Pacemaker implantation associated with tricuspid repair in the setting of mitral valve surgery: Insights from a Cardiothoracic Surgical Trials Network randomized trial

OBJECTIVES

In a recent trial, tricuspid annuloplasty (TA) during mitral valve surgery (MVS) for degenerative mitral regurgitation and moderate or less tricuspid regurgitation (TR) reduced the composite rate of death, reoperation for TR, or TR progression at 2 years. However, this benefit was counterbalanced by an increase in implantation of permanent pacemakers (PPMs). In this study, we analyzed the timing, indications, and risk factors for these implantations.

METHODS

We randomized 401 patients (MVS alone = 203; MVS + TA = 198). Potential risk factors for PPMs were assessed using multivariable time-to-event models with death and PPM implantation for heart failure indications as competing risks.

RESULTS

A PPM was implanted in 36 patients (9.6; 95% CI, 6.8-13.0) within 2 years of randomization, with 30/187 (16.0%) in the MVS + TA and 6/188 (3.2%) in the MVS groups (rate ratio, 5.08; 95% CI, 2.16-11.94; P < .001). Most (29/36; 80.6%) implantations occurred within 30 days postoperatively. Independent risk factors for PPM implantation within 2 years were TA (hazard ratio [HR], 5.94; 95% CI, 2.27-15.53; P < .001), increasing age (5 years, HR, 1.23; 95% CI, 1.01-1.52; P = .04), and left ventricular ejection fraction (LVEF; HR, 0.96; 95% CI, 0.92-0.99; P = .02). In the subset of TA recipients (n = 197), age (5 years, HR, 1.05; 95% CI, 1.00-1.10; P = .04) and LVEF (HR, 0.95; 95% CI, 0.91-0.99; P = .01) were associated with PPM within 2 years.

CONCLUSIONS

Concomitant TA, age, and baseline LVEF were risk factors for PPM implantation in patients who underwent MVS for degenerative mitral regurgitation. Although TA was effective in preventing progression of TR, innovation is needed to identify ways to decrease PPM implantation rates.

Association of adherence to individual components of Society of Thoracic Surgeons cardiac surgery antibiotic guidelines and postoperative infections

OBJECTIVES

The study objectives were to measure the association among the 4 components of Society of Thoracic Surgeons antibiotic guidelines and postoperative complications in a cohort of patients undergoing valve or coronary artery bypass grafting requiring cardiopulmonary bypass.

METHODS

In this retrospective observational study, adult patients undergoing coronary revascularization or valvular surgery who received a Surgical Care Improvement Project-compliant antibiotic from January 1, 2016, to April 1, 2021, at a single, tertiary care hospital were included. The primary exposures were adherence to the 4 individual components of Society of Thoracic Surgeons antibiotic best practice guidelines. The association of each component and a combined metric was tested in its association with the primary outcome of postoperative infection as determined by Society of Thoracic Surgeons data abstractors, controlling for several known confounders.

RESULTS

Of the 2829 included patients, 1084 (38.3%) received care that was nonadherent to at least 1 aspect of Society of Thoracic Surgeons antibiotic guidelines. The incidence of nonadherence to the 4 individual components was 223 (7.9%) for timing of first dose, 639 (22.6%) for antibiotic choice, 164 (5.8%) for weight-based dose adjustment, and 192 (6.8%) for intraoperative redosing. In adjusted analyses, failure to adhere to first dose timing guidelines was directly associated with Society of Thoracic Surgeons-adjudicated postoperative infection (odds ratio, 1.9; 95% confidence interval, 1.1-3.3; P = .02). Failure of weight-adjusted dosing was associated with both postoperative sepsis (odds ratio, 6.9; 95% confidence interval, 2.5-8.5; P < .01) and 30-day mortality (odds ratio, 4.3; 95% confidence interval, 1.7-11.4; P < .01). No other significant associations among the 4 Society of Thoracic Surgeons metrics individually or as a combination were observed with postoperative infection, sepsis, or 30-day mortality.

CONCLUSIONS

Nonadherence to Society of Thoracic Surgeons antibiotic best practices is common. Failure of antibiotic timing and weight-adjusted dosing is associated with odds of postoperative infection, sepsis, and mortality after cardiac surgery.

Implementing Formal Mitral Heart Team Improves Multidisciplinary Evaluation Rate and Survival of Patients With Severe Primary Mitral Regurgitation

BACKGROUND

Multidisciplinary heart team (HT) evaluation is recommended for patients with severe primary mitral regurgitation to optimize treatment decisions. However, its impact on patient outcomes remains unknown. We evaluated the impact of implementing mitral HT on patient survival.

METHODS AND RESULTS

We conducted a retrospective cohort study of patients with new diagnoses of severe primary mitral regurgitation in a large healthcare network echocardiogram database between 2016 and 2020. We compared the incidence of multidisciplinary evaluation by structural cardiology and cardiac surgery services and 2-year survival before and after mitral HT implementation. The 1:1 propensity-score matching between pre- and post-mitral HT used Society of Thoracic Surgeons Predicted Risk of Mortality for mitral repair, age, sex, race, heart failure symptoms, inpatient setting, history of MI, and dementia as covariates. Logistic regression identified variables associated with the likelihood of undergoing multidisciplinary evaluation. Among 70 510 echocardiograms performed, 391 patients had severe primary mitral regurgitation (median age, 77 years; 46% women). Multidisciplinary evaluation increased from 29% to 89% (P<0.001), and intervention increased from 24% to 75% following mitral HT implementation (P<0.001). Among 180 propensity-score matched patients, mortality was lower post-mitral HT at 2 years (19% versus 32%, P=0.04). The multivariable model showed that mitral HT implementation and heart failure symptoms were associated with higher odds of undergoing multidisciplinary evaluation (OR [odds ratio], 18.7 and 2.72, respectively), whereas female sex and older age were associated with lower odds (OR, 0.39 and 0.93, respectively).

CONCLUSIONS

Implementation of mitral HT was associated with drastic improvement in multidisciplinary evaluation for patients with severe primary mitral regurgitation. This coincided with higher proportions of patients undergoing mechanical correction of MR and improved overall patient survival.

Extremely Long-Term Follow-Up of Dr William Glenn's Original Patient Cohort With Superior Cavopulmonary Anastomosis (1958-1990)

BACKGROUND

Historically, Dr William Glenn performed the first classic superior cavopulmonary anastomosis in a seven-year-old child at Yale in 1958. By 1990, this operation was performed consecutively in over 90 patients. With over 60 years of follow-up, this is the longest survival record of early Glenn patients from the first 30 years.

METHODS

We performed a single center, retrospective evaluation of patients undergoing a Glenn operation. A collected list of surviving patients, previously updated in 1988, included demographics, age at procedure, and underlying diagnosis. Follow-up data were obtained in May 2022 using electronic medical records to determine survival, age of survivors, and age of deceased.

RESULTS

Ninety-five patients underwent the Glenn operation from 1958 to 1990: 58.9% (n = 56) were male and 41.1% (n = 39) female. Fifteen patients were lost to follow-up, but 12 were alive in 1988. Sixty patients were deceased (68.1%), with an average age of 33.5 ± 18.3(range, 2-78, excluding seven early deaths) years. The oldest patient who passed away was a 78-year-old male with tetralogy of Fallot. Twenty patients remain alive, with an average age of 47.5 (range, 32-66) years. Four patients who are still alive today (20% survivors) are older than 60 years.

CONCLUSIONS

Since Dr Glenn's original operation, the technique, timing, and indications have been modified (ie, bidirectional Glenn) to adapt to the current era. By following this initial group of patients, we can approach completion of the survival rates for adult congenital patients who were some of the first pediatric patients to receive this ground-breaking palliative procedure.

Early outcomes following transatrial transcatheter mitral valve replacement in patients with severe mitral annular calcification

OBJECTIVE

Implantation of a transcatheter valve-in-mitral annular calcification (ViMAC) has emerged as an alternative to traditional surgical mitral valve (MV) replacement. Previous studies evaluating ViMAC aggregated transseptal, transapical, and transatrial forms of the procedure, leaving uncertainty about each technique's advantages and disadvantages. Thus, we sought to evaluate clinical outcomes specifically for transatrial ViMAC from the largest multicenter registry to-date.

METHODS

Patients with symptomatic MV dysfunction and severe MAC who underwent ViMAC were enrolled from 12 centers across the United States and Europe. Clinical characteristics, procedural details, and clinical outcomes were abstracted from the electronic record. The primary end point was all-cause mortality.

RESULTS

We analyzed 126 patients who underwent ViMAC (median age 76 years [interquartile range {IQR}, 70-82 years], 28.6% female, median Society of Thoracic Surgeons score 6.8% [IQR, 4.0-11.4], and median follow-up 89 days [IQR, 16-383.5]). Sixty-one (48.4%) had isolated mitral stenosis, 25 (19.8%) had isolated mitral regurgitation (MR), and 40 (31.7%) had mixed MV disease. Technical success was achieved in 119 (94.4%) patients. Thirty (23.8%) patients underwent concurrent septal myectomy, and 8 (6.3%) patients experienced left ventricular outflow tract obstruction (7/8 did not undergo myectomy). Five (4.2%) patients of 118 with postprocedure echocardiograms had greater than mild paravalvular leak. Thirty-day and 1-year all-cause mortality occurred in 16 and 33 patients, respectively. In multivariable models, moderate or greater MR at baseline was associated with increased risk of 1-year mortality (hazard ratio, 2.31; 95% confidence interval, 1.07-4.99, P = .03).

CONCLUSIONS

Transatrial ViMAC is safe and feasible in this selected, male-predominant cohort. Patients with significant MR may derive less benefit from ViMAC than patients with mitral stenosis only.

Racial/Ethnic Disparities in Aortic Valve Replacement Among Medicare Beneficiaries in the United States, 2012-2019

PURPOSE

There are concerns that transcatheter or surgical aortic valve replacement (TAVR/SAVR) procedures are preferentially available to White patients. Our objective was to examine differences in utilization of aortic valve replacement and outcomes by race/ethnicity in the US for patients with aortic stenosis.

METHODS

We performed a serial cross-sectional cohort study of 299,976 Medicare beneficiaries hospitalized with principal diagnosis of aortic stenosis between 2012 and 2019 stratified by self-reported race/ethnicity (Black, Hispanic, Asian, Native American, and White). Outcomes included aortic valve replacement rates within 6 months of index hospitalization and associated procedural outcomes, including 30-day readmission, 30-day and 1-year mortality.

RESULTS

Within 6 months of an index admission for aortic stenosis, 86.8% (122,457 SAVR; 138,026 TAVR) patients underwent aortic valve replacement. Overall, compared with White people, Black (HR 0.87 [0.85-0.89]), Hispanic (0.92 [0.88-0.96]), and Asian (0.95 [0.91-0.99]) people were less likely to receive aortic valve replacement. Among patients who were admitted emergently/urgently, White patients (41.1%, 95% CI, 40.7-41.4) had a significantly higher aortic valve replacement rate compared with Black (29.6%, 95% CI, 28.3-30.9), Hispanic (36.6%, 95% CI, 34.0-39.3), and Asian patients (35.4%, 95% CI, 32.3-38.9). Aortic valve replacement rates increased annually for all race/ethnicities. There were no significant differences in 30-day or 1-year mortality by race/ethnicity.

CONCLUSIONS

Aortic valve replacement rates within 6 months of aortic stenosis admission are lower for Black, Hispanic, and Asian people compared to White people. These race-related differences in aortic stenosis treatment reflect complex issues in diagnosis and management, warranting a comprehensive reassessment of the entire care spectrum for disadvantaged populations.

The high-risk features among patients undergoing mitral valve operation for ischemic mitral regurgitation: The 3-strike score

Objective

Ischemic mitral regurgitation is prevalent and associated with high surgical risk. With the less-invasive option of transcatheter edge-to-edge repair, the optimal patient selection for mitral valve operation for ischemic mitral regurgitation remains unclear. We sought to identify high-risk features in this group to guide patient selection.

Methods

Using the Cardiothoracic Surgery Trial Network's severe ischemic mitral regurgitation trial data, we identified patient and echocardiographic characteristics associated with an increased risk of 2-year mortality using the support vector classifier and Cox proportional hazards model. We identified 6 high-risk features associated with 2-year survival. Patients were categorized into 3 groups, each having 1 or less, 2, or 3 or more of the 6 identified high-risk features.

Results

Among the 251 patients, the median age was 69 (Q1 62, Q3 75) years, and 96 (38%) were female. Two-year mortality was 21% (n = 53). We identified 6 high-risk preoperative features: age 75 years or more (n = 69, 28%), prior sternotomy (n = 49, 20%), renal insufficiency (n = 69, 28%), gastrointestinal bleeding (n = 15, 6%), left ventricular ejection fraction less than 40% (n = 131, 52%), and ventricular end-systolic volume index less than 50 mL/m2 (n = 93, 37%). In patients who had 1 or less, 2, and 3 or more high-risk features, 90-day mortality was 4.2% (n = 5), 9.9% (n = 4), and 20.0% (n = 10), respectively (P = .006), and 2-year mortality was 10% (n = 12), 22% (n = 18), and 46% (n = 23) (P < .001), respectively.

Conclusions

We developed the 3-strike score by identifying high-risk preoperative features for mitral valve surgery for ischemic mitral regurgitation. Patients having 3 or more of such high-risk features should undergo careful evaluation for surgical candidacy given the high early and late mortality after mitral valve operations.

Living in disadvantaged neighborhoods linked to less intervention for severe aortic stenosis

To investigate the association between area deprivation index (ADI) and aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). Patients aged 40-95 years with severe AS confirmed by echocardiography were included. The 9-digit zip code of patient residence address was used to identify the ADI ranking, based on which patients were divided into 5 groups (with Group E being most deprived). The rates of AV intervention were compared among 5 groups using competing risks analysis, with death as a competing event. We included 1751 patients with severe AS from 2013 to 2018 followed for a median 2.8 (interquartile range, 1.5-4.8) years. The more distressed ADI groups tended to be younger (P = 0.002), female (P < 0.001), and of African American race (P < 0.001), have higher presentation of sepsis (P = 0.031), arrhythmia (P = 0.022), less likely to have previous diagnosis of AS (P < 0.001); and were less likely to undergo AVR (52.5% vs 46.9% vs 46.1% vs 48.9% vs 39.7%, P = 0.023). Using competing risk analysis, the highest ADI group (E) were the least and the lowest ADI group (A) the most likely to undergo AVR (Gray's test, P = 0.025). The association between ADI ranking and AVR rates was influenced by sex and race. Within group analysis, there was significant association between race and AVR (Gray's test, P < 0.001), and between sex and AVR (Gray's test, P < 0.001). Patients with severe AS living in more deprived neighborhoods were less likely to undergo aortic valve interventions, which was influenced by female gender, and African American race.

Assessment of online information on robotic cardiac and thoracic surgery

Online health resources are important for patients seeking perioperative information on robotic cardiac and thoracic surgery. The value of the resources depends on their readability, accuracy, content, quality, and suitability for patient use. We systematically assess current online health information on robotic cardiac and thoracic surgery. Systematic online searches were performed to identify websites discussing robotic cardiac and thoracic surgery. For each website, readability was measured by nine standardized tests, and accuracy and content were assessed by an independent panel of two robotic cardiothoracic surgeons. Quality and suitability of websites were evaluated using the DISCERN and Suitability Assessment of Materials tools, respectively. A total of 220 websites (120 cardiac, and 100 thoracic) were evaluated. Both robotic cardiac and thoracic surgery websites were very difficult to read with mean readability scores of 13.8 and 14.0 (p = 0.97), respectively, requiring at least 13 years of education to be comprehended. Both robotic cardiac and thoracic surgery websites had similar accuracy, amount of content, quality, and suitability (p > 0.05). On multivariable regression, academic websites [Exp (B)], 2.25; 95% confidence interval [CI], 1.60-3.16; P < 0.001), and websites with higher amount of content [Exp (B)],1.73; 95% CI, 1.24-2.41; P < 0.001) were associated with higher accuracy. There was no association between readability of websites and accuracy [Exp (B)], 1.04; 95% CI, 0.90-1.21; P = 0.57). Online information on robotic cardiac and thoracic surgery websites overestimate patients' understanding and require at least 13 years of education to be comprehended. As website accuracy is not associated with ease of reading, the readability of online resources can be improved without compromising accuracy.

Totally endoscopic, robotic-assisted tricuspid valve repair and biatrial CryoMAZE

We describe in detail our technique for totally endoscopic, robotic-assisted tricuspid valve repair for iatrogenic tricuspid regurgitation and biatrial cryoMAZE.

Robotic Mitral Valve Repair for Degenerative Mitral Regurgitation

BACKGROUND

Contemporary national utilization and comparative safety data of robotic mitral valve repair for degenerative mitral regurgitation compared with nonrobotic approaches are lacking. The study aimed to characterize national trends of utilization and outcomes of robotic mitral repair of degenerative mitral regurgitation compared with sternotomy and thoracotomy approaches.

METHODS

Patients undergoing intended mitral repair of degenerative mitral regurgitation in The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2015 and 2021 were examined. Mitral repair was performed in 61,322 patients. Descriptive analyses characterized center-level volumes and outcomes. Propensity score matching separately identified 5540 pairs of robotic vs thoracotomy approaches and 6962 pairs of robotic vs sternotomy approaches. Outcomes were operative mortality, composite mortality and major morbidity, postoperative length of stay, and conversion to mitral replacement.

RESULTS

Through the 7-year study period, 116 surgeons across 103 hospitals performed mitral repair robotically. The proportion of robotic cases increased from 10.9% (949 of 8712) in 2015 to 14.6% (1274 of 8730) in 2021. In both robotic-thoracotomy and robotic-sternotomy matched pairs, mortality and morbidity were not significantly different, whereas the robotic approach had lower conversion (1.2% vs 3.1% for robotic-thoracotomy and 1.0% vs 3.7% for robotic-sternotomy), shorter length of stay, and fewer 30-day readmissions. Mortality and morbidity were lower at higher-volume centers, crossing the national mean mortality and morbidity at a cumulative robotic mitral repair case of 40.

CONCLUSIONS

Robotic mitral repair is a safe and effective approach and is associated with comparable mortality and morbidity, a lower conversion rate, a shorter length of stay, and fewer 30-day readmissions than thoracotomy or sternotomy approaches.

Outcomes of patients with advanced liver disease undergoing cardiac surgery

Objective

Liver disease (LD) is considered a risk factor for inferior outcomes in general and cardiac surgery, yet current cardiac surgery risk estimators exclude LD, and literature on the topic remains scant. We sought to evaluate whether the presence of advanced LD is associated with inferior outcomes following cardiac surgery.

Methods

This single-center, retrospective, observational study included 285 patients diagnosed with LD who underwent cardiac surgery in 2010 to 2020. The cohort contained 3 groups, Child-Turcotte-Pugh (CTP) class A (n = 219), CTP early-class B (n = 34), and CTP advanced-class B (n = 32). A model for end-stage liver disease score of 12.7 points (determined using a receiver-operating characteristic curve analysis on 30-day mortality) dichotomized class B into early- and advanced-groups. Univariate and multivariate logistic regression analyses were performed to identify predictors of 30-day mortality.

Results

Patients in CTP advanced-class B had the longest length of stay (14 days), highest incidence of prolonged ventilation (46.9%), renal failure (21.9%), 30-day mortality (18.8%), and in-hospital mortality (18.8%). Incidence of ≥1 postoperative complication was higher in CTP advanced-class B (59.4%), compared with CTP class A (37.9%) and CTP early-class B (38.2%). Multivariate logistic regression analysis demonstrated that female sex (odds ratio, 3.01; 95% CI, 1.07-8.77; P = .037) and peripheral vascular disease (odds ratio, 4.01; 95% CI, 1.33-12.2; P = .013) were independent predictors of 30-day mortality in patients with advanced LD.

Conclusions

Severity of LD influences perioperative outcomes following cardiac surgery. Our data suggest that patients in CTP class A and selected patients in CTP class B (model for end-stage liver disease score <12.7) can undergo surgery with acceptable risk.

Pacemaker implantation following tricuspid valve annuloplasty

Objective

Tricuspid annuloplasty is associated with increased risk of atrioventricular block and subsequent implantation of a permanent pacemaker. However, the exact incidence of permanent pacemaker, associated risk factors, and outcomes in this frame remain debated. The aim of the study was to report permanent pacemaker incidence, risk factors, and outcomes after tricuspid annuloplasty from nationwide databases.

Methods

By using data from multiple Swedish mandatory national registries, all patients (n = 1502) who underwent tricuspid annuloplasty in Sweden from 2006 to 2020 were identified. Patients who needed permanent pacemaker within 30 days from surgery were compared with those who did not. The cumulative incidence of permanent pacemaker implantation was estimated. A multivariable logistic regression model was fit to identify risk factors of 30-day permanent pacemaker implantation. The association between permanent pacemaker implantation and long-term survival was evaluated with multivariable Cox regression.

Results

The 30-day permanent pacemaker rate was 14.2% (214/1502). Patients with permanent pacemakers were older (69.8 ± 10.3 years vs 67.5 ± 12.4 years, P = .012). Independent risk factors of permanent pacemaker implantation were concomitant mitral valve surgery (odds ratio, 2.07; 95% CI, 1.34-3.27), ablation surgery (odds ratio, 1.59; 95% CI, 1.12-2.23), and surgery performed in a low-volume center (odds ratio, 1.85; 95% CI, 1.17-2.83). Permanent pacemaker implantation was not associated with increased long-term mortality risk (adjusted hazard ratio, 0.74; 95% CI, 0.53-1.03).

Conclusions

This nationwide study demonstrated a high risk of permanent pacemaker implantation within 30 days of tricuspid annuloplasty. However, patients who needed a permanent pacemaker did not have worse long-term survival, and the cumulative incidence of heart failure and major adverse cardiovascular events was similar to patients who did not receive a permanent pacemaker.

Transplantation Outcomes with Donor Hearts after Circulatory Death

BACKGROUND

Data showing the efficacy and safety of the transplantation of hearts obtained from donors after circulatory death as compared with hearts obtained from donors after brain death are limited.

METHODS

We conducted a randomized, noninferiority trial in which adult candidates for heart transplantation were assigned in a 3:1 ratio to receive a heart after the circulatory death of the donor or a heart from a donor after brain death if that heart was available first (circulatory-death group) or to receive only a heart that had been preserved with the use of traditional cold storage after the brain death of the donor (brain-death group). The primary end point was the risk-adjusted survival at 6 months in the as-treated circulatory-death group as compared with the brain-death group. The primary safety end point was serious adverse events associated with the heart graft at 30 days after transplantation.

RESULTS

A total of 180 patients underwent transplantation; 90 (assigned to the circulatory-death group) received a heart donated after circulatory death and 90 (regardless of group assignment) received a heart donated after brain death. A total of 166 transplant recipients were included in the as-treated primary analysis (80 who received a heart from a circulatory-death donor and 86 who received a heart from a brain-death donor). The risk-adjusted 6-month survival in the as-treated population was 94% (95% confidence interval [CI], 88 to 99) among recipients of a heart from a circulatory-death donor, as compared with 90% (95% CI, 84 to 97) among recipients of a heart from a brain-death donor (least-squares mean difference, -3 percentage points; 90% CI, -10 to 3; P<0.001 for noninferiority [margin, 20 percentage points]). There were no substantial between-group differences in the mean per-patient number of serious adverse events associated with the heart graft at 30 days after transplantation.

CONCLUSIONS

In this trial, risk-adjusted survival at 6 months after transplantation with a donor heart that had been reanimated and assessed with the use of extracorporeal nonischemic perfusion after circulatory death was not inferior to that after standard-care transplantation with a donor heart that had been preserved with the use of cold storage after brain death. (Funded by TransMedics; ClinicalTrials.gov number, NCT03831048.).

A ZFYVE21-Rubicon-RNF34 signaling complex promotes endosome-associated inflammasome activity in endothelial cells

Internalization of complement membrane attack complexes (MACs) assembles NLRP3 inflammasomes in endothelial cells (EC) and promotes IL-β-mediated tissue inflammation. Informed by proteomics analyses of FACS-sorted inflammasomes, we identify a protein complex modulating inflammasome activity on endosomes. ZFVYE21, a Rab5 effector, partners with Rubicon and RNF34, forming a "ZRR" complex that is stabilized in a Rab5- and ZFYVE21-dependent manner on early endosomes. There, Rubicon competitively disrupts inhibitory associations between caspase-1 and its pseudosubstrate, Flightless I (FliI), while RNF34 ubiquitinylates and degradatively removes FliI from the signaling endosome. The concerted actions of the ZRR complex increase pools of endosome-associated caspase-1 available for activation. The ZRR complex is assembled in human tissues, its associated signaling responses occur in three mouse models in vivo, and the ZRR complex promotes inflammation in a skin model of chronic rejection. The ZRR signaling complex reflects a potential therapeutic target for attenuating inflammasome-mediated tissue injury.

Impact of Mitral Regurgitation Etiology on Mitral Surgery After Transcatheter Edge-to-Edge Repair: From the CUTTING-EDGE Registry

BACKGROUND

Although >150,000 mitral TEER procedures have been performed worldwide, the impact of MR etiology on MV surgery after TEER remains unknown.

OBJECTIVES

The authors sought to compare outcomes of mitral valve (MV) surgery after failed transcatheter edge-to-edge repair (TEER) stratified by mitral regurgitation (MR) etiology.

METHODS

Data from the CUTTING-EDGE registry were retrospectively analyzed. Surgeries were stratified by MR etiology: primary (PMR) and secondary (SMR). MVARC (Mitral Valve Academic Research Consortium) outcomes at 30 days and 1 year were evaluated. Median follow-up was 9.1 months (IQR: 1.1-25.8 months) after surgery.

RESULTS

From July 2009 to July 2020, 330 patients underwent MV surgery after TEER, of which 47% had PMR and 53.0% had SMR. Mean age was 73.8 ± 10.1 years, median STS risk at initial TEER was 4.0% (IQR: 2.2%-7.3%). Compared with PMR, SMR had a higher EuroSCORE, more comorbidities, lower LVEF pre-TEER and presurgery (all P < 0.05). SMR patients had more aborted TEER (25.7% vs 16.3%; P = 0.043), more surgery for mitral stenosis after TEER (19.4% vs 9.0%; P = 0.008), and fewer MV repairs (4.0% vs 11.0%; P = 0.019). Thirty-day mortality was numerically higher in SMR (20.4% vs 12.7%; P = 0.072), with an observed-to-expected ratio of 3.6 (95% CI: 1.9-5.3) overall, 2.6 (95% CI: 1.2-4.0) in PMR, and 4.6 (95% CI: 2.6-6.6) in SMR. SMR had significantly higher 1-year mortality (38.3% vs 23.2%; P = 0.019). On Kaplan-Meier analysis, the actuarial estimates of cumulative survival were significantly lower in SMR at 1 and 3 years.

CONCLUSIONS

The risk of MV surgery after TEER is nontrivial, with higher mortality after surgery, especially in SMR patients. These findings provide valuable data for further research to improve these outcomes.

Mild aortic insufficiency following transcatheter aortic valve replacement: A systematic review and meta-analysis

BACKGROUND

Post-procedural aortic insufficiency (AI) continues to be prevalent following transcatheter aortic valve replacement (TAVR). While several studies have assessed the outcomes of moderate-severe AI following TAVR, the incidence, predictors, and outcomes of mild AI remain unclear.

METHODS

A systematic literature review was performed to identify studies reporting on mild AI following TAVR. The primary outcome was pooled incidence of post-TAVR mild AI. Secondary outcomes included pooled incidence of mild AI at 30 days and long term. The pooled incidence of midterm mortality in patients with post-TAVR mild AI was also evaluated. The random effect generalized linear mixed-effects model with logit-transformed proportions and Hartung-Knapp adjustment was used to calculate pooled incidence rates. Meta-regression was performed to identify predictors of mild AI.

RESULTS

The pooled analysis included 19,241 patients undergoing TAVR across 50 studies. The mean age of patients ranged from 73 to 85 years, and female patients ranged from 20.0% to 83.3%. The overall pooled incidence of post-TAVR mild AI was 56.1% (95% confidence interval [CI] 0.31-0.64). The pooled incidence of mild AI at 30 days was 33.7% (95% CI 0.12-0.37). At mean follow-up of 1.15 years, the pooled incidence of mild AI was 37.0% (95% CI 0.16-0.45). The overall pooled incidence of Midterm mortality (mean follow-up 1.22 years) in patients with mild AI was 14.8% (95% CI 0.10-0.25). At meta-regression, none of the explored variables correlated with a difference in mild AI incidence.

CONCLUSIONS

In published studies to date, 50% of patients undergoing TAVR develop mild AI postoperatively. In 37% of patients, this persists in long term. Though the incidence of AI is likely improving with newer generation TAVR valves, the prevalence and outcomes of mild AI should be closely monitored as TAVR volume and indications expand to younger patients with long life expectancy. The long-term outcomes of mild AI remain unclear. Further dedicated studies on post-TAVR mild AI are needed.

De-Airing Maneuvers After Minimally Invasive and Robotic-Assisted Intracardiac Procedures

In the setting of minimally invasive and robotic-assisted intracardiac procedures, de-airing requires further technical considerations due to limited access to the pericardial space and the subsequent difficulty of directly manipulating the heart. We summarize the technical steps for de-airing according to different cannulation strategies for minimally invasive and robotic-assisted intracardiac procedures.

Explant vs Redo-TAVR After Transcatheter Valve Failure: Mid-Term Outcomes From the EXPLANTORREDO-TAVR International Registry

BACKGROUND

Valve reintervention after transcatheter aortic valve replacement (TAVR) failure has not been studied in detail.

OBJECTIVES

The authors sought to determine outcomes of TAVR surgical explantation (TAVR-explant) vs redo-TAVR because they are largely unknown.

METHODS

From May 2009 to February 2022, 396 patients in the international EXPLANTORREDO-TAVR registry underwent TAVR-explant (181, 46.4%) or redo-TAVR (215, 54.3%) for transcatheter heart valve (THV) failure during a separate admission from the initial TAVR. Outcomes were reported at 30 days and 1 year.

RESULTS

The incidence of reintervention after THV failure was 0.59% with increasing volume during the study period. Median time from index-TAVR to reintervention was shorter in TAVR-explant vs redo-TAVR (17.6 months [IQR: 5.0-40.7 months] vs 45.7 months [IQR: 10.6-75.6 months]; P < 0.001], respectively. TAVR-explant had more prosthesis-patient mismatch (17.1% vs 0.5%; P < 0.001) as the indication for reintervention, whereas redo-TAVR had more structural valve degeneration (63.7% vs 51.9%; P = 0.023), with a similar incidence of ≥moderate paravalvular leak between groups (28.7% vs 32.8% in redo-TAVR; P = 0.44). There was a similar proportion of balloon-expandable THV failures (39.8% TAVR-explant vs 40.5% redo-TAVR; P = 0.92). Median follow-up was 11.3 (IQR: 1.6-27.1 months) after reintervention. Compared with redo-TAVR, TAVR-explant had higher mortality at 30 days (13.6% vs 3.4%; P < 0.001) and 1 year (32.4% vs 15.4%; P = 0.001), with similar stroke rates between groups. On landmark analysis, mortality was similar between groups after 30 days (P = 0.91).

CONCLUSIONS

In this first report of the EXPLANTORREDO-TAVR global registry, TAVR-explant had a shorter median time to reintervention, with less structural valve degeneration, more prosthesis-patient mismatch, and similar paravalvular leak rates compared with redo-TAVR. TAVR-explant had higher mortality at 30 days and 1 year, but similar rates on landmark analysis after 30 days.

Hedgehog-induced ZFYVE21 promotes chronic vascular inflammation by activating NLRP3 inflammasomes in T cells

The zinc finger protein ZFYVE21 is involved in immune signaling. Using humanized mouse models, primary human cells, and patient samples, we identified a T cell-autonomous role for ZFYVE21 in promoting chronic vascular inflammation associated with allograft vasculopathy. Ischemia-reperfusion injury (IRI) stimulated endothelial cells to produce Hedgehog (Hh) ligands, which in turn induced the production of ZFYVE21 in a population of T memory cells with high amounts of the Hh receptor PTCH1 (PTCHhi cells, CD3+CD4+CD45RO+PTCH1hiPD-1hi), vigorous recruitment to injured endothelia, and increased effector responses in vivo. After priming by interferon-γ (IFN-γ), Hh-induced ZFYVE21 activated NLRP3 inflammasome activity in T cells, which potentiated IFN-γ responses. Hh-induced NLRP3 inflammasomes and T cell-specific ZFYVE21 augmented the vascular sequelae of chronic inflammation in mice engrafted with human endothelial cells or coronary arteries that had been subjected to IRI before engraftment. Moreover, the population of PTCHhi T cells producing high amounts of ZFYVE21 was expanded in patients with renal transplant-associated IRI, and sera from these patients expanded this population in control T cells in a manner that depended on Hh signaling. We conclude that Hh-induced ZFYVE21 activates NLRP3 inflammasomes in T cells, thereby promoting chronic inflammation.

A Retrospective Evaluation of Endo-Aortic Balloon Occlusion Compared to External Clamping in Minimally Invasive Mitral Valve Surgery

We compare outcomes of endo-aortic balloon occlusion (EABO) vs external aortic clamping (EAC) in patients undergoing minimally invasive mitral valve surgery (MIMVS) in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. Adults undergoing mitral valve surgery (July 2017-December 2018) were identified within the STS database (N = 60,607). Total 7,978 patients underwent a minimally invasive approach (including robotically assisted). About 1,163 EABO patients were 1:1 propensity-matched to EAC patients using exact matching on age, sex, and type of mitral procedure, and propensity score average matching for 16 other risk indicators. Early outcomes were compared. Categorical variables were compared using logistic regression; hospital and intensive care unit length of stay were compared using negative binomial regression. In the matched cohort, mean age was 62 years; 35.9% were female, and 86% underwent mitral valve repair. Cardiopulmonary bypass time was shorter for EABO vs EAC group (125.0 ± 53.0 vs 134.0 ± 67.0 minutes, P = 0.0009). There was one aortic dissection in the EAC group and none in the EABO group (P value > 0.31), and no statistically significant differences in cross-clamp time, major intraoperative bleeding, perioperative mortality, stroke, new onset of atrial fibrillation, postoperative acute kidney injury, success of repair. Median hospital LOS was shorter for EABO vs EAC procedures (4 vs 5 days, P < 0.0001). In this large, retrospective, STS database propensity-matched analysis ofpatients undergoing MIMVS, we observed similar safety outcomes for EABO and EAC, including no aortic dissections in the EABO group. The EABO group showed slightly shorter CPB times and hospital LOS.

Type A Aortic Dissection Repair in Patients With Prior Cardiac Surgery

BACKGROUND

Emergency surgery for acute type A aortic dissection in patients with previous cardiac surgery is controversial. This study aimed to evaluate the association between previous cardiac surgery and outcomes after surgery for acute type A aortic dissection, to appreciate whether emergency surgery can be offered with acceptable risks.

METHODS

All patients operated on for acute type A aortic dissection between 2005 and 2014 from the Nordic Consortium for Acute Type A Aortic Dissection database were eligible. Patients with previous cardiac surgery were compared with patients without previous cardiac surgery. Univariable and multivariable statistical analyses were performed to identify predictors of 30-day mortality and early major adverse events (a secondary composite endpoint comprising 30-day mortality, perioperative stroke, postoperative cardiac arrest, or de novo dialysis).

RESULTS

In all, 1159 patients were included, 40 (3.5%) with previous cardiac surgery. Patients with previous cardiac surgery had higher 30-day mortality (30% vs 17.8%, P = .049), worse medium-term survival (51.7% vs 71.2% at 5 years, log rank P = .020), and higher unadjusted prevalence of major adverse events (52.5% vs 35.7%, P = .030). In multivariable analysis, previous cardiac surgery was not associated with 30-day mortality (odds ratio 0.78; 95% CI, 0.30-2.07; P = .624) or major adverse events (odds ratio 1.07; 95% CI, 0.45-2.55, P = .879).

CONCLUSIONS

Major adverse events after surgery for acute type A aortic dissection were more frequent in patients with previous cardiac surgery. Previous cardiac surgery itself was not an independent predictor for adverse events, although the small sample size precludes definite conclusions. Previous cardiac surgery should not deter from emergency surgery.

A robotic-assisted approach to sliding plasty, neochordoplasty, and annuloplasty in a technically complex mitral valve repair

In experienced hands, complex mitral valve repair can be safely and effectively performed in a totally endoscopic, robotic-assisted manner. We present a technically complex case of a 76-year-old man with severe, symptomatic mitral regurgitation due to Barlow's disease, moderate-to-severe tricuspid regurgitation, and atrial fibrillation.

Multidisciplinary Management of Opioid Use-Related Infective Endocarditis: Treatment, QTc Values, and Cardiac Arrests due to Ventricular Fibrillation

(1) Background: The opioid epidemic has led to an increase in cardiac surgery for infective endocarditis (IE-CS) related to injection use of opioids (OUD) and other substances and a call for a coordinated approach to initiate substance use disorder treatment, including medication for OUD (MOUD), during IE-CS hospitalizations. We sought to determine the effects of the initiation of a multi-disciplinary endocarditis evaluation team (MEET) on MOUD use, electrocardiographic QTc measurements and cardiac arrests due to ventricular fibrillation (VF) in patients with OUD. (2) Methods and Results: A historical group undergoing IE-CS at Yale-New Haven Hospital prior to MEET initiation, Group I (43 episodes of IE-CS, 38 patients) was compared to 24 patients undergoing IE-CS after MEET involvement (Group II). Compared to Group l, Group II patients were more likely to receive MOUD (41.9 vs. 95.8%, p < 0.0001), predominantly methadone (41.9 vs. 79.2%, p = 0.0035) at discharge. Both groups had similar QTcs: approximately 30% of reviewed electrocardiograms had QTcs ≥ 470 ms and 17%, QTcs ≥ 500 ms. Cardiac arrests due to VF were not uncommon: Group I: 9.3% vs. Group II: 8.3%, p = 0.8914. Half occurred in the 1-2 months after surgery and were contributed to by pacemaker malfunction/ management and half were related to opioid use. (3) Conclusions: MEET was associated with increased MOUD (predominantly methadone) use during IE-CS hospitalizations without an increase in QTc prolongation or cardiac arrest due to VF compared to Group I, but events occurred in both groups. These arrests were associated with pacemaker issues or a return to opioid use. Robust follow-up of IE-CS patients is essential, as is further research to clarify the longer-term effects of MEET on outcomes.

TAVR explant with aortic root replacement using a homograft for an aortic rupture

This case report describes the explantation of an Evolut PRO valve 9 months after implantation in a 69-year-old male presenting with an aortic rupture adjacent to the stent frame of the prosthesis. Imaging was consistent with aortic sinus pseudoaneurysm and a large haemopericardium. Degeneration of the aortic root compounded by the transcatheter prosthesis in addition to the aortic rupture required replacement of the aortic root. The complexity of the procedure also required a modified Cabrol extension of the left coronary button and reconstruction of the left coronary button with bovine pericardium. We describe the technical challenges posed by the self-expanding transcatheter aortic valve prosthesis and tips and tricks to circumvent these challenges.

Temperature effects on incidence of surgery for acute type A aortic dissection in the Nordics

We aimed to investigate a hypothesised association between daily mean temperature and the risk of surgery for acute type A aortic dissection (ATAAD). For the period of 1 January 2005 until 31 December 2019, we collected daily data on mean temperatures and date of 2995 operations for ATAAD at 10 Nordic cities included in the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) collaboration. Using a two-stage time-series approach, we investigated the association between hot and cold temperatures relative to the optimal temperature and the rate of ATAAD repair in the selected cities. The relative risks (RRs) of cold temperatures (≤-5°C) and hot temperatures (≥21°C) compared to optimal temperature were 1.47 (95% CI: 0.72-2.99) and 1.43 (95% CI: 0.67-3.08), respectively. In line with previous studies, we observed increased risk at cold and hot temperatures. However, the observed associations were not statistically significant, thus only providing weak evidence of an association.

Characterization of multi-domain postoperative recovery trajectories after cardiac surgery using a digital platform

Understanding postoperative recovery is critical for guiding efforts to improve post-acute phase care. How recovery evolves during the first 30 days after cardiac surgery is not well-understood. A digital platform may enable granular quantification of recovery by frequently capturing patient-reported outcome measures (PROM) that can be clinically implemented to support recovery. We conduct a prospective cohort study using a digital platform to measure recovery after cardiac surgery using a PROM sent every 3 days for 30 days after surgery to characterize recovery in multiple domains (e.g., pain, sleep, activities of daily living, anxiety) and to identify factors related to the patient's perception of overall recovery. We enroll patients who underwent cardiac surgery at a tertiary center between January 2019 and March 2020 and automatically deliver PROMs and reminders electronically. Of the 10 surveys delivered per patient, 8 (IQR 6-10) are completed. Patients who experienced postoperative complications more commonly belong to the worst overall recovery trajectory. Of the 12 domains modeled, only the worst anxiety trajectory is associated with the worse overall recovery trajectory membership, suggesting that even when patients struggle in the recovery of other domains, the patient may still feel progress in their recovery. We demonstrate that using a digital platform, automated PROM data collection, and characterization of multi-domain recovery trajectories is feasible and likely implementable in clinical practice. Overall recovery may be impacted by complications, while slow progress in constituent domains may still allow for the perception of overall recovery progression.

Variability in surveillance practice for patients with diagnosis of bicuspid aortic valve syndrome

In patients with bicuspid aortic valves, guidelines call for regular follow-up to monitor disease progression and guide intervention. We aimed to evaluate how closely these recommendations are followed at a tertiary care center. Among 48,504 patients who received echocardiograms (2013-2018) at a tertiary care center, 245 patients were identified to have bicuspid aortic valve. Bivariate analyses compared characteristics between patients who did and did not receive follow-up by a cardiovascular specialist. During a median follow-up of 3.5 ± 2.2 years (mean age 55.2 ± 15.6 years, 30.2% female), 72.7% of patients had at least one visit with a cardiovascular specialist after diagnosis of bicuspid aortic valve. These patients had a higher proportion of surveillance by echocardiogram (78.7% vs. 34.3%, p < .0001), CT or MRI (41.0% vs. 3.0%, p < .0001), and were more likely to undergo surgery. Patients with moderate-severe valvular or aortic pathology were not more likely to be followed by a specialist or receive follow-up echocardiograms. Follow-up care for patients with bicuspid aortic valve was highly variable, and surveillance imaging was sparse despite guidelines. There is an urgent need for mechanisms to monitor this population with increased risk of progressive valvulopathy and aortopathy.

Clinical implications of Type 2 diabetes on outcomes after cardiac transplantation

BACKGROUND

T2D is an increasingly common disease that is associated with worse outcomes in patients with heart failure. Despite this, no contemporary study has assessed its impact on heart transplantation outcomes. This paper examines the demographics and outcomes of patients with type 2 diabetes (T2D) undergoing heart transplantation.

METHODS

Using the United Network for Organ Sharing (UNOS) database, patients listed for transplant were separated into cohorts based on history of T2D. Demographics and comorbidities were compared, and cox regressions were used to examine outcomes.

RESULTS

Between January 1st, 2011 and June 12th, 2020, we identified 9,086 patients with T2D and 23,676 without T2D listed for transplant. The proportion of patients with T2D increased from 25.2% to 27.9% between 2011 and 2020. Patients with T2D were older, more likely to be male, less likely to be White, and more likely to pay with public insurance (p<0.001, all). After adjustment, T2D patients had a lower likelihood of transplantation (Hazard Ratio [HR]: 0.93, CI: 0.90-0.96, p<0.001) and a higher likelihood of post-transplant mortality (HR: 1.30, CI: 1.20-1.40, p<0.001). Patients with T2D were more likely to be transplanted in the new allocation system compared to the old allocation system (all, p<0.001).

CONCLUSIONS

Over the last ten years, the proportion of heart transplant recipients with T2D has increased. These patients are more likely to be from traditionally underserved populations. Patients with T2D have a lower likelihood of transplantation and a higher likelihood of post-transplant mortality. After the allocation system change, likelihood of transplantation has improved for patients with T2D.

Midterm outcomes of mitral valve repair versus replacement in elderly patients: A propensity score-matched analysis

BACKGROUND

Current literature reports better short-term mortality rates in mitral valve repair over replacement in elderly patients. However, valve durability, postoperative complications, and reintervention rates in these cohorts remain understudied. As such, we aimed to investigate 5-year rates of mortality and reoperation after initial mitral repair or replacement in elderly patients.

METHODS

Using the TriNetX Research Network database, we identified patients aged ≥70 who underwent mitral valve repair or replacement for nonrheumatic mitral insufficiency between January 2010 and December 2020. We 1:1 propensity score-matched cohorts for 33 covariates including demographics, comorbidities, and surgical history. After matching, we compared 5-year mortality and reoperation rates between cohorts using Kaplan-Meier estimates and multivariable Cox proportional hazards models.

RESULTS

We compared 823 mitral valve repair patients to a propensity score-matched cohort of 823 mitral valve replacement patients over a 5-year follow-up period. All variables of interest were adequately matched. Cumulative 5-year mortality rate was significantly lower among mitral valve repair patients (17.0% vs. 24.9%; hazard ratio [HR]: 0.66, 95% confidence interval [95% CI]: 0.51-0.87, p < 0.0025). Reoperation rates at 5-year did not differ (2.6% vs. 2,1%; HR: 1.34, 95% CI: 0.67-2.68, p = 0.401).

CONCLUSIONS

We observed lower 5-year mortality rates and nonsignificantly different reoperation rates among elderly patients with mitral regurgitation undergoing mitral valve repair compared to replacement. Our data support the current understanding that mitral valve repair should be considered as the first treatment line whenever possible, even in elderly patients.

Direct relationship between transvalvular velocity and cardiac dysfunction, morbidity, and mortality in patients with aortic stenosis

OBJECTIVE

Current guidelines recommend intervention in subjects with severe symptomatic aortic stenosis (AS), even though any degree of AS is associated with a higher risk of mortality. We investigated the association between the degree of AS, delineated by transvalvular flow velocity, and patient morbidity and mortality.

METHODS

Medically managed patients aged 40-95 years with maximum flow velocity (V_max ) by echocardiography between 2013 and 2018 were stratified into five groups (A-E) based on the 75th, 90th, 97.5th, and the 99th percentiles of V_max distribution. Patient characteristics, cardiac structural changes, and end-organ disease were compared using Kruskal-Wallis and Cochran-Armitage tests. Mortality over a median of 2.8 (1.52-4.8) years was compared using Kaplan-Meier curves and risk estimates were derived from the Cox model.

RESULTS

The V_max was reported in 37,131 patients. There was a steady increase (from Group A towards E) in age, Caucasian race, structural cardiac changes, end-organ morbidities, and all-cause mortality. In reference to Group A, there as an increased risk of mortality in Groups B (hazard ratio [HR] = 1.3; confidence interval [CI]: 1.2-1.35; p < .0001), C (HR = 1.5; CI: 1.4-1.6; p < .0001), and D (HR = 1.8; CI: 1.6-2; p < .0001), with an exponential increase in Group E (HR = 2.5; CI: 2.2-2.8; p < .0001).

CONCLUSIONS

A direct, strong correlation exists between the degree of AS and cardiac structural changes and mortality. Patients with V_max  ≥ 97.5th percentile (≥3.2 m/s) might benefit from early intervention.