Importance As transcatheter aortic valve replacement (TAVR) is considered for younger and lower-risk populations, the durability of bioprosthetic valves is increasingly important. Limited data exist on long-term (7 years and beyond) valve durability. Objective To report 7-year valve durability outcomes for low-risk patients with symptomatic severe aortic stenosis treated with TAVR vs surgery. Design, Setting, and Participants Between March 2016 and October 2017, a total of 1000 patients were enrolled at 71 centers in the US and Canada and randomized to undergo TAVR vs surgery. The patient population for the present analysis consisted of all patients who underwent valve implantation (495 with TAVR and 453 with surgery). The last 7-year follow-up occurred in March 2025. Interventions Patients were randomized to balloon-expandable TAVR with the SAPIEN 3 valve or surgery with any commercially available valve. Main Outcomes and Measures The main outcomes of this analysis were stage 2 or 3 bioprosthetic valve dysfunction (BVD) related to structural valve deterioration (SVD), thrombosis, or endocarditis; all-cause bioprosthetic valve failure (BVF); BVF related to SVD; and aortic valve reintervention at 7 years. Analyses are presented as cumulative incidence rates with death as a competing risk. Results The mean (SD) age of the study population was 73.5 (6.0) years, and 657 participants (69.3%) were male. Of 671 patients who were still alive and enrolled in the study at 7-year follow-up, 537 (80.0%) were available for echocardiographic analysis. Cumulative incidence rates of stage 2 or 3 SVD-related BVD (7.3% vs 7.6%; hazard ratio [HR], 0.96; 95% CI, 0.59-1.57; P = .88), all-cause BVF (6.9% vs 7.5%; HR, 0.91; 95% CI, 0.55-1.49; P = .69), SVD-related BVF (3.9% vs 5.3%; HR, 0.72; 95% CI, 0.39-1.36; P = .31), and valve reintervention (6.0% vs 5.5%; HR, 1.09; 95% CI, 0.62-1.90; P = .77) were low and similar for TAVR and surgery, respectively. Stage 2 or 3 thrombosis-related BVD (subclinical and clinical) occurred more frequently with TAVR (5.2% vs 0.9%; HR, 5.52; 95% CI, 1.92-15.85; P < .001), although most events occurred within 3 years and few progressed to BVF. Rates of stage 2 or 3 endocarditis-related BVD were also low and similar (0.4% in the TAVR group vs 0.5% in the surgery group; HR, 0.85; 95% CI, 0.12-6.07; P = .87). The proportion of patients alive and free of all-cause BVF was 73.4% (331/451) with TAVR vs 74.8% (288/385) with surgery ( P = .69). Conclusions and Relevance In this ad hoc analysis of a randomized clinical trial among low-risk patients with symptomatic severe aortic stenosis randomized to TAVR or surgery, both TAVR and surgery demonstrated comparable and sustained valve durability, with low and similar rates of SVD, all-cause BVF, and reintervention through 7 years. These findings may inform discussions of valve replacement strategies. Trial Registration ClinicalTrials.gov Identifier: NCT02675114

Coronary obstruction is a rare but life-threatening complication following transcatheter aortic valve replacement (TAVR). Comparative analysis between snorkel stenting and BASILICA (Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction) remain limited. We analyzed 122 patients from the COBRA registry, including 68 who underwent BASILICA and 54 who received snorkel stents. In-hospital survival was numerically higher in the BASILICA group compared to the snorkel stent group (97% vs. 89%). BASILICA was also associated with lower rates of life-threatening bleeding (0.0% vs. 10%) and major vascular complications (1.5% vs. 12%). In patients at risk, a preemptive BASILICA strategy may offer an attractive approach for primary prevention of coronary obstruction in patients undergoing TAVR.

BACKGROUND:Neuroprotection during aortic arch surgery often involves hypothermia and the use of adjunctive cerebral perfusion. While antegrade cerebral perfusion (ACP) is favored for extended hypothermic circulatory arrest (HCA), debate continues regarding the optimal cerebral protection strategy during shorter durations of circulatory arrest. This study evaluates the association between cerebral perfusion strategies and stroke risk among patients undergoing aortic arch surgery with an HCA time <30 minutes. METHODS:Registry data from 1079 patients across 42 centers who underwent elective aortic surgery with HCA between 2018 and 2024 were analyzed. Patients with aortic dissection, HCA duration >30 minutes, or receiving both ACP and retrograde cerebral perfusion (RCP) were excluded. Cerebral perfusion strategies were categorized as no cerebral perfusion (NCP), RCP, or ACP. Preoperative, intraoperative, and postoperative variables were compared across cerebral perfusion strategies. Multivariable logistic regression was used to assess the associations between perfusion strategy and postoperative stroke, adjusting for age, sex, race, prior stroke, chronic lung disease, lowest HCA temperature, cardiopulmonary bypass (CPB) time, and duration of circulatory arrest. RESULTS:ACP was the most common strategy (n = 560; 51.9%), followed by RCP (n = 264; 24.5%) and NCP (n = 255; 23.6%). Baseline characteristics were similar across cerebral perfusion strategies, although chronic lung disease was more frequent among ACP patients. The median HCA temperature was 19.4 °C (interquartile range [IQR], 18.0 °C-24.4 °C) in the NCP group, 25.8 °C (IQR, 22.9 °C-27.7 °C) in the ACP group, and 21.6 °C (IQR, 18.9 °C-23.5 °C) in the RCP group (P < .01). In the 3 groups, the median HCA time was 14 (IQR, 10-20) minutes, 14 (IQR, 9-20) minutes, and 16 (IQR, 13-19) minutes, and median CPB time was 201 (IQR, 158-250) minutes, 154 (IQR, 115-207) minutes, and 172 (IQR, 132-214) minutes, respectively (P < .01). Stroke rates were lowest in the RCP group, with an 86.5% reduction in the adjusted odds of stroke compared to NCP (adjusted odds ratio, 0.135, 95% confidence interval, 0.023-0.783; P = .03). There was a nonsignificant protective effect associated with ACP. CONCLUSIONS:In this large, multicenter cohort of patients undergoing elective aortic arch surgery with short HCA times, RCP was associated with a significantly lower risk of postoperative stroke compared to NCP. Physician-led quality improvement collaboratives may provide an effective mechanism for advancing performance related to cerebral perfusion strategies and mitigation of stroke in the setting of elective aortic arch surgery with short circulatory arrest.

BACKGROUND:Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is being performed frequently for patients with bioprosthetic aortic valve (AV) degeneration. There is little guidance on appropriate antithrombotic selection after ViV TAVR. We aimed to analyze the impact of different antithrombotic strategies on AV hemodynamics and clinical outcomes following ViV TAVR. METHODS:Consecutive patients who underwent ViV TAVR at our center from January 1, 2019, to June 30, 2023, were included. Patients were divided into antiplatelet plus anticoagulant (AP + AC) or antiplatelet (AP) only groups based on the therapies prescribed on discharge. AV hemodynamics at discharge, 1 month, and 1 year, along with 1-year clinical outcomes, were compared between AP + AC and AP groups. RESULTS:This study included 104 patients with 74 patients (71.2%) in the AP + AC group and 30 patients (28.8%) in the AP group. Atrial fibrillation history (p = 0.003) was associated with AP + AC whereas GI bleeding history (p = 0.01) was associated with AP alone. There was no significant difference in antithrombotic therapy selection by TAVR type, but patients without a pre-existing indication for AC were more often discharged on AP + AC after receiving smaller diameter Sapien valves (p = 0.036). Additionally, patients were discharged on AP + AC more often if they required leaflet modification during TAVR (p = 0.043). There were no significant differences in AV gradients or clinical outcomes between antithrombotic strategies throughout follow-up. CONCLUSIONS:Anticoagulation was used more often than AP alone following ViV TAVR, but there were no significant differences in AV hemodynamics by echocardiography or clinical outcomes between antithrombotic groups through 1 year of follow-up.

Development of functional tricuspid regurgitation (TR) because of chronic mitral disease and subsequent heart failure is common. However, the effect of TR on clinical outcomes after transcatheter mitral valve replacement (TMVR) remains unclear. We aimed to evaluate the impact of baseline TR on outcomes after TMVR. This was a single-center, retrospective analysis of patients who received valve-in-valve or valve-in-ring TMVR between 2012 and 2022. Patients were categorized into none/mild TR and moderate/severe TR based on baseline echocardiography. The primary outcome was 3 years all-cause death and the secondary outcomes were in-hospital events. Of the 135 patients who underwent TMVR, 64 (47%) exhibited none/mild TR at baseline, whereas 71 (53%) demonstrated moderate/severe TR. There were no significant differences in in-hospital events between the groups. At 3 years, the moderate/severe TR group exhibited a significantly increased risk of all-cause death (adjusted hazard ratio 3.37, 95% confidence interval 1.35 to 8.41, p = 0.009). When patients with baseline moderate/severe TR were stratified by echocardiography at 30 days into improved (36%) and nonimproved (64%) TR groups, although limited by small sample size, there was no significant difference in 3-year all-cause mortality (p = 0.48). In conclusion, this study investigating the impact of baseline TR on clinical outcomes revealed that moderate/severe TR is prevalent in those who underwent TMVR and is an independent predictor of 3-year all-cause mortality. Earlier mitral valve intervention before the development of significant TR may play a pivotal role in improving outcomes after TMVR. (c) 2024 Elsevier Inc. All rights reserved. (Am J Cardiol 2024;220:84 -91)

BACKGROUND:Left ventricular outflow tract (LVOT) obstruction is a common, often fatal complication of transcatheter mitral valve replacement (TMVR). Laceration of the anterior mitral leaflet to prevent outflow obstruction (LAMPOON) was safe and effective at preventing LVOT obstruction at 30 days in the National Heart, Lung, and Blood Institute LAMPOON trial. OBJECTIVES:The authors report the 5-year outcomes of intentional anterior mitral leaflet laceration before SAPIEN 3 TMVR, in patients at risk of LVOT obstruction. METHODS:The National Heart, Lung, and Blood Institute LAMPOON trial was a prospective, multicenter, single-arm safety and feasibility study of LAMPOON and transseptal SAPIEN 3 TMVR in annuloplasty rings (valve-in-ring) or native mitral annular calcification (MAC) (valve-in-MAC). All subjects had high predicted risk for LVOT obstruction. Subjects were not excluded for excessive frailty or comorbidity. The primary endpoints were technical success and safety at 30 days. Secondary clinical and echocardiographic endpoints were assessed at 1 year and clinical follow-up at 5 years. RESULTS:Thirty subjects were enrolled between June 2017 and June 2018, equally between the valve-in-MAC and valve-in-ring arms. At 30 days, LAMPOON was successful in all 30 subjects, with no strokes, 1 (3%) death, and 1 (3%) moderate LVOT obstruction. Eighteen (65%) survived to 1 year, and 7 (25%) survived to 5 years. Six (20%) were hospitalized for heart failure in the first year. From baseline to 1 year, there was a 24-point improvement in Kansas City Cardiomyopathy Questionnaire score and a 60-m improvement in 6-minute walk distance. There was no significant change in N-terminal pro-brain natriuretic peptide. At 1 year, LVOT gradients remained low. CONCLUSIONS:LAMPOON enabled TMVR despite the risk for LVOT obstruction. There were no long-term complications associated with LAMPOON. The selection of inoperable patients limited assessment of long-term survival following TMVR. (NHLBI DIR LAMPOON Study: Intentional Laceration of the Anterior Mitral Leaflet to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter Mitral Valve Implantation; NCT03015194).

BACKGROUND:Atrial fibrillation (AF) occurs commonly after cardiac surgery and is associated with multiple adverse outcomes. Older randomized trials suggested that perioperative β- blockade reduced postoperative AF, and The Society of Thoracic Surgeons (STS) coronary artery bypass grafting (CABG) composite measure includes β-blocker administration preoperatively within 24 hours of surgery and at discharge. However, some more recent studies suggest preoperative β-blockade has limited value and question its continuation as an STS quality measure. METHODS:In 2022, an STS Preoperative Beta Blocker Working Group was formed with representatives from the STS and the Society of Cardiovascular Anesthesiologists. Published randomized trials, observational studies, societal guidelines, and the current state of available data from the STS Adult Cardiac Surgery Database (ACSD) were reviewed. RESULTS:Review of existing studies reveals substantial heterogeneity or insufficient detail regarding specific β-blockers used, timing of initiation, management of patients on chronic β-blockade, and whether other proarrhythmic or antiarrhythmic drugs were used concurrently. Further, β-blocker data currently collected in the STS ACSD lack sufficient granularity. CONCLUSIONS:Because a new randomized trial seems unlikely, the Working Group believes that more granular data on real-world practice would facilitate assessment of the value of preoperative β-blockade in the current era, development of best practice recommendations, and evaluation of their continued appropriateness as an STS quality metric. STS ACSD participants have been invited to participate in a voluntary survey whose additional data, when linked to STS ACSD records, will better delineate contemporary β-blocker practice and outcomes.

BACKGROUND:Left ventricular outflow tract (LVOT) obstruction is a source of morbidity in hypertrophic cardiomyopathy (HCM) and a life-threatening complication of transcatheter mitral valve replacement (TMVR) and transcatheter aortic valve replacement (TAVR). Available surgical and transcatheter approaches are limited by high surgical risk, unsuitable septal perforators, and heart block requiring permanent pacemakers. OBJECTIVES:The authors report the initial experience of a novel transcatheter electrosurgical procedure developed to mimic surgical myotomy. METHODS:We used septal scoring along midline endocardium (SESAME) to treat patients, on a compassionate basis, with symptomatic LVOT obstruction or to create space to facilitate TMVR or TAVR. RESULTS:In this single-center retrospective study between 2021 and 2023, 76 patients underwent SESAME. In total, 11 (14%) had classic HCM, and the remainder underwent SESAME to facilitate TMVR or TAVR. All had technically successful SESAME myocardial laceration. Measures to predict post-TMVR LVOT significantly improved (neo-LVOT 42 mm2 [Q1-Q3: 7-117 mm2] to 170 mm2 [Q1-Q3: 95-265 mm2]; P < 0.001; skirt-neo-LVOT 169 mm2 [Q1-Q3: 153-193 mm2] to 214 mm2 [Q1-Q3: 180-262 mm2]; P < 0.001). Among patients with HCM, SESAME significantly decreased invasive LVOT gradients (resting: 54 mm Hg [Q1-Q3: 40-70 mm Hg] to 29 mm Hg [Q1-Q3: 12-36 mm Hg]; P = 0.023; provoked 146 mm Hg [Q1-Q3: 100-180 mm Hg] to 85 mm Hg [Q1-Q3: 40-120 mm Hg]; P = 0.076). A total of 74 (97.4%) survived the procedure. Five experienced 3 of 76 (3.9%) iatrogenic ventricular septal defects that did not require repair and 3 of 76 (3.9%) ventricular free wall perforations. Neither occurred in patients treated for HCM. Permanent pacemakers were required in 4 of 76 (5.3%), including 2 after concomitant TAVR. Lacerations were stable and did not propagate after SESAME (remaining septum: 5.9 ± 3.3 mm to 6.1 ± 3.2 mm; P = 0.8). CONCLUSIONS:With further experience, SESAME may benefit patients requiring septal reduction therapy for obstructive hypertrophic cardiomyopathy as well as those with LVOT obstruction after heart valve replacement, and/or can help facilitate transcatheter valve implantation.

Objective: Professional standards recommend stopping cardiotomy suction termination of cardiopulmonary bypass before protamine administration based perceived safety concerns. This study evaluated a multidisciplinary collaborative quality-improvement intervention promoting this agreed-upon cardiotomy suction practice during coronary artery bypass grafting (CABG). Methods: A statewide intervention (eg, unblinded surgeon and perfusionist back, evidence-based lectures, evaluating barriers to change) involved 32 centers participating in the PERForm (ie, Perfusion Measures and Outcomes) Registry standardize cardiotomy suction practices at cardiopulmonary bypass termination during CABG. Four non-Michigan registry participating centers were not exposed to collaborative learning. Cardiotomy suction practice was defined fi ned as the absence of or stopping cardiotomy suction before protamine administration. The practice changes attributed to the intervention, including Michigan and non-Michigan parisons, were evaluated with the change of time effect modeled using splines. Multivariable regression was used to evaluate the intervention's ' s associated impact (eg, mortality, reoperation, transfusion). Results: Among 10,394 patients undergoing CABG at Michigan centers, 80.7% achieved agreed-upon cardiotomy suction practices. The Michigan centers nonsignificant fi cant changes in agreed-upon cardiotomy suction practices during preintervention period (P P 1 / 4 .24), with significant increased monthly change in tice thereafter, absent adjusted morbidity and mortality increases. The Michigan centers achieved a significantly fi cantly greater adjusted monthly improvement agreed-upon practices relative to non-Michigan centers within 7 months the intervention (adjusted odds ratio for change of trends: 2.53, P < .001). Conclusions: This initiative demonstrates the effectiveness of multidisciplinary collaborative quality improvement in advancing agreed-upon cardiotomy suction practices without negatively impacting clinical outcomes. (JTCVS 2024;17:121-44)

Background:Transcatheter aortic valve replacement (TAVR) explantation is currently the fastest-growing cardiac surgery procedure. Issues surrounding TAVR explantation and subsequent surgical aortic valve replacement (SAVR), specifically aortic root surgery, merit further investigation. Methods:A retrospective review of an institutional database identified cases of SAVR after TAVR, with or without concomitant aortic root operations, performed between January 1, 2014, and July 1, 2023, identifying 26 patients. Conventional statistical methods were used to compare groups. Results:The mean Society of Thoracic Surgeons predicted risk of mortality for aortic valve replacement was 11.1 ± 6.0% in our cohort. Eight of 26 patients (30.8%) had undergone prior cardiac surgery. Concomitant aortic root enlargement or replacement was required in 12 of the 26 patients (46.2%). The time from TAVR to removal was longer for those requiring root operations compared to those who did not (mean, 783 ± 908 days vs 492 ± 486 days; P = .046). There was a trend toward more frequent infective endocarditis in patients requiring root operations (46.2% [n = 5/12] vs 21.4% [n = 3/14]; P = .155). The 30-day mortality was 19.2% (n = 5/26), with an observed-to-expected ratio of 1.72. Mortality was not significantly different between the 2 groups. Conclusions:TAVR explant remains a high-risk procedure, although adding aortic root enlargement/replacement does not appear to amplify the short-term mortality risk when performed at an experienced institution. These results are important when considering lifetime management of aortic stenosis, particularly in low-risk patients likely to require multiple interventions.

BACKGROUND:The Perfusion Measures and Outcomes (PERForm) registry was established in 2010 to advance cardiopulmonary bypass (CPB) practices and outcomes. The registry is maintained through the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative and is the official registry of the American Society of Extracorporeal Technology.METHODS:This first annual PERForm registry report summarizes patient characteristics as well as CPB-related practice patterns in adult (≥18 years of age) patients between 2019 and 2022 from 42 participating hospitals. Data from PERForm are probabilistically matched to institutional surgical registry data. Trends in myocardial protection, glucose, anticoagulation, temperature, anemia (hematocrit), and fluid management are summarized. Additionally, trends in equipment (hardware/disposables) utilization and employed patient safety practices are reported.RESULTS:A total of 40,777 adult patients undergoing CPB were matched to institutional surgical registry data from 42 hospitals. Among these patients, 54.9% underwent a CABG procedure, 71.6% were male, and the median (IQR) age was 66.0 [58.0, 73.0] years. Overall, 33.1% of the CPB procedures utilized a roller pump for the arterial pump device, and a perfusion checklist was employed 99.6% of the time. The use of conventional ultrafiltration decreased over the study period (2019 vs. 2022; 27.1% vs. 24.9%) while the median (IQR) last hematocrit on CPB has remained stable [27.0 (24.0, 30.0) vs. 27.0 (24.0, 30.0)]. Pump sucker termination before protamine administration increased over the study period: (54.8% vs. 75.9%).CONCLUSION:Few robust clinical registries exist to collect data regarding the practice of CPB. Although data submitted to the PERForm registry demonstrate overall compliance with published perfusion evidence-based guidelines, noted opportunities to advance patient safety and outcomes remain.

BackgroundThe advent of transcatheter aortic valve replacement (TAVR) has directly impacted the lifelong management of patients with aortic valve disease. The U.S. Food and Drug Administration has approved TAVR for all surgical risk: prohibitive (2011), high (2012), intermediate (2016), and low (2019). Since then, TAVR volumes are increasing and surgical aortic valve replacements (SAVR) are decreasing. This study sought to evaluate trends in isolated SAVR in the pre- and post-TAVR eras.MethodsFrom January 2000 to June 2020, 3,861 isolated SAVRs were performed at a single academic quaternary care institution which participated in the early trials of TAVR beginning in 2007. A formal structural heart center was established in 2012 when TAVR became commercially available. Patients were divided into the pre-TAVR era (2000–2011, n = 2,426) and post-TAVR era (2012–2020, n = 1,435). Data from the institutional Society of Thoracic Surgeons National Database was analyzed.ResultsThe median age was 66 years, similar between groups. The post-TAVR group had a statistically higher rate of diabetes, hypertension, dyslipidemia, heart failure, more reoperative SAVR, and lower STS Predicted Risk of Mortality (PROM) (2.0% vs. 2.5%, p < 0.0001). There were more urgent/emergent/salvage SAVRs (38% vs. 24%) and fewer elective SAVRs (63% vs. 76%), (p < 0.0001) in the post-TAVR group. More bioprosthetic valves were implanted in the post-TAVR group (85% vs. 74%, p < 0.0001). Larger aortic valves were implanted (25 vs. 23 mm, p < 0.0001) and more annular enlargements were performed (5.9% vs. 1.6%, p < 0.0001) in the post-TAVR era. Postoperatively, the post-TAVR group had less blood product transfusion (49% vs. 58%, p < 0.0001), renal failure (1.4% vs. 4.3%, p < 0.0001), pneumonia (2.3% vs. 3.8%, p = 0.01), shorter lengths of stay, and lower in-hospital mortality (1.5% vs. 3.3%, p = 0.0007).ConclusionThe approval of TAVR changed the landscape of aortic valve disease management. At a quaternary academic cardiac surgery center with a well-established structural heart program, patients undergoing isolated SAVR in the post-TAVR era had lower STS PROM, more implantation of bioprosthetic valves, utilization of larger valves, annular enlargement, and lower in-hospital mortality. Isolated SAVR continues to be performed in the TAVR era with excellent outcomes. SAVR remains an essential tool in the lifetime management of aortic valve disease.

Background: Stroke is a known complication of cardiac surgery. The objective of this study was to implement a systemwide strategy to reduce perioperative stroke after isolated coronary artery bypass graft (CABG) surgery utilizing best practices from cardiothoracic surgery and neurology expertise. Methods: A prospective, quality improvement study of all isolated CABG patients at three hospitals within a multicenter academic healthcare system, in a large metropolitan area, was completed from January 1, 2021 to June 30, 2022. Utilizing Lean methodology, a multidisciplinary team of cardiothoracic surgeons, neurologists, anesthesiologists, certified stroke nurses, and process improvement specialists conducted a gap analysis to identify interventions to decrease the observed to expected (O/E) ratio of risk-adjusted perioperative strokes. The team developed a pre-operative evaluation process for patients with a history of stroke, formalized the utilization of intra-operative epiaortic ultrasound, and deployed education on BE-FAST symptoms and the purpose of stroke alerts to providers, nurses, and ancillary staff caring for the patient population. Results: During the study period, 1175 patients underwent isolated CABG. Risk adjusted perioperative stroke rates in the first 6 months of 2021 compared to 2022 declined from an O/E ratio of 1.32 to 0.78. Among patients with new post-operative stroke symptoms, the time frame from last known well to symptom recognition decreased from 704 to 486 minutes. Following the implementation of the protocol, one site saw the utilization of inpatient stroke alerts after CABG increase from 81.3% to 100% for patients with new BE-FAST symptoms. Conclusion: Multidisciplinary implementation of best practices was associated with lower risk adjusted perioperative stroke rates, reductions in time to new symptom recognition, and increased utilization of inpatient stroke alert processes. Further study is needed to monitor the effects of the pre-operative evaluation process and the standardization of epiaortic ultrasound. Future goals are to standardize the methods and assess the benefit to other types of cardiac surgery.

With the continued growth of transcatheter aortic valve replacement (TAVR) procedure volume, so too there is an increasing focus on the still-uncertain and evolving treatment algorithm for severe aortic stenosis, especially in younger, lower-risk patients likely to require multiple interventions and devices over their lifetime.1,2 For better or worse, much of the decision making is currently driven by patient choice. Recent reports describing the technical challenges and generally suboptimal outcomes of explanting failed TAVR devices from either native or surgical valves have served to validate growing concerns.

Objectives: We aim to compare in-hospital and 30-day outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) for native aortic insufficiency (AI).Background: TAVR is increasingly used off-label in patients with AI deemed high risk for SAVR. There isa paucity of data comparing TAVR and SAVR with current commercially available TAVR devices.Methods: A single-center, retrospective cohort study of patients undergoing TAVR or SAVR for native AI between 2014 and 2020 was performed. Data were obtained from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database, Transcatheter Valve Therapy (TVT) registry, and chart review. In-hospital and 30-day outcomes are reported.Results: Of 125 total patients, 91 underwent SAVR and 34 underwent TAVR. The TAVR group had a higher STS predictive risk of mortality (PROM) (TAVR = 3.96 %, SAVR = 1.25 %, p < 0.0001). In the postoperative period, the SAVR group had higher rates of new-onset atrial fibrillation (20.9 % vs. 0 %, p < 0.001), while the TAVR group had higher rates of complete heart block requiring permanent pacemaker implantation (20.6 % vs. 2.2 %, p < 0.001). There was no difference in in-hospital or 30-day mortality, stroke, myocardial infarction, residual AI, or repeat valve intervention.Conclusions: Despite higher STS PROM and more comorbidities, patients who underwent TAVR for AI had similar in-hospital and 30-day outcomes as patients who underwent SAVR for AI. These results support TAVR in selected high-risk patients with AI, with the knowledge that pacemaker needs may be higher than patients undergoing SAVR.(c) 2022 Elsevier Inc. All rights reserved.

BACKGROUND:Pneumonia, the most common infection following cardiac surgery, is associated with major morbidity and mortality. Although prior work has identified preoperative risk factors for pneumonia, the present study evaluated the role and associated impact of intraoperative and postoperative risk factors on pneumonia after cardiac surgery. METHODS:This observational cohort study evaluated 71,165 patients undergoing coronary and/or aortic valve surgery across 33 institutions between 2011 and 2021. Terciles of estimated pneumonia risk were compared between a validated preoperative model (Model One) and a model additionally accounting for significant intraoperative (eg, bypass duration) and postoperative (eg, extubation time) factors (Model Two). Logistic regression was used to develop and validate Model Two. RESULTS:Postoperative pneumonia occurred in 2.62% of the patients. A total of 9 significant intraoperative and early postoperative risk factors were identified. The absolute risk of pneumonia increased across Model One terciles: low (≤1.04%), medium (1.04%-2.40%), and high (>2.40%). Model two performed well (c-statistic = 0.771). Most patients (60.1%) had no change in their preoperative versus intraoperative/postoperative risk tercile. The 19.6% of patients who increased their risk tercile with Model Two accounted for 18.6% of all pneumonia events. CONCLUSIONS:This study identified 9 significant perioperative risk factors for pneumonia. Nearly 1 of every 5 patients moved into a higher pneumonia risk category based on their intraoperative and postoperative course. These findings may serve as the focus of future quality improvement efforts to reduce a patient's risk of postoperative pneumonia.

HomeCirculation: Cardiovascular InterventionsVol. 17, No. 1Hemodynamic Comparison of Resilia and Sapien 3/Ultra Transcatheter Heart Valves in Transcatheter Aortic Valve Replacement No AccessResearch ArticleRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessResearch ArticleRequest AccessFull TextHemodynamic Comparison of Resilia and Sapien 3/Ultra Transcatheter Heart Valves in Transcatheter Aortic Valve Replacement Hiroki A. Ueyama, Joe Xie, George S. Hanzel, Isida Byku, Gaetano Paone, Kendra J. Grubb, Chandan M. Devireddy, Adam B. Greenbaum, Vasilis C. Babaliaros and Patrick T. Gleason Hiroki A. UeyamaHiroki A. Ueyama Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.). , Joe XieJoe Xie Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.). , George S. HanzelGeorge S. Hanzel https://orcid.org/0000-0003-3041-5947 Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.). , Isida BykuIsida Byku https://orcid.org/0000-0002-3951-6368 Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.). , Gaetano PaoneGaetano Paone Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (G.P., K.J.G.). , Kendra J. GrubbKendra J. Grubb https://orcid.org/0000-0002-1369-5521 Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (G.P., K.J.G.). , Chandan M. DevireddyChandan M. Devireddy https://orcid.org/0000-0002-6263-9411 Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.). , Adam B. GreenbaumAdam B. Greenbaum https://orcid.org/0000-0001-7496-5954 Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.). , Vasilis C. BabaliarosVasilis C. Babaliaros Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.). and Patrick T. GleasonPatrick T. Gleason Correspondence to: Patrick Gleason, MD, Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, 550 Peachtree St, NE, Atlanta, GA 30306. Email E-mail Address: [email protected] Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.A.U., J.X., G.S.H., I.B., C.M.D., A.B.G., V.C.B., P.T.G.). Originally published4 Dec 2023https://doi.org/10.1161/CIRCINTERVENTIONS.123.013325Circulation: Cardiovascular Interventions. 2024;17FootnotesFor Sources of Funding and Disclosures, see page 80.Correspondence to: Patrick Gleason, MD, Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, 550 Peachtree St, NE, Atlanta, GA 30306. Email patrick.t.gleason@emory.eduREFERENCES1. Flameng W, Hermans H, Verbeken E, Meuris B. 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