Purpose Recurrent valvular endocarditis and thoracic aortic graft infection (TAGI) present complex clinical problems with difficult management options and poor reported outcomes. Omental flap coverage has been described for these infections, but published experience remains limited. The purpose of this study was to describe our institutional experience with staged mediastinal antibiotic irrigation followed by delayed mediastinal omental flap coverage. Methods We performed a retrospective review of a prospectively maintained institutional database. Adult patients treated at a single institution from January 1, 2017, through December 31, 2019, were included if they underwent operative management for recurrent valvular endocarditis and/or TAGI with mediastinal antibiotic irrigation followed by planned, delayed mediastinal omental flap coverage. Patients were excluded if they were managed nonoperatively, underwent surgery without this staged strategy, had isolated superficial sternal wound infection without graft or valvular involvement, or had insufficient documentation to determine 30-day outcomes. Results Seventeen patients were treated with mediastinal antibiotic irrigation followed by delayed omental flap coverage. Thirty-day mortality was 1/17 (5.9%). Major complications within 30 days occurred in 4/17 (23.5%), including renal failure requiring hemodialysis in 2/17 (11.8%), stroke in 1/17 (5.9%), and reoperation for recurrent infection in 1/17 (5.9%). The composite 30-day major adverse event rate, defined as death, stroke, renal failure requiring hemodialysis, or reoperation for recurrent infection, was 5/17 (29.4%). Conclusions In this single-center series, staged mediastinal antibiotic irrigation followed by delayed omental flap coverage was feasible and was associated with acceptable short-term mortality and complication rates. Further study is needed to determine the optimal timing and patient selection criteria for omental flap coverage in this setting.

Chronic superior vena cava obstruction is a recognized complication of transvenous pacemaker and implantable cardioverter-defibrillator leads. A 39-year-old woman with genetically confirmed left ventricular non-compaction cardiomyopathy and a transvenous implantable cardioverter-defibrillator placed for primary prevention developed progressive superior vena cava syndrome. Computed tomography angiography demonstrated chronic occlusion of the superior vena cava and left brachiocephalic vein with extensive collateralization. Endovascular recanalization was attempted from femoral, bilateral internal jugular, and left brachial approaches, but no guidewire could traverse the multilevel chronic occlusion, precluding balloon angioplasty or stenting. Open reconstruction was performed. The left femoral-popliteal vein was harvested, inverted and rendered valve-free. Lead extraction was performed in two stages: the generator and extrathoracic lead were mobilized using a locking stylet and mechanical extraction sheaths, followed by intrathoracic lead removal through median sternotomy and a controlled superior vena cava venotomy. The autologous graft was anastomosed end-to-side to the right subclavian vein, tunnelled through the mediastinum, and anastomosed to the superior vena cava venotomy. Doppler ultrasound confirmed excellent flow. Follow-up imaging demonstrated a patent graft with marked symptomatic improvement.

Treatment of aortic arch pathology is rapidly evolving. Current techniques utilize a combination of open and endovascular approaches. Existing techniques such as B-SAFER require endograft modification for complete arch debranching which may predispose the graft to failure or endoleak. We developed the FETHAR, a novel method for hybrid aortic repair and demonstrate its use in a patient who presented with an acute dissection with contained rupture. Following repair, we demonstrate excellent seal without endoleak on the post-operative CT scan. Ultimately, this repair allows for complete arch debranching, an anastomosis in zone 2 of the aortic arch, and no endograft modification.

Aim The “2026 HRS Expert Consensus Statement Update on Cardiovascular Implantable Electronic Device Lead Management and Extraction” provides updated recommendations to guide clinicians in the management of cardiovascular implantable electronic device (CIED) leads. Background Since the publication of the “2017 HRS Expert Consensus Statement on Cardiovascular Implantable Electronic Device Lead Management and Extraction,” the field has evolved quickly. New evidence on CIED lead management and the blooming development of new CIED technologies, including leadless pacing and implantable cardioverter defibrillator leads implanted outside the vascular system and new lumenless pacing leads and lead extraction tools, have contributed to the field's rapid evolution. Methods and results A comprehensive literature search was conducted in accordance with the Institute of Medicine standards. The writing committee reviewed evidence gathered through electronic literature searches encompassing clinical trials, original studies, and meta-analyses conducted on human subjects published in English from MEDLINE, PubMed, EMBASE, and the Cochrane Library up to December 2024. The comprehensive literature review supports each evidence-based recommendation and is compiled in the evidence tables. A predefined threshold of > 70% approval for each recommendation was required, with a quorum of two-thirds of the writing committee. The final mean consensus of 108 recommendations was 93.61%. Discussion The recommendations from the “2017 Expert Consensus Statement on Cardiovascular Implantable Electronic Device Lead Management and Extraction” have been updated with new evidence to guide clinicians. The new recommendations address the latest CIED technologies with the advantages over transvenous leads, new evidence supporting diagnosis, treatment, and prevention for CIED infection, appropriate lead management in transcatheter tricuspid valve replacement for tricuspid regurgitation, and standardization of transvenous lead extraction approach, protocol, and facilities to improve the outcomes of CIED lead management and extraction.

OBJECTIVE:To describe the case of a 52-year-old man who developed severe mitral regurgitation 4 years after undergoing aortic valve replacement, maze procedure, and mitral vegetation removal during surgery for infective endocarditis; the mitral regurgitation was due to a perforation of the anterior mitral leaflet (A2) identified on transthoracic echocardiography. KEY STEPS:Key procedural steps included: 1) right minithoracotomy access; 2) adhesiolysis and wedge resection of pleural perforations; 3) leaflet perforation repair with bovine pericardial patch; and 4) annuloplasty ring implantation. POTENTIAL PITFALLS:Patch repair can fail if the patch is undersized, poorly positioned, or not well integrated, leading to residual regurgitation or early breakdown. Anterior leaflet repairs also carry a risk of systolic anterior motion, and prior surgery may complicate access owing to adhesions. TAKE-HOME MESSAGES:Mitral valve repair using a pericardial patch is a reasonable option for anterior leaflet perforation, even in complex reoperative settings. Early recognition and a tailored, minimally invasive approach may offer favorable outcomes in selected patients.

Background:Intra-aortic balloon pumps (IABPs) have been employed to stabilize patients with acute-on-chronic cardiogenic shock. The use of IABP to optimize patients for successful left ventricular assist device (LVAD) implantation has not been well-studied. Methods:This is a single-center retrospective cohort of adults (>18 years) undergoing durable LVAD implantation between April 2011 and June 2019. One-to-one propensity matching paired patients requiring preoperative IABP placement with those who did not. The primary outcome assessed was 1-year mortality, with secondary outcomes, including hospital and intensive care unit (ICU), length of stay (LOS), duration of mechanical ventilation, and complications. Further analysis examined postoperative changes in systolic pulmonary artery pressure (PAP), cardiac index (CI), and pulmonary capillary wedge pressure (PCWP). Results:Among 189 patients, preoperative IABP was used in 53 patients (28.0%). Of these, 32 patients were matched to 32 patients not requiring preoperative IABP placement. One-year mortality was not significantly different between IABP and non-IABP groups (17.0 vs 12.5%, p = 0.422). After matching, there were no significant differences in hospital LOS, ICU LOS, hours of postoperative mechanical ventilation, or complications including stroke, requirement for new renal replacement therapy, right heart failure, hemorrhagic complication, or infection requiring antibiotics. From the time of admission to within 24 hours prior to LVAD implantation, patients supported with IABP had greater reductions in systolic PAP and PCWP, and larger increases in CI. Conclusions:In our study, patients requiring IABP support for stabilization undergoing durable LVAD implant had similar 1-year survival to those not requiring IABP support. Patients supported on IABP had larger reductions in PCWP and sPAP with greater increases in CI prior to LVAD implant.

Background Aortic root replacement (ARR) is a challenging procedure that requires aortic root implantation, coronary reimplantation, and concomitant aortic and valve surgery. Prior sternotomy (PS) increases case complexity for patients requiring ARR. We aimed to compare outcomes in PS patients undergoing primary ARR and patients undergoing true redo ARR. Methods This single-center retrospective study included adult patients (≥18 years) undergoing ARR after a PS between 2011 and 2023. Descriptive statistics were compared between the primary ARR and true redo ARR groups. Continuous and categorical variables were reported. Associations between groups were determined, with a P value < .05 considered significant. Results A total of 394 patients with history of PS underwent ARR, including 324 with primary ARR and 70 with true redo ARR. There were no differences in baseline comorbidities between groups, with most undergoing true redo ARRs for endocarditis (34.3%). True redo ARR patients were more likely to undergo a “modified Cabrol” for coronary management (17.9% for primary ARR vs 51.4% for true redo ARR; P < .001). There were no between-group differences in cardiopulmonary bypass time (P = .123), permanent cerebrovascular accident (3.7% for primary ARR vs 4.3% for true redo ARR; P = .518), in-hospital mortality (6.8% vs 7.1%; P = .514), and estimated longitudinal survival at 5 years following ARR (82.2% vs 81.5%; P = .82). Conclusions ARR in PS patients can be performed safely with good short- and long-term outcomes. Despite the challenges associated with reoperative aortic root surgery, there was no increase in adverse outcomes for primary ARR compared with true redo ARR.

OBJECTIVE:Atrial fibrillation management is rapidly evolving, particularly for patients who are intolerant to medical therapy. Several catheter-based, surgical, and hybrid approaches currently exist, each with unique benefits that may be harnessed to provide optimal outcomes for these patients. This review focuses on the use of a biatrial lesion set versus an isolated left atrial lesion set for ablation. METHODS:Major representative articles for each ablation strategy were identified and included. Terms searched on PubMed, Google Scholar, and Scopus included "atrial fibrillation ablation," "atrial fibrillation surgery," and "maze procedure," among others. Additional articles were included based on expert opinion. RESULTS:The complete Cox maze biatrial lesion set has the highest efficacy but requires cardiopulmonary bypass. An isolated left atrial lesion set can also be performed, and these approaches are often less invasive but not as efficacious as the traditional complete maze operation. CONCLUSIONS:Although biatrial ablation may carry a higher risk of conduction abnormalities than isolated left atrial ablation in the setting of atrial fibrillation, biatrial ablation is more efficacious in maintaining sinus rhythm.

Porcelain aorta, though rare, is often considered a contraindication for open surgery due to the risk of associated neurological complications due to calcium embolization. We present the case of a 70-year-old female with a prior 19mm bioprosthetic aortic valve replacement who, during routine follow-up, was found to have significant aortic valve stenosis, severely reduced leaflet mobility and a mean gradient of 40mmHg. Pre-operative computed tomography angiography revealed a calcified 'porcelain aorta'. Transcatheter aortic valve-in-valve replacement was not possible due to the small 19mm valve and small aortic sinuses, leading to referral for open aortic surgery.

BACKGROUND:This study evaluates the impact of pretransplant HeartMate III (HM3) left ventricular assist device (LVAD) support duration on post-transplant survival in a contemporary cohort. METHODS:A retrospective review of the United Network for Organ Sharing database was conducted for adult heart transplant recipients from January 2019 to December 2023 who were bridged with an HM3 LVAD. We utilized a restricted cubic spline fitted to a Cox proportional hazards model to stratify patients into duration groups based on risk inflection points (<1, 1-2, and >2 years), and outcomes were compared between and across groups. RESULTS:Among 1,996 patients, 35.2% (n = 702), 32.2% (n = 642), and 32.7% (n = 652) had support durations of <1, 1 to 2, and >2 years, respectively. Median support duration was 518 days [interquartile range: 289-864]. Postoperative rates of stroke and acute rejection did not vary across groups (p > 0.05); however, rates of postoperative dialysis significantly increased with increasing support time (p > 0.001). One-year survival was significantly higher for patients bridged <1 year (90.7% [95% confidence interval: 88.5-93.0]) compared to those bridged >2 years (84.3% [95% CI: 81.4-87.4], p < 0.001) but not for those bridged 1 to 2 years (89.0% [95% CI: 86.6-91.6], p = 0.300). In multivariable analysis, patients supported 1 to 2 years (hazards ratio: 1.34 [1.01-1.79], p = 0.045) and >2 years (hazards ratio: 1.77 [1.32-2.38], p < 0.001) had a higher hazard of post-transplant mortality than those bridged <1 year. CONCLUSIONS:While the HM3 enables extended bridging to transplant, durations longer than 2 years of support are linked to worse post-transplant survival.

BACKGROUND:Transfusion has a persistent low risk of transfusion-transmitted infection and transfusion-associated graft-versus-host disease that may be addressed using pathogen reduction. The Red Cell Pathogen Inactivation (ReCePI) trial tested whether amustaline/glutathione pathogen-reduced red cells are noninferior to conventional transfusions for support of acute surgical blood loss. METHODS:A phase 3, double-blinded, noninferiority trial randomized cardiac or thoracic-aorta surgery patients with increased risk of red cell transfusion to receive pathogen-reduced or conventional red cells during and for 7 days postsurgery. The primary endpoint was the proportion of patients with acute kidney injury (AKI), which is defined as an increase from baseline of greater than or equal to 0.3 mg/dl serum creatinine within 48 h of surgery. Noninferiority was claimed if the upper bound 95% CI of the treatment difference was less than half (50%) of the observed conventional arm incidence. Adverse events and treatment-emergent red cell antibodies were assessed for 28 and 75 days, respectively. RESULTS:A total of 581 subjects were randomized, and 321 (55%) were transfused with study red cells. Transfused subjects in both arms had similar baseline demographics, medical histories, hemoglobin levels, and surgical procedures. Hemoglobin day 3 nadir levels (8.6 g/dl [7.8 to 9.2] in the pathogen-reduced arm; 8.4 g/dl [7.8 to 9.3] in the conventional arm; P = 0.52) were comparable. Incidence of AKI by 48 h was 46 of 157 (29.3%) in the pathogen-reduced arm and 45 of 161 (28.0%) in the conventional arm (treatment difference, 0.7%; 95% CI, -8.9 to 10.4%; noninferiority margin, 14.0%; P = 0.001 for noninferiority). AKI within 7 days by Kidney Disease Improving Global Outcomes staging criteria was not different (59 of 159 [37.1%] in the pathogen-reduced arm; 55 of 162 [34.0%] in the conventional arm; P = 0.53), but stage III was more common in the pathogen-reduced arm (pathogen-reduced arm, 15 of 159 [9.4%]; conventional arm, 7 of 162 [4.3%]; P = 0.075). Of 159 pathogen-reduced red cell recipients, 5 (3.1%) developed specific, low-titer antibodies without evidence of hemolysis. CONCLUSIONS:The incidence of AKI in recipients of pathogen-reduced red cells was noninferior to conventional red cell transfusion. Treatment-emergent antibodies were uncommon and not clinically significant.

OBJECTIVE:Open aortic repair is considered the standard of care for patients with connective tissue disease (CTD) due to the perceived durability advantages compared with endovascular intervention. However, some complex CTD patient presentations increase risk with open repair, favoring endovascular intervention. This analysis sought to review our experience with endovascular intervention in CTD patients and identify scenarios in which this approach may reasonably be considered. METHODS:Patients with CTD undergoing endovascular intervention at our institution from 2006 to 2023 were retrospectively reviewed. The primary outcome was freedom from aorta-related mortality. Secondary outcomes included all-cause mortality and freedom from secondary intervention. RESULTS:Forty-five CTD patients underwent endovascular intervention. Thirty-five patients (77.8%) had at least 1 previous aortic intervention. Urgent or emergent presentation was common (n = 31, 68.8%). At index hospitalization, 32 patients (71.1%) underwent thoracic endovascular aortic repair, and 6 patients (13.3%) underwent fenestrated and/or branched endovascular repair. Aneurysm (n = 40, 88.9%) and dissection (n = 36, 80.0%) were the most common indications; many patients (n = 31, 68.9%) presented with both. Freedom from aorta-related mortality was 88.7% ± 5% and 83.2% ± 6% at 1 and 3 years, respectively. No clinical or procedural factors were predictive of aorta-related mortality. Twenty-one patients (46.7%) required secondary intervention; the median time to secondary intervention was 6.5 months (6.5, 18.9 months). Freedom from secondary intervention was 60.0% ± 8% and 51.4% ± 9% at 1 and 3 years, respectively. CONCLUSIONS:Endovascular intervention is often lifesaving in CTD patients who are not initially candidates for open repair. Aorta-related mortality was low, and fewer than half of patients required secondary intervention during the study period. This illustrates the utility of endovascular intervention in bridging CTD patients to definitive open repair.

BACKGROUND:The human sinoatrial node (SAN) pacemaker is a complex structure located at the right atrium (RA)-superior vena cava (SVC) junction. OBJECTIVE:This study aimed to perform in vivo endocardial and epicardial electroanatomic mapping of human SAN in inappropriate sinus node tachycardia (IST) and to correlate electrical findings with anatomic observations from thoracoscopy during hybrid SAN-sparing IST ablation. METHODS:All consecutive patients with diagnosis of symptomatic IST, refractory to or intolerant of drugs, and endocardial and epicardial mapping of SAN during hybrid ablation were included. Local activation time was defined by steepest -dV/dT on unipolar electrogram (EGM). Exit zone (EZ) was defined as the earliest activation site on endocardial and epicardial maps. Endo-epicardial delay was the time difference between the first endo-epicardial activations. Bipolar EGM morphology and SVC sleeve extension were analyzed. RESULTS:A total of 61 patients were included. The SAN-EZ area was 1.4 ± 0.6 cm2; it was located in the superior anterior region of the RA in 46 (75.4%) patients and in the mid RA in 15 (24.6%) patients. The earliest activation occurred on epicardial SAN-EZ in all patients. The local activation time of the epicardial vs endocardial SAN-EZ was -30.8 ms vs -12.4 ms (P < .001). Endo-epicardial delay was 19.7 ms. Bipolar EGM reversed polarity at SAN-EZs was observed in 43 (70.5%) patients. SVC sleeve extension was 31.2 mm and inversely correlated with age. CONCLUSION:The earliest SAN-EZ was found in the epicardium. Bipolar EGM reversed polarity is a novel electrophysiologic marker for SAN-EZs.

BACKGROUND:The optimal management of incidental coronary artery disease (CAD) for renal transplant candidates is not well-defined. This study examined transplant and survival outcomes in patients undergoing coronary artery bypass grafting (CABG) for asymptomatic CAD. METHODS:A retrospective review of patients undergoing CABG solely to facilitate renal transplant was conducted at four tertiary centers. Exclusion criteria were symptoms or acute coronary syndrome (ACS). The primary outcomes were successful renal transplant and survival analyzed using Kaplan-Meier curves with log-rank testing, compared to US Renal Data System (USRDS)-predicted life expectancy matched for age and gender. RESULTS:86 patients (59.0 [IQR 51.0,65.0] years, 88% male) were identified. At follow-up of 4.41 (2.74,6.04) years, 19.8% (n = 17) had successful renal transplant; 29.1% (n = 25) were never listed, 44.2% (n = 38) listed but removed (29 permanently, 9 temporarily), 7.0% (n = 6) awaiting transplant. Pre- and intraoperative characteristics were similar between those transplanted and not. For the entire cohort, CABG was associated with worse 1-year survival, similar 5-year survival, and better 8-year survival compared to USRDS-predicted life expectancy (log-rank p = 0.027).  Considering those not transplanted, 8-year survival was similar to USRDS (log-rank p = 0.94). CONCLUSIONS:In patients with Stage V CKD and asymptomatic CAD, renal transplant rates are low. Whether surgical revascularization offers survival benefit due to successful renal transplant or due to revascularization remains an area of future study. Longer follow-up, study of patient/procedural factors, and multidisciplinary efforts may improve patient selection and transplantation rates.

Background: The purpose of this study was to evaluate the clinical outcomes of patients undergoing a simpler (hemiarch) vs complex (zone 2 arch) aortic repair for acute type A aortic dissection (TAAD). Study design: Adults (18 years or older) who underwent hemiarch or zone 2 arch repair for acute, hyperacute, or acute on chronic TAAD at a single institution between January 2018 and April 2024 were reviewed. Disabling stroke was defined as a modified Rankin scale of 4 or greater. Statistical analysis included univariate comparisons, Kaplan-Meier analysis, and multivariable modeling. Results: Two hundred eighty-three patients with acute TAAD underwent hemiarch (44.5%, n = 126) and/or zone 2 arch (55.5%, n = 157) repair. Hemiarch patients were older (63.3 +/- 14.1 vs 56.3 +/- 12.2 years, p < 0.001), but had lower rates of preoperative cerebrovascular disease (11.1% [n = 14] vs 21.7% [n = 34], p = 0.03), chronic kidney disease (16.7% [n = 21] vs 33.1% [n = 52], p = 0.003), and previous sternotomy (13.5% [n = 17] vs 35.0% [n = 55], p < 0.001). Cardiopulmonary bypass and cross-clamp times were shorter in hemiarch patients (214 +/- 78.5 vs 261 +/- 62.3 minutes, p < 0.001; 135 +/- 54.4 vs 182 +/- 60.0 minutes, p < 0.001, respectively). Postoperatively, there was no difference in the rate of disabling stroke (4.5% [n = 13], p = 0.12), tracheostomy (14.8% [n = 43], p = 0.15), pneumonia (17.2% [n = 50], p = 0.24), or renal failure requiring permanent dialysis (6.2% [n = 18], p = 0.47). In multivariable analysis, older age (hazard ratio 1.05, 95% CI 1.02 to 1.08) was a risk factor for longitudinal mortality, while complex aortic arch repair did not confer an increased risk (hazard ratio 0.68, 95% CI 0.35 to 1.31). Conclusions: Complex aortic arch reconstruction provides a framework for downstream endovascular procedures for the remaining aorta and can be performed in acute TAAD without increased risk of morbidity or mortality compared with a simpler repair.