Outcomes of the Ross procedure in patients older versus younger than 50 years old.

OBJECTIVES: The Ross procedure is traditionally considered for young adult patients with aortic valve disease. This study compares long-term outcomes of patients undergoing the Ross procedure who are ≥50 and <50-years old. METHODS: Data were collected from 225 patients undergoing Ross procedure at a single centre from 1994 to 2019. Patients were categorized into younger (<50-years old; n = 156) and older (≥50-years old; n = 69) cohorts. Baseline demographics clinical outcomes were compared. RESULTS: The mean age was 36 ± 8.1 and 55 ± 4.2 years in the younger and older cohort, respectively. Both groups were predominantly male (58.5% vs 69.6%; P = 0.59). The younger group had a higher rate of aortic insufficiency (51% vs 26.1%; P < 0.01), and bicuspid aortic valve (81.4% vs 58.0%; P < 0.01). Aortic stenosis was more prevalent in the older cohort (25.6% vs 58.0%; P < 0.01). Operative mortality was acceptable in both groups (1.3% vs 4.3%; P = 0.15). Survival up to 10 years was not statistically different between 2 groups (96.2% vs 91.3% P = 0.16), whereas survival up to 15 years for younger patients was significantly higher (94.9% vs 85.5%; P = 0.03). After non-cardiac related deaths were excluded, survival up to 15 years (98.7% vs 91.3%; P = 0.02) was significantly lower than younger patients. In both groups, survival after the Ross procedure was similar to the age- and sex-matched US population. CONCLUSIONS: Survival up to 10 years after Ross procedure were similar, but up to 15 years was significantly higher in younger patients. The Ross procedure restored patients from both groups to expected survival. Our results suggest that at experienced centres, the Ross procedure is a safe and reasonable option for patients who are 50 years and older.

Assessment of TVT and STS Risk Score Performances in Patients Undergoing Transcatheter Aortic Valve Replacement.

Background: The Society of Thoracic Surgeons (STS) score has been used to risk stratify patients undergoing transcatheter aortic valve replacement (TAVR). The Transcatheter Valve Therapy (TVT) score was developed to predict in-hospital mortality in high/prohibitive-risk patients. Its performance in low and intermediate-risk patients is unknown. We sought to compare TVT and STS scores' ability to predict clinical outcomes in all-surgical-risk patients undergoing TAVR. Methods: Consecutive patients undergoing TAVR from 2012-2020 within a large health care system were retrospectively reviewed and stratified by STS risk score. Predictive abilities of TVT and STS scores were compared using observed-to-expected mortality ratios (O:E) and area under the receiver operating characteristics curves (AUCs) for 30-day and 1-year mortality. Results: We assessed a total of 3270 patients (mean age 79 ± 9 years, 45% female), including 191 (5.8%) low-risk, 1093 (33.4%) intermediate-risk, 1584 (48.4%) high-risk, and 402 (5.8%) inoperable. Mean TVT and STS scores were 3.5% ± 2.0% and 6.1% ± 4.3%, respectively. Observed 30-day and 1-year mortality were 2.8% (92/3270; O:E TVT 0.8 ± 0.16 vs STS 0.46 ± 0.09), and 13.2% (432/3270), respectively. In the all-comers population, both TVT and STS risk scores showed poor prediction of 30-day (AUC: TVT 0.68 [0.62-0.74] vs STS 0.64 [0.58-0.70]), and 1-year (AUC: TVT 0.65 [0.62-0.58] vs STS 0.65 [0.62-0.58]) mortality. After stratifying by surgical risk, discrimination of the TVT and STS scores remained poor in all categories at 30 days and 1 year. Conclusions: An updated TAVR risk score with improved predictive ability across all-surgical-risk categories should be developed based on a larger national registry.

Drug-Coated Balloon Angioplasty for Carotid Artery In-Stent Restenosis: Case Series.

OBJECTIVES: Few case reports have demonstrated promising results of drug-coated balloons (DCBs) as an emerging management for carotid artery in-stent restenosis (CAISR). Herein, we report 6 cases of CAISR which were treated with a DCB with or without new stent deployment. BACKGROUND: Carotid artery in-stent restenosis is a high-risk condition with an estimated incidence rate that varies widely from 6% to 40%. Several strategies are available now for the management of the CAISR including conventional balloon angioplasty, plaque modification balloon angioplasty, and new stent placement. METHODS: A retrospective review of consecutive patients with a diagnosis of severe CAISR at Baylor Scott & White The Heart Hospital Plano from 2011 to 2021 was performed. This study was approved by the Baylor Scott & White Research Institute institutional review board. RESULTS: Six patients underwent DCB angioplasty with or without stent placement under an embolic protection device. Resolution of CAISR was achieved in all cases with 0% to 10% residual stenosis in all cases. Following the procedure, 1 patient had a brief episode of syncope with balloon inflation with immediate recovery on deflation of the balloon. There were otherwise no significant neurological or cardiac events prior to discharge. All patients were asymptomatic at their follow-up visit with no neurological or cardiac events reported at 12, 24, and 36 months following the procedure. CONCLUSION: While CAISR treatment remains a challenging condition, our study shows that the use of DCB with or without stent placement is a feasible and promising treatment option when compared with other conventional treatment options. CLINICAL IMPACT: Carotid artery in-stent restenosis treatment remains a challenging condition. Our study shows that the use of drug coated balloon with or without stent placement is a feasible and promising treatment option when compared with current conventional treatment options.

Impact of preoperative Impella support on destination left ventricular assist device outcomes.

BACKGROUND: Although left ventricular assist device (LVAD) implantation is associated with improved heart failure survival, the impact of pre-implantation Impella support on outcomes is unknown. We undertook this study to evaluate the impact of preoperative Impella support on LVAD outcomes. METHODS: We conducted a retrospective review of all Heartmate 3 LVAD implants. Primary stratification was by the need for preoperative Impella support with the 5.0/5.5 device. Longitudinal survival was assessed by the Kaplan-Meier method. Multivariable Cox proportional hazards regression models were developed to evaluate mortality. Secondary outcomes included changes in laboratory values during Impella support. RESULTS: From 2017 to 2021, 87 patients underwent LVAD implantation. Sixteen were supported with a single inotrope, 36 with dual inotropes, 27 with Impella, and 3 with extracorporeal membrane oxygenation (ECMO). When stratified by the need for Impella, there was no difference in survival at 30-days (98.3 [88.2-99.8]% vs. 96.3 [76.5-99.5]%, p = .59), 1-year (91.0 [79.8-96.2] vs. 74.9 [51.7-88.2], p = .10), or at 2 years (87.9 [74.3-94.5] vs. 74.9 [51.7-88.2], p = .15). On multivariable modeling, the need for preoperative Impella was not associated with an increased hazard of 1-year (1.24 [0.23-6.73], p = .81) or 2-year mortality (1.05 [0.21-5.19], p = .95). After 7 (5-10) days of Impella support, recipient creatinine (p < .01), creatinine clearance (p = .02), and total bilirubin (p = .053) improved and lactic acidosis resolved (p < .01). CONCLUSIONS: Preoperative Impella support is not associated with increased short or long-term mortality but is associated with improved renal and hepatic function as well as total body perfusion before LVAD implantation.

Bloodstream and respiratory coinfections in patients with COVID-19 on ECMO.

BACKGROUND: Although several studies have characterized the risk of coinfection in COVID pneumonia, the risk of the bloodstream and respiratory coinfection in patients with COVID-19 pneumonia on extracorporeal membrane oxygenation (ECMO) supports severe acute respiratory distress syndrome (ARDS) is poorly understood. METHODS: This is a retrospective analysis of patients with COVID-19 ARDS on ECMO at a single center between January 2020 and December 2021. Patient characteristics and clinical outcomes were compared. RESULTS: Of 44 patients placed on ECMO support for COVID-19 ARDS, 30 (68.2%) patients developed a coinfection, and 14 (31.8%) patients did not. Most patients underwent venovenous ECMO (98%; 43/44) cannulation in the right internal jugular vein (98%; 43/44). Patients with coinfection had a longer duration of ECMO (34 [interquartile range, IQR: 19.5, 65] vs. 15.5 [IQR 11, 27.3] days; p = .02), intensive care unit (ICU; 44 [IQR: 27,75.5] vs 31 [IQR 20-39.5] days; p = .03), and hospital (56.5 [IQR 27,75.5] vs 37.5 [IQR: 20.5-43.3]; p = .02) length of stay. When stratified by the presence of a coinfection, there was no difference in hospital mortality (37% vs. 29%; p = .46) or Kaplan-Meier survival (logrank p = .82). Time from ECMO to first positive blood and respiratory culture were 12 [IQR: 3, 28] and 10 [IQR: 1, 15] days, respectively. Freedom from any coinfection was 50 (95% confidence interval: 37.2-67.2)% at 15 days from ECMO initiation. CONCLUSIONS: There is a high rate of co-infections in patients placed on ECMO for COVID-19 ARDS. Although patients with coinfections had a longer duration of extracorporeal life support, and longer length of stays in the ICU and hospital, survival was not inferior.

Real-world validation of fractional flow reserve computed tomography in patients with stable angina: Results from the prospective AFFECTS trial.

BACKGROUND: Fractional flow reserve computed tomography (FFRct) allows for non-invasive assessment of hemodynamically significant coronary artery disease (CAD). Real-world data regarding the diagnostic performance of FFRct is scarce. We aim to validate the diagnostic performance of FFRct against invasive coronary angiography (ICA) in patients with stable angina and an abnormal single photon emission computed tomography (SPECT) study. METHODS: This prospective, single-cohort, real-world study enrolled consecutive adult patients with stable angina and an abnormal SPECT study who were referred for ICA. Prior to ICA, FFRct analysis was performed. Sensitivity and specificity of FFRct were evaluated at the patient and vessel level against ICA. Physician intuition-based diagnosis of hemodynamically significant CAD was also documented prior to ICA. RESULTS: A total of 66 patients were enrolled; 10 were excluded due to protocol deviation or missing studies. FFRct achieved 95% sensitivity and 83% specificity at the patient level, and 78% sensitivity and 88% specificity at the vessel level. FFRct was most accurate in the left circumflex artery (sensitivity 83%, specificity 92%) and the least in the left anterior descending artery (80% sensitivity, 78% specificity). FFRct identified hemodynamically significant CAD more accurately than physician intuition (sensitivity 95% vs 84%; specificity 83% vs 46%). If physicians had been unblinded to FFRct, ICA may have been avoided in up to 53% of patients. CONCLUSION: We performed a real-world study to validate the diagnostic performance of FFRct against gold-standard invasive imaging. FFRct has high sensitivity and specificity for the diagnosis of hemodynamically significant CAD in intermediate-to-high risk patients.

Robotic mitral valve surgery after prior sternotomy.

Objective: Despite the recent increase in the use of minimally invasive approaches to mitral valve surgery in patients with a prior sternotomy, the outcomes of the robotic approach to mitral valve surgery in this patient population have not been examined. Methods: We retrospectively reviewed 342 consecutive patients who underwent mitral valve surgery after a prior sternotomy between 2013 and 2020, in which the robotic approach was used in 21 patients (6.1%). We reviewed the clinical details of these 21 patients. Results: The median age was 71 years [interquartile range 64.00, 74.00 years], and mean Society of Thoracic Surgeons Predicted Risk of Mortality was 4.2% ± 3.8%. The indication for mitral valve surgery was degenerative mitral valve disease in 33.3% (7/21), functional disease in 28.6% (6/21), mixed disease in 4.8% (1/21), rheumatic disease in 9.5% (2/21), and failed repair for degenerative disease in 23.8% (5/21). No cases required conversion from robotic assistance to alternative approaches, there were no intraoperative deaths, and intraoperative transesophageal echocardiogram confirmed complete elimination of mitral regurgitation in 90.5% (19/21) of cases. Thirty-day mortality was 0.0% (0/21), and 1-year mortality was 4.8% (1/21). There were no strokes or wound infections at 30 days, and 14.3% (3/21) of patients received intraoperative blood product transfusions. Conclusions: The results of this retrospective review suggest that the robotic approach to mitral valve surgery in patients with a prior sternotomy is safe in experienced hands. Although some centers have considered prior sternotomy a relative contraindication to robotic mitral valve surgery, this approach is feasible and can be considered an option for experienced surgeons.

Outcomes of aortic root enlargement during isolated aortic valve replacement.

OBJECTIVES: Aortic root enlargement (ARE) lowers the risk of patient prosthesis mismatch after surgical aortic valve replacement (SAVR) in patients with small annular size. Whether ARE is associated with increased operative mortality is controversial. This study compares the early and intermediate outcomes in patients undergoing SAVR with and without ARE. METHODS: All patients undergoing isolated SAVR with and without ARE from 2015 to 2020 were analyzed. Propensity-matching was used to adjust for possible confounding variables. Kaplan-Meier analysis and log-rank test were used to estimate and compare overall outcomes and survival in the study cohorts. RESULTS: Among 868 isolated SAVRs, ARE was performed in 54 (6.2%) patients. Before matching, mean age was similar but female sex (67.4% vs. 29.6%; SD: -0.82) and previous AVR (18.9% vs. 3.9%; SD: -0.48) were more common in patients undergoing SAVR + ARE versus SAVR alone. A bovine pericardial patch was used for 81.5% (44 of 54) of ARE, with a Dacron patch in the rest. After propensity matching, the average cardiopulmonary bypass (138.2 ± 34.9 vs. 102.9 ± 33.0 min; p < 0.01) and cross-clamp times (113.8 ± 26.7 vs. 83.0 ± 28.4 min; p < 0.01) were longer in the SAVR + ARE group. There were no significant differences in postoperative stroke, new-onset dialysis, pacemaker placement, reoperation for bleeding, length of hospital stay, or 30-day readmission. Thirty-day mortality (0% vs. 0.6%, p = 1.0) and 5-year survival (96.3% vs. 95.7%, p = 0.86) were also similar. CONCLUSIONS: ARE during surgical AVR can be safely performed without an increase in complications with excellent early and intermediate-term survival.

Extracorporeal membrane oxygenation for respiratory failure in phases of COVID-19 variants.

BACKGROUND: Adaptive mutations of the severe acute respiratory syndrome-related coronavirus (SARS-CoV-2) virus have emerged throughout the coronavirus disease 2019 (COVID-19) pandemic. The characterization of outcomes in patients requiring extracorporeal membrane oxygenation (ECMO) for severe respiratory distress from COVID-19 during the peak prevalence of different variants is not well known. METHODS: There were 131 patients with laboratory-confirmed SARS-CoV-2 infection supported by ECMO at two referral centers within a large healthcare system. Three predominant variant phase time windows (Pre-Alpha, Alpha, and Delta) were determined by a change-point analyzer based on random population sampling and viral genome sequencing. Patient demographics and outcomes were compared. RESULTS: The average age of patients was 46.9 ± 10.5 years and 70.2% (92/131) were male. Patients cannulated for ECMO during the Delta variant wave were younger compared to earlier Pre-Alpha (39.3 ± 7.8 vs. 48.0 ± 11.1 years) and Alpha phases (39.3 ± 7.8 vs. 47.2 ± 7.7 years) (p < .01). The predominantly affected race in the Pre-Alpha phase was Hispanic (52.2%; 47/90), while in Alpha (61.5%; 16/26) and Delta (40%; 6/15) variant waves, most patients were White (p < .01). Most patients received a tracheostomy (82.4%; 108/131) with a trend toward early intervention in later phases compared to Pre-Alpha (p < .01). There was no significant difference between the duration of ECMO, mechanical support, intensive care unit (ICU) length of stay (LOS), or hospital LOS over the three variant phases. The in-hospital mortality was overall 41.5% (54/131) and was also similar. Six-month survival of patients who survived to discharge was 92.2% (71/77). CONCLUSIONS: There was no significant difference in survival or time on ECMO support in patients during the peak prevalence of the three variants.

Atrial tachyarrhythmia as a presenting symptom leading to the diagnosis of pulmonary sarcoidosis treated with catheter-based ablation.

A 55-year-old woman was referred for recurrent palpitations. A 48-hour ambulatory cardiac monitor revealed an atrial tachycardia rate up to 170 beats per minute. A subsequent electrophysiology study revealed atrial fibrillation and both typical and atypical atrial flutter. Computed tomography revealed multiple pulmonary nodules, and an endobronchial ultrasound-guided fine-needle aspiration confirmed the diagnosis of pulmonary sarcoidosis. The patient underwent radiofrequency ablation of the cavotricuspid isthmus and left common, right superior, and right inferior pulmonary vein isolation via cryoablation, without recurrent symptoms.

Minimally invasive mitral valve surgery after previous sternotomy: A propensity-matched analysis.

BACKGROUND: Although the incidence of mitral valve (MV) surgery after previous open-heart surgery is increasing, there is no consensus regarding the optimal surgical approach. Reoperative MV surgery is most commonly performed via sternotomy (ST). We sought to determine whether minimally-invasive (MIS) reoperative MV surgery is safe and feasible. METHODS: All patients with a history of ST undergoing MV surgery with or without concomitant tricuspid or atrial fibrillation surgery at a single institution from 2007 to 2018 were retrospectively reviewed. ST and MIS approaches were compared using propensity-matched analysis. The coprimary endpoints were operative mortality and 1-year survival, and secondary endpoints were operative complications and length of stay. RESULTS: A total of 305 isolated MV reoperations were performed: 199 (65%) MIS and 106 (35%) ST. MIS patients were older than ST patients (71 [63, 76.5] vs. 66 [56, 72] years, p < .01), more likely to have undergone prior coronary artery bypass grafting (57% vs. 27%, p < .01), and less likely to have had prior valve surgery (55% vs. 78%, p < .01). In unmatched comparisons, operative mortality was significantly lower among MIS patients (3.0% vs. 8.5%, p = .04), but 1-year mortality was similar (14.4% vs. 15.6%, p = .8). After propensity matching, 88 pairs had excellent balance across baseline characteristics. Mortality was similar among MIS and ST patients at 30 days (3.4% vs. 8%, p = .19) and 1 year (15.9% vs. 16.5%, p = .9). RBC and fresh frozen plasma transfusions were significantly lower in the MIS group (p < .01). CONCLUSIONS: A minimally invasive approach is a safe alternative in patients with prior ST undergoing MV surgery.