Transcatheter Aortic Valve Replacement Improves Quality of Life and Ventricular Function With Low-Flow/Low-Gradient Aortic Stenosis.

Background: D2 aortic stenosis (AS) is the highest risk AS subtype with worse operative and mortality outcomes. This study aimed to investigate the quality of life (QoL) and left ventricular ejection fraction (LVEF) in patients with classic (D2 subtype) low-flow/low-gradient AS who underwent transcatheter aortic valve replacement (TAVR). Methods: In total, 634 patients with severe AS underwent TAVR at our institution from 2014 to 2020, of whom 76 met criteria for classic D2 AS with reduced LVEF. Echocardiographic and clinical outcomes including mortality, stroke, pacemaker placement (PPM), and readmission at baseline were compared with those at 30 days and 1 year. QoL data were extracted from the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Results: The average baseline Society of Thoracic Surgeons risk score for patients with D2 AS was 7.66 ± 6.76. Patients with D2 AS reported improved QoL post-TAVR. The average baseline KCCQ-12 score was 39.5 ± 20, with improvement to 68.9 ± 20.6 at 30 days (P < .01) and 74.9 ± 17.5 at 1 year (P < .01). Mortality was 0% at 30 days and 18.4% at 1 year. The average baseline LVEF was 36.1 ± 9.4. Left ventricular function improved to 43.5 ± 12.9 (P <.001) at 30 days and 46.3 ± 11.2 (P = .03) at 1 year. Complications post-TAVR at 30 days included stroke (1.3%) and PPM (11.8%). Patients with D2 AS exhibited higher baseline conduction defects including atrial fibrillation and higher postoperative PPM than those with other subtypes. Conclusions: Patients with D2 AS had significantly improved LVEF and QoL following TAVR at 30 days and 1 year. Postoperative rates of new PPM were higher than other subtypes, while stroke, dialysis, and mortality were lower than expected, supporting the benefit of TAVR in this high-risk group.

Familial Associations of Prevalence and Cause-Specific Mortality for Thoracic Aortic Disease and Bicuspid Aortic Valve in a Large-Population Database.

BACKGROUND: Thoracic aortic disease and bicuspid aortic valve (BAV) likely have a heritable component, but large population-based studies are lacking. This study characterizes familial associations of thoracic aortic disease and BAV, as well as cardiovascular and aortic-specific mortality, among relatives of these individuals in a large-population database. METHODS: In this observational case-control study of the Utah Population Database, we identified probands with a diagnosis of BAV, thoracic aortic aneurysm, or thoracic aortic dissection. Age- and sex-matched controls (10:1 ratio) were identified for each proband. First-degree relatives, second-degree relatives, and first cousins of probands and controls were identified through linked genealogical information. Cox proportional hazard models were used to quantify the familial associations for each diagnosis. We used a competing-risk model to determine the risk of cardiovascular-specific and aortic-specific mortality for relatives of probands. RESULTS: The study population included 3 812 588 unique individuals. Familial hazard risk of a concordant diagnosis was elevated in the following populations compared with controls: first-degree relatives of patients with BAV (hazard ratio [HR], 6.88 [95% CI, 5.62-8.43]); first-degree relatives of patients with thoracic aortic aneurysm (HR, 5.09 [95% CI, 3.80-6.82]); and first-degree relatives of patients with thoracic aortic dissection (HR, 4.15 [95% CI, 3.25-5.31]). In addition, the risk of aortic dissection was higher in first-degree relatives of patients with BAV (HR, 3.63 [95% CI, 2.68-4.91]) and in first-degree relatives of patients with thoracic aneurysm (HR, 3.89 [95% CI, 2.93-5.18]) compared with controls. Dissection risk was highest in first-degree relatives of patients who carried a diagnosis of both BAV and aneurysm (HR, 6.13 [95% CI, 2.82-13.33]). First-degree relatives of patients with BAV, thoracic aneurysm, or aortic dissection had a higher risk of aortic-specific mortality (HR, 2.83 [95% CI, 2.44-3.29]) compared with controls. CONCLUSIONS: Our results indicate that BAV and thoracic aortic disease carry a significant familial association for concordant disease and aortic dissection. The pattern of familiality is consistent with a genetic cause of disease. Furthermore, we observed higher risk of aortic-specific mortality in relatives of individuals with these diagnoses. This study provides supportive evidence for screening in relatives of patients with BAV, thoracic aneurysm, or dissection.

Minimally Invasive versus Full Sternotomy SAVR in the Era of TAVR: An Institutional Review.

In the era of advancing transcatheter aortic valve replacement (TAVR) technology, traditional open surgery remains a valuable intervention for patients who are not TAVR candidates. We sought to compare perioperative variables and postoperative outcomes of minimally invasive and full sternotomy surgical aortic valve replacement (SAVR) at a single institution. A retrospective analysis of 113 patients who underwent isolated SAVR via full sternotomy or upper hemi-sternotomy between January 2015 and December 2019 at the University of Utah Hospital was performed. Preoperative comorbidities and demographic information were not different among groups, with the exception of diabetes, which was significantly more common in the full sternotomy group (p = 0.01). Median procedure length was numerically shorter in the minimally invasive group but was not significant following the Bonferroni correction (p = 0.047). Other perioperative variables were not significantly different. The two groups showed no difference in the incidence of postoperative adverse events (p = 0.879). As such, minimally invasive SAVR via hemi-sternotomy remains a safe and effective alternative to full sternotomy for patients who meet the criteria for aortic valve replacement.

Premature atrial stimulation accentuates conduction abnormalities in cardiac surgery patients that develop postoperative atrial fibrillation.

BACKGROUND: postoperative atrial fibrillation (POAF) is a common cardiac surgery complication that is associated with increased complications and negative outcomes, but the association between presurgical atrial conduction abnormalities and POAF has not been investigated clinically during premature atrial S1S2 stimulation. This clinical study sought to examine whether intraoperative premature atrial stimulation reveals increased areas of slowed and/or blocked conduction in patients that develop POAF. METHODS: High-density intraoperative epicardial left atrial mapping was conducted in 20 cardiac surgery patients with no prior history of atrial fibrillation (AF). In 20 patients, 6 (30%) developed POAF. A flexible-array of 240-electrodes was placed on the posterior left atrial wall in between the pulmonary veins. Activation maps were generated for sinus and premature atrial S1S2 stimulated beats. The area of conduction block (CB), conduction delay (CD) and the combination of both (CDCB) for conduction velocity < 0.1, 0.1 ≤ x < 0.2 and < 0.2 m/s, respectively were quantified. RESULTS: For a premature atrial S2 beat with shortest cycle length captured, conduction velocity maps revealed a significantly higher area for CD (13.19 ± 6.59 versus 6.06 ± 4.22 mm2, p = 0.028) and CDCB (17.36 ± 8.75 versus 7.41 ± 6.39 mm2, p = 0.034), and a trend toward a larger area for CB (4.17 ± 3.66 versus 1.34 ± 2.86 mm2, p = 0.063) in patients who developed POAF in comparison to those that remained in the sinus. Sinus and S1 paced beats did not show substantial differences in abnormal conduction areas between patients with and without POAF. CONCLUSION: In comparison to sinus and S1 beats, premature atrial S2 beats accentuate conduction abnormalities in the posterior left atrial wall of cardiac surgery patients that developed POAF.

Predictors of Adherence to Anti-Impulse Therapy among Patients Treated for Acute Type-B Aortic Dissections.

BACKGROUND: Medical management remains the mainstay of treatment for patients who present with acute Type-B aortic dissections (TBAD). However, it is unclear whether patients maintain adherence to their anti-impulse therapy medication regimen following hospital discharge. This study was designed to evaluate rates and predictors of medication adherence among insured patients treated for acute TBAD. METHODS: We used the Truven MarketScan database to identify US patients who presented with an acute TBAD between 2008 to 2017. Patients with continuous health insurance (Commercial or Medicare Part C) for at least 12 months after TBAD diagnosis were stratified by whether they underwent open surgical repair (OPEN), thoracic endovascular aortic repair (TEVAR), or only medication management (MED). Prescriptions for anti-impulse therapy medications were captured and adherence was defined by the medication possession ratio as > 80% fill rate over the follow-up period. Mixed-effects logistic regression models were used to identify predictors for medication adherence. RESULTS: A total of 6,702 patients were identified that underwent treatment for TBAD (3% TEVAR, 9% OPEN, & 74% MED), whereas 14% received no intervention. The overall mean (±SD) rate of adherence to anti-impulse therapy was 72.6% ( ± 26), and varied based on type of TBAD intervention (73.4% TEVAR, 74.4% OPEN, & 72.4% MED). The majority of patients across all treatment groups were prescribed ≥ 2 agents, with beta-blockers and diuretics being the most common medication classes. The odds of adherence to anti-impulse therapy were significantly lower for patients who were female (OR: 0.93; 95%CI:0.85-0.99; P = 0.03), aged < 45 years (OR: 0.81; 95%CI:0.69-0.96; P < 0.001), nonadherent on preexisting therapy (OR: 0.81; 95%CI: 0.73-0.89; P < 0.001), and when medications were obtained in less than a 90 days supply from retail pharmacies. CONCLUSIONS: Nearly a quarter of patients were nonadherent with anti-impulse therapy prescribed following an acute TBAD, which was more likely among younger female patients not adherent before their event. Adherence was improved among patients who received their medications by mail and when a > 90 days supply was prescribed. These findings may be used by quality improvement initiatives to improve medication adherence following TBAD and help prevent further complications.

Evaluating Quality in Adult Cardiac Surgery.

National and institutional quality initiatives provide benchmarks for evaluating the effectiveness of medical care. However, the dramatic growth in the number and type of medical and organizational quality-improvement standards creates a challenge to identify and understand those that most accurately determine quality in cardiac surgery. It is important that surgeons have knowledge and insight into valid, useful indicators for comparison and improvement. We therefore reviewed the medical literature and have identified improvement initiatives focused on cardiac surgery. We discuss the benefits and drawbacks of existing methodologies, such as comprehensive regional and national databases that aid self-evaluation and feedback, volume-based standards as structural indicators, process measurements arising from evidence-based research, and risk-adjusted outcomes. In addition, we discuss the potential of newer methods, such as patient-reported outcomes and composite measurements that combine data from multiple sources.

Preventing or Minimizing Acute Kidney Injury in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is now routinely performed in patients with aortic stenosis with low mortality and complication rates. Although periprocedural risks have been substantially minimized, procedure- and contrast-induced acute kidney injury (AKI) remains a major concern. AKI remains a frequent complication of contrast-guided interventional procedures and is associated with a significantly adverse prognosis. We review the currently available clinical data related to AKI, with emphasis on contrast-induced nephropathy (CIN), and discuss a novel, integrated approach aiming to minimize AKI risk in high-risk patients. A stepwise algorithm is also proposed for the management of these complex patients.

Is timing everything? Bioprosthetic valve fracture in valve-in-valve TAVR.

We present a challenging case of early bioprosthetic valve degeneration following valve-in-valve transcatheter aortic valve replacement and bioprosthetic valve fracture.

Surgical explantation of atrial septal closure devices for refractory nickel allergy symptoms.

OBJECTIVES: Systemic allergic reactions to nickel alloys in percutaneous atrial septal defect occlusion devices have a poorly defined natural history. We describe our experience of surgical removal of the offending device in a series of patients with nickel allergy and refractory symptoms. METHODS: Patients with atrial septal defect device explants for nickel allergy were reviewed. Administered questionnaires focused on symptoms, quality of life, and satisfaction along with the 36-Item Short Form Health Survey to measure physical and mental health postsurgery. RESULTS: Atrial septal defect devices were removed for nickel allergy in 58 patients during the past 10 years. The median age was 42 years (range, 24-71 years) and 95% were women. Explantation occurred at a median of 8 years (range, 6 months-18 years) after insertion. Symptoms included fatigue (82%), chest pain (78%), headache (73%), and palpitation (58%). Surveys were available for 45 patients: 58% rated their quality of life as poor and 69% were not at all satisfied with their device. Postexplant, all patients reported improvement in their symptoms, with 18 patients (42%) noting complete resolution. In 12 patients prospectively studied, the preoperative scores in physical and mental health domains were lower than the validation group, indicating significant disability. Similarly, there was marked improvement in each domain postremoval. CONCLUSIONS: Patients with nickel allergy and severe refractory symptoms after atrial septal defect device implantation experience profound resolution of symptoms and improved quality of life after removal. Nickel allergy should be considered before device insertion, and a low threshold should exist for surgical removal for refractory symptoms.

Rapid-deployment aortic valve replacement after aortic root replacement: A safe alternative to redo root replacement.

Reoperative aortic root replacement, following prior biologic or mechanical valved conduit aortic root prosthesis, presents a technical challenge. The rapid-deployment aortic valve prosthesis is an approved alternative to traditional bioprosthetic aortic valve replacement. We present three clinical cases in which rapid-deployment aortic valve prostheses were utilized in lieu of reoperative full aortic root replacement. All three patients recovered uneventfully. The rapid-deployment valve insertion in a prior surgical aortic root prosthesis is a safe option to avoid reoperative full aortic root replacement.

Evaluation of the Sex-and-Age-Specific Effects of PM2.5 on Hospital Readmission in the Presence of the Competing Risk of Mortality in the Medicare Population of Utah 1999-2009.

Acute ambient air pollution exposure increases risk of cardiac events. We evaluated sex-and-age-specific effects of PM2.5 on hospital readmission and death among 19,602 Medicare beneficiaries (Nevents = 30,510) who survived cardiovascular events including myocardial infarction (MI), heart failure (HF), ischemic heart disease (IHD), and cardiac arrhythmias in Utah from 1999-2009. Fine and Gray regression jointly modeled the effect of PM2.5 on readmission hazard rates while allowing for the competing risk of death. Models were stratified by age and sex and adjusted for Charlson Comorbidity Index, dual enrollment in Medicare Parts A and B, temperature, and household income. There were 2032 cardiac readmissions and 1420 deaths after discharge. Among males age 65-74 years admitted for HF, a 10 µm/m3 increase in PM2.5 was associated with a 30% increase in risk of readmission (p = 0.01). Among females age 75-84 admitted for HF, PM2.5 was associated with a 22% increase in risk of readmission (p = 0.01). Among females age 75-84 years admitted for IHD, PM2.5 was associated with a 25% decrease in readmission (p = 0.01), however this was explained by a 36% increase in risk of death (p = 0.01). Exposure to PM2.5 was associated with increased risk of readmission and death. Associations were dependent upon age, sex, and index condition.

Transesophageal echocardiography identification of aortic dissection during cardiac arrest and cessation of ECMO initiation.

Cardiac arrest is a challenging clinical presentation that emergency medicine providers often encounter. Aortic dissection is an uncommon etiology in all-comers presenting in cardiac arrest. The use of bedside point of care echocardiography to aid in resuscitative efforts is expanding, particularly with the increasing use of transesophageal echocardiography (TEE) by emergency medicine providers. Additionally, emergency department initiation of extracorporeal membrane oxygenation (ECMO) is a relatively newer development in emergency department practice. We report the case of a 64-year old male presenting to the emergency department in cardiac arrest with TEE identification of aortic dissection as the etiology resulting in discontinuation of ECMO initiation attempts.

Value-driven cardiac surgery: Achieving "perfect care" after coronary artery bypass grafting.

OBJECTIVE: The objective of this study was to determine if the implementation of a value-driven outcomes tool comprising modifiable quality and utilization metrics lowers cost and improves value of coronary artery bypass grafting (CABG) postoperative care. METHODS: Ten metrics were defined for CABG patients in 2 temporally separated phases. Clinical care protocols were designed and implemented to increase compliance with these metrics. Clinical outcomes and cost data were harvested from the electronic medical record using a proprietary value-driven outcomes tool and verified by a data management team. "Perfect care" was defined as achieving all 10 metrics per patient episode. RESULTS: Over a 45-month period, data of 467 consecutive patients who underwent isolated CABG were analyzed. "Perfect care" was successfully achieved in 304 patients (65.1%). There were no observed differences in mortality between patient groups. Linear regression analysis showed a negative correlation between percent compliance with "perfect care" and mean cost. When multivariate analysis was used to adjust for preoperative risk score, mean cost for patients with "perfect care" was 37.0% less than for those without "perfect care." CONCLUSIONS: In the context of focused institution-specific interventions to target quality and utilization metrics for CABG care, clinical care pathways and protocols informed by innovative tools that link automated tracking of these metrics to cost data might simultaneously promote quality and decrease costs, thereby enhancing value. This descriptive study provides preliminary support for a systematic approach to define, measure, and modulate the drivers of value for cardiothoracic surgery patients.

Evolutionary Improvements in the Jarvik 2000 Left Ventricular Assist Device.

Mechanical circulatory support devices experience a wide range of operating conditions during patient use. Since its first implant in June 2000, the Jarvik 2000 left ventricular assist device has witnessed systematic stepwise modifications to reduce the risk of serious adverse events and improve patient outcomes. Over time, clinical experience revealed a number of low-incidence failure modes that presented opportunities for improvement. Design changes have included, but are not limited to, a Y cable to permit battery changes without pump stoppage, increased pull strength of external cables from 35 to 200 lbs, an intermittent low-speed controller to improve aortic root washout, sintered titanium microsphere surface on the pump housing to prevent apical thrombus, and novel cone bearings to reduce thrombus formation. In summary, real world conditions challenge devices in ways that laboratory or animal experiments do not. Thorough case reviews have led to many improvements as the Jarvik 2000 continues through its second decade of implants.

PHD-2 Suppression in Mesenchymal Stromal Cells Enhances Wound Healing.

BACKGROUND: Cell therapy with mesenchymal stromal cells is a promising strategy for tissue repair. Restoration of blood flow to ischemic tissues is a key step in wound repair, and mesenchymal stromal cells have been shown to be proangiogenic. Angiogenesis is critically regulated by the hypoxia-inducible factor (HIF) superfamily, consisting of transcription factors targeted for degradation by prolyl hydroxylase domain (PHD)-2. The aim of this study was to enhance the proangiogenic capability of mesenchymal stromal cells and to use these modified cells to promote wound healing. METHODS: Mesenchymal stromal cells harvested from mouse bone marrow were transduced with short hairpin RNA (shRNA) against PHD-2; control cells were transduced with scrambled shRNA (shScramble) construct. Gene expression quantification, human umbilical vein endothelial cell tube formation assays, and wound healing assays were used to assess the effect of PHD knockdown mesenchymal stromal cells on wound healing dynamics. RESULTS: PHD-2 knockdown mesenchymal stromal cells overexpressed HIF-1α and multiple angiogenic factors compared to control (p < 0.05). Human umbilical vein endothelial cells treated with conditioned medium from PHD-2 knockdown mesenchymal stromal cells exhibited increased formation of capillary-like structures and enhanced migration compared with human umbilical vein endothelial cells treated with conditioned medium from shScramble-transduced mesenchymal stromal cells (p < 0.05). Wounds treated with PHD-2 knockdown mesenchymal stromal cells healed at a significantly accelerated rate compared with wounds treated with shScramble mesenchymal stromal cells (p < 0.05). Histologic studies revealed increased blood vessel density and increased cellularity in the wounds treated with PHD-2 knockdown mesenchymal stromal cells (p < 0.05). CONCLUSIONS: Silencing PHD-2 in mesenchymal stromal cells augments their proangiogenic potential in wound healing therapy. This effect appears to be mediated by overexpression of HIF family transcription factors and up-regulation of multiple downstream angiogenic factors.

Repair of ascending aortic aneurysms following cardiac transplantation.

Ascending aortic aneurysms arising from the native aorta following cardiac transplantation are rare. We report two patients who developed aneurysms of the native ascending aorta requiring surgical repair post-transplantation. Both patients underwent ascending and hemi-arch replacement and recovered uneventfully. Heart transplant patients with pre-existing aortic dilation/ectasia may display more rapid aneurysmal growth compared to non-transplant patients. Therefore close observation is warranted in these patients.