Type A aortic dissection (TAAD) has been associated with thoracic endovascular aortic repair (TEVAR) for aortic conditions: dissection and aneurysm. Our purpose was to study a subset of patients who had an initial TEVAR for type B aortic dissection, followed by a TAAD, which was treated by open ascending aortic repair. Over a 6-year period, 171 consecutive patients underwent open ascending aortic repair for TAAD, of whom 21(12%) had a previous cardiovascular procedure, 17 of which were endovascular. A total of 9 (5.2%) of 171 patients with TAAD had a previous TEVAR for a type B. The mean interval from TEVAR to open ascending aortic repair for TAAD was 4.6 years, with only 1 occurring within a month. Only 1 patient had abnormal aortic media by histology. In 5 of the 9 patients, the entry tear was in the proximal ascending aorta, remote from the endograft, which suggests that a TAAD late after TEVAR for type B represents a new spontaneous event. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

A congenitally malformed aortic valve, unicuspid (UAV), or bicuspid (BAV), occurs in about 1% of the population and is known to be more frequent in patients with aortic dissection. The clinical and operative findings in a series of 134 patients with spontaneous, acute type A aortic dissection were studied, comparing patients with normal and abnormal aortic valve morphology. The aortic valve was normal in 123 of 134 (92%) patients and abnormal in 11 of 134 (8%) patients: BAV in 10 of 134 (7.5%) and UAV in 1 of 134 (0.7%). Demographics were similar between groups, except for a lower frequency of systemic hypertension in the UAV/BAV group (46 vs 82%, p <0.01). The University of Pennsylvania malperfusion class stratification was also similar in the 2 groups. The UAV/BAV group had a greater frequency of aortic root aneurysm (64 vs 18%, p <0.01) and a larger median root diameter (5.7 vs 4.6 cm, p = 0.02). In the UAV/BAV group, the entry tear was more frequently in proximal (intrapericardial) zone 0 (91 vs 62%, p = 0.049). The frequency of abnormal aortic media histology was similar. The rate of root replacement was higher in the UAV/BAV group and early mortality was similar. The frequency of congenitally malformed aortic valve in this series was 8 times higher than in the normal population. The 1 UAV in the series was the only severely stenotic valve. In patients with type A aortic dissection with a congenitally malformed valve, aortic root aneurysm was more common and the entry tear was nearly always proximal. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Background Surgical ablation (SA) at the time of isolated mitral valve surgery (MVS) is recommended in patients with preexisting atrial fibrillation (AF). However, SA remains infrequently utilized during MVS with a poorly quantified impact on stroke and survival. Methods Medicare claims (2008-2019) were queried to identify beneficiaries with preexisting AF undergoing MVS. All-cause mortality and the postoperative incidence of stroke/transient ischemic attack were evaluated as separate endpoints. Overlap propensity score weighting was used to risk-adjust for measured confounding variables. Analyses were repeated using surgeon frequency of SA as an instrumental variable to adjust for unmeasured confounding variables. Results From 2008-2019, 41,795 Medicare beneficiaries with a preexisting diagnosis of AF underwent MVS. Surgeons were categorized, with 1326 infrequently (bottom quartile) performing SA (<30%; 10,364 beneficiaries) and 740 frequently (top quartile) performing SA (≥62%; 10,476 beneficiaries) during MVS. Beneficiaries undergoing MVS with SA (“as-treated” analysis) had a risk-adjusted median survival advantage of 0.56 (95% CI, 0.33-0.81) years (8.85 [95% CI, 8.64-9.04] vs 8.29 [95% CI, 8.11-8.47] years, P < .001 for risk-adjusted survival comparison) compared to those without. Beneficiaries undergoing MVS by frequent SA surgeons (“surgeon-preference” analysis) had a risk-adjusted median survival advantage of 0.35 (95% CI, 0.05-0.71) years (8.59 [95% CI, 8.40-8.85] vs 8.24 [95% CI, 7.97-8.40] years, P = .0015 for risk-adjusted survival comparison) compared to surgeons who infrequently performed SA. Conclusions In Medicare beneficiaries with preexisting AF, concomitant SA during MVS is associated with improved survival, as is undergoing surgery by a frequent SA surgeon. When analyzed based on surgeon preference for SA, the magnitude and time-dependent nature of the treatment effect of SA were substantially different compared to the “as-treated” analysis, suggesting that “as-treated” analyses may be subject to bias from unmeasured confounding variables.

Background:Although the Impella device has an established role in high-risk percutaneous intervention and cardiogenic shock, its role in open cardiac surgery remains unclear. We undertook this study to better understand the role of Impella support in cardiac surgical intervention. Methods:This is a retrospective cohort study of consecutive patients who underwent cardiac surgery with surgically placed Impella 5.5 device support from October 2020 through June 2023. Patient charts were identified and systematically reviewed for relevant information. The primary outcome for this study was patient survival to discharge. Secondary outcomes included intraoperative survival, 30-day survival and 1-year survival. Results:From 2020-2023, ten patients underwent open cardiac surgery with Impella 5.5 support. Five patients were male and the median age was 56.5 years [interquartile range (IQR), 52-63.8 years]. Three patients (30%) presented for isolated revascularization, 3 patients (30%) presented for single valve surgical intervention, 3 patients (30%) presented for revascularization and valve intervention, and 1 patient (10%) presented for multivalve intervention. The median ejection fraction (EF) of patients was 25% (IQR, 21.25-32.5%), the median Society of Thoracic Surgeons risk score was 4.32% (IQR, 1.73-11.06%). Of the patients, 40% underwent axillary cannulation while 60% had central cannulation. Intraoperative survival was 100%, survival to discharge was 90% and 30-day survival was 80%. Conclusions:Our study suggests the use of surgical Impella in high-risk cardiac surgical patients is associated with acceptable survival regardless of site or timing of cannulation. However, Impella usage is associated with significant morbidity. Further investigation is warranted to better understand which patients benefit perioperative Impella support.

Valve-in-valve (ViV) transcatheter aortic replacement (TAVR) is an alternative to redo surgery for failing aortic bioprosthesis. Most ViV-TAVR procedures have been performed in failing stented bioprosthetic valves; stentless bioprostheses are more challenging for transcatheter therapy. This study sought to evaluate the outcomes after TAVR in previous homograft/stentless surgical aortic replacement (SAVR).

BACKGROUND Triple valve surgery (TVS) is a complex operation with high perioperative mortality. Limited data exists regarding the predictors of success associated with this surgery. We report our experience. METHODS Two hundred and eleven sequential patients underwent TVS at one hospital from November 2007 through July 2022. Baseline characteristics, operative details and mortality outcomes were reviewed. RESULTS Eighty-two (38.9%) were redo operations and 68 (32.2%) were urgent. Commonly, aortic (N= 194; 91.4%) and mitral (N= 140; 66.4%) valves were replaced, and the tricuspid valve (N= 189; 89.6%) repaired. Concomitant procedures were done in 28% of patients. Thirty-day mortality was 21/211 (9.95%). Kaplan Meyer survival at 1 and 7 years was 86.0% [79%-93%] and 64.0% [55%-74%], respectively. On multivariate regression, end-stage renal disease [hazard ratio (HR): 4.16; p=0.003)] was associated with mortality, and mitral valve replacement (HR: 0.44; p= 0.009) was associated with improved long-term survival. CONCLUSIONS Despite the high number of redo and concomitant procedures, we report a 30-day mortality rate under 10% and an 86% 1-year survival. In our series, mitral valve replacement conferred a long-term survival benefit.

Objective:To report the accuracy of preoperative 4-dimensional cardiac computed tomography angiogram (CTA), real-time 3-dimensional transesophageal echocardiography (TEE) and intraoperative techniques in aortic valve (AV) measurement and phenotype determination in patients undergoing surgery for aortic insufficiency and/or root aneurysm. Methods:This is a prospective, observational study of preoperative AV imaging for AV repair surgery. Twenty-two patients were accrued over 12 months. Preoperative TEE and CTA were obtained and measurements provided by dedicated imaging cardiologists. Intraoperative measurements were obtained from the arrested heart and reported by the surgeon before repair. Intraoperative assessment was considered the gold standard of height measurements, with CTA being the standard assessment for commissural orientation. Correlation coefficients were used to describe agreement of measurements. Results:Baseline characteristics and assessment of phenotype and measurement of commissural orientation, geometric height and commissural heights are reported. TEE (κ = 0.833; P < .01) and CTA (κ = 0.729; P < .01) both agreed with intraoperative assessment of AV phenotype. TEE appeared more accurate than intraoperative measurement at predicting commissural orientation (r s  = 0.79; P < .01 vs r s  = 0.58; P = .01). CTA and TEE were unlikely to predict and measured shorter than intraoperative geometric height measurement. Measurements of commissural heights by CTA did not agree with and were shorter than intraoperative measurement. Conclusions:TEE and CTA both appear accurate in predicting the AV phenotype identified intraoperatively. CTA and TEE predicted shorter heights than intraoperative measurement.

OBJECTIVE:Long-term outcomes after multivalve cardiac surgery remain underevaluated. METHODS:Medicare administrative claims from 2008 to 2019 identified beneficiaries undergoing multivalve surgery. Operative characteristics were doubly adjudicated using International Classification of Diseases and Current Procedural Technology codes. A multivariable flexible parametric model evaluated predictors of survival; regression standardization was performed to predict standardized survival probabilities (SSPs) at varying percentiles of annual valvar volume. RESULTS:Of 476,092 cardiac surgeries involving the aortic (AVS), mitral (MVS), or tricuspid (TVS) valve, 63,083 (13.3%) were identified as involving multi-valve surgery, including 22,884 MVS/TVS, 30,697 AVS/MVS, 3443 AVS/TVS, and 6059 AVS/MVS/TVS. Surgery occurred at 1157 hospitals by 2922 surgeons. Annual valvar volume (total AVS/MVS/TVS) was tallied for surgeons and hospitals. Median survival varied substantially by type of multivalve surgery: 8.09 (95% CI: 7.90-8.24) years in MVS/TVS, 6.65 (95% CI: 6.49-6.81) years in AVS/MVS, 5.77 (95% CI: 5.37-6.13) years in AVS/TVS, and 6.02 (95% CI: 5.64-6.38) years in AVS/MVS/TVS. SSPs were calculated across combined hospital/surgeon volume percentiles; the median SSP increased with increasing percentile of combined hospital/surgeon volume: 5th percentile, 5.77 (95% CI: 5.58-5.98), 25th percentile, 6.18 (95% CI: 6.07-6.28), 50th percentile, 6.56 (95% CI: 6.44-6.68), 75%th percentile, 6.86 (95% CI: 6.75-6.97), and 95th percentile, 7.58 (95% CI: 7.34-7.83) years, respectively. CONCLUSIONS:Survival varied significantly by type of multivalve surgery, worsened with addition of concomitant interventions and improved substantially with increasing annual hospital and surgeon volume. Hospital volume was associated with an improved early hazard for death that abated beyond 3 months post surgery, while surgeon volume was associated with an improved hazard for death that persisted even beyond the first postoperative year. Consideration should be given to referring multivalve cases to high-volume hospitals and surgeons.

Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has been associated with favorable outcomes in patients with degenerated stentless bioprosthesis. However, whether the outcomes after ViV TAVR for failed stentless bioprosthesis differ between balloon-expandable valves (BEVs) and self-expanding valves (SEVs) remains unknown. Therefore, we retrospectively analyzed 59 consecutive patients who underwent ViV TAVR for failed stentless bioprsothesis with BEVs (n = 42) versus SEVs (n = 17) in a single-health care system between 2013 and 2022. Overall, the mean age was 70.8 years and 74.6% were men. The mean transcatheter valve size was 26.3 ± 2.2 mm for BEVs and 26.4 ± 4 mm for SEVs (p = 0.93). The mean Society of Thoracic Surgeons score was 6.0 ± 3.6 for BEVs and 7.5 ± 5.5 for SEVs (p = 0.22). Compared with patients who received BEVs, those who received SEVs had higher rates of device malposition (2.4% vs 23.5%, p <0.01), postdeployment balloon dilation (11.9% vs 35.5%, p = 0.04) and need for a second transcatheter device (2.4% vs 35.5%, p <0.01). However, both groups showed similar improvement in aortic valve function at 30-day and 1-year follow-up (incidence of 1-year severe patient-prosthesis mismatch in BEVs: 17.6% vs 14.3% in SEVs, p = 0.78). The 1- and 3-year mortality did not differ between BEVs and SEVs (11.9% vs 11.8% and 25% vs 30%, respectively, Log rank p = 0.9). In conclusion, performing ViV TAVR for failed stentless bioprsothesis is technically challenging, especially when using SEVs; however, satisfactory positioning is possible in most cases, with excellent hemodynamic and clinical outcomes with BEVs and SEVs.

Transcatheter tricuspid valve intervention (TTVI) has recently emerged as a promising alternative to surgery for tricuspid regurgitation (TR). However, a significant proportion of patients fail screening for TTVI, and little is known about their characteristics and natural history. This study sought to investigate causes of screen failure and outcomes of patients declined for TTVI. This was a retrospective single-center study of 32 patients who were ineligible for participation in TTV replacement (TTVR) and tricuspid transcatheter edge-to-edge repair (T-TEER) trials. Patients were classified into 2 groups according to the therapy they received: Optimized Medical Therapy (OMT) group or Intervention group. Mean age was 82 ±7.8 years and 68.8% were female. The most common reasons for TTVI exclusion were anatomic/procedural impediment (53.1%), inclusion criteria not met (40.6%), and multivalvular disease (6.3%). Overall, 19 patients (59.4%) did not undergo subsequent tricuspid intervention. The clinical outcomes of these patients who received OMT alone were poor, with a 1-year composite of cardiac death or heart failure readmission of 47.4%. These rates were worse than in patients who subsequently underwent an intervention, albeit not statistically significant (OMT: 47.7% vs. 23.1% Interventions, p= 0.3), and were significantly more pronounced in the subgroup of patients who were excluded for anatomic/procedural limitations (OMT: 70% vs. 14.3% Interventions, p= 0.05). In conclusion, patients ineligible for TTVI, particularly those with anatomic/procedural limitations, and treated medically have poor outcomes. These data underscore the importance of earlier referral and support the need for further transcatheter therapy iterations.

Objectives: Deep venous thrombosis (DVT) is a known surgical complication that can lead to pulmonary embolism with subsequent morbidity and mortality. The incidence of DVT following coronary artery bypass grafting is unclear. Prophylaxis regimens vary and some guidelines advocate against use of routine chemoprophylaxis in patients at low-moderate risk for venous thromboembolism. We utilized postoperative lower extremity venous ultrasound to determine the incidence of DVT following coronary artery bypass grafting in patients with low- to moderate-risk of venous thromboembolism receiving aggressive postoperative DVT prophylaxis. Methods: This is a single-center, retrospective study of all patients who underwent coronary artery bypass grafting between April 2022 and January 2023. All patients who completed postoperative venous ultrasound of the bilateral lower extremities were initially included. Patients who underwent concurrent valve or aortic surgery, were at high risk of venous thromboembolism, or were receiving anticoagulation therapy for nonvenous thromboembolism indications were excluded. The primary outcome was in-hospital incidence of DVT. Secondary outcomes were rates of mortality, postoperative bleeding, and thromboembolic events from discharge to 30 days postoperatively and from 30 days to 3 months postoperatively. Results: No DVTs were observed in 211 included patients. In hospital, there were 3 significant bleeding events and 1 stroke. Following discharge there were 3 additional bleeding events, 1 death, 1 transient ischemic attack, and 1 pulmonary embolism. Conclusions: We observed a 0% rate of DVT in low- to moderate-risk patients undergoing isolated coronary artery bypass grafting and receiving a comprehensive DVT prophylaxis regimen. In hospital bleeding and other thromboembolic event rates were 2.84% and 0.47% respectively. (JTCVS Open 2024;17:145-51)

Synthetic interposition graft from the aorta to the origin of the left coronary artery. Central MessageWe demonstrated repair of an anomalous left coronary artery arising from the pulmonary artery in an adult on a beating heart with pump assist.

Background: Although left ventricular assist device (LVAD) implantation is associated with improved survival, long-term impact on functional class is less well understood in high-risk implants. We undertook this study to better understand how destination therapy (DT) LVAD implantation affects patient functional status and predictors of functional improvement. Methods: We conducted a single-center, retrospective review of all primary LVAD implantations. Primary outcome was New York Heart Association (NYHA) functional class. An improved sustainable functional improvement was defined as being alive at 1-year with NYHA class I or II symptoms. Multivariable logistic regression was performed to identify predictors of sustainable functional improvement. Results: From 2017 to 2023, 151 primary LVAD implantations were performed. Operative mortality was 7.95% (n=12). At 6-month follow-up, 113 (92.62%) of patients had experienced an improvement in functional class with 35 (28.69%) class I, 53 (43.44%) class II, 29 (23.77%) class III, and 5 (4.10%) class IV. At 12 months, 86 (91.49%) patients had sustained improvement in NYHA class with 32 (34.04%) class I, 40 (42.55%) class II, 19 (20.21%) class III, and 3 (3.19%) class IV. At 2 years, 57 (91.94%) patients still experienced improved symptoms. On multivariable logistic regression analysis, an ischemic etiology of heart failure (HF) was associated with a sustainable functional improvement [odds ratio: 5.53 (95% confidence Conclusions: LVAD implantation is associated with significant functional improvement as measured by NYHA class. The high-risk cohort showed similar improvement in functional status. In our series, the best predictor of a sustainable improvement in functional status is an ischemic etiology of HF.

Patients with massive pulmonary embolism undergoing catheter-directed therapy are at high risk for cardiopulmonary arrest in the periprocedural period due to severe right ventricular dysfunction. We report the outcomes of 3 patients with massive pulmonary embolism treated successfully with catheter-directed thrombolytic therapy and venoarterial extracorporeal membrane oxygenation.