studies, but the issue of postoperative pain has not been fully elucidated. We evaluated pain scores and medication use in patients undergoing MV repair by minimally invasive surgery (MIS) and open sternotomy (OS). METHODS Between 2008 and 2019, 1332 patients underwent isolated MV repair by OS, and 913 underwent minimally invasive MV repair. After 1:1 propensity score matching, the study included 709 patients in each group. Opioid use was quantified as oral morphine equivalents in milligrams for each hospital day. The highest pain scores were collected from a visual analogue scale at 6-hour intervals. Predictive modeling was employed to compare pain medications and pain scores between the groups. RESULTS The postoperative median length of stay was 3 (3-4) and 5 (4-5) days for the MIS and OS groups, respectively (P < .001). The predicted geometric mean oral morphine equivalents demonstrated lower opioid use for the MIS group compared with the OS group for the first 4 days. However, the predicted mean pain score was higher in the first 24 hours for the MIS group compared with the OS group (4.7 [4.5-4.8] vs 4.4 [4.3-4.5], respectively, on a visual analogue scale of 0 to 10). CONCLUSIONS MV repair by MIS methods was associated with decreased opioid use but not with decreased postoperative pain scores. Possible explanations include the difference in incision site pain and subjective differences in postoperative pain expectations.
Collapse
Affiliation(s)
- Sepideh Jahanian
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Erica D Wittwer
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
35
|
El Shaer A, Chavez Ponce A, Mazur P, Greason K, Arghami A, Eleid MF, Guerrero M, Rihal CS, Crestanello JA, Alkhouli M. Mitral Valve Surgery for Persistent or Recurrent Mitral Regurgitation After Transcatheter Edge-to-Edge Repair Is Associated With Improved Survival. J Am Heart Assoc 2022; 11:e026236. [PMID: 36250668 PMCID: PMC9673655 DOI: 10.1161/jaha.122.026236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background The management of severe mitral regurgitation (MR) after transcatheter edge‐to‐edge repair (TEER) remains a clinical conundrum. Considering the growing volume of TEER, more outcomes data for mitral surgery in this cohort are needed. Methods and Results Symptomatic patients with persistent or recurrent severe MR after TEER evaluated between May 2014 and June 2021 were included. The primary outcome was all‐cause mortality in patients who were treated with surgery versus medical therapy. The Kaplan–Meier and Cox regression methods were used to report risk‐adjusted survival analyses. Among the 142 included patients, 44 (31.0%) underwent mitral surgery. Patients who underwent surgery were younger than those treated medically (74.1±8.9 versus 78.6±10.5 years, P=0.01). Major comorbidities were similar except obesity, sleep apnea, left ventricular dimensions, and ejection fraction. Society of Thoracic Surgeons Predicted Risk of Operative Mortality was 9.0±4.7 versus 7.9±4.9 in the surgical versus medical therapy groups, respectively, P=0.22. Time from TEER to detection of severe MR was similar in both groups (median [interquartile range] 97.5 [39.5–384] versus 93.5 [40–389] days in the surgical versus medical groups, respectively [P>0.05]). In the surgical group, valve replacement was performed in all patients. Operative mortality was 4.5% (observed/expected ratio 0.55), and major complications were uncommon. After risk‐adjustment, surgery was associated with significantly lower all‐cause mortality (adjusted hazard ratio, 0.33 [95% CI, 0.12–0.92], P=0.001) compared with medial therapy. Conclusions Compared with medical therapy, mitral surgery in patients with severe persistent or recurrent MR after TEER is associated with lower mortality despite the high‐risk profile of these patients. Patients with severe MR after TEER should be considered for surgery at a referral mitral surgical center.
Collapse
Affiliation(s)
- Ahmed El Shaer
- Department of Cardiovascular Disease Mayo Clinic Rochester MN
| | | | - Piotr Mazur
- Department of Cardiovascular Surgery Mayo Clinic Rochester MN
| | - Kevin Greason
- Department of Cardiovascular Surgery Mayo Clinic Rochester MN
| | - Arman Arghami
- Department of Cardiovascular Surgery Mayo Clinic Rochester MN
| | - Mackram F Eleid
- Department of Cardiovascular Surgery Mayo Clinic Rochester MN
| | - Mayra Guerrero
- Department of Cardiovascular Disease Mayo Clinic Rochester MN
| | | | | | | |
Collapse
|
36
|
Kolluri N, Oguz D, Scott CG, Crestanello JA, Nkomo VT. Impact of atrial fibrillation in clinical outcomes of low gradient aortic stenosis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Aortic stenosis (AS) is the most common significant valvular heart disease in developed countries. A significant portion of the AS populations have low-gradient AS (LGAS), defined as aortic valve area ≤1.0 cm2 and a trans-aortic mean systolic gradient and peak velocity <40 mmHg and <4 m/s, respectively. LGAS has been shown previously to have worse mortality compared to high-gradient AS (HGAS). Atrial fibrillation (AF) is associated with LGAS and AF has been associated with worse outcomes compared to sinus rhythm (SR) in HGAS. The prognostic impact of AF in LGAS is not well described in previous literature.
Hypothesis
AF will be associated with worse clinical outcomes compared to SR in patients with LGAS.
Methods
3400 patients diagnosed with LGAS from 2010–2020 were retrospectively identified and analyzed. Their electrical rhythm was analyzed at the time of their echocardiographic diagnosis of LGAS and patients were split into 3 separate groups: SR (n=2036), SR with history of AF (n=519), and AF (n=845). After adjustment for age, sex, and Charlson Comorbidity Index (CCI), primary endpoints of overall mortality and cardiac mortality were assessed for patients.
Results
Compared to those with SR, patients with AF and history of AF had significantly higher overall mortality (HR 1.52, p<0.0001 and HR 1.22, p=0.004, respectively) and cardiac mortality (HR 2.05, p<0.0001 and HR 1.37, p=0.03, respectfully) (Figure 1). On further sub group analysis, AF seemed to be most importantly associated with mortality and cardiac mortality in patients with preserved ejection fraction (EF >50%, normal flow LGAS) compared to those patients with reduced EF (classical low-flow LGAS), where there was no statistically significant difference in outcomes between AF and SR (Figure 2).
Conclusions
Atrial fibrillation, compared to sinus rhythm, is associated with worse overall mortality and cardiac mortality in patients with LGAS and preserved EF. Specifically, this association was strongest in patients with preserved EF >50%. Given these findings, the presence of AF should be factored into clinical decision making regarding LGAS management given the higher risk of age, sex, and CCI adjusted overall and cardiac mortality. Further research needs to be done to see if earlier aortic valve intervention in these patients would improve mortality compared to their SR counterparts.
Funding Acknowledgement
Type of funding sources: None.
Collapse
Affiliation(s)
- N Kolluri
- Mayo Clinic , Rochester , United States of America
| | - D Oguz
- Mayo Clinic , Rochester , United States of America
| | - C G Scott
- Mayo Clinic , Rochester , United States of America
| | | | - V T Nkomo
- Mayo Clinic , Rochester , United States of America
| |
Collapse
|
37
|
Naser J, Gochanour BR, Scott CG, Luis SA, Greason KL, Crestanello JA, Gulati R, Eleid MF, Nkomo VT, Pislaru SV. The use of warfarin as part of antithrombotic strategy after transcutaneous aortic valve replacement is not associated with better medium-term outcomes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Bioprosthetic valve thrombosis is currently a well-recognized cause of bioprosthetic valve dysfunction. It was found to be associated with accelerated degeneration of the bioprosthesis with higher rates of valve re-replacement, even after treatment with anticoagulation. We hypothesized that the use of warfarin for three months after transcatheter aortic valve replacement (TAVR) protects against accelerated valve degeneration and is therefore associated with better outcomes compared to dual antiplatelet therapy (DAPT).
Methods
Consecutive adult patients who underwent TAVR in our clinic between 2012 and 2019 were identified retrospectively. Patients with atrial fibrillation were excluded. Subsequently, patients who received DAPT were propensity matched to up to 2 patients who received three months of warfarin as part of their anti-thrombotic regimen. Matching was performed for variables that were significantly different at baseline between the two groups and included diabetes mellitus, prior myocardial infarctions, chronic lung disease, peripheral arterial disease, hemoglobin at time of TAVR, kidney function [creatinine>2], use of angiotensin-converting enzyme inhibitors / angiotensin II receptor blockers, beta blockers, the Society of Thoracic Surgeons (STS) score [STS ≥8, STS 4–8, STS<4], and valve size. The two groups were then compared for outcomes of ischemic stroke, death, valve re-replacement/intervention, the composite endpoint of the aforementioned three outcomes, as well as the three-month outcome of hemorrhagic strokes. Kaplan Meier was used for outcome analysis, and discharge date was considered time zero. Patients who had their anti-thrombotic therapy interrupted were censored at that time point.
Results
A total of 1,373 patients who underwent TAVR were identified. Of these, 576 patients with atrial fibrillation were excluded. Baseline characteristics were compared between 633 patients who received three months of warfarin and 164 patients who received DAPT after TAVR. After matching the two groups, 435 patients were included in the final analysis [warfarin in 281, DAPT in 154; median time to last follow up 2.61 years], Table 1. There was no difference in matched (Figure 1) or unmatched analysis (not shown) in outcomes of ischemic stroke, death, valve re-replacement/intervention, their composite endpoint, or hemorrhagic strokes (p>0.05 for all).
Conclusion
Antithrombotic regimen including three months of warfarin after TAVR was not associated with better outcomes of ischemic strokes, deaths, and valve re-replacement/intervention or with increased risk of hemorrhagic strokes compared to DAPT.
Funding Acknowledgement
Type of funding sources: None.
Collapse
Affiliation(s)
- J Naser
- Mayo Clinic , Rochester , United States of America
| | | | - C G Scott
- Mayo Clinic , Rochester , United States of America
| | - S A Luis
- Mayo Clinic , Rochester , United States of America
| | - K L Greason
- Mayo Clinic , Rochester , United States of America
| | | | - R Gulati
- Mayo Clinic , Rochester , United States of America
| | - M F Eleid
- Mayo Clinic , Rochester , United States of America
| | - V T Nkomo
- Mayo Clinic , Rochester , United States of America
| | - S V Pislaru
- Mayo Clinic , Rochester , United States of America
| |
Collapse
|
38
|
Zheng CR, Mazur P, Arghami A, Jahanian S, Viehman JK, King KS, Dearani JA, Daly RC, Rowse PG, Bagameri G, Crestanello JA. Robotic vs. minimally invasive mitral valve repair: A 5-year comparison of surgical outcomes. J Card Surg 2022; 37:3267-3275. [PMID: 35989503 DOI: 10.1111/jocs.16849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/15/2022] [Accepted: 07/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Minimally invasive mitral valve repair (MVr) is commonly performed. Data on the outcomes of robotic MVr versus nonrobotic minimally invasive MVr are lacking. We sought to compare the short-term and mid-term outcomes of robotic and nonrobotic MVr. METHODS We reviewed all patients who underwent robotic MVr (n = 424) or nonrobotic MVr via right mini-thoracotomy (n = 86) at Mayo Clinic, Rochester, MN, from January 2015 to February 2020. Data on baseline and operative characteristics, operative and long-term outcomes were analyzed. Patients were matched 1:1 using propensity scores. RESULTS Sixty-nine matched pairs were included in the study. The median age was 59 years (interquartile range [IQR]: 54-69) and 75% (n = 103) were male. Baseline characteristics were similar after matching. Robotic and nonrobotic MVr had similar operative characteristics, except that robotic had longer cross-clamp times (57 [48-67] vs. 47 [37-58] min, p < .001) and more P2 resections (83% vs. 68%, p = .05) compared to nonrobotic MVr. There was no difference in operative outcomes between groups. Hospital stay was shorter after robotic MVr (4 [3-4] vs. 4 [4-6] days, p = .003). After a median follow-up of 3.3 years (IQR, 2.1-4.5), there was no mortality in either group, and there was no difference in freedom from mitral valve reoperations between robotic and nonrobotic MVr (5 years: 97.1% vs. 95.7%, p = .63). Follow-up echocardiogram analysis predicted excellent freedom from recurrent moderate-or-severe mitral regurgitation at 3 years after robotic and nonrobotic MVr (90% vs. 92%, p = .18, respectively). CONCLUSIONS Both short-term and mid-term outcomes of robotic and nonrobotic minimally invasive mitral repair surgery are comparable.
Collapse
Affiliation(s)
- Clark R Zheng
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Piotr Mazur
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sepideh Jahanian
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason K Viehman
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Phillip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan A Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
39
|
Hasan IS, Qrareya M, Crestanello JA, Daly RC, Dearani JA, Lahr BD, Lee AT, Stulak JM, Greason KL, Schaff HV. Impact of tricuspid valve regurgitation on intermediate outcomes of degenerative mitral valve surgery. J Thorac Cardiovasc Surg 2022:S0022-5223(22)01025-X. [PMID: 36280428 DOI: 10.1016/j.jtcvs.2022.09.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/28/2022] [Accepted: 09/20/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND In patients undergoing mitral valve surgery, optimal management of less-than-severe concomitant tricuspid valve regurgitation (TR) is unclear, as there are few long-term data. This study examines progression of TR, patient survival, and reoperations in patients undergoing mitral valve surgery. METHODS There were 1588 patients who underwent degenerative mitral valve surgery and had pre- and postoperative echocardiograms for assessment of TR severity and tricuspid annulus diameter. Analysis used repeated-measures ordinal regression to model the longitudinal trends in TR grade and proportional hazards regression for long-term survival and reoperation outcomes. RESULTS Concomitant tricuspid valve (TV) surgery was performed in 235 (14.8%) patients. In response to surgery, TR grades improved more in patients with concomitant TV intervention regardless of the severity of preoperative TR, and these early trends were sustained over long-term follow-up. Risk of progression to severe TR was not influenced by tricuspid annulus diameter (P = .226). After we adjusted for underlying health characteristics, survival following mitral valve surgery was similar in patients with and without TV intervention. Late TV reoperation was observed in 22 patients (5-year cumulative risk 1.5%), but among these, only 6 patients had severe TR as the primary indication for reoperation; preoperative TR grade and initial concomitant TV surgery were not associated with incidence of reoperation. CONCLUSIONS Concomitant TV surgery for moderate TR reduces progression of TR but did not influence survival or incidence of reoperation. Among patients with less-than-severe preoperative TR, tricuspid annular diameter was not associated with progression to severe TR.
Collapse
Affiliation(s)
- Irsa S Hasan
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Mohammad Qrareya
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Brian D Lahr
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - Alex T Lee
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minn
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | | |
Collapse
|
40
|
Goldstein DJ, Puskas JD, Alexander JH, Chang HL, Gammie JS, Marks ME, Iribarne A, Vengrenyuk Y, Raymond S, Taylor BS, Yarden O, Orion E, Dagenais F, Ailawadi G, Chu MWA, DiMaio JM, Narula J, Moquete EG, O’Sullivan K, Williams JB, Crestanello JA, Jessup M, Rose EA, Scavo V, Acker MA, Gillinov M, Mack MJ, Gelijns AC, O’Gara PT, Moskowitz AJ, Bagiella E, Voisine P. External Support for Saphenous Vein Grafts in Coronary Artery Bypass Surgery: A Randomized Clinical Trial. JAMA Cardiol 2022; 7:808-816. [PMID: 35675092 PMCID: PMC9178499 DOI: 10.1001/jamacardio.2022.1437] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Intimal hyperplasia and subsequent saphenous vein graft failure may have significant adverse clinical effects in patients undergoing coronary artery bypass surgery. External support of saphenous vein grafts has the potential to prevent vein graft dilation and hence slow the rate of intimal hyperplasia and increase long-term vein patency. Objective To determine efficacy, as measured by intimal hyperplasia, and safety of an external saphenous vein graft support device in patients undergoing a coronary bypass graft procedure. Design, Setting, and Participants This within-patient randomized, open-label, multicenter study was conducted at 17 Cardiothoracic Surgical Trials Network centers in North America. Between January 2018 and February 2019, 224 patients with multivessel coronary artery disease undergoing isolated bypass surgery were enrolled. For each patient, 1 of 2 vein grafts was randomized to receive external support or no support. Interventions External vein graft support or no support. Main Outcomes and Measures The primary efficacy end point was intimal hyperplasia area assessed by intravascular ultrasound at 12 months postrandomization for each study graft. Secondary confirmatory end points were lumen diameter uniformity assessed by angiography and graft failure (≥50% stenosis) by quantitative coronary angiography. Major cardiac and cerebrovascular events were collected through month 12. Results Among 224 patients (mean [SD] age, 65.8 [8.3] years; 178 [79.5%] male), 203 (90.6%) were eligible for intravascular ultrasound, of which 85 (41.9%) had at least 1 study graft occluded or severely diseased at 12 months (55 supported, 56 unsupported). After imputation of data missing because of graft occlusion or severe disease, the estimated mean (SE) intimal hyperplasia area was 5.11 (0.16) mm2 in supported grafts and 5.79 (0.20) mm2 in unsupported grafts (P = .07). In a sensitivity analysis of 113 patients with both grafts imaged, the mean intimal hyperplasia area was 4.58 (0.18) mm2 and 5.12 (0.23) mm2 in supported and unsupported grafts, respectively (P = .04). By 12 months, 5 patients (2.2%) died and 16 patients (7.1%) experienced a major cardiac or cerebrovascular event. Conclusions and Relevance The 12-month difference in intimal hyperplasia area between supported and unsupported grafts did not achieve statistical significance. Cumulative mortality and major cardiac or cerebrovascular events rates were similar to those in other randomized coronary artery bypass trials. Further investigation to assess the effect of external graft support devices on long-term graft patency and clinical outcomes is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT03209609.
Collapse
Affiliation(s)
- Daniel J. Goldstein
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Bronx, New York
| | - John D. Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, New York
| | - John H. Alexander
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Helena L. Chang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - James S. Gammie
- Johns Hopkins Heart and Vascular Institute, Johns Hopkins Health System, Baltimore, Maryland
| | - Mary E. Marks
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexander Iribarne
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Yuliya Vengrenyuk
- Division of Cardiology, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York
| | - Samantha Raymond
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bradley S. Taylor
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore
| | - Orit Yarden
- Vascular Graft Solutions Ltd, Tel Aviv, Israel
| | - Eyal Orion
- Vascular Graft Solutions Ltd, Tel Aviv, Israel
| | - François Dagenais
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec City, Quebec, Canada
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor
| | - Michael W. A. Chu
- Division of Cardiac Surgery, Western University, London Health Sciences Centre, London, Ontario, Canada
| | | | - Jagat Narula
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ellen G. Moquete
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karen O’Sullivan
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judson B. Williams
- Cardiovascular Surgery, WakeMed Health and Hospitals, Raleigh, North Carolina
| | | | | | - Eric A. Rose
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vincent Scavo
- Cardiovascular and Thoracic Surgery, Lutheran Medical Group, Ft Wayne, Indiana
| | - Michael A. Acker
- Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael J. Mack
- Cardiothoracic Surgery, Baylor Scott & White Health, Plano, Texas
| | - Annetine C. Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Patrick T. O’Gara
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alan J. Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Pierre Voisine
- Department of Surgery, Institut de Cardiologie et Pneumologie de Québec, Québec City, Quebec, Canada
| |
Collapse
|
41
|
Choi K, Locker C, Fatima B, Schaff HV, Stulak JM, Lahr BD, Villavicencio MA, Dearani JA, Daly RC, Crestanello JA, Greason KL, Khullar V. Coronary Artery Bypass Grafting in Octogenarians-Risks, Outcomes, and Trends in 1283 Consecutive Patients. Mayo Clin Proc 2022; 97:1257-1268. [PMID: 35738944 DOI: 10.1016/j.mayocp.2022.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/03/2022] [Accepted: 03/31/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the risks, outcomes, and trends in patients older than 80 years undergoing coronary artery bypass grafting (CABG). METHODS We retrospectively studied 1283 consecutive patients who were older than 80 years and underwent primary isolated CABG from January 1, 1993, to October 31, 2019, in our clinic. Kaplan-Meier survival probability and quartile estimates were used to analyze patients' survival. Logistic regression models were used for analyzing temporal trends in CABG cases and outcomes. A multivariable Cox proportional hazards regression model was developed to study risk factors for mortality. RESULTS Operative mortality was overall 4% (n=51) but showed a significant decrease during the study period (P=.015). Median follow-up was 16.7 (interquartile range, 10.3-21.1) years, and Kaplan-Meier estimated survival rates at 1 year, 5 years, 10 years, and 15 years were 90.2%, 67.9%, 31.1%, and 8.2%, respectively. Median survival time was 7.6 years compared with 6.0 years for age- and sex-matched octogenarians in the general US population (P<.001). Multivariable Cox regression analysis identified older age (P<.001), recent atrial fibrillation or flutter (P<.001), diabetes mellitus (P<.001), smoking history (P=.006), cerebrovascular disease (P=.04), immunosuppressive status (P=.01), extreme levels of creatinine (P<.001), chronic lung disease (P=.02), peripheral vascular disease (P=.02), decreased ejection fraction (P=.03) and increased Society of Thoracic Surgeons predicted risk score (P=.01) as significant risk factors of mortality. CONCLUSION Although CABG in octogenarians carries a higher surgical risk, it may be associated with favorable outcomes and increase in long-term survival. Further studies are warranted to define subgroups benefiting more from surgical revascularization.
Collapse
Affiliation(s)
- Kukbin Choi
- Department of Cardiovascular Surgery, Rochester, MN
| | - Chaim Locker
- Department of Cardiovascular Surgery, Rochester, MN
| | | | | | | | - Brian D Lahr
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | |
Collapse
|
42
|
Naser JA, van Zyl M, Gruber LM, Gulati R, Friedman PA, Young WF, Hemmati P, Foley TA, Schaff HV, Crestanello JA, Pislaru SV. Role of Multimodality Imaging and Preoperative Management in Intrapericardial Paragangliomas. JACC Case Rep 2022; 4:871-877. [PMID: 35912325 PMCID: PMC9334143 DOI: 10.1016/j.jaccas.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/28/2022]
Abstract
Intrapericardial paragangliomas are rare, highly vascular tumors that frequently adhere to adjacent structures and blood vessels, making surgical resection challenging. In this case series, we discuss the role of multimodality imaging and preoperative embolization in the management of 3 patients presenting with intrapericardial paragangliomas. (Level of Difficulty: Advanced.)
Collapse
Affiliation(s)
- Jwan A. Naser
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Martin van Zyl
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Lucinda M. Gruber
- Department of Endocrinology and Metabolism, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Paul A. Friedman
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - William F. Young
- Department of Endocrinology and Metabolism, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Pouya Hemmati
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Thomas A. Foley
- Department of Radiology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Hartzell V. Schaff
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Sorin V. Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Address for correspondence: Dr Sorin V. Pislaru, Division of Cardiovascular Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, Minnesota 55905, USA. @SorinVPislaru
| |
Collapse
|
43
|
Schumer EM, Crestanello JA. Right atrial thrombus in transit. Eur Heart J 2022; 43:3274. [PMID: 35751530 DOI: 10.1093/eurheartj/ehac346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Erin M Schumer
- Mayo Clinic Department of Cardiovascular Surgery, 200 1st St SW, Rochester, MN 55905, USA
| | - Juan A Crestanello
- Mayo Clinic Department of Cardiovascular Surgery, 200 1st St SW, Rochester, MN 55905, USA
| |
Collapse
|
44
|
Kawajiri H, Schaff HV, Dearani JA, Daly RC, Greason KL, Arghami A, Rowse PG, Viehman JK, Lahr BD, Gallego-Navarro C, Crestanello JA. Clinical Outcomes of Mitral Valve Repair for Degenerative Mitral Regurgitation in Elderly Patients. Eur J Cardiothorac Surg 2022; 62:6582572. [PMID: 35532171 DOI: 10.1093/ejcts/ezac299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 02/21/2022] [Accepted: 05/04/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES This study analyzes the safety and outcomes of mitral valve repair for degenerative mitral valve regurgitation in patients 75 years of age or older. METHODS We retrospectively reviewed the clinical results of 343 patients aged ≥75 years who underwent mitral valve repair for degenerative mitral valve regurgitation as a primary indication between January 1998 and June 2017. RESULTS The median (IQR) age of the patients was 79.4 (76.9, 82.9) years, and 132 (38.5%) patients were women. Concomitant procedures were performed in 123 patients: tricuspid surgery in 68 (19.8%) and a maze procedure or pulmonary vein isolation in 55 (16.0%). Operative mortality was 1.2%. Operative complications included atrial fibrillation in 37.9%, prolonged ventilation in 7.0%, pacemaker implantation in 3.8, renal failure requiring dialysis in 1.5, and troke in 3 (0.9%). Median follow-up was 7.4 years (IQR, 3.5-14.1 years). The cumulative incidence rates of mitral valve reoperation were 2.2%, 3.2%, and 3.2% at 1, 5, and 10 years, respectively. Overall survival at 1, 5, and 10 years were 95%, 83%, and 51%, respectively. Older age, smoking, and over and under weight were associated with increased risk of mortality, while higher left ventricular ejection fraction and hypertension were associated with reduced risk. CONCLUSIONS Mitral valve repair in elderly patients can be accomplished with low operative mortality and complications. Mitral valve repair in the elderly remains the preferred treatment for degenerative mitral regurgitation.
Collapse
Affiliation(s)
| | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Philip G Rowse
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Jason K Viehman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | | |
Collapse
|
45
|
Mazur P, Arghami A, Zheng C, Alkhouli M, Schaff HV, Dearani J, Daly RC, Greason K, Crestanello JA. Mitral valve surgery after failed transcatheter edge-to-edge repair. JTCVS Tech 2022; 14:79-88. [PMID: 35967213 PMCID: PMC9366625 DOI: 10.1016/j.xjtc.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/19/2022] [Accepted: 05/03/2022] [Indexed: 10/27/2022] Open
|
46
|
Vogl BJ, Darestani YM, Crestanello JA, Lindman BR, Alkhouli MA, Hatoum H. A Preliminary Study on the Usage of a Data-Driven Probabilistic Approach to Predict Valve Performance Under Different Physiological Conditions. Ann Biomed Eng 2022; 50:941-950. [PMID: 35471674 DOI: 10.1007/s10439-022-02971-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 04/17/2022] [Indexed: 11/27/2022]
Abstract
Predicting potential complications after aortic valve replacement (AVR) is a crucial task that would help pre-planning procedures. The goal of this work is to generate data-driven models based on logistic regression, where the probability of developing transvalvular pressure gradient (DP) that exceeds 20 mmHg under different physiological conditions can be estimated without running extensive experimental or computational methods. The hemodynamic assessment of a 26 mm SAPIEN 3 transcatheter aortic valve and a 25 mm Magna Ease surgical aortic valve was performed under pulsatile conditions of a large range of systolic blood pressures (SBP; 100-180 mmHg), diastolic blood pressures (DBP; 40-100 mmHg), and heart rates of 60, 90 and 120 bpm. Logistic regression modeling was used to generate a predictive model for the probability of having a DP > 20 mmHg for both valves under different conditions. Experiments on different pressure conditions were conducted to compare the probabilities of the generated model and those obtained experimentally. To test the accuracy of the predictive model, the receiver operation characteristics curves were generated, and the areas under the curve (AUC) were calculated. The probabilistic predictive model of DP > 20 mmHg was generated with parameters specific to each valve. The AUC obtained for the SAPIEN 3 DP model was 0.9465 and that for Magna Ease was 0.9054 indicating a high model accuracy. Agreement between the DP probabilities obtained between experiments and predictive model was found. This model is a first step towards developing a larger statistical and data-driven model that can inform on certain valves reliability during AVR pre-procedural planning.
Collapse
Affiliation(s)
- Brennan J Vogl
- Biomedical Engineering Department, Michigan Technological University, Houghton, MI, USA
| | - Yousef M Darestani
- Department of Civil, Environmental and Geospatial Engineering, Michigan Technological University, Houghton, MI, USA
| | | | - Brian R Lindman
- Structural Heart and Valve Center, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Hoda Hatoum
- Biomedical Engineering Department, Michigan Technological University, Houghton, MI, USA.
- Health Research Institute, Center of Biocomputing and Digital Health and Institute of Computing and Cybernetics, Michigan Technological University, Houghton, MI, USA.
| |
Collapse
|
47
|
Katz MS, Greason KL, Crestanello JA, Mankad SV, Guerrero ME, Gulati R, Alkhouli M, Michelena HI, Nkomo VT, Rihal CS, Eleid MF. Renal function changes associated with transcatheter aortic valve-in-valve for prosthetic regurgitation compared to stenosis. IJC Heart & Vasculature 2022; 39:100999. [PMID: 35310374 PMCID: PMC8927844 DOI: 10.1016/j.ijcha.2022.100999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/08/2022] [Indexed: 11/28/2022]
Abstract
Background Renal dysfunction is frequently encountered in patients with aortic prosthesis degeneration requiring valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR). The effect of VIV TAVR on renal function in patients with bioprosthetic aortic regurgitation (AR) and stenosis (AS) is unknown. Objectives The aims of this study were to describe the change in renal function after VIV TAVR and to compare differences in renal function changes in those with predominant prosthetic regurgitation compared to stenosis. Methods All VIV TAVR between June of 2014, and October 2019 (n = 141) at a single institution were reviewed. Baseline renal function parameters including estimated glomerular filtration rate (eGFR) were compared with post-discharge follow-up values in both prosthetic AR and AS patient groups. Linear regression analysis was performed to determine correlates of renal function change. Results Mean baseline eGFR was lower in the AR group (55 SD21 vs. 64 SD24 ml/min/1.73 m2 p = 0.0495). At post-discharge follow-up there was an increase in mean eGFR in the AR group which was not present in the AS group (8 SD12 vs. 0 SD11 ml/min/1.73 m2 respectively p = 0.0006). There were strong correlations between change in creatinine (β = −0.57, R2 = 0.64, p < 0.0001) and BUN (β = −0.61, R2 = 0.51, p < 0.0001), and pre-procedure values in the AR group. Conclusions Patients who underwent VIV TAVR for AR experienced significant improvement of renal function at post-discharge follow-up. More advanced renal dysfunction at baseline was associated with greater improvement in renal function at post discharge in AR patients.
Collapse
Affiliation(s)
- Matthew S. Katz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kevin L. Greason
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Juan A. Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Sunil V. Mankad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mayra E. Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Hector I. Michelena
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Vuyisile T. Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Charanjit S. Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mackram F. Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Corresponding author at: Department of Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, United States.
| |
Collapse
|
48
|
Hassler KR, Schumer EM, Crestanello JA, Stulak JM, Ramakrishna H. FFR-guided PCI versus CABG: Analysis of new data. J Cardiothorac Vasc Anesth 2022; 36:3389-3391. [DOI: 10.1053/j.jvca.2022.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 04/19/2022] [Indexed: 11/11/2022]
|
49
|
Naser JA, Crestanello JA, Nkomo VT, Luis SA, Thaden JJ, Geske JB, Anderson JH, Sinak LJ, Michelena HI, Pislaru SV, Padang R. Immobile Leaflets at Time of Bioprosthetic Valve Implantation: A Novel Risk Factor for Early Bioprosthetic Failure: A Novel Risk Factor for Early Bioprosthetic Failure. Heart Lung Circ 2022; 31:1166-1175. [PMID: 35339372 DOI: 10.1016/j.hlc.2022.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/18/2022] [Accepted: 02/16/2022] [Indexed: 12/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jwan A Naser
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sushil A Luis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lawrence J Sinak
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ratnasari Padang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
50
|
Elsisy MF, Schaff HV, Crestanello JA, Alkhouli MA, Stulak JM, Stephens EH. Outcomes of cardiac surgery in nonagenarians. J Card Surg 2022; 37:1664-1670. [DOI: 10.1111/jocs.16396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 01/14/2022] [Accepted: 02/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Mohamed F. Elsisy
- Department of Cardiovascular Surgery Mayo Clinic Rochester Minnesota USA
| | - Hartzell V. Schaff
- Department of Cardiovascular Surgery Mayo Clinic Rochester Minnesota USA
| | | | | | - John M. Stulak
- Department of Cardiovascular Surgery Mayo Clinic Rochester Minnesota USA
| | | |
Collapse
|