Late Outcomes of Porcine and Pericardial Bioprostheses After Mitral Valve Replacement in 1162 Patients.

BACKGROUND: Debate continues regarding the superiority of porcine vs pericardial bioprostheses, and data relevant to this comparison are scant. This study compared late survival and structural valve deterioration of porcine and pericardial mitral valve prostheses. METHODS: Adults undergoing mitral valve replacement with 1 first-generation porcine valve model and 1 pericardial valve line were reviewed from a prospectively maintained institutional database between 1976 and 2020. Multivariable regression and Cox proportional hazards analysis were used to compare late outcomes. RESULTS: Of 1162 consecutive patients, 612 (53%) received porcine valves and 550 (47%) received pericardial valves. At 10 years, patient survival (porcine, 36% ± 2%; pericardial, 38% ± 3%; P = .5) and cumulative incidence of mitral valve structural deterioration (porcine, 18% ± 2%; pericardial, 19% ± 3%; P = .3) were similar. The structural failure mode was more likely severe mitral stenosis in pericardial valves (35 of 50 [70%] vs 38 of 106 [36%]; P < .001), and it was more likely severe mitral regurgitation in porcine valves (80 of 106 [75%] vs 19 of 50 [38%]; P < .0001). After adjustment, structural deterioration was associated with younger patient age (P < .001) but not valve type. At 10 years, porcine valves demonstrated a higher cumulative incidence of mitral reoperation (19% ± 2% vs 9% ± 2%; P < .001) and reoperation for structural deterioration (15% ± 1% vs 6% ± 2%; P = .007). CONCLUSIONS: This study demonstrated similar rates of 10-year survival and structural deterioration with porcine and pericardial bioprostheses in mitral valve replacement. The study suggests a lack of major improvement in durability of mitral bioprosthetic valves over time. The failure mode may have a greater influence on surgeon decision making regarding valve choice.

Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery.

BACKGROUND: Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS: This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS: A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS: This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.

Long-term outcomes for hybrid aortic arch repair.

OBJECTIVE: Since its inception in the early 2000s, hybrid arch repair (HAR) has evolved from novel approach to well-established treatment modality for aortic arch pathology in appropriately selected patients. Despite this nearly 20-year history of use, long-term results of HAR remain to be determined. As such, objectives of this study are to detail the long-term outcomes for HAR within an expanded classification scheme. METHODS: From August 2005 to August 2022, 163 consecutive patients underwent HAR at a single referral institution. Operative approach was selected according to an institutional algorithm and included zone 0/1 HAR in 25% (n = 40), type I HAR in 34% (n = 56), and type II/III HAR in 41% (n = 67). Specific zone 0/1 technique was zone 1 HAR in 31 (78%), zone 0 with innominate snorkel (zone 0S HAR) in 7 (18%), and zone 0 with single side-branch endograft (zone 0B HAR) in 2 (5%). The 30-day and long-term outcomes, including overall and aortic-specific survival, as well as freedom from reintervention, were assessed. RESULTS: The mean age was 63 ± 13 years and almost one-half of patients (47% [n = 77]) had prior sternotomy. Presenting pathology included degenerative aneurysm in 44% (n = 71), residual dissection after prior type A repair in 38% (n = 62), chronic type B dissection in 12% (n = 20), and other indications in 6% (n = 10). Operative outcomes included 9% mortality (n = 14) at 30 days, 5% mortality (n = 8) in hospital, 4% stroke (n = 7), 2% new dialysis (n = 3), and 2% permanent paraparesis/plegia (n = 3). The median follow-up was 44 month (interquartile range, 12-84 months). Overall survival was 59% and 47% at 5 and 10 years, respectively, whereas aorta-specific survival was 86% and 84% at the same time points. At 5 and 10 years, freedom from major reintervention was 92% and 91%, respectively. Institutional experience had a significant impact on both early and late outcomes: comparing the first (2005-2012) and second (2013-2022) halves of the series, 30-day mortality decreased from 14% to 1% (P = .01) and stroke from 6% to 3% (P = .62). Improved operative outcomes were accompanied by improved late survival, with 78% of patients in the later era vs 45% in the earlier era surviving to 5 years. CONCLUSIONS: HAR is associated with excellent operative outcomes, as well as sustained protection from adverse aortic events as evidenced by high long-term aorta-specific survival and freedom from reintervention. However, surgeon and institutional experience appear to play a major role in achieving these superior outcomes, with a five-fold decrease in operative mortality and a two-fold decrease in stroke rate in the latter half of the series. These long-term results expand on prior midterm data and continue to support use of HAR for properly selected patients with arch disease.

Late Survival After Redo Mitral Operation With Minithoracotomy Compared With Sternotomy.

BACKGROUND: The long-term effectiveness of minithoracotomy over redo median sternotomy for reoperative mitral operation is not well described. Here we present long-term survival after reoperative mitral operation based on operative approach. METHODS: Adults undergoing mitral valve operation with previous sternotomy by redo sternotomy and minithoracotomy were reviewed from our prospectively maintained institutional database from 1997 to 2022. Propensity score matching was performed to compare short- and long-term outcomes. RESULTS: Of 750 consecutive patients, thoracotomy was performed in 503 (67%). Median follow-up was 5.0 years (interquartile range, 0-23 years). Intraoperatively, sternotomy patients were more likely to have central aortic cannulation (205 of 223 [93%] vs 265 of 481 [56%]), cardioplegic arrest (220 of 223 [99%] vs 124 of 481 [26%]), and mitral valve replacement (190 of 223 [85%] vs 358 of 481 [74%]). Thoracotomy patients were older (63 ± 13 vs 58 ± 14 years) with elective presentation (387 of 503 [77%] vs 128 of 247 [52%]). Sternotomy patients were more likely to have endocarditis (52 of 247 [21%] vs 45 of 503 [9%], P < .001). At 10 years, thoracotomy patients experienced improved survival (52% ± 3% vs 46% ± 4%, P = .004). After propensity matching, 10-year survival was significantly higher for thoracotomy patients compared with sternotomy patients (60% ± 5% vs 42% ± 5%, P = .0006). The greatest difference in survival was at the first 6 months after operation (96% ± 1% vs 81% ± 3%, P < .001). CONCLUSIONS: For patients undergoing reoperative mitral valve operation, minimally invasive right anterior thoracotomy can significantly decrease risk of death in the first 6 months, with durable survival benefit out to 10 years. We present a large single-center series to suggest an important opportunity to durably improve outcomes after reoperative mitral operation through wider use of right minithoracotomy.

Infarct exclusion repair of postmyocardial infarction ventricular septal rupture with a hybrid patch and septal occluder device compared with patch only.

Objective: We developed a hybrid technique for repairing post-myocardial infarction (MI) ventricular septal defect (VSD) that combines infarct exclusion with patch and a nitinol-mesh septal occluder device (SOD) to provide a scaffold to support the damaged septal wall. Here, we compare outcomes of patients with post-MI VSD repaired using patch only or hybrid patch/SOD. Methods: Patients undergoing post-MI VSD repair at our institution from 2013 to 2022 who received patch alone or patch/SOD repair were analyzed. Primary outcome was survival to hospital discharge. Clinical outcomes and echocardiograms were also analyzed. Results: Over a 9-year period, 24 patients had post-MI VSD repair at our institution with either hybrid patch/SOD (n = 10) or patch only repair (n = 14). VSD size was 18 ± 5.8 mm for patch/SOD and 17 ± 4.6 mm for patch only. In the patch/SOD repair cohort, average size of SOD implant was 23.6 ± 5.6 mm. Mild left ventricular dysfunction was present prerepair and was unchanged postrepair in both groups; however, moderate-to-severe right ventricular (RV) dysfunction was common in both groups before repair. RV function worsened or persisted as severe in 10% of hybrid versus 54% of patch-only patients postrepair. Tricuspid annular systolic excursion and RV:left ventricle diameter ratio, quantitative metrics of RV function, improved after patch/SOD repair. No intraoperative mortality occurred in either group. Postoperative renal, hepatic, and respiratory failure requiring tracheostomy was common in both groups. Survival to hospital discharge in both cohorts was 70%. Conclusions: Post-MI VSD repair with patch/SOD has comparable short-term outcomes with patch alone. Addition of a SOD to patch repair provides a scaffold that may enhance the repair of post-MI VSD with patch exclusion.

Long-term outcomes of phenoclusters in severe tricuspid regurgitation.

AIMS: Severe tricuspid regurgitation (TR) exhibits high 1-year morbidity and mortality, yet long-term cardiovascular risk overall and by subgroups remains unknown. This study characterizes 5-year outcomes and identifies distinct clinical risk profiles of severe TR. METHODS AND RESULTS: Patients were included from a large US tertiary referral center with new severe TR by echocardiography based on four-category American Society of Echocardiography grading scale between 2007 and 2018. Patients were categorized by TR etiology (with lead present, primary, and secondary) and by supervised recursive partitioning (survival trees) for outcomes of death and the composite of death or heart failure hospitalization. The Kaplan-Meier estimates and Cox regression models were used to evaluate any association by (i) TR etiology and (ii) groups identified by survival trees and outcomes over 5 years. Among 2379 consecutive patients with new severe TR, median age was 70 years, 61% were female, and 40% were black. Event rates (95% confidence interval) were 30.9 (29.0-32.8) events/100 patient-years for death and 49.0 (45.9-52.2) events/100 patient-years for the composite endpoint, with no significant difference by TR etiology. After applying supervised survival tree modeling, two separate groups of four phenoclusters with distinct clinical prognoses were separately identified for death and the composite endpoint. Variables discriminating both outcomes were age, albumin, blood urea nitrogen, right ventricular function, and systolic blood pressure (all P < 0.05). CONCLUSION: Patients with newly identified severe TR have high 5-year risk for death and death or heart failure hospitalization. Partitioning patients using supervised survival tree models, but not TR etiology, discriminated clinical risk. These data aid in identifying relevant subgroups in clinical trials of TR and clinical risk/benefit analysis for TR therapies.

Tailored approach and outcomes of aortic arch reconstruction after acute type A dissection repair.

OBJECTIVE: After limited root/ascending with or without hemiarch repair for acute type A aortic dissection (ATAAD), 20% to 30% of patients require distal reintervention, frequently for arch pathology. In this report, we describe an institutional algorithm for arch management after previous limited ATAAD repair and detail operative and long-term outcomes. METHODS: From August 2005 to April 2021, 71 patients status post previous limited ATAAD repair underwent reoperative arch repair involving zones 1 to 3 for aneurysmal degeneration of residual arch dissection including complete cervical debranching with zone 0/1 thoracic endovascular aortic repair in 6 (8%), open total arch in 13 (18%), type I hybrid arch repair in 23 (32%), and type II/III hybrid arch repair in 29 (41%). RESULTS: Mean age was 59 ± 12 years; time from index ATAAD repair to reoperation was 4 (interquartile range, 2-9) years. There were 2 (2.8%) in-hospital deaths and 2 (2.8%) postdischarge deaths within 30 days of surgery. Three patients suffered stroke (4.2%) and 2 (2.8%) had acute renal failure requiring dialysis. Overall Kaplan-Meier survival was 78%, 70%, and 58% at 1, 3, and 5 years, respectively. Institutional experience appeared to play a significant role in early and late outcomes, because there have been no operative mortalities in the past 9 years and improved survival of 87% versus 66%, 79% versus 58%, and 79% versus 40% at 1, 3, and 5 years in comparisons of the past 9 years with the previous era (P = .01). CONCLUSIONS: Aneurysmal degeneration of residual arch dissection after limited ATAAD repair presents a complex reoperative challenge. An algorithmic operative approach tailored to patient anatomy and comorbidities yields excellent early and late outcomes, which continue to improve with increasing institutional experience.

A single center experience with minimally invasive approaches in congenital cardiac surgery.

BACKGROUND: Cardiac surgery is a technically demanding field with an appreciable learning curve that extends beyond formal training. Minimally invasive congenital cardiac surgery has one of the steepest learning curves. Early complications often discourage surgeons, particularly those at lower volume centers, from pursuing innovative approaches. Over the past three years, we have utilized a number of minimally invasive approaches including pulmonary valve replacement, anomalous aortic origin coronary artery repair, atrial septal defect repair, epicardial lead placement, and partial anomalous pulmonary venous return. Herein we report on our experience performing minimally invasive congenital cardiac surgery, lessons learned, and how our approach has evolved. METHODS: We performed a single institution, retrospective review, wherein continuous variables were reported as median (interquartile range). RESULTS: Between September 2017 and May 2020, minimally invasive approaches were attempted on 49 patients with a median age of 19 years (14-47 years) for nine distinct congenital cardiac diagnoses. Seven patients (14%) required conversion to larger incisions, including four patients or 36% of those undergoing anomalous aortic origin of a coronary artery repair. Patients who were converted had a higher body mass index 33.1 (31.7-37.8) than those who were not (24.2, 20.8-29.3) (P=0.009). CONCLUSIONS: Minimally invasive approaches for congenital cardiac conditions require a team approach. Patients with a body mass index greater than 30 should be counseled on the higher rate of conversion. We no longer perform minimally invasive anomalous aortic origin of a coronary artery repair given the high rate of conversions and complications. Surgeons attempting this procedure should do so cautiously.

Long-term outcomes of aortic root replacement for endocarditis.

BACKGROUND: Infective endocarditis (IE) involving the aortic valve and root is associated with high risk requiring thoughtful surgical decision-making. The impact of valve and conduit choices and patient factors on long-term outcomes in this patient population is poorly documented. METHODS: From January 1976 to December 2013, 485 patients underwent aortic root and valve replacement at a single institution. Cox's proportional hazard model identified predictors of long-term survival and cumulative incidence functions were compared to assess need for reoperation with death as a competing risk. RESULTS: Median age at time of operation was 56.6 years (interquartile range: 23.1) with the indication for operation being endocarditis in 14.6% (n = 71). Stentless root replacement was used in 70% IE versus 34% non-IE (p < .001). Endocarditis at time of root replacement did not have a significant impact on survival through 15 years (IE: 37.3% vs. non-IE: 42.5%; log-rank; p = .13). After multivariable adjustment, survival was similar between patients with and without endocarditis (hazard ratio: 1.1; 95% confidence interval: [0.77, 1.62]; p = .57). Freedom from reoperation at 15 years did not vary significantly by endocarditis status (IE: 95.9% vs. non-IE: 73.6%; p = .07). Among endocarditis patients, freedom from reoperation at 10 years was similar between homograft and stentless bioprosthetic conduits (95.3% vs. 88.5%; log-rank; K-sample; p = .46). CONCLUSIONS: In a sample with frequent use of stentless prostheses, aortic root replacement for infective endocarditis had acceptable risk and long-term survival similar to root replacement for other indications. In the setting of endocarditis, root replacement with homograft or stentless bioprosthetic root has excellent durability through 15 years.

Does deeper hypothermia reduce the risk of acute kidney injury after circulatory arrest for aortic arch surgery?

OBJECTIVES: The impact of hypothermic circulatory arrest (HCA) temperature on postoperative acute kidney injury (AKI) has not been evaluated. This study examined the association between circulatory arrest temperatures and AKI in patients undergoing proximal aortic surgery with HCA. METHODS: A total of 759 consecutive patients who underwent proximal aortic surgery (ascending ± valve ± root) including arch replacement requiring HCA between July 2005 and December 2016 were identified from a prospectively maintained institutional aortic surgery database. The primary outcome was AKI as defined by Risk, Injury, Failure, Loss, End Stage Renal Disease (ESRD) criteria. The association between minimum nasopharyngeal (NP) and bladder temperatures during HCA and postoperative AKI was assessed, adjusting for patient-level factors using multivariable logistic regression. RESULTS: A total of 85% (n = 645) of patients underwent deep hypothermia (14.1-20.0°C), 11% (n = 83) low-moderate hypothermia (20.1-24.0°C) and 4% (n = 31) high-moderate hypothermia (24.1-28.0°C) as classified by NP temperature. When analysed by bladder temperature, 59% (n = 447) underwent deep hypothermia, 22% (n = 170) low-moderate, 16% (n = 118) high-moderate and 3% mild (n = 24) (28.1-34.0°C) hypothermia. The median systemic circulatory arrest time was 17 min. The incidence of AKI did not differ between hypothermia groups, whether analysed using minimum NP or bladder temperature. In the multivariable analysis, the association between degree of hypothermia and AKI remained non-significant whether analysed as a categorical variable (hypothermia group) or as a continuous variable (minimum NP or bladder temperature) (all P > 0.05). CONCLUSIONS: In patients undergoing proximal aortic surgery including arch replacement requiring HCA, degree of systemic hypothermia was not associated with the risk of AKI. These data suggest that moderate hypothermia does not confer increased risk of AKI for patients requiring circulatory arrest, although additional prospective data are needed.

Impact of dual energy cardiac CT for metal artefact reduction post aortic valve replacement.

PURPOSE: Assess image quality of dual-energy (DE) and single-energy (SE) cardiac multi-detector computed tomographic (MDCT) post aortic valve replacement (AVR) on a dual source MDCT scanner. METHODS: Eighty patients with cardiac MDCT acquisitions (ECG gated, dual-source) post-surgical and transcatheter AVR were retrospectively identified. Forty DE (cohort 1) and 40 SE acquisitions (cohort 2; 100 or 120 kVp) were reviewed. Metal artefact at valve coaptation (VC) and valve insertion site (VIS), and contrast enhancement were assessed. Valve leaflet edge definition was graded on a 4-point scale by three radiologists. RESULTS: The mean percentage valve area obscured by metal artifact differed between the cohorts; cohort 1 DE blended, high keV and low keV: 14.8 %, 11.1 % and 17.8 % at VC and 16.4 %, 13 %, 20.4 % at VIS respectively. Cohort 2: 25.8 % and 33.6 % (VC and VIS); each DE reconstruction vs SE: P < 0.0001. Average contrast opacification and coefficient of variance for cohort 1: 562.9 ± 144.7, 281.1 ± 60.3 and 1132.7 ± 300.8 Hounsfield Units (HU) and 9.6 %, 10 % and 8.9 %. For cohort 2: 437.2 ± 119.2 HU and 10.8 % (P < 0.01). Average leaflet edge definition cohort 1: 2.3 ± 0.4, 2.7 ± 0.2 and 2.3 ± 0.2, and cohort 2: 2.9 ± 0.2. CONCLUSION: DE high keV renderings can result in up to 17.2 % less metal artefact compared to standard SE acquisition for cardiac CT. Contrast opacification and homogeneity is higher for DE blended and low keV renderings compared to SE acquisition with leaflet visibility preferred for low keV and blended DE renderings.

Permissive Hypertension and Collateral Revascularization May Allow Avoidance of Cerebrospinal Fluid Drainage in Thoracic Endovascular Aortic Repair.

BACKGROUND: The utility of cerebrospinal fluid drainage (CSFD) for prevention of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) remains unclear. We previously published our institutional algorithm restricting preoperative CSFD to patients deemed high risk for SCI. Since that publication, our algorithm has evolved with preoperative CSFD avoided in all patients undergoing isolated descending TEVAR with or without arch involvement (+/- arch TEVAR). This study evaluated the updated algorithm in a contemporary cohort. METHODS: Patients who underwent TEVAR for descending aortic +/-arch pathology between February 2012 and September 2018 at a single center were identified from an institutional aortic surgery database. The algorithm includes left subclavian artery (LSA) revascularization in cases of coverage with no preservation of antegrade flow, permissive hypertension, and use of evoked potential monitoring. The primary end points were SCI or postoperative CSFD. RESULTS: During the study interval, 225 patients underwent descending +/- arch TEVAR. CSFD was used before TEVAR in 2 patients (0.9%) in violation of the algorithm, and they were excluded from the study cohort. Endograft coverage below T6 occurred in 81%. The LSA was fully covered in 100 patients (47%), all of whom underwent LSA revascularization. Following the updated algorithm, the incidence of temporary or permanent SCI was 0%. No patient required postoperative CSFD. CONCLUSIONS: A restrictive lumbar CSFD algorithm, including permissive hypertension and LSA revascularization in the setting of descending +/- arch TEVAR, appears safe, with a 0% incidence of SCI in 223 consecutive patients treated during a 6.5-year interval. We recommend consideration of further prospective study to evaluate this algorithm.

Association of postoperative complications and outcomes following coronary artery bypass grafting.

BACKGROUND: The long-term effects of postoperative complications following coronary artery bypass grafting (CABG) are unknown. METHODS: Medicare-linked records from the Society of Thoracic Surgeons Adult Cardiac Surgery Database were queried for isolated CABG records from 2007 through 2012. Unadjusted and adjusted associations between individual postoperative complications and both mortality and all-cause rehospitalization were evaluated to 7 years using Cox proportional-hazards models and cumulative incidence functions. Because of nonproportional hazards, associations are presented as early (0 to 90 days) and late (90 days to 7 years). RESULTS: Of the 294,533 isolated CABG patients who had records linked to Medicare for long-term follow-up (median age, 73 years; 30% female), 120,721 (41%) experienced at least 1 of the complications of interest, including new-onset atrial fibrillation (30.0%), prolonged ventilation (12.3%), renal failure (4.5%), reoperation (3.5%), stroke (1.9%), and sternal wound infection (0.4%). Each of the 6 postoperative complications was associated with a significantly increased risk of mortality and rehospitalization to 7 years despite adjustment for baseline characteristics and the presence of multiple complications. Although the predominant effect of postoperative complications was observed in the first 90 days, the increased risk-adjusted hazard for death and rehospitalization continued through 7 years. CONCLUSIONS: Postoperative complications are associated with an increased risk of both early and late mortality and all-cause rehospitalization, particularly during the "value" window within 90 days of CABG. These findings underscore the need to develop avoidance strategies as well as cost-adjustment methods for each of these complications.

Surgically implanted aortic valve bioprostheses deform after implantation: insights from computed tomography.

OBJECTIVE: Little is known about the prevalence and degree of deformation of surgically implanted aortic biological valve prostheses (bio-sAVRs). We assessed bio-sAVR deformation using multidetector-row computed tomography (MDCT). METHODS: Three imaging databases were searched for patients with MDCT performed after bio-sAVR implantation. Minimal and maximal valve ring diameters were obtained in systole and/or diastole, depending on the acquired cardiac phase(s). The eccentricity index (EI) was calculated as a measure of deformation as (1 - (minimal diameter/maximal diameter)) × 100%. EI of < 5% was considered none or trivial deformation, 5-10% mild deformation, and > 10% non-circular. Indications for MDCT and implanted valve type were retrieved. RESULTS: One hundred fifty-two scans of bio-sAVRs were included. One hundred seventeen measurements were performed in systole and 35 in diastole. None or trivial deformation (EI < 5%) was seen in 67/152 (44%) of patients. Mild deformation (EI 5-10%) was seen in 59/152 (39%) and non-circularity was found in 26/152 (17%) of cases. Overall, median EI was 5.5% (IQR 3.4-7.8). In 77 patients, both systolic and diastolic measurements were performed from the same scan. For these scans, the median EI was 6.5% (IQR 3.4-10.2) in systole and 5.1% (IQR3.1-7.6) in diastole, with a significant difference between both groups (p = 0.006). CONCLUSIONS: Surgically implanted aortic biological valve prostheses show mild deformation in 39% of cases and were considered non-circular in 17% of studied valves. KEY POINTS: • Deformation of surgically implanted aortic valve bioprostheses (bio-sAVRs) can be adequately assessed using MDCT. • Bio-sAVRs show at least mild deformation (eccentricity index > 5%) in 56% of studied cases and were considered non-circular (eccentricity index > 10%) in 17% of studied valves. • The higher deformity rate found in bio-sAVRs with (suspected) valve pathology could suggest that geometric deformity may play a role in leaflet malformation and thrombus formation similar to that of transcatheter heart valves.

Use of left atrial appendage occlusion among older cardiac surgery patients with preoperative atrial fibrillation: a national cohort study.

PURPOSE: Patients with atrial fibrillation (AF) undergoing cardiac surgery are at substantially increased risk for stroke. Increasing evidence has suggested that surgical left atrial appendage occlusion (S-LAAO) may have the potential to substantially mitigate this stroke risk; however, S-LAAO is performed in a minority of patients with AF undergoing cardiac surgery. We sought to identify factors associated with usage of S-LAAO. METHODS: In a nationally-representative, contemporary cohort (07/2011-06/2012) of older patients undergoing cardiac surgery with preoperative AF (n = 11,404) from the Medicare-linked Society of Thoracic Surgeons Adult Cardiac Surgery Database, we evaluated patient and hospital characteristics associated with S-LAAO use by employing logistic and linear regression models. RESULTS: In this cohort (average age, 76 years; 39% female), 4177 (37%) underwent S-LAAO. Neither S-LAAO nor discharge anticoagulation was used in 25% ("unprotected" patients). The overall propensity for S-LAAO decreased significantly with increasing CHA2DS2-VASc (congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; stroke, transient ischemic attack, or thromboembolism; vascular disease; age 65 to 74 years; sex category (female)) score (ptrend < 0.001). There was substantial variability in S-LAAO use across geographic regions, and S-LAAO was more commonly performed at academic and higher-volume valve surgery centers. CONCLUSIONS: Substantial variability in use of S-LAAO exists. In many instances, the procedure is being deferred in the patients that may be poised to benefit the most (i.e., those with increased CHA2DS2-VASc score-defined stroke risk).

Impact of Microbiological Organism Type on Surgically Managed Endocarditis.

BACKGROUND: This study describes the impact of organism and valve type on surgically managed infective endocarditis (IE) from The Society of Thoracic Surgeons (STS) database. We developed a risk model for surgically managed endocarditis that includes the microbiological organism. METHODS: The STS database was queried for adult patients with surgically managed endocarditis from July 1, 2011, to June 30, 2016. Outcomes were compared based on (1) causative microbiological organism, (2) valve type (native vs prosthetic), and (3) endocarditis on the right (tricuspid) vs left (mitral, aortic) sides. Univariate and risk adjusted models were developed with odds ratios for mortality for each organism type referenced against Streptococcus. RESULTS: The study population included 21,388 operations (93%) for left-sided IE and 1698 (7%) for right-sided IE. Streptococcus (28%) and Staphylococcus (27%) were the most common infecting organisms, followed by Enterococcus (11%). After multivariate adjustment, microbiological organism type was significantly associated with operative mortality for patients with left-sided endocarditis, with an adjusted odds ratio of 2.9 for fungal, 1.4 for Staphylococcus, and 1.3 for culture-negative vs Streptococcus. For right-sided endocarditis, there were no differences in outcomes by organism type. Left-sided prosthetic valve endocarditis had a higher operative mortality than left-sided native valve endocarditis (12% vs 8%, P < .001). In contrast, surgery for right-sided endocarditis carried lower operative mortality, with no mortality difference between prosthetic valve endocarditis and native valve endocarditis (5% vs 4%, P = .6). CONCLUSIONS: Organism type influences the operative mortality for left-sided endocarditis. Surgery for left-sided and prosthetic valve endocarditis is associated with higher operative mortality. Risk adjustment for operative outcomes in endocarditis may need to account for microbiological organism type.

Three-factor prothrombin complex concentrates for refractory bleeding after cardiovascular surgery within an algorithmic approach to haemostasis.

BACKGROUND/OBJECTIVES: Prothrombin complex concentrates (PCC) are increasingly administered off-label in the United States to treat bleeding in cardiovascular surgical patients and carry the potential risk for acquired thromboembolic side-effects after surgery. Therefore, we hypothesized that the use of low-dose 3-factor (3F) PCC (20-30 IU/kg), as part of a transfusion algorithm, reduces bleeding without increasing postoperative thrombotic/thromboembolic complications. MATERIALS/METHODS: After IRB approval, we retrospectively analysed 114 consecutive, complex cardiovascular surgical patients (age > 18 years), between February 2014 and June 2015, that received low-dose 3F-PCC (Profilnine® ), of which seven patients met established exclusion criteria. PCC was dosed according to an institutional perioperative algorithm. Allogeneic transfusions were recorded before and after PCC administration (n = 107). The incidence of postoperative thromboembolic events was determined within 30 days of surgery, and Factor II levels were measured in a subset of patients (n = 20) as a quality control measure to avoid excessive PCC dosing. RESULTS: Total allogeneic blood product transfusion reached a mean of 12·4 ± 9·9 units before PCC and 5·0 ± 6·3 units after PCC administration (P < 0·001). The mean PCC dose was 15·8 ± 7·1 IU/kg. Four patients (3·8%) each experienced an ischaemic stroke on postoperative day 1, 2, 4 and 27. Seven patients (6·5%) had acquired venous thromboembolic disease within 10 days of surgery. Median factor II level after transfusion algorithm adherence and PCC administration was 87%. CONCLUSIONS: 3F-PCC use for refractory bleeding after cardiovascular surgery resulted in reduced transfusion of allogeneic blood and blood products. Adherence to this algorithmic approach was associated with an acceptable incidence of postoperative thrombotic/thromboembolic complications.