Transcatheter prosthetic valve endocarditis of an aortic valve-in-valve bioprosthesis in an elderly male.

Transcatheter aortic valve replacement (TAVR) is the percutaneous alternative to traditional surgery. Infective endocarditis is a fatal complication of TAVR, especially in the elderly. A 65-year-old male with a history of valve-in-valve TAVR presented to our emergency room with altered mentation. On examination, he was febrile. Laboratory investigations and echocardiography suggested infective endocarditis. Explantation and surgical aortic valve replacement were planned. The biopsy of the prostheses showed acute inflammation. Transcatheter prosthetic valve endocarditis warrants early diagnosis, particularly in the elderly. Our case emphasizes the importance of the prompt inclusion of endocarditis in the differential and surgical referral.

Different clinical characteristics and outcomes of adult hospitalized SARS-CoV-2 pneumonia patients complicated by cardiovascular events during the first, delta and omicron waves of COVID-19.

Background: The effects of SARS-CoV-2 have varied between significant waves of hospitalization. Research question: Are cardiovascular complications different among the first, delta and omicron waves of hospitalized COVID-19 pneumonia patients? Study design and methods: This was a multi-centre retrospective study of patients hospitalized with SARS-CoV-2 pneumonia: 632 were hospitalized during the first wave (March-July 2020), 1013 during the delta wave (September 2020-March 2021), and 323 during the omicron wave (January 2022-July 2022). Patients were stratified by wave and occurrence of cardiovascular events. Results: Among all hospitalized patients with cardiovascular events, patients in the omicron wave were younger (62.4 ± 14 years) than patients in the first wave (67.4 ± 7.8 years) and the delta wave (66.9 ± 12.6 years) and had a higher proportion of non-Hispanic White people than in the first wave (78.6% vs. 61.7%). For COVID-19 patients who suffered from cardiovascular events, the omicron wave patients had significantly higher neutrophil/lymphocyte ratio, white blood cell and platelet counts when compared to the first wave. Omicron wave patients had significantly lower albumin and B-type natriuretic peptide levels (only 5.8% of the first wave and 14.6% of the delta wave) when compared to either the first wave or delta wave patients. In COVID-19 patients who suffered cardiovascular events during hospitalization, mortality rate in the omicron wave (26.8%) was significantly lower than the first wave (48.3%), time to mortality for non-survivors of COVID-19 patients who suffered cardiovascular events was significantly longer in the omicron wave (median 16 days) than in the first wave (median 10 days). Conclusions: Younger and white patients were affected with cardiovascular complications more often by the omicron variant. Despite higher neutrophil/lymphocyte ratio and WBC counts, the omicron patients with cardiovascular events showed lower heart injuries, lower mortality and longer time to mortality for non-survivors when compared to the first and delta waves.

Cannula Placement for Cerebral Protection Without Circulatory Arrest in Patients Undergoing Hemiarch Aortic Aneurysm Repair.

BACKGROUND: Aortic aneurysms involving the proximal aortic arch, which require hemiarch-type repair, typically require circulatory arrest with antegrade cerebral perfusion. Left carotid antegrade cerebral perfusion (LCP) via distal arch cannulation without circulatory arrest was used in this study's patient population. The goal was to assess the operative efficiency and clinical outcomes of using a distal arch cannulation technique that would not require any hypothermic circulatory arrest (HCA) time compared with more traditional brachiocephalic artery cannulation with right-sided unilateral antegrade cerebral perfusion (RCP) and HCA. METHODS: A single-center retrospective review of patients with replacement of the distal ascending aorta involving the proximal arch was performed. Patients with an intramural hematoma or dissection were excluded. Between January 2015 and December 2019, 68 adult patients had undergone a hemiarch repair because of aneurysmal disease. Analysis of baseline demographics, operative data, and clinical outcomes was performed. RESULTS: Comparing the 68 patients: 21 patients were treated with RCP (via brachiocephalic artery graft with HCA), and 47 patients were treated with LCP (via distal aortic arch cannulation with cross-clamp between the brachiocephalic and left common carotid arteries without HCA). Baseline characteristics and outcomes were evaluated for both groups. The LCP group was younger (LCP median [IQR] age, 60 [53-65] years vs RCP median [IQR] age, 67 [59-71] years]. Sex, race, body mass index, comorbidities, and ejection fraction were similar between the groups. Cardiopulmonary bypass time (LCP, 123 minutes vs RCP, 149 minutes) and unilateral cerebral perfusion time (LCP, 17 minutes vs RCP, 22 minutes) were longer in the RCP group. Bleeding, prolonged ventilatory support, kidney failure, and length of stay were similar. In-hospital mortality was 2% in the LCP group vs 0% in the RCP group. Stroke occurred in 2 patients (4.2%) in the LCP group and in 0% of the RCP group. Mortality at 6 months in the LCP and RCP groups was 3% and 10%, respectively. CONCLUSION: Distal arch cannulation with LCP without HCA is a reasonable and safe alternative strategy for patients requiring hemiarch replacement for aneurysmal disease. This technique may provide additional benefits by avoiding circulatory arrest in these complex cases.

Predictors of Survival After Heart Transplant in the New Allocation System: A UNOS Database Analysis.

Clinical predictors of posttransplant graft loss since the United Network for Organ Sharing (UNOS) heart allocation system change have not been well characterized. Single organ adult heart transplants from the UNOS database were identified (n = 10,252) and divided into a test cohort (n = 6,869, 67%) and validation cohort (n = 3,383, 33%). A Cox regression analysis was performed on the test cohort to identify recipient and donor risk factors for posttransplant graft loss. Based on the risk factors, a score (max 16) was developed to classify patients in the validation cohort into risk groups of low (≤1), mid (2-3), high (≥4) risk. Recipient factors of advanced age, Black race, recipient blood group O, diabetes, etiology of heart failure, renal dysfunction, elevated bilirubin, redo-transplantation, elevated pulmonary artery pressure, transplant with a durable ventricular assist device, or transplant on extracorporeal membrane oxygenation (ECMO) or ventilator were associated with more posttransplant graft loss. Donor factors of ischemic time and donor age were also associated with outcomes. One year graft survival for the low-, mid-, high-risk groups was 94%, 91%, and 85%, respectively. In conclusion, easily obtainable clinical characteristics at time of heart transplant can predict posttransplant outcomes in the current era.

Surgical Ablation for Atrial Fibrillation During Mitral Valve Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Although surgical ablation has been shown to produce excellent outcomes at follow-up for patients with atrial fibrillation who underwent mitral valve replacement/repair (MVR), this procedure is not commonly performed. Our objective was to conduct a systematic review and meta-analysis to evaluate the outcomes of concomitant surgical ablation during MVR. Three databases were systematically reviewed for randomized clinical trials published by August 2022. The primary outcome was sinus rhythm (SR) at 12 months. Secondary outcomes included SR at discharge and 6 months, all-cause mortality, permanent pacemaker implantation, and stroke and thromboembolic events. A random-effects meta-analysis was performed, calculating odds ratios (ORs) for each outcome. Thirteen studies were included, involving 1,089 patients comparing patients who underwent either isolated MVR ("MVR-only") or concomitant surgical ablation during MVR ("MVR+Ablation"). The odds of SR were significantly higher in the MVR+Ablation group at discharge (OR 9.62, 95% confidence interval [CI] 4.87 to 19.02, I2 = 55%), at 6-month follow-up (OR 7.21, 95% CI 4.30 to 12.11, I2 = 34%), and at 1-year follow-up (OR 8.41, 95% CI 5.14 to 13.77, I2 = 48%). All-cause mortality was not different in the groups, as were stroke and thromboembolic events, whereas the odds of permanent pacemaker implantation were slightly higher in the MVR+Ablation group (OR 1.87, 95% CI 1.11 to 3.17, I2 = 0%). Concomitant surgical ablation during MVR showed excellent outcomes at short-term follow-up, despite a slightly higher rate of permanent pacemaker implantation. Further studies with longer follow-ups are needed to assess if the SR is maintained over the years.

Durable left ventricular assist device implant-how I teach it.

Left ventricular assist devices (LVADs) have become a mainstay of advanced heart failure therapy. The technical aspects of performing a device implant are nuanced and attention to these details allows for successful therapy with good outcomes. As more patient with heart failure are expected to benefit from mechanical circulatory support, the need for a concise and consistent technique for LVAD implantation is needed. Teaching this procedure is most comprehensible when broken down into separate steps, as with many other procedures. Here, we describe our standard protocol for LVAD implantation, as well as rudimentary outcomes of 6-year experience in our center. We hope this will provide some insight and guidance to centers who are expanding into the field of mechanical circulatory support and can help them form a foundation with which to build their own experience and success.

Managing valvular pathology during LVAD implantation.

Since the time of their invention, implantable continuous flow left ventricular assist devices (LVADs) have improved the quality of life and extended survival for patients with advanced heart failure. The decision surgeons and their physician colleagues make with these patients to undergo implantation must come with full understanding of the immediate, short-term, and long-term implications of such a life-changing procedure. The presence of pathology regarding the aortic, mitral, and tricuspid valves introduces particularly complex problems for the surgical treatment strategy. Concomitant valve repair or replacement increases cardiopulmonary bypass and cross clamp times, and could potentially lead to worse outcomes in the perioperative setting. Following perioperative recovery, valvular pathology may worsen or arise de novo given the often drastic immediate physiologic changes in blood flow, septal function, and, over time, ventricular remodeling. Over the past two decades, there has been vast improvement in the device manufacturing, surgical techniques, and medical management surrounding LVAD implantation. Yet, addressing concomitant valvular pathology remains a complex question with no perfect solutions. This review aims to briefly describe the evolution of approach to valvular pathology in the LVAD patient and offer our opinion and treatment rationale.

Venous External Support in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis.

Neointimal hyperplasia and lumen irregularities are major contributors to vein graft failure and the use of VEST(R) should prevent this. In this review, we aim to evaluate the angiographic outcomes of externally supported vein grafts. Medline, Embase and Cochrane Library were systematically reviewed for randomized clinical trials published by August 2022. The primary outcome was graft failure. Secondary outcomes included graft ectasia, intimal hyperplasia area and thickness, and graft nonuniformity. Odds ratios (OR) for dichotomous variables and mean difference (MD) for continuous variables with 95% confidence intervals (CI) were pooled using a fixed-effects model. Three randomized controlled trials with a total of 437 patients were included with follow-up ranging from 1 to 2 years. The odds of graft failure were similar in the 2 groups (OR 1.22; 95%CI 0.88-1.71; I²â€¯= 0%). Intimal hyperplasia area [MD -0.77 mm2; 95%CI -1.10 to -0.45; I2 = 0%] and thickness [MD -0.06 mm; 95% CI -0.08 to -0.04; I2=0%] were significantly lower in the VEST group. Fitzgibbon Patency Scale of II or III (representing angiographic conduit nonuniformity; OR 0.67; 95%CI 0.48-0.94; I2 = 0%) and graft ectasia (OR 0.53; 95%CI 0.32-0.88; I2 = 33%) were also significantly lower in the VEST group. At short-term follow-up, VEST does not seem to reduce the incidence of graft failure, although it is associated with attenuation of intimal hyperplasia and nonuniformity. Longer angiographic follow-up is warranted to determine whether these positive effects might translate into a positive effect in graft failure and in long-term clinical outcomes.

Pediatric Epicardial Devices: Early and Midterm Outcomes.

BACKGROUND: Lead performance is suboptimal in young patients and a main cause of device system failure. Our objective was to assess early and midterm outcomes after epicardial device implantation in a contemporary pediatric cohort. METHODS: A total of 116 consecutive pediatric patients underwent 137 epicardial device implantations from 2010 to 2019. Forty pacemakers and 97 implantable cardioverter defibrillators (ICDs) were implanted. Lead failure was defined as leads repaired, replaced, or abandoned due to fracture, dislodgement, or dysfunction. Freedom from device system failure was determined using Kaplan-Meier analysis. RESULTS: Mean age at implantation was 10 ± 5 years, 46 (34%) were younger than 8 years old, 41 (30%) had prior cardiac surgery, and 38 (28%) had prior devices. Main indications were acquired heart block (17/40 [43%]), sinus node dysfunction (14/40 [35%]), and congenital heart block (7/40 [18%]) for pacemakers, and hypertrophic cardiomyopathy (46/97 [47%]), long QT syndrome (31/97 [32%]), and ventricular arrhythmia (17/97 [18%]) for ICDs. There were no early deaths. Three-year freedom from device system failure was 80% (95% CI 73%, 88%) for all patients and 88% (95% CI 79%, 99%) for patients <8 years old. Device system failure causes included lead fracture (20/34 [59%]), lead dysfunction (5/34 [15%]), lead dislodgement (5/34 [15%]), infection (3/34 [9%]), and pericarditis (1/34 [3%]). Reintervention was required in 26/34 (76%) device system failures. CONCLUSIONS: Epicardial device implantation is safe, shows acceptable midterm outcomes in children, and is an effective option in patients younger than 8 years old. Close device surveillance continues to be essential to detect lead failure early and ensure timely reintervention.

Coronary Artery Bypass Grafting complicated by post-operative coronavirus infection - two similar presentations with dissimilar outcomes.

Patients diagnosed with COVID-19 infection undergoing surgical procedures have been reported to have increased post-operative complications and mortality. These findings are important when considering cardiac surgical procedures, specifically coronary artery bypass grafting (CABG) during this pandemic, since the Society of Thoracic Surgeons (STS) describes most of these operations as 'urgent'. In addition, the majority of cardiac surgical patients are at increased risk of infection and death with COVID-19, as they are frequently of old age, obese, hypertensive, and diabetic, with severe cardiac or pulmonary diseases. This case series describes the clinical course following a CABG procedure in two patients that went on to develop COVID-19 infection post-operatively. We aim to illustrate the similarities in clinical presentation, but differences in eventual outcomes for both patients and hypothesize the reasons for the differences.

Use of Impella in Patients Listed for Heart Transplantation.

The new United Network for Organ Sharing (UNOS) policy has resulted in a significantly higher number of temporary mechanical circulatory support device usage such as extracorporeal membrane oxygenation, Impella, and intra-aortic balloon pump due to provision of higher priority with their use while on the waiting list. We aimed to identify Impella use in patients awaiting heart transplantation and temporal changes in its usage. The UNOS database was queried between years 2015 and 2019 for patients aged greater than or equal to 18 years, listed to undergo heart transplantation. A total of 378 patients had Impella support while listed for heart transplantation. Impella use skyrocketed from 2015 (1%) to 2019 (4%, p < 0.01). The most substantial increase in Impella use occurred after the UNOS policy change. The patients listed on Impella support after the policy change had significantly lower waiting time (median 12 days vs. 45 days, p < 0.01). More patients with Impella were directly transplanted (80% vs. 56%, p < 0.01) after the policy change, had significantly lower waitlist mortality (25% vs. 13%, p < 0.01) and fewer converted to a durable support (13% vs. 3%). The translatability (likelihood for receiving organs faster) was significantly improved after the policy change. A multivariable Cox regression model showed that post-transplant survival of Impella patients was not adversely affected after the policy change (hazard ratio = 0.9; p = 0.8). This increase in Impella use represents a substantial change in practice patterns of listing and managing patients on the heart transplant waiting list.

Apixaban: Alternative Anticoagulation for HeartMate 3 Ventricular Assist Device.

Patients with left ventricular assist devices currently require long-term anticoagulation with warfarin. Warfarin requires frequent blood tests and is associated with adverse events when not in the therapeutic range. Apixaban is a possible alternative that is potentially better for compliance and requires no additional testing. The purpose of this study was to compare adverse events in patients with a HeartMate 3 LVAD receiving apixaban versus warfarin. Thirty-five patients underwent HM3 implantation between January 01, 2016 to January 31, 2021. The groups compared were apixaban (n = 15, 43%) and warfarin (n = 20, 57%). All patients received 325 mg aspirin daily. Stroke, bleeding, and death were identified as primary outcomes after LVAD implant. Univariate nonparametric statistical analysis was performed. The median duration of treatment with apixaban was 148 days (37-606 days). The groups were comparable in terms of age (56 vs. 54 years), gender (male, 85% vs. 75%), and renal function (Cr 1.5 vs. 1.4). The apixaban group had significantly higher mean pulmonary artery pressure (41 vs. 34, p = 0.03) and there were more (p < 0.05) ischemic cardiomyopathy and INTERMACS profile >3 in the warfarin group. At 6 months, thrombotic complications and death were not different between the groups. The two deaths in the apixaban group were from right heart failure. The apixaban group had clinically lower rates of bleeding complications (5% vs. 30%). The adverse events of bleeding, stroke, and death were similar in HM3 patients receiving warfarin or apixaban. Apixaban may be a safe alternative anticoagulant therapy in HM 3 LVAD patients.

Electrocardiographic Features and Outcome: Correlations in 124 Hospitalized Patients With COVID-19 and Cardiovascular Events.

OBJECTIVES: Electrocardiographic (ECG) changes have been associated with coronavirus disease 2019 (COVID-19) severity. However, the progression of ECG findings in patients with COVID-19 has not been studied. The purpose of this study was to describe ECG features at different stages of COVID-19 cardiovascular (CV) events and to examine the effects of specific ECG parameters and cardiac-related biomarkers on clinical outcomes in COVID-19. DESIGN: Retrospective, cohort study. SETTING: Major tertiary-care medical centers and community hospitals in Louisville, KY. PARTICIPANTS: A total of 124 patients with COVID-19 and CV events during hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twelve-lead ECG parameters, biomarkers of cardiac injuries, and clinical outcomes were analyzed with Spearman correlation coefficients and Kruskal-Wallis 1-way analysis of variance. Atrial fibrillation/atrial flutter was more frequent on the ECG obtained at the time of the CV event when compared with admission ECG (9.5% v 26.9%; p = 0.007). Sinus tachycardia was higher in the last available hospital ECG than the CV event ECG (37.5% v 20.4%; p = 0.031). Admission ECG-corrected QT interval was significantly associated with admission troponin levels (R = 0.52; p < 0.001). The last available hospital ECG showed nonsurvivors had longer QRS duration than survivors (114.6 v 91.2 ms; p = 0.026), and higher heart rate was associated with longer intensive care unit length of stay (Spearman ρ = 0.339; p = 0.032). CONCLUSIONS: In hospitalized patients with COVID-19 and CV events, ECGs at various stages of COVID-19 hospitalization showed significantly different features with dissimilar clinical outcome correlations.

Racial disparities in cardiac transplantation: Chronological perspective and outcomes.

BACKGROUND: The objective of this study was to evaluate annual heart transplant volumes and 3-year post-transplant outcomes since establishment of United Network for Organ Sharing (UNOS) database stratified by race. METHODS: The UNOS thoracic transplant database was evaluated for adult patients since 1987. The available database was then stratified by Race: Black, White and Other and era of transplant: group 1(1987-1991), group 2(1992-1996), group 3(1997-2001), group 4(2002-2006), group 5(2007-2011), group 6(2012-2016) and group 7(2017 and later). Demographic and clinical factors were evaluated. RESULTS: A total of 105,266 adults have been listed since 1987 and 67,824 have been transplanted. Of the transplanted patients 11,235 were Black, 48,786 White and 6803 were of Other race. The proportion of Black patients listed increased from 7% in 1987 to 13.4% in 1999 and 25% in 2019 and those transplanted increased from 5% in 1987 to 13.4% in 2001 and 26% in 2019. The survival of Black patients gradually improved. CONCLUSION: Historically, fewer Black patients received cardiac transplantation however, their access gradually improved over the years and account for over 25% of cardiac transplantations performed in recent years. The historically poor survival of Black patients has recently improved and became comparable to the rest.