Background:In patients with aortic insufficiency, annular dilatation often accompanies valve incompetence, necessitating annuloplasty. However, primary leaflet defects also are common, and when found unexpectedly at the time of planned repair, inadequate leaflet tissue often prompts prosthetic valve replacement. A method for achieving stable repair for severe leaflet deficiencies would be useful. Methods:In this report, major leaflet defects due to ruptured large fenestrations were encountered in 2 patients, the first repaired with extensive plication, which failed. In the second patient, the defect was reconstructed using an autologous aortic wall patch. After geometric annuloplasty, the aortic wall strip was sutured with interrupted 6-0 sutures from the nodulus to the commissural top, with the intima facing coaptation. Leaflet free-edge length was adjusted to match the other normal leaflets at approximately reconstructed annular diameter x 1.5. Results:In the aortic wall patch patient, grade 4 preoperative aortic insufficiency fell to zero after repair, and the patient is doing well with continued excellent echo parameters at 1 year postoperatively. Conclusions:As a leaflet substitute during aortic valve repair, aortic wall patches seem to provide an excellent solution to managing severe leaflet deficiencies.

Background Guidelines recommend shared decision making when choosing treatment for severe aortic stenosis but implementation has lagged. We assessed the feasibility and impact of a novel decision aid for severe aortic stenosis at point-of-care. Methods This prospective multi-site pilot cohort study included adults with severe aortic stenosis and their clinicians. Patients were referred by their heart team when scheduled to discuss treatment options. Outcomes included shared decision-making processes, communication quality, decision-making confidence, decisional conflict, knowledge, stage of decision making, decision quality, and perceptions of the tool. Patients were assessed at baseline (T0), after using the intervention (T1), and after the clinical encounter (T2); clinicians were assessed at T2. Before the encounter, patients reviewed the intervention, Aortic Valve Improved Treatment Approaches (AVITA), an interactive, online decision aid. AVITA presents options, frames decisions, clarifies patient goals and values, and generates a summary to use with clinicians during the encounter. Results 30 patients (9 women [30.0%]; mean [SD] age 70.4 years [11.0]) and 14 clinicians (4 women [28.6%], 7 cardiothoracic surgeons [50%]) comprised 28 clinical encounters Most patients [85.7%] and clinicians [84.6%] endorsed AVITA. Patients reported AVITA easy to use [89.3%] and helped them choose treatment [95.5%]. Clinicians reported the AVITA summary helped them understand their patients’ values [80.8%] and make values-aligned recommendations [61.5%]. Patient knowledge significantly improved at T1 and T2 (p = 0.004). Decisional conflict, decision-making stage, and decision quality improved at T2 (p = 0.0001, 0.0005, and 0.083, respectively). Most patients [60%] changed treatment preference between T0 and T2. Initial treatment preferences were associated with low knowledge, high decisional conflict, and poor decision quality; final preferences were associated with high knowledge, low conflict, and high quality. Conclusions AVITA was endorsed by patients and clinicians, easy to use, improved shared decision-making quality and helped patients and clinicians arrive at a treatment that reflected patients’ values. Trial registration Trial ID: NCT04755426, Clinicaltrials.gov/ct2/show/NCT04755426.

A 72-year-old female with severe symptomatic aortic stenosis was referred for aortic valve replacement. She was found to have a bicuspid aortic valve with left ventricular outflow tract calcification (Figure 1a and b) and an enlarged ascending aorta (40 mm). She was considered prohibitive risk for surgery after evaluation by several surgeons due to multiple comorbidities and significant frailty that left her wheelchair bound. A transcatheter aortic valve replacement (TAVR) with Evolut Pro was planned. Intraprocedurally, there was significant difficulty advancing the Evolut valve across the native aortic valve due to aortic enlargement and angulation, which caused the body of the valve frame to deflect against the greater curve of the aorta and directed the nosecone into the coronary sinus (Figure 2). The valve was removed and balloon valvuloplasty was performed with a 20 mm True balloon. Despite this, the body of the valve continued to buck against the greater curvature. The nosecone repeatedly became lodged in the sinuses and multiple attempts to cross the aortic valve were unsuccessful. A 25 mm Gooseneck snare was then used to atraumatically pull the Evolut valve toward the inner curve of the ascending aorta, allowing passage across the annulus. The valve was deployed and then postdilated with a 24 mm True balloon. The patient reported chest pain 2 to 3 ​hours after the procedure, prompting review of the intraprocedural aortograms, which raised suspicion for an aortic root dissection (Figure 1c and d, Supplemental Videos 1 and 2). Computed tomography angiography (CTA) demonstrated a dissection beginning in the aortic root and sparing the coronary ostium. The flap appeared to be pinned behind the anterior aspect of the Evolut valve cage (Figure 1e and f, Supplemental Video 3). The patient was re-evaluated for open surgical repair, but again determined to have prohibitive risk. She was managed medically with esmolol titrated to a systolic blood pressure of 120 mmHg and heart rate of 60 bpm and demonstrated no signs of end-organ malperfusion or dissection propagation. She was discharged 72 ​hours later with return precautions. At 6- and 12-week follow-up, the patient remained asymptomatic without dissection flap extension or propagation on CTA (Figure 1g). The external force provided by the self-expanding TAVR valve cage at the distal end of the dissection flap was thought to partially explain this stability. On 18-month post-TAVR CTA, the dissection flap was unchanged, and the patient remained asymptomatic. Aortic dissection during TAVR is a rare but catastrophic complication occurring in ∼0.2 to 0.3% of TAVRs and presents a unique dilemma as many patients undergoing TAVR are at high or prohibitive surgical risk.1Hashemi H. Khera S. Anastasius M. et al.Acute type A aortic dissection after TAVR in an octogenarian with ascending aorta aneurysm.JACC Cardiovasc Interv. 2022; 15: 220-222https://doi.org/10.1016/j.jcin.2021.10.021Crossref Scopus (1) Google Scholar,2Langer N.B. Hamid N.B. Nazif T.M. et al.Injuries to the aorta, aortic annulus, and left ventricle during transcatheter aortic valve replacement.Circ Cardiovasc Interv. 2017; 10e004735https://doi.org/10.1161/CIRCINTERVENTIONS.116.004735Crossref Scopus (41) Google Scholar It may happen secondary to intimal damage from stiff wires, device trauma, or balloon valvuloplasty injury. Iatrogenic type A dissection has traditionally been thought of, and managed, like spontaneous type A aortic dissection, which has a mortality rate exceeding 90% if left unrepaired. Heart team discussion and prompt surgical repair is the standard of care for those not at prohibitive surgical risk, but there is a growing body of evidence to support medical management with intravenous ß-blockade, dihydropyridine calcium channel blockers, or sodium nitroprusside to a systolic blood pressure of 120 mmHg and heart rate of 60 bpm.3Elefteriades J.A. Zafar M.A. Ziganshin B.A. Iatrogenic aortic dissection: review of the literature.Aorta (Stamford). 2016; 4: 240-243https://doi.org/10.12945/j.aorta.2016.16.081Crossref Scopus (6) Google Scholar,4Hiruma T. Higuchi R. Saji M. Takamisawa I. Shimokawa T. Nanasato M. Transcatheter aortic valve replacement-related aortic dissection: a clinical case series.Catheter Cardiovasc Interv. 2023; 101: 668-675https://doi.org/10.1002/ccd.30574Crossref Scopus (3) Google Scholar Other case reports have described successful management with endovascular thoracic aortic repair for those with prohibitive surgical risk who experience end-organ malperfusion despite medical therapy.2Langer N.B. Hamid N.B. Nazif T.M. et al.Injuries to the aorta, aortic annulus, and left ventricle during transcatheter aortic valve replacement.Circ Cardiovasc Interv. 2017; 10e004735https://doi.org/10.1161/CIRCINTERVENTIONS.116.004735Crossref Scopus (41) Google Scholar The role of TAVR in patients with a bicuspid aortic valve and aortopathy is incompletely understood. Patients with bicuspid aortic valve have not been represented in TAVR trials, yet nearly 10% of all patients undergoing TAVR have a bicuspid aortic valve.5Vincent F. Ternacle J. Denimal T. et al.Transcatheter aortic valve replacement in bicuspid aortic valve stenosis.Circulation. 2021; 143: 1043-1061https://doi.org/10.1161/CIRCULATIONAHA.120.048048Crossref PubMed Scopus (60) Google Scholar Early case series suggested a higher rate of periprocedural complications and mortality in patients with bicuspid compared to tricuspid valves, but more contemporary cohorts suggest that this is not only feasible, but can be done safely.6Makkar R.R. Yoon S.H. Chakravarty T. et al.Association between transcatheter aortic valve replacement for bicuspid vs tricuspid aortic stenosis and mortality or stroke among patients at low surgical risk.JAMA. 2021; 326: 1034-1044https://doi.org/10.1001/jama.2021.13346Crossref PubMed Scopus (32) Google Scholar Patients with bicuspid valves will often have coexisting aortopathies, but only 25% will be large enough to necessitate concurrent prophylactic repair at the time of valve replacement.5Vincent F. Ternacle J. Denimal T. et al.Transcatheter aortic valve replacement in bicuspid aortic valve stenosis.Circulation. 2021; 143: 1043-1061https://doi.org/10.1161/CIRCULATIONAHA.120.048048Crossref PubMed Scopus (60) Google Scholar TAVR does not address the underlying aortopathy or any genetic predisposition to progressive dilation, but is a viable option in those without a surgical indication, as correcting underlying mechanical hemodynamic disturbances may slow progression.5Vincent F. Ternacle J. Denimal T. et al.Transcatheter aortic valve replacement in bicuspid aortic valve stenosis.Circulation. 2021; 143: 1043-1061https://doi.org/10.1161/CIRCULATIONAHA.120.048048Crossref PubMed Scopus (60) Google Scholar However, patients with underlying aortopathy are likely at increased risk for complications such as iatrogenic dissection, even with standard equipment manipulation and aortic wall trauma, as was seen in this case. We present a medically managed case of iatrogenic type A aortic root dissection during TAVR. The dissection flap was fortuitously pinned behind the long Evolut frame, which maintained coronary perfusion, and a normally functioning TAVR valve maintained normal cardiac output through the left ventricular outflow track. This case adds to the growing body of evidence that iatrogenic type A aortic dissection can be successfully managed with medical therapy for impulse control in hemodynamically stable patients. Endovascular interventions are a potential bailout in those who ultimately require repair but are prohibitive surgical risk. Patient consent was given for case publication. Alexander E. Sullivan is supported by the National Institute of General Medical Science of the National Institutes of Health under award number T32 GM007569.

A 35-year-old woman presented at 22 weeks gestation with severe symptomatic aortic stenosis with a mean gradient of 94 mm Hg and an aortic valve area of 0.53 cm2. After multidisciplinary discussion, she underwent transcatheter aortic valve replacement during pregnancy.

Background: Optimal management of intramural hematoma (IMH) remains controversial. Previous studies offer conflicting information on how outcomes differ between patients with acute aortic dissection (AAD) and IMH. Methods: Patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between 1996 and 2023 were stratified by AAD and IMH. True IMH, defined as the presence of intramural hematoma in the absence of both double lumen and intimal flap, was noted in 605 patients (7.7%). Results: IMH was more common in Type B patients (12.7% IMH versus 5.1% with Type A). In both groups, IMH patients were older (mean age 70.4 vs. 61.3 years, p<0.001) and less frequently male (51.4% vs. 67.2%, p<0.001). Marfan Syndrome was less common with IMH (1.1% vs. 4.0%, p<0.001).For both dissection types, IMH patients less frequently demonstrated presenting mesenteric ischemia (Type A: 0.8% vs. 4.3%, p=0.003; Type B: 0.7% vs. 6.3%, p<0.001) or limb ischemia (Type A: 3.2% vs. 12.3%, p<0.001; Type B: 2.7% vs. 9.3%, p<0.001). Tamponade at presentation was more common in Type A IMH (17.9% vs. 11.6%, p=0.005). Type B IMH patients had less presenting renal failure (7.5% vs. 16.9%, p<0.001). Medical management alone was more commonly employed as a treatment strategy for IMH versus AAD, both in Type A (18.8% vs. 8.7%, p<0.001) and Type B (78.7% vs. 56.9%, p<0.0001). Correspondingly, Type B IMH patients had less endovascular management (15.6% vs. 29.3%, p<0.001). Surgery was delayed beyond 48 hours of diagnosis in almost twice as many surgical Type A IMH patients (14.9% vs. 8.4%, p=0.009). Additionally, medically managed type A IMH patients had lower mortality than those with AAD (33.3% vs. 58.0%, p=0.001), although medical mortality was still higher than that of surgical patients with IMH (33.3% vs. 12.0%, p<0.001). Kaplan-Meier analyses of 1-year post-discharge death, late intervention, and aortic growth were similar between groups. Conclusions: Intervention was less common among patients with IMH for both Type A and Type B. While a select subset of non-operative IMH patients had more favorable in-hospital outcomes compared to those with AAD, this mortality was still higher than for those IMH patients receiving surgery.

Importance In the setting of uncertain efficacy and additional, unreimbursed cost, use of an embolic protection device (EPD) during transcatheter aortic valve replacement (TAVR) has had variable uptake. The Centers for Medicare & Medicaid Services (CMS) instituted a new technology add-on payment to cover EPD use in October 2018. Objective To evaluate the association between CMS TAVR reimbursement rates and EPD use. Design, Setting, and Participants This cohort study used the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry to identify patients who underwent TAVR between January 2018 and September 2019. Analysis took place between July 2020 and February 2022. Main Outcomes and Measures The association between EPD use and CMS reimbursement was assessed using multivariable logistic regression models adjusted for patient characteristics (model 1) and patient/hospital (annualized TAVR volume and teaching status) characteristics (model 2). Results Among 511 institutions, CMS reimbursement for TAVR ranged from $28 062 to $111 280 with a median (IQR) of $45 884 ($40 331-$53 627). Among 84 353 patients (median [IQR] age, 81.0 [75.0-86.0] years; 46 247 male individuals [54.8%]; 3958 [4.7%] of Hispanic or Latino ethnicity; 78 170 White individuals [92.7%]) treated at the sites, 6012 (7.1%) underwent TAVR with EPD. Patient characteristics associated with EPD use included prior stroke (adjusted odds ratio [aOR], 1.13 [95% CI, 1.00-1.27]; P = .048), female sex (aOR, 0.85 [95% CI, 0.78-0.93]; P < .001), hemodialysis (aOR, 0.52 [95% CI, 0.40-0.68]; P < .001), and shock (aOR, 0.62 [95% CI, 0.41-0.94]; P = .03). Higher CMS reimbursement up to $50 000 per TAVR was associated with greater likelihood of EPD use in model 1 (per $1000; aOR, 1.08 [95% CI, 1.01-1.16]; P = .02). However, this association was no longer apparent after adjusting for site characteristics (model 2; aOR, 1.03 [95% CI, 0.96-1.11]; P = .38). Higher TAVR volume was associated with increased EPD use (per 25 TAVRs; aOR, 1.15 [95% CI, 1.09-1.21]; P < .001). There was no significant change in the odds of EPD uptake before vs after institution of the CMS new technology add-on payment across tertiles of CMS TAVR reimbursement (Wald χ2 = 3.59; P = .17). Conclusions and Relevance EPD use during TAVR remains infrequent and is associated with multiple patient and site characteristics. While CMS reimbursement varies significantly across institutions, TAVR case volume, rather than CMS TAVR reimbursement or the CMS new technology add-on payment, appears to be the predominant factor associated with EPD use. Ongoing work is needed to understand the economic drivers that contribute to the association between procedural volume and EPD use.

Central MessageCongenital left atrial aneurysms are rare and are associated with arrhythmias and intraatrial thrombus. Minimally invasive resection is a safe and effective management, particularly in young patients. Congenital left atrial aneurysms are rare and are associated with arrhythmias and intraatrial thrombus. Minimally invasive resection is a safe and effective management, particularly in young patients. Congenital left atrial aneurysms are extremely rare and have been associated with the development of supraventricular arrhythmia, as well as increased risk of intraatrial thrombus formation, thromboembolic complications, and rupture.1Aryal M.R. Hakim F.A. Ghimire S. Ghimire S. Giri S. Pandit A. et al.Left atrial appendage aneurysm: a systematic review of 82 cases.Echocardiography. 2014; 31: 1312-1318Crossref PubMed Scopus (55) Google Scholar, 2Chowdhury U.K. Seth S. Govindappa R. Jagia P. Malhotra P. Congenital left atrial appendage aneurysm: a case report and brief review of literature.Heart Lung Circ. 2009; 18: 412-416Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 3Fakhri G. Obeid M. El Rassi I. Tabbakh A. Bitar F. Alameddine M. et al.Large congenital left atrial wall aneurysm: an updated and comprehensive review of the literature.Echocardiography. 2020; 37: 965-970Crossref PubMed Scopus (4) Google Scholar Due to the risk of catastrophic thromboembolism or aneurysmal rupture, surgical resection is frequently recommended for management of this condition, regardless of symptoms.1Aryal M.R. Hakim F.A. Ghimire S. Ghimire S. Giri S. Pandit A. et al.Left atrial appendage aneurysm: a systematic review of 82 cases.Echocardiography. 2014; 31: 1312-1318Crossref PubMed Scopus (55) Google Scholar,3Fakhri G. Obeid M. El Rassi I. Tabbakh A. Bitar F. Alameddine M. et al.Large congenital left atrial wall aneurysm: an updated and comprehensive review of the literature.Echocardiography. 2020; 37: 965-970Crossref PubMed Scopus (4) Google Scholar We present a unique case report of a pediatric patient with giant left atrial appendage aneurysm who was successfully managed with a minimally invasive resection technique. The Institutional Review Board of Vanderbilt University deemed this study “nonresearch” (number: 211716, decision date: September 8, 2021). An otherwise-healthy 17-year-old female patient presented after having a syncopal event. Her physical examination was unremarkable, and electrocardiogram revealed a normal sinus rhythm. Her initial work-up included a transthoracic echocardiogram (Figure 1, A, C-F), which revealed a large left atrial aneurysm with normal biventricular function and no valvular abnormalities. To further characterize this, cardiac magnetic resonance imaging was performed, which confirmed the left atrial appendage aneurysm measuring 7.1 × 7.6 × 5.7 cm (Figure 2). A multidisciplinary team discussion regarding the management of this case was initiated and surgical resection was recommended. Given the patient's young age, a minimally invasive approach was preferred.Figure 2T1-weighted cardiac magnetic resonance image of large left atrial appendage aneurysm. An, Aneurysm; RVOT, right ventricular outflow tract; RV, right ventricle; LV, left ventricle; LVOT, left ventricular outflow tract.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient was brought to the operating room and transesophageal electrocardiogram images were obtained to confirm the identified anatomy (Figure 1, B). A 4-cm left anterolateral thoracotomy incision was made, at the fourth intercostal space from the midclavicular line to the anterior axillary line. The pericardium was opened posterior to the phrenic nerve, and the left atrial appendage aneurysm was visualized (Figure 3, A). The right femoral artery and vein were then exposed. Heparin was administered, and the right femoral artery and vein were cannulated over a wire using transesophageal echocardiogram guidance. After initiation of cardiopulmonary bypass, a vascular stapler was inserted through a more lateral keyhole counter-incision. Using both ports, similar to a thoracic wedge resection, the aneurysm was stapled across at its base with care to avoid the left circumflex coronary artery. The staple line was reinforced with interrupted 4-0 polypropylene suture with pledgets. The resected specimen is shown in Figure 3, B. Transesophageal echocardiography demonstrated no residual aneurysmal outpouching and preserved biventricular function. The patient had a routine postoperative course, and her incision was well healed with excellent cosmetic result at 2-month follow-up. Congenital left atrial aneurysms can be either intrapericardial or extrapericardial in nature. The extrapericardial type is felt to be due to a congenital defect of the pericardium, through which the otherwise-normal left atrium herniates.2Chowdhury U.K. Seth S. Govindappa R. Jagia P. Malhotra P. Congenital left atrial appendage aneurysm: a case report and brief review of literature.Heart Lung Circ. 2009; 18: 412-416Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar,4Kim Y.W. Kim H.J. Ju M.H. Lee J.W. The treatment of left atrial appendage aneurysm by a minimally invasive approach.Korean J Thorac Cardiovasc Surg. 2018; 51: 146-148Crossref PubMed Scopus (4) Google Scholar The intrapericardial type, however, is thought to be due to a developmental weakness in pectinate muscles of the left atrium.2Chowdhury U.K. Seth S. Govindappa R. Jagia P. Malhotra P. Congenital left atrial appendage aneurysm: a case report and brief review of literature.Heart Lung Circ. 2009; 18: 412-416Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar,3Fakhri G. Obeid M. El Rassi I. Tabbakh A. Bitar F. Alameddine M. et al.Large congenital left atrial wall aneurysm: an updated and comprehensive review of the literature.Echocardiography. 2020; 37: 965-970Crossref PubMed Scopus (4) Google Scholar,5Clark J.B. Ting J.G. Polinsky Jr., R.J. Wolfe L.T. Resection of a giant left atrial appendage aneurysm via limited thoracotomy.World J Pediatr Congenit Heart Surg. 2014; 5: 475-477Crossref PubMed Scopus (7) Google Scholar Patients with congenital left atrial aneurysms typically present in their third decade of life; however, the age at presentation in the literature ranges from less than 1 day to 88 years,1Aryal M.R. Hakim F.A. Ghimire S. Ghimire S. Giri S. Pandit A. et al.Left atrial appendage aneurysm: a systematic review of 82 cases.Echocardiography. 2014; 31: 1312-1318Crossref PubMed Scopus (55) Google Scholar,3Fakhri G. Obeid M. El Rassi I. Tabbakh A. Bitar F. Alameddine M. et al.Large congenital left atrial wall aneurysm: an updated and comprehensive review of the literature.Echocardiography. 2020; 37: 965-970Crossref PubMed Scopus (4) Google Scholar with more severe cases typically presenting at younger ages.3Fakhri G. Obeid M. El Rassi I. Tabbakh A. Bitar F. Alameddine M. et al.Large congenital left atrial wall aneurysm: an updated and comprehensive review of the literature.Echocardiography. 2020; 37: 965-970Crossref PubMed Scopus (4) Google Scholar Symptoms of left atrial aneurysms can include palpitations, tachycardia, shortness of breath, chest pain, and cardiac decompensation in severe cases.2Chowdhury U.K. Seth S. Govindappa R. Jagia P. Malhotra P. Congenital left atrial appendage aneurysm: a case report and brief review of literature.Heart Lung Circ. 2009; 18: 412-416Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar,3Fakhri G. Obeid M. El Rassi I. Tabbakh A. Bitar F. Alameddine M. et al.Large congenital left atrial wall aneurysm: an updated and comprehensive review of the literature.Echocardiography. 2020; 37: 965-970Crossref PubMed Scopus (4) Google Scholar Unfortunately, in some patients the first symptom is due to a catastrophic thromboembolic complication or aneurysmal rupture.2Chowdhury U.K. Seth S. Govindappa R. Jagia P. Malhotra P. Congenital left atrial appendage aneurysm: a case report and brief review of literature.Heart Lung Circ. 2009; 18: 412-416Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar Various approaches have been described for the surgical management of the congenital left atrial aneurysm. The most widely used approach is median sternotomy with cardiopulmonary bypass, aortic crossclamping, and surgical resection of the aneurysm with left atrial reconstruction. This strategy may be particularly useful when the aneurysm is extremely large, there are other cardiac defects, or when thrombus is present,1Aryal M.R. Hakim F.A. Ghimire S. Ghimire S. Giri S. Pandit A. et al.Left atrial appendage aneurysm: a systematic review of 82 cases.Echocardiography. 2014; 31: 1312-1318Crossref PubMed Scopus (55) Google Scholar,3Fakhri G. Obeid M. El Rassi I. Tabbakh A. Bitar F. Alameddine M. et al.Large congenital left atrial wall aneurysm: an updated and comprehensive review of the literature.Echocardiography. 2020; 37: 965-970Crossref PubMed Scopus (4) Google Scholar,6Wang B. Li H. Zhang L. He L. Zhang J. Liu C. et al.Congenital left atrial appendage aneurysm: a rare case report and literature review.Medicine (Baltimore). 2018; 97: e9344Crossref PubMed Scopus (19) Google Scholar as full sternotomy and circulatory support allow for better visualization and improved control. Less-invasive surgical approaches, such as left mini-thoracotomy, provide the advantage of cosmesis and may be appropriate for patients for whom thrombi have been ruled out on preoperative imaging.1Aryal M.R. Hakim F.A. Ghimire S. Ghimire S. Giri S. Pandit A. et al.Left atrial appendage aneurysm: a systematic review of 82 cases.Echocardiography. 2014; 31: 1312-1318Crossref PubMed Scopus (55) Google Scholar,3Fakhri G. Obeid M. El Rassi I. Tabbakh A. Bitar F. Alameddine M. et al.Large congenital left atrial wall aneurysm: an updated and comprehensive review of the literature.Echocardiography. 2020; 37: 965-970Crossref PubMed Scopus (4) Google Scholar,6Wang B. Li H. Zhang L. He L. Zhang J. Liu C. et al.Congenital left atrial appendage aneurysm: a rare case report and literature review.Medicine (Baltimore). 2018; 97: e9344Crossref PubMed Scopus (19) Google Scholar This approach can be accomplished without cardiopulmonary bypass, if the aneurysm is small or located far from the atrial wall; however, the use of cardiopulmonary bypass is best left to the judgment of the surgeon. Our preferred approach is to use full cardiopulmonary bypass. Circulatory support with cardiopulmonary bypass runs the major risks of systemic inflammatory response syndrome, kidney injury, and coagulopathy but carries the advantages of hemodynamic support, improved visualization of the neck of the aneurysm via decompression, and better control in case of acute hemorrhage. For aneurysms with short and/or wide necks that preclude the placement of a vascular stapler, cardiopulmonary bypass can be helpful to facilitate surgical ligation of the neck. In addition, it is our practice to reenforce the stapled or surgical suture line with either a double suture layer or interrupted felt pledgets. Caution should be instituted when considering the use of an external left atrial appendage ligation clip alone.4Kim Y.W. Kim H.J. Ju M.H. Lee J.W. The treatment of left atrial appendage aneurysm by a minimally invasive approach.Korean J Thorac Cardiovasc Surg. 2018; 51: 146-148Crossref PubMed Scopus (4) Google Scholar These devices may not be occlusive. Therefore, more definitive management of the aneurysm sac is recommended. In this case, surgical resection of the aneurysm was recommended, given its excessive size, to reduce the risk of supraventricular arrhythmia and thromboembolism. Endovascular closure was considered; however, this was not feasible due to the large size of the aneurysmal neck. Resection also obviates the need for placing a young person on warfarin, which is of particular concern in young female patients of childbearing age. Our approach, via a small left anterolateral thoracotomy with a counter incision for the stapler, allowed excellent visualization and control, and the added benefit of an exceptional cosmetic outcome in a young person. We decided to use cardiopulmonary bypass in this case due to the large aneurysmal neck and to maximize exposure by decompressing the aneurysm. Even though this aneurysm was large, carefully selected patients with appropriate anatomy may benefit from this approach. This case report highlights the need for additional literature on the safety and efficacy of less-invasive surgical approaches to the congenital left atrial aneurysm.

Journal of Cardiac SurgeryVolume 37, Issue 12 p. 4133-4137 INVITED REVIEW The role of coronary CTA and CT-fractional flow reserve evaluating coronary artery disease in transcatheter aortic valve replacement Yuliya Tipograf MD, Yuliya Tipograf MD Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USASearch for more papers by this authorThomas McLaren MD, Thomas McLaren MD Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USASearch for more papers by this authorBrent Savoie MD, Brent Savoie MD Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USASearch for more papers by this authorAnupam Kumar MD, Anupam Kumar MD Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USASearch for more papers by this authorMelissa M. Levack MD, Corresponding Author Melissa M. Levack MD [email protected] Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA Correspondence Melissa M. Levack, MD, Department of Cardiac Surgery, Vanderbilt University Medical Center East, 1215 21st Ave South Suite 5025, Nashville, TN 37232, USA. Email: [email protected]Search for more papers by this author Yuliya Tipograf MD, Yuliya Tipograf MD Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USASearch for more papers by this authorThomas McLaren MD, Thomas McLaren MD Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USASearch for more papers by this authorBrent Savoie MD, Brent Savoie MD Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USASearch for more papers by this authorAnupam Kumar MD, Anupam Kumar MD Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USASearch for more papers by this authorMelissa M. Levack MD, Corresponding Author Melissa M. Levack MD [email protected] Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA Correspondence Melissa M. Levack, MD, Department of Cardiac Surgery, Vanderbilt University Medical Center East, 1215 21st Ave South Suite 5025, Nashville, TN 37232, USA. Email: [email protected]Search for more papers by this author First published: 02 October 2022 https://doi.org/10.1111/jocs.16967Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat REFERENCES 1Douglas PS, De Bruyne B, Pontone G, et al. 1-year outcomes of FFRCT-guided care in patients with suspected coronary disease: The PLATFORM Study. 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An update on coronary artery calcium interpretation at chest and cardiac CT. Radiol Cardiothorac Imaging. 2021; 3:e200484. 9Karády J, Mayrhofer T, Ivanov A, et al. Cost-effectiveness analysis of anatomic vs functional index testing in patients with low-risk stable chest pain. JAMA Netw Open. 2020; 3:e2028312. 10 Physician Fee Schedule. Vol. 2022. Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched Volume37, Issue12December 2022Pages 4133-4137 ReferencesRelatedInformation

Ischaemic mitral regurgitation is a complex process with debate in the literature as to the optimal treatment pathway. Multiple therapies are available to alleviate mitral regurgitation including medical management, transcatheter edge-to-edge repair, mitral valve repair and mitral valve replacement. Medical management with goal-directed therapy should be utilised in patients with heart failure and mild-to-moderate regurgitation. Transcatheter approaches are typically used in patients with prohibitive operative risk, although their use is expanding, especially in those with functional mitral regurgitation who are not responding to goal-directed medical therapy. It is generally accepted that patients with mild-to-moderate disease can avoid valve intervention if successful revascularisation is performed. A higher consideration should be given to valve replacement over repair in patients with severe mitral regurgitation in the setting of myocardial ischaemia. Operative course must be personalised to each patient, and continues to develop with improving technologies and ongoing research into optimal treatment.

Background Guidelines recommend including the patient’s values and preferences when choosing treatment for severe aortic stenosis (sAS). However, little is known about what matters most to patients as they develop treatment preferences. Our objective was to identify, prioritize, and organize patient-reported goals and features of treatment for sAS. Methods This multi-center mixed-methods study conducted structured focus groups using the nominal group technique to identify patients’ most important treatment goals and features. Patients separately rated and grouped those items using card sorting techniques. Multidimensional scaling and hierarchical cluster analyses generated a cognitive map and clusters. Results 51 adults with sAS and 3 caregivers with experience choosing treatment (age 36–92 years) were included. Participants were referred from multiple health centers across the U.S. and online. Eight nominal group meetings generated 32 unique treatment goals and 46 treatment features, which were grouped into 10 clusters of goals and 11 clusters of features. The most important clusters were: 1) trust in the healthcare team, 2) having good information about options, and 3) long-term outlook. Other clusters addressed the need for and urgency of treatment, being independent and active, overall health, quality of life, family and friends, recovery, homecare, and the process of decision-making. Conclusions These patient-reported items addressed the impact of the treatment decision on the lives of patients and their families from the time of decision-making through recovery, homecare, and beyond. Many attributes had not been previously reported for sAS. The goals and features that patients’ value, and the relative importance that they attach to them, differ from those reported in clinical trials and vary substantially from one individual to another. These findings are being used to design a shared decision-making tool to help patients and their clinicians choose a treatment that aligns with the patients’ priorities. Trial registration ClinicalTrials.gov, Trial ID: NCT04755426 , Trial URL https://clinicaltrials.gov/ct2/show/NCT04755426 .

Background On October 18, 2018, several changes to the donor heart allocation system were enacted. We hypothesize that patients undergoing orthotopic heart transplantation (OHT) under the new allocation system will see an increase in ischemic times, rates of primary graft dysfunction, and 1-year mortality due to these changes. Methods In this single-center retrospective study, we reviewed the charts of all OHT patients from October 2017 through October 2019. Pre- and postallocation recipient demographics were compared. Survival analysis was performed using the Kaplan-Meier method. Results A total of 184 patients underwent OHT. Recipient demographics were similar between cohorts. The average distance from donor increased by more than 150 km (p = .006). Patients in the postallocation change cohort demonstrated a significant increase in the rate of severe left ventricle primary graft dysfunction from 5.4% to 18.7% (p = .005). There were no statistically significant differences in 30-day mortality or 1-year survival. Time on the waitlist was reduced from 203.8 to 103.7 days (p = .006). Conclusions Changes in heart allocation resulted in shorter waitlist times at the expense of longer donor distances and ischemic times, with an associated negative impact on early post-transplantation outcomes. No significant differences in 30-day or 1-year mortality were observed.

Background: Increased intravascular volume has been associated with protection from acute kidney injury (AKI), but in patients with congestive heart failure, venous congestion is associated with increased AKI. We tested the hypothesis that intraoperative venous congestion is associated with AKI after cardiac surgery. Methods: In patients enrolled in the Statin AKI Cardiac Surgery trial, venous congestion was quantified as the area under the curve (AUC) of central venous pressure (CVP) >12, 16, or 20 mm Hg during surgery (mm Hg min). AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria and urine concentrations of tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ([TIMP-2],[IGFBP7]), a marker of renal stress. We measured associations between venous congestion, AKI and [TIMP-2],[IGFBP7], adjusted for potential confounders. Values are reported as median (25the75th percentile). Results: Based on KDIGO criteria, 104 of 425 (24.5%) patients developed AKI. The venous congestion AUCs were 273 mm Hg min (81-567) for CVP >12 mm Hg, 66 mm Hg min (12-221) for CVP >16 mm Hg, and 11 mm Hg min (1-54) for CVP >20 mm Hg. A 60 mm Hg min increase above the median venous congestion AUC above each threshold was independently associated with increased AKI (odds ratio= 1.06; 95% confidence interval [CI], 1.02e1.10; P= 0.008; odds ratio= 1.12; 95% CI, 1.02-1.23; P= 0.013; and odds ratio= 1.30; 95% CI, 1.06-1.59; P= 0.012 for CVP>12, >16, and >20 mm Hg, respectively). Venous congestion before cardiopulmonary bypass was also associated with increased [TIMP-2],[IGFBP7] measured during cardiopulmonary bypass and after surgery, but neither venous congestion after cardiopulmonary bypass nor venous congestion throughout surgery was associated with postoperative [TIMP-2],[IGFBP7]. Conclusion: Intraoperative venous congestion was independently associated with increased AKI after cardiac surgery.

OBJECTIVE:The aim of this study was to model the short term and 2-year overall survival (OS) for intermediate-risk and low-risk patients with severe symptomatic aortic stenosis (AS) undergoing timely or delayed transcatheter aortic valve replacement (TAVR) during the 2019 novel coronavirus (COVID-19) pandemic.METHODS:We developed a decision analysis model to evaluate 2 treatment strategies for both low-risk and intermediate-risk patients with AS during the COVID-19 novel coronavirus pandemic.RESULTS:Prompt TAVR resulted in improved 2-year OS compared with delayed intervention for intermediate-risk patients (0.81 vs 0.67) and low-risk patients (0.95 vs 0.85), owing to the risk of death or the need for urgent/emergent TAVR in the waiting period. However, if the probability of acquiring COVID-19 novel coronavirus is >55% (intermediate-risk patients) or 47% (low-risk patients), delayed TAVR is favored over prompt intervention (0.66 vs 0.67 for intermediate risk; 0.84 vs 0.85 for low risk).CONCLUSIONS:Prompt transcatheter aortic valve replacement for both intermediate-risk and low-risk patients with symptomatic severe AS results in improved 2-year survival when local healthcare system resources are not significantly constrained by the COVID-19.

Purpose This study was to evaluate the effects of ischemic mitral regurgitation (IMR) on vortex formation and leaflet dynamics using an established porcine infarct model of IMR. Methods Using direct coronary ligation, five animals were subjected to a posterolateral myocardial infarction (MI) followed by an MRI at 12-weeks post MI. MR imaging consisted of 4D time-resolved left ventricular (LV) flow, full coverage 2D LV cine, and high resolution 2D cine of mitral valve dynamics. Five additional naïve animals underwent identical imaging protocols to serve as controls. Image analysis was performed to obtain mitral transvalvular flows as well as LV volumes throughout the cardiac cycle. In addition, anterior to posterior mid-leaflet tip distances were measured throughout the cardiac cycle for determination of temporal leaflet dynamics. Results It was found IMR caused asymmetric vortex ring formation with the anterior vortex having a lower vorticity relative to its posterior counterpart. In contrast, normal ventricles create symmetric and tightly curled vortices in the basal chamber just underneath the mitral leaflets which conserve kinetic energy and aid in effective ejection. IMR animals were also evaluated for leaflet separation and were found to have a greater leaflet opening and achieved peak vorticity and peak leaflet opening later than control animals. Conclusion In conclusion, this study shows the effects that altered vortex formation, due to IMR, can have on ventricular filling and leaflet dynamics. These findings have important implications for understanding blood flow through the dilated heart and how ring annuloplasty and volume reduction interventions may influence mitral valve dynamics.

BACKGROUND: Given the shortage of suitable donor hearts for cardiac transplantation and the growing interest in donation after circulatory death (DCD), our institution recently began procuring cardiac allografts from DCD donors. METHODS: Between October 2020 and March 2021, 15 patients with heart failure underwent cardiac transplantation using DCD allografts. Allografts were procured using a modified extracorporeal membrane oxygenation circuit for thoracic normothermic regional perfusion (TA-NRP) and were subsequently transported using cold static storage. Data collection and analysis were performed with institutional review board approval. RESULTS: The mean age of the DCD donors was 23 +/- 7 years and average time on TA-NRP was 56 +/- 8 minutes. Total ischemic time was 183 +/- 31 minutes and distance from transplant center was 373 +/- 203 nautical miles. Recipient age was 55 +/- 14 years, with 8 (55.3%) recipients on durable left ventricular assist device support. Post-transplant, 6 (40%) recipients experienced mild left ventricle primary graft dysfunction (PGD-LV), 3 (20%) recipients experienced moderate PGD-LV, and no recipients experienced severe PGD-LV. Postoperative transthoracic echocardiogram demonstrated left ventricular ejection fraction >55% in all recipients. One recipient (6.6%) developed International Society for Heart and Lung Transplantation 2R acute cellular rejection on first biopsy. At last follow-up, all 15 recipients were alive past 30-days. CONCLUSIONS: Cardiac DCD provides an opportunity to increase the availability of donor hearts for transplantation. Utilizing TA-NRP with cold static storage, we have extended the cold ischemic time of DCD allografts to almost 3 hours, allowing for inter-hospital organ transport. (C) 2021 International Society for Heart and Lung Transplantation. All rights reserved.

Objective: Positive remodeling after thoracic endovascular aortic repair (TEVAR) for chronic thoracic aortic dissection is variable due to incomplete distal seal and retrograde false lumen perfusion. We assessed the outcomes of adjunctive balloon fracture fenestration (BFF) during TEVAR in patients with chronic aortic dissection complicated by negative remodeling. Methods: From June 2013 to January 2016, 49 patients with chronic aortic dissection complicated by aneurysm due to negative remodeling underwent TEVAR with BFF. Contrast-enhanced computed tomography was performed before discharge, at 3 to 6 months, and annually. Results: Intraoperatively, endovascular stent graft expansion was achieved in all patients. There was 1 hospital death due to visceral malperfusion related to acute-onchronic dissection noted before planned BFF. There were no occurrences of paraplegia, 3 patients had stroke, and 3 had acute renal failure. Survival at 1 year was 91%. Late reintervention for incomplete false lumen exclusion was required in 16 patients and freedom from reintervention was 75% at 1 year. Thirty-six patients (73.5%) had complete false lumen thrombosis through the treated segment. True lumen area increased following TEVAR with BFF and continued to incrementally expand with subsequent aortic remodeling at 1-year follow-up. Thirteen patients had positive remodeling, defined as thrombosis of false lumen, >= 10% decrease in aortic dimension, and >= 10% increase in true lumen diameter. Patients with positive remodeling had an average decrease of 11 mm in maximal aortic diameter at final follow-up. Conclusions: BFF of chronic dissection membrane is a beneficial adjunct to TEVAR during short-term follow-up and may promote positive aortic remodeling and is worthy of further study.

Background. Bundled payments for coronary artery bypass grafting (CABG) provide a single reimbursement for care provided from admission through 90 days postdischarge. We aim to explore the impact of complications on total institutional costs, as well as the drivers of high costs for index hospitalization. Methods. We linked clinical and internal cost data for patients undergoing CABG from 2014 to 2017 at a single institution. We compared unadjusted average variable direct costs, reporting excess cost from an uncomplicated baseline. We stratified by The Society of Thoracic Surgeons preoperative risk and quality outcome measures as well as value-based outcomes (readmission, post-acute care utilization). We performed multivariable linear regression to evaluate drivers of high costs, adjusting for preoperative and intraoperative characteristics and postoperative complications. Results. We reviewed 1789 patients undergoing CABG with an average of 2.7 vessels (SD 0.89). A significant proportion of patients were diabetic (51.2%) and obese (mean body mass index 30.6, SD 6.1). Factors associated with increased adjusted costs were preoperative renal failure (P = .001), diabetes (P = .001) and body mass index (P = .05), and postoperative stroke (P < .001), prolonged ventilation (P < .001), rebleeding requiring reoperation (P < .001) and renal failure (P < .001) with varying magnitude. Preoperative ejection fraction and insurance status were not associated with increased adjusted costs. Conclusions. Preoperative characteristics had less of an impact on costs post-CABG than postoperative complications. Postoperative complications vary in their impact on internal costs, with reoperation, stroke, and renal failure having the greatest impact. In preparation for bundled payments, hospitals should focus on understanding and preventing drivers of high cost. (C) 2021 by The Society of Thoracic Surgeons