Topic: Congenital

Abstract

Prognostic Relevance of Thyroid Disorders in Adults With Congenital Heart Disease.

Fusco F, Scognamiglio G, Guarguagli S, Merola A, ... Romeo E, Sarubbi B
Adults with congenital heart disease (ACHD) are frequently affected by thyroid diseases (TDs). However, the clinical relevance of TD in ACHD remains unknown. We aimed to describe the prevalence of TD in the ACHD population and to ascertain whether TD are associated with worse outcome. Patients with ACHD >18 years attending our tertiary center for a day-case between 2014 and 2019 were included. Clinical data between patients\' first visit and December 2020 were collected. Primary end point was a combination of death, hospitalization for heart failure (HF), and new-onset of arrhythmic events. Secondary end points were each part of the primary outcome as separate end points. A total of 495 patients with ACHD (32.2 [24.5 to 45.6] years; 54% women) were included. Median follow-up was 9.4 (4.5 to 13.1) years. The prevalence of TD was 30%. TD group showed worse clinical status, as demonstrated by N-terminal pro b-type natriuretic peptide values (243.5 [96.5 to 523] vs 94 [45 to 207] pg/ml, p <0.001) and New York Heart Association class (27% vs 13% in class III to IV, p <0.0001) with higher incident rate of adverse events at follow-up (4.45 [3.43 to 5.69] % vs 1.29[0.94 to 1.75] % per person-year, p <0.001). TD were independently associated with higher risk of death (hazard ratio [HR] 4.1, p = 0.009), arrhythmic events (HR 3.8, p <0.0001), and hospitalization for HF (HR 8.02, p <0.0001). There was a fourfold increased risk of primary end point in the TD group even after propensity score matching for clinical variables including age, gender, disease complexity, physiological stage, previous palliative surgery, ventricular function, pulmonary arterial hypertension, cyanosis, and presence of systemic right ventricle (HR 4.47, p <0.0001). In conclusion, TD are predictive of adverse outcome in the ACHD population. Routine screening of thyroid function during follow-up in this population may be helpful to identify those with higher risk of death, arrhythmias, and HF.

Copyright © 2021 Elsevier Inc. All rights reserved.

Am J Cardiol: 28 Feb 2022; 166:107-113
Fusco F, Scognamiglio G, Guarguagli S, Merola A, ... Romeo E, Sarubbi B
Am J Cardiol: 28 Feb 2022; 166:107-113 | PMID: 34930612
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Abstract

Fetal Brain Volume Predicts Neurodevelopment in Congenital Heart Disease.

Sadhwani A, Wypij D, Rofeberg V, Gholipour A, ... Ortinau CM, Rollins CK
Background: Neurodevelopmental impairment is common in children with congenital heart disease (CHD), yet postnatal variables explain only 30% of the variance in outcomes. To explore whether the antecedents for neurodevelopmental disabilities might begin in utero, we analyzed whether fetal brain volume predicted subsequent neurodevelopmental outcome in children with CHD.
Methods:
Fetuses with isolated CHD and sociodemographically comparable healthy control fetuses underwent fetal brain MRI and 2-year neurodevelopmental evaluation with the Bayley Scales of Infant and Toddler Development (Bayley-III) and the Adaptive Behavior Assessment System (ABAS-3). Hierarchical regression evaluated potential predictors of Bayley-III and ABAS-3 outcomes in the CHD group, including fetal total brain volume adjusted for gestational age and sex, sociodemographic characteristics, birth parameters, and medical history.
Results:
The CHD group (n=52) had lower Bayley-III cognitive, language, and motor scores than the control group (n=26), but fetal brain volumes were similar. Within the CHD group, larger fetal total brain volume correlated with higher Bayley-III cognitive, language, and motor scores, and ABAS-3 adaptive functioning scores (r=0.32-0.47; all P<0.05), but not in the control group. Fetal brain volume predicted 10 21% of the variance in neurodevelopmental outcome measures in univariate analyses. Multivariable models that also included social class and postnatal factors explained 18-45% of the variance in outcome, depending on developmental domain. Moreover, in final multivariable models, fetal brain volume was the most consistent predictor of neurodevelopmental outcome across domains. Conclusions: Small fetal brain volume is a strong independent predictor of 2-year neurodevelopmental outcomes and may be an important imaging biomarker of future neurodevelopmental risk in CHD. Future studies are needed to support this hypothesis. Our findings support inclusion of fetal brain volume in risk stratification models and as a possible outcome in fetal neuroprotective intervention studies.




Circulation: 09 Feb 2022; epub ahead of print
Sadhwani A, Wypij D, Rofeberg V, Gholipour A, ... Ortinau CM, Rollins CK
Circulation: 09 Feb 2022; epub ahead of print | PMID: 35143287
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Abstract

Practice patterns of female cardiothoracic surgeons older than age 58 years: Are we making progress?

Ferrel MN, Gerhard EF, Johnstad CM, Nesbitt K, Pereira SJ, Fiedler AG
Objective
Women remain a small minority of cardiothoracic surgeons, and within adult cardiac surgery, the gender gap widens. This study examines the career pathway and trajectory of female adult cardiac surgeons.
Methods
Female cardiothoracic surgeons were identified from the American Board of Thoracic Surgery diplomates over 58 years. Publicly available information was obtained to determine years in practice, practice type, academic and leadership title(s), and location of practice.
Results
The average number of years in practice for female adult cardiac surgeons was 13.1. Those categorized as adult cardiac surgeons composed 25.4% (n = 90) of all female cardiothoracic diplomates and 134 (37.9%) were categorized as other subspecialty practice. Of the adult cardiac surgeons, 33.3% (n = 30) practiced privately and the remainder in academic practice. Academic titles were held by 47.8% (43 out of 90) and 30% (27 out of 90) held a position of leadership. Of those in academic practice, 25% (11 out of 42) are titled professor, whereas 43% (18 out of 42) are assistant professors. Most commonly, those in positions of leadership held the title \"director,\" which reflects 37% (10 out of 27) of individuals. Practice locations were distributed throughout the United States, with the highest number in the northeast (26.7%).
Conclusions
Only a small portion of female cardiothoracic surgeons pursue a career in adult cardiac surgery compared to their male counterparts. From 1999 to 2009, 1300 individuals were board certified cardiothoracic surgeons, of whom only 103 (7.9%) were female. Of these, the majority of female cardiothoracic surgeons entered academic practice. Although the overall number of practicing female adult cardiac surgeons has increased with a growth rate of 10.7%, this number remains extremely low. A discrepancy remains between gender representation of academic titles and leadership positions. Although the field has increased female representation over the past few decades, work remains to ensure all potential talent is encouraged and supported.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 09 Feb 2022; epub ahead of print
Ferrel MN, Gerhard EF, Johnstad CM, Nesbitt K, Pereira SJ, Fiedler AG
J Thorac Cardiovasc Surg: 09 Feb 2022; epub ahead of print | PMID: 35249755
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Abstract

Deep learning-based computer-aided heart sound analysis in children with left-to-right shunt congenital heart disease.

Liu J, Wang H, Yang Z, Quan J, Liu L, Tian J
Objective
The purpose of this study was to explore a new algorithm model capable of leverage deep learning to screen and diagnose specific types of left-to-right shunt congenital heart disease (CHD) in children.
Methods
Using deep learning, screening models were constructed to identify 884 heart sound recordings from children with left-to-right shunt CHD. The most suitable model for each type was summarized and compared with expert auscultation. An exploratory analysis was conducted to assess whether there were correlations between heart sounds and left ventricular ejection fraction (LVEF), pulmonary artery pressure, and malformation size.
Results
The residual convolution recurrent neural network (RCRnet) classification model had higher accuracy than other models with respect to atrial septal defect (ASD), ventricular septum defect (VSD), patent ductus arteriosus (PDA) and combined CHD, and the best auscultation sites were determined to be the 4th, 5th, 2nd and 3rd auscultation areas, respectively. The diagnostic results of this model were better than those derived from expert auscultation, with sensitivity values of 0.932-1.000, specificity values of 0.944-0.997, precision values of 0.888-0.997 and accuracy values of 0.940-0.994. Absolute Pearson correlation coefficient values between heart sounds of the four types of CHD and LVEF, right ventricular systolic pressure (RVSP) and malformation size were all less than 0.3.
Conclusions
The RCRnet model can preliminarily determine types of left-to-right shunt CHD and improve diagnostic efficiency, which may provide a new choice algorithmic CHD screening in children.

Copyright © 2021 Elsevier B.V. All rights reserved.

Int J Cardiol: 31 Jan 2022; 348:58-64
Liu J, Wang H, Yang Z, Quan J, Liu L, Tian J
Int J Cardiol: 31 Jan 2022; 348:58-64 | PMID: 34902505
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Abstract

Primary cardiac sarcomas: Treatment strategies.

Chan EY, Ali A, Zubair MM, Nguyen DT, ... MacGillivray TE, Reardon MJ
Objective
Our multidisciplinary cardiac tumor team now has an experience of operating on 122 cases of primary cardiac sarcoma over a 23-year period. The purpose of this study is to present our short- and long-term outcomes for cardiac sarcoma.
Methods
We performed a retrospective review of a prospectively collected Institutional Review Board-approved cardiac tumor database for cardiac sarcoma. Patient characteristics, surgical factors, and patient outcomes were analyzed. Perioperative data were collected from direct patient communication and all available medical records. The primary end point was all-cause mortality at 1, 3, and 5 years from the time of our surgery and 1, 3, and 5 years from the initial diagnosis. The secondary end point was all-cause mortality between the first and second halves of the study.
Results
From October 1998 to April 2021, we operated on 122 patients with a primary cardiac sarcoma. The mean age was 45.3 years old, and 52.5% were male. Tumors were most frequently found in the left atrium (40.2%) and right atrium (32.0%). The most common type of tumor histologically was an angiosarcoma (38.5%), followed by high-grade sarcoma (14.8%). Survival from initial diagnosis at 1, 3, and 5 years was 88.4%, 43.15%, and 27.8%, respectively. Survival from surgery at our institution at 1 and 3 years was 57.1% and 24.5%, respectively. When comparing outcomes from different time periods, we found no significant difference in survival between the previous era (1998-2011) and the current era (2011-2021).
Conclusions
Management of these complex patients can show reasonable outcomes in centers with a multidisciplinary cardiac tumor team. Mortality has not improved with time and is likely related to the systemic nature of this disease.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 31 Jan 2022; epub ahead of print
Chan EY, Ali A, Zubair MM, Nguyen DT, ... MacGillivray TE, Reardon MJ
J Thorac Cardiovasc Surg: 31 Jan 2022; epub ahead of print | PMID: 35219517
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Abstract

One-year results with a low-profile endograft in subjects with thoracic aortic aneurysm and ulcer pathologies.

Szeto WY, Vallabhajosyula P, Matsuda H, Moainie SL, ... Ramaiah V, RelayPro-A Investigators
Objective
The study objective was to evaluate the safety and effectiveness of the second-generation, low-profile RelayPro (Terumo Aortic) thoracic endograft for the treatment of descending thoracic aortic aneurysm or penetrating atherosclerotic ulcer.
Method
A prospective, international, nonblinded, nonrandomized, pivotal trial analyzed a primary safety end point of major adverse events at 30 days (death, myocardial infarction, stroke, renal/respiratory failure, paralysis, bowel ischemia, procedural blood loss) and a primary effectiveness end point of treatment success at 1 year (technical success, patency, absence of aneurysm rupture, type I/III endoleaks, stent fractures, reinterventions, aneurysm expansion, and migration) compared with performance goals from the previous generation Relay pivotal study. The study was conducted in 36 centers in the United States and Japan and enrolled participants between 2017 and 2019.
Results
The study population of 110 patients had a median (interquartile range) age of 76 (70-81) years, 69 (62.7%) were male, and 43 (39.1%) were Asian. Patients were treated for 76 fusiform aneurysms (69%), 24 saccular aneurysms (22%), and 10 penetrating atherosclerotic ulcers (9%). Most patients (82.7%) were treated with a non-bare stent configuration. Technical success was 100%. The median (interquartile range) procedure time was 91 (64-131) minutes, and the deployment time was 16 (10-25) minutes. A total of 50 patients (73.5%) in the US cohort had percutaneous access, whereas centers in Japan used only surgical cutdown. The 30-day composite major adverse events rate was 6.4% (95% upper confidence interval, 11.6%; P = .0002): 2 strokes, 2 procedural blood losses greater than 1000 mL requiring transfusion, 2 paralysis events, and 1 renal failure. Primary effectiveness was 89.2% (lower 95% confidence interval, 81.8%; P = .0185). Nine subjects experienced 11 events (1 aneurysm expansion, 6 secondary interventions, and 4 type I endoleaks). There was no loss of stent-graft patency, no rupture, no fractures, and no migration.
Conclusions
The low-profile RelayPro thoracic endograft met the study primary end points and demonstrated satisfactory 30-day safety and 1-year effectiveness for the treatment of patients with aneurysms of the descending thoracic aorta or penetrating atherosclerotic ulcers. Follow-up is ongoing to evaluate longer-term outcomes and durability.

Copyright © 2022. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 31 Jan 2022; epub ahead of print
Szeto WY, Vallabhajosyula P, Matsuda H, Moainie SL, ... Ramaiah V, RelayPro-A Investigators
J Thorac Cardiovasc Surg: 31 Jan 2022; epub ahead of print | PMID: 35241276
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Abstract

Screening of Native Valvular Heart Disease Using a Pocket-Sized Transthoracic Echocardiographic Device.

Kikoïne J, Hauguel-Moreau M, Hergault H, Aidan V, ... Szymanski C, Mansencal N
Background
The authors assessed the performance of pocket-sized transthoracic echocardiography (pTTE) compared with standard transthoracic echocardiography (sTTE) and auscultation for early screening of valvular heart disease (VHD). Early diagnosis of significant VHD is a challenge, but it enables appropriate follow-up and implementation of the best therapeutic strategy.
Methods
sTTE, pTTE, and auscultation were performed by three different experienced physicians on 284 unselected patients. All cases of VHD detected by each of these three techniques were noted. sTTE was the gold standard. Each physician performed one examination and was blinded to the results of other examinations.
Results
We diagnosed a total of 301 cases of VHD, with a large predominance of regurgitant lesions: 269 cases (89.3%) of regurgitant VHD and 32 (10.7%) of stenotic VHD. pTTE was highly sensitive (85.7%) and specific (97.9%) for screening for VHD, while auscultation detected only 54.1%. All significant cases of VHD (at least mild severity) were detected on pTTE. The weighted κ coefficient between pTTE and sTTE for the assessment of mitral regurgitation was 0.71 (95% CI, 0.70-0.72), indicating good agreement. The weighted κ coefficients between pTTE and sTTE for the assessment of aortic regurgitation and aortic stenosis were 0.97 (95% CI, 0.96-0.98) and 0.98 (95% CI, 0.97-0.99), respectively, indicating excellent agreement.
Conclusions
pTTE performed by physicians with level III competency in echocardiography is reliable for identifying significant VHD and should be proposed as a new screening tool.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jan 2022; 35:196-202
Kikoïne J, Hauguel-Moreau M, Hergault H, Aidan V, ... Szymanski C, Mansencal N
J Am Soc Echocardiogr: 30 Jan 2022; 35:196-202 | PMID: 34461249
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Abstract

Whole genome sequencing in transposition of the great arteries and associations with clinically relevant heart, brain and laterality genes.

Blue GM, Mekel M, Das D, Troup M, ... Dunwoodie SL, Winlaw DS
Background
The most common cyanotic congenital heart disease (CHD) requiring management as a neonate is transposition of great arteries (TGA). Clinically, up to 50% of TGA patients develop some form of neurodevelopmental disability (NDD), thought to have a significant genetic component. A \"ciliopathy\" and links with laterality disorders have been proposed. This first report of whole genome sequencing in TGA, sought to identify clinically relevant variants contributing to heart, brain and laterality defects.
Methods
Initial whole genome sequencing analyses on 100 TGA patients focussed on established disease genes related to CHD (n = 107), NDD (n = 659) and heterotaxy (n = 74). Single variant as well as copy number variant analyses were conducted. Variant pathogenicity was assessed using the American College of Medical Genetics and Genomics-Association for Molecular Pathology guidelines.
Results
Fifty-five putatively damaging variants were identified in established disease genes associated with CHD, NDD and heterotaxy; however, no clinically relevant variants could be attributed to disease. Notably, case-control analyses identified significantly more predicted-damaging, silent and total variants in TGA cases than healthy controls in established CHD genes (P < .001), NDD genes (P < .001) as well as across the three gene panels (P < .001).
Conclusion
We present compelling evidence that the majority of TGA is not caused by monogenic rare variants and is most likely oligogenic and/or polygenic in nature, highlighting the complex genetic architecture and multifactorial influences on this CHD sub-type and its long-term sequelae. Assessment of variant burden in key heart, brain and/or laterality genes may be required to unravel the genetic contributions to TGA and related disabilities.

Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.

Am Heart J: 30 Jan 2022; 244:1-13
Blue GM, Mekel M, Das D, Troup M, ... Dunwoodie SL, Winlaw DS
Am Heart J: 30 Jan 2022; 244:1-13 | PMID: 34670123
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Abstract

Open versus hybrid versus totally minimally invasive Ivor Lewis esophagectomy: Systematic review and meta-analysis.

Bras Harriott C, Angeramo CA, Casas MA, Schlottmann F
Background
Hybrid and minimally invasive approaches have emerged as less invasive alternatives to open Ivor Lewis esophagectomy. The aim of this study was to compare surgical outcomes between open (OE), hybrid (HE), and totally minimally invasive esophagectomy (TMIE).
Methods
A systematic literature search was performed to analyze outcomes after OE, HE, and TMIE with intrathoracic anastomosis. Main outcomes included anastomotic leak rate, overall morbidity, and 30-day mortality. A meta-analysis of proportions was used to assess the effect of each approach on different outcomes.
Results
A total of 130 studies comprising 16,053 patients were included for analysis; 8081 (50.3%) underwent OE, 1524 (9.5%) HE, and 6448 (40.2%) TMIE. The risk of anastomotic leak was lower after OE (odds ratio [OR], 0.71; 95% CI, 0.62-0.81; P < .0001). Overall morbidity rate was 45% (95% CI, 38%-52%) after OE, 40% (95% CI, 25%-59%) after HE, and 37% (95% CI, 32%-43%) after TMIE. Risk estimation showed higher odds of postoperative mortality after OE (OR, 2.22; 95% CI, 1.76-2.81; P < .0001) and HE (OR, 1.93; 95% CI, 1.32-2.81; P < .001), compared with TMIE. Median length of hospital stay (LOS) was 14.1 (range, 8-28), 12.5 (range, 8-18), and 11.9 (range, 7-30) days after OE, HE and TMIE, respectively (P = .003).
Conclusions
HE and TMIE are associated with lower rates of overall morbidity, reduced postoperative mortality, and shorter LOS, compared with OE. TMIE is associated with lower mortality rates and shorter LOS than HE. Further efforts are needed to widely embrace TMIE in a safe manner.

Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 17 Jan 2022; epub ahead of print
Bras Harriott C, Angeramo CA, Casas MA, Schlottmann F
J Thorac Cardiovasc Surg: 17 Jan 2022; epub ahead of print | PMID: 35164948
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Abstract

Safety of transoesophageal echocardiography during structural heart disease interventions under procedural sedation: a single-centre study.

Afzal S, Zeus T, Hofsähs T, Kuballa M, ... Kelm M, Hellhammer K
Aims
The aim of this study was to determine the incidence of transoesophageal echocardiography (TOE)-related adverse events (AEs) during structural heart disease (SHD) interventions and to identify potential risk factors.
Methods and results
We retrospectively analysed 898 consecutive patients undergoing TOE-guided SHD interventions under procedural sedation. TOE-related AEs were classified as bleeding complications, mechanical lesions, conversion to general anaesthesia with intubation, and the occurrence of pneumonia. A follow-up was conducted up to 3 months after the intervention. TOE-related AEs were observed in 5.3% of the patients (n = 48). The highest rate of AEs was observed in the percutaneous mitral valve repair (PMVR) group with 8.2% (n = 32), whereas 4.8% (n = 11) of the patients in the left atrial appendage group and 1.8% (n = 5) in the patent foramen ovale/atrial septal defect group developed a TOE-related AE (P = 0.001). The most frequent AE was pneumonia with an incidence of 2.6% (n = 26) in the total cohort. Bleeding events occurred in 1.8% (n = 16) of the patients, mostly in the PMVR group with 2.1% (n = 8). In the multivariate regression analysis, we found a lower haemoglobin {odds ratio (OR) [95% confidence interval (CI)]: 8.82 (0.68-0.98) P = 0.025} and an obstructive sleep apnoea syndrome (OSAS) [OR (95% CI): 2.51 (1.08-5.84) P = 0.033] to be associated with AE. Furthermore, AEs were related to procedural time [OR (95% CI): 1.01 (1.0-1.01) P = 0.056] and oral anticoagulation [OR (95% CI): 1.97 (0.9-4.3) P = 0.076] with borderline significance in the multivariate regression analysis. No persistent damages were observed.
Conclusion
TOE-related AEs during SHD interventions are clinically relevant. It was highest in patients undergoing PMVR. A lower baseline haemoglobin level and an OSAS were found to be associated with the occurrence of a TOE-related AE.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Cardiovasc Imaging: 02 Jan 2022; epub ahead of print
Afzal S, Zeus T, Hofsähs T, Kuballa M, ... Kelm M, Hellhammer K
Eur Heart J Cardiovasc Imaging: 02 Jan 2022; epub ahead of print | PMID: 34977935
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Abstract

Pulmonary percutaneous valve implantation in large native right ventricular outflow tract with 32 mm Myval transcatheter heart valve.

Rodríguez Ogando A, Ballesteros F, Martínez JLZ
Pulmonary percutaneous valve implantation (PPVI) is feasible with satisfactory mid-term results in patients with native right ventricular outflow tract (RVOT) and has been increasingly used instead of surgically implantable pulmonary valves. Creating a stable landing zone with a diameter less than the largest commercially available valve (previously available 29 mm and currently available 32 mm) is crucial for technical success of the procedure, limiting the number of suitable candidates for PPVI. We report the case of PPVI with a 32 mm Myval transcatheter heart valve in a patient with a large native RVOT (pre-stented with AndraStent XXL mounted on a 35 × 60 mm valve balloon catheter) lesion who had Tetralogy of Fallot surgically corrected. The post-procedural outcomes of this case were satisfactory with no complications reported during the hospital stay.

© 2021 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 31 Dec 2021; 99:E38-E42
Rodríguez Ogando A, Ballesteros F, Martínez JLZ
Catheter Cardiovasc Interv: 31 Dec 2021; 99:E38-E42 | PMID: 34674370
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Abstract

Orifice Areas of Balloon-Expandable Transcatheter Heart Valves: A Three-Dimensional Transesophageal Echocardiographic Study.

Watson RA, Vishnevsky A, Dikdan S, Marcantuono R, ... Ruggiero N, Mehrotra P
Background
Accurate expected effective orifice area (EOA) values for balloon-expandable (BE) transcatheter heart valves (THV) are crucial for preventing patient-prosthesis mismatch (PPM) and assessment of THV function. Currently published reference EOAs, however, are based on transthoracic echocardiography (TTE), which may be subject to left ventricular outflow tract diameter underestimation and/or suboptimal THV Doppler interrogation. The objective of this study was to establish reference EOA values for BE THVs on the basis of Doppler and three-dimensional (3D) transesophageal echocardiography (TEE).
Methods
Two hundred twelve intraprocedural transesophageal echocardiographic examinations performed during BE THV implantation with optimal postimplantation Doppler and 3D imaging were retrospectively reviewed. Continuity equation-derived EOAs were compared with geometric orifice areas by 3D planimetry (GOA3D). Performance indices (i.e., EOA normalized to valve size) and PPM rates were determined. TTE-based EOAs obtained within 30 days were also calculated in a subset of 170 patients.
Results
The average EOA for all BE THV valves (77% SAPIEN 3) was 2.3 ± 0.5 cm2, while the average EOA was 1.6 ± 0.2 cm2 for 20-mm, 2.0 ± 0.2 cm2, for 23-mm, 2.5 ± 0.3 cm2 for 26-mm, and 3.0 ± 0.3 cm2 for 29-mm THV size (P < .001). Bland-Altman analysis demonstrated very good agreement between EOA and GOA3D (bias -0.04 ± 0.15 cm2). There were strong correlations between annular area and TEE-based EOA (R = 0.84) and GOA3D (R = 0.87). The mean performance index was 47 ± 5% and was similar for all THV sizes (P = .21). EOAs based on TTE were smaller compared with those based on TEE, while the correlation with annular area (R = 0.67) and agreement with GOA3D (bias -0.26 ± 0.43 cm2) was not as strong. The overall PPM rate was 2% in the TEE cohort and 12% in the TTE cohort.
Conclusions
EOAs for BE THVs based on intraprocedural Doppler and 3D TEE suggest that previously published TTE-based reference values for EOA are underestimated, while PPM rates may be overestimated. Our findings have important clinical implications for preimplantation decision-making and for the evaluation of THV hemodynamics and function during follow-up.

Copyright © 2021 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 21 Dec 2021; epub ahead of print
Watson RA, Vishnevsky A, Dikdan S, Marcantuono R, ... Ruggiero N, Mehrotra P
J Am Soc Echocardiogr: 21 Dec 2021; epub ahead of print | PMID: 34954049
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Abstract

Chronic haemodynamic performance of a biorestorative transcatheter heart valve in an ovine model.

Serruys PW, Kawashima H, Chang CC, Modolo R, ... Flameng W, Soliman O
Background
The Xeltis biorestorative transcatheter heart valve (BTHV) leaflets are made from an electrospun bioabsorbable supramolecular polycarbonate-urethane and are mounted on a self-expanding nitinol frame. The acute haemodynamic performance of this BTHV was favourable.
Aims
We sought to demonstrate the preclinical feasibility of a novel BTHV by evaluating the haemodynamic performances of five pilot valve designs up to 12 months in a chronic ovine model.
Methods
Five design iterations (A, B, B\', C, and D) of the BTHV were transapically implanted in 46 sheep; chronic data were available in 39 animals. Assessments were performed at implantation, 3, 6, and 12 months including quantitative aortography, echocardiography, and histology.
Results
At 12 months, greater than or equal to moderate AR on echocardiography was seen in 0%, 100%, 33.3%, 100%, and 0% in the iterations A, B, B\', C, and D, respectively. Furthermore, transprosthetic mean gradients on echocardiography were 10.0±2.8 mmHg, 19.0±1.0 mmHg, 8.0±1.7 mmHg, 26.8±2.4 mmHg, and 11.2±4.1 mmHg, and effective orifice area was 0.7±0.3 cm2, 1.1±0.3 cm2, 1.5±1.0 cm2, 1.5±0.6 cm2, and 1.0±0.4 cm2 in the iterations A, B, B\', C, and D, respectively. On pathological evaluation, the iteration D demonstrated generally intact leaflets and advanced tissue coverage, while different degrees of structural deterioration were observed in the other design iterations.
Conclusions
Several leaflet material iterations were compared for the potential to demonstrate endogenous tissue restoration in an aortic valve in vivo. The most promising iteration showed intact leaflets and acceptable haemodynamic performance at 12 months, illustrating the potential of the BTHV.



EuroIntervention: 16 Dec 2021; 17:e1009-e1018
Serruys PW, Kawashima H, Chang CC, Modolo R, ... Flameng W, Soliman O
EuroIntervention: 16 Dec 2021; 17:e1009-e1018 | PMID: 34278989
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Abstract

Analysis of the revised heart allocation policy and the influence of increased mechanical circulatory support on survival.

Elde S, He H, Lingala B, Baiocchi M, ... Shudo Y, Woo YJ
Objectives
In 2018, the new United Network for Organ Sharing heart allocation policy took effect. This study evaluated waitlist mortality, mechanical circulatory support utilization, and its influence on posttransplant survival.
Methods
Two 12-month cohorts matched for time of year before and after the policy change were defined by inclusion criteria of first-time transplant recipients aged 18 years or older who were listed and underwent transplant during the same era. Student t test and Wilcoxon rank-sum test were used for mean and median differences, respectively. Categorical variables were compared using χ2 or Fisher exact test. Kaplan-Meier curves were used to characterize survival, including time-to-event analysis with the log-rank test. Fine-Gray modeling was used to characterize waitlist mortality. Cox proportional-hazard models were used for multivariate analysis.
Results
Waitlist mortality in the new era is significantly improved based on a competing-risks model (Gray test P = .0064). Unadjusted 180-day posttransplant mortality increased from 5.8% during the old era to 8.0% during the new (P = .0134). However, time-to-event analysis showed similar 180-day survival in both eras. After risk adjustment, the hazard ratio for posttransplant 180-day mortality during the new era was 1.18 (95% CI, 0.85-1.64; P = .333). The posttransplant 180-day mortality of the extracorporeal membrane oxygenation bridge-to-transplant subgroup improved from 28.6% in the old era to 8.4% in the new era (P = .0103; log-rank P = .0021). Patients with an intra-aortic balloon pump at the time of transplant had similar 180-day posttransplant mortality between eras (5.4% vs 7.0%; P = .4831).
Conclusions
The United Network for Organ Sharing policy change is associated with reduced waitlist mortality and similar risk adjusted posttransplant 180-day mortality. The new era is also associated with improved 180-day survival in patients undergoing bridge to transplant with extracorporeal membrane oxygenation.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 08 Dec 2021; epub ahead of print
Elde S, He H, Lingala B, Baiocchi M, ... Shudo Y, Woo YJ
J Thorac Cardiovasc Surg: 08 Dec 2021; epub ahead of print | PMID: 35027214
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Impact:
Abstract

Applicant perception of virtual interviews in cardiothoracic surgery: A Thoracic Education Cooperative Group Study.

Taylor M, Freeman K, Mehaffey JH, Wallen T, Okereke IC
Objectives
Cardiothoracic programs used virtual interviews exclusively this year. As programs consider using virtual interviews permanently, our goal was to evaluate the experience of applicants with virtual interviews.
Methods
All 2020-2021 traditional cardiothoracic fellowship applicants received an anonymous electronic survey after the Match process ended. The survey assessed the number of interviews, strengths, and inadequacies of virtual interviews and factors that affected rank decision.
Results
Forty-three percent of applicants responded (60/139). The average number of interviews was 16.0. Eighty percent (48/60) of respondents successfully matched. Eighty-seven percent (52/60) of respondents had a favorable experience with virtual interviews, and 97% (58/60) found them to be convenient. However, only 50% (30/60) were able to evaluate a program fully. Respondents who matched were more likely to have a favorable experience (P = .02), but not more likely to be able to evaluate a program fully (P = .35). The most valued aspect was the informal meet and greet session with fellows (4.2 of 5). The least valued aspect was the program\'s social media site (2.0 of 5). The factors most frequently used to decide ranking were case numbers by 92% (55/60) and culture/personality by 82% (49/60).
Conclusions
Virtual interviews were perceived more favorably compared with last year, but half of applicants were still unable to evaluate a program fully. Fellow interactions were the most popular aspect of virtual interviews. As programs consider using virtual interviews permanently, more exposure to current trainees and a more robust social media/online presence will improve favorability.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 07 Dec 2021; epub ahead of print
Taylor M, Freeman K, Mehaffey JH, Wallen T, Okereke IC
J Thorac Cardiovasc Surg: 07 Dec 2021; epub ahead of print | PMID: 34955283
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Impact:
Abstract

Abnormal Extracardiac Development in Fetuses With Congenital Heart Disease.

Dovjak GO, Zalewski T, Seidl-Mlczoch E, Ulm PA, ... Kasprian GJ, Ulm B
Background
Knowledge about extracardiac anomalies (ECA) in fetal congenital heart disease (CHD) can improve our understanding of the developmental origins of various outcomes in these infants. The prevalence and spectrum of ECA, including structural brain anomalies (SBA), on magnetic resonance imaging (MRI) in fetuses with different types of CHD and at different gestational ages, is unknown.
Objectives
The purpose of this study was to evaluate ECA rates and types on MRI in fetuses with different types of CHD and across gestation.
Methods
A total of 429 consecutive fetuses with CHD and MRI between 17 and 38 gestational weeks were evaluated. ECA and SBA rates were assessed for each type of CHD and classified by gestational age (<25 or ≥25 weeks) at MRI.
Results
Of all 429 fetuses with CHD, 243 (56.6%) had ECA on MRI, and 109 (25.4%) had SBA. Among the 191 fetuses with normal genetic testing results, the ECA rate was 54.5% and the SBA rate 19.4%. Besides SBA, extrafetal (21.2%) and urogenital anomalies (10.7%) were the most prevalent ECA on MRI in all types of CHD. Predominant SBA were anomalies of hindbrain-midbrain (11.0% of all CHD), dorsal prosencephalon (10.0%) development, and abnormal cerebrospinal fluid spaces (10.5%). There was no difference in the prevalence or pattern of ECA between early (<25 weeks; 45.7%) and late (≥25 weeks; 54.3%) fetal MRI.
Conclusions
ECA and SBA rates on fetal MRI are high across all types of CHD studied, and ECA as well as SBA are already present from midgestation onward.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 06 Dec 2021; 78:2312-2322
Dovjak GO, Zalewski T, Seidl-Mlczoch E, Ulm PA, ... Kasprian GJ, Ulm B
J Am Coll Cardiol: 06 Dec 2021; 78:2312-2322 | PMID: 34857093
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Impact:
Abstract

Combined Norwood and cavopulmonary shunt as the first palliation in late presenters with hypoplastic left heart syndrome and single-ventricle lesions.

Elmahrouk AF, Ismail MF, Arafat AA, Dohain AM, ... Jamjoom AA, Al-Radi OO
Objective
A primary cavopulmonary shunt as a component of the initial Norwood palliation could be an option in patients with hypoplastic left heart syndrome and single-ventricle lesions. We present our initial experience with this approach in carefully selected patients with unrestricted pulmonary blood flow and low pulmonary vascular resistance.
Methods
The study included 16 patients; the mean age was 137.9 ± 84.2 days. All patients underwent a Norwood palliation consisting of atrial septectomy, Damus-Kaye-Stansel connection, and arch augmentation in addition to the cavopulmonary shunt as the initial palliation.
Results
The mean preoperative pulmonary to systemic blood flow (Qp/Qs) ratio on room air (n = 9) and with 100% oxygen (n = 8) was 5.3 ± 3.2 and 8.6 ± 4.3, respectively. The mean pulmonary vascular resistance on room air (n = 10) and 100% oxygen (n = 9) was 4.8 ± 3.1 and 1.7 ± 0.97 WU/m2, respectively. Delayed chest closure was needed in 12 patients, and 6 patients required postoperative inhaled nitric oxide. One patient underwent takedown of the cavopulmonary shunt and construction of the right ventricle to pulmonary artery conduit after 1 month. The mean intensive care unit stay was 18.9 ± 15.4 days. There were 2 in-hospital deaths (48 hours and 8 days after surgery) and 2 postdischarge deaths (6 months and 2 years after hospital discharge). Seven patients have undergone the Fontan completion successfully, and 5 patients await further surgery.
Conclusions
First-stage Norwood palliation with cavopulmonary shunt for patients with hypoplastic left heart syndrome or single-ventricle lesions is feasible in late presenters with low pulmonary vascular resistance.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 29 Nov 2021; epub ahead of print
Elmahrouk AF, Ismail MF, Arafat AA, Dohain AM, ... Jamjoom AA, Al-Radi OO
J Thorac Cardiovasc Surg: 29 Nov 2021; epub ahead of print | PMID: 35027212
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Impact:
Abstract

Traits of the current traditional pathway cardiothoracic surgery training pool: Results of a cross-sectional study.

Deboever N, Bayley EM, Vaporciyan AA, Antonoff MB
Objective
As new paradigms for cardiothoracic surgery training emerged in recent years, the traditional 2- or 3-year pathway has persisted as an option for trainees completing general surgery residencies. Although the applicant pool for 6-year integrated cardiothoracic surgery training programs has been superficially explored, little data exist characterizing those applicants to the traditional cardiothoracic surgery training pathway and the influence of 6-year integrated expansion on the traditional applicant pool.
Methods
We reviewed materials from candidates applying to a single 2-year cardiothoracic surgery training program between 2015 and 2020. Descriptive and comparative analyses of multiple characteristics were performed over the years of the study.
Results
During the years 2015 through 2020, we received 571 applications, accounting for 72% of the total National Residency Matching Program applicant pool. We saw no significant trends in numbers of peer-reviewed publications or presentations. There was a minimal year-to-year increase in number of first-authored posters, 2.04 in 2015 to 2.13 in 2020 (P = .008). Online publications, book chapters, and other publications were stable throughout the study period. Applicants consistently provided an average of 3.6 letters of recommendation, 1.9 from cardiothoracic surgery faculty. Mean in-service score percentiles were stable at the 54th percentile, whereas US Medical Licensing Examination scores increased.
Conclusions
Despite expansion of the 6-year integrated pathway to cardiothoracic surgery, we have seen no substantial year-to-year changes in attributes of traditional applicants. Our findings suggest that the cardiothoracic surgery applicant pool continues to be composed of a stable group of highly productive trainees. Future initiatives in candidate selection should emphasize interview strategies to highlight aspects of grit, emotional intelligence, and team dynamics.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 26 Nov 2021; epub ahead of print
Deboever N, Bayley EM, Vaporciyan AA, Antonoff MB
J Thorac Cardiovasc Surg: 26 Nov 2021; epub ahead of print | PMID: 34920868
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Impact:
Abstract

Access site complications of postcardiotomy extracorporeal life support.

Schaefer AK, Distelmaier K, Riebandt J, Goliasch G, ... Laufer G, Wiedemann D
Objective
To assess the influence of primary arterial access in patients receiving peripheral postcardiotomy extracorporeal life support on associated complications and outcome.
Methods
Of 573 consecutive patients requiring PC-ECLS between 2000 and 2019 at a single center, 436 were included in a retrospective analysis and grouped according to primary arterial extracorporeal life support access site. Survival and rate of access-site-related complications with special emphasis on fatal/disabling stroke were compared.
Results
The axillary artery was cannulated in 250 patients (57.3%), whereas the femoral artery was used as primary arterial access in 186 patients (42.6%). There was no significant difference in 30-day (axillary: 62%; femoral: 64.7%; P = .561) and 1-year survival (axillary: 42.5%; femoral: 44.8%; P = .657). Cerebral computed tomography-confirmed stroke with a modified ranking scale ≥4 was significantly more frequent in the axillary group (axillary: n = 28, 11.2%; femoral: n = 4, 2.2%; P = .0003). Stroke localization was right hemispheric (n = 20; 62.5%); left hemispheric (n = 5; 15.6%), bilateral (n = 5; 15.6%), or infratentorial (n = 2; 6.25%). Although no difference in major cannulation site bleeding was observed, cannulation site change for bleeding was more frequent in the axillary group (axillary: n = 13; 5.2%; femoral: n = 2; 1.1%; P = .03). Clinically apparent limb ischemia was significantly more frequent in the femoral group (axillary: n = 12, 4.8%; femoral: n = 31, 16.7%; P < .0001).
Conclusions
Although survival did not differ, surgeons should be aware of access-site-specific complications when choosing peripheral PC-ECLS access. Although lower rates of limb ischemia and the advantage of antegrade flow seem beneficial for axillary cannulation, the high incidence of right hemispheric strokes in axillary artery cannulation should be considered.

Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 25 Nov 2021; epub ahead of print
Schaefer AK, Distelmaier K, Riebandt J, Goliasch G, ... Laufer G, Wiedemann D
J Thorac Cardiovasc Surg: 25 Nov 2021; epub ahead of print | PMID: 34949456
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Impact:
Abstract

Normal Ranges of Global Left Ventricular Myocardial Work Indices in Adults: A Meta-Analysis.

Truong VT, Vo HQ, Ngo TNM, Mazur J, ... Nagueh SF, Chung ES
Background
Recent studies have demonstrated that left ventricular myocardial work (MW) is incremental in diagnosis and prognostication compared with left ventricular ejection fraction and myocardial strain. The authors performed a meta-analysis of normal ranges of noninvasive MW indices including global work index, global constructive work, global wasted work, and global work efficiency and determined confounders that may contribute to variance in reported values.
Methods
Four databases (PubMed, Scopus, Embase, and the Cochrane Library) were searched through January 2021 using the key terms \"myocardial work,\" \"global constructive work,\" \"global wasted work,\" \"global work index,\" and \"global work efficiency.\" Studies were included if the articles reported LV MW using two-dimensional transthoracic echocardiography in healthy normal subjects, either in a control group or comprising the entire study cohort. The weighted mean was estimated by using the random-effect model with a 95% CI. Heterogeneity across included studies was assessed using the I2 test. Funnel plots and the Egger regression test were used to assess potential publication bias.
Results
The search yielded 476 articles. After abstract and full-text screening, we included 13 data sets with 1,665 patients for the meta-analysis. The reported normal mean values of global work index and global constructive work among the studies were 2,010 mm Hg% (95% CI, 1,907-2,113 mm Hg%) and 2,278 mm Hg% (95% CI, 2,186-2,369 mm Hg%), respectively. Mean global wasted work was 80 mm Hg% (95% CI, 73-87 mm Hg%), and mean global work efficiency was 96.0% (95% CI, 96%-96%). Furthermore, gender significantly contributed to variations in normal values of global work index, global wasted work, and global work efficiency. No evidence of significant publication bias was observed.
Conclusions
In this meta-analysis, the authors provide echocardiographic reference ranges for noninvasive indices of MW. These normal values could serve as a reference for clinical and research use.

Copyright © 2022. Published by Elsevier Inc.

J Am Soc Echocardiogr: 17 Nov 2021; epub ahead of print
Truong VT, Vo HQ, Ngo TNM, Mazur J, ... Nagueh SF, Chung ES
J Am Soc Echocardiogr: 17 Nov 2021; epub ahead of print | PMID: 34800670
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Impact:
Abstract

Monitoring and evaluation of the surgical Potts shunt physiology using 4-dimensional flow magnetic resonance imaging.

Schäfer M, Frank BS, Grady RM, Eghtesady P, ... Jaggers J, Ivy DD
Objective
The reversed Potts shunt is an increasingly applied mode of surgical palliation of severe pulmonary hypertension (PH). However, the long-term flow hemodynamic effect of the Potts shunt physiology and desirable long-term hemodynamic end points are not defined. The purpose of this descriptive study was to analyze a series of pediatric patients who underwent surgical Potts shunt as a part of end-stage PH palliation using 4-dimensional (4D)-flow magnetic resonance imaging (MRI) to (1) quantitate the flow through the anastomosis, (2) correlate the shunting pattern with phases of cardiac cycle and PH comorbidities, and (3) describe chronologic changes in shunting pattern.
Methods
This was a 2-center study evaluating 4 patients seen in the Pulmonary Hypertension Clinic at Children\'s Hospital Colorado who were evaluated and selected to undergo surgical reverse Potts shunt at Washington University School of Medicine and were serially followed using comprehensive imaging including cardiac MRI and 4D-flow MRI.
Results
After the procedure, each child underwent 2 4D-flow MRI evaluations. Pulmonary pressure offload was evident in all patients, as demonstrated by positive systolic right-to-left flow across the Potts shunt. All patients experienced some degree of the flow reversal, which occurs primarily in diastole. Interventricular dyssynchrony further contributed to flow reversal across the Potts shunt. Lastly, systemic and pulmonary blood mixing in the descending aorta results in secondary helical flow persisting throughout the diastole.
Conclusions
4D-flow MRI demonstrates that children who have undergone a Potts shunt for severe PH can experience shunt flow reversal. Cumulatively, this left-to-right pulmonary shunt adds to right ventricular volume overload. We speculate that a valved conduit may decrease the left to right shunting and improve overall cardiac output.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Nov 2021; epub ahead of print
Schäfer M, Frank BS, Grady RM, Eghtesady P, ... Jaggers J, Ivy DD
J Thorac Cardiovasc Surg: 16 Nov 2021; epub ahead of print | PMID: 34872760
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Impact:
Abstract

Status of women in congenital heart surgery: Results from a national survey.

Sinha R, Herbst K, Romano JC
Objective
Gender disparity in cardiothoracic surgery, but not specifically in congenital heart surgery, has been a growing focus. The aim of this study was to describe the experiences related to gender for women in this field.
Methods
This cross-sectional survey was designed to assess gender perception in 5 domains: training, professional career, clinical practice, personal life, and career outlook. Inclusion criteria were women who trained and are practicing congenital heart surgery in the United States.
Results
Eighteen women were identified with a survey response rate of 94% (17/18). The majority of respondents were aged more than 40 years (94%) and White (69%), chose their career in congenital heart surgery during residency (77%), and completed more than 10 years of postgraduate education (56%). More than half were discouraged from congenital heart surgery because of their gender and reported its negative impact on their ability to obtain their first job. The need to \"outperform\" their male colleagues was nearly universal (94%), and gender pay disparity was reported by 81%. The majority (65%) reported sexual harassment both during surgical training and as staff surgeons.
Conclusions
This survey highlights many areas (discouragement due to gender, sexual harassment, and gender disparities in pay and leadership opportunities) that women may perceive as barriers to a successful career in congenital heart surgery. There is an increasing call to action to mitigate these hurdles for women, both to enter and succeed. It is encouraging that the women surveyed would repeat their career choice and are actively mentoring other women to join this field.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 12 Nov 2021; epub ahead of print
Sinha R, Herbst K, Romano JC
J Thorac Cardiovasc Surg: 12 Nov 2021; epub ahead of print | PMID: 34895726
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Impact:
Abstract

Surgical management strategy of slide tracheoplasty for infants with congenital tracheal stenosis.

Chen L, Zhu L, Wang H, Lu Z, ... Du X, Wang S
Objective
The study objective was to evaluate the outcomes of slide tracheoplasty in infancy and identify predictors of adverse outcomes.
Methods
We retrospectively reviewed the clinical data of infants aged less than 1 year with congenital tracheal stenosis who underwent slide tracheoplasty at a single center from April 2010 to September 2020.
Results
Of 120 infants, 71.7% (86/120) had a pulmonary artery sling and 37.5% (45/120) had simultaneous intracardiac repairs. Additionally, 52.5% (63/120) of the patients had anomalous tracheobronchial arborization, and 17.5% (21/120) had diffuse tracheal stenosis. Six airway reoperations (5%) and 6 deaths (5%) occurred, and the mortality decreased annually. Multivariate analysis revealed that a low body weight, cardiovascular anomalies, and normal tracheobronchial arborization predicted a longer intubation duration. Univariate analysis revealed that a low body weight, preoperative invasive ventilation, a long cardiopulmonary bypass time, and granulation tissue were associated with death. After surgery, 26 patients had dysphagia, 24 of whom resumed oral feeding during follow-up. Ninety-two patients underwent chest computed tomography reexamination, and the trachea diameter had increased significantly from 2.32 ± 0.72 mm to 5.46 ± 1.24 mm. Nineteen and 29 patients underwent spirometry before and after surgery, respectively, and showed improvements in ventilation function, with the ratio of time to peak tidal expiratory flow to total expiratory time and ratio of volume to peak tidal expiratory flow to total expiratory volume values significantly improved from 19.80% (interquartile range, 16.90-23.80) and 23.10% (interquartile range, 21.10-25.90) to 26.80% (interquartile range, 21.20-34.40) and 30.20% (interquartile range, 25.00-34.50), respectively (P < .05).
Conclusions
A tailored individual management strategy of slide tracheoplasty in infancy facilitates favorable clinical outcomes. Close postoperative follow-up and long-term functional evaluations including clinical symptoms and pulmonary function are still needed.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 04 Nov 2021; epub ahead of print
Chen L, Zhu L, Wang H, Lu Z, ... Du X, Wang S
J Thorac Cardiovasc Surg: 04 Nov 2021; epub ahead of print | PMID: 34872757
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Impact:
Abstract

Redo orthotopic heart transplantation in the current era.

Hess NR, Hickey GW, Sultan I, Kilic A
Objective
This study aims to investigate the trends, outcomes, and risk factors for mortality after redo orthotopic heart transplantation.
Methods
The United Network for Organ Sharing registry was used to identify adult orthotopic heart transplantation recipients from 2000 to 2020 and stratify into primary and redo cohorts. Five-year post-transplant survival was compared between 2 propensity-matched cohorts. Multivariable modeling was performed to identify risk-adjusted predictors of redo post-transplant mortality, both conditional and nonconditional on shorter-term survival.
Results
A total of 40,711 recipients were analyzed, 39,657 (97.4%) primary and 1054 (2.6%) redo. Redo recipients had a lower median age and were more frequently bridged with intravenous inotropes, intra-aortic balloon pump, or extracorporeal membrane oxygenation (all P < .05). One- and 5-year survivals were lower after redo orthotopic heart transplantation (90.0% vs 83.4% and 77.6% vs 68.6%, respectively) and remained lower after comparing 2 propensity-matched cohorts. Multivariable modeling found factors such as increasing donor age and graft ischemic times, along with pretransplant mechanical ventilation and blood transfusion, to negatively affect 90-day survival. Contingent on 1-year survival, donor factors such as hypertension (hazard ratio, 1.51; 95% confidence interval, 1.15-2.00, P = .004) and left ventricular ejection fraction less than 50% (hazard ratio, 2.22, 95% confidence interval, 1.16-4.24, P = .016) negatively affected survival at 5 years.
Conclusions
Although infrequently performed, redo orthotopic heart transplantation remains associated with worse post-transplant outcomes compared with primary orthotopic heart transplantation. Although several high-risk features were identified to affect post-retransplant outcomes in the acute perioperative period, donor characteristics such as hypertension and decreased ejection fraction continue to have lasting negative impacts in the longer term.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 30 Oct 2021; epub ahead of print
Hess NR, Hickey GW, Sultan I, Kilic A
J Thorac Cardiovasc Surg: 30 Oct 2021; epub ahead of print | PMID: 35012779
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Impact:
Abstract

A mapping algorithm for International Classification of Diseases 10th Revision codes for congenital heart surgery benchmark procedures.

Zafar F, Allen P, Bryant R, Tweddell JS, ... Anderson BR, Karamlou T
Background
Administrative billing data are critical to many initiatives in congenital heart surgery. Mapping algorithms for International Classification of Disease, 10th Revision diagnosis and procedure codes to clinical registry procedure definitions will allow identification of surgical cases and account for patient and procedural factors within administrative data. Our objectives were to develop mapping logic to crosswalk International Classification of Disease, 10th Revision procedure codes to 10 Society of Thoracic Surgeons Congenital Heart Surgery Database benchmark and beta-test the algorithm.
Methods
Patients undergoing Society of Thoracic Surgeons Congenital Heart Surgery Database benchmark procedures from 2015 to 2019 were identified and served as the gold standard. Cases were linked on direct identifiers to cases from the Pediatric Health Information System Database. Two independent teams developed International Classification of Disease, 10th Revision-based algorithms for cases capture. Algorithms were compared and iteratively refined to optimize sensitivity and specificity. Operative mortalities for cases identified in the administrative versus registry data were compared.
Results
Overall sensitivity was 91% and specificity was 99% for capture of benchmark operations using International Classification of Diseases 10th Revision codes. Sensitivity was more than 90% in identifying 6 of the 10 individual benchmark procedures and more than 98% sensitive in identifying Fontan, Glenn, and arterial switch with ventricular septal defect procedures. Specificity was more than 98% for all benchmark operations. There were no statistical differences in operative mortality between cases identified in the administrative versus the registry data.
Conclusions
Novel mapping algorithm for International Classification of Disease, 10th Revision procedure codes enables identification of congenital heart benchmark procedures within administrative billing data. This crosswalk facilitates population-based congenital heart surgical research and quality assessment.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 21 Oct 2021; epub ahead of print
Zafar F, Allen P, Bryant R, Tweddell JS, ... Anderson BR, Karamlou T
J Thorac Cardiovasc Surg: 21 Oct 2021; epub ahead of print | PMID: 34749937
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Impact:
Abstract

Surgical management of transvenous lead-induced tricuspid regurgitation in adult and pediatric patients with congenital heart disease.

Huang Y, Dearani JA, Lahr BD, Stephens EH, ... Cannon BC, Schaff HV
Objective
The objective of this study was to evaluate outcomes of surgical management of lead-induced tricuspid regurgitation (TR) in patients with congenital heart disease.
Methods
We analyzed data of 54 consecutive patients who underwent tricuspid valve (TV) surgery from 1998 to 2015 for lead-induced TR. Primary end points, including mortality, TV reinterventions, and longitudinal TR measurements, were analyzed with the Kaplan-Meier method or with repeated measures proportional odds modeling.
Results
The median age of patients was 48.2 years (interquartile range, 37.3-59.0 years); 31 (57.4%) were female; 2 (3.7%) were children. Thirty patients (55.6%) underwent TV repair and 24 (44.4%) had replacement, and 52 underwent concomitant cardiac procedures. Thirty-day mortality was 1.9% (repair: 3.3%, replacement: 0.0%). Five-year survival was 80.4% overall and 79.7% and 81.4% for the repair and replacement groups, respectively. In response to surgery, TR improved in both groups (each P < .001) but more with replacement than repair (P < .001); longitudinal analysis showed that TR trends observed early on favoring replacement were sustained across follow-up (P < .001). The model-estimated risk of moderate or severe TR at 5-year follow-up, conditional on having severe preoperative TR, was 74.4% for the repair and 10.7% for the replacement group. Five-year cumulative risk of TV reintervention was comparable for valve repair and replacement.
Conclusions
Despite the need for concomitant cardiac procedures in most of the patients, early mortality was low after TV surgery. Survival and rate of TV reintervention were comparable for the repair and replacement groups. However, TV repair was associated with progressive TR during intermediate follow-up, especially in patients with severe preoperative TR.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 09 Oct 2021; epub ahead of print
Huang Y, Dearani JA, Lahr BD, Stephens EH, ... Cannon BC, Schaff HV
J Thorac Cardiovasc Surg: 09 Oct 2021; epub ahead of print | PMID: 34753592
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Impact:
Abstract

Preoperative left ventricular longitudinal strain predicts outcome of septal myectomy for obstructive hypertrophic cardiomyopathy.

Cui H, Schaff HV, Nishimura RA, Geske JB, ... Newman DB, Ommen SR
Objective
The objective of this study was to determine the characteristics of longitudinal strain and its effect on outcomes in patients with obstructive hypertrophic cardiomyopathy (HCM) who underwent septal myectomy.
Methods
We reviewed patients with obstructive HCM who underwent septal myectomy at our clinic from 2007 to 2016. Data of those who had strain echocardiography within 6 months before isolated myectomy were analyzed.
Results
The median age of the 857 patients studied was 55 (interquartile range [IQR], 44-63) years, and 451 (52.6%) were male. Left ventricular ejection fraction was 71% (IQR, 67%-74%), and the resting peak outflow tract gradient was 58 (IQR, 27-85) mm Hg. The median global longitudinal strain (GLS) was -14.6% (IQR, -12.0% to -17.3%). Regional longitudinal strain was nonuniform as reflected by more normal values in apical segments and more abnormal in basal segments. Moreover, GLS correlated poorly with ejection fraction and outflow tract gradient. In 64 patients who had postoperative strain echocardiography, GLS was comparable before and after septal myectomy, but regional strain was more uniform after myectomy. Over a follow-up of 8.3 (IQR, 6.5-10.3) years, when patients were equally stratified according to GLS (cutoff, -14.64%), the group with worse GLS had significantly poorer survival compared with the better GLS group (P = .002). Left ventricular ejection fraction had no association with survival.
Conclusions
Left ventricular longitudinal strain is nonuniform and might be significantly reduced in patients with obstructive HCM. Septal myectomy does not impair GLS but is associated with more uniform regional strains. Most importantly, reduced GLS preoperatively is strongly and independently associated with increased all-cause mortality after septal myectomy for obstructive HCM.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 06 Oct 2021; epub ahead of print
Cui H, Schaff HV, Nishimura RA, Geske JB, ... Newman DB, Ommen SR
J Thorac Cardiovasc Surg: 06 Oct 2021; epub ahead of print | PMID: 34763894
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Impact:
Abstract

Surgical treatment of infective endocarditis at comprehensive versus primary valve centers.

Squiers JJ, DiMaio JM, Banwait JK, Mack MJ, Ryan WH, Baylor Scott & White Surgery for Endocarditis Working Group
Background
A recent expert consensus statement proposed designation of comprehensive and primary valve centers, with a recommendation that comprehensive centers house surgical skill and resources to treat patients with infective endocarditis (IE). We sought to compare outcomes of patients who underwent valve surgery for IE at comprehensive versus primary valve centers within a large health care system.
Methods
We reviewed 513 consecutive patients who underwent IE surgery at 8 hospitals (2 comprehensive and 6 primary valve centers) from 2014 to 2020. Outcomes from comprehensive and primary valve centers were compared after propensity score matching on the basis of patient characteristics, valve involvement, valve type, and IE treatment status. Multivariate logistic regression was used to identify risk factors for operative mortality.
Results
Propensity score matching generated comparable groups with similar mean Society of Thoracic Surgeons/Gaca IE risk scores among comprehensive and primary valve center cohorts. Comprehensive valve centers were more likely to perform the Bentall procedure (60.4% vs 21.7%; P < .01) when aortic root abscess was present and mitral valve repair (50.4% vs 26.3%; P < .01) in cases of mitral valve involvement. Operative mortality was significantly lower at comprehensive valve centers (6.2% vs 13.0%; P = .04), and multivariate logistic regression suggested that surgery at comprehensive valve centers was protective against operative mortality (odds ratio, 0.39; 95% confidence interval, 0.17-0.88; P = .02). Similar findings were present in a sensitivity analysis limited to patients with active IE only.
Conclusions
An increased risk for operative mortality was associated with surgery performed at primary valve centers compared with comprehensive valve centers. Referral or transfer of patients with IE and surgical indications to comprehensive valve centers should be considered.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 20 Sep 2021; epub ahead of print
Squiers JJ, DiMaio JM, Banwait JK, Mack MJ, Ryan WH, Baylor Scott & White Surgery for Endocarditis Working Group
J Thorac Cardiovasc Surg: 20 Sep 2021; epub ahead of print | PMID: 34627605
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Impact:
Abstract

Ex vivo biomechanical analysis of the Ross procedure using the modified inclusion technique in a 3-dimensionally printed left heart simulator.

Zhu Y, Marin-Cuartas M, Park MH, Imbrie-Moore AM, ... Mullis DM, Woo YJ
Objective
The inclusion technique was developed to reinforce the pulmonary autograft to prevent dilation after the Ross procedure. Anticommissural plication (ACP), a modification technique, can reduce graft size and create neosinuses. The objective was to evaluate pulmonary valve biomechanics using the inclusion technique in the Ross procedure with and without ACP.
Methods
Seven porcine and 5 human pulmonary autografts were harvested from hearts obtained from a meat abattoir and from heart transplant recipients and donors, respectively. Five additional porcine autografts without reinforcement were used as controls. The Ross procedure was performed using the inclusion technique with a straight polyethylene terephthalate graft. The same specimens were tested both with and without ACP. Hemodynamic parameter data, echocardiography, and high-speed videography were collected via the ex vivo heart simulator.
Results
Porcine autograft regurgitation was significantly lower after the use of inclusion technique compared with controls (P < .01). ACP compared with non-ACP in both porcine and human pulmonary autografts was associated with lower leaflet rapid opening velocity (3.9 ± 2.4 cm/sec vs 5.9 ± 2.4 cm/sec; P = .03; 3.5 ± 0.9 cm/sec vs 4.4 ± 1.0 cm/sec; P = .01), rapid closing velocity (1.9 ± 1.6 cm/sec vs 3.1 ± 2.0 cm/sec; P = .01; 1.8 ± 0.7 cm/sec vs 2.2 ± 0.3 cm/sec; P = .13), relative rapid opening force (4.6 ± 3.0 vs 7.7 ± 5.2; P = .03; 3.0 ± 0.6 vs 4.0 ± 2.1; P = .30), and relative rapid closing force (2.5 ± 3.4 vs 5.9 ± 2.3; P = .17; 1.4 ± 1.3 vs 2.3 ± 0.6; P = .25).
Conclusions
The Ross procedure using the inclusion technique demonstrated excellent hemodynamic parameter results. The ACP technique was associated with more favorable leaflet biomechanics. In vivo validation should be performed to allow direct translation to clinical practice.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 16 Sep 2021; epub ahead of print
Zhu Y, Marin-Cuartas M, Park MH, Imbrie-Moore AM, ... Mullis DM, Woo YJ
J Thorac Cardiovasc Surg: 16 Sep 2021; epub ahead of print | PMID: 34625236
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Impact:
Abstract

Mitral regurgitation severity at left ventricular assist device implantation is associated with distinct myocardial transcriptomic signatures.

Duggal NM, Lei I, Wu X, Aaronson KD, ... Tang PC, Michigan Congestive Heart Failure Investigators
Objectives
We examined for differences in pre-left ventricular assist device (LVAD) implantation myocardial transcriptome signatures among patients with different degrees of mitral regurgitation (MR).
Methods
Between January 2018 and October 2019, we collected left ventricular (LV) cores during durable LVAD implantation (n = 72). A retrospective chart review was performed. Total RNA was isolated from LV cores and used to construct cDNA sequence libraries. The libraries were sequenced with the NovaSeq system, and data were quantified using Kallisto. Gene Set Enrichment Analysis (GSEA) and Gene Ontology analyses were performed, with a false discovery rate <0.05 considered significant.
Results
Comparing patients with preoperative mild or less MR (n = 30) and those with moderate-severe MR (n = 42), the moderate-severe MR group weighted less (P = .004) and had more tricuspid valve repairs (P = .043), without differences in demographics or comorbidities. We then compared both groups with a group of human donor hearts without heart failure (n = 8). Compared with the donor hearts, there were 3985 differentially expressed genes (DEGs) for mild or less MR and 4587 DEGs for moderate-severe MR. Specifically altered genes included 448 DEGs for specific for mild or less MR and 1050 DEGs for moderate-severe MR. On GSEA, common regulated genes showed increased immune gene expression and reduced expression of contraction and energetic genes. Of the 1050 genes specific for moderate-severe MR, there were additional up-regulated genes related to inflammation and reduced expression of genes related to cellular proliferation.
Conclusions
Patients undergoing durable LVAD implantation with moderate-severe MR had increased activation of genes related to inflammation and reduction of cellular proliferation genes. This may have important implications for myocardial recovery.

Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 14 Sep 2021; epub ahead of print
Duggal NM, Lei I, Wu X, Aaronson KD, ... Tang PC, Michigan Congestive Heart Failure Investigators
J Thorac Cardiovasc Surg: 14 Sep 2021; epub ahead of print | PMID: 34689984
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Impact:
Abstract

The growth of xenotransplanted hearts can be reduced with growth hormone receptor knockout pig donors.

Goerlich CE, Griffith B, Hanna P, Hong SN, ... Singh AK, Mohiuddin MM
Objective
Genetically engineered pigs are thought to be an alternative organ source for patients in end-stage heart failure unable to receive a timely allograft. However, cardiac xenografts exhibit growth and diastolic heart failure within 1 month after transplantation. Grafts function for up to 6 months, but only after administration of temsirolimus and afterload-reducing agents to reduce this growth. In this study we investigated the growth and hemodynamics of growth hormone receptor (GHR) knockout xenografts, without the use of adjuncts to prevent intrinsic graft growth after transplantation.
Methods
Genetically engineered pig hearts were transplanted orthotopically into weight-matched baboons between 15 and 30 kg, using continuous perfusion preservation before implantation (n = 5). Xenografts included knockout of carbohydrate antigens and knockin of human transgenes for thromboregulation, complement regulation, and inflammation reduction (grafts with intact growth hormone, n = 2). Three grafts contained the additional knockout of GHR (GHR knockout grafts; n = 3). Transthoracic echocardiograms were obtained twice monthly and comprehensively analyzed by a blinded cardiologist. Hemodynamics were measured longitudinally after transplantation.
Results
All xenografts demonstrated life-supporting function after transplantation. There was no difference in intrinsic growth, measured using septal and posterior wall thickness and left ventricular mass, on transthoracic echocardiogram out to 1 month in either GHR knockout or GHR intact grafts. However, hypertrophy of the septal and posterior wall was markedly elevated by 2 months post transplantation. There was minimal hypertrophy out to 6 months in GHR knockout grafts. Physiologic mismatch was present in all grafts after transplantation, which is largely independent of growth.
Conclusions
Xenografts with GHR knockout show reduced post-transplantation xenograft growth using echocardiography >6 months after transplantation, without the need for other adjuncts.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 03 Sep 2021; epub ahead of print
Goerlich CE, Griffith B, Hanna P, Hong SN, ... Singh AK, Mohiuddin MM
J Thorac Cardiovasc Surg: 03 Sep 2021; epub ahead of print | PMID: 34579956
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Impact:
Abstract

Wall stresses of early remodeled pulmonary autografts.

Xuan Y, Alonso E, Emmott A, Wang Z, ... Ge L, Tseng EE
Objective
The Ross procedure is an excellent option for children or young adults who need aortic valve replacement because it can restore survival to that of the normal aged-matched population. However, autograft remodeling can lead to aneurysmal formation and reoperation, and the biomechanics of this process is unknown. This study investigated postoperative autograft remodeling after the Ross procedure by examining patient-specific autograft wall stresses.
Methods
Patients who have undergone the Ross procedure who had intraoperative pulmonary root and aortic specimens collected were recruited. Patient-specific models (n = 16) were developed using patient-specific material property and their corresponding geometry from cine magnetic resonance imaging at 1-year follow-up. Autograft ± Dacron for aneurysm repair and ascending aortic geometries were reconstructed to develop patient-specific finite element models, which incorporated material properties and wall thickness experimentally measured from biaxial stretching. A multiplicative approach was used to account for prestress geometry from in vivo magnetic resonance imaging. Pressure loading to systemic pressure (120/80) was performed using LS-DYNA software (LSTC Inc, Livermore, Calif).
Results
At systole, first principal stresses were 809 kPa (25%-75% interquartile range, 691-1219 kPa), 567 kPa (485-675 kPa), 637 kPa (555-755 kPa), and 382 kPa (334-413 kPa) at the autograft sinotubular junction, sinuses, annulus, and ascending aorta, respectively. Second principal stresses were 360 kPa (310-426 kPa), 355 kPa (320-394 kPa), 272 kPa (252-319 kPa), and 184 kPa (147-222 kPa) at the autograft sinotubular junction, sinuses, annulus, and ascending aorta, respectively. Mean autograft diameters were 29.9 ± 2.7 mm, 38.3 ± 5.3 mm, and 26.6 ± 4.0 mm at the sinotubular junction, sinuses, and annulus, respectively.
Conclusions
Peak first principal stresses were mainly located at the sinotubular junction, particularly when Dacron reinforcement was used. Patient-specific simulations lay the foundation for predicting autograft dilatation in the future after understanding biomechanical behavior during long-term follow-up.

Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 30 Aug 2021; epub ahead of print
Xuan Y, Alonso E, Emmott A, Wang Z, ... Ge L, Tseng EE
J Thorac Cardiovasc Surg: 30 Aug 2021; epub ahead of print | PMID: 34538420
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Impact:
Abstract

Surgical implantation of balloon-expandable heart valves for the treatment of mitral annular calcification.

Smith RL, Hamandi M, Ailawadi G, George TJ, ... Ryan WH, BEV-in-MAC Collaborative
Objectives
The treatment of mitral valve disease in the presence of mitral annular calcification (MAC) is associated with an increased risk of cardiovascular and all-cause mortality. Various surgical and transcatheter techniques for the treatment of mitral disease with severe MAC have been described. However, these procedures are associated with high risk of operative morbidity and mortality. We describe our experience with open surgical implantation of a balloon-expandable valve (BEV) in patients with severe MAC as an alternative approach.
Methods
BEV implantation was performed with direct vision through the left atrium via a median sternotomy or minimally invasive approach. The midportion of the anterior leaflet is excised, and a ventricular septal myectomy performed if there is high risk for left ventricular outflow tract obstruction. The primary outcome was technical success according to the Mitral Valve Academic Research Consortium criteria; secondary outcomes were 30-day and 1-year mortality.
Results
From October 2015 through October 2020, 51 patients at 2 institutions underwent BEV-in-MAC (mean age, 73.9 ± 8.8 years; 60.8% [31/51] were female; mean Society of Thoracic Surgeons predicted risk of mortality: 6.8% ± 4.8%). Technical success was 94.1% (48/51). Thirty-day and 1-year mortality were 13.7% (7/51) and 33.3% (15/45), and for stroke 3.9% (2/51) and 4.4% (2/45), respectively.
Conclusions
Surgical implantation of a BEV in the mitral position offers a treatment option for patients with mitral valve disease complicated by severe MAC who are at increased risk for conventional surgical approaches and at risk for left ventricular outflow tract obstruction with transcatheter approaches.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 25 Aug 2021; epub ahead of print
Smith RL, Hamandi M, Ailawadi G, George TJ, ... Ryan WH, BEV-in-MAC Collaborative
J Thorac Cardiovasc Surg: 25 Aug 2021; epub ahead of print | PMID: 34635317
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Impact:
Abstract

Influence of right ventricular pressure and volume overload on right and left ventricular diastolic function.

Jani V, Konecny F, Shelby A, Kulkarni A, ... Danford D, Kutty S
Background
Ventricular interdependence may account for altered ventricular mechanics in congenital heart disease. The present study aimed to identify differences in load-dependent right ventricular (RV)-left ventricular (LV) interactions in porcine models of pulmonary stenosis (PS) and pulmonary insufficiency (PI) by invasive admittance-derived hemodynamics in conjunction with noninvasive cardiovascular magnetic resonance (CMR).
Methods
Seventeen pigs were used in the study (7 with PS, 7 with PI, and 3 controls). Progressive PS was created by tightening a Teflon tape around the pulmonary artery, and PI was created by excising 2 leaflets of the pulmonary valve. Admittance catheterization data were obtained for the RV and LV at 10 to 12 weeks after model creation, with the animal ventilated under temporary diaphragm paralysis. CMR was performed in all animals immediately prior to pressure-volume catheterization.
Results
In the PS group, RV contractility was increased, manifested by increased end-systolic elastance (mean difference, 1.29 mm Hg/mL; 95% confidence interval [CI], 0.57-2.00 mm Hg/mL). However, in the PI group, no significant changes were observed in RV systolic function despite significant changes in RV diastolic function. In the PS group, LV end-systolic volume was significantly lower compared with controls (mean difference, 25.1 mL; 95% CI, -40.5 to -90.7 mL), whereas in the PI group, the LV showed diastolic dysfunction, demonstrated by an elevated isovolumic relaxation constant and ventricular stiffness (mean difference, 0.03 mL-1; 95% CI, -0.02 to 0.09 mL-1).
Conclusions
The LV exhibits systolic dysfunction and noncompliance with PI. PS is associated with preserved LV systolic function and evidence of some LV diastolic dysfunction. Interventricular interactions influence LV filling and likely account for differential effects of RV pressure and volume overload on LV function.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Jul 2021; epub ahead of print
Jani V, Konecny F, Shelby A, Kulkarni A, ... Danford D, Kutty S
J Thorac Cardiovasc Surg: 27 Jul 2021; epub ahead of print | PMID: 34446290
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Impact:
Abstract

Lobar size reduction in lung transplantation: A propensity score study.

Schiavon M, Mendogni P, Faccioli E, Lorenzoni G, ... Rea F, Lung Transplantation Working Group
Objective
For small-sized recipients of lung transplantation, the time span for organ reception from standard donors is generally longer than for normal-sized patients. Despite its underuse, lobar reduction may be a concrete option for these patients. This study aims to assess early and long-term outcomes associated with lobar reduction in lung transplantation.
Methods
A retrospective study was performed on 608 consecutive lung transplantations at 2 centers between January 2005 and August 2019 (559 standard lung transplantations [standard transplantation] and 49 with lobar reduction [lung transplantation group]). A propensity-score weighting approach was used to account for potential confounding related to patients\' nonrandom allocation to the 2 intervention groups. The effects of the intervention on postoperative outcomes were assessed with a weighted regression approach.
Results
The propensity score was estimated on 571 patients (522 in standard transplantation group and 49 in lung transplantation group). In terms of early outcomes, the lung transplantation group showed a higher percentage of severe primary graft dysfunction at 0 hours and reported longer intensive care unit stay than the standard transplantation group. No other differences in terms of morbidity, mortality, mechanical ventilation time, hospital stay, and anastomotic complications were observed. Although the lung transplantation group showed worse long-term pulmonary function, the 2 populations had comparable survival outcomes.
Conclusions
The use of lobar reduction showed early and long-term results comparable to those after standard lung transplantation. Although a higher rate of early severe primary graft dysfunction and slightly reduced respiratory function were detected in the lobar group, these did not affect patients\' morbidity and survival.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 20 Jul 2021; epub ahead of print
Schiavon M, Mendogni P, Faccioli E, Lorenzoni G, ... Rea F, Lung Transplantation Working Group
J Thorac Cardiovasc Surg: 20 Jul 2021; epub ahead of print | PMID: 34353616
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Impact:
Abstract

Three-dimensional imaging of pulmonary arterial vasa vasorum using optical coherence tomography in patients after bidirectional Glenn and Fontan procedures.

Hayabuchi Y, Homma Y, Kagami S
Aims
We evaluated pulmonary arterial (PA) vasa vasorum (VV) in Fontan candidate patients with a novel three-dimensional (3D) imaging technique using optical coherence tomography (OCT).
Methods and results
This prospective study assessed the development of adventitial VV in the distal PA of 10 patients with bidirectional Glenn circulation (BDG group, 1.6 ± 0.3 years) and Fontan circulation (Fontan group, 3.3 ± 0.3 years), and in 20 children with normal PA haemodynamics and morphology (Control group, 1.5 ± 0.3 years). We assessed the PA VV with two-dimensional (2D) cross-sectional, multi-planar reconstruction (MPR), and volume rendering (VR) imaging. VV development was evaluated by the VV area/volume ratio, defined as the VV area/volume divided by the adventitial area/volume. Compared to the control group, the observed VV number and diameter on 3D images of MPR and VR were significantly higher, and curved and torturous-shaped VV were more frequently observed in the BDG and Fontan groups (P < 0.001, all). The median VV volume ratio was significantly greater in the BDG than in the control group (3.38% vs. 0.61%; P < 0.001). Although the VV volume ratio decreased significantly after the Fontan procedure (2.64%, P = 0.005 vs. BDG), the ratio remained higher than in the control group (P < 0.001 vs. control).
Conclusion
3D OCT imaging is a novel method that can be used to evaluate adventitial PA VV and may provide pathophysiological insight into the role of the PA VV in these patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Cardiovasc Imaging: 19 Jul 2021; 22:941-949
Hayabuchi Y, Homma Y, Kagami S
Eur Heart J Cardiovasc Imaging: 19 Jul 2021; 22:941-949 | PMID: 32413104
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Impact:
Abstract

Left ventricle-mitral valve ring size mismatch following ring annuloplasty for nonischemic dilated cardiomyopathy.

Misumi Y, Kainuma S, Toda K, Miyagawa S, ... Sawa Y, Osaka Cardiovascular Surgery Research (OSCAR) Study Group
Background
In patients with ischemic mitral regurgitation (MR) undergoing restrictive mitral annuloplasty (RMA), the ratio of left ventricular (LV) end-systolic dimension (LVESD) to mitral valve (MV) ring size (ie, LV-MV ring mismatch) is associated with postoperative recurrent MR. However, the impact of LV-MV ring mismatch on postoperative recurrent MR, LV function recovery, and long-term survival in patients with nonischemic dilated cardiomyopathy (DCM) remains unknown.
Methods
Sixty-six patients with nonischemic DCM (mean LVESD, 62 mm) underwent RMA (mean ring size, 26 mm) between 2003 and 2014. Recurrent MR was defined as MR grade ≥2+ at a 6-month echocardiographic evaluation.
Results
At the 6-month follow-up, 23 patients (35%) had developed recurrent MR. In univariable logistic regression analysis, larger LVESD (P = .012) and LVESD/ring size ratio (P = .008) were associated with recurrent MR. In multivariable models adjusted for age, sex, baseline LV ejection fraction, and severe MR, only LVESD/ring size ratio (odds ratio, 4.65; 95% confidence interval, 1.04-25.0; P = .048) remained significantly associated with MR recurrence. Receiver operating characteristic curve analysis demonstrated an optimal cutoff value for the LVESD/ring size ratio of 2.42. Patients with an LVESD/ring size ratio >2.42 (n = 30; mismatch) had a lower 5-year cumulative survival rate compared with those with an LVESD/ring size ratio ≤2.42 (n = 36; nonmismatch) (52% vs 71%; P = .045). Postoperatively, LV dimensions were significantly reduced in both groups; however, improvements in LVEF were only modest in the mismatched group (P = .091).
Conclusions
LV-MV ring size mismatch was associated with an increased risk of recurrent MR in our series. This finding may aid the formulation of surgical strategies for patients with nonischemic DCM.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 07 Jun 2021; epub ahead of print
Misumi Y, Kainuma S, Toda K, Miyagawa S, ... Sawa Y, Osaka Cardiovascular Surgery Research (OSCAR) Study Group
J Thorac Cardiovasc Surg: 07 Jun 2021; epub ahead of print | PMID: 34246489
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Impact:
Abstract

Comparison of SYNTAX score strata effects of percutaneous and surgical revascularization trials: A meta-analysis.

Gaudino M, Hameed I, Di Franco A, Naik A, ... Biondi-Zoccai G, Bangalore S
Objectives
The evidence supporting the use of the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) score for risk stratification is controversial. We performed a systematic review and meta-analysis of all the randomized controlled trials comparing percutaneous coronary intervention versus coronary artery bypass grafting that reported their outcomes stratified by SYNTAX score, focusing on between-strata comparisons.
Methods
A systematic review of MEDLINE, EMBASE, Cochrane Library databases was performed. Incidence rate ratios were pooled with a random effect model. Between-group statistical heterogeneity according to accepted SYNTAX score tertiles was computed in the main analysis. Ratios of incidence rate ratios were computed to appraise between-strata effect, as sensitivity analysis. Primary and secondary outcomes were major adverse cardiac and cerebrovascular events and all-cause mortality, respectively. Separate sub-analyses were performed for left main and multivessel disease.
Results
From 425 citations, 6 trials were eventually included (8269 patients [4134 percutaneous coronary interventions, 4135 coronary artery bypass graftings]; mean follow-up: 6.2 years [range: 3.8-10]). Overall, percutaneous coronary intervention was associated with a significant increase in major adverse cardiac and cerebrovascular events (incidence rate ratio, 1.39, 95% confidence interval, 1.27-1.51) and nonsignificant increase in all-cause mortality (incidence rate ratio, 1.17, 95% confidence interval, 0.98-1.40). There was no significant statistical heterogeneity of treatment effect by SYNTAX score for major adverse cardiac and cerebrovascular events or mortality (P = .40 and P = .34, respectively). Results were consistent also for patients with left main and multivessel disease (major adverse cardiac and cerebrovascular events: P = .85 in left main, P = .78 in multivessel disease 0.78; mortality: P = .12 in left main; P = .34 in multivessel disease). Results of analysis based on ratios of incidence rate ratios were consistent with the main analysis.
Conclusions
No significant association was found between SYNTAX score and the comparative effectiveness of percutaneous coronary intervention and coronary artery bypass grafting. These findings have implications for clinical practice, future guidelines, and the design of percutaneous coronary intervention versus coronary artery bypass grafting trials.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 01 Jun 2021; epub ahead of print
Gaudino M, Hameed I, Di Franco A, Naik A, ... Biondi-Zoccai G, Bangalore S
J Thorac Cardiovasc Surg: 01 Jun 2021; epub ahead of print | PMID: 34176619
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Impact:
Abstract

Surgery for severe congenital heart diseases in children from developing nations.

Lacour-Gayet F, Gouton M, Bical O, Lucet V, Roussin R, Leca F
Background
Children with severe congenital heart disease (CHD) are rarely treated in developing countries and have very little to no chance to survive in their local environment. Mécénat Chirurgie Cardiaque (MCC) flies to France children with CHD from developing countries. This report focuses on the early, mid, and late outcomes of 531 children with severe CHD sent to MCC for surgery from 1996 to 2019.
Methods
The inclusion criteria were based on diagnosis and not on procedure. MCC is present in 66 countries and has developed a robust staff, including 12 permanent employees and 700 volunteers, with 350 host families based in France, 120 local correspondents, and 100 local physicians. Since 1996, MCC has organized a basic training of local pediatric cardiologists yearly, offering a free 1-month training course. Over time, MCC could count on a pool of doctors trained in basic pediatric cardiology. Flights were secured by the Aviation Sans Frontieres Foundation. Nine French centers performed the surgeries. A robust follow-up was conducted in all the nations where MCC operates.
Results
The most frequent pathologies were single ventricle (n = 126), double-outlet right ventricle (n = 116), pulmonary atresia with ventricular septal defect (n = 68), transposition of the great arteries with ventricular septal defect and transposition of the great arteries with intact ventricular septum (n = 61), arterial trunk (n = 39), transposition of the great arteries with ventricular septal defect and left ventricle outflow tract obstruction (n = 35), complete atrioventricular septal defect (n = 18), congenitally corrected transposition of the great arteries (n = 16), and so on. The median age was 5.4 years (range, 1 month-26 years). The mean perioperative mortality was 5.5% (29 out of 531) (95% confidence limit, 3.5%-7.4%). The follow-up was 91.3%, with a mean follow-up of 5.1 years. The global actuarial survival at 5, 10, and 15 years was, respectively, 85%, 83%, and 74%. There was a significant higher late mortality for patients surviving only with a Blalock-Taussig shunt (P = .001).
Conclusions
Operating on 531 children with severe CHD from developing nations was achieved with satisfactory early and long-term results. Children with severe CHD are rarely operated on in developing nations. Programs like MCC\'s offer a viable option to save these children born with severe CHD.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 13 May 2021; epub ahead of print
Lacour-Gayet F, Gouton M, Bical O, Lucet V, Roussin R, Leca F
J Thorac Cardiovasc Surg: 13 May 2021; epub ahead of print | PMID: 34053740
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Impact:
Abstract

Difference in spontaneous myocardial infarction and mortality in percutaneous versus surgical revascularization trials: A systematic review and meta-analysis.

Gaudino M, Di Franco A, Spadaccio C, Rahouma M, ... Fremes S, Doenst T
Objectives
It has been hypothesized that the survival benefit of coronary artery bypass (CABG) compared with percutaneous interventions (PCI) may be associated with the reduction in spontaneous myocardial infarction (SMI) achieved by surgery. This, however, has not been formally investigated. The present meta-analysis aims to evaluate the association between the difference in SMI and in survival in PCI versus CABG randomized controlled trials (RCTs).
Methods
A systematic search was performed to identify all RCTs comparing PCI with CABG for the treatment of coronary artery disease and reporting SMI outcomes. Generic inverse variance method was used to pool outcomes as natural logarithms of the incident rate ratios across studies. Subgroup analysis and interaction test were used to compare the difference of the primary outcome among trials that did and did not report a significant reduction in SMI- in the patients treated by CABG. Primary outcome was all-cause mortality; secondary outcome was SMI.
Results
Twenty RCTs were included in the meta-analysis. A statistically significant difference in SMI in favor of CABG was found in 7 of the included trials (35%). Overall, PCI was associated with significantly greater all-cause mortality (incident rate ratio, 1.13; 95% confidence interval, 1.01-1.28). At subgroup analysis, a significant difference in survival in favor of CABG was seen only in trials that reported a significant reduction in SMI in the surgical arm (P for interaction 0.02).
Conclusions
In the published PCI versus CABG trials, the reduction in all-cause mortality in the surgical arm is associated with the protective effect of CABG against SMI.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 28 Apr 2021; epub ahead of print
Gaudino M, Di Franco A, Spadaccio C, Rahouma M, ... Fremes S, Doenst T
J Thorac Cardiovasc Surg: 28 Apr 2021; epub ahead of print | PMID: 34045061
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Impact:
Abstract

Value of psychosocial evaluation for left ventricular assist device candidates.

Olt CK, Thuita LW, Soltesz EG, Tong MZ, ... Hsich EM, Stanford Integrated Psychosocial Assessment for Transplant Research Group
Objective
Left ventricular assist devices require a psychosocial assessment to determine candidacy despite limited data correlating with outcome. Our objective is to determine whether the Stanford Integrated Psychosocial Assessment for Transplant, a tool validated for transplant and widely used by left ventricular assist device programs, predicts left ventricular assist device program hospital readmissions and death.
Methods
We performed a retrospective analysis of adults at the Cleveland Clinic with Stanford Integrated Psychosocial Assessment for Transplant scores before primary left ventricular assist device program implantation from April 1, 2013, to December 31, 2018. The primary outcome was unplanned hospital readmissions censored at death, transplantation, and transfer of care. The secondary outcome was death.
Results
There were 263 patients in the left ventricular assist device program with a median (Q1, Q3) Stanford Integrated Psychosocial Assessment for Transplant score of 16 (8, 28). During a median follow-up 1.2 years, 56 died, 65 underwent transplantation, and 21 had transferred care. There were 640 unplanned hospital readmissions among 250 patients with at least 1 outpatient visit at our center. In a multivariable analysis, Stanford Integrated Psychosocial Assessment for Transplant components but not total Stanford Integrated Psychosocial Assessment for Transplant score was associated with readmissions. Psychopathology (Stanford Integrated Psychosocial Assessment for Transplant C-IX) was associated with hemocompatibility (coefficient 0.21 ± standard error 0.11, P = .040) and cardiac (0.15 ± 0.065, P = .02) readmissions. Patient readiness was associated with noncardiac (Stanford Integrated Psychosocial Assessment for Transplant A-III, 0.24 ± 0.099, P = .016) and cardiac (Stanford Integrated Psychosocial Assessment for Transplant A-low total, 0.037 ± 0.014, P = .007) readmissions. Poor living environment (Stanford Integrated Psychosocial Assessment for Transplant B-VIII) was associated with device-related readmissions (0.83 ± 0.34, P = .014). Death was associated with organic psychopathology or neurocognitive impairment (Stanford Integrated Psychosocial Assessment for Transplant C-X, 0.59 ± 0.21, P = .006).
Conclusions
Total Stanford Integrated Psychosocial Assessment for Transplant score was not associated with left ventricular assist device program readmission or mortality. However, we identified certain Stanford Integrated Psychosocial Assessment for Transplant components that were associated with outcome and could be used to create a left ventricular assist device program specific psychosocial tool.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 28 Apr 2021; epub ahead of print
Olt CK, Thuita LW, Soltesz EG, Tong MZ, ... Hsich EM, Stanford Integrated Psychosocial Assessment for Transplant Research Group
J Thorac Cardiovasc Surg: 28 Apr 2021; epub ahead of print | PMID: 34053742
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Abstract

Application of deep hypothermic circulatory arrest in open left chest aortic aneurysm repair.

Alhussaini M, Falasa MP, Jeng EI, Martin T, ... Neal D, Beaver TM
Objectives
Deep hypothermic circulatory arrest (DHCA) is often required for patients undergoing repair of descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm via left thoracotomy when proximal crossclamping is not feasible or when aneurysmal disease extends into the transverse aortic arch. Historical literature suggests higher complications rates due to the technical complexity of this approach; we examined outcomes with this approach at our center.
Methods
Between January 2008 and May 2018, 84 patients with DTAA or Crawford extent I thoracoabdominal aortic aneurysm underwent open repair. DHCA was employed in 46 of 84 (55%) patients, of which 33 (72%) required repair of distal arch and DTAA, and 13 (28%) required repair of the distal arch and extent I thoracoabdominal aortic aneurysm. Patients who underwent DHCA had more chronic dissections than those in the non-DHCA group (70% vs 34%; P ≤ .05).
Results
Major adverse outcomes for the DHCA group versus non-DHCA group were as follows: early mortality 3 out of 46 (7%) versus 4 out of 38 (11%) (P = .70), stroke 3 out of 46 (7%) versus 1 out of 38 (3%) (P = .62), permanent spinal cord deficit 2 out of 46 (4%) versus 3 out of 38 (8%) (P = .65), permanent renal failure necessitating dialysis 1 out of 46 (2%) versus 2 out of 38 (5%) (P = .59). Freedom from major adverse outcomes was 38 out of 46 (83%) versus 31 out of 38 (82%) for DHCA versus non-DHCA (P = 1).
Conclusions
DHCA can be employed via left thoracotomy for combined arch and DTAA or extent I thoracoabdominal aortic aneurysm open repair.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 30 Mar 2021; epub ahead of print
Alhussaini M, Falasa MP, Jeng EI, Martin T, ... Neal D, Beaver TM
J Thorac Cardiovasc Surg: 30 Mar 2021; epub ahead of print | PMID: 33934896
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Abstract

Bioprosthetic versus mechanical mitral valve replacements in patients with rheumatic heart disease.

Chen CY, Chan YH, Wu VC, Liu KS, ... Chu PH, Chen SW
Background
Rheumatic heart disease (RHD) remains a critical problem in developed countries. Few studies have compared the long-term outcomes of bioprosthetic valves and mechanical valves in patients with RHD who have received mitral valve (MV) replacement.
Methods
Patients with RHD who received MV replacement with bioprosthetic or mechanical valves were identified between 2000 and 2013 from Taiwan\'s National Health Insurance Research Database. The primary late outcomes of interest were all-cause mortality and redo MV surgery. Propensity score matching at a 1:1 ratio was performed.
Results
We identified 3638 patients with RHD who underwent MV replacement. Among those patients, 1075 (29.5%) and 2563 (70.5%) chose a bioprosthetic valve and mechanical valve, respectively. After matching, 788 patients were assigned to each group. No significant difference in the risk of in-hospital mortality was observed between groups (P = .920). Higher risks of all-cause mortality (10-year actuarial estimates: 50.6% vs 45.5%; hazard ratio, 1.19; 95% confidence interval, 1.01-1.41; P = .040) and MV reoperation (10-year actuarial estimates: 8.9% vs 0.93%; subdistribution hazard ratio, 4.56; 95% confidence interval, 1.71-12.17; P <.01) were observed in the bioprosthetic valve group. Furthermore, the relative mortality benefit associated with mechanical valves was more apparent in younger patients and the beneficial effect persisted until approximately 65 years of age.
Conclusions
In the patients with RHD who underwent MV replacement, mechanical valves were associated with more favorable long-term outcomes in patients younger than the age of 65 years.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 17 Mar 2021; epub ahead of print
Chen CY, Chan YH, Wu VC, Liu KS, ... Chu PH, Chen SW
J Thorac Cardiovasc Surg: 17 Mar 2021; epub ahead of print | PMID: 33840468
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Abstract

Allocation changes in heart transplantation: What has really changed?

Ganapathi AM, Lampert BC, Mokadam NA, Emani S, ... Tamer R, Whitson BA
Objective
In 2018, the heart allocation system changed status classifications and broadened geographic distribution. We examined this change at a national level based on the immediate pre- and postchange periods.
Methods
Using the Scientific Registry of Transplant Recipients database, we identified all adult primary, isolated heart transplants from October 18, 2017, to October 17, 2019. Two time periods were compared: (1) October 18, 2017, to October 17, 2018 (pre); and (2) October 18, 2018, to October 17, 2019 (post). Comparisons were made between groups, and a multivariable logistic regression model was created to identify factors associated with pretransplant temporary mechanical circulatory support. Volume analysis at the regional, state, and center level was also conducted as the primary focus.
Results
A total of 5381 independent heart transplants were identified within the time frame. On unadjusted analysis, there was a significant increase in temporary mechanical circulatory support (pre, 11.1%; post, 36.2%, P < .01) and decrease in waitlist days (pre, 93 days; post, 41 days; P < .01). Distance traveled (nautical miles) (pre, 83; post, 225; P < .01) and ischemic time (hours) (pre, 3.0; post, 3.4; P < .01) were significantly increased. On multivariable analysis, the postallocation time period was independently associated with temporary MCS (odds ratio, 4.463; 95% confidence interval, 3.844-5.183; P < .001). Transplant volumes did not significantly change after the allocation change at a regional, state, and center level.
Conclusions
Since the planned alteration to the allocation system, there have been changes in the use of temporary mechanical circulatory support as well as distance and ischemic time associated with transplant, but no significant volume changes were observed. Continued observation of outcomes and volume under the new allocation system will be necessary in the upcoming years.

Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 15 Mar 2021; epub ahead of print
Ganapathi AM, Lampert BC, Mokadam NA, Emani S, ... Tamer R, Whitson BA
J Thorac Cardiovasc Surg: 15 Mar 2021; epub ahead of print | PMID: 33875259
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Abstract

Tracheal surgery for airway anomalies associated with increased mortality in pediatric patients undergoing heart surgery: Society of Thoracic Surgeons Database analysis.

Riggs KW, Zafar F, Jacobs ML, Jacobs JP, ... Bryant R, Tweddell JS
Objectives
Airway anomalies are common in children with cardiac disease but with an unquantified impact on outcomes. We sought to define the association between airway anomalies and tracheal surgery with cardiac surgery outcomes using the Society of Thoracic Surgery Congenital Heart Surgery Database.
Methods
Index cardiac operations in children aged less than 18 years (January 2010 to September 2018) were identified from the Society of Thoracic Surgery Congenital Heart Surgery Database. Patients were divided on the basis of reported diagnosis of an airway anomaly and subdivided on the basis of tracheal lesion and tracheal surgery. Multivariable analysis evaluated associations between airway disease and outcomes controlling for covariates from the Society of Thoracic Surgery Congenital Heart Surgery Database Mortality Risk Model.
Results
Of 198,674 index cardiovascular operations, 6861 (3.4%) were performed in patients with airway anomalies, including 428 patients (0.2%) who also underwent tracheal operations during the same hospitalization. Patients with airway anomalies underwent more complex cardiac operations (45% vs 36% Society of Thoracic Surgeons/European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality category ≥3 procedures) and had a higher prevalence of preoperative risk factors (73% vs 39%; both P < .001). In multivariable analysis, patients with airway anomalies had increased odds of major morbidity and tracheostomy (P < .001). Operative mortality was also increased in patients with airway anomalies, except those with malacia. Tracheal surgery within the same hospitalization increased the odds of operative mortality (adjusted odds ratio, 3.9; P < .0001), major morbidity (adjusted odds ratio, 3.7; P < .0001), and tracheostomy (adjusted odds ratio, 16.7; P < .0001).
Conclusions
Patients undergoing cardiac surgery and tracheal surgery are at significantly higher risk of morbidity and mortality than patients receiving cardiac surgery alone. Most of those with unoperated airway anomalies have higher morbidity and mortality, which makes it an important preoperative consideration.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1112-1121.e7
Riggs KW, Zafar F, Jacobs ML, Jacobs JP, ... Bryant R, Tweddell JS
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:1112-1121.e7 | PMID: 33419543
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Abstract

First in human experience with an epicardial beating heart device for secondary mitral regurgitation.

Thourani VH, George I, Rucinskas K, Kalinauskas G, ... Smith R, Mack MJ
Objective
We describe a novel, off-pump, epicardial implant that is intended to reshape both the mitral valve annulus and the left ventricle (LV) in those with secondary mitral regurgitation (MR).
Methods
Five patients underwent an epicardial implant with the Mitral Touch device (Mitre Medical Corp, Morgan Hill, Calif), during concomitant off-pump coronary artery bypass for secondary MR. The median age was 71.2 years; 4 patients had severe MR and 1 moderate. Patients were followed for 1 year with transthoracic echocardiography and computed tomography. Safety, cardiac remodeling, and MR were assessed by an independent core laboratory.
Results
One patient died within 30 days from nondevice-related organ failure and the remaining 4 survived through 1-year follow-up. Implant technical success was 100% and took an average of 52 minutes. Paired computed tomography showed mean left ventricular end-systolic volume remodeling at 1 and 12 months of -35% and -31%, respectively. They averaged left atrial end-systolic volume remodeling of -12% and -15% at 1 and 12 months. Right ventricular end-systolic volume changes of -19% and -8% and right atrial end-systolic volume remodeling of -5% and 1%, at the 1- and 12-month time points were noted. Regurgitant volume by transthoracic echocardiography decreased by 46% and 44% and the ejection fraction from 34.6% to 32.1% and 39.5%, at 1 and 12 months, respectively. There were no device-related complications reported to 1 year.
Conclusions
The Epicardial Mitral Touch System for Mitral Regurgitation (ENRAPT-MR) study demonstrates a first-in-man, off-pump, epicardial repair of secondary MR. Procedural safety and geometric correction of the mitral valve apparatus and LV was achieved. Further studies in the United States are underway.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:949-958.e4
Thourani VH, George I, Rucinskas K, Kalinauskas G, ... Smith R, Mack MJ
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:949-958.e4 | PMID: 33436291
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Abstract

Pathologic concordance of resected metastatic nonseminomatous germ cell tumors in the chest.

Donahoe LL, Nason GJ, Bedard PL, Hansen AR, ... Hamilton RJ, de Perrot M
Objective
Men with metastatic nonseminomatous germ cell tumors (NSGCTs) often present with residual chest tumors after chemotherapy. We examined the pathologic concordance of intrathoracic disease and outcomes based on the worst pathology of disease resected at first thoracic surgery.
Methods
A retrospective analysis was performed of consecutive patients undergoing thoracic resection for metastatic NSGCT in our institution between 2005 and 2018.
Results
Eighty-nine patients (all men) were included. The median age was 29 years (interquartile range [IQR], 23-35 years). Primary sites were testis (n = 84; 94.4%) and retroperitoneum (n = 5; 5.6%). Eighty-seven patients received chemotherapy before undergoing surgery. Nineteen patients (21.3%; group 1) had malignancy resected at first surgery (OR1), and the other 70 patients had benign disease at OR1 (78.7%; group 2). Concordant pathology between lungs was 85.2% in group 1 and 91% in group 2, and between lung and mediastinum was 50% in group 1 and 72.7% in group 2. Despite no teratoma at OR1, 3 patients (15.8%) in group 2 had resection of teratoma (n = 2) or malignancy (n = 1) at future surgery. After a mean follow-up of 65.5 months (IQR, 23.1-89.2 months) for group 1 and 47.7 months (IQR, 13.0-75.1 months) for group 2, overall survival was significantly worse for group 1 (68.4% vs 92.9%; P = .03).
Conclusions
The wide range of pathology resected in patients with intrathoracic NSGCT metastases requires careful decision making regarding treatment. Pathologic concordance between lungs is better than that between lung and mediastinum in patients with intrathoracic NSGCT metastases. Aggressive surgical management should be considered for all residual disease due to the low concordance between sites and the potential for excellent long-term survival even in patients with chemotherapy-refractory disease.

Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:856-868.e1
Donahoe LL, Nason GJ, Bedard PL, Hansen AR, ... Hamilton RJ, de Perrot M
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:856-868.e1 | PMID: 33478834
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Abstract

Operative risks of the Ross procedure.

Stelzer P, Mejia J, Varghese R
Background
The risk of the Ross procedure continues to be debated. We sought to determine the immediate outcomes of the Ross procedure in a large consecutive cohort that included patients undergoing reoperative cardiac surgery and/or concomitant cardiac procedures.
Methods
Between March 1987 and September 2019, 702 patients underwent a full root Ross procedure. There were 530 male patients and 172 female patients, with a mean age of 41.6 years. One hundred and one patients had at least one previous sternotomy; 323 patients had concomitant procedures. Patients were stratified into 2 groups: simple and complex. Simple Ross patients were those who had no previous sternotomy and had only minor concomitant procedures performed at the time of their Ross, such as aortoplasty or closure of patent foramen ovale. The complex Ross group included patients with at least one previous sternotomy and/or additional procedures that we deemed complex, such as ascending aortic replacement and mitral valve repair. Complexity and group outcomes were evaluated in consecutive terciles of time.
Results
There were 7 (1%) operative deaths. Morbidity affected 46 other patients (6.6%). The simple Ross group comprised 419 patients (59.7%), with mortality in 3 (0.7%) and morbidity in 20 (4.8%). The complex Ross comprised 283 patients (40.3%), with mortality in 4 (1.4%) and morbidity in 26 (9.2%). Simple Ross cases decreased in volume over time, with complex cases increasing from 34% to 48%.
Conclusions
Excellent results can be achieved with the Ross procedure despite broader indications that include patients with previous sternotomy and with the need for concomitant procedures.

Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

J Thorac Cardiovasc Surg: 27 Feb 2021; 161:905-915.e3
Stelzer P, Mejia J, Varghese R
J Thorac Cardiovasc Surg: 27 Feb 2021; 161:905-915.e3 | PMID: 33451826
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Abstract

Percutaneous mitral valve repair in adults with congenital heart disease: Report of the first case-series.

Alshawabkeh L, Mahmud E, Reeves R
Background
Systemic atrioventricular valve regurgitation (AVVR) is frequently encountered in adults with congenital heart disease (CHD). Surgical intervention is the mainstay of therapy, but in a specific high-risk subset, percutaneous valve repair might offer a lower-risk alternative.
Methods
Three patients with complex CHD and severe symptomatic AVVR underwent percutaneous mitral valve repair at a single center. All were deemed to be high-risk for surgery by a multidisciplinary CHD team and provided informed consent for the compassionate use of the MitraClip (Abbott, Santa Clara, CA). Three-dimensional heart models were generated for the procedure, which was performed by an adult CHD cardiologist (who provided imaging support) and an interventional cardiologist with expertise in CHD and percutaneous mitral valve repair.
Results
The first case was a 39 year-old-woman with [S,L,D] dextrocardia, double outlet right ventricle, mild tricuspid hypoplasia, and a secundum atrial septal defect, who was palliated at age 35 with a right bidirectional Glenn and later developed severe, symptomatic mitral regurgitation, and underwent placement of one MitraClip XTR device. Two patients with L-loop transposition of the great arteries each successfully underwent placement of two MitraClip XTR devices; one patient had a single-leaflet detachment of one of the clips with no change in regurgitation or clip position on follow-up. All patients had significant reduction of AVVR and improvement in NYHA functional class.
Conclusions
Percutaneous atrioventricular valve repair in adults with CHD is feasible with the MitraClip but requires significant preprocedural planning and a multidisciplinary team that combines CHD and interventional therapeutic expertise.

© 2020 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 14 Feb 2021; 97:542-548
Alshawabkeh L, Mahmud E, Reeves R
Catheter Cardiovasc Interv: 14 Feb 2021; 97:542-548 | PMID: 32898313
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Abstract

Peroral endoscopic myotomy provides effective palliation in type III achalasia.

Sudarshan M, Raja S, Adhikari S, Murthy S, ... Ahmad U, Sanaka M
Background
Type III achalasia outcomes have historically been met with limited success after conventional laparoscopic Heller myotomy (LHM) and pneumatic dilation. Peroral endoscopic myotomy (POEM) has emerged as a promising alterative for a multitude of reasons. Our objective was to investigate POEM outcomes in palliating type III achalasia.
Methods
A retrospective analysis of a prospectively maintained database was conducted in a tertiary care institution between April 2014 and July 2019. The primary outcome was postoperative Eckardt score. We also explored the effect of lower esophageal sphincter (LES) integrated resting pressure (IRP) on manometry, barium column height and width, and complications. Standard statistical methods were applied using R.
Results
A total of 518 patients in the achalasia database were identified, with 308 patients undergoing LHM and 210 undergoing POEM during the study period. POEM was used for type III achalasia in 36 patients (median age, 60 years; 61.7% male), with a median operative time of 85 minutes (interquartile range [IQR], 71-115 minutes) and follow-up of 1 year (IQR, 0.16-2.25 years). Within the POEM group, 11 patients (33%) had previous interventions, including Botox injections to the LES (n = 7), pneumatic dilation (n = 1), and LHM (n = 3). A significant decrease in median Eckardt score was observed (7 preoperatively [IQR, 6-8.75] vs 0 postoperatively [IQR, 0-1]; P < .01). Similar improvements after POEM were noted in median LES IRPs (25.5 mmHg vs 4.5 mmgHg; P < .01), 1-minute barium column height (10 cm vs 0 cm; P < .01), and 1-minute barium column width (2 cm vs 0 cm; P < .01). Patients reported a return to activities of daily living in a median of 7 days (IQR, 3-7 days). Three patients experienced complications, including mucosal perforation resolving with conservative management (n = 1), readmission for bleeding duodenal ulcer responding to proton pump inhibitors (n = 1), and readmission for dysphagia and rehydration (n = 1). Postoperative esophageal pH studies were conducted in 21 patients (62%), demonstrating a Demeester score of >14.72 in 13 patients (62%).
Conclusions
POEM provides effective and durable palliation for type III achalasia, as demonstrated by symptom relief, esophageal manometry, and radiographic measurement. Considering its low morbidity profile, POEM should be considered as first-line therapy in this challenging disease subtype.

Copyright © 2021. Published by Elsevier Inc.

J Thorac Cardiovasc Surg: 05 Feb 2021; epub ahead of print
Sudarshan M, Raja S, Adhikari S, Murthy S, ... Ahmad U, Sanaka M
J Thorac Cardiovasc Surg: 05 Feb 2021; epub ahead of print | PMID: 33741133
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Older ...

This program is still in alpha version.