BACKGROUND:Although patients treated with extracorporeal membrane oxygenation (ECMO) can have reduced long-term lung function, impaired quality of life, and high rates of posttraumatic stress disorder, data on patients with severe COVID-19 requiring ECMO are limited. We undertook a prospective study of our post-COVID ECMO population to assess long-term lung function and quality of life. METHODS:For patients with COVID who required ECMO support, survival, pulmonary function, spirometry, arterial blood gas, and patient quality of life were assessed. RESULTS:Twelve patients completed follow-up at a median of 674.5 days. Pulmonary function testing, reported as median percentage of predicted, was as follows: forced vital capacity (FVC), 73.2% (59.8-82); forced expiratory volume over 1 second (FEV1), 72.3% (67.1-88.3); FEV1/FVC, 110% (100-113.1); total lung capacity, 59.3% (50.6-76.7); vital capacity, 75% (57.5-85.3); and diffusing capacity of the lungs for carbon monoxide, 84.5% (71.9-87.4). Arterial blood gas at follow up was pH 7.41 (7.41-7.43); partial pressure of carbon dioxide, 40 mm Hg (39-42); partial pressure of oxygen, 81 mm Hg (76-83); and arterial oxygen saturation, 96% (95-96). The median Short-Form Kansas City Cardiomyopathy Questionnaire overall summary score was 88.8 (72.1-94.8). The Rand Short Form 36 scores were markedly reduced. CONCLUSION:These findings suggest that patients who required ECMO for COVID-related acute respiratory distress syndrome achieved improvement in objective lung function over time, despite persistent functional limitations. Patients also reported decreased self-reported quality of life.

Background: Post-cardiotomy right ventricular failure (RVF) may be refractory to conservative measures and temporary mechanical circulatory support may be indicated. Little data exists regarding intraoperative post-cardiotomy RVF requiring concomitant right ventricular assist device (RVAD) placement. We undertook this study to analyze the impact of intraoperative RVF requiring concomitant RVAD placement. Methods: This is a retrospective analysis of consecutive patients from 2018 to 2023 who experienced postcardiotomy RVF and received intraoperative RVAD support. The primary outcome was patient survival to discharge. All patients were included in analysis, and none were excluded. Results: From 2018 to 2023, 23 patients experienced intraoperative post-cardiotomy RVF and underwent concomitant RVAD placement. During this time frame, a total of 9,268 cardiac surgeries were performed at Baylor Scott & White Research Institute. Those who underwent concomitant RVAD placement had a median follow-up time of 152 [interquartile range (IQR), 52-418] days. Fifty-six percent (13/23) were male, and the median age was 67 (IQR, 60-72) years. Eight patients received isolated RVAD placement, 14 received RVAD and left ventricular assist device (LVAD), and 1 received RVAD with venoarterial (VA)extracorporeal membrane oxygenation (ECMO) configuration. All RVADs consisted of the Protek Duo (LivaNova) cannula connected to an ECMO circuit. Two patients required two rounds of RVAD support. The median duration of RVAD support was 8 (IQR, 7-17) days. Survival to discharge was 78.3% (18/23), and the median length of stay was 30 (IQR, 20-41) days. Of the five in-hospital mortalities, 60% (3/5) of patients were unable to be weaned from extracorporeal life support. Overall patient survival at 30-day was 78.3% (18/23). In patients successfully weaned from RVAD support, survival to discharge and 30-day survival were 90%. Conclusions: Concomitant RVAD placement appears to be a helpful treatment strategy for intraoperative RVF. Patients who are successfully weaned from RVAD support have acceptable short-term outcomes following discontinuation of support, although further research is needed.

Introduction Although left ventricular assist device (LVAD) therapy improves survival and quality of life in patients with end-stage heart failure, appropriate patient selection is complex, with many patients being turned down for implantation because of perceived medical, surgical, or social barriers. However, some patients turned down for an implant at one center will go on to be successfully implanted elsewhere. Methods We conducted a retrospective review of all primary LVAD implantations at our center. Primary stratification was by prior turndown status. Primary outcome was survival as assessed by the Kaplan-Meier method and Cox proportional hazards regression modeling. Secondary outcomes included length of stay and commonly encountered postoperative complications. Results From 2017 to 2025, 237 patients underwent primary LVAD implantation, 28 (11.81%) of whom were turned down for implantation at another center. When stratified by turndown status, there was no difference in operative mortality (17/209, 8.13% vs 2/28, 7.14%, p = 0.86) or 5-year survival (p = 0.73). On multivariable analysis, prior LVAD turndown was not associated with 1-year survival (HR: 0.41[0.09-1.17], p = 0.23). Moreover, patients previously turned down for LVAD had similar lengths of stay and rates of bleeding, stroke, respiratory failure, renal failure, and right ventricular failure. Conclusions Patients turned down for LVAD implantation at another center prior to referral to our center had similar short-term morbidity and mortality compared to patients not previously turned down for surgery. These findings suggest that patients with end-stage heart failure who are turned down for LVAD therapy at one center should seek or be referred for a second opinion at another center.

Objective:Guidelines recommend a multidisciplinary heart team approach for managing complex coronary artery disease (CAD), yet its impact on clinical outcomes and adherence to recommendations is rarely reported. Methods:Between June 2021 and August 2022, 210 high-risk patients with isolated, complex CAD were evaluated at our institution's weekly heart team conference for consideration of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), hybrid PCI/CABG, or optimal medical therapy (OMT). Adherence to recommendations and clinical outcomes, including 30-day, 1-year, and 2-year mortality, were assessed. Results:Overall adherence to heart team recommendations was 92%, with 96% adherence for CABG, 90% for PCI, 87% for OMT, and 75% for hybrid PCI/CABG. CABG was the most frequently recommended treatment (53%) and demonstrated the lowest mortality at 1 year (4%) and 2 years (6%) compared with PCI (1 year, 28%; 2 year, 40%) and OMT (1 year, 10%; 2 year, 20%). CABG patients had a lower-than-expected mortality (observed-to-expected ratio 0.9), while PCI was associated with significantly higher mortality (observed-to-expected ratio 3.0). Conclusion:This single-center multidisciplinary heart team approach for complex CAD offers a collaborative, patient-centered model that facilitates high adherence rates and favorable patient outcomes. These findings highlight the potential benefits of integrating multidisciplinary evaluation and support its implementation into standard practice for high-risk CAD patients.

Background:Pulmonary embolism (PE) is a major cause of morbidity and mortality, particularly in massive and submassive cases that lead to right ventricular (RV) strain and long-term complications. The EkoSonic Endovascular System (EKOS) offers a catheter-directed thrombolytic treatment option for patients with contraindications to systemic thrombolysis, but data on long-term outcomes remain limited. We aimed to evaluate long-term mortality, RV function, and quality of life (QoL) in patients with massive or submassive PE who were treated with EKOS therapy. Methods:The EKOS-PE is a retrospective cohort study of 137 patients with massive or submassive PE who underwent EKOS therapy within a single health care system from 2020 to 2024. The primary outcome was all-cause mortality; secondary outcomes included changes in the RV-to-left ventricular (LV) (RV/LV) ratio, residual RV dysfunction, and QoL as assessed using the Pulmonary Embolism Quality of Life questionnaire. Results:All-cause mortality was 7.2% at a mean follow-up of 26.5 ± 17.2 months. During the index hospitalization, 1 retroperitoneal bleed (0.7%) and 1 ischemic stroke (0.7%) were observed. The mean RV/LV ratio decreased from 1.13 ± 0.24 to 0.83 ± 0.19 (P < .01). No residual RV dysfunction was evident in 105 (75.5%) patients, whereas 16 (11.5%) exhibited moderate to severe residual dysfunction. Of 52 respondents who completed the QoL survey at a mean follow-up of 37.2 ± 12.1 months, minimal residual symptoms, limited functional interference, and improved perceived lung health were reported. Conclusions:The EKOS therapy is associated with significant long-term improvement in RV function, low mortality, and favorable perceived QoL, supporting its use in massive and submassive PE, aligning with current guideline recommendations for high-risk patients.

BACKGROUND:Despite guideline recommendations, use of concomitant surgical ablation during isolated coronary artery bypass grafting (CABG) in patients with preexisting atrial fibrillation is low, with a poorly quantified impact on stroke and survival. METHODS:A retrospective review of Medicare data identified 87,699 beneficiaries with preexisting atrial fibrillation undergoing CABG, with or without concomitant surgical ablation, from 2008 to 2019. All-cause mortality and the incidence of stroke were evaluated as separate end points. Overlap propensity score weighting adjusted for measured confounding variables. Analyses were repeated using surgeon frequency of ablation as an instrumental variable to adjust for unmeasured confounding variables. RESULTS:Of 87,699 beneficiaries with atrial fibrillation undergoing CABG, 19,384 (22.2%) underwent concomitant surgical ablation. During CABG, 1193 surgeons infrequently performed ablation (<5%; 16,242 beneficiaries), 1834 occasionally performed ablation (≥5% but <40%; 55,820 beneficiaries), and 652 frequently performed ablation (≥40%; 15,637 beneficiaries). Beneficiaries undergoing surgical ablation (as-treated analysis) had a risk-adjusted median survival advantage of 4.40 months (95% CI, 2.40-6.36 months; 7.82 years [95% CI, 7.65-7.98 years] vs 7.46 years [95% CI, 7.38-7.57 years]; P < .001 for risk-adjusted survival comparison) compared with those without. Beneficiaries undergoing CABG by surgeons who frequently ablate (provider-preference analysis) had a risk-adjusted median survival advantage of 4.96 months (95% CI, 2.10-7.82 months; 7.03 years [95% CI, 6.90-7.20 years] vs 6.62 years [95% CI, 6.46-6.79 years], P < .001 for risk-adjusted survival comparison) compared with surgeons who infrequently ablate. CONCLUSIONS:In Medicare beneficiaries with preexisting atrial fibrillation, concomitant surgical ablation during CABG is associated with improved survival, as is undergoing CABG by a surgeon who frequently ablates. Our findings support current guidelines recommending surgical ablation during CABG in patients with atrial fibrillation and highlight that ablation is currently underused in contemporary practice.

BACKGROUND:Retrospective studies of patients with ischemic mitral regurgitation (iMR) undergoing coronary artery bypass grafting (CABG) with concomitant mitral valve surgery frequently report improved survival with mitral valve repair/annuloplasty (MVr) over replacement (MVR). However, the only randomized controlled trial found no survival difference. METHODS:Medicare claims data were queried to identify beneficiaries with iMR undergoing CABG/MVr or CABG/MVR. Kaplan-Meier estimates of survival after CABG/MVr and CABG/MVR were generated, and 20-year restricted mean survival times (RMSTs) were compared. Then, surgeons were stratified by their rate of CABG/MVr into groups with a demonstrated preference for MVr (PA) or MVR (PR). Outcomes were reanalyzed by surgeon preference. Overlap propensity score weighting was used for risk adjustment in all analyses. RESULTS:Among 10,471 beneficiaries with iMR, 6457 (61.7%) underwent CABG/MVr and 4014 (38.3%) underwent CABG/MVR. Risk-adjusted RMSTs were 6.02 years (95% CI, 5.77-6.26 years) after CABG/MVr and 5.57 years (95% CI, 5.33-5.81 years) after CABG/MVR (difference, 5.4 months; 95% CI, 1.2-9.4 months; P = .01). Among 1118 surgeons, 223 were PA surgeons (performed 2191 operations; 89.5% MVr rate) and 235 were PR surgeons (performed 1930 operations; 23.0% MVr rate). Risk-adjusted RMSTs were 5.76 years (95% CI, 5.36-6.15 years) vs 5.77 years (95% CI, 5.40-6.14 years) among beneficiaries undergoing surgery by PA surgeons and PR surgeons, respectively (difference, 0.1 years; 95% CI, -6.6 to 6.6 months, P = .964). CONCLUSIONS:In Medicare beneficiaries with iMR undergoing CABG/mitral valve surgery, CABG/MVr was associated with improved survival, even after risk adjustment for measured confounders. This may be due to unmeasured confounding variables affecting the decision to perform MVr or MVR, such as valvular pathology and/or severity of regurgitation. After endeavoring to account for unmeasured confounders using surgeon preference as an instrumental variable, surgeons who preferred CABG/MVr or CABG/MVR achieved similar long-term survival for their patients.

Background:Physical therapy (PT) after cardiac surgery improves pain control and functional capacity. Portable pedal bikes, a promising adjunct to standard walking, may further enhance recovery. Whether portable pedal bikes plus routine postoperative PT improve outcomes following cardiac surgery was investigated.Methods:This is a prospective, quasi-experimental, single-center trial of patients undergoing cardiac surgery for coronary artery bypass grafting (CABG) and/or valve surgery over a 1-year period. Control patients were retrospectively identified and received standard postoperative PT. Intervention patients received a portable pedal bike (introduced on postoperative day 2) in addition to standard PT. The primary outcome was the change in walking distance between postoperative day 1 and the last inpatient PT assessment. Secondary outcomes included length of stay (LoS), time to first bowel movement, 30-day clinical endpoints, and patient-reported satisfaction (SF-20 survey).Results:A total of 118 patients met eligibility criteria (60 pedal bike; 58 control). Baseline characteristics and operative profiles were similar. The intervention group used the pedal bike for a median of 18.3[5.1, 31.5] minutes/day at 56.4[34.9, 69.9] RPMs. Walking distance was significantly higher in the intervention group than the control group (238[148,301] vs 150[75,258] ft; P < .01) and LoS was shorter (3.0[2.0-4.0] vs 3.5[2.0-5.0] days; P = .039). There were no differences in the 30-day mortality, emergency department visits, readmissions, or cardiac reinterventions. Patient satisfaction at 30 days was also similar.Conclusions:Addition of a portable pedal bike to standard PT improved walking distance and decreased LOS following cardiac surgery. Its implementation into enhanced recovery after surgery protocols should be considered.

Background:Outcomes of postcardiotomy extracorporeal membrane oxygenation (ECMO) are well studied, but preoperative ECMO bridging is less studied. This single-center review evaluates outcomes of patients supported with ECMO as a bridge to definitive cardiac surgery. Methods:We retrospectively reviewed all patients who underwent ECMO as a bridge to cardiac surgery between 2013 and 2024. Patients decannulated before surgery or bridged to advanced heart failure therapies were excluded. The primary outcome was survival to hospital discharge. Secondary outcomes included survival to ECMO decannulation, total ECMO duration, and postoperative complications such as hemodialysis, tracheostomy, stroke, reoperation, and survival at 30 days and 1 year. Results:Sixteen patients were analyzed, of whom 15 (94%) were cannulated for acute heart failure, 1 (6%) for respiratory failure, and 2 (13%) as an adjunct to cardiopulmonary resuscitation. The cohort was 56% female, with a median age of 59.5 years (interquartile range [IQR], 49.3-65.8 years). Surgical procedures included valve surgery (63%), ventricular septal defect repair (31%), and coronary artery bypass grafting (6%). The median ECMO duration was 7 days [IQR, 4-10.5 days]. Survival to decannulation occurred in 81.3%, and 50% survived through hospital discharge. Survivors had lower rates of postoperative dialysis (37.5% vs 87.5%; P = .04) but a longer length of stay (25 days vs 9.5 days; P = .01). Conclusions:Preoperative ECMO as a bridge to cardiac surgery is a viable strategy for select high-risk patients, with acceptable survival rates. Larger multicenter studies are needed to refine patient selection and optimize management strategies.

Background:Vasoplegia frequently complicates left ventricular assist device (LVAD) implantation, yet its impact on outcomes is not fully understood. The vasoactive-inotropic score (VIS), which quantifies vasoactive support, may predict outcomes in this population. Methods:A retrospective analysis of 146 patients undergoing HeartMate 3 LVAD implantation from 2017 to 2024 at a single institution was performed. VIS was calculated at 0, 6, 12, and 24 hours postoperatively, and the maximum VIS(VISmax) within the first 24 hours was determined: VIS = dopamine (mcg/kg/min) + dobutamine (mcg/kg/min) + 100*epinephrine (mcg/kg/min) + 10*milrinone (mcg/kg/min) + 10,000*vasopressin (units/kg/min) + 100*norepinephrine (mcg/kg/min). Patients were stratified by VISmax tertiles, and survival outcomes were compared using Kaplan-Meier estimates and Cox proportional hazards modeling. Secondary outcomes included predictors of vasodilation and postoperative complications. Results:The mean VISmax was 18.2 ± 10.1. Patients in the highest VISmax tertile (20-56) demonstrated lower 1-year survival (67.0% vs 84.3% vs 90.0%, p < 0.01). Preoperative Impella support (p = 0.02), elevated bilirubin (p < 0.01), and longer cardiopulmonary bypass time (p < 0.01) were predictors of increased VISmax. VISmax was an independent predictor of 1-year mortality (HR: 1.08[1.04-1.12], p < 0.01) and associated with increased odds of right ventricular assist device placement, renal replacement therapy, and tracheostomy (all p < 0.01). Hydroxocobalamin pre-treatment was associated with lower VISmax (15.65 ± 9.52 vs 19.40 ± 10.25, p = 0.04). Conclusion:Elevated VISmax is a predictor of morbidity and mortality following LVAD implantation. Strategies such as preoperative hydroxocobalamin administration may mitigate postoperative vasoplegia. Further studies are warranted to refine risk stratification and optimize management for these high-risk patients.

Postoperative renal failure following LVAD implantation is known to negatively impact outcomes. However, the role of preoperative predictors of renal failure remains unclear. Therefore, we sought to identify and assess preoperative factors potentially predictive of postoperative acute kidney injury (AKI) requiring renal replacement therapy (RRT) in destination therapy LVAD patients. A retrospective review of all primary LVAD implantations at a single, destination therapy center from 2022 to 2024 was conducted. LVAD exchanges were excluded. The primary outcome was postoperative AKI requiring RRT. Independent predictors of postoperative RRT were assessed using multivariable logistic regression modeling. The impact of postoperative RRT on survival was assessed using the Kaplan-Meier method. In total, 103 patients underwent primary LVAD implantation. The mean preoperative creatinine was 1.37 ± 0.46 mg/dL with an eGFRCr of 66.60 ± 35.25 mL/min/1.73m2. Twenty-one patients (20.39

INTRODUCTION:While left ventricular device implantation has been shown to improve both survival and quality of life in patients with end stage heart failure, these patients have a high rate of readmissions to the hospital. The incidence and factors associated with readmission are poorly characterized in the destination therapy population. METHODS:All patients who underwent HeartMate III left ventricular assist device therapy (LVAD) implantation at our facility from 2017 to 2023 were identified. Patients undergoing primary LVAD implantation were included. Primary outcome was readmission for any reason. Multivariable linear regression was utilized to identify predictors of readmissions. RESULTS:From 2017 to 2023, 151 primary LVAD implantations were performed with 12 (8.0%) perioperative moralities (defined as index implant hospitalization mortality). The 139 remaining patients suffered 456 separate readmissions with a median follow-up of 590 (303-1002) ds and a total follow-up of 270.7 patient-ys for a rate of 1.7 readmissions per patient-y. The most common cause of readmission was heart failure exacerbation (27.0%), major infection (17.8%), and major bleeding (13.6%). Patients who were readmitted within 6 mos were more likely to have New York Heart Association class III or IV symptoms compared to those who had not been readmitted 39.1% versus 11.8% versus 15%, P = 0.0008. On multivariable linear regression, increasing body mass index (P = 0.02), increased preoperative bilirubin (P = 0.04), and increased follow-up time (P < 0.01) were predictive of the need for readmissions. CONCLUSIONS:Following LVAD implantation, readmissions within 6 mos of surgery are associated with worse functional status at 6 mos and 1 y postoperatively. Increased body mass index and preoperative bilirubin were associated with more frequent readmissions.

Background Ventricular tachycardia is a relative contraindication for LVAD. However, when it occurs post implantation it can lead to profound RV failure and hemodynamic instability. These complex scenarios require team approach and often creative ways to achieve stability. Clinical Presentation 63-year-old male with a history of heart failure with reduced ejection fraction (LVEF <20%) w/ ICD, ischemic cardiomyopathy, multivessel CAD s/p PCI to LAD and RCA, hypertension, hyperlipidemia who reported refractory heart failure symptoms. A right heart catheterization was performed which showed elevated bilateral filling pressures and severely reduced cardiac index. He was started on inotropic support and underwent LVAD implantation with HeartMate III. Two days later, he suffered ventricular tachycardia (VT) storm requiring antiarrhythmic therapy and external/internal defibrillation despite no obvious signs of LV collapse. He subsequently developed RV failure thought to be due to ventricular arrythmia and altered hemodynamics. Right ventricular assist device (31 Fr Protek Duo) was placed. His hospital course was complicated by upper gastrointestinal bleed requiring intubation, multiple blood transfusions, and vasopressor support. He continued to have refractory VT despite anti-tachycardia pacing, escalation of antiarrhythmics, and deep sedation. Etiology of VT was suspected to be due to ischemic scar. VT ablation was planned but aborted when an aortic valve thrombus was noted on transthoracic echocardiogram. As VT ablation was now contraindicated, a bilateral sympathectomy was performed. This led to marked reduction of VT and NSVT burden. RVAD was removed, tracheostomy and PEG tube placed. Patient stabilized from hemodynamic standpoint and participating in physical and occupational therapy. Conclusion Management of refractory tachycardia can be challenging with limited advanced therapies. Our case highlights the utility of sympathectomy for the management of refractory VT as salvage therapy.

BACKGROUND:Little is known about how the role of the extracorporeal membrane oxygenation (ECMO) specialist (ES) impacts intensive care unit (ICU) staff retention. Our facility allows staff ICU registered nurses (RNs) and respiratory therapists (RTs) to dual in the role of ES. AIM:The aim of this project was to identify any contributing factors the role of the ES may have on ICU staff retention. METHODS:A retrospective review of Human Resource (HR) records of all ICU RNs and RTs was conducted and compared those who held the concurrent role of ES against those who did not, for length of tenure. We also surveyed 17 qualifying ES to identify any major factors that contribute to their retention. RESULTS:A total of 242 employees, 206 (85.1%) ICU RNs and 36 (14.9%) RTs' records were analysed, 13 (6.3%) were ES ICU RNs, and 193 (93.7%) non-ES ICU RNs. Similarly, 4 (11.1%) were ES RTs, and 32 (88.9%) non-ES RTs. The ES ICU RNs had a significantly longer length of tenure 6.11 [4.49-8.05] compared to non-ES ICU RNS at 2.34 [1.27-4.30] years (p < .001). Likewise, the ES RTs' 13.47 [8.23-21.84] years exceeded the tenure of non-ES RTs at 3.85 [1.37-10.67] years (p = .03). The ES survey identified four key factors of the ES role that positively contribute to staff retention: financial incentives, advanced skill set, team cohesion and the rarity of opportunity. CONCLUSION:This project found that the role of the ES may uniquely positively impact the retention of ICU RNs and RTs. RELEVANCE TO CLINICAL PRACTICE:Staff turnover in the ICU is a universal problem for all facilities. Interestingly, this project discovered supporting evidence that the role of the ECMO specialist may positively impact the retention of ICU staff that partakes in this role. Thus, it affects centres that currently have an ECMO programme but could also be used as a decisive tool for those centres that are considering developing one.

Background Surgical ablation (SA) at the time of isolated mitral valve surgery (MVS) is recommended in patients with preexisting atrial fibrillation (AF). However, SA remains infrequently utilized during MVS with a poorly quantified impact on stroke and survival. Methods Medicare claims (2008-2019) were queried to identify beneficiaries with preexisting AF undergoing MVS. All-cause mortality and the postoperative incidence of stroke/transient ischemic attack were evaluated as separate endpoints. Overlap propensity score weighting was used to risk-adjust for measured confounding variables. Analyses were repeated using surgeon frequency of SA as an instrumental variable to adjust for unmeasured confounding variables. Results From 2008-2019, 41,795 Medicare beneficiaries with a preexisting diagnosis of AF underwent MVS. Surgeons were categorized, with 1326 infrequently (bottom quartile) performing SA (<30%; 10,364 beneficiaries) and 740 frequently (top quartile) performing SA (≥62%; 10,476 beneficiaries) during MVS. Beneficiaries undergoing MVS with SA (“as-treated” analysis) had a risk-adjusted median survival advantage of 0.56 (95% CI, 0.33-0.81) years (8.85 [95% CI, 8.64-9.04] vs 8.29 [95% CI, 8.11-8.47] years, P < .001 for risk-adjusted survival comparison) compared to those without. Beneficiaries undergoing MVS by frequent SA surgeons (“surgeon-preference” analysis) had a risk-adjusted median survival advantage of 0.35 (95% CI, 0.05-0.71) years (8.59 [95% CI, 8.40-8.85] vs 8.24 [95% CI, 7.97-8.40] years, P = .0015 for risk-adjusted survival comparison) compared to surgeons who infrequently performed SA. Conclusions In Medicare beneficiaries with preexisting AF, concomitant SA during MVS is associated with improved survival, as is undergoing surgery by a frequent SA surgeon. When analyzed based on surgeon preference for SA, the magnitude and time-dependent nature of the treatment effect of SA were substantially different compared to the “as-treated” analysis, suggesting that “as-treated” analyses may be subject to bias from unmeasured confounding variables.

Background:Although the Impella device has an established role in high-risk percutaneous intervention and cardiogenic shock, its role in open cardiac surgery remains unclear. We undertook this study to better understand the role of Impella support in cardiac surgical intervention. Methods:This is a retrospective cohort study of consecutive patients who underwent cardiac surgery with surgically placed Impella 5.5 device support from October 2020 through June 2023. Patient charts were identified and systematically reviewed for relevant information. The primary outcome for this study was patient survival to discharge. Secondary outcomes included intraoperative survival, 30-day survival and 1-year survival. Results:From 2020-2023, ten patients underwent open cardiac surgery with Impella 5.5 support. Five patients were male and the median age was 56.5 years [interquartile range (IQR), 52-63.8 years]. Three patients (30%) presented for isolated revascularization, 3 patients (30%) presented for single valve surgical intervention, 3 patients (30%) presented for revascularization and valve intervention, and 1 patient (10%) presented for multivalve intervention. The median ejection fraction (EF) of patients was 25% (IQR, 21.25-32.5%), the median Society of Thoracic Surgeons risk score was 4.32% (IQR, 1.73-11.06%). Of the patients, 40% underwent axillary cannulation while 60% had central cannulation. Intraoperative survival was 100%, survival to discharge was 90% and 30-day survival was 80%. Conclusions:Our study suggests the use of surgical Impella in high-risk cardiac surgical patients is associated with acceptable survival regardless of site or timing of cannulation. However, Impella usage is associated with significant morbidity. Further investigation is warranted to better understand which patients benefit perioperative Impella support.

Background: Multidisciplinary cardiogenic shock (CS) programs have been associated with improved outcomes, yet practical guidance for developing a CS program is lacking. Methods: A survey on CS program development and operational best practices was administered to 12 institutions in diverse sociogeographic regions and practice settings. Common steps in program development were identified. Results: Key steps for program development were identified: measuring baseline outcomes; identifying subspecialty champions; gaining leadership and team buy-in; developing institution-specific CS protocols; educating staff and referring providers; consulting with external experts; and developing quality assessment and process improvement. Conclusions: An assessment of 12 US CS programs highlights a blueprint for establishing and maintaining a successful, multidisciplinary shock program.