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Kakavand M, Stembal F, Chen L, Mahboubi R, Layoun H, Harb SC, Xiang F, Elgharably H, Soltesz EG, Bakaeen FG, Hodges K, Vargo PR, Rajeswaran J, Firth A, Blackstone EH, Gillinov M, Roselli EE, Svensson LG, Pettersson GB, Unai S, Koprivanac M, Johnston DR. Contemporary experience with the Commando procedure for anterior mitral anular calcification. JTCVS Open 2024; 18:12-30. [PMID: 38690415 PMCID: PMC11056448 DOI: 10.1016/j.xjon.2023.10.038] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/22/2023] [Accepted: 10/10/2023] [Indexed: 05/02/2024]
Abstract
Objective Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. Methods From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). Results Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). Conclusions The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.
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Affiliation(s)
- Mona Kakavand
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Filip Stembal
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lin Chen
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Rashed Mahboubi
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Serge C. Harb
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Fei Xiang
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G. Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G. Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R. Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Austin Firth
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B. Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Rajeswaran J, Blackstone EH. Visualization of longitudinal data: How and why. J Thorac Cardiovasc Surg 2024; 167:778-794.e3. [PMID: 37562676 DOI: 10.1016/j.jtcvs.2023.08.006] [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: 07/06/2023] [Revised: 08/03/2023] [Accepted: 08/03/2023] [Indexed: 08/12/2023]
Affiliation(s)
- Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Rosinski BF, Hodges K, Vargo PR, Roselli EE, Koprivanac M, Tong M, Rajeswaran J, Blackstone EH, Svensson LG. Outcomes of aortic root replacement with tricuspid aortic valve reimplantation in patients with residual aortic regurgitation. J Thorac Cardiovasc Surg 2024; 167:101-111.e4. [PMID: 37532029 DOI: 10.1016/j.jtcvs.2023.07.038] [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: 05/05/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE To characterize residual aortic regurgitation (AR), identify its risk factors, and evaluate outcomes following aortic root replacement with aortic valve reimplantation. METHODS From 2002 to 2020, 756 patients with a tricuspid aortic valve underwent elective reimplantation for aortic root aneurysm. AR on transthoracic echocardiograms before hospital discharge was graded as mild or greater. Machine learning was used to identify risk factors for residual AR and subsequent aortic valve reoperation. RESULTS Sixty-five patients (8.6%) had mild (58 [7.7%]) or moderate (7 [0.93%]) residual postoperative AR. They had more severe preoperative AR (38% vs 12%; P < .0001), thickened cusps (7.7% vs 2.2%; P = .008), aortic valve repair (38% vs 23%; P = .004), and multiple returns to cardiopulmonary bypass for additional repair (11% vs 3.3%; P = .003) than those without AR. Predictors of residual AR were severe preoperative AR, smaller aortic root graft, and concomitant cusp repair. At 10 years, patients with versus without residual AR had more moderate or severe AR (48% vs 7.0%; P < .0001) and freedom from reoperation was worse (89% vs 98%; P < .0001). Residual AR was a risk factor for early reoperation. Concomitant coronary bypass, lower body mass index, and lower ejection fraction were risk factors for late reoperation. Ten-year survival was similar among patients with and without residual AR (97% vs 93%; P = .43). CONCLUSIONS Residual AR after elective reimplantation of a tricuspid aortic valve for aortic root aneurysm is uncommon. Patients with severe preoperative AR and those who undergo valve repair have higher risk for residual AR, which can progress and increase risk of aortic valve reoperation.
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Affiliation(s)
- Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Michael Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- The Aorta Center, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio.
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Patel V, Unai S, Moore R, Layoun H, Harb S, Tong MZ, Karamlou T, Najm HK, Svensson LG, Rajeswaran J, Blackstone EH, Pettersson GB. The Ozaki Procedure: Standardized Protocol Adoption of a Complex Innovative Procedure. Struct Heart 2024; 8:100217. [PMID: 38283567 PMCID: PMC10818143 DOI: 10.1016/j.shj.2023.100217] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/30/2023] [Accepted: 08/10/2023] [Indexed: 01/30/2024]
Abstract
Background The Ozaki procedure using autologous pericardium is an interesting but complex alternative for aortic valve replacement. We present a standardized approach to minimize the learning curve and confirm reproducibility. Methods After careful preparation, from May 2015 to February 2021, an Ozaki procedure was performed on 46 patients age 51 ± 14 years. Seven had unicuspid (15%), 29 bicuspid (63%), and 10 tricuspid (22%) aortic valves, and 2 patients had endocarditis. Endpoints were operative learning curves, perioperative outcomes, intermediate-term valve hemodynamics, reintervention, health-related quality of life (MacNew Heart Disease Health-Related Quality of Life questionnaire), and mortality. Results Cardiopulmonary bypass and aortic clamp times decreased from 145 to 125 minutes and 120 to 100 minutes, respectively, over the first 20 cases, reflecting the learning curve. There was no major perioperative morbidity or mortality. Median postoperative stay was 6.9 days. Aortic regurgitation was mild or less in all but 2 patients who developed moderate aortic regurgitation. Mean aortic valve gradient was 7.9 mmHg postoperatively, 9.2 mmHg by 6 months, and constant thereafter. Left ventricular ejection fraction was 58% preoperatively, 60% at 6 months, and remained stable thereafter. One patient developed infective endocarditis 7 months postoperatively, failed medical management, and underwent valve replacement at 14 months. Two-year survival was 96%, with 1 noncardiac death at 16 months. Health-related quality of life in mental, physical, and emotional domains was better than matched norms, global 6.2 vs. 5.0 (p < 0.0001). Conclusions Using a well-prepared standardized approach, the Ozaki procedure is reproducible with a short learning curve, excellent hemodynamic performance, and good quality of life.
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Affiliation(s)
- Viral Patel
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ryan Moore
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serge Harb
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Z.Y. Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hani K. Najm
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gösta B. Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Hodges K, Rosinski BF, Roselli EE, Rajeswaran J, Griffin B, Vargo PR, Koprivanac M, Tong M, Blackstone EH, Svensson LG. Aortic valve cusp repair does not affect durability of modified aortic valve reimplantation for tricuspid aortic valves. JTCVS Open 2023; 16:105-122. [PMID: 38204640 PMCID: PMC10774985 DOI: 10.1016/j.xjon.2023.06.021] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/09/2023] [Accepted: 06/27/2023] [Indexed: 01/12/2024]
Abstract
Objective During aortic valve reimplantation, cusp repair may be needed to produce a competent valve. We investigated whether the need for aortic valve cusp repair affects aortic valve reimplantation durability. Methods Patients with tricuspid aortic valves who underwent aortic valve reimplantation from January 2002 to January 2020 at a single center were retrospectively analyzed. Propensity matching was used to compare outcomes between patients who did and did not require aortic valve cusp repair. Results Cusp repair was performed in 181 of 756 patients (24%). Patients who required cusp repair were more often male, were older, had more aortic valve regurgitation, and less often had connective tissue disease. Patients who underwent cusp repair had longer aortic clamp time (124 ± 43 minutes vs 107 ± 36 minutes, P = .001). In-hospital outcomes were similar between groups and with no operative deaths. A total of 98.3% of patients with cusp repair and 99.3% of patients without cusp repair had mild or less aortic regurgitation at discharge. The median follow-up was 3.9 and 3.2 years for the cusp repair and no cusp repair groups, respectively. At 10 years, estimated prevalence of moderate or more aortic regurgitation was 12% for patients with cusp repair and 7.0% for patients without cusp repair (P = .30). Mean aortic valve gradients were 6.2 mm Hg and 8.0 mm Hg, respectively (P = .01). Ten-year freedom from reoperation was 99% versus 99% (P = .64) in the matched cohort and 97% versus 97%, respectively (P = .30), in the unmatched cohort. Survival at 10 years was 98% after cusp repair and 93% without cusp repair (P = .05). Conclusions Aortic valve reimplantation for patients with tricuspid aortic valves has excellent long-term results. Need for aortic valve cusp repair does not affect long-term outcomes and should not deter surgeons from performing valve-sparing surgery.
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Affiliation(s)
- Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bradley F. Rosinski
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Science, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Griffin
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R. Vargo
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Tong
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Science, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Aortic Valve Center, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Svensson LG, Rosinski BF, Miletic K, Hodges K, Rajeswaran J, Griffin B, Desai MY, Kalahasti V, Goff Z, Johnston DR, Vargo PR, Roselli EE, Blackstone EH. Effect of ascending aorta replacement on the long-term outcomes of bicuspid aortic valve repair. J Thorac Cardiovasc Surg 2023; 166:1561-1571.e8. [PMID: 37061909 DOI: 10.1016/j.jtcvs.2023.02.024] [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: 06/25/2022] [Revised: 01/18/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
OBJECTIVE The study objective was to determine the effect of sinutubular junction stabilization on long-term outcomes of bicuspid aortic valve repair. METHODS From January 1998 to January 2020, 419 patients underwent bicuspid aortic valve repair with ascending aorta replacement and 421 without (bicuspid aortic valve repair alone). Propensity score matching (97 pairs) was used to compare outcomes. RESULTS Before matching, prevalence of severe aortic regurgitation at 10 years was 5.4% after bicuspid aortic valve repair + ascending aorta replacement and 10% after bicuspid aortic valve repair alone; aortic valve gradient was 20 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 19 mm Hg after bicuspid aortic valve repair alone. Ten-year freedom from reoperation overall was 79% after bicuspid aortic valve repair + ascending aorta replacement and 75% after bicuspid aortic valve repair alone; freedom from late aortic regurgitation was 93% after bicuspid aortic valve repair + ascending aorta replacement and 92% after bicuspid aortic valve repair alone; and freedom from aortic stenosis was 87% after bicuspid aortic valve repair + ascending aorta replacement and 93% after bicuspid aortic valve repair alone. Ten-year survival was 95% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone. After matching, prevalence of severe aortic regurgitation at 10 years was 11% after bicuspid aortic valve repair + ascending aorta replacement and 9.1% after bicuspid aortic valve repair alone (P = .33); aortic valve gradient was 16 mm Hg after bicuspid aortic valve repair + ascending aorta replacement and 25 mm Hg after bicuspid aortic valve repair alone (P < .0001). Ten-year freedom from reoperation was 85% after bicuspid aortic valve repair + ascending aorta replacement and 72% after bicuspid aortic valve repair alone (P = .08) overall. Ten-year freedom from reoperation for late aortic regurgitation was 88% after bicuspid aortic valve repair + ascending aorta replacement and 86% after bicuspid aortic valve repair alone (P = .65). Freedom from aortic stenosis was 97% after bicuspid aortic valve repair + ascending aorta replacement and 91% after bicuspid aortic valve repair alone (P = .03). Ten-year survival was 96% after bicuspid aortic valve repair + ascending aorta replacement and 96% after bicuspid aortic valve repair alone (P = .16). CONCLUSIONS Bicuspid aortic valve repair with or without ascending aorta replacement is associated with good short- and long-term outcomes. Bicuspid aortic valve repair + ascending aorta replacement has a minimal effect on long-term repair durability. Sinutubular junction stabilization should not be performed for the sole purpose of long-term repair durability.
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Affiliation(s)
- Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio.
| | - Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Education Institute, Lerner Research Institute, Cleveland, Ohio
| | - Kyle Miletic
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Education Institute, Lerner Research Institute, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Education Institute, Lerner Research Institute, Cleveland, Ohio
| | | | - Brian Griffin
- The Aorta Center, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y Desai
- The Aorta Center, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- The Aorta Center, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zackary Goff
- Education Institute, Lerner Research Institute, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Burns DJ, Rajeswaran J, Desai MY, Gillinov AM, Hodges K, Roselli EE, Vargo PR, Svensson LG. Survival and repair durability in patients undergoing concomitant aortic valve reimplantation and mitral valve repair. JTCVS Tech 2023; 22:159-168. [PMID: 38152191 PMCID: PMC10750876 DOI: 10.1016/j.xjtc.2023.09.015] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/26/2023] [Accepted: 09/06/2023] [Indexed: 12/29/2023] Open
Abstract
Objective The study objective was to determine repair durability and survival in patients with and without connective tissue disorders undergoing concomitant aortic valve reimplantation and mitral valve repair. Methods From 2002 to 2019, 68 patients underwent concomitant aortic valve reimplantation and mitral valve repair, including 27 patients with Marfan syndrome (39.7%). Follow-up echocardiograms were analyzed using nonlinear multiphase mixed-effects cumulative logistic regression. The regurgitation grade over time was estimated by averaging patient-specific profiles. Survival and freedom from reoperation were estimated by the Kaplan-Meier method. Results At 7 years, 11% of patients had aortic insufficiency greater than mild (severe in 2 patients). There was no difference in greater than mild aortic insufficiency between patients with or without Marfan syndrome (P = .37). Twenty percent of patients had progressed to mitral regurgitation greater than mild (severe in only 1 patient). The prevalence of recurrent mitral regurgitation was higher in those without Marfan syndrome, with greater than mild regurgitation increasing to 24% by 2 years and remaining constant thereafter (P = .04). Freedom from reoperation on the aortic valve or mitral valve was 83% at 10 years and did not differ between Marfan syndrome groups. There were no cases of perioperative mortality. Survival at 5 and 10 years was 94% and 87%, respectively, without a difference between those with and without Marfan syndrome. Conclusions Patients can undergo a total repair strategy using combined aortic valve reimplantation and mitral valve repair procedures with a low risk of mortality and complications, with favorable freedom from both residual valve regurgitation and reoperation.
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Affiliation(s)
- Daniel J.P. Burns
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | | | - A. Marc Gillinov
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R. Vargo
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lars G. Svensson
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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Svensson LG, Vargo PR, Desai MY, Kalahasti V, Griffin B, Roselli EE, Rosinski BF, Rajeswaran J, Blackstone EH. Aortic valve reimplantation in patients with connective tissue disorders: Are the leaflets durable? J Thorac Cardiovasc Surg 2023; 166:1617-1626.e6. [PMID: 36740496 DOI: 10.1016/j.jtcvs.2022.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 06/22/2022] [Revised: 10/27/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The durability of reimplanted myxomatous aortic valves in root replacements for patients with connective tissue disorders (CTD) is unclear; therefore, we sought to evaluate the long-term resilience of these repairs. METHODS From January 1980 to January 2020, 214 patients with CTD and 645 without CTD underwent primary, elective aortic valve reimplantation operations at Cleveland Clinic. The CTD cohort included 164 (77%) with Marfan, 23 (11%) with Loeys-Dietz, and 7 (3.3%) with Ehlers-Danlos CTD. We accounted for differing patient characteristics between the groups by propensity score matching to compare outcomes, yielding 96 matched pairs. Longitudinal echocardiographic measures were compared using nonlinear mixed effects models. RESULTS In the CTD cohort, there were no operative mortalities (30-day or in-hospital), 1 (0.47%) stroke, and 1 (0.47%) early in-hospital reoperation for valve dysfunction. Ten-year prevalence of no aortic regurgitation was 86%, mild 11%, and moderate 3%. Ten-year freedom from reoperation was 97%. In propensity matched cohorts, there were no significant differences in in-hospital outcomes, longitudinal aortic regurgitation and mean gradient, risk of reoperation on the aortic valve, or risk of late death. CONCLUSIONS Aortic valve reimplantation is a durable operation in patients with CTD and root aneurysms. These patients do not experience early degeneration of their reimplanted aortic valves.
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Affiliation(s)
- Lars G Svensson
- Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Patrick R Vargo
- Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y Desai
- Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Griffin
- Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Aorta Center, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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9
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Mahboubi R, Kakavand M, Soltesz EG, Rajeswaran J, Blackstone EH, Svensson LG, Johnston DR. The decreasing risk of reoperative aortic valve replacement: Implications for valve choice and transcatheter therapy. J Thorac Cardiovasc Surg 2023; 166:1043-1053.e7. [PMID: 35397951 DOI: 10.1016/j.jtcvs.2022.02.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 06/25/2020] [Revised: 12/31/2021] [Accepted: 02/10/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Increasing use of bioprostheses for surgical aortic valve replacement (SAVR) in younger patients, together with wider use of transcatheter aortic valve replacement, necessitates understanding risks associated with surgical valve reintervention. Therefore, we sought to identify risks of reoperative SAVR compared with those of primary isolated SAVR. METHODS From January 1980 to July 2017, 7037 patients underwent nonemergency isolated SAVR, with 753 reoperations and 6284 primary isolated operations. These 2 groups were propensity score-matched on 46 preoperative variables, yielding 581 patient pairs for comparing outcomes. RESULTS Among propensity score-matched patients, aortic clamp time (median 63 vs 52 minutes; P < .0001), cardiopulmonary bypass time (median 88 vs 67 minutes; P < .0001), and postoperative stay (median 7.1 vs 6.9 days; P = .003) were longer for reoperative SAVR than primary isolated SAVR. Hospital mortality after reoperative SAVR decreased from 3.4% in 1985 to 1.3% in 2011, similar to that of primary isolated SAVR. Occurrence of stroke, deep sternal wound infection, and new renal dialysis was similar. Blood transfusion (67% vs 36%; P < .0001) and reoperations for bleeding/tamponade (6.4% vs 3.1%; P = .009) were more common after reoperative SAVR. Survival at 1, 5, 10, and 20 years was 94%, 82%, 64%, and 33% after reoperative SAVR and 95%, 86%, 72%, and 46% after elective primary isolated SAVR. CONCLUSIONS Risk of mortality and morbidity after reoperative SAVR has declined and is now similar to that of primary isolated SAVR. Decisions regarding prosthesis choice and SAVR versus transcatheter aortic valve replacement should be made in the context of lifelong disease management rather than avoidance of reoperation.
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Affiliation(s)
- Rashed Mahboubi
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mona Kakavand
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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10
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Blackstone EH, Pettersson GB, Pande A, Gillinov M, Bakaeen FG, McCurry KR, Roselli EE, Smedira NG, Soltesz EG, Tong M, Unai S, Rajeswaran J, Bakhos JJ, Svensson LG. Increasing Surgeon Experience and Cumulative Institutional Experience Drive Decreasing Hospital Mortality after Reoperative Cardiac Surgery. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00875-9. [PMID: 37778501 DOI: 10.1016/j.jtcvs.2023.09.049] [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: 05/04/2023] [Revised: 08/24/2023] [Accepted: 09/13/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE To identify effects of surgeon experience and age, in the context of cumulative institutional experience, on risk-adjusted hospital mortality after cardiac reoperations. METHODS From 1951-2020, 36 surgeons performed 160,338 cardiac operations, including 32,871 reoperations. Hospital death was modeled using a novel tree-bagged, generalized varying-coefficient method with 6 variables reflecting cumulative surgeon and institutional experience up to each cardiac operation: 1) number of total and 2) reoperative cardiac operations performed by a surgeon, 3) cumulative institutional number of total and 4) reoperative cardiac operations, 5) year of surgery, and 6) surgeon age at each operation. These were adjusted for 46 patient characteristics and surgical components. RESULTS 1,470 hospital deaths occurred after cardiac reoperations (4.5%). At the institutional level, hospital death fell exponentially and became less variable, leveling at 1.2% after approximately 14,000 cardiac reoperations. For all surgeons as a group, hospital death decreased rapidly over the first 750 reoperations, then gradually decreased with increasing experience to below 1% after about 4,000 reoperations. Surgeon age up to 75 was associated with ever-decreasing hospital death. CONCLUSIONS Surgeon age and experience have been implicated in adverse surgical outcomes, particularly after complex cardiac operations, with young surgeons being novices and older surgeons having declining ability. However, at Cleveland Clinic, outcome of cardiac reoperations improved with increasing primary surgeon experience, without any suggestion to mid-70s of an age cut-off. Patients were protected by the cumulative background of institutional experience that created a culture of safety and teamwork that mitigated adverse events after cardiac surgery.
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Affiliation(s)
- Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amol Pande
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kenneth R McCurry
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jules Joel Bakhos
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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11
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Meza JM, Blackstone EH, Argo MB, Thuita L, Lowry A, Rajeswaran J, Jegatheeswaran A, Caldarone CA, Kirklin JK, DeCampli WM, Pourmoghadam K, Gruber PJ, McCrindle BW. A dynamic Norwood mortality estimation: Characterizing individual, updated, predicted mortality trajectories after the Norwood operation. JTCVS Open 2023; 14:426-440. [PMID: 37425467 PMCID: PMC10329031 DOI: 10.1016/j.xjon.2023.04.010] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/28/2023] [Indexed: 07/11/2023]
Abstract
Objective Post-Norwood mortality remains high and unpredictable. Current models for mortality do not incorporate interstage events. We sought to determine the association of time-related interstage events, along with (pre)operative characteristics, with death post-Norwood and subsequently predict individual mortality. Methods From the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort, 360 neonates underwent Norwood operations from 2005 to 2016. Risk of death post-Norwood was modeled using a novel application of parametric hazard analysis, in which baseline and operative characteristics and time-related adverse events, procedures, and repeated weight and arterial oxygen saturation measurements were considered. Individual predicted mortality trajectories that dynamically update (increase or decrease) over time were derived and plotted. Results After the Norwood, 282 patients (78%) progressed to stage 2 palliation, 60 patients (17%) died, 5 patients (1%) underwent heart transplantation, and 13 patients (4%) were alive without transitioning to another end point. In total, 3052 postoperative events occurred and 963 measures of weight and oxygen saturation were obtained. Risk factors for death included resuscitated cardiac arrest, moderate or greater atrioventricular valve regurgitation, intracranial hemorrhage/stroke, sepsis, lower longitudinal oxygen saturation, readmission, smaller baseline aortic diameter, smaller baseline mitral valve z-score, and lower longitudinal weight. Each patient's predicted mortality trajectory varied as risk factors occurred over time. Groups with qualitatively similar mortality trajectories were noted. Conclusions Risk of death post-Norwood is dynamic and most frequently associated with time-related postoperative events and measures, rather than baseline characteristics. Dynamic predicted mortality trajectories for individuals and their visualization represent a paradigm shift from population-derived insights to precision medicine at the patient level.
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Affiliation(s)
- James M. Meza
- Division of Cardiothoracic and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Madison B. Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wis
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Ashley Lowry
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, The Cleveland Clinic, Cleveland, Ohio
| | - Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - James K. Kirklin
- Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Ala
| | - William M. DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Kamal Pourmoghadam
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Peter J. Gruber
- Division of Cardiothoracic Surgery, Yale New Haven Children's Hospital, New Haven, Conn
| | - Brian W. McCrindle
- Labatt Family Heart Center, The Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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12
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Lee LJ, Tucker DL, Gupta S, Shaheen N, Rajeswaran J, Karamlou T. Characterizing the anatomic spectrum, surgical treatment, and long-term clinical outcomes for patients with Shone's syndrome. J Thorac Cardiovasc Surg 2023; 165:1224-1234.e9. [PMID: 35798609 DOI: 10.1016/j.jtcvs.2022.05.030] [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: 11/16/2021] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Shone's syndrome (SS) has a varied anatomic spectrum without consensus on need and timing for mitral valve intervention (MVI). We sought to (1) characterize the anatomic spectrum and treatment pathways; (2) describe long-term outcomes and their determinants; and (3) define the impact of MVI timing on survival. METHODS In total, 121 patients with SS who underwent operation at Cleveland Clinic between 1956 and 2021 were reviewed. Multivariable parametric hazard analyses including time-varying covariables, and modulated renewal to account for repeated events, were performed. End points included time-related survival and reintervention. RESULTS Median follow-up was 9.9 years. Mitral stenosis (MS) (98%), coarctation (80%), and aortic stenosis (70%) predominated. The most common combination was MS + aortic stenosis + coarctation (26%). Median initial mean mitral and aortic gradients were 3.6 (15th/85th percentiles: 2.0/6.8) and 9.0 (2.1/46) mm Hg, respectively. Median initial surgery age was 0.041 (0.011/3.2) years. Initial surgeries included coarctation repair (43%), arch repair (18%), and staged biventricular repair (18%). Overall survival was 92% at 20 years. Freedom from reoperation was 66% and 24% at 1 and 20 years. Patients with no MVI or initial MVI (N = 7) tended to be associated with better early survival compared with those with MVI at subsequent operation (N = 29) (P = .06). Risk factors for early reintervention included initial Norwood operation, with younger age and arch hypoplasia increasing later reintervention. CONCLUSIONS Despite excellent long-term survival, reoperation in SS is frequent and occurs most commonly on left ventricular outflow tract and mitral valve. Although MS is present in most, few require MVI. Delaying MVI may compromise early survival.
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Affiliation(s)
- Leah J Lee
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Dominique L Tucker
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Sohini Gupta
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Naseeb Shaheen
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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13
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Ghandour HZ, Hammoud MS, Zia A, Rajeswaran J, Najm HK, Pettersson G, Blackstone E, Karamlou T. Characterization of Favorable Right Ventricular Dimensions for Optimal Reverse Remodeling following Pulmonary Valve Replacement. Semin Thorac Cardiovasc Surg 2023:S1043-0679(23)00033-3. [PMID: 36841346 DOI: 10.1053/j.semtcvs.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 02/27/2023]
Abstract
OBJECTIVE We sought to couple current cardiac magnetic resonance (CMR) thresholds of right ventricular (RV) size and function with longitudinal trajectories of RV recovery, after pulmonary valve replacement (PVR). We aimed to identify optimal timing of PVR and couple CMR-based metrics with contemporaneous echocardiographic metrics. METHODS From 6/2002 to 1/2019, 174 patients with severe pulmonary regurgitation and peak RV outflow tract gradient <30 mmHg underwent PVR at Cleveland Clinic. Mean age was 35±16 years and 60 (34%) had concomitant tricuspid valve surgery. RV end diastolic area index (RVEDAi) and function metrics were measured by offline image review on preoperative and 794 postoperative echocardiograms. Contemporaneous RV end diastolic volume index (RVEDVi) was assessed on CMR and correlated to RVEDAi. Multiphase nonlinear mixed-effects models were used to analyze the longitudinal change in RV size and function after PVR. RESULTS RVEDAi was correlated with RVEDVi (P<.0001, r=.59). RVEDAi decreased slowly over 10 years following PVR. An inflection point at 24 cm2/m2 was noted at 1 year post-PVR and was associated with failure of RV reverse remodelling and RVEDVi ≥ 150 ml/m2. Compared to patients with preoperative RVEDVi ≥ 150 mL/m2, patients with RVEDVi < 150 mL/m2 had accelerated recovery of longitudinal trajectories of RV size and function metrics on echocardiograms. CONCLUSION Reverse remodeling of RV following PVR is an ongoing process. Current accepted threshold values for PVR are associated with greatest RV recovery, suggesting that earlier PVR is warranted. Echocardiography can potentially be utilized in lieu of CMR for surveillance and interventional triage.
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Affiliation(s)
- Hiba Z Ghandour
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Miza Salim Hammoud
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Aisha Zia
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Hani K Najm
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Gosta Pettersson
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH
| | - Eugene Blackstone
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland, OH
| | - Tara Karamlou
- Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH.
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14
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Unai S, Ozaki S, Johnston DR, Saito T, Rajeswaran J, Svensson LG, Blackstone EH, Pettersson GB. Aortic Valve Reconstruction With Autologous Pericardium Versus a Bioprosthesis: The Ozaki Procedure in Perspective. J Am Heart Assoc 2023; 12:e027391. [PMID: 36628965 PMCID: PMC9939068 DOI: 10.1161/jaha.122.027391] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 01/12/2023]
Abstract
Background We assessed the Ozaki procedure, aortic valve reconstruction using autologous pericardium, with respect to its learning curve, hemodynamic performance, and durability compared with a stented bioprosthesis. Methods and Results From January 2007 to January 2016, 776 patients underwent an Ozaki procedure at Toho University Ohashi Medical Center. Learning curves, aortic regurgitation (AR), and peak gradient, assessed by serial echocardiograms, valve rereplacement, and survival were investigated. Valve performance and durability were compared with 627 1:1 propensity-matched patients receiving stented bovine pericardial valves implanted from 1982 to 2011 at Cleveland Clinic. Learning curves were observed for aortic clamp and cardiopulmonary bypass times, AR prevalence, and early mortality. Decreased aortic clamp time was observed over the first 300 cases. New surgeons performing parts of the procedure after case 400 resulted in a slight increase in aortic clamp and cardiopulmonary bypass times. Among matched patients, the Ozaki cohort had more AR than the PERIMOUNT cohort (severe AR at 1 and 6 years, 0.58% and 3.6% versus 0.45% and 1.0%, respectively; P[trend]=0.006), although with a steep learning curve. Peak gradient showed the opposite trend: 14 and 17 mm Hg for Ozaki and 24 and 28 mm Hg for PERIMOUNT at these times (P[trend]<0.001). Freedom from rereplacement was similar (P=0.491). Survival of the Ozaki cohort was 85% at 6 years. Conclusions Patients undergoing the Ozaki procedure had lower gradients but more recurrent AR than those receiving PERIMOUNT bioprostheses. Although recurrent AR is concerning, results confirm low risk and good midterm performance of the Ozaki procedure, supporting its continued use.
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Affiliation(s)
- Shinya Unai
- Department of Thoracic and Cardiovascular SurgeryHeart, Vascular, and Thoracic InstituteCleveland ClinicClevelandOH
| | - Shigeyuki Ozaki
- Department of Cardiovascular SurgeryToho University Ohashi Medical CenterTokyoJapan
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular SurgeryHeart, Vascular, and Thoracic InstituteCleveland ClinicClevelandOH
| | - Tomohiro Saito
- Department of Cardiovascular SurgeryToho University Ohashi Medical CenterTokyoJapan
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health SciencesLerner Research InstituteCleveland ClinicClevelandOH
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular SurgeryHeart, Vascular, and Thoracic InstituteCleveland ClinicClevelandOH
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular SurgeryHeart, Vascular, and Thoracic InstituteCleveland ClinicClevelandOH,Department of Quantitative Health SciencesLerner Research InstituteCleveland ClinicClevelandOH
| | - Gösta B. Pettersson
- Department of Thoracic and Cardiovascular SurgeryHeart, Vascular, and Thoracic InstituteCleveland ClinicClevelandOH
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15
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Jiang MX, Brinza EK, Ghobrial J, Tucker DL, Gupta S, Rajeswaran J, Karamlou T. Coronary artery disease in adults with anomalous aortic origin of a coronary artery. JTCVS Open 2022; 10:205-221. [PMID: 36004264 PMCID: PMC9390708 DOI: 10.1016/j.xjon.2022.04.022] [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] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/01/2022] [Accepted: 04/12/2022] [Indexed: 12/01/2022]
Abstract
Objectives This study sought to characterize coronary artery disease (CAD) among adults diagnosed with an anomalous aortic origin of a coronary artery (AAOCA). We hypothesized that coronaries with anomalous origins have more severe CAD stenosis than coronaries with normal origins. Methods This single-center study of 763 adults with AAOCA consisted of 620 patients from our cardiac catheterization database (1958-2009) and 273 patients from electronic medical records query (2010-2021). Within left main, anterior descending, circumflex, and right coronary arteries, the CAD stenosis severity, assessed by invasive or computer tomography angiography, was modeled with coronary-level variables (presence of an anomalous origin) and patient-level variables (age, sex, comorbidities, and which of the four coronaries was anomalous). Results Of the 763 patients, 472 (60%) had obstructive CAD, of whom, 142/472 (30%) had obstructive CAD only in the anomalous coronary. Multivariable modeling showed similar CAD stenosis severity between coronaries with anomalous versus normal origins (P = .8). Compared with AAOCA of other coronaries, the anomalous circumflex was diagnosed at older ages (59.7 ± 11.1 vs 54.3 ± 15.8 years, P < .0001) and was associated with increased stenosis in all coronaries (odds ratio, 2.7; 95% confidence interval, 2.2-3.4, P < .0001). Conclusions Among adults diagnosed with AAOCA, the anomalous origin did not appear to increase the severity of CAD within the anomalous coronary. In contrast to the circumflex, AAOCA of the other vessels may contribute a greater ischemic burden when they present symptomatically at younger ages with less CAD. Future research should investigate the interaction between AAOCA, CAD, and ischemic risk to guide interventions.
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Affiliation(s)
- Michael X. Jiang
- Department of Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Ellen K. Brinza
- Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | - Joanna Ghobrial
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Dominique L. Tucker
- Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Sohini Gupta
- Case Western Reserve University School of Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Address for reprints: Tara Karamlou, MD, MSc, Division of Pediatric Cardiac Surgery and the Heart Vascular, and Thoracic Institute, 9500 Euclid Ave, M41-022A, Cleveland, OH 44195.
| | - Cleveland Clinic Adult AAOCA Working Group∗BlackstoneEugene H.MDefSaarelElizabeth V.MDghGuptaSohiniBAiHammoudMiza SalimMDfVaidyaKiran A.BSbHauptMichael J.BSbCockrumJoshua W.BSbMhannaChristianeDOaGhobrialJoannaMDjAhmadMunirMDfSchoenhagenPaulMDkPetterssonGösta B.MD, PhDfNajmHani K.MD, MScfStewartRobert D.MD, MPHflDepartment of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OhioDepartment of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OhioDepartment of Pediatric Cardiology, Cleveland Clinic, Cleveland, OhioDepartment of Pediatric Cardiology, St. Luke's Children's Hospital, Boise, IdahoCase Western Reserve University School of Medicine, Cleveland, OhioCleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OhioDepartment of Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, OhioDepartment of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OhioDepartment of Cardiovascular Imaging, Cleveland Clinic, Cleveland, OhioDepartment of Cardiovascular Surgery, Akron Children's Hospital, Akron, Ohio
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16
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Nair RM, Johnson M, Kravitz K, Huded C, Rajeswaran J, Anabila M, Blackstone E, Menon V, Lincoff AM, Kapadia S, Khot UN. Relationship between Index Myocardial Infarction Type and Early Recurrent Myocardial Infarction. Am J Cardiol 2022; 169:160-162. [PMID: 35227501 DOI: 10.1016/j.amjcard.2022.01.041] [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: 01/14/2022] [Accepted: 01/26/2022] [Indexed: 11/01/2022]
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17
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Svensson LG, Rosinski BF, Tucker NJ, Gillinov AM, Rajeswaran J, Roselli EE, Johnston DR, Desai MY, Griffin BP, Blackstone EH. Comparison of Outcomes of Patients Undergoing Reimplantation versus Bentall Root Procedure. Aorta (Stamford) 2022; 10:57-68. [PMID: 35933986 PMCID: PMC9357471 DOI: 10.1055/s-0042-1744135] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background
A bioprosthesis- or mechanical-prosthesis–containing polyester graft (composite graft) is standard surgical management for aortic root aneurysms (Bentall procedure), but particularly in the young patient in whom a bioprosthesis is likely to deteriorate and a mechanical prosthesis mandates life-long anticoagulation, valve-sparing procedures have been devised. One such procedure involves reimplantation of the native aortic valve in the polyester graft. With focus on selecting the optimum procedure for young relatively asymptomatic patients, we compared outcomes of reimplantation of the aortic valve versus the Bentall procedure and identified factors influencing outcomes.
Methods
From January 2000 to January 2017, 643 adults age ≤ 70 with tricuspid aortic valves underwent elective aortic root replacement with either reimplantation (
n
= 448/70%) or a composite valve graft (Bentall) procedure (
n
= 195/30%). Outcomes were compared in 100 propensity-matched pairs.
Results
Patients with fewer symptoms, less aortic regurgitation (AR), higher left ventricular ejection fraction, and smaller cross-sectional aortic area/height ratio had a higher likelihood of valve repair with reimplantation (all
p
< 0.02) versus receiving a Bentall procedure. Operative mortality was 0.16% (reimplantation, 1/448, 0.22%; Bentall 0/195, 0%). After reimplantation, 8-year freedom from severe AR was 95% and 10-year freedom from reintervention was 98%. Ten-year survival was 95%. Higher preoperative AR grade (
p
< 0.0001) but not larger root diameter (
p
= 0.3) was associated with higher grade of late regurgitation after a reimplantation procedure. Among propensity-matched patients, reimplantation compared with a Bentall was associated with similar 10-year survival (89% vs. 94%), but more late AR (8-year freedom from severe AR: 93% vs. 99.9%) and greater early reduction in, but similar late, left ventricular mass (104 vs. 105 g•m
–2
at 8 years).
Conclusion
Excellent aortic valve reimplantation results versus Bentall lead us to recommend reimplantation more often in patients who present with even moderately severe or severe AR and significantly enlarged aortic roots.
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Affiliation(s)
- Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brad F. Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas J. Tucker
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - A. Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y. Desai
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian P. Griffin
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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18
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Brar R, Zia A, Hammoud MS, Xu S, Rajeswaran J, Karamlou T, Komarlu R. LONG TERM OUTCOMES OF CONGENITALLY CORRECTED TRANSPOSITION OF THE GREAT ARTERIES WITH BIVENTRICULAR PHYSIOLOGY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02351-8] [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: 11/25/2022]
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19
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Mokashi SA, Rosinski BF, Desai MY, Griffin BP, Hammer DF, Kalahasti V, Johnston DR, Rajeswaran J, Roselli EE, Blackstone EH, Svensson LG. Aortic root replacement with bicuspid valve reimplantation: Are outcomes and valve durability comparable to those of tricuspid valve reimplantation? J Thorac Cardiovasc Surg 2022; 163:51-63.e5. [PMID: 32684389 DOI: 10.1016/j.jtcvs.2020.02.147] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [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: 04/26/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess intermediate-term outcomes of aortic root replacement with valve-sparing reimplantation of bicuspid aortic valves (BAV), compared with tricuspid aortic valves (TAV). METHODS From January 2002 to July 2017, 92 adults underwent aortic root replacement with BAV reimplantation and 515 with TAV reimplantation at the Cleveland Clinic. Balancing-score matching based on 28 preoperative variables yielded 71 well-matched BAV and TAV pairs (77% of possible pairs) for comparison of postoperative mortality and morbidity, longitudinal echocardiogram data, aortic valve reoperation, and survival. RESULTS In the BAV group, 1 hospital death occurred (1.1%); mortality among all reimplantations was 0.2%. Among matched patients, procedural morbidity was low and similar between BAV and TAV groups (1 stroke in TAV group; renal failure requiring dialysis, 1 patient each; red cell transfusion, 25% each). Five-year results: Severe aortic regurgitation was present in 7.4% of the BAV group and 2.9% of the TAV group (P = .7); 39% of BAV and 65% of TAV patients had none. Higher mean gradients (10 vs 7.4 mm Hg; P = .001) and left ventricular mass index (111 vs 101 g/m2; P = .5) were present in BAV patients. Freedom from aortic valve reoperation was 94% in the BAV group and 98% in the TAV group (P = .10), and survival was 100% and 95%, respectively (P = .07). CONCLUSIONS Both BAV and TAV reimplantations can be performed with equal safety and good midterm outcomes; however, the constellation of higher gradients, less ventricular reverse remodeling, and more aortic valve reoperations with BAV reimplantations raises concerns requiring continued long-term surveillance.
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Affiliation(s)
- Suyog A Mokashi
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Donald F Hammer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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20
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Yun JJ, Saleh OA, Chung JW, Bakaeen FG, Unai S, Tong MZ, Roselli EE, Johnston DR, Soltesz EG, Rajeswaran J, Kapadia S, Blackstone EH, Pettersson GB, Gillinov AM, Svensson LG. Cardiac Operations after Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2021; 114:52-59. [PMID: 34800488 DOI: 10.1016/j.athoracsur.2021.10.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 03/01/2021] [Revised: 08/20/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is now frequently performed for severe aortic stenosis. Data regarding cardiac operations after TAVR are limited, however. Therefore, we investigated patient characteristics, operative timing and indications, and outcomes of these operations in a single-center experience. METHODS From 1/2012-7/2020, 59 patients (median age 70) underwent cardiac operations after TAVR, 38 (64%) of the latter performed outside our center. Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was calculated at time of prior TAVRs and at applicable index cardiac operations. RESULTS From 2012-2018, there were fewer than 10 operations after TAVR, but 18 in 2019. Interval between prior TAVR and cardiac surgery decreased exponentially from 7 to less than 1 year over the experience. In applicable cases (n=19; 32%), median STS-PROM was 5.5% (15th-85th percentiles, 3.1%-25%); 40 (68%) were complex operations with no calculable STS-PROM. The TAVR valve was explanted in 46 (78%); 5 were isolated surgical AVRs. TAVR valve stenosis/regurgitation (n=34; 58%) was the leading indication, followed by paravalvular leak (14; 24%) and endocarditis (n=10/17%). When the TAVR valve was not explanted, mitral regurgitation was the leading indication for operation. Operative mortality was 5 (8.5%), postoperative stroke 2 (3.4%), and postoperative dialysis 6 (10%). CONCLUSIONS Cardiac operations after TAVR are increasing and interval between TAVR and operation decreasing. Most cardiac operations are complex, high-risk reoperations and isolated AVR rare. These findings should be considered when TAVR is selected for low-intermediate risk patients, particularly with multiple cardiac pathologies not addressed by TAVR.
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Affiliation(s)
- James J Yun
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Osama Abou Saleh
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jin Woo Chung
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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21
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Nair R, Johnson M, Kravitz K, Huded C, Rajeswaran J, Anabila M, Blackstone E, Menon V, Lincoff AM, Kapadia S, Khot UN. Characteristics and Outcomes of Early Recurrent Myocardial Infarction After Acute Myocardial Infarction. J Am Heart Assoc 2021; 10:e019270. [PMID: 34333986 PMCID: PMC8475017 DOI: 10.1161/jaha.120.019270] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background We aimed to understand the characteristics and outcomes of patients readmitted with a recurrent myocardial infarction (RMI) within 90 days of discharge after an acute myocardial infarction (early RMI). Methods and Results We analyzed the timing of reinfarction, etiology, and outcome for all patients admitted with an early RMI within 90 days of discharge after an acute myocardial infarction between January 1, 2010 and January 1, 2017. We identified 6626 admissions for acute myocardial infarction (index myocardial infarction) which led to 168 cases of RMI within 90 days of discharge. The mean patient age was 65.1±13.1 years, and 37% were women. The 90-day probability of readmission with an early RMI was 2.5%. Black race, medical management, higher troponin T, and shorter length of stay were independent predictors of early RMI. Medically managed group had a higher risk for early RMI compared with percutaneous coronary intervention (P=0.04) or coronary artery bypass grafting (P=0.2). Predominant mechanisms for reinfarction were stent thrombosis (17%), disease progression (12%), and unchanged coronary artery disease (11%). At 5 years, the all-cause mortality rate for patients with an early RMI was 49% (95% CI, 40%-57%) compared with 22% (95% CI, 21%-23%) for patients without an early RMI (P<0.0001). Conclusions Early RMI is a life-threatening condition with nearly 50% mortality within 5 years. Stent-related events and progression in coronary artery disease account for most early RMI. Medication compliance, aggressive risk factor management, and care transitions should be the cornerstone in preventing early RMI.
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Affiliation(s)
- Raunak Nair
- Cleveland Clinic Heart, Vascular and Thoracic Institute Cleveland OH.,Cleveland Clinic Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation Cleveland OH
| | - Michael Johnson
- Cleveland Clinic Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation Cleveland OH.,University Cardiology Associates Augusta GA
| | - Kathleen Kravitz
- Cleveland Clinic Heart, Vascular and Thoracic Institute Cleveland OH.,Cleveland Clinic Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation Cleveland OH
| | - Chetan Huded
- Cleveland Clinic Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation Cleveland OH.,Saint Luke's Mid America Heart Institute Kansas City MO
| | | | - Moses Anabila
- Cleveland Clinic Heart, Vascular and Thoracic Institute Cleveland OH
| | - Eugene Blackstone
- Cleveland Clinic Heart, Vascular and Thoracic Institute Cleveland OH
| | - Venu Menon
- Cleveland Clinic Heart, Vascular and Thoracic Institute Cleveland OH
| | - A Michael Lincoff
- Cleveland Clinic Heart, Vascular and Thoracic Institute Cleveland OH
| | - Samir Kapadia
- Cleveland Clinic Heart, Vascular and Thoracic Institute Cleveland OH
| | - Umesh N Khot
- Cleveland Clinic Heart, Vascular and Thoracic Institute Cleveland OH.,Cleveland Clinic Heart, Vascular and Thoracic Institute Center for Healthcare Delivery Innovation Cleveland OH
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22
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Nair R, Johnson M, Kravitz K, Rajeswaran J, Blackstone E, Menon V, Lincoff A, Kapadia S, Khot U. RISK OF READMISSION FOLLOWING NSTEMI STRATIFIED BY TREATMENT STRATEGY INTO REVASCULARIZATION VS MEDICAL MANAGEMENT. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)01563-1] [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: 10/21/2022]
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23
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Yongue C, Lopez DC, Soltesz EG, Roselli EE, Bakaeen FG, Gillinov AM, Pettersson GB, Semple ME, Rajeswaran J, Tong MZ, Jaber W, Blackstone EH, Svensson LG, Johnston DR. Durability and Performance of 2298 Trifecta Aortic Valve Prostheses: A Propensity-Matched Analysis. Ann Thorac Surg 2021; 111:1198-1205. [DOI: 10.1016/j.athoracsur.2020.07.040] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
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24
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Geube M, Sale S, Bakdash S, Rajeswaran J, Roselli E, Blackstone E, Johnston D. Prepump autologous blood collection is associated with reduced intraoperative transfusions in aortic surgery with circulatory arrest: A propensity score-matched analysis. J Thorac Cardiovasc Surg 2021; 164:1572-1580.e5. [PMID: 33610366 DOI: 10.1016/j.jtcvs.2021.01.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 08/05/2020] [Revised: 12/23/2020] [Accepted: 01/06/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate the effect of autologous whole blood (AWB) collection on intraoperative/postoperative allogeneic blood transfusion rate in complex aortic surgery with hypothermic circulatory arrest. METHODS This retrospective study included adults who underwent aortic surgery with hypothermic circulatory arrest at a single institution between 2014 and 2019. Out of 509 cases (414 patients), 110 (22%) received the AWB protocol. We performed propensity-score matching, including 35 preoperative and procedural variables, which resulted in 95 well-matched pairs, to compare outcomes in patients who received AWB protocol versus those who did not. Study outcomes were percentage of patients who received transfusion of allogeneic blood products intraoperatively and postoperatively. RESULTS Mean volume of collected autologous blood was 826 ± 263 mL. Intraoperatively, fewer AWB patients received red blood cell concentrate (33% vs 49%; P = .02), plasma (35% vs 62%; P = .0002), platelets (61% vs 81%; P = .003), and cryoprecipitate (43% vs 56%; P = .08) compared with non-AWB patients. During the entire hospital stay, the differences in transfusion rate between the 2 groups were: red blood cells (58% vs 62%; P = .6), plasma (49% vs 66%; P = .01), platelets (72% vs 82%; P = .09), and cryoprecipitate (56% vs 63%; P = .3). CONCLUSIONS Pre-pump autologous blood collection may reduce the need for intraoperative transfusion of allogenic non-red-cell blood products in patients undergoing complex aortic surgery with hypothermic circulatory arrest. A larger study is needed to clarify the influence of this association on patient outcomes and resource utilization.
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Affiliation(s)
- Mariya Geube
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio.
| | - Shiva Sale
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio
| | - Suzanne Bakdash
- Department of Clinical Pathology, Division of Transfusion Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric Roselli
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eugene Blackstone
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Douglas Johnston
- Department of Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
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25
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Attia T, Yang Y, Svensson LG, Toth AJ, Rajeswaran J, Blackstone EH, Johnston DR. Similar long-term survival after isolated bioprosthetic versus mechanical aortic valve replacement: A propensity-matched analysis. J Thorac Cardiovasc Surg 2021; 164:1444-1455.e4. [PMID: 33892946 DOI: 10.1016/j.jtcvs.2020.11.181] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 05/03/2018] [Revised: 08/26/2020] [Accepted: 11/02/2020] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Improved durability and preference to avoid anticoagulation have led to increasing use of bioprostheses in younger patients despite the need for eventual reoperation. Therefore, we compared in-hospital complications, reoperation, and survival after bioprosthetic and mechanical aortic valve replacement. METHODS From January 1990 to January 2020, 6143 patients underwent isolated aortic valve replacement at Cleveland Clinic; 637 patients received a mechanical prosthesis and 5506 a bioprosthesis. Propensity matching identified 527 well-matched pairs (83% of possible matches) for comparison of perioperative outcomes. The average age of patients was 54 years in the bioprosthesis group and 55 years in the mechanical prosthesis group. Random Forest machine-learning analysis was performed to compare survival using the entire cohort of 6143 patients. RESULTS Among matched patients, major in-hospital complications, including stroke, deep sternal wound infection, and reoperation for bleeding, were similar, as was in-hospital mortality (2 in the bioprosthesis group [0.38%] vs 3 in the mechanical prosthesis group [0.57%]; P > .9). Patients receiving a bioprosthesis had shorter hospital stays (median 6 vs 7 days, P < .0001). Fifty-one patients (32% at 14 years) in the bioprosthesis group and 17 patients in the mechanical prosthesis group (8% at 14 years) underwent reoperation (P [log-rank] < .0001); 5-year survival after reoperation was 85% versus 82% (P = .6). Risk-adjusted Random Forest prediction of 18-year survival was 60% in the bioprosthetic group and 58% in the mechanical prosthesis group. CONCLUSIONS Aortic valve bioprostheses are associated with excellent short-term outcomes and 18-year survival similar to that of patients receiving mechanical valves. Reoperation does not adversely affect survival. These results suggest that risk for reoperation alone should not deter the use of bioprostheses in younger patients.
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Affiliation(s)
- Tamer Attia
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio
| | - Yanzhi Yang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Research Institute, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio
| | - Andrew J Toth
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | | | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland, Ohio.
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26
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Barrios PA, Zia A, Pettersson G, Najm HK, Rajeswaran J, Bhimani S, Karamlou T. Outcomes of treatment pathways in 240 patients with congenitally corrected transposition of great arteries. J Thorac Cardiovasc Surg 2020; 161:1080-1093.e4. [PMID: 33436290 DOI: 10.1016/j.jtcvs.2020.11.164] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 06/07/2020] [Revised: 10/09/2020] [Accepted: 11/10/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Congenitally corrected transposition of the great arteries (ccTGA) encompasses a diverse morphologic cohort, for which multiple treatment pathways exist. Understanding surgical outcomes among various pathways and their determinants are challenged by limited sample size and follow-up, and heterogeneity. We sought to investigate these questions with a large cohort of ccTGA patients presenting at different ages and representing the full therapeutic spectrum. METHODS Retrospective review of 240 patients diagnosed with ccTGA from Cleveland Clinic coupled with prospective cross-sectional follow-up. Forty-six patients whose definitive procedure was completed elsewhere were excluded. Time-related survival was described among treatment pathways using actuarial, time-varying covariate, and competing risks analyses. Temporal trends in longitudinal valve and ventricular function were assessed using nonlinear mixed-effects models. RESULTS Median follow-up was 10 years. Seventy-nine patients with ccTGA underwent anatomic repair, 45 physiologic repair, 24 Fontan palliation, and 6 primary transplant. Forty patients managed expectantly had excellent long-term survival when considered from time of presentation, but benefited from failures captured following transition to physiologic repair or transplant. Morphologic right ventricular dysfunction after physiologic repair increased from 68% to 85% after 5 years, whereas morphologic left ventricular function was stable in anatomic repair, especially with early surgery. Transplant-free survival at 15 years for anatomic and physiologic repair was 80% and 71%, respectively. CONCLUSIONS Early anatomic repair may be preferable to physiologic repair for select ccTGA patients. Late attrition after physiologic repair represents failure of expectant management and progressive tricuspid valve and morphologic right ventricular dysfunction compared with anatomic repair, where morphologic left ventricular function is relatively preserved.
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Affiliation(s)
- Paola A Barrios
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Aisha Zia
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Salima Bhimani
- Division of Pediatric Cardiology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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27
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Levack MM, Kindzelski BA, Miletic KG, Vargo PR, Bakaeen FG, Johnston DR, Rajeswaran J, Blackstone EH, Roselli EE. Adjunctive endovascular balloon fracture fenestration for chronic aortic dissection. J Thorac Cardiovasc Surg 2020; 164:2-10.e5. [DOI: 10.1016/j.jtcvs.2020.09.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/30/2020] [Accepted: 09/18/2020] [Indexed: 01/29/2023]
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28
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Blackstone EH, Rajeswaran J. Commentary: Excitement at the interface of disciplines: The mean cumulative function. J Thorac Cardiovasc Surg 2020; 160:687-688. [DOI: 10.1016/j.jtcvs.2019.07.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 07/25/2019] [Indexed: 10/26/2022]
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29
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Preethish-Kumar V, Shah A, Kumar M, Ingalhalikar M, Polavarapu K, Afsar M, Rajeswaran J, Vengalil S, Nashi S, Thomas PT, Sadasivan A, Warrier M, Nalini A, Saini J. In Vivo Evaluation of White Matter Abnormalities in Children with Duchenne Muscular Dystrophy Using DTI. AJNR Am J Neuroradiol 2020; 41:1271-1278. [PMID: 32616576 DOI: 10.3174/ajnr.a6604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 03/23/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Duchenne muscular dystrophy is an X-linked disorder characterized by progressive muscle weakness and prominent nonmotor manifestations, such as a low intelligence quotient and neuropsychiatric disturbance. We investigated WM integrity in patients with Duchenne muscular dystrophy using DTI. MATERIALS AND METHODS Fractional anisotropy and mean, axial, and radial diffusivity (DTI measures) were used to assess WM microstructural integrity along with neuropsychological evaluation in patients with Duchenne muscular dystrophy (n = 60) and controls (n = 40). Exon deletions in the DMD gene were confirmed using multiplex ligation-dependent probe amplification. Patients were classified into proximal (DMD Dp140+) and distal (DMD Dp140-) subgroups based on the location of the exon deletion and expression of short dystrophin Dp140 isoform. WM integrity was examined using whole-brain Tract-Based Spatial Statistics and atlas-based analysis of DTI data. The Pearson correlation was performed to investigate the possible relationship between neuropsychological scores and DTI metrics. RESULTS The mean ages of Duchenne muscular dystrophy and control participants were 8.0 ± 1.2 years and 8.2 ± 1.4 years, respectively. The mean age at disease onset was 4.1 ± 1.8 years, and mean illness duration was 40.8 ± 25.2 months. Significant differences in neuropsychological scores were observed between the proximal and distal gene-deletion subgroups, with more severe impairment in the distal-deletion subgroup (P < .05). Localized fractional anisotropy changes were seen in the corpus callosum, parietal WM, and fornices in the patient subgroup with Dp140+, while widespread changes were noted in the Dp140- subgroup. The Dp140+ subgroup showed increased axial diffusivity in multiple WM regions relative to the Dp140- subgroup. No significant correlation was observed between clinical and neuropsychological scores and diffusion metrics. CONCLUSIONS Widespread WM differences are evident in patients with Duchenne muscular dystrophy relative to healthy controls. Distal mutations in particular are associated with extensive WM abnormalities and poor neuropsychological profiles.
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Affiliation(s)
| | - A Shah
- Symbiosis Centre for Medical Image Analysis (A.Shah, M.I.), Symbiosis International University, Mulshi Pune, Maharashtra, India
| | - M Kumar
- Neuroimaging and Interventional Radiology (M.K., J.S.)
| | - M Ingalhalikar
- Symbiosis Centre for Medical Image Analysis (A.Shah, M.I.), Symbiosis International University, Mulshi Pune, Maharashtra, India
| | - K Polavarapu
- From the Departments of Neurology (V.P.-K., K.P., S.V., S.N., A.N.)
| | - M Afsar
- Neuropsychology (M.A., J.R.)
| | | | - S Vengalil
- From the Departments of Neurology (V.P.-K., K.P., S.V., S.N., A.N.)
| | - S Nashi
- From the Departments of Neurology (V.P.-K., K.P., S.V., S.N., A.N.)
| | - P T Thomas
- Psychiatric Social Work (P.T.T., A.Sadasivan, M.W.), National Institute of Mental Health and Neurosciences, Bangalore, India
| | - A Sadasivan
- Psychiatric Social Work (P.T.T., A.Sadasivan, M.W.), National Institute of Mental Health and Neurosciences, Bangalore, India
| | - M Warrier
- Psychiatric Social Work (P.T.T., A.Sadasivan, M.W.), National Institute of Mental Health and Neurosciences, Bangalore, India
| | - A Nalini
- From the Departments of Neurology (V.P.-K., K.P., S.V., S.N., A.N.)
| | - J Saini
- Neuroimaging and Interventional Radiology (M.K., J.S.)
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Nair R, Johnson M, Kravitz KA, Anabila M, Rajeswaran J, Blackstone EH, Menon V, Lincoff AMM, Kapadia SR, Khot U. Abstract 245: Risk of Readmission With Recurrent Myocardial Infarction After Index Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.245] [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: 11/16/2022]
Abstract
Background:
Recurrent Myocardial Infarction (MI) after an index MI is a cause for considerable morbidity and mortality. However, the underlying factors that precipitate patients for a recurrent MI remain unclear. We aimed to assess the effect of index MI treatment strategy on the risk of developing a recurrent MI.
Methods:
We reviewed all cases of MI at a single quaternary care medical center from January 1
st
, 2010 to January 1
st
, 2017 and identified all cases of recurrent MI within 90 days after index MI. Readmissions were further stratified depending on the treatment strategy undertaken during index MI into medically managed and revascularized patients. The instantaneous risk of readmission following each of these treatment strategies was estimated by the parametric method.
Results:
We identified 6,626 patients admitted with an index MI, of which 168 patients were readmitted with a recurrent MI within 90 days. Among the index admissions, 4354 (66%) patients underwent revascularization and 2272 (34%) patients underwent medical management. Time-varying instantaneous risk of readmission analysis showed an early peaking risk followed by a late increasing risk in the revascularization group whereas, in the medically managed group, the analysis yielded an early peaking followed by a late almost constant risk of readmission for MI.
Conclusion:
Patients with acute MI who are medically treated are at a higher risk of developing a recurrent MI than patients who undergo revascularization. Defining the characteristics and underlying factors contributing to these readmissions can be pivotal in improving patient outcomes.
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Affiliation(s)
- Raunak Nair
- Cleveland Clinic Fairview Hosp, Cleveland, OH
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Nair R, Johnson M, Kravitz KA, Anabila M, Rajeswaran J, Blackstone EH, Menon V, Lincoff AMM, Kapadia SR, Khot U. Abstract 357: Comparison of Comorbidities Between Patients Admitted With Index Myocardial Infarction and Recurrent Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.357] [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: 11/16/2022]
Abstract
Background:
Several comorbidities are known to increase the risk of coronary artery disease. However, the relationship between modifiable risk factors and recurrent Myocardial Infarction (MI) has not been clearly defined. The purpose of our study was to assess if there were certain comorbidities that increase the risk of recurrent myocardial infarction.
Methods:
We reviewed 6,626 cases of MI at a single quaternary care medical center from January 1
st
, 2010 to January 1
st
, 2017 (29% STEMI, 71% NSTEMI), and we identified all cases of readmission with a recurrent MI within 90 days after index MI. All patients with index MI were screened for accompanying comorbidities and compared with patients with recurrent MI.
Results:
There were a total of 2051 readmissions (31%) within 90-days of index MI, of which 168 readmissions were for recurrent MI. Hypertension and Dyslipidemia appeared to be the most prominent modifiable risk factors in patients with index MI and recurrent MI (86%, 94% for HTN & 81%, 93% for DLP). All comorbidities were substantially more prevalent in patients with recurrent MI than in patients with index MI.
Conclusion:
Patients with recurrent MI have a higher risk factor burden than the general population with MI. This highlights the importance of risk factor management in patients with acute Myocardial infarction.
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Affiliation(s)
- Raunak Nair
- Cleveland Clinic Fairview Hosp, Cleveland, OH
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Nair R, Johnson M, Kravitz KA, Anabila M, Rajeswaran J, Blackstone EH, Menon V, Lincoff AM, Kapadia SR, Khot U. Abstract 383: Effect of Race on Risk of Recurrent Myocardial Infarction After Index Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.383] [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: 11/16/2022]
Abstract
Background:
Though the prevalence of coronary artery disease is known to be highest in African Americans, it is unclear if there are any racial factors predisposing patients for a recurrent Myocardial Infarction (MI) after index MI.
Methods:
We reviewed 6,626 cases of MI at a single quaternary care medical center from January 1
st
, 2010 to January 1
st
, 2017 (29% STEMI, 71% NSTEMI), and we identified all cases of recurrent MI within 90 days of discharge after index MI. The patients were categorized according to their corresponding races into White Americans, African Americans, and Others.
Result:
Out of the 6626 initial cases of MI, 72% were white patients, 25% were African Americans and 3% belonged to other races. A total of 2051 patients were readmitted within 90 days of index admission, of which 168 patients were readmitted with an MI. Only 2.1% of White patients developed a recurrent MI whereas 4% of African Americans were readmitted with a recurrent MI (P=0.003).
Conclusion:
We observed that African Americans were more likely to be readmitted with a recurrent MI than White Americans. Understanding the reasons for this increased risk in MI can translate into improved care for African Americans.
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Affiliation(s)
- Raunak Nair
- Cleveland Clinic Fairview Hosp, Cleveland, OH
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Nair R, Johnson M, Kravitz KA, Anabila M, Rajeswaran J, Blackstone EH, Menon V, Lincoff AMM, Kapadia SR, Khot U. Abstract 225: Impact of Revascularization Strategy on Risk of Readmission After Non-ST Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.225] [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: 11/16/2022]
Abstract
Background:
It is unclear how revascularization strategy (medical management vs percutaneous coronary intervention vs coronary artery bypass surgery), affects 90-day readmissions after Non-ST Elevation Myocardial Infarction (NSTEMI).
Methods:
We identified cases of NSTEMI at a single quaternary care medical center between January 1
st
, 2010 to January 1
st
, 2017 and readmissions within 90 days. Cases were categorized based on revascularization strategy into medical management, PCI (percutaneous coronary intervention) or CABG (coronary artery bypass surgery). The readmissions were categorized according to the time of readmission into early (0-30 days) and late (31-90 days) after discharge. The instantaneous risk of readmission following each treatment option was calculated using the parametric method.
Results:
We identified 6626 patients with index MI, of which 4692 patients had NSTEMI. There were a total of 2051 readmissions within 90 days. The risk of readmission for CABG and PCI treatment groups yielded an early peaking phase followed by a constant risk whereas the risk of readmission in the medically managed group showed an early decreasing phase followed by a constant risk. An unadjusted comparison of the risk of readmission between the three groups showed that the PCI group had the lowest early risk of readmission (P=0.03). The medically managed group had the highest risk of readmission.
Conclusion:
Patients with NSTEMI who are medically managed appear to be at higher risk for readmission than revascularized patients. Understanding the care processes for these patients may serve as a future opportunity to improve outcomes in these high-risk patients.
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Affiliation(s)
- Raunak Nair
- Cleveland Clinic Fairview Hosp, Cleveland, OH
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Nair R, Johnson M, Kravitz KA, Anabila M, Rajeswaran J, Blackstone EH, Menon V, Lincoff AMM, Kapadia SR, Khot U. Abstract 246: Effect of Racial Factors on Timing of Readmissions After Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.246] [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: 11/16/2022]
Abstract
Background:
Readmissions following acute myocardial infarction (MI) are associated with increased cost, healthcare utilization, and morbidity. The purpose of this study was to assess racial factors in influencing time for readmission after being admitted with myocardial infarction.
Methods:
We reviewed 6,626 cases of MI at a single quaternary care medical center from January 1
st
, 2010 to January 1
st
, 2017 (29% STEMI, 71% NSTEMI), and we identified all readmissions within 90 days after index MI. The patients were categorized according to their race into White Americans (72%), African Americans (25%) and others (3%). Readmissions were stratified into early (0-30 days) and late (31-90 days) time periods depending on the timing of readmission and these readmissions were also separated according to their corresponding race into White Americans (62%), African Americans (35%) and others (3%). Since White Americans and African Americans contributed to the bulk of our patient population, we analyzed the difference between these two groups.
Results:
There were a total of 2051 readmissions within 90 days after index MI. Overall, 50% of readmissions were in the early time period and 50% in the late period (after 30 days). 46% of African Americans were readmitted in the early time period compared to 52% of white patients whereas 54% of African Americans were readmitted in the late time period compared to 48% of white patients (P=0.0037).
Conclusions:
The temporal pattern of readmissions after myocardial infarction differed between Whites and African Americans. These findings may have implications regarding the development of readmission reduction strategies.
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Affiliation(s)
- Raunak Nair
- Cleveland Clinic Fairview Hosp, Cleveland, OH
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Blackstone EH, Pande A, Rajeswaran J. Commentary: Enhancing risk assessment by incorporating more of what we know. J Thorac Cardiovasc Surg 2020; 163:1388-1390.e3. [PMID: 32505455 DOI: 10.1016/j.jtcvs.2020.03.132] [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: 03/30/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Amol Pande
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
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Greason KL, Blackstone EH, Rajeswaran J, Lowry AM, Svensson LG, Webb JG, Tuzcu EM, Smith CR, Makkar RR, Mack MJ, Thourani VH, Kodali SK, Leon MB, Miller DC. Inter- and intrasite variability of mortality and stroke for sites performing both surgical and transcatheter aortic valve replacement for aortic valve stenosis in intermediate-risk patients. J Thorac Cardiovasc Surg 2020; 159:1233-1244.e4. [DOI: 10.1016/j.jtcvs.2019.04.112] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 03/15/2019] [Accepted: 04/20/2019] [Indexed: 11/15/2022]
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Stackhouse KA, McCrindle BW, Blackstone EH, Rajeswaran J, Kirklin JK, Bailey LL, Jacobs ML, Tchervenkov CI, Jacobs JP, Pettersson GB. Surgical palliation or primary transplantation for aortic valve atresia. J Thorac Cardiovasc Surg 2020; 159:1451-1461.e7. [DOI: 10.1016/j.jtcvs.2019.08.104] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 08/16/2019] [Accepted: 08/25/2019] [Indexed: 11/30/2022]
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Nair RM, Huded C, Abdallah MS, Johnson MJ, Kravitz K, Rajeswaran J, Anabila M, Blackstone E, Lincoff A, Kapadia S, Menon V, Khot U. CHARACTERIZING REASONS FOR READMISSION EARLY, LATE, AND VERY LATE AFTER ACUTE MYOCARDIAL INFARCTION. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)30867-6] [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: 10/24/2022]
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Nair RM, Abdallah MS, Johnson MJ, Kravitz K, Anabila M, Rajeswaran J, Blackstone E, Lincoff A, Menon V, Kapadia S, Khot U. IMPACT OF TREATMENT STRATEGY FOLLOWING ACUTE MYOCARDIAL INFARCTION ON READMISSION RISK. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)30868-8] [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: 11/15/2022]
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40
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Nair RM, Abdallah MS, Huded C, Johnson MJ, Kravitz K, Rajeswaran J, Anabila M, Blackstone E, Lincoff A, Menon V, Kapadia S, Khot U. RECURRENT MYOCARDIAL INFARCTION AFTER STEMI VS. NSTEMI. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)30855-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: 11/26/2022]
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41
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Khot UN, Johnson MJ, Wiggins NB, Lowry AM, Rajeswaran J, Kapadia S, Menon V, Ellis SG, Goepfarth P, Blackstone EH. Long-Term Time-Varying Risk of Readmission After Acute Myocardial Infarction. J Am Heart Assoc 2019; 7:e009650. [PMID: 30375246 PMCID: PMC6404216 DOI: 10.1161/jaha.118.009650] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 11/29/2022]
Abstract
Background Readmission after myocardial infarction (MI) is a publicly reported quality metric with hospital reimbursement linked to readmission rates. We describe the timing and pattern of readmission by cause within the first year after MI in consecutive patients, regardless of revascularization strategy, payer status, or age. Methods and Results We identified patients discharged after an MI from April 2008 to June 2012. Readmission within 12 months was the primary end point. Readmissions were classified into 4 groups: MI related, other cardiovascular, noncardiovascular, and planned. A total of 3069 patients were discharged after an MI (average age, 65±13 years; and 1941 [63%] men). A total of 655 patients (21.3%) were readmitted at least once (897 total readmissions). A total of 147 patients (4.8%) were readmitted ≥2 times, accounting for 389 readmissions (43%). The instantaneous risk of all‐cause readmission was highest (15 readmissions/100 patients per month; 95% confidence interval, 12–19 readmissions/100 patients per month) immediately after discharge, decreased by almost half (8.1 readmissions/100 patients per month; 95% confidence interval, 7.2–9.0 readmissions/100 patients per month) within 15 days, and was substantially lower and relatively constant (1.4 readmissions/100 patients per month; 95% confidence interval, 1.2–1.6 readmissions/100 patients per month) out to 1 year. Cardiovascular causes of readmission were more common early after discharge. Conclusions Most patients with MI are never readmitted, whereas a small minority (≈5%) account for nearly half of 1‐year readmissions. The readmission pattern after MI is characterized by an early peak (first 15 days) of cardiovascular readmissions, followed by a middle period (months 1–4) of noncardiovascular readmissions, and ending with a low‐risk period (>4 months) during which the risk appears independent of cause. See Editorial by Levy and Allen
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Affiliation(s)
- Umesh N Khot
- 1 Department of Cardiology Heart and Vascular Institute Center for Healthcare Delivery Innovation Cleveland OH
| | - Michael J Johnson
- 1 Department of Cardiology Heart and Vascular Institute Center for Healthcare Delivery Innovation Cleveland OH
| | - Newton B Wiggins
- 1 Department of Cardiology Heart and Vascular Institute Center for Healthcare Delivery Innovation Cleveland OH
| | - Ashley M Lowry
- 2 Department of Quantitative Health Sciences Research Institute Cleveland OH
| | | | - Samir Kapadia
- 3 Department of Cardiology Heart and Vascular Institute Cleveland OH
| | - Venu Menon
- 3 Department of Cardiology Heart and Vascular Institute Cleveland OH
| | - Stephen G Ellis
- 3 Department of Cardiology Heart and Vascular Institute Cleveland OH
| | - Pamela Goepfarth
- 3 Department of Cardiology Heart and Vascular Institute Cleveland OH
| | - Eugene H Blackstone
- 2 Department of Quantitative Health Sciences Research Institute Cleveland OH.,3 Department of Cardiology Heart and Vascular Institute Cleveland OH
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42
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Rajeswaran J, Bennett C. Emerging hope: EEG neurofeedback training in TBI. J Neurol Sci 2019. [DOI: 10.1016/j.jns.2019.10.451] [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] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kapadia SR, Huded CP, Kodali SK, Svensson LG, Tuzcu EM, Baron SJ, Cohen DJ, Miller DC, Thourani VH, Herrmann HC, Mack MJ, Szerlip M, Makkar RR, Webb JG, Smith CR, Rajeswaran J, Blackstone EH, Leon MB. Stroke After Surgical Versus Transfemoral Transcatheter Aortic Valve Replacement in the PARTNER Trial. J Am Coll Cardiol 2019; 72:2415-2426. [PMID: 30442284 DOI: 10.1016/j.jacc.2018.08.2172] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [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: 06/07/2018] [Revised: 08/07/2018] [Accepted: 08/20/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transfemoral-transcatheter aortic valve replacement (TF-TAVR) is increasingly used to treat aortic stenosis, but risk of post-procedure stroke is uncertain. OBJECTIVES The purpose of this study was to assess stroke risk and its association with quality of life after surgical aortic valve replacement (SAVR) versus TF-TAVR. METHODS The authors performed a propensity-matched study of 1,204 pairs of patients with severe aortic stenosis treated with SAVR versus TF-TAVR in the PARTNER (Placement of AoRTic TraNscathetER Valves) trials from April 2007 to October 2014. Outcomes were: 1) 30-day neurological events; 2) time-varying risk of neurological events early (≤7 days) and late (7 days to 48 months) post-procedure; and 3) association between stroke and quality of life 1 year post-procedure by the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score. RESULTS Thirty-day stroke (5.1% vs. 3.7%; p = 0.09) was similar, but 30-day major stroke (3.9% vs. 2.2%; p = 0.018) was lower after TF-TAVR than SAVR. In both groups, risk of stroke peaked in the first post-procedure day, followed by a near-constant low-level risk to 48 months. Major stroke was associated with a decline in quality of life at 1 year in both SAVR (KCCQ score median [15th, 85th percentile]: 79 [53, 94] without major stroke vs. 64 [30, 94] with major stroke; p = 0.03) and TF-TAVR (78 [49, 96] without major stroke vs. 60 [8, 99] with major stroke; p = 0.04). CONCLUSIONS Despite similar early-peaking (<1 day post-procedure) neurological risk profiles, SAVR is associated with a higher risk of early major stroke than TF-TAVR. Periprocedural strategies are needed to reduce stroke risk after aortic valve procedures. (Placement of AoRTic TraNscathetER Valve Trial [PARTNER]; NCT00530894).
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Affiliation(s)
- Samir R Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
| | - Chetan P Huded
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Susheel K Kodali
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York Presbyterian Hospital, New York, New York
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - E Murat Tuzcu
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Suzanne J Baron
- Department of Cardiology, Saint Luke's Health System, Kansas City, Missouri
| | - David J Cohen
- Department of Cardiology, Saint Luke's Health System, Kansas City, Missouri
| | - D Craig Miller
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Vinod H Thourani
- Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, DC
| | - Howard C Herrmann
- Division of Cardiology, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Michael J Mack
- Department of Cardiovascular Surgery, Baylor Scott & White Health, Plano, Texas
| | - Molly Szerlip
- Department of Cardiology, Baylor Scott & White Health, Plano, Texas
| | - Raj R Makkar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - John G Webb
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Craig R Smith
- Department of Surgery, Columbia University Medical Center/New York Presbyterian Hospital, New York, New York
| | | | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Martin B Leon
- Division of Cardiology, Columbia University Medical Center/New York Presbyterian Hospital, New York, New York
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44
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Blackstone EH, Rajeswaran J, Cruz VB, Hsich EM, Koprivanac M, Smedira NG, Hoercher KJ, Thuita L, Starling RC. Continuously Updated Estimation of Heart Transplant Waitlist Mortality. J Am Coll Cardiol 2019; 72:650-659. [PMID: 30071995 DOI: 10.1016/j.jacc.2018.05.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [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: 01/22/2018] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heart transplant allocation in the United States is made on the basis of coarse tiers, defined by mechanical circulatory devices and therapy for advanced heart failure, updated infrequently as a patient's condition deteriorates. Thus, many patients die awaiting heart transplantation. What is needed is a tool that continuously updates risk of mortality as a patient's condition changes to inform clinical decision making. OBJECTIVES This study sought to develop a decision aid that aggregates adverse events and measures of end-organ function into a continuously updated waitlist mortality estimate. METHODS From 2008 to 2013, 414 patients were listed for heart transplantation at Cleveland Clinic, Cleveland, Ohio. The endpoint was waitlist death. Pre-listing patient characteristics and events and laboratory results during listing were analyzed. At each event or measurement change, mortality was recomputed from the resulting model. RESULTS There were 77 waitlist deaths, with 1- and 4-year survival of 85% and 57%, respectively. When time-varying events and measurements were incorporated into a mortality model, pre-listing patient characteristics became nonsignificant. Neurological events (hazard ratio [HR]: 13.5; 95% confidence interval [CI]: 7.63 to 23.8), new requirement for dialysis (HR: 3.67; 95% CI: 1.88 to 7.14), more respiratory complications (HR: 1.79 per episode; 95% CI: 1.23 to 2.59), and higher serum bilirubin (p < 0.0001) and creatinine (p < 0.0001) yielded continuously updated estimates of patient-specific mortality across the waitlist period. CONCLUSIONS Mortality risk for patients with advanced heart failure who are listed for transplantation is related to adverse events and end-organ dysfunction that change over time. A continuously updated mortality estimate, combined with clinical evaluation, may inform status changes that could reduce mortality on the heart transplant waiting list.
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Affiliation(s)
- Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vincent B Cruz
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Eileen M Hsich
- Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Katherine J Hoercher
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Randall C Starling
- Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
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45
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Hurst TE, Xanthopoulos A, Ehrlinger J, Rajeswaran J, Pande A, Thuita L, Smedira NG, Moazami N, Blackstone EH, Starling RC. Dynamic prediction of left ventricular assist device pump thrombosis based on lactate dehydrogenase trends. ESC Heart Fail 2019; 6:1005-1014. [PMID: 31318170 PMCID: PMC6816063 DOI: 10.1002/ehf2.12473] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 04/08/2019] [Accepted: 05/13/2019] [Indexed: 12/04/2022] Open
Abstract
Aims The risk of HeartMate II (HMII) left ventricular assist device (LVAD) thrombosis has been reported, and serum lactate dehydrogenase (LDH), a biomarker of haemolysis, increases secondary to LVAD thrombosis. This study evaluated longitudinal measurements of LDH post‐LVAD implantation, hypothesizing that LDH trends could timely predict future LVAD thrombosis. Methods and results From October 2004 to October 2014, 350 HMIIs were implanted in 323 patients at Cleveland Clinic. Of these, patients on 339 HMIIs had at least one post‐implant LDH value (7996 total measurements). A two‐step joint model combining longitudinal biomarker data and pump thrombosis events was generated to assess the effect of changing LDH on thrombosis risk. Device‐specific LDH trends were first smoothed using multivariate boosted trees, and then used as a time‐varying covariate function in a multiphase hazard model to analyse time to thrombosis. Pre‐implant variables associated with time‐varying LDH values post‐implant using boostmtree were also investigated. Standardized variable importance for each variable was estimated as the difference between model‐based prediction error of LDH when the variable was randomly permuted and prediction error without permuting the values. The larger this difference, the more important a variable is for predicting the trajectory of post‐implant LDH. Thirty‐five HMIIs (10%) had either confirmed (18) or suspected (17) thrombosis, with 15 (43%) occurring within 3 months of implant. LDH was associated with thrombosis occurring both early and late after implant (P < 0.0001 for both hazard phases). The model demonstrated increased probability of HMII thrombosis as LDH trended upward, with steep changes in LDH trajectory paralleling trajectories in probability of pump thrombosis. The most important baseline variables predictive of the longitudinal pattern of LDH were higher bilirubin, higher pre‐implant LDH, and older age. The effect of some pre‐implant variables such as sodium on the post‐implant LDH longitudinal pattern differed across time. Conclusions Longitudinal trends in surveillance LDH for patients on HMII support are useful for dynamic prediction of pump thrombosis, both early after implant and late. Incorporating upward and downward trends in LDH that dynamically update a model of LVAD thrombosis risk provides a useful tool for clinical management and decisions.
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Affiliation(s)
- Thomas E Hurst
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Andrew Xanthopoulos
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
| | - John Ehrlinger
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | - Amol Pande
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
| | - Nader Moazami
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene H Blackstone
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH, USA
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Shereena EA, Gupta RK, Bennett CN, Sagar KJV, Rajeswaran J. EEG Neurofeedback Training in Children With Attention Deficit/Hyperactivity Disorder: A Cognitive and Behavioral Outcome Study. Clin EEG Neurosci 2019; 50:242-255. [PMID: 30453757 DOI: 10.1177/1550059418813034] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 11/15/2022]
Abstract
BACKGROUND Attention deficit/hyperactivity disorder (ADHD) is a highly prevalent childhood disorder with symptoms of inattention, impulsivity, and hyperactivity. EEG neurofeedback training (NFT) is a new intervention modality based on operant conditioning of brain activity, which helps reduce symptoms of ADHD in children. METHODS AND PROCEDURES To examine the efficacy of NFT in children with ADHD, an experimental longitudinal design with pre-post comparison was adopted. A total of 30 children in the age range of 6 to 12 years diagnosed as ADHD with or without comorbid conditions were assigned to treatment group (TG; n = 15) and treatment as usual group (TAU; n = 15). TG received EEG-NFT along with routine clinical management and TAU received routine clinical management alone. Forty sessions of theta/beta NFT at the C3 scalp location, 3 to 4 sessions in a week for a period of 3.5 to 5 months were given to children in TG. Children were screened using sociodemographic data and Binet-Kamat test of intelligence. Pre-and postassessment tools were neuropsychological tests and behavioral scales. Follow-up was carried out on 8 children in TG using parent-rated behavioral measures. RESULTS Improvement was reported in TG on cognitive functions (sustained attention, verbal working memory, and response inhibition), parent- and teacher-rated behavior problems and on academic performance rated by teachers. Follow-up of children who received NFT showed sustained improvement in ADHD symptoms when assessed 6 months after receiving NFT. CONCLUSION The present study suggests that NFT is an effective method to enhance cognitive deficits and helps reduce ADHD symptoms and behavior problems. Consequently, academic performance was found to be improved in children with ADHD. Improvement in ADHD symptoms induced by NFT were maintained at 6-month follow-up in children with ADHD.
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Affiliation(s)
- E A Shereena
- 1 National Institute of Mental Health & Neuro Sciences, Bengaluru, Karnataka, India
| | - R K Gupta
- 1 National Institute of Mental Health & Neuro Sciences, Bengaluru, Karnataka, India
| | - C N Bennett
- 2 Department of Psychology, Christ (Deemed to be University), Bengaluru, Karnataka, India
| | - K J V Sagar
- 1 National Institute of Mental Health & Neuro Sciences, Bengaluru, Karnataka, India
| | - J Rajeswaran
- 1 National Institute of Mental Health & Neuro Sciences, Bengaluru, Karnataka, India
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Douglas PS, Leon MB, Mack MJ, Svensson LG, Webb JG, Hahn RT, Pibarot P, Weissman NJ, Miller DC, Kapadia S, Herrmann HC, Kodali SK, Makkar RR, Thourani VH, Lerakis S, Lowry AM, Rajeswaran J, Finn MT, Alu MC, Smith CR, Blackstone EH. Longitudinal Hemodynamics of Transcatheter and Surgical Aortic Valves in the PARTNER Trial. JAMA Cardiol 2019; 2:1197-1206. [PMID: 28973520 DOI: 10.1001/jamacardio.2017.3306] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [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]
Abstract
Importance Use of transcatheter aortic valve replacement (TAVR) for severe aortic stenosis is growing rapidly. However, to our knowledge, the durability of these prostheses is incompletely defined. Objective To determine the midterm hemodynamic performance of balloon-expandable transcatheter heart valves. Design, Setting, and Participants In this study, we analyzed core laboratory-generated data from echocardiograms of all patients enrolled in the Placement of Aortic Transcatheter Valves (PARTNER) 1 Trial with successful TAVR or surgical AVR (SAVR) obtained preimplantation and at 7 days, 1 and 6 months, and 1, 2, 3, 4, and 5 years postimplantation. Patients from continued access observational studies were included for comparison. Interventions Successful implantation after randomization to TAVR vs SAVR (PARTNER 1A; TAVR, n = 321; SAVR, n = 313), TAVR vs medical treatment (PARTNER 1B; TAVR, n = 165), and continued access (TAVR, n = 1996). Five-year echocardiogram data were available for 424 patients after TAVR and 49 after SAVR. Main Outcomes and Measures Death or reintervention for aortic valve structural indications, measured using aortic valve mean gradient, effective orifice area, Doppler velocity index, and evidence of hemodynamic deterioration by reintervention, adverse hemodynamics, or transvalvular regurgitation. Results Of 2795 included patients, the mean (SD) age was 84.5 (7.1) years, and 1313 (47.0%) were female. Population hemodynamic trends derived from nonlinear mixed-effects models showed small early favorable changes in the first few months post-TAVR, with a decrease of -2.9 mm Hg in aortic valve mean gradient, an increase of 0.028 in Doppler velocity index, and an increase of 0.09 cm2 in effective orifice area. There was relative stability at a median follow-up of 3.1 (maximum, 5) years. Moderate/severe transvalvular regurgitation was noted in 89 patients (3.7%) after TAVR and increased over time. Patients with SAVR showed no significant changes. In TAVR, death/reintervention was associated with lower ejection fraction, stroke volume index, and aortic valve mean gradient up to 3 years, with no association with Doppler velocity index or valve area. Reintervention occurred in 20 patients (0.8%) after TAVR and in 1 (0.3%) after SAVR and became less frequent over time. Reintervention was caused by structural deterioration of transcatheter heart valves in only 5 patients. Severely abnormal hemodynamics on echocardiograms were also infrequent and not associated with excess death or reintervention for either TAVR or SAVR. Conclusions and Relevance This large, core laboratory-based study of transcatheter heart valves revealed excellent durability of the transcatheter heart valves and SAVR. Abnormal findings in individual patients, suggestive of valve thrombosis or structural deterioration, were rare in this protocol-driven database and require further investigation. Trial Registration clinicaltrials.gov Identifier: NCT00530894.
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Affiliation(s)
| | - Martin B Leon
- New York Presbyterian Hospital, Columbia University Medical Center, New York
| | | | | | - John G Webb
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rebecca T Hahn
- New York Presbyterian Hospital, Columbia University Medical Center, New York
| | - Philippe Pibarot
- Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | | | | | | | | | - Susheel K Kodali
- New York Presbyterian Hospital, Columbia University Medical Center, New York
| | - Raj R Makkar
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | | | | | - Matthew T Finn
- New York Presbyterian Hospital, Columbia University Medical Center, New York
| | - Maria C Alu
- New York Presbyterian Hospital, Columbia University Medical Center, New York
| | - Craig R Smith
- New York Presbyterian Hospital, Columbia University Medical Center, New York
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Henderson G, Abdallah M, Johnson M, Anabila M, Kravitz K, Rajeswaran J, Menon V, Ellis S, Lincoff A, Blackstone E, Kapadia S, Khot U. READMISSION RISK FOR ACUTE MYOCARDIAL INFARCTION AFTER ACUTE MYOCARDIAL INFARCTION STRATIFIED BY INITIAL PRESENTATION OF STEMI VERSUS NSTEMI. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30884-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Henderson G, Abdallah M, Johnson M, Anabila M, Kravitz K, Rajeswaran J, Menon V, Ellis S, Lincoff A, Blackstone E, Kapadia S, Khot U. IMPACT OF TREATMENT STRATEGY OF ACUTE MYOCARDIAL INFARCTION ON DISCHARGE MEDICATIONS. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30882-4] [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: 11/26/2022]
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50
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Henderson G, Abdallah M, Johnson M, Anabila M, Kravitz K, Rajeswaran J, Menon V, Ellis S, Lincoff A, Blackstone E, Kapadia S, Khot U. RECURRENT ACUTE MYOCARDIAL INFARCTION AFTER AN ACUTE MYOCARDIAL INFARCTION. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30883-6] [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: 10/27/2022]
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