Background:The goal was to conduct a pilot randomized controlled trial (RCT) of direct oral anticoagulants (DOACs) early after cardiac surgery to determine the feasibility of a larger RCT. Methods:We conducted an open-label, 2-site, pilot RCT of adults undergoing cardiac surgery with an indication for anticoagulation, excluding mechanical valves and bioprosthetic mitral valve replacements. We randomized patients 1:1 to receive a DOAC or warfarin started during the index hospitalization with a standardized time of postoperative initiation and bridging for high thrombosis risk. The coprimary feasibility outcome goals were recruitment of ≥ 70% eligible patients and adherence to the anticoagulation protocol in ≥ 80% patients. The primary clinical composite outcome included all-cause mortality, major bleeding, stroke, systemic embolism, or pericardial effusion requiring intervention within 3 months. Results:Between October 2022 and February 2024, a total of 547 patients were screened, 163 met inclusion criteria, 104 were randomized, and 100 were analyzed (50 in each group). The median age was 72 years; 22% were female; 54% had preexisting atrial fibrillation; 37% had postoperative atrial fibrillation, with a median Congestive Heart Failure, Hypertension, Age ≥ 75 Years, Diabetes Mellitus, Stroke, Vascular Disease, Age 65 to 74 Years, Sex Category (CHA2DS2-VASc) score of 3 and a Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly (> 65 Years), Drugs/Alcohol Concomitantly (HAS-BLED) score of 2. We recruited 64% of eligible patients, and anticoagulation protocol adherence was 91%. The clinical composite outcome occurred in 8% with DOAC (2 major bleeding, 1 pericardial effusion, 1 death) vs 4% with warfarin (2 strokes); log-rank P = 0.42. Conclusions:Although the a priori recruitment goal was not met, this trial supports the need for and provides valuable insights into key challenges to mitigate, thereby guiding the design of a large, definitive multicentre RCT comparing DOACs vs warfarin in cardiac surgery patients. Clinical Trial Registration:NCT05006287.

Background Despite the high prevalence and significant mortality associated with aortic stenosis (AS), data demonstrate low rates of referral to specialized heart valve teams. The objectives of this study were therefore to highlight contemporary referral patterns in patients with significant AS and identify potential barriers to referral. Methods Patients undergoing transthoracic echocardiography (TTE) in a large public health catchment had automatically generated text inserted into their TTE report and electronic medical record if the TTE met the American Society of Echocardiography criteria for moderate or severe AS. Text recommended referral to a heart valve team for further assessment or treatment. Patients were prospectively identified and followed. Structured telehealth was performed to clarify symptom status and perceived barriers to referral. Results Over 6 months, 343 patients with severe (n = 142) or moderate (n = 201) AS were identified. Despite significant AS alongside a referral prompt, only 86 (61%) patients with severe and 44 (22%) with moderate AS were referred for assessment. Patient and echocardiographic characteristics were similar between referred and nonreferred. Mortality was significantly higher in nonreferred patients with severe AS (19.6 vs. 2.3% referred, p < 0.001). Of the nonreferred patients who died, 5/11 (45%) had no compelling reason for lack of referral. Most nonreferred patients with severe AS reported progressive symptoms (75% New York Heart Association class II/III). Over half (51.2%) reported being managed with a “watchful waiting” strategy despite meeting a class I indication for aortic valve replacement, and nearly one-third (27.5%) were unaware of their diagnosis. Conclusions Despite automatically generated referral prompts in patients with severe AS, many patients without a compelling reason for lack of referral were not appropriately assessed and died.

OBJECTIVES:The SavvyWire(OpSens Medical) is a support wire for transcatheter aortic valve replacement (TAVR) procedures that, in addition to its dedicated left ventricle (LV) pacing capabilities, has a distal pressure sensor that measures live transvalvular hemodynamics during the procedure. We aimed to determine the safety, efficacy, and functionality of the SavvyWire during TAVR procedures in an all-comer population. METHODS:We performed a multicentric, prospective, observational, single-arm, all-comers registry of patients with symptomatic, severe aortic stenosis undergoing TAVR in 3 Canadian centers. Data were collected in a dedicated database, and pre-specified questionnaires were fulfilled by the heart team implanters after each procedure. RESULTS:A total of 60 patients were included (mean age: 78.6 ± 7.2 years; 51% women; mean Society of Thoracic Surgeons score: 2.2 ± 1.6%). TAVR was performed through a transfemoral approach in 90% of cases, and balloon- and self-expandable valves were used in 73% and 27% of patients, respectively. There were no cases of LV perforation, guidewire deformation, significant loss of capture, or major software malfunction. The rate of successful delivery of the TAVR system was 100%, and effective LV pacing was achieved in 98% of patients. The pre-TAVR mean gradient was 39 ± 14 mm Hg while the final post-TAVR gradient was 8 ± 5 mm Hg; the mean aortic systolic pressure during rapid pacing was 54 ± 12 mm Hg. In 97% of the TAVR procedures, SavvyWire's functionality was reported to be better or similar to other TAVR workhorse support wires. CONCLUSIONS:SavvyWire was safe, effective, and functional for live transvalvular hemodynamic evaluation and rapid pacing during TAVR procedures. More studies with larger sample sizes and comparison against different wires and gradient measurement methods are warranted.

Rosai-Dorfman disease (RDD) is a non-malignant disease of histiocyte proliferation.RDD usually presents with painless cervical lymphadenopathy, although extranodal involvement can occur.Cardiac involvement was reported in < 0.1% of cases.We present a case of cardiac RDD with obstruction at the inferior vena cava-right atrial junction.

Minimally invasive mitral valve surgery (MiMVS) has been increasing in prevalence. This review will focus on the approaches, the clinical outcomes, and patient selection for MiMVS. There are four minimally invasive approaches to the mitral valve: Right mini-thoracotomy, both video-assisted and fully endoscopic, robotic mitral surgery, and transapical, beating heart off-pump neochordal repair. Advantages over conventional surgery include less blood loss and transfusion, improved postoperative mobility, shorter length of stay, less postoperative atrial fibrillation, fewer surgical site infections, and improved cosmesis. This range of minimally invasive techniques will continue to evolve, providing options that are tailored for different patient populations.

BACKGROUND The rate of chronic opioid use after cardiac surgery is high compared with other surgical specialties; however evidence regarding optimal prescribing is limited. The purpose of this study was to evaluate patterns of opioid consumption after cardiac surgery to guide prescribing practices. METHODS Consecutive patients undergoing sternotomy-based cardiac operations were considered for enrollment. Patients with opioid use within 3 months of surgery and those discharged to a nonhome facility were excluded. A patient diary and researcher-directed pill count was used to track pain and opioid use for 10 days after discharge. RESULTS One hundred four patients were included in the final analysis. Of the 63 patients discharged with an opioid, 22 (34.9%) used none and 12 (19.0%) used fewer than half of the pills prescribed. Overall, pain and opioid consumption decreased significantly throughout the discharge period (P < .001). In those who used opioids after discharge, median total consumption was 64 morphine milligram equivalents (interquartile range, 38-128), or the equivalent of 9 oxycodone 5-mg tablets. Patients who used opioids were younger (60.9 vs 70.0, P < .001), but there were no differences based on sex, history of substance use, smoking, or procedure. After risk adjustment the mean pain score >= 3 on the day of discharge was predictive of opioid use (odds ratio, 2.9; 95% confidence interval, 1.8-4.8; P < .001). Most patients (88.5%) were satisfied or very satisfied with pain management. CONCLUSIONS Fewer than half of all patients used opioids after discharge in this study. These data support the need for the development of prescription recommendations after cardiac surgery. (C) 2023 by The Society of Thoracic Surgeons

OBJECTIVE:Severe postoperative pain has been shown to affect many patients following minimally invasive cardiac surgeries (MICS). Multimodal pain management with regional anesthesia, particularly by delivery of local anesthetics using a paravertebral catheter (PVC), has been shown to reduce pain in operations involving thoracotomy incisions. However, few studies have reported high-quality safety and efficacy outcomes of PVCs following MICS.METHODS:Patients who underwent MICS at Vancouver General Hospital between 2016 and 2019 (N = 123) were reviewed for perioperative opioid-narcotic use. Primary outcomes were postoperative opioid use and hospital length of stay (LOS). Statistical analyses were performed using univariate and multivariable regression models to determine independent risk factors.RESULTS:A total of 54 patients received routine systemic analgesia (control), 53 patients received a paravertebral catheter (PVC), and 16 patients received another mode of regional analgesia (non-PVC). The mean hospital LOS was significantly different in patients in the PVC group at 5.8 ± 2.0 days versus 8.3 ± 7.1 days in the control and 6.6 ± 2.3 days in the non-PVC group (P = 0.033). The percentage of patients who did not require postoperative oxycodone was significantly higher in the PVC group (48.1%), compared with the control (24.5%) and non-PVC (37.5%; P = 0.043) groups.CONCLUSIONS:The administration of regional anesthesia using PVCs was associated with reduced need for opioids and a shorter LOS. The reduction in postoperative opioids may reduce the risk of potential opioid dependency in this population. Future studies should involve randomized controlled trials with systematic evaluation of pain scores to verify current study results.

Objective: This study was performed to investigate the long-term outcomes in patients with degenerative mitral regurgitation (MR) undergoing mitral valve repair (MVr) versus mitral valve replacement (MVR) without concomitant surgeries. Methods: The study cohort comprised 1493 patients with degenerative MR who were treated with isolated mitral valve surgery between January 2000 and December 2017 in a large multicenter (5 hospitals) registry of the Province of British Columbia, Canada, including 991 with repair and 502 with replacement. A propensity-matched comparison and risk-adjusted model were used to analyze the outcomes. Results: After propensity matching (415 matched pairs), the 30-day mortalities were 2.4% and 3.6% in the MVr and MVR groups respectively (odds ratio [OR], 1.500; 95% confidence interval [CI], 0.674-3.339; P = .32). The MVR group had significantly greater rates of prolonged inotrope usage >24 hours (P = .024), prolonged ventilation (P = .039), and blood transfusion (P = .023). The respective 1-, 5-, 10-, and 15-year survival rates were 95.7%, 88.8%, 71.4%, and 53.3% in the MVr group, and 93.0%, 81.6%, 61.3%, and 46.0% in the MVR group (hazard ratio [HR], 1.355; 95% CI, 1.105-1.661; P = .004). A multivariable analysis revealed that MVR was an independent risk factor for 30-day mortality (OR, 2.270; 95% CI, 1.089-4.732; P = .029) and long-term mortality (HR, 1.417; 95% CI, 1.161-1.729; P < .001). The HR of MVR over MVr remained consistently greater than 1.0 across all ages. Conclusions: MVr is associated with lower postoperative morbidity and better long-term survival compared with MVR in patients undergoing isolated mitral valve surgery for degenerative MR. The benefit of MVr appears age-independent.