Objective:Hypothermic perfusion has been introduced for donor heart storage for ∼9 hours. However, opportunities exist to further define the optimal physiological conditions for a more prolonged period with 18 hours of preservation. In particular, the utility of exogenous cellular therapies such as administration of mitochondria are unknown in this setting. Methods:We examined several key aspects of the protocol for hypothermic perfusion of the donor heart. Yorkshire pigs hearts were used for perfusion with histidine-tryptophan-ketoglutarate (HTK) solution at ∼8 °C for 18 hours under different conditions followed by reanimation with normothermic perfusion for 3 hours. Results:HTK perfusate oxygenation was associated with worse contractility (Max dP/dt 630.38 ± 376.63 mm Hg/s vs 1101.80 ± 338.93 mm Hg/s, P = .028) and relaxation (Min dP/dt -512.31 ± 275.23 mm Hg/s vs -1009.26 ± 443.31 mm Hg/s, P = .028) as well as increased cell death and lower coronary blood flow. Compared with fresh HTK perfusion, recirculation of the perfusate was associated with worse contractility (Max dP/dt 671.60 ± 249.00 mm Hg/s vs 987.18 ± 219.16 mm Hg/s, P = .021) and relaxation (Min dP/dt -477.83 ± 158.02 mm Hg/s vs -824.48 ± 270.93 mm Hg/s, P = .003), which was accompanied by greater cell death. Antegrade coronary perfusion was better than retrograde via coronary sinus, resulting in superior contractility (Max dP/dt 987.18 ± 219.16 mm Hg/s vs 612.67 ± 258.40 mm Hg/s, P = .005) and relaxation (Min dP/dt -824.48 ± 270.93 mm Hg/s vs -401.59 ± 143.59 mm Hg/s, P = .001) as well as less cell death. The administration of porcine mitochondria promptly improved contractility (Max dP/dt 1764.06 ± 542.34 mm Hg/s vs 1101.80 ± 338.93 mm Hg, P = .007). Conclusions:Avoidance of excess oxygenation, use of fresh HTK, antegrade cardioplegia delivery, as well as delivery of stored frozen mitochondria are key for the success of greatly prolonged hypothermic cardiac perfusion preservation.

BACKGROUND:With rapid advances in donor heart preservation technology, insights into related molecular responses are needed. METHODS:We performed single-nuclei RNA sequencing and metabolomics on the human left ventricle to elucidate differences between donation after brain (DBD) vs cardiac death (DCD). RESULTS:Our study revealed fundamentally different human cardiac biology at the transcriptomic and metabolomic levels between DBD vs DCD. DCD hearts are marked by ischemic metabolic responses and generation of oxidative substrates. DCD cardiomyocytes and fibroblasts also display robust proinflammatory and profibrotic responses, while endothelial cells are already primed for leukocyte recruitment at the time of procurement. Interestingly, resident cardiac macrophages also shifted towards a proinflammatory phenotype with an increase in human leukocyte antigen expression in DCD hearts. DBD hearts have a more favorable transcriptional profile for oxidative phosphorylation processes but also harbor a proinflammatory endothelium, possibly related to brain death. CONCLUSIONS:These insights offer an understanding of biological processes underlying these donation protocols which may impact early donor heart function as well as graft longevity after transplantation. Our study also describes potential molecular targets for developing future therapies to mitigate preservation-induced cardiac injury and immune-mediated rejection.

Heart transplantation is the gold standard treatment for patients with end-stage heart failure. However, there is a shortage of donor hearts available. The short tolerable cold ischemic time for delivering donor hearts to matching recipients is closely responsible for this shortage. Here we uncover the phenomenon of mineralocorticoid receptor (MR) phase separation, which exacerbates injury to the murine and human donor heart during cold storage and can be modulated with pharmacological inhibition to improve preservation quality. Interestingly, donor cardiomyocytes strongly expressed MR, which undergoes preservation-related phase separation. The phenomenon of macromolecular phase separation is not limited to the heart or MR during preservation. Cold preservation of the lung, liver and kidney also displays phase separation of other transcriptional regulators including histone deacetylase 1 (HDAC1), bromodomain-containing 4 (BRD4) and MR. Our results reveal an understudied area of preservation biology that may be further exploited to improve the preservation of multiple solid organs. Lei et al. show that cold preservation of heart transplants triggers mineralocorticoid receptor clustering in cardiomyocyte nuclei, and blocking this improves heart transplant function.

Chapter 3 Continuous-Flow Left Ventricular Assist Devices: Perspective on Engineering and Pump Technology Paul C. Tang MD, PhD, Paul C. Tang MD, PhDSearch for more papers by this authorFrancis D. Pagani MD, PhD, Francis D. Pagani MD, PhDSearch for more papers by this author Paul C. Tang MD, PhD, Paul C. Tang MD, PhDSearch for more papers by this authorFrancis D. Pagani MD, PhD, Francis D. Pagani MD, PhDSearch for more papers by this author Book Editor(s):Yaron D. Barac, Yaron D. BaracSearch for more papers by this authorScott C. Silvestry, Scott C. SilvestrySearch for more papers by this authorMani A. Daneshmand, Mani A. DaneshmandSearch for more papers by this authorDaniel J. Goldstein, Daniel J. GoldsteinSearch for more papers by this author First published: 08 September 2023 https://doi.org/10.1002/9781119633884.ch3 AboutPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShareShare a linkShare onEmailFacebookTwitterLinkedInRedditWechat Abstract This chapter on continuous flow (CF) device technology engages in an in-depth discussion on the engineering aspects of CF devices. It examines the energy transfer mechanics of centrifugal versus axial devices and the impact of novel noncontact pump bearings. CF rotary pumps dominate the field of mechanical circulatory support, with nearly all left ventricular assist device implants in the USA representing CF rotary pump technology. There are essentially two types of CF rotary pumps that have been used for clinical circulatory support: a centrifugal flow pump and axial flow pump. CF rotary pump designs can be further distinguished by the mechanism of impeller suspension or levitation and include use of mechanical bearings; hydrodynamic bearings; hydrodynamic bearings working in synergy with magnetic suspension; or variations of active and/or passive magnetic suspension. Depending on pump design and hemodynamic conditions, CF rotary pumps can provide either full support or partial support. References Wesolowski SA , Fisher JH , Welch CS . Perfusion of the pulmonary circulation by nonpulsatile flow . Surgery . 1953 ; 33 : 370 – 375 . CASPubMedWeb of Science®Google Scholar Nose Y . Is a pulsatile cardiac prosthesis a dying dinosaur? Artif Organs . 1992 ; 16 : 233 – 234 . 10.1111/j.1525-1594.1992.tb00302.x CASPubMedWeb of Science®Google Scholar Hindman BJ , Dexter F , Ryu KH , Smith T , Cutkomp J . Pulsatile versus nonpulsatile cardiopulmonary bypass. No difference in brain blood flow or metabolism at 27 degrees C . Anesthesiology . 1994 ; 80 : 1137 – 1147 . 10.1097/00000542-199405000-00023 CASPubMedWeb of Science®Google Scholar Mehra MR , Uriel N , Naka Y , et al. A fully magnetically levitated left ventricular assist device—final report . N Engl J Med . 2019 ; 380 : 1618 – 1627 . 10.1056/NEJMoa1900486 PubMedWeb of Science®Google Scholar Allen SR , Slaughter MS , Ahmed MM , et al. COMPETENCE trial: the EVAHEART 2 continuous flow left ventricular assist device . J Heart Lung Transplant . 2023 ; 42 ( 1 ): 33 – 39 . 10.1016/j.healun.2022.10.011 PubMedWeb of Science®Google Scholar Shah P , Yuzefpolskaya M , Hickey GW , et al. Twelfth Interagency Registry for Mechanically Assisted Circulatory Support Report: readmissions after left ventricular assist device . Ann Thorac Surg . 2022 ; 113 : 722 – 737 . 10.1016/j.athoracsur.2021.12.011 PubMedWeb of Science®Google Scholar Schumer EM , Black MC , Monreal G , Slaughter MS . Left ventricular assist devices: current controversies and future directions . Eur Heart J . 2016 ; 37 : 3434 – 3439 . 10.1093/eurheartj/ehv590 PubMedWeb of Science®Google Scholar O'Connor MJ , Lorts A , Davies RR , et al. Early experience with the HeartMate 3 continuous-flow ventricular assist device in pediatric patients and patients with congenital heart disease: a multicenter registry analysis . J Heart Lung Transplant . 2020 ; 30 : 573 – 579 . 10.1016/j.healun.2020.02.007 Google Scholar McGiffin D , Kure C , McLean J , et al. The results of a single-center experience with HeartMate 3 in a biventricular configuration . J Heart Lung Transplant . 2021 ; 40 : 193 – 200 . 10.1016/j.healun.2020.12.006 PubMedWeb of Science®Google Scholar Lavee J , Mulzer J , Krabatsch T , et al. An international multicenter experience of biventricular support with HeartMate 3 ventricular assist systems . J Heart Lung Transplant . 2018 ; 37 : 1399 – 1402 . 10.1016/j.healun.2018.08.008 PubMedWeb of Science®Google Scholar Hanke JS , Dogan G , Haverich A , Schmitto JD . Implantation of two HeartMate 3s in the setting of a total artificial heart . J Optechstcvs . 2021 ; 26 : 67 – 80 . Google Scholar Daneshmand MA , Bishawi M , Milano CA , et al. The HeartMate 6 . ASAIO J . 2020 ; 66 : e46 – e49 . 10.1097/MAT.0000000000001011 PubMedWeb of Science®Google Scholar Kocabeyoglu SS , Kervan U , Sert DE , et al. Is it possible to implant HeartMate 3 less invasively? New pump, new approach . Artif Organs . 2018 ; 42 : 1132 – 1138 . 10.1111/aor.13289 PubMedWeb of Science®Google Scholar Pagani FD . Continuous-flow rotary left ventricular assist devices with "3rd generation" design . Semin Thorac Cardiovasc Surg . 2008 ; 20 : 255 – 263 . 10.1053/j.semtcvs.2008.08.002 PubMedGoogle Scholar Moazami N , Fukamachi K , Kibayashi M , et al. Axial and centrifugal continuous-flow rotary pumps: a translation from pump mechanics to clinical practice . J Heart Lung Transplant . 2013 ; 32 : 1 – 11 . 10.1016/j.healun.2012.10.001 PubMedWeb of Science®Google Scholar Mehra MR , Naka Y , Goldstein DJ , et al. A fully magnetically levitated circulatory pump for advanced heart failure . N Engl J Med . 2017 ; 376 : 440 – 450 . 10.1056/NEJMoa1610426 PubMedWeb of Science®Google Scholar Capoccia M . Mechanical circulatory support for advanced heart failure: are we about to witness a new "Gold Standard"? J Cardiovasc Dev Dis . 2016 ; 3 ( 4 ): 35 . 10.3390/jcdd3040035 PubMedGoogle Scholar Bottrell S , Bennett M , Augustin S , et al. A comparison study of haemolysis production in three contemporary centrifugal pumps . Perfusion . 2014 ; 29 : 411 – 416 . 10.1177/0267659113509000 CASPubMedWeb of Science®Google Scholar Wiegmann L , Thamsen B , de Zélicourt D , et al. Fluid dynamics in the HeartMate 3: influence of the artificial pulse feature and residual cardiac pulsation . Artif Organs . 2019 ; 43 : 363 – 376 . 10.1111/aor.13346 PubMedWeb of Science®Google Scholar Hosseinipour M , Gupta R , Bonnell M , Elahinia M . Rotary mechanical circulatory support systems . J Rehab Ass Technol Eng . 2017 ; 4 : 1 – 24 . Google Scholar Sundareswaran KS , Reichenbach SH , Masterson KB , Butler KC , Farrar D . Low bearing wear in explanted HeartMate II left ventricular assist devices after chronic clinical support . ASAIO J . 2013 ; 59 : 41 – 45 . 10.1097/MAT.0b013e3182768cfb PubMedWeb of Science®Google Scholar Starling RC , Moazami N , Silvestry SC , et al. Unexpected abrupt increase in left ventricular assist device thrombosis . N Engl J Med . 2014 ; 370 : 33 – 40 . 10.1056/NEJMoa1313385 CASPubMedWeb of Science®Google Scholar Larose JA , Tamez D , Ashenuga M , Reyes C . Design concepts and principle of operation of the HeartWare ventricular assist system . ASAIO J . 2010 ; 56 : 285 – 289 . 10.1097/MAT.0b013e3181dfbab5 PubMedWeb of Science®Google Scholar Loree HM , Bourque K , Gernes DB , et al. The HeartMate III: design and in vivo studies of a MagLev centrifugal left ventricular assist device . Artif Organs . 2001 ; 25 : 386 – 391 . 10.1046/j.1525-1594.2001.025005386.x CASPubMedWeb of Science®Google Scholar Salamonsen RF , Mason DG , Ayre PJ . Response of rotary blood pumps to changes in preload and afterload at a fixed speed setting are unphysiological when compared with the natural heart . Artif Organs . 2011 ; 35 : E47 – E53 . 10.1111/j.1525-1594.2010.01168.x PubMedWeb of Science®Google Scholar Salamonsen RF , Pellegrino V , Frazer JF , et al. Exercise studies in patients with rotary blood pumps: cause, effects, and implications for Starling-like control of changes in pump flow . Artif Organs . 2013 ; 37 : 695 – 703 . 10.1111/aor.12070 PubMedWeb of Science®Google Scholar Saeed O , Jermyn R , Kargoli F , et al. Blood pressure and adverse events during continuous flow left ventricular assist device support . Circ Heart Fail . 2015 ; 8 : 551 – 556 . 10.1161/CIRCHEARTFAILURE.114.002000 PubMedWeb of Science®Google Scholar Ising MS , Sobieski MA , Slaughter MS , Koenig SC , Giridharan G . Feasibility of pump speed modulation for restoring vascular pulsatility with rotary blood pumps . ASAIO J . 2015 ; 61 : 526 – 532 . 10.1097/MAT.0000000000000262 PubMedWeb of Science®Google Scholar Tchantchaleishvili V , Luc JGY , Cohan CM , et al. Clinical implications of physiologic flow adjustment in continuous-flow left ventricular assist devices . ASAIO J . 2017 ; 63 : 241 – 250 . 10.1097/MAT.0000000000000477 PubMedWeb of Science®Google Scholar Schmitto JD , Hanke JS , Rojas S , Avsar M , Haverich A . First implantation in man of a new magnetically levitated left ventricular assist device (HeartMate III) . J Heart Lung Transplant . 2015 ; 34 : 858 – 860 . 10.1016/j.healun.2015.03.001 PubMedWeb of Science®Google Scholar Mehra MR , Goldstein DJ , Cleveland JC , et al. Two-year outcomes with a magnetically levitated cardiac pump in heart failure . N Engl J Med . 2018 ; 378 : 1386 – 1395 . 10.1056/NEJMoa1800866 PubMedWeb of Science®Google Scholar Pagani FD , Cantor R , Cowger J , et al. Concordance of treatment effect: an analysis of the Society of Thoracic Surgeons Intermacs Database . Ann Thorac Surg . 2022 ; 113 : 1172 – 1182 . 10.1016/j.athoracsur.2021.05.017 PubMedWeb of Science®Google Scholar Teuteberg JJ , Cleveland JC Jr , Cowger J , et al. The Society of Thoracic Surgeons Intermacs 2019 annual report: the changing landscape of devices and indications . Ann Thorac Surg . 2020 ; 109 : 649 – 660 . 10.1016/j.athoracsur.2019.12.005 PubMedWeb of Science®Google Scholar Textbook of Transplantation and Mechanical Support for End‐Stage Heart and Lung Disease ReferencesRelatedInformation

The evaluation of durable mechanical circulatory support (MCS) candidacy is critical for reaching the goal of acceptable long-term outcomes with the understanding that it is often an unfamiliar technology for patients.1-3 Therefore, psychosocial assessment is essential for promoting synchrony in patient, carer, and provider expectations for a device with immense postoperative management implications. However, standardized assessment of complex psychosocial issues between programs and within institutional evaluators surrounding social support, psychological health, and financial resources has been challenging.

Extracorporeal membrane oxygenation (ECMO) is a type of extracorporeal life support (ECLS) in which the function of the heart and/or lungs is partially or completely replaced by a portable system that provides prolonged support to critically ill patients with respiratory or cardiac failure. There are two major variants of ECMO: veno-venous (VV) ECMO and veno-arterial (VA) ECMO. VV ECMO replaces the function of the lung in which it uses a cannula to remove venous blood and oxygenates it using the extracorporeal system, and returns the blood to the right atrium to be pumped to the body. VA ECMO is slightly different in that it replaces the function of the heart and lungs by returning oxygenated blood to the aorta. As a therapy for respiratory failure, ECMO minimizes hypoxia, diminishes lung stress and strain, and allows lung protective mechanical ventilation. As a support for acute and terminal heart failure, ECMO reduces preload, increases aortic flow, and allows for end-organ perfusion. Due to its physiological support and advantages, it is used for a variety of chronic and acute support purposes such as bridge therapy for heart/lung transplant, durable ventricular assist devices, and intermediate-term mechanical support postoperatively. Our review gives a broad overview of the two main types of ECMO strategies and their clinical indications, cannulation strategies, unique clinical utility, and their limitations.

Women with advanced heart failure receive advanced surgical therapies such as durable left ventricular assist device (LVAD) implantation or heart transplantation at a rate much lower compared to males. Reasons for this discrepancy remain largely unknown. Much of what is understood reflects outcomes of those patients who ultimately receive device implant or heart transplantation. Females have been shown to have a higher mortality following LVAD implantation and experience higher rates of bleeding and clotting phenomena and right ventricular failure. Beyond outcomes, the literature is limited in the identification of pre-operative factors that drive lower than expected LVAD implant rates in this population. More focused research is needed to define the disparities in advance heart failure therapy delivery in women and other underserved populations.

Objective To present clinicians at the point-of-care with real-world data on the effectiveness of various treatment options in a precision cohort of patients closely matched to the index patient. Materials and Methods We developed disease-specific, machine-learning, patient-similarity models for hypertension (HTN), type II diabetes mellitus (T2DM), and hyperlipidemia (HL) using data on approximately 2.5 million patients in a large medical group practice. For each identified decision point, an encounter during which the patient’s condition was not controlled, we compared the actual outcome of the treatment decision administered to that of the best-achieved outcome for similar patients in similar clinical situations. Results For the majority of decision points (66.8%, 59.0%, and 83.5% for HTN, T2DM, and HL, respectively), there were alternative treatment options administered to patients in the precision cohort that resulted in a significantly increased proportion of patients under control than the treatment option chosen for the index patient. The expected percentage of patients whose condition would have been controlled if the best-practice treatment option had been chosen would have been better than the actual percentage by: 36% (65.1% vs 48.0%, HTN), 68% (37.7% vs 22.5%, T2DM), and 138% (75.3% vs 31.7%, HL). Conclusion Clinical guidelines are primarily based on the results of randomized controlled trials, which apply to a homogeneous subject population. Providing the effectiveness of various treatment options used in a precision cohort of patients similar to the index patient can provide complementary information to tailor guideline recommendations for individual patients and potentially improve outcomes.

To support point-of-care decision making by presenting outcomes of past treatment choices for cohorts of similar patients based on observational data from electronic health records (EHRs), a machine-learning precision cohort treatment option (PCTO) workflow consisting of (1) data extraction, (2) similarity model training, (3) precision cohort identification, and (4) treatment options analysis was developed. The similarity model is used to dynamically create a cohort of similar patients, to inform clinical decisions about an individual patient. The workflow was implemented using EHR data from a large health care provider for three different highly prevalent chronic diseases: hypertension (HTN), type 2 diabetes mellitus (T2DM), and hyperlipidemia (HL). A retrospective analysis demonstrated that treatment options with better outcomes were available for a majority of cases (75%, 74%, 85% for HTN, T2DM, HL, respectively). The models for HTN and T2DM were deployed in a pilot study with primary care physicians using it during clinic visits. A novel data-analytic workflow was developed to create patient-similarity models that dynamically generate personalized treatment insights at the point-of-care. By leveraging both knowledge-driven treatment guidelines and data-driven EHR data, physicians can incorporate real-world evidence in their medical decision-making process when considering treatment options for individual patients.

Background: We aimed to quantify incidence and operative risks associated with reoperative valve surgeries (RVS) in patients with drug-associated infective endocarditis in a multi-center setting. Methods: We formed a registry of patients with drug-associated infective endocarditis who underwent valve surgeries at 8 US centers between 2011 and 2017. Outcomes of first-time valve surgery (FVS) and RVS were compared. Multivariable logistic regression models related RVS to 30-day mortality. Poisson regression models were fitted to evaluate temporal trends in overall case volume and proportions of patients undergoing RVS. Results: The cohort consisted of 925 patients with drug-associated infective endocarditis who underwent a valve surgery, of which 652 were FVS and 273 were RVS. Patients undergoing FVS had fewer comorbidities than those undergoing RVS. Overall case volume increased from 108 in 2012 to 229 cases in 2017 (P < .001). The proportion of redo valve cases increased from 19% in 2012 to 28% in 2017 (P < .001). The 30-day mortality in RVS was higher compared with FVS (8.1% vs 4.8%; P = .049). An increase in unadjusted mortality rates were observed as the number of prior cardiac surgeries increased, from 4.8% in FVS to 11.8% in >= 3 RVS. Multivariable model demonstrated that RVS was associated with an increased risk of 30-day mortality (odds ratio, 2.22; 95 % confidence interval, 1.22-4.06; P = .010). Conclusions: An increasing proportion of valve surgery for drug-associated infective endocarditis is for RVS. Despite being young and harboring few comorbidities, the RVS cohort is still susceptible to increased risk of 30-day mortality compared with those undergoing FVS.

If you are suicidal and need emergency help, call 911 immediately or 1-800-273-8255 if in the United States. If you are in another country, find a 24/7 hotline at www.iasp.info/resources/Crises_Centres. […]

Background: This study compares the morphology and outcomes of acute retrograde type A dissections (RTADs) with acute antegrade type A dissections (ATADs), and acute type B dissections.Materials and methods: From 2000 to 2016, there were 12 acute RTADs, 96 ATADs, and 92 type B dissections with available imaging. Dissections were characterized using computerized tomography angiography images. We examined clinical features, tear characteristics, and various morphologic measurements.Results: Compared with acute type B dissections, RTAD primary tears were more common in the distal arch (75% versus 43%, P = 0.04), and the false-to-true lumen contrast intensity ratio at the mid-descending thoracic aorta was lower (0.46 versus 0.71, P = 0.020). RTAD had less false lumen decompression because there were fewer aortic branch vessels distal to the subclavian that were perfused through the false lumen (0.40 versus 2.19, P < 0.001). Compared with ATAD, RTAD had less root involvement where root true-to-total lumen area ratio was higher (0.88 versus 0.76, P = 0.081). Furthermore, RTAD had a lower false-to-true lumen contrast intensity ratio at the root (0.25 versus 0.57, P < 0.05), ascending aorta (0.25 versus 0.72, P < 0.001), and proximal arch (0.39 versus 0.67, P < 0.05). RTAD were more likely to undergo aortic valve resuspension (100% versus 74%, P = 0.044).Conclusions: RTAD tends to occur when primary tears occur in close proximity to the aortic arch and when false lumen decompression through the distal aortic branches are less effective. Compared with ATAD, RTAD has less root involvement, and successful aortic valve resuspension is more likely. Published by Elsevier Inc.

Health insurance status at the time of heart transplant (HTX) influences long term patient (PT) survival. However, its impact on HTX graft failure is unclear.

This Viewpoint from the National Academy of Medicine's 2016 Vital Directions initiative explores several topics that are key to the democratization of health care and proposes policy considerations to engage the United States in a journey to better health.

Background. This study investigates the efficacy of aortic valve (AV) resuspension with preservation of the native aortic root in maintaining AV competence during type A dissection repair.Methods. A total of 154 acute type A dissection repairs were performed from January 2000 to July 2015. AV resuspension was performed in 120 patients to address AV insufficiency (AI). Survival data were derived from 120 patients who had AV resuspensions and all 154 acute type A dissection repairs.Results. Of the 70 patients who presented initially with moderate-to-severe AI, 43 underwent AV resuspension. Echocardiographic data for analysis were available in 40 of these 43 patients. In the group with moderate-to-severe AI at presentation, AV resuspension was able to achieve mild or less AI in 38 of 40 patients (95%) and trivial or noAI in 29 of 40 patients (73%) after weaning from cardiopulmonary bypass. The presence of moderate-to-severe preoperative AI did not predict the ability to achieve trivial or noAIwith resuspension immediately after coming off cardiopulmonary bypass (p = 0.3) or on subsequent follow-up (p = 0.8). Mean echocardiographic follow-up for AV resuspension was 1.21 +/- 2.57 years. Three patients who underwent AV resuspension required AV reoperation at follow-up. There was no survival difference between patients who did or did not have AV resuspension (p = 0.3).Conclusions. AV resuspension is able to improve valve competency with good outcomes even in patients with moderate or severe AI at presentation. Overall long-term survival is unchanged compared with other operative strategies for the AV. (C) 2017 by The Society of Thoracic Surgeons

Over the last 5 years, stimulated by the changing healthcare environment and the Health Information Technology for Economic and Clinical Health (HITECH) Meaningful Use (MU) Electronic Health Record (EHR) Incentive program, EHR adoption has increased remarkably, and there is early evidence that such adoption has resulted in healthcare safety and quality benefits.1,2 However, with this broad adoption, many clinicians are voicing concerns that EHR use has had unintended clinical consequences, including reduced time for patient-clinician interaction,3 new and burdensome data entry tasks being transferred to front-line clinicians,4,5 and lengthened clinician workdays.6–8 Additionally, interoperability between different EHR systems has languished despite large efforts towards that goal.9,10 These challenges are contributing to physicians’ decreased satisfaction with their work lives.11–13 In professional journals,14 press reports,15–17 on wards, and in clinics, we have heard of the difficulties that the transition from paper records to EHRs has created.18 As a result, clinicians are seeking help to get through their work days, which often extend into evenings devoted to writing notes. Examples of comments we have received from clinicians and patients include: “Computers always make things faster and cheaper. Not this time,” and “My doctor pays more attention to the computer than to me.” Ultimately the healthcare system's goal is to create a robust, integrated, and interoperable healthcare system that includes patients, physician practices, public health, population management, and support for clinical and basic sciences research. This ecosystem has been referred to as the “learning health system.”19 EHRs are an important part of the learning health system, along with many other clinical systems, but future ways in which information is transformed into knowledge will likely require all parts of the system working together. Potentially every patient encounter could present an …