BACKGROUND:The optimal timing of coronary artery bypass grafting (CABG) after non-ST elevation myocardial infarction (NSTEMI) remains debated. We assessed national practice patterns and outcomes of CABG timing after NSTEMI, including inpatient vs delayed surgery, and specific timing of inpatient surgery. METHODS:Medicare beneficiaries aged ≥65 years presenting nonelectively with NSTEMI who underwent diagnostic angiography from October 2016 to October 2021 were identified. Patients undergoing percutaneous coronary intervention during the index admission and those who died before any revascularization were excluded. Patients undergoing inpatient CABG were compared with those discharged and returning for elective CABG within 3 months using propensity score matching, with a primary end point of 30-day mortality and a secondary end point of 4-year survival. Among inpatient CABG patients, 30-day mortality of patients undergoing intervention at 0 to 1, 2 to 3, 4 to 7, and >7 days after diagnosis was assessed with logistic regression with natural cubic splines. RESULTS:Of 704,638 patients with NSTEMI who underwent angiography, 90,551 (27.1%) underwent inpatient CABG and 5715 (2.3%) returned for elective CABG. After propensity matching, 30-day mortality was lower with elective readmission (3.6% vs 4.9%, P < .001), although 4-year survival was similar (P = .553). Among discharged patients, 1.3% required urgent CABG (30-day mortality of 6.3%) and 9.1% died without revascularization within 3 months. Among inpatient CABG patients, optimal short-term outcomes were observed at 2 to 4 days after angiography. CONCLUSIONS:Optimal CABG outcomes after NSTEMI occur when surgery is performed 2 to 4 days after diagnosis. Although delayed elective CABG offers short-term survival advantages in highly-selected patients, the risk of mortality and urgent intervention in discharged patients suggest most should undergo inpatient revascularization.

AIMS:Use of bioprosthetic tissue valves in surgical aortic valve replacement (SAVR) has increased in recent years. The effect of novel bovine pericardial tissue valves on short-term costs and utilization has not been established. We assessed INSPIRIS RESILIA aortic tissue valves (*Edwards Lifesciences, Irvine CA) during SAVR hospitalization and 90 days post-discharge compared to other tissue valves for all ages, and to mechanical valves for patients of shared decision-making age (50-65). MATERIALS AND METHODS:Retrospective observational study using US hospital data. Adults admitted for first-time SAVR 2018-2021 with identifiable tissue or mechanical valves were analyzed. Outcomes were adjusted for demographics, comorbidities, procedure and hospital characteristics using generalized linear modeling. RESULTS:20,125 patients were analyzed; majority were male, with elective procedures in academic hospitals. Compared to other tissue valves, length of stay and ICU stay were shorter with INSPIRIS (p < 0.001). In-hospital mortality was not statistically different. Readmissions at 30 days were 7.1% with INSPIRIS, 9.0% other tissue valves; 10.4% vs. 13.0% at 90 days (both p < 0.001). Reduced cost of readmission (-$1,013 at 90 days) partially offset the difference of $2,429 in initial hospitalization cost. INSPIRIS valves compared to mechanical valves (ages 50-65) showed similar patterns in utilization. In-hospital mortality was lower with INSPIRIS than mechanical valves (2.0% vs. 3.2%, p = 0.009), but did not differ when limited to isolated SAVR only. Initial hospitalization cost was higher for INSPIRIS ($7,079, p < 0.001), with lower 90-day readmissions cost (-$899, p < 0.05). LIMITATIONS:Non-randomized analysis of real-world data. CONCLUSIONS:Patients undergoing SAVR with INSPIRIS valves had shorter length of stay and fewer readmissions compared to other tissue valves and to mechanical valves. Reduced cost of readmissions partially offset higher cost of initial SAVR admission. Further research is warranted to explore this association between valve used and utilization outcomes.

BACKGROUND:Surgical left atrial appendage occlusion (sLAAO) is known to prevent strokes in patients with atrial fibrillation (AF). However, for AF patients on long-term anticoagulation (AC), little is known about the safety of AC discontinuation after sLAAO. METHODS:The study included Medicare patients with AF on AC undergoing coronary artery bypass grafting or valve surgery from 2016 to 2019. By propensity score matching, patients who did not continue AC more than 90 days after surgery were compared with patients continuing AC. RESULTS:Of 10,407 patients undergoing sLAAO, 2470 (14.0%) exhibited early AC discontinuation and had 5-year risk of embolic events that was 1% higher (6.3% vs 5.3%; subdistribution hazard ratio [HR], 1.32 [1.05-1.59]; P = .043). However, the risk of major bleeding was much lower in those patients (13.7% vs 17.8%; subdistribution HR, 0.68 [0.57-0.82]; P < .001) such that no difference was observed in the composite outcome of mortality, embolism, or major bleeding (34.0% vs 34.0%; HR, 0.97 [0.86-1.10]; P = .64). Moreover, risk of embolism in sLAAO patients discontinuing AC was no different from that in AF patients continuing AC after surgery who did not undergo sLAAO (6.5% vs 6.5%; HR, 1.20 [0.93-1.47]; P = .18), and the risk of mortality, embolism, or major bleeding was lower (34.5% vs 38.6%; HR, 0.84 [0.74-0.95]; P = .006). CONCLUSIONS:AF patients on long-term AC who underwent sLAAO and discontinued AC after surgery were not at increased composite risk with respect to mortality, embolism, or major bleeding during 5 years. Discontinuation of long-term AC after sLAAO may be associated with acceptable long-term outcomes in many patients.

OBJECTIVES:We sought to characterize the durability of aortic root reconstruction with felt neomedia for acute type A aortic dissection (ATAAD). METHODS:Of 894 patients undergoing type A aortic dissection repair between 2010 and 2024 at a single institution, 537 underwent aortic root reconstruction with felt neomedia and aortic valve resuspension (median age 64 years, 37.2% female). Median follow-up was 4.3 years. Outcomes included survival, proximal aortic reintervention, greater than moderate aortic insufficiency, and root dilatation. Predictors of a composite outcome-defined as proximal aortic reintervention, greater than moderate aortic insufficiency, or root dilatation ≥ 50 mm-were evaluated. RESULTS:Preoperatively, 19.9% of patients had greater than moderate aortic insufficiency, and median root diameter was 39.0 mm. Thirty-day mortality was 12.8%, and 10-year survival was 52.3%. The cumulative incidence of proximal aortic reintervention at 1, 5, and 10 years was 0.4%, 2.4%, and 5.5%. During follow-up, 13 patients developed greater than moderate aortic insufficiency and 16 developed root dilatation ≥ 50 mm. Freedom from the composite outcome was 98.8% at 1 year and 91.9% at 5 years. On multivariable analysis, preoperative aortic insufficiency and baseline root diameter ≥ 45 mm were independent predictors of the composite outcome. CONCLUSIONS:Aortic root reconstruction with felt neomedia and aortic valve resuspension is a durable technique for ATAAD. Patients with preoperative aortic insufficiency or root dilatation are at increased risk for root-related events and warrant close surveillance.

Objectives Preoperative assessment of radial artery suitability commonly relies on the Allen’s test, a subjective bedside maneuver. We evaluated whether duplex ultrasonography flow metrics predict postoperative hand function after radial artery harvest for coronary artery bypass grafting (CABG). Methods Patients undergoing elective CABG (October 2024–February 2026) with an appropriate second arterial conduit target, underwent preoperative Allen’s testing and upper-extremity duplex ultrasonography, including palmar arch velocity with radial artery occlusion (PAVRO) and ulnar augmentation (percentage increase in ulnar artery flow with radial occlusion). Hand function (grip and pinch strength, fatigue, and dexterity) and patient-reported symptoms were measured preoperatively and at 1 month. ANCOVA and logistic regression models were adjusted for baseline hand function, age, sex, and diabetes. Results Thirty-nine patients underwent radial harvest with complete follow-up. Low PAVRO was not associated with postoperative change in any hand function metrics. Increased ulnar augmentation was associated with greater postoperative mean grip strength (p = 0.017) and fatigue resistance (p = 0.002); no patient with ulnar augmentation >40% had a clinically meaningful (>20%) decline in grip strength. Allen’s test results had low concordance with duplex ultrasonography: 11 of 23 patients deemed unsuitable by duplex had a normal Allen’s at the 3-second threshold, and 13 of 47 harvested patients had an abnormal Allen’s. Conclusions Low PAVRO does not predict hand dysfunction after radial artery harvest, whereas lower ulnar augmentation may better identify patients at risk of grip strength decline postoperatively. Duplex ultrasonography provides objective flow metric data and should be prioritized in preoperative assessment.

BACKGROUND:Intraoperative transesophageal echocardiography (TEE) is used in approximately half of isolated coronary artery bypass grafting (CABG) procedures in the United States, yet its routine use remains unsupported by randomized evidence. OBJECTIVES:The objective of the study was to assess the feasibility and protocol adherence of routine vs selective intraoperative TEE strategies during isolated CABG surgery. METHODS:We conducted a pragmatic, randomized feasibility trial at 2 tertiary-care hospitals within a single health system. Adults undergoing isolated CABG for whom both strategies were clinically acceptable were randomized 1:1 to TEE-by-default (routine use) or TEE-on-demand (selective use). In the selective group, TEE was performed as clinically indicated. Primary feasibility outcomes included enrollment, successful randomization, and protocol adherence. Exploratory outcomes included perioperative clinical events, patient-centered recovery measures, and TEE-related adverse events. RESULTS:A total of 274 patients were screened and 72 were eligible. Of these, 46 (64%) consented, and 40 (56% of eligible; 87% of consented) were randomized following induction of anesthesia (20 per group). Protocol adherence was high (39/40; 98%) with 1 allocation error. In the TEE-on-demand arm, 3 of 20 patients (15%) underwent clinically triggered TEE. No deaths occurred within 90 days. Three serious adverse events were adjudicated as related to TEE exposure including 2 esophageal complications and 1 conversion to combined CABG and mitral valve replacement. CONCLUSIONS:In this pragmatic randomized feasibility trial, both TEE strategies were successfully implemented with high protocol adherence and preserved clinician and patient equipoise, supporting a multicenter randomized trial evaluating routine vs selective TEE during isolated CABG.

OBJECTIVE:As alternatives to conventional coronary artery bypass grafting (CABG), robot-assisted CABG (R-CABG) and percutaneous coronary intervention (PCI) offer less invasive treatments for coronary artery disease (CAD). However, data comparing outcomes of R-CABG versus PCI are limited. METHODS:Databases were systematically searched for studies comparing R-CABG versus PCI. Random-effects models were used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs), both overall and stratified by left main or multivessel (LM+MV) or isolated left anterior descending artery (LAD) disease. Kaplan-Meier curves were digitally extracted to reconstruct individual participant data (IPD), from which hazard ratios (HRs) were estimated for survival analyses. RESULTS:Six retrospective studies, including 1,896 patients (R-CABG: 894, 47.1%), were analyzed. The mean age was 63.8 ± 11.3 years, and 78.7% were male patients. Follow-up ranged from 2 to 8 years. Overall, R-CABG was associated with a lower odds of target vessel revascularization (TVR; OR = 0.50, 95% CI: 0.27 to 0.93, P = 0.03) and myocardial infarction (MI; OR = 0.44, 95% CI: 0.26 to 0.76, P < 0.01), with no significant difference in all-cause mortality. Among patients with LM+MV disease, R-CABG reduced TVR and MI. In LAD lesions, R-CABG significantly lowered the likelihood of MI (OR = 0.18, 95% CI: 0.04 to 0.71) as well as major adverse cardiovascular events (MACE; OR = 0.51, 95% CI: 0.28 to 0.93). Time-to-event analysis from reconstructed IPD demonstrated significantly improved freedom from reintervention (HR = 0.31, 95% CI: 0.16 to 0.60) and MACE (HR = 0.24, 95% CI: 0.15 to 0.60) with R-CABG, whereas no significant difference was found for all-cause mortality. CONCLUSIONS:R-CABG was associated with less TVR and MI compared with PCI in CAD patients, with no difference in all-cause mortality.

Objective: To compare elective interval thoracic endovascular aortic repair (TEVAR) with ongoing medical management (MM) within 90 days for uncomplicated type B aortic dissection (uTBAD). Methods: Medicare MedPar files from 2001 to 2020 were queried for patients with acute uTBAD who were discharged after index hospitalization without operative intervention. The exposure was elective interval TEVAR versus MM within the first 90 days. Outcomes were overall survival, aortic reintervention, and reintervention-free survival. Propensity score matching, Kaplan-Meier analysis and Fine-Gray regression landmarking at 90 days were used. Results: In total, 23,697 patients were discharged without surgical intervention after admission for acute uTBAD. Within 90 days from diagnosis, 22,857 patients underwent MM, 399 elective TEVAR, and 441 emergent/urgent TEVAR. Matching between MM and elective TEVAR resulted in a well-balanced nearly 27:1 match with 10,608 patients in the MM cohort and 399 in the elective TEVAR cohort. The mean age was 73.5 years, and 51% of patients were female. 90-day mortality was 10.4% for MM and 4.3% for elective TEVAR. Landmarking at 90 days, there was no associated difference in overall survival with 5-year mortality of ∼63%. Similarly, there was no associated difference in reintervention-free survival. The 5-year cumulative incidence of aortic reintervention for MM was 11% and for TEVAR was 14% (P = .04). Conclusions: Among Medicare patients with acute uTBAD, there was no associated difference in overall survival or reintervention free survival between ongoing MM and elective interval TEVAR within 90 days.

OBJECTIVES:As transcatheter aortic valve replacement (TAVR) expands to lower-risk populations, understanding contemporary patterns of complications requiring surgical intervention remains critical. This study examines the incidence, predictors, and outcomes of major TAVR complications. METHODS:The National Inpatient Sample (2016-2021) was queried to identify adult patients undergoing TAVR. Major complications were defined as surgical aortic valve replacement, coronary artery bypass grafting, aortic intervention, pericardial drainage, VA-ECMO, cardiac repair, or diagnosis of aortic dissection/rupture. Multivariable logistic regression identified predictors of complications and failure-to-rescue. RESULTS:Among 383 395 TAVRs, 4685 (1.2%) experienced major complications. Overall in-hospital mortality was 1.3%. Mortality was 26.0% in patients with major complications versus 1.0% without (P < .001). Stroke rates were also higher in patients with major complications (7.5% versus 1.8%, P < .001). Complications were associated with longer length of stay (8 vs 2 days) and higher hospital costs ($79,302 vs $45,469). Independent predictors of complications included age <65 (OR 2.27), bicuspid aortic valve (OR 1.79), thoracic aortic aneurysm (OR 1.49) and female sex (OR 1.24), while elective admission was protective (OR 0.51). Among patients with complications, VA-ECMO cannulation (OR 10.36), cardiac chamber repair (OR 3.14), and aortic dissection/rupture (OR 1.68) were strongest predictors of mortality. CONCLUSIONS:While the proportion of TAVR patients experiencing surgical emergencies has remained stable over time, the overall prevalence is increasing with the growth of TAVR, and these complications are associated with an in-hospital mortality rate of greater than 25%. Younger age, female sex, bicuspid valve, and thoracic aneurysm are associated with increased risk of major complications.

OBJECTIVES:The objective of this study was to compare perioperative and long-term outcomes of hemiarch versus zone 2 arch replacement for DeBakey type I acute aortic dissection. METHODS:From 2002 to 2023, 743 patients underwent surgical repair for DeBakey type I acute aortic dissection with either hemiarch (N = 605, 81.4%) or zone 2 arch replacement (N = 138, 18.6%). 4:1 propensity-score matching yielded a cohort of 437 hemiarch patients (76.1%) and 137 zone 2 patients (23.9%). Key outcomes included 30-day mortality, 10-year survival, and distal reintervention. RESULTS:In the matched cohort, 30-day mortality was 11.9% for hemiarch and 8.0% for zone 2 arch replacement (P = .198). On multivariable analysis, zone 2 arch replacement was not associated with increased risk of 30-day mortality. Ten-year survival was similar between groups, at 56.2% (50.6%-62.6%) in the hemiarch group and 59.8% (46.4%-77.1%) in the zone 2 group. Distal reintervention was more common after zone 2 arch replacement (46.7% vs 15.8%), though the majority of reinterventions in the zone 2 group were thoracic endovascular aortic repair procedures (95.3%). In contrast, over half (53.6%) of distal reinterventions after hemiarch repair were open procedures. CONCLUSIONS:Zone 2 arch replacement resulted in comparable early and late survival to hemiarch replacement. Although distal reinterventions were more common after zone 2 arch replacement, these were predominantly low-risk thoracic endovascular aortic repair procedures. In appropriately selected patients, zone 2 arch replacement may enable more complete aortic repair without added perioperative risk.

BACKGROUND:The choice between bioprosthetic or mechanical surgical aortic valve replacement (SAVR) for dialysis patients is debated. Rapid adoption of transcatheter aortic valve replacement (TAVR) complicates decision-making further. This study compared AVR prosthesis choices among dialysis patients. METHODS:Dialysis patients who underwent bioprosthetic AVR (bAVR), mechanical AVR (mAVR), and TAVR from 2009 to 2019 were queried from Medicare Provider Analysis and Review data. Two propensity score matches were performed: bAVR vs mAVR and SAVR (bAVR + mAVR) vs TAVR. Survival at 5 years was compared using restricted mean survival time (RMST). Secondary outcomes were compared using subhazard regression with death as a competing risk. RESULTS:Among 2590 patients who underwent mAVR, 4752 underwent bAVR and 7739 underwent TAVR; mean ages were 61.5, 66.6, and 73.2 years, respectively. Matching mAVR and bAVR yielded 2460 patients each. Survival was similar, with RMST of 2.67 years for mAVR and 2.60 years for bAVR (difference = -0.07, P = .170). For mAVR, gastrointestinal bleeding readmission was higher (32.7% vs 28.6%, P = .002), whereas reoperation was lower (3.6% vs. 5.8%, P < .001). Matching SAVR and TAVR yielded 2709 patients each. SAVR had worse early but improved 5-year survival, with RMST of 2.43 vs 2.18 years (difference = -0.25, P < .001). Readmissions for gastrointestinal bleeding (∼31%) and reoperation (∼3%) were similar. CONCLUSIONS:Dialysis patients undergoing SAVR and TAVR have poor survival, high bleeding risk, and low reoperation rate regardless of prosthesis choice. Our data suggest no difference in 5-year overall survival between bAVR and mAVR, whereas SAVR was associated with worse early but improved 5-year overall survival compared with TAVR.

BACKGROUND:Robotic-assisted aortic valve replacement (RAVR) has emerged as a novel minimally invasive approach to surgically manage aortic valve disease. CASE SUMMARY:A 74-year-old man presented with several months of worsening dyspnea and chest pain on exertion. Preoperative work-up identified severe aortic stenosis along with coronary artery disease. Despite being at low operative risk, the patient had a small aortic root, coronary disease not amenable to surgical revascularization, and wanted to avoid sternotomy. The decision was made to perform RAVR with percutaneous coronary intervention in a hybrid approach to manage his concomitant pathologies. DISCUSSION:We demonstrate the safety and feasibility of performing RAVR using a sutureless aortic valve prosthesis to optimize hemodynamics in a patient with a small aortic root. We also describe the combination of RAVR and percutaneous coronary intervention as part of a hybrid treatment paradigm to manage concomitant aortic stenosis and coronary artery disease.

Robotic-assisted, minimally invasive direct coronary artery bypass is a surgical technique that involves robotic-assisted harvest of the left internal mammary artery, small left-anterior thoracotomy and minimally invasive, off-pump, direct left internal mammary artery to left anterior descending artery anastomosis. It is indicated in the setting of proximal or diffuse single-vessel left anterior descending artery disease, chronic total occlusion of the left anterior descending artery or a hybrid approach to revascularization in combination with percutaneous treatment of other lesions. Benefits include avoidance of sternotomy and rapid recovery, particularly in medically complex patients, while achieving the survival benefit associated with a left internal mammary artery-left anterior descending artery anastomosis. Although there is an initial learning curve for surgeons, an understanding of positioning and exposure techniques can minimize early challenges. We present a step-by-step video tutorial of robotic-assisted, minimally invasive direct coronary artery bypass, including patient positioning, robotic port orientation, analgesic and local anaesthetic strategies, conduit harvest and anastomotic technique.

Aortic pseudoaneurysms, rare but potentially life-threatening complications following coronary artery bypass grafting (CABG), are ideally addressed with re-exploration and open repair. We present a 67-year-old female who had recently undergone a CABG and developed a large mediastinal pseudoaneurysm from the site of the proximal saphenous vein graft anastomosis but was at prohibitive risk for redo open surgery due to significant comorbidities. An application of current endovascular devices was required to treat this post-CABG complication. Thoracic endovascular aortic repair of the ascending aorta was effective in treating the aortic pseudoaneurysm CABG complication in this patient who was at prohibitive risk of redo open surgery.

Purpose:This article reviews techniques of supra-aortic anastomosis and presents the use of the novel Duett Vascular Graft System during a complex total arch repair. Description:The literature was reviewed for existing techniques and devices pioneered to facilitate anastomoses of the supra-aortic vessels during a total arch procedure. A case was then presented to showcase the utility of the Duett Vascular Graft System. Evaluation:Improving the efficiency of supra-aortic branch vessel anastomosis can reduce circulatory arrest time and the resulting cerebral, spinal, and distal organ ischemia. Therefore, various techniques and technologies have been developed for more expeditious revascularization. The Duett Vascular Graft System is one such device currently in clinical trial that facilitates supra-aortic vessel anastomosis during open aortic arch surgery. Conclusions:This case showcases the utility of the Duett Vascular Graft System. This novel device allows surgeons to more efficiently perform supra-aortic anastomoses, which can reduce cerebral ischemia and circulatory arrest.

Objective To compare the outcomes between bioprosthetic and mechanical prosthesis choice for aortic valve and mitral valve infective endocarditis (IE) in patients >65 years old. Methods Medicare Provider Analysis and Review files from 2011 to 2019 were queried for adult patients >65 years old with de novo IE who underwent isolated bioprosthetic aortic valve replacement (bAVR), mechanical aortic valve replacement (mAVR), bioprosthetic mitral valve replacement (bMVR), or mechanical mitral valve replacement (mMVR). Patients with preoperative ischemic or hemorrhagic stroke were excluded. Analyses were conducted separately for the aortic and mitral position: bAVR versus mAVR, and bMVR versus mMVR. Propensity score matching was used to account for measured confounders. The primary outcome was 5-year overall survival analyzed using restricted mean survival time; secondary outcomes were the 5-year cumulative incidences of valve reoperation, heart failure readmission, recurrent IE, bleeding, and ischemic stroke analyzed using Fine-Gray regression with death as a competing risk. Results Matching yielded 330 patients in each AVR group and 250 patients in each MVR group. Five-year survival favored bAVR over mAVR (66.1% vs 56.7%, RMST: 3.96 years vs 3.46 years, P = .001), whereas 5-year survival was similar for bMVR versus mMVR (53.1% vs 53.1%, RMST: 3.50 years vs 3.35 years, P = .451). There were no significant differences in the cumulative incidences of secondary outcomes. Conclusions This analysis of patients >65 years old with left-sided IE demonstrated that mechanical valves were associated with worse early mortality, no 5-year survival advantage over bioprosthetic valves, and provide no benefit in this population.

Objective: Valve selection in acute type A aortic dissection (ATAAD) requiring aortic root replacement is challenging given the clinical acuity, unknown patient preferences, risk of surgical bleeding, and limited life expectancy. We sought to identify long-term outcomes of mechanical versus bioprosthetic aortic root replacement in young patients with ATAAD. Methods: Retrospective review of our institution's database of ATAAD was conducted to identify patients aged 65 years and younger who underwent mechanical Bentall (mech-Bentall) or bioprosthetic Bentall (bio-Bentall) for ATAAD from 2002 to 2022. The primary end point was 10-year survival, which was compared in a propensity score-matched cohort and multivariable Cox proportional hazards model. A composite outcome of 10-year freedom from death, stroke, major bleeding, and valvular reintervention was assessed as a secondary end point. Results: Of 1114 patients who underwent ATAAD repair, there were 79 mech-Bentalls and 67 bio-Bentalls in patients aged 65 years or younger. Patients undergoing mech-Bentall were younger, and they were less likely to undergo an extended arch operation; there was no difference in gender, race, comorbidities, or malperfusion on presentation. In a propensity score-matched analysis, mech-Bentall patients demonstrated a nonsignificant increase in 10-year mortality (P = .058) and demonstrated higher rates of the composite end point (P = .026). In a Cox proportional hazards model, mech-Bentall (hazard ratio, 1.892; P = .023) was independently associated with 10-year composite end point occurrence. Conclusions: There is no survival advantage of mech-Bentall in ATAAD in young patients at 10 years, and it is associated with a significantly higher rate of morbid complications. When the aortic valve cannot be spared, bio-Bentall should be considered in ATAAD, even in young patients.

Total arterial, anaortic, off-pump coronary artery bypass grafting is seen by many as a complex, specialized operation; however, when broken down into its component parts, it can be approached as multiple reproducible techniques that all trainees should master. These components include skeletonized mammary harvest, construction of composite arterial grafts and off-pump cardiac surgery. In this video tutorial, we describe step-by-step approaches to each of these elements and demonstrate how these principles come together to facilitate an excellent surgical outcome for the patient: revascularization of all diseased coronary arteries with arterial grafts while avoiding arresting the heart or aortic manipulation.

Objective: To evaluate risk factors and clinical outcomes of patients who underwent elective aortic root replacement (ARR) and required unplanned intraoperative coronary artery bypass grafting (CABG). Methods: This is a multicenter, single-institution, retrospective study of all elective ARRs that occurred from 2014 to 2022. We compared baseline and intraoperative differences, as well as short-term outcomes, between patients who did (ARR-UC) and did not (ARR) require unplanned CABG (UC). Multivariate logistic regression identified predictors of UC and predictors of 30-day mortality. Kaplan-Meier curves were generated with log-rank test to compare long-term survival. Results: A total of 884 patients underwent elective ARR, of whom 30 (3.4%) required UC. Female sex was more common in the ARR-UC group (63.3% vs 19.8%, P < .001). Cardiopulmonary bypass time was longer in the ARR-UC group (259 vs 224, P < .001), and the Bentall procedure was more commonly used (93.3 vs 67.6%, P = .002). Thirty-day mortality was greater in the ARR-UC group (13.33% vs 1.64%, P < .001), as was the need for mechanical circulatory support, prolonged ventilation, new dialysis, and length of stay, with less frequent discharge to home. Multivariate analysis identified UC as an independent risk factor of 30-day mortality (odds ratio [OR], 10.4, P = .001). Female sex was strongly associated with the need for UC (OR, 6.46, P < .001); on subgroup analysis, non-dominant RCA was not (OR, 0.71, P = .614). Conclusions: The need for UC at the time of elective aortic root surgery significantly increases the incidence of major complications and 30-day mortality. Female sex is an important risk factor for UC, whereas nondominant RCA is not.

CASE SUMMARY:A 33-year-old patient at 20 weeks of gestation presented with a dilated aortic root and abdominal aorta, and a diagnosis of Loeys-Dietz syndrome was made. KEY QUESTIONS:What is the incidence of pregnancy-related aortic dissection in patients with heritable thoracic aortic disease (HTAD)? What are the key management principles for pregnant patients with HTAD? OUTCOME:A shared plan was made by a multidisciplinary team of maternal fetal medicine, cardio-obstetrics, and cardiothoracic surgery, consisting of imaging surveillance, blood pressure control, scheduled cesarean delivery, and future elective aortic surgery. After an uncomplicated delivery, the patient experienced an acute type A dissection requiring staged total aortic replacement, including aortic root and arch replacement, thoracoabdominal aortic replacement, and endovascular aortic repair. TAKE-HOME MESSAGES:Patients with HTAD are at an increased risk of pregnancy-related aortic dissection. Key management principles include multidisciplinary evaluation, imaging surveillance, blood pressure control, and delivery with cardiothoracic surgical backup.