Objective: We evaluated how event definitions, data-collection methods, and follow-up completeness influence reporting of long-term nonfatal complications after mechanical aortic valve replacement in local versus referral patients. Methods: We analyzed 558 patients undergoing primary mechanical aortic valve replacement from 2000 to 2023. Patients were stratified by residential distance (<50 miles, local vs >50 miles, referral) to assess completeness of follow-up. Outcomes included major bleeding, neurological thromboembolic events, and survival. Major bleeding was defined by International Society on Thrombosis and Hemostasis criteria or by restricted International Classification of Diseases codes. Events were captured by manual review and by International Classification of Diseases coding. Propensity score–matched local (n = 186) and referral groups (n = 372) were analyzed using Fine-Gray competing risk models for nonfatal outcomes and Kaplan–Meier analysis for survival. Results: Baseline and perioperative characteristics of propensity score–matched local and referral patients were comparable. Median clinical follow-up was longer in the less than 50-mile group (10.2 vs 4.1 years, P < .001). Local patients had higher crude event rates for major bleeding (40.9% vs 24.2%, P < .001) and neurological events (13.4% vs 4.0%, P < .001). These differences were mitigated but still statistically significant in time-dependent competing risk analysis. Rates varied with ascertainment method: International Classification of Diseases coding amplified differences compared with manual adjudication. Long-term survival did not differ significantly between groups (P = .44). Conclusions: Reporting late nonfatal events after aortic valve replacement varies with event definitions, data-collection methods, and follow-up completeness. Although mortality estimates remain robust, bleeding and stroke may be underestimated in referral patients. Competing risk analysis enables more accurate interpretation of late outcomes.

BACKGROUND:Caseous calcification of the mitral annulus (CCMA) fistulizing into the aortic root has not been described. CASE SUMMARY:A 66-year-old man with severe regurgitation from mitral valve prolapse presented with a calcified mass extending from the anterolateral trigone of the mitral valve to the anterolateral papillary muscle. Multimodality imaging revealed a pseudoaneurysm in the anterolateral trigone communicating with the aortic root without aortic valve dysfunction. A 3-dimensional (3D) printed model delineated anatomy and supported valve repair, fistula closure, and aortic valve preservation. DISCUSSION:This novel case of CCMA with pseudoaneurysm fistulizing into the aortic root demonstrated how multimodality imaging and 3D modeling facilitate valve-sparing repair. TAKE-HOME MESSAGES:Fistulization of CCMA into the aortic root is exceptionally rare. Multimodality imaging and 3D modeling enabled precise anatomic characterization, mitral valve repair, and closure of the fistulous tract. Advanced imaging can expand surgical options and support preservation of native valves in anatomically complex diseases.

Objective: To evaluate the safety and effectiveness of hybrid cerebral perfusion in open total/partial arch replacement. Methods: A retrospective analysis was performed of all adult patients (n = 366) undergoing open total/partial arch replacement from January 1993 through December 2024. Cerebral perfusion strategies included hybrid (retrograde followed by antegrade; n = 223, 60.9%), antegrade-only (n = 100, 27.4%), retrograde-only (n = 17, 5.0%), and deep hypothermic circulatory arrest alone without cerebral perfusion (n = 26, 7.1%). For comparison, patients were grouped as antegrade-only versus hybrid. Results: Over 30 years, total/partial arch replacement volume increased significantly (1993-2002: n = 16, 4.4%; 2003-2012: n = 90, 24.6%; 2013-2024: n = 260, 71.0%, P < .001), with most being reoperations (n = 202, 62.5%). Compared with antegrade-only, the hybrid group had a greater proportion of redo total/partial arch replacement (n = 149, 66.8% vs n = 53, 53.0%, P = .018) and frozen elephant trunk procedures (n = 109, 48.8% vs n = 20, 20.0%, P < .001) as well as longer cross-clamp and bypass times (both, P < .001). Although not statistically significant, stroke was nearly twice as frequent in the antegrade-only group (n = 6, 6.0% vs n = 8, 3.6%, P = .325). The operative mortality was greater in the antegrade-only group. Conclusions: Hybrid cerebral perfusion in total/partial arch replacement demonstrates a strong safety profile with excellent early outcomes, including in complex or redo cases.

Objective: To evaluate operative and midterm outcomes, including 1-, 3-, and 5-year survival, of transatrial transcatheter mitral valve replacement (TA-TMVR) with a balloon-expandable valve for severe mitral annular calcification (MAC). Methods: We retrospectively reviewed patients with severe MAC who underwent TA-TMVR from 2014 to 2024 using a balloon-expandable prosthesis. Results: Twenty-five patients (68% were female, mean age 75 years) had TA-TMVR for mitral valve disease (92% severe stenosis, 52% moderate-to-severe mitral regurgitation). Previous cardiac surgery was common (48%). Median Society of Thoracic Surgeons Predicted Risk of Operative Mortality was 9% (2%-26%). Most patients were New York Heart Association class III or IV (76%). Preoperative left ventricular ejection fraction was 66%. Concomitant procedures were performed in 68% of cases (aortic valve replacement in 11, septal myectomy in 6, other procedures in 9). A SAPIEN 3 valve was used in 24 patients; most were modified with a felt skirt to improve sealing. Anterior leaflet resection was performed in 24 patients. Operative mortality was 12%. Median length of stay was 14 days. Postoperative left ventricular ejection fraction was 64%, and the mean mitral valve gradient was 5 mm Hg. Paravalvular leak were observed in 6 patients; 3 underwent successful transcatheter closure. One of these patients required a percutaneous valve-in-valve for on-going hemolysis. One-, 3-, and 5-year survival was 68%, 59.5%, and 50.6%, respectively. Conclusions: TA-TMVR with a balloon-expandable valve is a feasible and durable option for high-risk patients with severe MAC and those requiring concomitant procedures, offering an alternative to conventional surgery in anatomically complex or otherwise-inoperable cases.

OBJECTIVES:This study examined the indications, frequency, and outcomes of cardiac surgery following transcatheter aortic valve replacement (TAVR) at a single institution. As TAVR volumes increase, understanding the nature and outcomes of subsequent cardiac operations is critical, particularly as the procedure expands to younger, lower-risk populations. METHODS:We analysed outcomes of 61 patients who underwent cardiac surgery after TAVR at our institution from August 2011 to September 2023, excluding periprocedural complications and staged procedures. Patients were stratified into 2 groups: those requiring surgical aortic valve replacement (SAVR) with or without concomitant procedures (n = 33) and those undergoing non-SAVR cardiac operations (n = 28). Data were collected from a prospectively maintained cardiovascular surgery database and electronic health records. Indications for surgery, operative characteristics, and outcomes were analysed, with survival assessed using Kaplan-Meier estimates. RESULTS:The median interval between TAVR and cardiac surgery was 19 months. Indications for SAVR included infective endocarditis (36%), non-structural valve deterioration (36%), structural valve deterioration (12%), and valve thrombosis (6%). Non-SAVR operations primarily addressed mitral valve disease (43%) and coronary artery disease (29%). Operative mortality was 6.6%, with no deaths in the endocarditis subgroup. Postoperative complications included prolonged mechanical ventilation (18%), new-onset renal failure (7%), and stroke (2%). Kaplan-Meier survival estimates were 83% at 1 year and 50% at 5 years. CONCLUSIONS:Although complex, cardiac operations in patients who have undergone TAVR can be performed with acceptable mortality rates. Structural valve deterioration, paravalvular leak, and endocarditis were the primary indications for SAVR, while mitral valve and coronary artery disease predominated in non-SAVR cases. These findings highlight the importance of considering nonaortic valve pathologies in TAVR planning, particularly as the procedure expands to younger, lower-risk populations.

Background We examined the potential influence of effective orifice area (EOA) and EOA index (EOAi) on survival between bioprosthetic and mechanical valves. Methods We analyzed 3265 patients aged 75 years or younger undergoing aortic valve replacement with or without coronary artery bypass grafting. EOA and EOAi were obtained from predischarge echocardiograms. Bootstrapped logistic regression and restricted cubic splines identified optimal survival cut points for EOA and EOAi. Multivariable Cox proportional hazards models were fitted, and adjusted Kaplan-Meier survival curves were generated using the identified EOA cut points. Results The mechanical aortic valve replacement group was younger (age 60 vs 69 years; P < .001). For mechanical and bioprosthetic aortic valve replacement groups, respectively, the median EOA was (2.0 cm2; range, 1.6-2.4 vs 2.1 cm2; range, 1.7-2.6 cm2; P < .001) and EOA index was (1.0 cm2/m2; range, 0.8-1.2 cm2/m2 vs 1.1 cm2/m2, range, 0.9-1.3 cm2/m2; P < .001) In patients with EOA ≥2 cm2, long-term adjusted risk of mortality was higher in the bioprosthesis group compared with the mechanical group (hazard ratio, 1.33; P = .010). However, no significant difference was observed for those with EOA <2 cm2 (hazard ratio, 1.01; 95% CI, 0.83-1.23; P = .932). Similarly, for EOA index ≥1.08 cm2/m2, the bioprosthesis group was associated with higher risk of long-term mortality (hazard ratio, 1.29; 95% CI, 1.01-1.64, P = .040), whereas no significant association was found for those with an EOA index <1.08 cm2/m2 (hazard ratio, 1.05; P = .621). Conclusions In this cohort, there was a survival advantage of mechanical valves over bioprostheses in larger valve sizes but not in patients with smaller EOA metrics.

Left ventricular outflow tract (LVOT) obstruction is mostly caused by hypertrophic obstructive cardiomyopathy and subaortic stenosis. Rarely, malignancy can lead to dynamic LVOT obstruction and has only been sporadically documented. We present the first case of dynamic and/or nearly fixed LVOT obstruction caused by a cardiac myxoid spindle cell sarcoma.

OBJECTIVE:To describe the clinical characteristics of patients with obstructive hypertrophic cardiomyopathy and less severe hypertrophy (septal thickness <15 mm) undergoing transaortic septal myectomy, explore possible mechanisms of obstruction, and assess operative outcomes. METHODS:We identified 51 consecutive patients with septal thicknesses <15 mm who underwent septal myectomy for obstructive hypertrophic cardiomyopathy between 2000 and 2021. They were matched in a 1:2 ratio with patients with obstructive hypertrophic cardiomyopathy with septal thickness ≥15 mm undergoing myectomy. RESULTS:After propensity matching, the preoperative left ventricular outflow tract (LVOT) gradient and severity of mitral valve regurgitation were similar in the 2 groups, but patients with less hypertrophy were more likely to have latent obstruction (55% vs 30%; P = .004). Both propensity score-matched groups had similar mitral valve anterior leaflet lengths (27 mm in both; P = .4). Patients with lesser hypertrophy had more acute angulation between the septum and the LVOT tract (118° vs 130°; P < .001). There was no significant difference in operative outcomes (bypass time median, 31 vs 34 minutes; P = .4), crossclamp time was 25 minutes in both; (P = .5), nor postoperative complications, including iatrogenic ventricular septal defect (1 [2%] vs 0 [0%]; P = .3). LVOT gradient before discharge was similar in both groups (median gradient, 0 mm Hg in both; P = .1). No patients died during their hospital stay. CONCLUSIONS:Severe LVOT obstruction in patients with hypertrophic cardiomyopathy can occur in the absence of significant septal hypertrophy, particularly in women with acute LVOT angulation. Extended septal myectomy can be performed safely in these patients, with favorable outcomes, and mitral valve replacement is not necessary for most patients.

OBJECTIVE:In patients with obstructive hypertrophic cardiomyopathy and degenerative mitral regurgitation, some advocate valve replacement because it addresses both valve disease and outflow tract obstruction. To avoid late prosthesis-related complications, we have favored septal myectomy and concomitant mitral valve repair, and the present study assesses the outcomes of this approach. METHODS:Among 3029 patients with obstructive hypertrophic cardiomyopathy undergoing septal myectomy, 120 received concomitant mitral valve repair for leaflet prolapse. Patients were matched by propensity score to those undergoing mitral valve repair for isolated degenerative mitral regurgitation. RESULTS:Patients' median age was 63.7 years, and 35.6% were female. Preoperatively, patients with obstructive hypertrophic cardiomyopathy were less likely to have grade 2+ or greater mitral regurgitation (87.6% vs 100%, P < .001). Patients with obstructive hypertrophic cardiomyopathy more often required leaflet plication or Alfieri sutures, whereas those with isolated degenerative mitral regurgitation were more likely to undergo leaflet resections and artificial neochordae placement. Mitral annuloplasty was performed less frequently in patients with obstructive hypertrophic cardiomyopathy (60.0% vs 99.2%, P < .001). Early morbidity and mortality were comparable, with 1 (0.8%) death in each group. There were no significant differences in late survival (10 years, 79% for obstructive hypertrophic cardiomyopathy vs 82% for isolated degenerative mitral regurgitation, P = .85). Recurrence of severe mitral regurgitation at 10 years was similar between groups (10.2% for obstructive hypertrophic cardiomyopathy vs 6.5% isolated degenerative mitral regurgitation, P = .61), as was the rate of mitral valve reoperation (5.5% vs 2.7%, P = .79). CONCLUSIONS:Mitral valve repair for concomitant degenerative mitral regurgitation in patients with obstructive hypertrophic cardiomyopathy is feasible, safe, and durable, with similar survival and reoperation rates to those of patients with isolated degenerative mitral regurgitation.

BACKGROUND:The Cox-Maze procedure treats atrial fibrillation (AF) through surgical lesion sets designed to isolate pulmonary veins (PVs) and interrupt atrial reentrant circuits. OBJECTIVE:This study aimed to characterize mechanisms of recurrent atrial arrhythmias after Maze procedures using electroanatomic mapping. METHODS:We retrospectively analyzed 86 patients who underwent Maze procedures from 2008 to 2023 and later required endocardial catheter ablation for recurrent AF or atrial flutter (AFl). Electroanatomic mapping assessed lesion integrity, arrhythmia patterns, and ablation outcomes. RESULTS:After the 3-month postoperative blanking period, 31.8% of patients had both AF and AFl recurrence, 33.7% had AF only, and 33.7% had AFl only. PV reconnection occurred in 78.3% of patients who initially underwent PV isolation. Reconnection rates were significantly lower with cut-and-sew Maze III (5%) than cryothermal (67%; odds ratio 0.07; P < .0001) and radiofrequency ablations (56%; odds ratio 0.11; P < .0001). Macroreentrant flutter was inducible in 77.9% of patients during catheter mapping, frequently associated with incomplete linear lesions. Surgical left atrial appendage-to-mitral annulus lesions were associated with significantly higher overall flutter (100% vs 71.2%; P = .005), left AFl (80% vs 36.4%; P = .001), and atypical flutter (90% vs 50%; P = .002). Mitral valve repair correlated with increased overall flutter (92.6% vs 71.2%; P = .028), cavotricuspid isthmus flutter (55.6% vs 30.5%; P = .033), and atypical flutter (81.5% vs 49.2%; P = .005). CONCLUSION:Recurrent arrhythmias after Maze primarily result from PV reconnection and incomplete linear lesions. Cut-and-sew lesions demonstrate greater durability than thermal ablation. Meticulous lesion formation and intraoperative verification may reduce recurrence and improve outcomes.

Objective:To evaluate the impact of pulmonary hypertension and right ventricular dysfunction on outcomes of isolated tricuspid valve surgery. Methods:From 2004 to 2022, 298 patients (age 71.0 ± years, 59.4% female) underwent isolated tricuspid valve surgery. Pulmonary hypertension was defined as right ventricular systolic pressure ≥50 mm Hg, and right ventricular dysfunction as right ventricular fractional area change <32% on preoperative transthoracic echocardiogram. Patients were stratified into 4 groups: group I: No pulmonary hypertension or right ventricular dysfunction (n = 199), group II: pulmonary hypertension without right ventricular dysfunction (n = 45), group III: right ventricular dysfunction without pulmonary hypertension (n = 43), and group IV: pulmonary hypertension and right ventricular dysfunction (n = 11). Uni- and multivariable analyses were performed to evaluate association of pulmonary hypertension and right ventricular function with outcomes. Results:Tricuspid valve replacement was performed in 218 (73.2%) and repair in 80 (26.8%) patients. Operative mortality was 4.7%, similar for reoperations (5.2%) and primary procedures (4.5%) (P = .907). Median follow-up was 5.4 (interquartile range, 2.3-12.5) years, survival was 74.4%, 48.4%, 39.8%, and 67.3% in groups I-IV, respectively (P < .0001). Multivariable analysis identified pulmonary hypertension (hazard ratio, 2.9; 1.83-4.62, P < .001) and right ventricular dysfunction (hazard ratio, 2.83; 1.76-4.56, P < .001) as independent predictors of greater long-term all-cause mortality, in addition to older age (P < .001) and severe chronic lung disease (P < .001). Conclusions:Among patients who underwent isolated tricuspid valve surgery, presence of pulmonary hypertension or right ventricular dysfunction at baseline is linked to greater long-term mortality.