Carcinoid heart disease (CHD) is associated with advanced neuroendocrine tumor liver metastases (NETLM) and may preclude surgical cytoreduction. We assessed perioperative and long-term outcomes of hepatectomy in patients with CHD. We retrospectively analyzed 311 patients undergoing cytoreductive hepatectomy for intestinal NETLM: non-functional (n = 163), carcinoid syndrome (CS) without CHD (n = 110), and CHD (n = 38), including patients undergoing pre-hepatectomy valve replacement. CHD patients more frequently had >10 liver metastases (78%) and larger lesions (median 9.5 cm) and required major hepatectomy more often (58%). Major morbidity was higher in CHD (up to 47%), yet 90-day mortality remained low (≤4%). Median overall survival after hepatectomy was comparable across groups (12.5 vs. 9.1 vs. 11.4 years; p = .19), including matched analyses. With optimal cardiac management, cytoreductive hepatectomy in CHD is feasible and provides long-term survival comparable to patients without CHD.

Objective: To define the indications and characteristics for redo aortic valve replacement (AVR) after primary mechanical AVR and to determine whether operative indication influences early and late outcomes. Methods: We analyzed 379 consecutive patients undergoing redo AVR after previous mechanical AVR (2000-2023) at a single tertiary center. Baseline, operative, and outcomes data were obtained from a prospectively maintained database and electronic health records. Outcomes were compared across principal indications, with survival estimated by Kaplan-Meier analysis and predictors of mortality identified using multivariable Cox regression. Results: Median age at redo surgery was 61.8 years (interquartile range, 52.4-69.4 years); 61.2% were male. The median interval to reoperation was 10.2 years (3.9-18.2). Indications included endocarditis (26.6%), pannus obstruction (18.7%), prosthesis-patient mismatch (11.6%), and elective replacement during aortic surgery (16.0%). Endocarditis cases were frequently nonelective and had longer operative times, greater complication rates, and greater operative mortality (13.0% vs 1.4% pannus and 3.4% others; P < .001). Independent predictors of all-cause mortality were older age, diabetes, dialysis dependence, previous myocardial infarction, and nonelective surgery. Indication, including endocarditis, and valve size were not independent predictors. Lower overall survival in endocarditis and bioprosthetic redo cases reflected excess early mortality; beyond 1 year, survival was similar across indications. Conclusions: Redo AVR after previous mechanical AVR is uncommon and arises from heterogeneous indications. Early risk is greatest with endocarditis and nonelective presentation, whereas long-term survival is driven largely by comorbidities rather than indication or prosthesis type. These findings may guide risk assessment, prosthesis selection, and timing of intervention.

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 Conversion from mechanical to bioprosthetic valves is sometimes pursued for anticoagulation-related complications, yet outcomes after such conversion remain poorly characterized. Methods We analyzed 62 consecutive patients undergoing mechanical-to-bioprosthetic valve replacement owing to major bleeding, recurrent thromboembolism, or nonbleeding/nonthromboembolic warfarin-related difficulty between 2000 and 2005. The primary endpoint was time to first postoperative bleeding or thromboembolic event, with death treated as a competing risk. Survival was estimated using Kaplan-Meier analysis. Results The median interval from mechanical valve implantation to conversion was 7 years (interquartile range, 1-17 years). Fifty-eight percent of procedures were urgent or emergent, and hospital mortality was 13%. Among hospital survivors, 66% were discharged on and remained on warfarin therapy beyond 3 months. Overall survival was 82% at 1 year and 71% at 5 years. The 5-year cumulative incidence of bleeding or thromboembolism was 27%, with 63% of events occuring while patients were receiving warfarin. Conclusions Conversion from a mechanical valve to a bioprosthetic valve for anticoagulation-related complications carries substantial early risk and frequently does not eliminate the need for anticoagulation. Recurrent bleeding and thromboembolic events remain clinically significant, underscoring the importance of careful patient counseling and shared decision making.

OBJECTIVE:To investigate associations and characteristics of patients with infective endocarditis (IE) admitted to the cardiac intensive care unit. PATIENTS AND METHODS:Adult patients admitted to the Mayo Clinic cardiac intensive care unit from January 1, 2007, through April 30, 2018, with confirmed acute IE were included. We conducted a retrospective cohort study of data on demographic characteristics, clinical factors, laboratory findings, and outcomes. Patients were categorized by cardiac surgery status: performed, indicated but declined, or not indicated. Primary outcomes were 30-day and 1-year all-cause mortality, analyzed using the Kaplan-Meier method and Cox proportional hazards regression model and adjusted for predictors. RESULTS:A total of 233 patients were included. Native valve IE occurred in 104 patients and prosthetic/device-associated IE in 129 patients. Staphylococcus aureus was the most common organism (99 [42.7%]) and was present in most 30-day deaths (42 [72.4%]). Surgical treatment was indicated in 182 patients (78.1%): 129 underwent a surgical procedure, 53 declined, and 51 had no indication for surgical intervention. The 30-day mortality was 24.9% (58 patients), with older age, higher illness severity and comorbidities, and critical care needs as predictors. The 30-day mortality was higher for those declining surgical treatment (60.4%; adjusted hazard ratio [HR], 2.32; P<.021) and lower for those who underwent surgical intervention vs patients with no indication for such treatment (11.9% vs 23.8%; adjusted HR, 0.40; P=.026). The 1-year mortality was 39.9% (93 patients), with higher mortality in patients who declined surgical intervention (85.1%; adjusted HR, 3.94; P<.001) but similar mortality for those who underwent a surgical procedure vs those with no indication for surgical treatment (31.8% vs 29.3%; adjusted HR, 0.92; P=.80). CONCLUSION:Infective endocarditis in cardiac intensive care unit patients is associated with high mortality. Severity scores, comorbidities, and critical care needs were mortality predictors. Early surgical treatment improved short-term outcomes, but long-term mortality remained high.

Transcatheter aortic valve replacement is increasingly used off-label for native aortic regurgitation in high surgical risk patients, although the absence of annular calcification—particularly after prior valve-sparing aortic root replacement—complicates valve anchoring and increases migration risk. We report a 66-year-old man with severe symptomatic aortic regurgitation after valve-sparing aortic root replacement and hemiarch repair who underwent transcatheter aortic valve replacement. Following deployment of a 29-mm Evolut FX+ valve (Medtronic), valve migration into the left ventricular outflow tract caused severe regurgitation and instability. A second 26-mm SAPIEN 3 Ultra valve (Edwards Lifesciences) was successfully implanted to stabilize the prosthesis, restoring competence and enabling uneventful recovery.

BACKGROUND:Carcinoid heart disease (CaHD) typically affects the right-sided valves. Rarely, CaHD affecting the left-sided valves has been observed in the setting of patent foramen ovale (PFO). However, the impact of PFO on valve disease progression and prognosis in CaHD is not well understood. OBJECTIVES:The purpose of this study was to evaluate the impact of PFO on CaHD progression and clinical outcomes. METHODS:Patients diagnosed with neuroendocrine tumor and carcinoid syndrome (CS), and with serial transthoracic echocardiograms, were included. The primary endpoint was progression of left-sided valve disease. Secondary endpoints included the requirement for left-sided cardiac valve surgery, progression of right-sided valve disease, mortality, and stroke. RESULTS:Of 413 patients with neuroendocrine tumor and CS, 175 met the inclusion criteria; mean age 61.3 ± 11.3 years, 54.9% male, and 67 patients had a PFO. Through 3.6 years (1.1-5.9) between serial transthoracic echocardiograms, patients with PFO were more likely to have progression of left-sided valve disease (adjusted HR [aHR]: 1.93; 95% CI: 1.09-3.42; P = 0.025) and require left-sided valve replacement (13.6% vs 2.1%, log-rank; P = 0.012). Patients with PFO did not have a significant increase in right-sided progression (aHR: 1.51; 95% CI: 0.91-2.51; P = 0.111). Patients with a PFO also had an increased risk of stroke (aHR: 5.42; 95% CI: 1.57-18.70; P = 0.007). CONCLUSIONS:Patients with CS and PFO were at increased risk of progression of left-sided valve disease and valve surgery. PFO presence was also associated with an increased risk of stroke, highlighting the importance of surveillance and consideration of potential early intervention.

BACKGROUND Artificial intelligence (AI) has garnered considerable attention in healthcare. Although often regarded as new, it is a rapidly evolving field with decades-long foundations now reaching clinical inflection points, with potential applications across cardiac surgical practice. This mini review examines the current landscape and future directions of AI tools with direct relevance to cardiac surgery, distinguishing clinically validated applications from those that remain investigational or aspirational. METHODS We conducted a narrative review of AI applications across the cardiac surgical care continuum, drawing from peer-reviewed literature published primarily within the past five years alongside clinical expertise from an established cardiovascular surgery programme and an AI and informatics specialist. Applications were categorised by phase of care and evaluated according to their development stage and proximity to clinical use. RESULTS Preoperatively, machine learning-based risk stratification models and AI-enhanced electrocardiogram analysis show the strongest evidence base for cardiac surgical application. AI-assisted imaging segmentation is approaching clinical utility for surgical planning. Intraoperatively, augmented reality-assisted visualisation and AI-enabled robotic platforms are under active investigation, though most remain confined to research settings. Postoperatively, remote monitoring with wearable devices and AI-based alert systems demonstrate early potential for complication detection. Across all phases, important limitations persist regarding data quality, algorithmic bias, regulatory uncertainty, and absence of robust cost-effectiveness data. CONCLUSIONS AI holds genuine promise for enhancing cardiac surgical care, but the field requires tempered expectations alongside rigorous, surgery-specific validation. Successful integration will depend upon transparent reporting of algorithmic limitations, prioritisation of equity, and preservation of true clinical expertise.

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.

INTRODUCTION:Surgical intervention for aortic regurgitation (AR) is often deferred for high-risk patients. Our study evaluated patient outcomes with non- or minimally calcified AR undergoing TAVR with self-expanding valves, regardless of anatomical features, including those with LVAD support. METHODS:A retrospective observational cohort study was conducted at a single academic center from 01/01/2012 to 12/01/2024. Eligible patients were those with greater than moderate AR, high/inoperable surgical risk, aortic valve calcium score < 400. Primary outcomes were all-cause and cardiovascular (CV)-related mortality rates at 1 and 12 months. Secondary outcomes included rehospitalization rates, procedural complications, in-hospital events, and Valve Academic Research Consortium-3 (VARC) success rates at 1 month. RESULTS:25 patients who underwent TAVR were included, 13 were female with mean age 67 ± 14 years. The majority (76%) of patients presented with severe AR with a mean aortic valve calcium score of 61.5 ± 109.2. No intraprocedural death or conversion to open surgery occurred. Only one all-cause mortality occurred within 30 days, with Kaplan-Meier survival rate of 96% and 84%, at 1 month and 12 months, respectively. Heart failure-related hospitalization occurred in less than 10% of patients at 12 months. Technical success rate was 80%, with ventricular device migration occurring in five patients (20%), two of which were on LVAD support. In those cases, a second balloon-expandable valve was implanted achieving ≤ mild AR. All patients achieved mild or less residual AR at 12 months. CONCLUSION:Off-label TAVR use with self-expanding valves for AR is achievable with favorable safety and efficacy in select patients with and without LVADs.

The biomechanical performance of bileaflet transcatheter mitral valves (TMVs) depends on complex interactions between leaflet material behavior and stent design. However, the contributions of leaflet materials and constitutive models, stent materials, and stent geometry to valve function and durability remain poorly understood. A parametric finite element study was conducted using a CAD model of a bileaflet TMV subjected to physiological pressure loading. Five leaflet material models were evaluated: 3 glutaraldehyde-fixed tissues—bovine pericardium (BP; FBP1, FBP2) and porcine pericardium (PP; FPP)—and 2 unfixed tissues—bovine (UBP) and porcine pericardium (UPP). BP was modeled as a linear elastic (FBP1) and Ogden (FBP2). Each was paired with 2 stent materials, cobalt chromium (CoCr) and nitinol, and 3 stent cell densities (low, medium, high), yielding 30 configurations. Von Mises stresses and relative leaflet opening were quantified. UPP achieved the largest opening (30–32

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.

Background Spontaneous coronary artery dissection (SCAD) is frequently associated with systemic arteriopathies, particularly fibromuscular dysplasia. Although extracoronary arterial screening is recommended, abnormalities of the internal mammary artery (IMA), the usual preferred conduit for coronary artery bypass grafting, is rarely described. Case Summary We report 2 women with systemic arteriopathy and recurrent SCAD who had structural abnormalities of the IMA. The first had Loeys-Dietz syndrome and prior cervical artery dissections, presented with neck pain, and was found to have vertebral artery dissection and focal aneurysmal dilation and suspected dissection of the left IMA. The second had multifocal fibromuscular dysplasia involving renal, cervicocephalic, and thoracic arteries, and presented with recurrent SCAD myocardial infarction. Beaded irregularity of the left IMA was noted. Both patients were managed conservatively. Discussion These cases highlight under-recognized IMA involvement in patients with SCAD and systemic arteriopathy, raising considerations regarding conduit assessment when surgical revascularization is contemplated.

Severe carcinoid heart disease (CaHD) may require bioprosthetic valve (BPV) replacement. Lutetium-177 (Lu-177) DOTATATE is increasingly utilized in patients with neuroendocrine tumors (NETs); however, its effect on BPVs remains unknown. A retrospective review of patients with CaHD who underwent BPV replacement at three tertiary centers in the United States was conducted. Patients were stratified by Lu-177 DOTATATE therapy with a propensity-matched non-exposed cohort. BPV degeneration and mortality were compared. Of 183 patients with CaHD and BPV replacement (median age 62.9 years, 50.8

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:Diastolic dysfunction is common in patients with aortic stenosis and may influence outcomes following surgical aortic valve replacement. We aimed to examine the association of preoperative artificial intelligence (AI)-generated diastolic function grades with early and late outcomes following aortic valve replacement and how postoperative progression influence prognosis. METHODS:We identified 5503 patients undergoing aortic valve replacement between 2000 and 2023. Diastolic function was assessed using a validated deep-learning AI model applied to 12-lead ECGs done preoperatively and on postoperative follow-up. Diastolic grades were classified by AI into Grades 1 to 3. Longitudinal trend analyses and multivariable regression models were used to assess study end points. RESULTS:Among 5503 patients (mean age 72.4±10.8 years; 39% female), higher AI ECG diastolic grades were associated with greater comorbidity burden, including diabetes, renal disease, and heart failure. AI ECG diastolic Grade 3 was independently associated with higher in-hospital mortality (odds ratio, 2.5; P=0.007) and other complications. At 5-year follow-up, patients with Grade 3 showed the least improvement in diastolic function by both ECG and echocardiography. Grades 2 and 3 diastolic function at baseline were independently associated with increased late mortality (hazard ratio, 1.3 and 2.45, respectively; both P<0.001). Additionally, lack of improvement in AI ECG diastolic grade by 1 year was also independently associated with late mortality. CONCLUSIONS:AI ECG-derived diastolic function grades strongly correlates with early complications and long-term mortality and diastolic progression after aortic valve replacement. AI ECG provides a powerful, noninvasive tool for risk stratification and longitudinal monitoring of patients with aortic stenosis.

BACKGROUND Extreme age is often considered relative contraindication to open sternotomy for cardiac surgical procedures. However, data on concomitant coronary artery bypass grafting (CABG) in nonagenarians undergoing surgical aortic valve replacement (SAVR) remain limited. METHODS We reviewed 107 consecutive patients aged ≥90 years who underwent SAVR with or without CABG at our Clinic between 1993 and 2025. Patients undergoing additional cardiac procedures (n=17) were excluded. Forty-five patients had SAVR+CABG and were compared to 45 patients undergoing isolated SAVR. Survival was analyzed using Kaplan-Meier estimates, and heart failure-related readmissions were assessed using a Fine-Gray competing risk model. Quality-of-life was assessed at 3 and 5 years postoperatively using structured self-reported physical activity surveys. RESULTS Median age was 91.9 years (90-93), and 47.8% were female. Median STS PROM was 9.6% (7%–13%). Bypass and cross-clamp times were longer in the SAVR+CABG group (P<0.001), and the left internal mammary artery was utilized in 57.8% (n=26) of CABG cases. Thirty-day mortality was 2.2% in SAVR+CABG vs. 6.7% in isolated SAVR (P=0.616). Overall 5-year survival was 43.1% (95% CI: 33–54), and heart failure-related readmissions were similar between groups (P=0.66). At 3 years, survey respondents (n=26) reported physical activity levels equal to or exceeding age-matched peers; at 5 years, 78.9% (n=25) maintained comparable or higher functional levels. CONCLUSIONS In selected nonagenarians, isolated SAVR with or without CABG can be performed with acceptable perioperative risk and durable functional outcomes, challenging the notion that extreme age alone is a contraindication to aortic valve intervention.