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

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

OBJECTIVE:Compare in-hospital mortality and complication rates between central and peripheral extracorporeal membrane oxygenation (ECMO) cannulation in adult patients with postcardiotomy shock. DESIGN:Retrospective observational study. SETTING:Tertiary academic center. PARTICIPANTS:Adult patients who received ECMO due to failure to wean from cardiopulmonary bypass or with cardiogenic shock or cardiac arrest <24 hours after weaning from cardiopulmonary bypass from 2010 to 2023. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Patients were grouped by cannulation type: central (n = 241) and peripheral (n = 78). Primary outcomes were in-hospital mortality, bleeding requiring reoperation, stroke, limb ischemia, mechanical ventilation >7 days, and sepsis. Stabilized inverse probability of treatment weighting based on propensity scores was used to adjust baseline differences. Median age was 68.5 years, and 37.3% were female. Peripheral ECMO was associated with higher left ventricular ejection fraction (p = 0.016) and posttransplant indication (p = 0.026). Baseline imbalances were satisfactorily corrected after inverse probability of treatment weighting. After propensity score weighting, there were no significant differences in in-hospital mortality (49.8% v 44.5%, p = 0.416) or the other primary outcomes. CONCLUSION:Central and peripheral ECMO cannulation showed no significant differences in in-hospital mortality or major complications. ECMO cannulation strategy should be guided by patient condition and institutional expertise.

Objective: To evaluate operative and midterm outcomes, including 1-, 3-, and 5-year survival, of transatrial transcatheter mitral valve replacement (TA-TMVR) with a balloon-expandable valve for severe mitral annular calcification (MAC). Methods: We retrospectively reviewed patients with severe MAC who underwent TA-TMVR from 2014 to 2024 using a balloon-expandable prosthesis. Results: Twenty-five patients (68% were female, mean age 75 years) had TA-TMVR for mitral valve disease (92% severe stenosis, 52% moderate-to-severe mitral regurgitation). Previous cardiac surgery was common (48%). Median Society of Thoracic Surgeons Predicted Risk of Operative Mortality was 9% (2%-26%). Most patients were New York Heart Association class III or IV (76%). Preoperative left ventricular ejection fraction was 66%. Concomitant procedures were performed in 68% of cases (aortic valve replacement in 11, septal myectomy in 6, other procedures in 9). A SAPIEN 3 valve was used in 24 patients; most were modified with a felt skirt to improve sealing. Anterior leaflet resection was performed in 24 patients. Operative mortality was 12%. Median length of stay was 14 days. Postoperative left ventricular ejection fraction was 64%, and the mean mitral valve gradient was 5 mm Hg. Paravalvular leak were observed in 6 patients; 3 underwent successful transcatheter closure. One of these patients required a percutaneous valve-in-valve for on-going hemolysis. One-, 3-, and 5-year survival was 68%, 59.5%, and 50.6%, respectively. Conclusions: TA-TMVR with a balloon-expandable valve is a feasible and durable option for high-risk patients with severe MAC and those requiring concomitant procedures, offering an alternative to conventional surgery in anatomically complex or otherwise-inoperable cases.

Objectives To evaluate whether change in QRS duration (ΔQRS), defined as postoperative QRS duration minus preoperative QRS duration, after septal myectomy for obstructive hypertrophic cardiomyopathy (oHCM) has prognostic significance for all-cause mortality. Methods We performed a retrospective, single-center cohort study of patients with oHCM who underwent transaortic septal myectomy between July 23, 2009, and July 30, 2020, with available preoperative and early postoperative (days 4-7) electrocardiography (ECG) data. Patients with a preoperative or postoperative permanent pacemaker were excluded. The primary outcome was all-cause mortality. Multivariable Cox models were adjusted for age, sex, operative time, major concomitant surgery, and preoperative right bundle branch block. ECG analyses examined preoperative QRS duration, ΔQRS (postoperative minus preoperative QRS), and, in exploratory models, postoperative left bundle branch block (LBBB) and absolute postoperative QRS duration. Results Among 1143 patients (1141 in complete-case multivariable analyses), the mean preoperative QRS duration was 129.5 ± 25.4 ms and increased modestly postoperatively (133.5 ± 26.0 ms); the mean ΔQRS was 4.0 ± 12.8 ms. A total of 122 deaths occurred during follow-up. Preoperative QRS duration was not associated with mortality (hazard ration [HR] per 10 ms, 1.01; 95% confidence interval [CI], 0.94-1.09; P = .78). In contrast, greater ΔQRS was independently associated with higher mortality (HR per 10 ms, 1.16; 95% CI, 1.01-1.34; P = .037), including after adjustment for preoperative QRS duration. Threshold analyses demonstrated increased risk with ΔQRS ≥0 ms (HR, 1.88; 95% CI, 1.17-3.03; P = .009) and ΔQRS ≥10 ms (HR, 1.84; 95% CI, 1.26-2.68; P = .001). Absolute postoperative QRS duration ≥150 ms was not associated with mortality (HR, 1.14; 95% CI, 0.76-1.71; P = .52). In exploratory comparison models, ΔQRS showed a stronger and more consistent association with mortality compared to postoperative LBBB or absolute postoperative QRS duration. Conclusions ΔQRS following transaortic septal myectomy for oHCM was independently associated with all-cause mortality. In exploratory comparison models, ΔQRS showed a stronger and more consistent association with mortality compared to postoperative LBBB or absolute postoperative QRS duration. ΔQRS may represent a simple, clinically available marker to enhance postoperative risk stratification following septal myectomy for oHCM.

BACKGROUND:Human leukocyte antigen (HLA) sensitization is a significant barrier to transplantation for many patients. Daratumumab has proven safety and tolerability in multiple myeloma. We hypothesized that daratumumab monotherapy could be an effective and safe desensitization strategy in highly sensitized patients awaiting cardiac transplantation. OBJECTIVES:The primary end-point of this trial was the scope of daratumumab in lowering HLA antibodies. Secondary end-points included presence of donor-specific antibody, incidence of cellular and antibody-mediated rejection (AMR) and cardiac allograft function. METHODS:Six consecutive highly sensitized patients were enrolled who had a calculated panel reactive antibody >50% using a mean fluorescence intensity (MFI) threshold >4,000 through a single antigen bead assay. Three completed the full 8 weeks of daratumumab therapy. HLA antibodies with MFI >10,000 were considered unacceptable for donor offers. All patients received weekly doses of 1,800 mg daratumumab and 30,000 units hyaluronidase subcutaneously for a planned total of 8 weeks. RESULTS:There was a significant reduction in HLA class I and class II antibodies by the time of heart transplantation. Daratumumab was well tolerated and without any serious adverse events. By the time of this publication, 5 of the total of 6 patients enrolled have been successfully transplanted. None of the patients enrolled experienced AMR and maintain normal cardiac allograft function. CONCLUSIONS:Daratumumab monotherapy may be a safe and effective desensitization strategy in highly sensitized patients who are otherwise eligible for heart transplantation and considered too ill for other desensitization strategies.

Objective: Previous studies have reported an increased risk of stroke with non-full sternotomy access during cardiac valve operations, but the clinical significance of these strokes has not yet been explored. We sought to determine the incidence and clinical magnitude of postoperative stroke following non-full versus full sternotomy access. Methods: We analyzed the records of 12,406 patients who underwent a cardiac valve operation with full median sternotomy (n = 10,863; 88%), partial sternotomy (n = 219; 1.8%), or thoracotomy (n = 1324;11%) access between January 1997 and March 2021. The primary outcome was permanent stroke, categorized using the modified Rankin Scale (mRS; score 0-6) at discharge. Multivariable logistic regression analysis was used to assess the risk of stroke. Results: The rate of stroke was 1.0% in the full sternotomy group, 2.7% in the partial sternotomy group, and 1.2% in the thoracotomy group (P = .044). The majority of strokes were mildly disabling (mRS <2), both overall (n = 82; 62%) and in each group (range, 60%-69%). There was an increased risk of stroke with partial versus full sternotomy (odds ratio [OR], 3.73; 95% confidence interval [CI], 1.59-8.78; P = .010) but not with thoracotomy versus full sternotomy (OR, 1.34; 95% CI, 0.48-3.77). There was no differential effect of sternotomy type on stroke risk according to type of valve operation (P = .985). Stroke-related mortality was uncommon (1.3%). Conclusions: Partial sternotomy versus full sternotomy is associated with increased risk of stroke, whereas thoracotomy versus full sternotomy is not. The risk of stroke is low, with most strokes being only mildly disabling. (JTCVS Open 2025;23:150-6)

Redo-bilateral lung transplant in previous heart-lung transplant is a rare operation. We describe our surgical and medical management experience with a heart-lung transplant recipient who developed chronic lung allograft dysfunction and invasive Scedosporium apiospermum infection. The patient underwent a redo-bilateral lung transplant followed by a combination of inhaled voriconazole, caspofungin, and olorofim for a prolonged period. We observed no issues with bronchial anastomosis healing, and the patient is doing well on 1-year follow-up. This report outlines a successful management approach to this rare complication of heart-lung transplant recipients.

OBJECTIVE:Coronary artery bypass grafting improves outcomes in patients with ischemic cardiomyopathy, but data on improvement in left ventricular ejection fraction after coronary artery bypass grafting, its impact on late survival, and predictors of left ventricular ejection fraction improvement are limited. METHODS:We analyzed 679 patients with severe left ventricular dysfunction (≤35%) undergoing isolated coronary artery bypass grafting at our institution (2003-2020). Change in left ventricular ejection fraction after surgery and longitudinal trends in left ventricular ejection fraction over follow-up were analyzed using repeated left ventricular ejection fraction measurements. Using a generalized least squares model, an association of baseline factors with longitudinal changes in left ventricular ejection fraction was evaluated. An extended Cox proportional hazards regression model with serial left ventricular ejection fraction measurements incorporated as a time-dependent covariate was used to assess whether improvements in left ventricular ejection fraction affected long-term outcomes. RESULTS:Median age of the study cohort was 67.6 [interquartile range, 60-76] years, and 79.1% were male. Operative mortality was 2.2% (n = 15). After coronary artery bypass grafting, left ventricular ejection fraction improved by a median of 5 units (interquartile range, 0-12) at the initial prehospital dismissal assessment (P <.001). Over a median follow-up period of 10.5 (interquartile range, 5.7-15.0) years, lower preoperative left ventricular ejection fraction showed a strong initial improvement followed by a steady decline, whereas patients with higher preoperative left ventricular ejection fraction values had smaller initial but more sustained improvements in predicted left ventricular ejection fraction over time. History of revascularization, higher preoperative left ventricular end-diastolic dimension, and mitral valve regurgitation were important risk factors for impaired left ventricular ejection fraction outcomes, whereas younger age and extremes of older age were associated with improved left ventricular ejection fraction. Both male and female patients had early improvements in left ventricular ejection fraction after coronary artery bypass grafting, but only female patients had sustained improvement in predicted left ventricular ejection fraction over time. In adjusted analyses, postoperative improvement in left ventricular ejection fraction was independently associated with a lower risk of mortality (hazard ratio, 0.57 [95% CI, 0.41-0.79]; P <.001). An absolute increase in postoperative left ventricular ejection fraction by 18% was associated with a 43% reduced hazard for late mortality. CONCLUSIONS:Early and late outcomes after coronary artery bypass grafting appear satisfactory in patients with ischemic cardiomyopathy. Improvement in left ventricular ejection fraction after coronary artery bypass grafting was associated with significantly lower mortality risk. Younger age and female sex were independently associated with sustained postoperative improvements in left ventricular ejection fraction.

BACKGROUND:The prevalence of mitral regurgitation (MR) increases with age, but the invasiveness of surgical intervention may delay treatment in older adult patients. The present study compares the results of robotic mitral valve (MV) repair in patients aged more than 65 years with outcomes of MV repair performed by median sternotomy. METHODS:The study identified 613 patients aged 65 years or older who underwent isolated MV repair for the first time through a robotic approach or standard median sternotomy. Propensity score matching was used to adjust for baseline differences. Primary end points were long-term all-cause mortality, reintervention-free survival, probability of moderate or severe MR during follow-up, and quality of life outcomes. RESULTS:The 189 matched patients in each group had similar baseline characteristics. The median age was 70 years (range, 67-74 years), and 33.1% of the participants were female. All patients had severe MR before operation. Overall operative mortality was 0.3%. Compared with patients in the sternotomy group, those in the robotic group required fewer blood transfusions (21% vs 32%), had a lower incidence of postoperative atrial fibrillation (33% vs 44%), and had shorter intensive care unit stays (-3 hours) and total hospital stays (-1 day). There was no significant difference in long-term survival between the matched groups (P = .65). Similarly, long-term trends of progression of MR were comparable, as were rates of MV reintervention (P = .77). Patients in both groups reported a similar degree of improvement in quality of life postoperatively. CONCLUSIONS:Robotic MV repair in older patients is associated with better short-term postoperative outcomes compared with standard median sternotomy, and long-term outcomes are similar.

Objective:To evaluate the impact of pulmonary hypertension and right ventricular dysfunction on outcomes of isolated tricuspid valve surgery. Methods:From 2004 to 2022, 298 patients (age 71.0 ± years, 59.4% female) underwent isolated tricuspid valve surgery. Pulmonary hypertension was defined as right ventricular systolic pressure ≥50 mm Hg, and right ventricular dysfunction as right ventricular fractional area change <32% on preoperative transthoracic echocardiogram. Patients were stratified into 4 groups: group I: No pulmonary hypertension or right ventricular dysfunction (n = 199), group II: pulmonary hypertension without right ventricular dysfunction (n = 45), group III: right ventricular dysfunction without pulmonary hypertension (n = 43), and group IV: pulmonary hypertension and right ventricular dysfunction (n = 11). Uni- and multivariable analyses were performed to evaluate association of pulmonary hypertension and right ventricular function with outcomes. Results:Tricuspid valve replacement was performed in 218 (73.2%) and repair in 80 (26.8%) patients. Operative mortality was 4.7%, similar for reoperations (5.2%) and primary procedures (4.5%) (P = .907). Median follow-up was 5.4 (interquartile range, 2.3-12.5) years, survival was 74.4%, 48.4%, 39.8%, and 67.3% in groups I-IV, respectively (P < .0001). Multivariable analysis identified pulmonary hypertension (hazard ratio, 2.9; 1.83-4.62, P < .001) and right ventricular dysfunction (hazard ratio, 2.83; 1.76-4.56, P < .001) as independent predictors of greater long-term all-cause mortality, in addition to older age (P < .001) and severe chronic lung disease (P < .001). Conclusions:Among patients who underwent isolated tricuspid valve surgery, presence of pulmonary hypertension or right ventricular dysfunction at baseline is linked to greater long-term mortality.

The number of highly sensitized patients in need of a multiorgan transplant is increasing. Criteria informing their transplant candidacy, approaches to management on the waitlist, and protocols related to alloantibody monitoring vary widely. We convened a consensus conference to discuss these different practices in the United States and the United Kingdom and to review the contemporary outcomes of these challenging cases. A detailed analysis of the data regarding the liver allografts' immunoprotective effect on simultaneously transplanted other organs was also completed, and the prospect of the use of liver allografts primarily to facilitate transplantation of highly sensitized patients in need of other organs was discussed. The ethical and allocation-related issues about such prospect were debated with a goal to standardize the approach and provide an evidence-based pathway for pre-, peri-, and post-transplantation management for the highly sensitized multiorgan transplantation candidate.

Introduction and Objective: The large-conductance Ca2+-activated K+ (BK) channel is critical in regulation coronary circulation, with its expression tightly regulated by Sorbin and SH3 domain-containing protein 2 (Sorbs2). Sorbs2 expression is downregulated in coronary arteries, contributing to BK channelopathy and vasculopathy in diabetic animals. However, the role of Sorbs2 in BK channel function in human vessels remains unclear. Methods: Using patch-clamp, video microscopy, and immunoblotting approaches, we examined Sorbs2 expression and BK channel function in coronary arteries from atrial appendages of patients undergoing CABG surgery. Results: Coronary microvessels were dissected from 9 type 1 diabetic (T1D) patients (6 males and 3 females, 62.8±3.3 years), 20 type 2 diabetic (T2D) patients (11 males and 9 females, 66.6±1.8 years), and 27 non-diabetic controls (18 males and 9 females, 68.8±2.0 years). Cardiac systolic function was similar across the groups (LVEF: 54.0±5.6% for T1D, 50.5±3.0% for T2D, and 56.8±1.9% for controls). However, BK channel-mediated maximal coronary vasodilation was reduced in T1D (27.3±3.4%)* and T2D (54.3±5.0%)* compared to controls (74.0±4.9%). BK channel activation to Ca2+ was also impaired, with EC50 values of 2.26±0.18 μM*# (T1D), 0.89±0.07 μM* (T2D), and 0.41±0.04 μM (controls). The expression of the BK channel α-subunit, but not the β1-subunit, was downregulated by 49.8%* in T1D and 42.6%* in T2D, accompanied by a decrease in Sorbs2 expression of 87.2%*# (T1D) and 37.5%* (T2D), respectively. *: p<0.05 vs. controls. #: p<0.05 vs. T2D. Conclusion: Diminished coronary BK channel function in human diabetes is associated with down-expression of Sorbs2, with a more pronounced decline in T1D. X. Xiong: None. X. Sun: None. B. Quam: None. B. Stanga: None. J. Stulak: None. R. Daly: Other Relationship; Neochord, Inc. Consultant; UNOS. K. Greason: None. P. Tang: None. P. Spencer: None. Q. Chai: None. Y. Cha: None. H. Lee: None. T. Lu: None. NHLBI, HL161821

BackgroundEmotional Affect reflects an individual’s emotional state and can be categorized as positive (PA) or negative (NA). We aimed to characterize affect in heart transplant candidates and evaluate its relationship with pre- and post-transplant psychological and clinical outcomes.MethodsUsing the Positive and Negative Affect Schedule (PANAS), we surveyed adult heart transplant candidates across three transplant centers at baseline (waitlist enrollment), annually on the waitlist, and post-transplant. We assessed PA, NA, and the positivity ratio (PR; PA/NA) as potential predictors of waitlist mortality, post-transplant hospital length of stay, readmissions, and quality of life.ResultsAmong 194 participants, the majority were male (68.6%) and Caucasian (84.3%). Baseline PA (36.0 ± 7.8) and NA (17.9 ± 6.4) were comparable to population norms and remained stable over time. PR was low at baseline (2.3 ± 1.0) and decreased post-transplant (−0.3 ± 1.2; p = 0.03). PA decreased and NA increased post-transplant, but neither change was statistically significant. Affect was not associated with waitlist mortality, delisting, length of stay, or readmissions, but baseline PANAS scores correlated with multiple domains of post-transplant quality of life.ConclusionHeart transplant candidates exhibit a suboptimal PR, which declines post-transplant, highlighting significant psychological stress. Pre-transplant PANAS scores correlated with post-transplant quality of life, suggesting a potential role for psychological screening and intervention in transplant care.

Objectives The study objectives were to analyze trends in bilateral internal thoracic artery grafting during isolated coronary artery bypass grafting over a 35-year interval and compare outcomes between bilateral internal thoracic artery and non–bilateral internal thoracic artery strategies. Methods A cohort of 15,991 patients underwent isolated multivessel coronary artery bypass grafting at our institution between 1990 and 2024. Trends in bilateral internal thoracic artery, radial artery, and left internal thoracic artery + saphenous vein graft were assessed using chi-square tests with Bonferroni correction. Changes in obesity and diabetes prevalence across intervals were also analyzed. Propensity score matching (1:1) yielded 2013 pairs for outcome comparisons between bilateral internal thoracic artery and non–bilateral internal thoracic artery groups. Results Between 1990 and 2024, use of bilateral internal thoracic artery and radial artery increased (11.0% and 13.2%, respectively), although bilateral internal thoracic artery declined during 2020 to 2024 as radial artery and left internal thoracic artery + saphenous vein graft use increased. This decline was unrelated to rising obesity or diabetes rates. Matched analysis revealed longer operative times for bilateral internal thoracic artery (+51 minutes, P < .001), whereas cardiopulmonary bypass and crossclamp durations remained similar. Wound-healing complication rates did not increase with bilateral internal thoracic artery grafting. Kaplan–Meier analysis showed superior 30-year survival for bilateral internal thoracic artery compared with other grafting strategies. Conclusions Bilateral internal thoracic artery grafting remains underused, particularly in recent years, despite demonstrated survival benefits and comparable wound-healing risks. The decline is not explained by patient risk factors, highlighting the need for broader adoption of bilateral internal thoracic artery grafting and further randomized trials to optimize coronary artery bypass grafting strategies.