<div><h4>The Importance of Timing in Post-Cardiotomy Veno-Arterial Extracorporeal Membrane Oxygenation: a Descriptive Multicenter Observational Study.</h4><i>Mariani S, Wang IW, van Bussel BCT, Heuts S, ... Lorusso R, PELS-1 Investigators</i><br /><b>Objectives</b><br />Post-cardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intra-operatively or post-operatively based on indications, settings, patient profile and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patients´ characteristics, in-hospital and long-term survival between intra-operative and post-operative ECMO.<br /><b>Methods</b><br />The retrospective, multicentre, observational Post-cardiotomy Extracorporeal Life Support (PELS-1) Study includes adults requiring ECMO due to post-cardiotomy shock between 2000 and 2020. We compare patients who received ECMO in the operating theatre (intra-operative) with those in the intensive care unit (post-operative) on in-hospital and post-discharge outcomes.<br /><b>Results</b><br />We studied 2003 patients [women:41.1%; median age:65 (IQR:55.0-72.0) years]. Intra-operative (n=1287), compared to post-operative (n=716), ECMO patients had worse pre-operative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for post-operative ECMO initiation, with cannulation occurring after (median) 1 day (IQR:1-3 days). Compared to intra-operative application, post-operative ECMO showed more complications, cardiac reoperations (intra-operative:19.7%; post-operative: 24.8%, p=0.011), percutaneous coronary interventions (intra-operative:1.8%; post-operative: 3.6%, p=0.026), and had higher in-hospital mortality (intra-operative:57.5%; post-operative: 64.5%, p=0.002). Among hospital survivors, ECMO duration was shorter after intra-operative ECMO (median:104, IQR:67.8-164.2 hours) compared to post-operative ECMO (median:139.7, IQR:95.8-192 hours, p<0.001), while post-discharge long-term survival was similar between the two groups (p=0.86).<br /><b>Conclusions</b><br />Intra-operative and post-operative ECMO implantations are associated with different patients\' characteristics and outcomes, with higher complications and in-hospital mortality after post-operative ECMO. Strategies to identify the optimal location and timing of post-cardiotomy ECMO in relation to specific patient\'s characteristics are warranted to optimize in-hospital outcomes.<br /><br />Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 16 May 2023; epub ahead of print</small></div>

<div><h4>Hybrid Palliation Versus Non-Hybrid Management for a Multi-Institutional Cohort of Infants with Critical Left Heart Obstruction.</h4><i>Argo MB, Barron DJ, Bondarenko I, Eckhauser A, ... Haw MP, McCrindle BW</i><br /><b>Objective</b><br />To compare patient characteristics and overall survival for infants with critical left heart obstruction (CLHO) after hybrid palliation (bilateral pulmonary artery banding ± ductal stenting) versus non-hybrid management (e.g., Norwood, primary transplantation, biventricular repair, transcatheter/surgical aortic valvotomy).<br /><b>Methods</b><br />From 2005-2019, 1,045 infants in the Congenital Heart Surgeons\' Society CLHO cohort underwent interventions across 28 institutions. Using a balancing score propensity analysis, 214 infants who underwent hybrid palliation and 831 infants who underwent non-hybrid management were proportionately matched regarding variables significantly associated with mortality and variables noted to significantly differ between groups. Overall survival between the two groups was adjusted by applying balancing scores to nonparametric estimates.<br /><b>Results</b><br />Compared to the non-hybrid management group, infants who underwent hybrid palliation had lower birth weight, smaller gestational age, and higher prevalence of in-utero interventions, non-cardiac comorbidities, preoperative mechanical ventilation, absent interatrial communication, and moderate or severe mitral valve stenosis (all p-values <0.03). Unadjusted 12-year survival after hybrid palliation and non-hybrid management, was 55% versus 69% respectively. After matching, 12-year survival after hybrid palliation versus non-hybrid management was 58% versus 63%, respectively (p=0.37). Among matched infants born weighing <2.5kg, 2-year survival after hybrid palliation versus non-hybrid management was 37% versus 51%, respectively (p=0.22).<br /><b>Conclusions</b><br />Infants born with CLHO who undergo hybrid palliation have more high-risk characteristics and anatomy versus infants who undergo non-hybrid management. Nonetheless, after adjustment, there was no significant difference in 12-year survival after hybrid palliation versus non-hybrid management. Mortality remains high, and hybrid palliation confers no survival advantage, even for lower birth weight infants.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 03 May 2023; epub ahead of print</small></div>

<div><h4>Surgical Management of Non-small-cell Lung Cancer with Limited Metastatic Disease Involving Only the Brain.</h4><i>Kumar A, Kumar S, Potter AL, Raman V, ... Lanuti M, Jeffrey Yang CF</i><br /><b>Objective</b><br />The optimal primary site treatment modality for non-small-cell lung cancer (NSCLC) with brain oligometastases is not well-established. This study sought to evaluate long-term survival of patients with NSCLC with isolated brain metastases undergoing multimodal therapy with or without thoracic surgery.<br /><b>Methods</b><br />Patients with cT1-3, N0-1, M1b-c NSCLC with synchronous limited metastatic disease involving only the brain treated with brain stereotactic radiosurgery (SRS) or neurosurgical resection in the National Cancer Database (2010-2017) were included. Long-term overall survival of patients who underwent multimodal therapy including thoracic surgery (\"Thoracic Surgery\") versus systemic therapy with or without radiation to the lung (\"No Thoracic Surgery\") was evaluated using Kaplan-Meier analysis, Cox proportional hazards modeling, and propensity score matching.<br /><b>Results</b><br />Of the 1,240 patients with NSCLC with brain-only metastases who received brain SRS or neurosurgery and met study inclusion criteria, 270 (21.8%) received primary site resection. The Thoracic Surgery group had improved overall survival compared to the No Thoracic Surgery group in Kaplan-Meier analysis (p<0.001) and after multivariable-adjusted Cox proportional hazards modeling (p<0.001). In a propensity score-matched analysis of 175 patients each in the Thoracic Surgery and No Thoracic Surgery groups, matching on 13 common prognostic variables, thoracic surgery was associated with better survival (p=0.012).<br /><b>Conclusions</b><br />In this national analysis, patients with cT1-3, N0-1, M1b-c NSCLC with isolated limited brain metastases had better overall survival after multimodal therapy including thoracic surgery compared to systemic therapy without surgery. Multimodal thoracic treatment including surgery can be considered for carefully selected patients with NSCLC and limited brain metastases.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 28 Apr 2023; epub ahead of print</small></div>

<div><h4>Social Vulnerability is Associated with Increased Post-Operative Morbidity following Esophagectomy.</h4><i>Stuart CM, Dyas AR, Byers S, Velopulos C, ... McCarter MD, Meguid RA</i><br /><b>Objectives</b><br />The effect of a patient\'s Social Vulnerability Index (SVI) on complication rates after esophagectomy remains unstudied. The purpose of this study was to determine how social vulnerability influences morbidity following esophagectomy.<br /><b>Methods</b><br />This was a retrospective review of a prospectively collected esophagectomy database at one academic institution, 2016-2022. Patients were grouped into low SVI (<75%ile) and high SVI (>75%ile) cohorts. The primary outcome was overall postoperative complication rate; secondary outcomes were rates of individual complications. Perioperative patient variables and postoperative complication rates were compared between the two groups. Multivariable logistic regression was used to control for covariates.<br /><b>Results</b><br />Of 149 esophagectomy patients identified, 27 (18.1%) were in the high SVI group. Patients with high SVI were more likely to be of Hispanic ethnicity (18.5% versus 4.9%, p=0.029), but there were no other differences in perioperative characteristics between groups. Patients with high SVI were significantly more likely to develop a post-operative complication (66.7% versus 36.9%, p=0.005), and had higher rates of postoperative pneumonia (25.9% versus 6.6%, p=0.007), jejunal feeding tube complications (14.8% versus 3.3%, p=0.036), and unplanned ICU readmission (29.6% versus 12.3%, p=0.037). Additionally, patients with high SVI had a longer postoperative hospital length of stay (13 versus 10 days, p=0.017). There were no differences in mortality rates. These findings persisted on multivariable analysis.<br /><b>Conclusions</b><br />Patients with high SVI have higher rates of postoperative morbidity following esophagectomy. The effect SVI on esophagectomy outcomes warrants further investigation and may prove useful in identifying populations that benefit from interventions to mitigate these complications.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 27 Apr 2023; epub ahead of print</small></div>

<div><h4>Distinct Hemodynamic Responses That Culminate With Postural Orthostatic Tachycardia Syndrome.</h4><i>de Oliveira MCS, Távora-Mehta MZP, Mehta N, Magajevski AS, ... Doubrawa E, Lofrano-Alves MS</i><br /><AbstractText>It is of paramount importance to characterize the individual hemodynamic response of patients with postural orthostatic tachycardia syndrome (POTS) to select the best therapeutic intervention. Our aim in this study was to describe the hemodynamic changes in 40 patients with POTS during the head-up tilt test and compare them with 48 healthy patients. Hemodynamic parameters were obtained by cardiac bioimpedance. Patients were compared in supine position and after 5, 10, 15, and 20 minutes of orthostatic position. Patients with POTS demonstrated higher heart rate (74 beats per minute [64 to 80] vs 67 [62 to 72], p <0.001) and lower stroke volume (SV) (83.0 ml [72 to 94] vs 90 [79 to 112], p <0.001) at supine position. The response to orthostatic challenge was characterized by a decrease in SV index (SVI) in both groups (ΔSVI in ml/m<sup>2</sup>: -16 [-25 to -7.] vs -11 [-17 to -6.1], p = NS). Peripheral vascular resistance (PVR) was reduced only in POTS (ΔPVR in dyne.seg/cm<sup>5</sup>:-52 [-279 to 163] vs 326 [58 to 535], p <0.001). According to the best cut-off points obtained using the receiver operating characteristic analysis for the variation of SVI (-15.5%) and PVR index (PVRI) (-5.5%), we observed 4 distinct groups of POTS: 10% presented an increase in both SVI and PVRI after the orthostatic challenge, 35% presented a PVRI decrease with SVI maintenance or increase, 37.5% presented an SVI decrease with PVRI maintenance or elevation, and 17.5% presented a reduction in both variables. Body mass index, ΔSVI, and ΔPVRI were strongly correlated with POTS (area under the curve = 0.86 [95% confidence interval 0.77 to 0.92], p <0.0001). In conclusion, the use of appropriate cut-off points for hemodynamic parameters using bioimpedance cardiography during the head-up tilt test could be a useful strategy to identify the main mechanism involved and to select the best individual therapeutic strategy in POTS.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 25 Apr 2023; 197:3-12</small></div>

<div><h4>Bicuspid Aortopathy does NOT Require Earlier Surgical Intervention.</h4><i>Zafar MA, Wu J, Vinholo TF, Li Y, ... Rizzo JA, Elefteriades JA</i><br /><b>Objectives</b><br />Guidelines for surgical correction of ascending thoracic aortic aneurysm (ATAA) in bicuspid aortic valve (BAV) patients have oscillated back and forth over the years. In this study, we outline the natural history of the ascending aorta in BAV and TAV (trileaflet aortic valve) ATAA patients followed over time, to ascertain if their behavior differs, and to determine if a different threshold for intervention is required.<br /><b>Methods</b><br />Aortic diameters and long-term complications (adverse aortic events; AAE) of 2428 patients (554 BAV and 1874 TAV) with ATAA prior to operative repair were reviewed. Growth rates, yearly complication rates, event-free survival (Kaplan-Meier), and risk of complications as a function of aortic size (regression analyses) were calculated. Long-term follow-up and precise cause of death granularity was achieved via a comprehensive six-pronged approach.<br /><b>Results</b><br />Aortic growth rate in BAV- vs. TAV-ATAA patients was 0.20 and 0.17 cm/year, respectively (p=0.009), with the rate increasing with increasing aortic size. Yearly AAE rates increased with ATAA size and were lower for BAV patients. The relative risk of AAE exhibited an exponential increase with aortic diameter. BAV patients had a lower all-cause and ascending aorta specific AAE hazard. Age-adjusted 10-year event free survival was significantly better for BAV patients, and BAV emerged as a protective factor against type A dissection, rupture, and ascending aortic death.<br /><b>Conclusion</b><br />The threshold for surgical repair of ascending aneurysm with BAV should not differ from that of TAV. Prophylactic surgery should be considered at 5.0cm for TAV (and BAV) patients at expert centers.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 21 Apr 2023; epub ahead of print</small></div>

<div><h4>Use of the Inspiris Valve in the Native Right Ventricular Outflow Tract is Associated with Early Prosthetic Regurgitation.</h4><i>Nguyen SN, Vinogradsky AV, Sevensky R, Crystal MA, Bacha EA, Goldstone AB</i><br /><b>Objective</b><br />The Inspiris Resilia prosthesis (Edwards Lifesciences, Irvine, CA) has been increasingly used in the pulmonic position with limited performance data. We sought to investigate its durability as a surgical pulmonary valve replacement (PVR).<br /><b>Methods</b><br />We retrospectively reviewed patients who underwent PVR or conduit replacement with an Inspiris or non-Inspiris valve/conduit from 2018-2022. The primary endpoint was freedom from a composite of at least moderate pulmonary regurgitation (PR), pulmonary stenosis (PS), or valve/conduit reintervention. Secondary endpoints were individual components of the composite outcome. To account for baseline differences, propensity matching identified 70 patient pairs.<br /><b>Results</b><br />A total of 227 patients (median age: 19.3 years [IQR, 11.8-34.4]) underwent PVR or conduit replacement (Inspiris: n=120 [52.9%], non-Inspiris: n=107 [47.1%]). Median follow-up was 26.6 months [IQR, 12.4-41.1]. Among matched patients, 2-year freedom from valve failure was lower in the Inspiris group (53.5%±9.3% vs. 78.5%±5.9%, p=0.03), as was freedom from at least moderate PR (54.2%±9.6% vs. 86.4%±4.9%, p<0.01). There was no difference in 2-year freedom from at least moderate PS (p=0.61) or reintervention (p=0.92). Inspiris durability was poorer when implanted in the native right ventricular outflow tract compared to as a conduit, with 18-month freedom from valve failure of 59.0%±9.5% vs. 85.9%±9.5% (p=0.03).<br /><b>Conclusions</b><br />Early durability of the Inspiris valve is poor when implanted in the native right ventricular outflow tract; its unique design may be incompatible with the compliant pulmonary root. Modified implantation techniques or alternative prostheses should be considered.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 21 Apr 2023; epub ahead of print</small></div>

<div><h4>Design of A Multi-Institutional Neurocognitive Discovery Study in Adult Congenital Heart Disease (MINDS-ACHD).</h4><i>Cohen S, Gurvitz M, Burns KM, Wheaton O, ... Zaidi AN, Pediatric Heart Network Investigators and the Alliance for Adult Research in Congenital Cardiology</i><br /><b>Background</b><br />Neurocognitive dysfunction (NCD) is a common comorbidity among children with congenital heart disease (CHD). However, it is unclear how underlying CHD and its sequelae combine with genetics and acquired cardiovascular and neurological disease to impact NCD and outcomes across the lifespan in adults with CHD.<br /><b>Methods</b><br />The Multi-Institutional Neurocognitive Discovery Study in Adults with Congenital Heart Disease (MINDS-ACHD) is a partnership between the Pediatric Heart Network (PHN) and the Adult Alliance for Research in Congenital Cardiology (AARCC) that examines objective and subjective neurocognitive function and genetics in young ACHD. This multicenter cross-sectional pilot study is enrolling 500 young adults between 18 and 30 years with moderate or severe complexity CHD at 14 centers in North America. Enrollment includes 4 groups (125 participants each): 1) d-looped Transposition of the Great Arteries (d-TGA); 2) Tetralogy of Fallot (TOF); 3) single ventricle (SV) physiology; and 4) \"other moderately or severely complex CHD.\" Participants complete the standardized tests from the NIH Toolbox Cognitive Battery, the NeuroQoL, the Hospital Anxiety and Depression Scale, and the PROMIS Global QoL measure. Clinical and demographic variables are collected by interview and medical record review, and an optional biospecimen is collected for genetic analysis. Due to the COVID-19 pandemic, participation may be done remotely. Tests are reviewed by a Neurocognitive Core Laboratory.<br /><b>Conclusions</b><br />MINDS-ACHD is the largest study to date characterizing NCD in young adults with moderate or severely complex CHD in North America. Its results will provide valuable data to inform screening and management strategies for NCD in ACHD and improve lifelong care.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>Am Heart J: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Normal Values of 3D Right Ventricular Size and Function Measurements: Results of the World Alliance of Societies of Echocardiography Study.</h4><i>Addetia K, Miyoshi T, Amuthan V, Citro R, ... Lang RM, WASE Investigators</i><br /><b>Background</b><br />Normal values for 3D right ventricular (RV) size and function are not well established, as they originate from small studies that involved predominantly white North American and European populations, did not use RV-focused views and relied on older 3D RV analysis software . The World Alliance of Societies of Echocardiography (WASE) study was designed to generate reference ranges for normal subjects around the world. In this study, we sought to assess the world-wide capability of 3D imaging of the right ventricle and report size and function measurements, including their dependency on age, sex and ethnicity.<br /><b>Methods</b><br />Healthy subjects free of cardiac, pulmonary and renal disease were prospectively enrolled at 19 centers in 15 countries, including 6 continents. 3D wide-angle RV datasets were obtained and analyzed using dedicated RV software (Tomtec) to measure end-diastolic and end-systolic volumes (EDV, ESV), stroke volume (SV) and ejection fraction (EF). Results were categorized by sex, age (18-40, 41-65 and >65 years) and ethnicity.<br /><b>Results</b><br />Of the 2007 subjects with attempted 3D RV acquisitions, 1051 had adequate image quality for confident measurements. Upper and lower limits for BSA-indexed EDV (mL/m<sup>2</sup>) and ESV (mL/m<sup>2</sup>) and EF (%) were [48, 95], [19, 43] and [44, 58] for men and [42, 81], [16, 36] and [46, 61] for women. Men had significantly larger EDV, ESV and SV (even after BSA indexing) and lower EF than women (p<0.05). EDV and ESV did not show any meaningful differences between age groups. 3D RV volumes were smallest in Asians.<br /><b>Conclusions</b><br />Reliability of 3D RV acquisition is low worldwide underscoring the importance for future improvements in imaging techniques. Sex and race must be taken into consideration in the assessment of both RV volumes and EF.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 19 Apr 2023; epub ahead of print</small></div>

<div><h4>Septal Annular Dilation in Chronic Ovine Functional Tricuspid Regurgitation.</h4><i>Iwasieczko A, Jazwiec T, Gaddam M, Gaweda B, ... Rausch MK, Timek TA</i><br /><b>Introduction</b><br />Annular reduction with prosthetic rings represents current surgical treatment of functional tricuspid regurgitation (FTR). However, alterations of annular geometry and dynamics associated with FTR are not well characterized.<br /><b>Methods</b><br />FTR was induced in 29 adult sheep with either eight weeks of pulmonary artery banding (PAB, n=15) or 3 weeks of tachycardia induced cardiomyopathy (TIC, n=14). Eight healthy sheep served as controls (CTL). At terminal procedure, all animals underwent sternotomy, epicardial echocardiography, and implantation of sonomicrometry crystals on the tricuspid annulus (TA) and RV free wall while on cardiopulmonary bypass. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were acquired after weaning from CPB and stabilization. Annular geometry and dynamics were calculated from 3D crystal coordinates.<br /><b>Results</b><br />Mean FTR grade (0-4) was 3.2±1.2 and 3.2±0.5 for PAB and TIC, respectively with both models of FTR associated with similar degree of RV dysfunction (RVFAC 38±7% and 37±9% for PAB and TIC, respectively). LV ejection fraction was significantly reduced in TIC versus baseline (33±9%, vs 58±4%, p=0.0001). TA area was 651±109, 881±242, and 995±232 mm<sup>2</sup> for CTL, FTR, and TIC, respectively (p=0.006) with TA area contraction of 16.6±4.2, 11.5±8.0, and 6.0±4.0%, respectively (p=0.003). Septal annulus increased from 33.8±3.1 to 39.7±6.4 and 43.1±3.2 mm for CTL, PAB, and TIC, respectively (p<0.0001).<br /><b>Conclusion</b><br />Ovine FTR was associated with annular dilation and reduced annular area contraction. Significant dilation of septal annulus was observed in both models of FTR. As tricuspid rings do not completely stabilize the septal annulus, continued remodeling may contribute to recurrent FTR after repair.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 13 Apr 2023; epub ahead of print</small></div>

<div><h4>Threats and Opportunities - Public Reporting in Congenital Heart Surgery.</h4><i>Caldarone CA, Romano JC, Jaquiss RD, Bacha E, Dearani JA, Overman DM</i><br /><AbstractText>Public reporting of outcomes in congenital heart surgery has provided transparency and an important stimulus for improvement. There are, however, unintended consequences of public reporting and associated public ranking which adversely affect quality of care and thereby threaten our patients. This manuscript provides a description of these unintended consequences and proposes some potential solutions to transform unintended consequences into positive incentives which would improve quality of care. The proposed remedies are not expected to be complete solutions - instead, they are put forward to initiate public discourse, elicit new ideas, and hopefully lead us to creative solutions that transform these threats into opportunities.</AbstractText><br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 28 Mar 2023; epub ahead of print</small></div>

<div><h4>Deep Learning for Improved Precision and Reproducibility of Left Ventricular Strain in Echocardiography: A Test-Retest Study.</h4><i>Salte IM, Østvik A, Olaisen SH, Karlsen S, ... Lovstakken L, Grenne B</i><br /><b>Aims</b><br />Assessment of left ventricular (LV) function by echocardiography is hampered by modest test-retest reproducibility. A novel artificial intelligence (AI) method based on deep learning provides fully automated measurements of LV global longitudinal strain (GLS) and may improve the clinical utility of echocardiography by reducing user related variability. The aim of this study was to assess within-patient test-retest reproducibility of LV GLS measured by the novel AI method in repeated echocardiograms recorded by different echocardiographers, and further, to compare the results to manual measurements.<br /><b>Methods and results</b><br />Two test-retest datasets (n=40 and n=32) were obtained at separate centers. Repeated recordings were acquired in immediate succession by two different echocardiographers at each center. For each dataset, four readers measured GLS in both recordings using a semi-automatic method to construct test-retest inter-reader and intra-reader scenarios. Agreement, mean absolute difference and minimal detectable change (MDC) were compared to analyses by AI. In a subset of 10 patients, beat-to-beat variability in three cardiac cycles was assessed by two readers and AI. Test-retest variability was lower with AI compared to inter-reader scenarios (dataset I: MDC 3.7 vs 5.5, mean absolute difference 1.4 vs 2.1; dataset II: MDC 3.9 vs 5.2, mean absolute difference 1.6 vs 1.9, all p<0.05). There was bias in GLS measurements in 13 of 24 test-retest inter-reader scenarios (largest bias 3.2 strain units). In contrast, there was no bias in measurements by AI. Beat-to-beat MDCs were 1,5, 2.1, and 2.3 for AI and the two readers, respectively. Processing time for analyses of GLS by the AI method was 7.9±2.8 seconds.<br /><b>Conclusion</b><br />A fast AI method for automated measurements of LV GLS reduced test-retest variability and removed bias between readers in both test-retest datasets. By improving the precision and reproducibility, AI may increase the clinical utility of echocardiography.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 16 Mar 2023; epub ahead of print</small></div>

<div><h4>Sex Differences in Extensive Mitral Annular Calcification With Associated Mitral Valve Dysfunction.</h4><i>Churchill TW, Yucel E, Bernard S, Namasivayam M, ... Hung J, Bertrand PB</i><br /><AbstractText>Mitral annular calcification (MAC)-related mitral valve (MV) dysfunction is an increasingly recognized entity, which confers a high burden of morbidity and mortality. Although more common among women, there is a paucity of data regarding how the phenotype of MAC and the associated adverse clinical implications may differ between women and men. A total of 3,524 patients with extensive MAC and significant MAC-related MV dysfunction (i.e., transmitral gradient ≥3 mm Hg) were retrospectively analyzed from a large institutional database, with the goal of defining gender differences in clinical and echocardiographic characteristics and the prognostic importance of MAC-related MV dysfunction. We stratified patients into low- (3 to 5 mm Hg), moderate- (5 to 10 mm Hg), and high- (≥10 mm Hg) gradient groups and analyzed the gender differences in phenotype and outcome. The primary outcome was all-cause mortality, assessed using adjusted Cox regression models. Women represented the majority (67%) of subjects, were older (79.3 ± 10.4 vs 75.5 ± 10.9 years, p <0.001) and had a lower burden of cardiovascular co-morbidities than men. Women had higher transmitral gradients (5.7 ± 2.7 vs 5.3 ± 2.6 mm Hg, p <0.001), more concentric hypertrophy (49% vs 33%), and more mitral regurgitation. The median survival was 3.4 years (95% confidence interval 3.0 to 3.6) among women and 3.0 years (95% confidence interval 2.6 to 4.5) among men. The adjusted survival was worse among men, and the prognostic impact of the transmitral gradient did not differ overall by gender. In conclusion, we describe important gender differences among patients with MAC-related MV dysfunction and show worse adjusted survival among men; although, the adverse prognostic impact of the transmitral gradient was similar between men and women.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 05 Mar 2023; 193:83-90</small></div>

<div><h4>Modeling of the Tricuspid Valve and Right Ventricle in Hypoplastic Left Heart Syndrome With a Fontan Circulation.</h4><i>Nam HH, Flynn M, Lasso A, Herz C, ... Fichtinger G, Jolley MA</i><br /><b>Background</b><br />In hypoplastic left heart syndrome, tricuspid regurgitation (TR) is associated with circulatory failure and death. We hypothesized that the tricuspid valve (TV) structure of patients with hypoplastic left heart syndrome with a Fontan circulation and moderate or greater TR differs from those with mild or less TR, and that right ventricle volume is associated with TV structure and dysfunction.<br /><b>Methods</b><br />TV of 100 patients with hypoplastic left heart syndrome and a Fontan circulation were modeled using transthoracic 3-dimensional echocardiograms and custom software in SlicerHeart. Associations of TV structure to TR grade and right ventricle function and volume were investigated. Shape parameterization and analysis was used to calculate the mean shape of the TV leaflets, their principal modes of variation, and to characterize associations of TV leaflet shape to TR.<br /><b>Results</b><br />In univariate modeling, patients with moderate or greater TR had larger TV annular diameters and area, greater annular distance between the anteroseptal commissure and anteroposterior commissure, greater leaflet billow volume, and more laterally directed anterior papillary muscle angles compared to valves with mild or less TR (all <i>P</i><0.001). In multivariate modeling greater total billow volume, lower anterior papillary muscle angle, and greater distance between the anteroposterior commissure and anteroseptal commissure were associated with moderate or greater TR (<i>P</i><0.001, C statistic=0.85). Larger right ventricle volumes were associated with moderate or greater TR (<i>P</i><0.001). TV shape analysis revealed structural features associated with TR, but also highly heterogeneous TV leaflet structure.<br /><b>Conclusions</b><br />Moderate or greater TR in patients with hypoplastic left heart syndrome with a Fontan circulation is associated with greater leaflet billow volume, a more laterally directed anterior papillary muscle angle, and greater annular distance between the anteroseptal commissure and anteroposterior commissure. However, there is significant heterogeneity of structure in the TV leaflets in regurgitant valves. Given this variability, an image-informed patient-specific approach to surgical planning may be needed to achieve optimal outcomes in this vulnerable and challenging population.<br /><br /><br /><br /><small>Circ Cardiovasc Imaging: 03 Mar 2023:e014671; epub ahead of print</small></div>

<div><h4>Giant-Cell Myocarditis, Cardiac Sarcoidosis, and Orthotopic Heart Transplantation.</h4><i>Roberts WC, Hasson L, Hassan MH</i><br /><AbstractText>Described herein are 2 patients diagnosed clinically as \"giant cell myocarditis.\" Both had short clinical courses (∼ 2 months) before lifesaving orthotopic heart transplantation (OHT). Examination of the hearts disclosed multiple widespread yellow lesions in the ventricular walls. The short clinical courses in these 2 patients are quite different from cardiac sarcoidosis, which typically has courses lasting years. In contrast to cardiac sarcoidosis, the ventricular myocardial lesions were yellow in color not white as in cardiac sarcoidosis. In conclusion, we consider giant-cell myocarditis and cardiac sarcoidosis to be different conditions and not simply different stages of the same condition.</AbstractText><br /><br />Copyright © 2022. Published by Elsevier Inc.<br /><br /><small>Am J Cardiol: 01 Mar 2023; 190:131-135</small></div>

<div><h4>TAVR in 2023: Who Should Not Get It?</h4><i>Bhogal S, Rogers T, Aladin A, Ben-Dor I, ... Yakubov SJ, Waksman R</i><br /><AbstractText>Since the first transcatheter delivery of an aortic valve prosthesis was performed by Cribier et al in 2002, the picture of aortic stenosis (AS) therapeutics has changed dramatically. Initiated from an indication of inoperable to high surgical risk, extending to intermediate and low risk, transcatheter aortic valve replacement (TAVR) is now an approved treatment for patients with severe, symptomatic AS across all the risk categories. The current evidence supports TAVR as a frontline therapy for treating severe AS. The crucial question remains concerning the subset of patients who still are not ideal candidates for TAVR because of certain inherent anatomic, nonmodifiable, and procedure-specific factors. Therefore, in this study, we focus on these scenarios and reasons for referring selected patients for surgical aortic valve replacement in 2023.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 27 Feb 2023; 193:1-18</small></div>

<div><h4>Prognostic Impact of Right Ventricular Strain in Isolated Severe Tricuspid Regurgitation.</h4><i>Hinojar R, Zamorano JL, González Gómez A, García-Martin A, ... Sanchez Recalde A, Fernández-Golfín C</i><br /><b>Background</b><br />Right ventricular (RV) systolic function is an established marker of outcomes in patients with severe tricuspid regurgitation (TR). Timely detection of RV dysfunction with conventional 2D echocardiography is challenging. RV strain has emerged as an accurate and sensitive tool for evaluation of RV function with the capability of detecting subclinical RV dysfunction. This study aimed to evaluate the prognostic value of RV strain parameters in early stages of severe TR.<br /><b>Methods</b><br />Consecutive patients with at least (≥) severe TR (severe, massive or torrential TR) and absence of a formal indication for tricuspid valve intervention in secondary TR evaluated in the Heart Valve Clinic were prospectively included. RV systolic function was measured with conventional echocardiographic indices (RV fractional area change [FAC], tricuspid annular plane systolic excursion [TAPSE], DTI S wave [`S]) and with Speckle-tracking echocardiography (STE) derived automatic peak global and free wall longitudinal strain (RV-GLS and RV-FWLS respectively) using an automated 2D strain analytical software. A combined endpoint of hospital admission due to heart failure (HF) or all-cause mortality was defined.<br /><b>Results</b><br />A total of 266 patients were enrolled in the study and 151 were finally included. Strain parameters detected a higher percentage of abnormal RV values compared to conventional indices. During a median follow up of 26 months (IQR: 13-42 months), 35% of the patients reached the combined endpoint. Cumulative event-free survival was significantly worse in patients with impaired RV-GLS and RV-FWLS. Conventional indices of RV systolic function were not associated with outcomes (p>0.05 for all). On multivariate analysis, RV-FWLS was independently associated with mortality and HF (adjusted HR for abnormal RV-FWLS: 5.90 (3.17-10.99), <0.001).<br /><b>Conclusion</b><br />In early stages of severe TR, RV-FWLS is more frequently impaired compared to conventional indices of RV function. Among all parameters, RV-FWLS is the strongest predictor of mortality and HF independently of additional prognostic markers.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 22 Feb 2023; epub ahead of print</small></div>

<div><h4>Analysis of recurrence in lung adenocarcinoma with spread through air spaces.</h4><i>Khalil HA, Shi W, Mazzola E, Lee DN, ... Sholl LM, Swanson SJ</i><br /><b>Objectives</b><br />Spread through air spaces is defined as tumor cells in air spaces away from the edge of tumor in lung carcinoma. It is associated with higher locoregional recurrence and lower survival in lung adenocarcinoma. The features of spread through air spaces portending worse outcomes are still under investigation. We reviewed our lung cancer experience to define potential factors related to spread through air spaces that influence recurrence and survival.<br /><b>Methods</b><br />Between January 2010 and December 2017, we identified 968 patients who underwent resection for T1-3N0M0 lung adenocarcinoma. Of these, histologic examination was possible in 787 patients. We examined the presence of spread through air spaces, spread through air spaces characteristics (micropapillary, solid nest, or single cell), average density (number per slide), and farthest distance from tumor at which spread through air spaces was detected, or maximal spread distance. Overall survival and recurrence-free survival were estimated using Kaplan-Meier curves, and differences between spread through air spaces positive versus spread through air spaces negative groups were assessed using the log-rank test.<br /><b>Results</b><br />Spread through air spaces was present in 389 of 787 of the reviewed cases (49.4%). Overall survival and recurrence-free survival were significantly lower in the spread through air spaces positive group over 10 years (P < .0001). The incidences of locoregional and distant recurrence were nearly doubled over 10 years in the spread through air spaces positive group compared with the spread through air spaces negative group (P = .002 and <.0001, respectively). In a multivariable Cox regression model adjusted for spread through air spaces characteristics, distance, and tumor size, lobar resection did not confer survival advantage in patients with spread through air spaces (hazard ratio of sublobar resection with respect to lobar resection, 1.44; 95% confidence interval, 0.98-2.11; P = .067). In the spread through air spaces positive group, spread through air spaces density was 2.7 ± 1.4 clusters per slide and the maximal spread distance was 2.2 ± 1.7 mm from the tumor edge. There was no observed correlation between spread through air spaces density or maximal spread distance and overall survival or recurrence.<br /><b>Conclusions</b><br />We show increased distant recurrence in spread through air spaces positive lung adenocarcinoma. Quantifiable measures of spread through air spaces do not appear to correlate with recurrence or survival metrics.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 16 Feb 2023; epub ahead of print</small></div>

<div><h4>Genetically engineered sheep: A new paradigm for future preclinical testing of biological heart valves.</h4><i>McGregor CGA, Byrne GW, Fan Z, Davies CJ, Polejaeva IA</i><br /><b>Background</b><br />Heart valve implantation in juvenile sheep to demonstrate biocompatibility and physiologic performance is the accepted model for regulatory approval of new biological heart valves (BHVs). However, this standard model does not detect the immunologic incompatibility between the major xenogeneic antigen, galactose-α-1,3-galactose (Gal), which is present in all current commercial BHVs, and patients who universally produce anti-Gal antibody. This clinical discordance leads to induced anti-Gal antibody in BHV recipients, promoting tissue calcification and premature structural valve degeneration, especially in young patients. The objective of the present study was to develop genetically engineered sheep that, like humans, produce anti-Gal antibody and mirror current clinical immune discordance.<br /><b>Methods</b><br />Guide RNA for CRISPR Cas9 nuclease was transfected into sheep fetal fibroblasts, creating a biallelic frame shift mutation in exon 4 of the ovine α-galactosyltransferase gene (GGTA1). Somatic cell nuclear transfer was performed, and cloned embryos were transferred to synchronized recipients. Cloned offspring were analyzed for expression of Gal antigen and spontaneous production of anti-Gal antibody.<br /><b>Results</b><br />Two of 4 surviving sheep survived long-term. One of the 2 was devoid of the Gal antigen (GalKO) and expressed cytotoxic anti-Gal antibody by age 2 to 3 months, which increased to clinically relevant levels by 6 months.<br /><b>Conclusions</b><br />GalKO sheep represent a new, clinically relevant advanced standard for preclinical testing of BHVs (surgical or transcatheter) by accounting for the first time for human immune responses to residual Gal antigen that persists after current BHV tissue processing. This will identify the consequences of immune disparity preclinically and avoid unexpected past clinical sequelae.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 15 Feb 2023; epub ahead of print</small></div>

<div><h4>Right Ventricular Systolic Dysfunction in Adults With Anatomic Repair of d-Transposition of Great Arteries.</h4><i>Egbe AC, Miranda WR, Stephens EH, Anderson JH, ... Ramachandran D, Connolly HM</i><br /><AbstractText>The purpose of this study was to assess the prevalence of right ventricular (RV) systolic dysfunction in adults with anatomic repair of dextro-transposition of great arteries (d-TGAs), and to determine its relation to clinical outcomes across multiple domains (functional status, peak oxygen consumption, N-terminal pro-brain natriuretic peptide, and heart failure hospitalization). Adults with anatomic repair for d-TGA and with echocardiographic images for strain analysis were divided into 2 groups: (1) d-TGA status after an arterial switch operation (d-TGA-ASO group) and (2) d-TGA status after a Rastelli operation (d-TGA-Rastelli group). RV systolic function was assessed using RV global longitudinal strain (RVGLS), and RV systolic dysfunction was defined as RVGLS >-18%. We identified 151 patients (median age 21 years [19 to 28]; d-TGA-ASO group 89 [59%], and d-TGA-Rastelli group 62 [41%]). The mean RVGLS was -22 ± 4%, and 47 patients (31%) had RV systolic dysfunction. The d-TGA-Rastelli group had lower (less negative) RVGLS than that of the d-TGA-ASO group (-19 ± 3% vs -25 ± 3%, p <0.001) and higher prevalence of RV systolic dysfunction (48% vs 19%, p <0.001). RVGLS (absolute value) was associated with peak oxygen consumption (r = 0.58, p <0.001; adjusted R<sup>2</sup> = 0.28), log-N-terminal pro-brain natriuretic peptide (r = -0.41, p = 0.004; adjusted R<sup>2</sup> = 0.21), New York Heart Association class III/IV (odds ratio 2.29, 1.56 to 3.19, p = 0.01), and heart failure hospitalization (hazard ratio 0.93, 0.88 to 0.98, p = 0.009). RV systolic dysfunction was common in adults with d-TGA and anatomic repair and was associated with clinical outcomes. Longitudinal studies are required to determine the risk factors for progressive RV systolic dysfunction and to identify strategies for preventing RV systolic dysfunction in this population.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 08 Feb 2023; 192:101-108</small></div>

<div><h4>Gender trends in cardiothoracic surgery authorship.</h4><i>Bryan DS, Debarros M, Wang SX, Xie Y, ... Bueno R, Marshall MB</i><br /><b>Objective</b><br />In recent years, the historically low proportion of women cardiothoracic surgeons and trainees has been a subject of intense focus. Publications remain a key metric of academic success and career advancement. We sought to identify trends in the gender of first and last author publications in cardiothoracic surgery.<br /><b>Methods</b><br />We searched for publications between 2011 and 2020 in 2 US cardiothoracic surgery journals, identifying those with Medical Subject Heading publication types of clinical trials, observational studies, meta-analyses, commentary, reviews, and case reports. A commercially available, validated software (Gender-API) was used to associate gender with author names. Association of American Medical Colleges Physician Specialty Data Reports were used to identify concurrent changes in the proportion of active women in cardiothoracic surgery.<br /><b>Results</b><br />We identified 6934 (57.1%) pieces of commentary; 3694 (30.4%) case reports; 1030 (8.5%) reviews, systematic analyses, meta-analyses, or observational studies; and 484 (4%) clinical trials. In total, 15,189 total names were included in analysis. Over the 10-year study period, first authorship by women rose from 8.5% to 16% (0.42% per year, on average), whereas the percentage of active US women cardiothoracic physicians rose from 4.6% to 8% (0.42% per year). Last authorship was generally flat over the decade, going from 8.9% in 2011% to 7.8% in 2020 and on average, increased at just 0.06% per year (P = .79).<br /><b>Conclusions</b><br />Over the past decade, authorship by women has steadily increased, more so at the first author position. Author-volunteered gender identification at the time of manuscript acceptance may be useful to more accurately follow trends in publication.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 03 Feb 2023; epub ahead of print</small></div>

<div><h4>Atrioventricular septal defect in Fontan circulation: Right ventricular dominance, not valve surgery, adversely affects survival.</h4><i>King G, Buratto E, Cordina R, Iyengar A, ... d\'Udekem Y, Konstantinov IE</i><br /><b>Objective</b><br />The effect of ventricular dominance and previous atrioventricular valve (AVV) surgery on patient outcomes after Fontan operation remains unclear. We sought to determine the effect of ventricular dominance and previous AVV surgery on transplantation-free survival and long-term AVV competency in patients with atrioventricular septal defect (AVSD) and Fontan circulation.<br /><b>Methods</b><br />We conducted a retrospective study of 1703 patients in the Australia and New Zealand Fontan Registry, who survived Fontan operation between 1987 and 2021.<br /><b>Results</b><br />Of 174 patients with AVSD, 60% (105/174) had right ventricular (RV) dominance and 40% (69/174) had left ventricular (LV) dominance. The cumulative incidence of moderate or greater AVV regurgitation at 25 years after Fontan operation in patients with LV dominance was 56% (95% CI, 35%-72%), compared with 54% (95% CI, 40%-67%) in patients with RV dominance (P = .6). Nonetheless, transplantation-free survival at 25 years in patients with LV dominance was 94% (95% CI, 86%-100%), compared with 67% (95% CI, 52%-87%) in patients with RV dominance (hazard ratio, 5.9; 95% CI, 1.4-25.4; P < .01). Of note, transplantation-free survival was not different in patients who underwent AVV surgery before or at Fontan completion compared with those who did not (15 years: 81% [95% CI, 62%-100%] vs 88% [95% CI, 81%-95%]; P = .3).<br /><b>Conclusions</b><br />In patients with AVSD and Fontan circulation the rate of moderate or greater common AVV regurgitation is similar in those with LV and RV dominance. RV dominance, rather than previous AVV surgery, is a risk factor for death or transplantation.<br /><br />Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 01 Feb 2023; 165:424-433</small></div>

<div><h4>Substance Use Disorders Are Prevalent in Adults With Congenital Heart Disease and Are Associated With Increased Healthcare Use.</h4><i>Shalen EF, McGrath LB, Bhamidipati CM, Garcia IC, ... Broberg CS, Khan AM</i><br /><AbstractText>Adults with congenital heart disease (CHD) represent a heterogeneous group with significant long-term health risks. Previous studies have demonstrated a high prevalence of psychiatric disorders among adults with CHD; however, little is known about the frequency of co-morbid substance use disorders (SUDs) in patients with CHD. The Oregon All Payer All Claims (APAC) database for the years 2014 to 2017 was queried for adults aged 18 to 65 years with International Classification of Diseases, Ninth or Tenth Revision codes consistent with CHD. Alcohol and substance use were identified by International Classification of Diseases codes for use or dependence and classified in mutually exclusive categories of none, alcohol only, and other drugs (with or without alcohol). Descriptive statistics were used to characterize prevalence and chi-square tests were used to test for associations between variables. A total of 12,366 adults with CHD were identified. The prevalence of substance use was 15.7%. The prevalence of isolated alcohol use was 3.9%. A total of 19% of patients used tobacco. Insurance type, presence of a concurrent mental health diagnosis, and age were associated with substance use, whereas CHD complexity was not. Cardiovascular co-morbidities were more common in patients with reported substance use. Inpatient and emergency care use were higher in those with SUD. In conclusion, this study of substance and alcohol use among adults with CHD demonstrates high rates of co-morbid SUD, particularly among patients with mental health disorders and Medicaid insurance, associated with increased healthcare utilization. We identify a population in need of targeted interventions to improve long-term health.</AbstractText><br /><br />Copyright © 2023 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 27 Jan 2023; 192:24-30</small></div>

<div><h4>Does valve size impact hemodynamic, left ventricular mass regression, and prosthetic valve deterioration with a sutureless aortic valve?</h4><i>Aldea GS, Burke CR, Fischlein T, Heimansohn DA, ... Suri RM, Ad N</i><br /><b>Objective</b><br />To assess the mid-term clinical outcomes, hemodynamics, left ventricular (LV) mass regression, and structural valve deterioration (SVD) in patients implanted with the Perceval aortic sutureless valve across valve sizes.<br /><b>Methods</b><br />Data were obtained from a multicenter European trial and a US Investigational Device Exemption trial. Echocardiography data were analyzed by an echocardiography core lab. A mixed-effects regression model was used to assess relationships between hemodynamic outcomes, time from the procedure, and valve sizes. The Valve Academic Research Consortium (VARC)-3 definition for bioprosthetic valve failure was applied.<br /><b>Results</b><br />A Perceval sutureless valve was implanted in 970 patients. The median patient age was 77.8 years, 57.2% were female, the median Society of Thoracic Surgeons predicated risk of mortality was 3.3% (range, 2.1%-6.2%), and 33.4% had a concomitant procedure. The median clinical follow-up was 45.7 months (range, 28.2-76.1 months). Small and medium valves were implanted more commonly in women than in men (16.9% vs 1.9% for small and 55.1% vs 19.5% for medium; P < .001). The mean aortic valve gradients decreased significantly postimplantation and remained stable across all valve sizes throughout the follow-up period. All patients were free from severe patient-prosthesis mismatch (with an effective orifice area/m<sup>2</sup> of >0.8). Significant LV mass regression was documented regardless valve sizes, plateaued at -9.1% at 5 years. Freedom from SVD and reintervention were 95.2% and 96.3%, respectively, at 5 years and were independent of implanted valve size (P = .22). The VARC-3 stage 3 bioprosthetic valve failure rate was low, 2.8% at 5 years.<br /><b>Conclusions</b><br />The Perceval valve demonstrated low and stable mean gradients, significant LV mass regression, and low SVD and reintervention rates across all valve sizes.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 23 Jan 2023; epub ahead of print</small></div>

<div><h4>Novel Utilization of Ultrasound Enhancing Agents in Complex Congenital Heart Disease Following Superior Cavopulmonary Connection.</h4><i>Chaszczewski KJ, Linder JR, Campbell MJ, Convery M, ... Kozyak BW, Quartermain MD</i><br /><b>Background</b><br />Children with single ventricle congenital heart disease (CHD) typically undergo a superior cavopulmonary connection (SCPC) as the second stage in their surgical palliation. Postoperatively, stenoses of the SCPC and branch pulmonary arteries (PAs) can occur. If there are clinical concerns and echocardiography is insufficient for diagnosis, patients undergo invasive evaluation with exposure to radiation and anesthesia. The use of ultrasound enhancing agents (UEAs) to improve echocardiographic diagnostic capabilities has not previously been described in this population.<br /><b>Methods</b><br />A single center, retrospective case review of children who underwent an echocardiogram with UEA, following SCPC from 3/1/2020 - 4/15/2022 at the Children\'s Hospital of Philadelphia. Twenty-two patients with hypoxemia or concern for obstruction following SCPC underwent UEA echocardiography. Extracted clinical data included patient demographics, echocardiographic images, angiography, surgical and transcatheter intervention as well as available follow-up data.<br /><b>Results</b><br />Six of the 22 UEA echocardiograms demonstrated stenosis or occlusion of either the SCPC or a PA. All six underwent cardiac catheterization - angioplasty was performed in 5 of these 6 patients, while one patient underwent surgical revision. Sixteen of 22 UEA echocardiograms demonstrated no evidence of stenosis. Ten of these 16 improved, while 6 experienced persistent hypoxemia prompting referral for cardiac catheterization. Angiography confirmed the UEA echocardiogram findings (absence of stenosis) in 4 of these 6 patients. There were no adverse reactions related to UEA administration.<br /><b>Conclusions</b><br />Echocardiography with UEAs is a valuable and safe adjunctive imaging modality following SCPC, particularly when 2D and color imaging is limited. This novel application of UEAs in complex CHD patients provides an \"angiogram-like\" image, better delineating vessel walls and improving assessment of postoperative obstruction. As experience with UEAs increases in the CHD population, there may be opportunities to decrease invasive and costly procedures, while expediting the care of patients in need of intervention.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 12 Jan 2023; epub ahead of print</small></div>

<div><h4>Anatomic, stage-based repair of secondary mitral valve disease.</h4><i>Drake DH, Zhang P, Zimmerman KG, Morrow CD, Sidebotham DA</i><br /><b>Objective</b><br />Intervention for repair of secondary mitral valve disease is frequently associated with recurrent regurgitation. We sought to determine if there was sufficient evidence to support inclusion of anatomic indices of leaflet dysfunction in the management of secondary mitral valve disease.<br /><b>Methods</b><br />We performed a systematic review and meta-analysis of published reports comparing anatomic indices of leaflet dysfunction with the complexity of valve repair and the outcome from intervention. Patients were stratified by the severity of leaflet dysfunction. A secondary analysis was performed comparing outcomes when procedural complexity was optimally matched to severity of leaflet dysfunction and when intervention was not matched to dysfunction.<br /><b>Results</b><br />We identified 6864 publications, of which 65 met inclusion criteria. An association between the severity of leaflet dysfunction and the procedural complexity was highly predictive of satisfactory freedom from recurrent regurgitation. Patients were categorized into 4 groups based on stratification of leaflet dysfunction. Satisfactory results were achieved in 93.7% of patients in whom repair complexity was appropriately matched to severity of leaflet dysfunction and in 68.8% in whom repair was not matched to dysfunction (odds ratio, 0.148; 95% confidence interval, 0.119-0.184; P < .0001).<br /><b>Conclusions</b><br />For patients with secondary mitral valve disease, satisfactory outcome from valve repair improves when procedural complexity is matched to anatomic indices of leaflet dysfunction. Anatomic indices of leaflet dysfunction should be considered when planning interventions for secondary mitral regurgitation. Routine inclusion of anatomic indices in trial design and reporting should facilitate comparison of results and strengthen guidelines. There are sufficient data to support anatomic staging of secondary mitral valve disease.<br /><br />Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 11 Jan 2023; epub ahead of print</small></div>

<div><h4>Biventricular Noncompaction Cardiomyopathy in a Patient Presenting With a New Cerebrovascular Event.</h4><i>Madnawat H, Atallah I, Ahmad A, Harjai K</i><br /><AbstractText>Noncompaction (NC) cardiomyopathy (NCCM) is a rare, genetically heterogeneous cardiomyopathy (CM) caused by failure to compact the intertrabecular recesses of the myocardium. This condition usually affects the apical segment of the left ventricle, yet there are noted basal segment, biventricular, and right ventricular predominant cases. NCCM is largely diagnosed in the pediatric population; however, there is increasing recognition in older patients with heart failure and stroke and patients with arrhythmias. Treatment focuses on symptomatic management of heart failure, anticoagulation, and implantable cardiac defibrillators.</AbstractText><br /><br />Copyright © 2022 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 06 Jan 2023; 190:110-112</small></div>

<div><h4>Complications Associated with Transesophageal Echocardiography in Transcatheter Structural Cardiac Interventions.</h4><i>Hasnie A, Parcha V, Hawi R, Trump M, ... Arora P, Arora G</i><br /><b>Background</b><br />Transesophageal echocardiograms (TEEs) performed during transcatheter structural cardiac interventions may have higher complications than those performed in the non-operative setting or even those performed during cardiac surgery. However, there are limited data on complications associated with TEE during these procedures. We evaluated the prevalence of major complications among these patients in the United States (US).<br /><b>Methods</b><br />A retrospective cohort study was conducted using an electronic health record database (TriNetX Research Network) from large academic medical centers across the US for patients undergoing TEE during transcatheter structural interventions from January 2012 to January 2022. Using the American Society of Echocardiography endorsed ICD-10 codes, patients undergoing TEE during a transcatheter structural cardiac intervention, including transaortic, mitral or tricuspid valve repair, left atrial appendage occlusion, atrial septal defect closure, patent foramen ovale closure, and paravalvular leak repair were identified. The primary outcome was major complications within 72 hours of the procedure (composite of bleeding, esophageal and upper respiratory tract injury). The secondary aim was the frequency of major complications, death, or cardiac arrest within 72 hours of patients who completed intraoperative TEE during surgical valve replacement.<br /><b>Results</b><br />Among 12,043 adult patients (mean age: 74 years old, 42% females) undergoing TEE for transcatheter structural cardiac interventions, 429 (3.6%) patients had a major complication. Complication frequency was higher in patients on anticoagulation or antiplatelet therapy compared with those not on therapy (3.9% vs. 0.5%, RR: 8.09, p < 0.001). Compared with those aged <65 years, patients aged ≥ 65 years had a higher frequency of major complications (3.9% vs. 2.2%, RR: 1.75, p < 0.001). Complication frequency was similar among males and females (3.5% vs 3.7%, RR: 0.96, p = 0.67). Among 28,848 patients who completed surgical valve replacement with TEE guidance, 728 (2.5%) suffered a major complication.<br /><b>Conclusions</b><br />This study found that more than 3% of patients undergoing TEE during transcatheter structural cardiac interventions have a major complication which is more common among those on anticoagulant or antiplatelet therapy or who were elderly. With a shift of poor surgical candidates to less invasive percutaneous procedures, the future of TEE-guided procedures relies on comprehensive risk discussion and updating practices beyond conventional methods to minimize risk for TEE-related complications.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 04 Jan 2023; epub ahead of print</small></div>

<div><h4>Adults With Congenital Heart Disease: Trends in Event-Free Survival Past Middle Age.</h4><i>Dellborg M, Giang KW, Eriksson P, Liden H, ... Rosengren A, Mandalenakis Z</i><br /><b>Background</b><br />The survival of children with congenital heart disease has increased substantially over the past decades, with 97% currently reaching adulthood. The total effect of advanced treatment on future mortality and morbidity in adult survivors with congenital heart disease (CHD) is less well described.<br /><b>Methods</b><br />We used data from the Swedish National Inpatient, Outpatient, and Cause of Death Register to identify patients with CHD who were born between 1950 and 1999 and were alive at 18 years of age. Ten controls identified from the Total Population Register were matched for year of birth and sex and with each patient with CHD. Follow-up was from 1968 and 18 years of age until death or at the end of the study (2017). Survival percentage with 95% CI for all-cause mortality were performed with Kaplan-Meier survival function. Cox proportional hazard regression models with hazard ratios (HRs) and 95% CI were used to estimate the risk of all-cause mortality.<br /><b>Results</b><br />We included 37 278 patients with adult CHD (ACHD) and 412 799 controls. Mean follow-up was 19.2 years (±13.6). Altogether, 1937 patients with ACHD (5.2%) and 6690 controls (1.6%) died, a death rate of 2.73 per 1000 person-years and 0.84 per 1000 person years, respectively. Mortality was 3.2 times higher (95% CI, 3.0-3.4; <i>P</i><0.001) among patients with ACHD compared with matched controls. Up to the maximum of 50 years of follow-up, >75% of patients with ACHD were still alive. Mortality was highest among patients with conotruncal defects (HR, 10.13 [95% CI, 8.78-11.69]), but also significantly higher for the more benign lesions, with the lowest risk in patients with atrial septal defects (HR, 1.36 [95% CI, 1.19-1.55]). At least 75% of patients with ACHD alive at 18 years of age lived past middle age and became sexagenerians.<br /><b>Conclusions</b><br />In this large, nationwide, register-based cohort study of patients with ACHD surviving to 18 years of age, the risk of mortality up to 68 years of age was >3 times higher compared with matched controls without ACHD. Despite this, at least 75% of patients with CHD alive at 18 years of age lived past middle age and became sexagenerians. A notable risk decline in the mortality for patients with ACHD was noted for those born after 1975.<br /><br /><br /><br /><small>Circulation: 26 Dec 2022; epub ahead of print</small></div>

<div><h4>Temporary ventricular assist device support with a catheter-based axial pump: Changing the paradigm at a pediatric heart center.</h4><i>Tume SC, Fuentes-Baldemar AA, Anders M, Spinner JA, ... Qureshi AM, Adachi I</i><br /><b>Objective</b><br />We report the largest pediatric single-center experience with an Impella (Abiomed Inc) catheter-based axial pump support.<br /><b>Methods</b><br />We conducted a retrospective cohort study of all patients with acute decompensated heart failure or cardiogenic shock requiring catheter-based axial pump support between October 2014 and February 2022. The primary outcome per individual encounter (hospital admission) was defined as bridge-to-recovery, bridge-to-durable ventricular assist device support, bridge-to-cardiac transplantation, or death at 6 months after catheter-based axial pump explantation. Adverse events were defined according to the Pediatric Interagency Registry for Mechanical Circulatory Support criteria.<br /><b>Results</b><br />Our final study cohort included 37 encounters with 43 catheter-based axial pump implantations. A single catheter-based axial pump device was used for support in 33 encounters (89%), with 2 catheter-based axial pump devices used in 3 (8%) separate encounters and 3 catheter-based axial pump devices used in 1 (3%) encounter. The median [range] age, weight, and body surface area at implantation were 16.8 [6.9-42.8] years, 61.1 [23.1-123.8] kg, and 1.7 [0.8-2.5] m<sup>2</sup>, respectively. The predominant causes of circulatory failure were graft failure/rejection in 16 patients (43%), followed by cardiomyopathy in 7 patients (19%), arrhythmia refractory to medical therapies in 6 patients (16%), myocarditis/endocarditis in 4 patients (11%), and heart failure due to congenital heart disease in 4 patients (11%). Competing outcomes analysis showed a positive outcome with bridge-to-recovery in 58%, bridge-to-durable VAD support in 14%, and bridge-to-cardiac transplantation in 14% at 6 months. Fourteen percent of encounters resulted in death at 6 months.<br /><b>Conclusions</b><br />We demonstrate that catheter-based axial pump support in children results in excellent 1- and 6-month survival with an acceptable adverse event profile.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 24 Dec 2022; epub ahead of print</small></div>

<div><h4>Improving lung cancer diagnosis with cancer, fungal, and imaging biomarkers.</h4><i>Marmor HN, Kammer MN, Deppen SA, Shipe M, ... Chen H, Grogan EL</i><br /><b>Objective</b><br />Indeterminate pulmonary nodules (IPNs) represent a significant diagnostic burden in health care. We aimed to compare a combination clinical prediction model (Mayo Clinic model), fungal (histoplasmosis serology), imaging (computed tomography [CT] radiomics), and cancer (high-sensitivity cytokeratin fraction 21; hsCYFRA 21-1) biomarker approach to a validated prediction model in diagnosing lung cancer.<br /><b>Methods</b><br />A prospective specimen collection, retrospective blinded evaluation study was performed in 3 independent cohorts with 6- to 30-mm IPNs (n = 281). Serum histoplasmosis immunoglobulin G and immunoglobulin M antibodies and hsCYFRA 21-1 levels were measured and a validated CT radiomic score was calculated. Multivariable logistic regression models were estimated with Mayo Clinic model variables, histoplasmosis antibody levels, CT radiomic score, and hsCYFRA 21-1. Diagnostic performance of the combination model was compared with that of the Mayo Clinic model. Bias-corrected clinical net reclassification index (cNRI) was used to estimate the clinical utility of a combination biomarker approach.<br /><b>Results</b><br />A total of 281 patients were included (111 from a histoplasmosis-endemic region). The combination biomarker model including the Mayo Clinic model score, histoplasmosis antibody levels, radiomics, and hsCYFRA 21-1 level showed improved diagnostic accuracy for IPNs compared with the Mayo Clinic model alone with an area under the receiver operating characteristics curve of 0.80 (95% CI, 0.76-0.84) versus 0.72 (95% CI, 0.66-0.78). Use of this combination model correctly reclassified intermediate risk IPNs into low- or high-risk category (cNRI benign = 0.11 and cNRI malignant = 0.16).<br /><b>Conclusions</b><br />The addition of cancer, fungal, and imaging biomarkers improves the diagnostic accuracy for IPNs. Integrating a combination biomarker approach into the diagnostic algorithm of IPNs might decrease unnecessary invasive testing of benign nodules and reduce time to diagnosis for cancer.<br /><br />Copyright © 2023. Published by Elsevier Inc.<br /><br /><small>J Thorac Cardiovasc Surg: 23 Dec 2022; epub ahead of print</small></div>

<div><h4>Characteristics of exercise intolerance in different subgroups of pulmonary arterial hypertension associated with congenital heart disease.</h4><i>Zhang HD, Yan Y, He YY, Liu QQ, ... Yan XX, Han ZY</i><br /><b>Background</b><br />Exercise intolerance is a major manifestation of pulmonary arterial hypertension associated with congenital heart disease (PAH-CHD). We aimed to investigate the characteristics of exercise intolerance in different subgroups of PAH-CHD.<br /><b>Methods</b><br />We retrospectively enrolled 171 adult patients with PAH-CHD and 30 age and sex-matched healthy subjects and performed cardiopulmonary exercise testing. Gas exchange parameters, including peak oxygen uptake (peak V̇o<sub>2</sub>), anaerobic threshold, and the slope of ventilatory equivalent for carbon dioxide (V̇e/V̇co<sub>2</sub> slope), were recorded.<br /><b>Results</b><br />The median age of patients at enrollment was 27.8 years, and 131 (76.6%) were female. Peak V̇o<sub>2</sub> was reduced in patients compared to healthy controls (median, 14.8 ml/kg/min versus 26.9 ml/kg/min, p < 0.001). Of all 171 patients, 60 (35.1%) had Eisenmenger syndrome, 35 (20.5%) had PAH associated with systemic-to-pulmonary shunts (PAH-SP), 39 (22.8%) had PAH with small defects (PAH-SD), and 37 (21.6%) had PAH after cardiac defect correction (PAH-CD). Patients with Eisenmenger syndrome had the lowest peak V̇o<sub>2</sub> (p = 0.003) and the highest V̇e/V̇co<sub>2</sub> slope (p = 0.012), compared with other patients, representing the worst exercise capacity and ventilatory efficiency. Patients with PAH-SP had the best exercise capacity among the four groups, indicated by the highest peak V̇o<sub>2</sub> (p = 0.003) compared with other patients. Peak V̇o<sub>2</sub> was negatively correlated with pulmonary vascular resistance (r = -0.411, p < 0.001).<br /><b>Conclusions</b><br />Exercise capacity was severely reduced in patients with PAH-CHD. Among the four subgroups, patients with Eisenmenger syndrome had the worst exercise capacity and ventilatory efficiency.<br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 21 Dec 2022; epub ahead of print</small></div>

<div><h4>Massively Hypertrophied Right-Sided Heart with Hypoplastic Left-Sided Heart in a Neonate (A Rare Type of Hypertrophic Cardiomyopathy).</h4><i>Roberts WC, Chinta S, Guileyardo JM</i><br /><AbstractText>Described herein is a newborn boy with likely right-sided hypertrophic cardiomyopathy (HC), who survived for 18 hours after birth. At necropsy, he had a severely thickened right ventricular free wall, ventricular septum, right atrial wall and a hypoplastic left-sided heart. There was a large fossa ovale type atrial septal defect and also a patent ductus arteriosus. During peak systole, the right ventricular outflow tract was obstructed, and its contents were pushed into the thick-walled right atrium, then rapidly into the thin-walled left atrium via a large fossa ovale atrial septal defect. The contents were then pushed into the thin-walled left ventricle and finally into the small ascending aorta and into the lungs via a large patent ductus arteriosus. We were unable to find a similar published case.</AbstractText><br /><br />Copyright © 2022. Published by Elsevier Inc.<br /><br /><small>Am J Cardiol: 15 Dec 2022; epub ahead of print</small></div>

<div><h4>Conduction mapping during complex congenital heart surgery: Creating a predictive model of conduction anatomy.</h4><i>Feins EN, O\'Leary ET, Davee J, Gauvreau K, ... Emani S, DeWitt ES</i><br /><b>Objectives</b><br />The study objectives were to report on a growing experience of conduction system mapping during complex congenital heart surgery and create a predictive model of conduction anatomy.<br /><b>Methods</b><br />Patients undergoing complex cardiac repair with conduction mapping were studied. Intraoperative mapping used a multielectrode catheter to collect His bundle electrograms in the open, decompressed, beating heart. Patient anatomy, operative details, His bundle location, and postoperative conduction status were analyzed. By using classification and regression tree analysis, a predictive model of conduction location was created.<br /><b>Results</b><br />A total of 109 patients underwent mapping. Median age and weight were 1.8 years (range, 0.2-14.9) and 10.8 kg (range, 3.5-50.4), respectively. Conduction was identified in 96% (105/109). Median mapping time was 6 minutes (range, 2-33). Anatomy included atrioventricular canal defect, double outlet right ventricle, complex transposition of the great arteries, and multiple ventricular septal defects. By classification and regression tree analysis, ventricular looping and visceroatrial situs were the greatest discriminators of conduction location. A total of 94 of 105 patients (89.5%) were free of complete heart block. Only 1 patient (2.9%) with heterotaxy syndrome developed complete heart block.<br /><b>Conclusions</b><br />The precise anatomic location of the conduction system in patients with complex congenital heart defects can be difficult for the surgeon to accurately predict. Intraoperative conduction mapping enables localization of the His bundle and adds to our understanding of the anatomic factors associated with conduction location. Predictive modeling of conduction anatomy may build on what is already known about the conduction system and help surgeons to better anticipate conduction location preoperatively and intraoperatively.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 13 Dec 2022; epub ahead of print</small></div>

<div><h4>Cardiopulmonary Exercise Testing in Athletes With Hypertrophic Cardiomyopathy.</h4><i>Newman DB, Garmany R, Contreras AM, Bos JM, ... Ommen SR, Ackerman MJ</i><br /><AbstractText>Patients with hypertrophic cardiomyopathy (HCM) have historically been restricted from athletic participation because of the perceived risk of sudden cardiac death. More contemporary research has highlighted the relative safety of competitive athletics with HCM. However, lack of published data on reference values for cardiopulmonary exercise testing (CPET) complicates clinical management and counseling on sports participation in the individual athlete. We conducted a single-center, retrospective cohort study to investigate CPET in athletes with HCM and clinical characteristics associated with objective measures of aerobic capacity. We identified 58 athletes with HCM (74% male, mean age 18 ± 3 years, mean left ventricular (LV) wall thickness 20 ± 7 mm). LV outflow tract obstruction was present in 22 (38%). A total of 15 (26%) athletes were taking a β blocker (BB), but only 4 (7%) reported exertional symptoms. Overall, exercise capacity was mildly reduced, with a peak myocardial oxygen consumption (peak VO<sub>2</sub>) of 37.9 ml/min/kg (83% of predicted peak VO<sub>2</sub>). Both LV outflow tract obstruction and BB use were associated with reduced exercise capacity. Limited peak heart rate was more common in athletes taking BB (47% vs 9%, p = 0.002). At a mean 5.6 years follow-up, 5 patients underwent myectomy (9%), and 8 (14%) received an implantable cardioverter defibrillator (ICD) for primary prevention. One individual with massive LV hypertrophy experienced recurrent ICD shocks for ventricular fibrillation and underwent myectomy 7 years after initial evaluation and was no longer participating in sports. There were no deaths over the follow-up period. In conclusion, the prognostic role of CPET remains unclear in athletes with HCM. Mildly reduced exercise capacity was common; however, reduced peak VO<sub>2</sub> did not correlate with symptom status or clinical outcomes. A significant proportion went on to require myectomy and/or ICD, thus highlighting the need for close follow-up. These data provide some initial insight into the clinical evaluation of \"real world\" athletes with HCM; however, further study is warranted to help guide shared decision-making, return-to-play discussions, and the potential long-term safety of competitive athletic participation.</AbstractText><br /><br />Copyright © 2022 Elsevier Inc. All rights reserved.<br /><br /><small>Am J Cardiol: 09 Dec 2022; 189:49-55</small></div>

<div><h4>Prognostic Value of Left Ventricular Global Longitudinal Strain in Patients With Congenital Heart Disease.</h4><i>Egbe AC, Miranda WR, Anderson JH, Pellikka PA, Connolly HM</i><br /><b>Background</b><br />Left ventricular global longitudinal strain (LVGLS) has been shown to improve risk stratification in patients with LV systolic dysfunction and subsequent recovery of LV ejection fraction (LVEF) in the acquired heart disease population. The purpose of this study was to assess the relationship between LVGLS and cardiovascular events (heart failure hospitalization, sustained ventricular tachycardia/appropriate shock, heart transplant, or cardiovascular death) and deterioration in LVEF (absolute decrease in LVEF ≥10% to LVEF <50%) in adults with congenital heart disease.<br /><b>Methods</b><br />Retrospective cohort study of congenital heart disease patients with previous diagnosis of LV systolic dysfunction (LVEF <50%) and subsequent recovery of LVEF (absolute increase in LVEF of ≥10% to LVEF ≥50%) on subsequent echocardiogram (index echocardiogram). Based on the index echocardiogram, patients were divided into normal LVGLS (absolute LVGLS >18%) versus abnormal LVGLS (absolute LVGLS ≤18%) groups.<br /><b>Results</b><br />Of 193 patients with recovered LVEF, 86 (45%) had normalization of LVGLS at index echocardiogram. A higher absolute LVGLS and use of renin angiotensin aldosterone system antagonist was associated with a lower risk of cardiovascular events and subsequent deterioration in LVEF, while hypertension was associated with higher risk of cardiovascular events and deterioration in LVEF.<br /><b>Conclusions</b><br />These results suggest that patients with congenital heart disease with recovered LVEF remained at risk for adverse outcomes, and LVGLS can be used to identify patients at risk for adverse outcomes. Medical therapy for heart failure and treatment of hypertension may reduce the risk of adverse outcome, but these findings require empirical validation, hence the need for a clinical trial.<br /><br /><br /><br /><small>Circ Cardiovasc Imaging: 07 Dec 2022:e014865; epub ahead of print</small></div>

<div><h4>Long-term survival and center volume for functionally single-ventricle congenital heart disease in England and Wales.</h4><i>Brown KL, Huang Q, Hadjicosta E, Seale AN, ... Franklin R, Ridout D</i><br /><b>Objectives</b><br />Long-term survival is an important metric for health care evaluation, especially in functionally single-ventricle (f-SV) congenital heart disease (CHD). This study\'s aim was to evaluate the relationship between center volume and long-term survival in f-SV CHD within the centralized health care service of England and Wales.<br /><b>Methods</b><br />This was a retrospective cohort study of children born with f-SV CHD between 2000 and 2018, using the national CHD procedure registry, with survival ascertained in 2020.<br /><b>Results</b><br />Of 56,039 patients, 3293 (5.9%) had f-SV CHD. Median age at first intervention was 7 days (interquartile range [IQR], 4, 27), and median follow-up time was 7.6 years (IQR, 1.0, 13.3). The largest diagnostic subcategories were hypoplastic left heart syndrome, 1276 (38.8%); tricuspid atresia, 440 (13.4%); and double-inlet left ventricle, 322 (9.8%). The survival rate at 1 year and 5 years was 76.8% (95% confidence interval [CI], 75.3%-78.2%) and 72.1% (95% CI, 70.6%-73.7%), respectively. The unadjusted hazard ratio for each 5 additional patients with f-SV starting treatment per center per year was 1.04 (95% CI, 1.02-1.06), P < .001. However, after adjustment for significant risk factors (diagnostic subcategory; antenatal diagnosis; younger age, low weight, acquired comorbidity, increased severity of illness at first procedure), the hazard ratio for f-SV center volume was 1.01 (95% CI, 0.99-1.04) P = .28. There was strong evidence that patients with more complex f-SV (hypoplastic left heart syndrome, Norwood pathway) were treated at centers with greater f-SV case volume (P < .001).<br /><b>Conclusions</b><br />After adjustment for case mix, there was no evidence that f-SV center volume was linked to longer-term survival in the centralized health service provided by the 10 children\'s cardiac centers in England and Wales.<br /><br />Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 25 Nov 2022; epub ahead of print</small></div>

<div><h4>Emergency arterial switch: Rescue therapy for life-threatening hypoxemia in infants with transposition of great arteries with intact intraventricular septum.</h4><i>Hussey AD, Gentles TL, Perelini F, Beca J, Finucane K</i><br /><b>Objective</b><br />A small percentage of infants with d-loop transposition of the great arteries with intact intraventricular septum have life-threatening refractory hypoxemia often due to coexistent persistent pulmonary hypertension of the newborn. In this case series we describe the outcomes of a \"rescue\" emergency arterial switch operation (ASO).<br /><b>Methods</b><br />We undertook a retrospective medical record analysis of infants with d-loop transposition of the great arteries with intact intraventricular septum who underwent an ASO in New Zealand from January 1, 1996, to April 30, 2017. Data were compared for those who received an emergency ASO and those with a nonemergency ASO for descriptive purposes. An emergency ASO was defined as one that was undertaken for life-threatening refractory hypoxemia when the only alternative stabilization strategy was preoperative extracorporeal life support. Primary outcome measures were 30-day postoperative mortality and abnormal neurodevelopmental outcome in the survivors. Secondary outcomes were low cardiac output, arrhythmia, renal dysfunction, postoperative seizures, and length of stay. Other known risk factors for morbidity and mortality were also assessed.<br /><b>Results</b><br />Two hundred seventy-two infants underwent an ASO with 25 (9%) who received an emergency ASO. No infants received preoperative extracorporeal life support. The emergency group had greater 30-day postoperative mortality (8.0% vs 0.4%; P = .01) with no difference in abnormal neurodevelopmental outcome among the survivors (17.4% vs 13.8%; P = .35). The emergency group had more therapies for low cardiac output syndrome, more postoperative seizures, and a longer length of stay.<br /><b>Conclusions</b><br />An emergency ASO is a definitive rescue therapy that can be undertaken with acceptable mortality and neurodevelopmental outcome with consideration of the preoperative clinical state.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 22 Nov 2022; epub ahead of print</small></div>

<div><h4>Left atrial structural and functional response in kidney transplant recipients treated with mesenchymal stromal cell therapy and early tacrolimus withdrawal.</h4><i>Meucci MC, Reinders MEJ, Groeneweg KE, Bezstarosti S, ... De Fijter JW, Delgado V</i><br /><b>Background</b><br />Autologous bone marrow derived mesenchymal stromal cell (MSC) therapy and withdrawal of calcineurin inhibitors (CNIs) in kidney transplant patients has shown to improve systemic blood pressure control and left ventricular hypertrophy regression. In the current sub-analysis, we aimed to evaluate the impact of this novel immunosuppressive regimen on the longitudinal changes of LA structure and function after kidney transplantation.<br /><b>Methods</b><br />Kidney transplant recipients randomized to MSC therapy - infused at week 6 and 7 after transplantation, with complete discontinuation at week 8 of tacrolimus (MSC group) - or standard tacrolimus dose (control group) were evaluated with transthoracic echocardiography at week 4 and 24 after kidney transplantation. The changes in echocardiographic parameters were compared between the randomization arms using an analysis of covariance model, adjusted for baseline variable.<br /><b>Results</b><br />54 participants (MSC therapy =27; tacromilus therapy =27) were included. There was no significant interaction between the allocated treatment and the changes of indexed maximal LA volume (LAVImax) over the time. Conversely, between 4 and 24 weeks post-transplantation, an increase in indexed minimal LA volume (LAVImin) was observed in control subjects, while it remained unchanged in the MSC group, leading to a significant difference between groups (p=0.021). Additionally, patients treated with MSC therapy showed a benefit in LA function, assessed by a significant interaction between changes in LA emptying fraction (LAEF) and LA reservoir strain and the randomization arm (p=0.012 and p=0.027, respectively).<br /><b>Conclusion</b><br />The combination of MSC therapy and CNIs withdrawal prevents progressive LA dilation and dysfunction in the first 6 months after kidney transplantation. LAVmin and LA reservoir strain may be more sensitive markers of LA reverse remodelling, as compared to LAVmax.<br /><br />Copyright © 2022. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 05 Nov 2022; epub ahead of print</small></div>

<div><h4>A new FDA approved stent for congenital heart disease: First-in-man experiences with G-ARMOR.</h4><i>Morgan GJ, Zablah J</i><br /><AbstractText>We present the first clinical experience with a new hybrid cell structure covered stent, designed for congenital heart disease applications. It represents a significant redesign of the Cheatham Platinum (CP) Stent (Numed Inc.), maintaining the traditional benefits of the covered CP whilst significantly decreasing shortening and allowing controlled flaring at the ends through its combination of larger and standard sized cells. We first implanted the stent in 2 patients with superior sinus venosus defects with anomalous drainage of the right upper and middle lobe pulmonary veins. The first was a 40 year male and the second a 36 year old female. The third case was a 60 year old patient with near atresia of the aorta, with pre and poststenotic aortic dilation. The clinical result in all cases was excellent with no obstruction to pulmonary venous return and no visible L-R shunt on the transthoracic echo on 24 h and 2 week follow-up for the patient with sinus venosus defects and uniform complete revascularization of the aorta without any vascular complications in the patient with coarctation. These are the first uses of this stent in human subjects. The design is specifically aimed toward procedures where stent shortening is undesirable. Hence, coarctation of the aorta as well as stent implantation in preparation for percutaneous pulmonary valve placement are obvious use areas, as well as the growing body of evidence supporting percutaneous treatment of sinus venosus defects.</AbstractText><br /><br />© 2022 Wiley Periodicals LLC.<br /><br /><small>Catheter Cardiovasc Interv: 02 Nov 2022; epub ahead of print</small></div>

<div><h4>Aortic valve repair using geometric ring annuloplasty in pediatric and congenital heart disease patients.</h4><i>Lancaster TS, Romano JC, Si MS, Ohye RG</i><br /><b>Objective</b><br />Existing replacement options for the aortic valve have significant drawbacks, especially in children. A geometric annuloplasty ring can help to achieve consistently successful aortic valve repair, but only limited experience with use of this device has been reported in pediatric and congenital heart disease patients.<br /><b>Methods</b><br />All pediatric and adult congenital patients at our institution who underwent aortic valve repair with placement of a geometric annuloplasty ring were reviewed. The study period spanned from July 2018 to April 2022. Hemodynamic outcomes were evaluated using transthoracic echocardiography.<br /><b>Results</b><br />The study included 36 subjects. The median age was 17.4 years (range, 8-30 years). Twenty-one subjects were younger than age 18 years. The most common primary diagnoses were neoaortic valve insufficiency or neoaortic root dilation, and congenital aortic stenosis with bicuspid or functionally unicuspid aortic valve. Of the 34 subjects with procedural success, 31 (91%) had use of additional valve repair techniques and 26 (76%) had an additional concomitant procedure performed. Operative mortality was 0% (0/33), and major complication rate was 6% (2/33). The median follow-up time was 1.9 years (maximum, 3.8 years). The mean grade of aortic insufficiency was signific antly reduced after repair, with no change in mean gradients. Freedom from reoperation over the follow-up period was 97% (33/34), and freedom from ≥3+ recurrent aortic insufficiency was 94% (32/34).<br /><b>Conclusions</b><br />A geometric annuloplasty ring can be used to help achieve consistently successful aortic valve repair with excellent perioperative and follow-up outcomes, even in pediatric and complex congenital heart disease patients.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 19 Oct 2022; epub ahead of print</small></div>

<div><h4>Spatio-temporal complexity of vena contracta and mitral regurgitation grading using 3D echocardiographic analysis.</h4><i>Lozano-Edo S, Jover-Pastor P, Osa-Saez A, Buendia-Fuentes F, ... Martinez-Dolz L, Aguero J</i><br /><b>Background</b><br />Spatio-temporal complexity of the color Doppler vena contracta challenging the assumption of a circular and constant orifice may lead to mitral regurgitation (MR) grading inconsistencies. Using 3D transesophageal echocardiography, we characterized spatio-temporal vena contracta complexity and its impact on MR severity grading.<br /><b>Methods</b><br />In 192 patients with suspected moderate or severe MR (100 primary MR, PMR; 92 secondary MR, SMR), we performed 3D vena contracta area (VCA) quantification using single-frame (mid-systolic or VCAmid, maximum or VCAmax) and multiframe (VCAmean) methods, as well as measures of orifice shape (shape index) and systolic variation of VCA. Vena contracta complexity and intermethod discrepancies were analyzed and correlated with functional class and pulmonary vein flow (PVF) patterns, and with cardiac magnetic resonance (CMR) in a subset of cases (n=20).<br /><b>Results</b><br />The vena contracta was non-circular (shape index>1.5) in 90% of patients. Severe non-circularity (shape index > 3) was more prevalent in SMR than in PMR (32.4 vs 14.6%). Variations of the VCA were more prominent in SMR than in PMR. VCAmid showed a low grading agreement with VCAmax (62%) and high with VCAmean (83.3%). PVF systolic reversal was associated with MR severity by VCA in SMR but not in PMR. VCAmid and VCAmean showed a stronger association with systolic flow reversal than VCAmax (AUC 0.88, 0.86 and 0.79, respectively). In the subset of patients with CMR quantification, severe MR by VCAmax was graded as non-severe by CMR more frequently as compared with VCAmid and VCAmean.<br /><b>Conclusions</b><br />Highly prevalent spatio-temporal vena contracta complexity features in MR challenge the assumption of a circular and constant orifice. VCAmid seems the best single-frame approximation to multiframe quantification, and VCAmax may lead to severity overestimation.<br /><br />Copyright © 2022. Published by Elsevier Inc.<br /><br /><small>J Am Soc Echocardiogr: 05 Oct 2022; epub ahead of print</small></div>

<div><h4>A multicenter evaluation of external outflow graft obstruction with a fully magnetically levitated left ventricular assist device.</h4><i>Wert L, Stewart GC, Mehra MR, Milwidsky A, ... Falk V, Potapov EV</i><br /><b>Background</b><br />The HeartMate 3 (HM 3; Abbott) left ventricular assist device (LVAD) has improved hemocompatibility-related adverse outcomes. In sporadic cases, external compression of the outflow graft causing obstruction (eOGO) can result from substance accumulation between the outflow graft and its bend relief. We sought to evaluate the prevalence, course, and clinical implications of eOGO in an international study.<br /><b>Methods</b><br />A multicenter retrospective analysis of HM 3 LVADs implanted between November 2014 and April 2021 (n = 2108) was conducted across 17 cardiac centers in 8 countries. We defined eOGO as obstruction >25% in the cross-sectional area in imaging (percutaneous angiography, computed tomography, or intravascular ultrasound). The prevalence and annual incidence were calculated. Serious adverse events and outcomes (death, transplantation, or device exchange) were analyzed for eOGO cases.<br /><b>Results</b><br />Of 2108 patients, 62 were diagnosed with eOGO at a median LVAD support duration of 953 (interquartile range, 600-1267) days. The prevalence of eOGO was 3.0% and the incidence at 1, 2, 3, 4, and 5 years of support was 0.6%, 2.8%, 4.0%, 5.2%, and 9.1%, respectively. Of 62 patients, 9 were observed, 27 underwent surgical revision, 15 underwent percutaneous stent implantation, 8 received a heart transplant, and 2 died before intervention. One patient underwent surgical revision and later stent implantation. The mortality with therapeutic intervention was 9/53 (17.0%).<br /><b>Conclusions</b><br />Although uncommon, HM 3 LVAD-supported patients might develop eOGO with an increasing incidence after 1 year of support. Although engineering efforts to reduce this complication are under way, clinicians must maintain a focus on early detection and remain vigilant.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 03 Oct 2022; epub ahead of print</small></div>

<div><h4>Implementation of Appropriate Use Criteria for Transthoracic Echocardiography in Follow-Up Care of Pediatric Patients with Congenital Heart Disease.</h4><i>Patel T, Kelleman M, Pickard S, Miller J, Suthar D, Sachdeva R</i><br /><b>Background</b><br />Indications for transthoracic echocardiography (TTE) from the 2020 Appropriate Use Criteria (AUC) for congenital heart disease (CHD) were incorporated into the institutional electronic ordering system as a clinical decision support tool. The purpose of this study was to evaluate the utilization of TTE and factors affecting the appropriateness of orders for TTE during follow-up care of patients with CHD.<br /><b>Methods</b><br />All transthoracic echocardiographic studies performed during follow-up clinic visits from May 1, 2020, to November 30, 2020, were included. Indications for TTE were rated appropriate, may be appropriate, or rarely appropriate on the basis of the AUC and unclassifiable if the indication was not in the document but related to included lesions. CHD was graded as simple, moderate, or complex on the basis of the Bethesda classification. Logistic regression was used to determine the association of ratings with patient age, insurance status, CHD complexity, and clinician experience and specialty.<br /><b>Results</b><br />Of the 5,158 studies, 3,979 (77.2%) were for CHD included in the AUC document, 322 (8%) were unclassifiable, 37 (0.7%) were for CHD not in the document, and 1,142 (22.1%) were for non-CHD indications. Of the 3,657 transthoracic echocardiographic examinations to which AUC ratings could be applied, 95.6% were rated appropriate, 2.4% may be appropriate, and 2.0% rarely appropriate. The highest utilization of TTE was for follow-up of ventricular septal defects, left ventricular outflow tract obstruction, and single ventricles; 46% for unrepaired CHD; 78% for routine surveillance; and the remaining for changes in clinical status. On multivariable analysis, the only significant factor associated with may be appropriate and rarely appropriate ratings was simple CHD (odds ratio, 11.58; 95% CI, 5.36 - 24.98; P < .001).<br /><b>Conclusions</b><br />Three quarters of transthoracic echocardiographic studies ordered during follow-up care in pediatric cardiology clinics are for indications related to CHD. Most examinations for follow-up of CHD were for routine surveillance and indications rated appropriate. Orders for TTE for may be appropriate and rarely appropriate ratings were associated with simple CHD. Although the 2020 AUC document successfully stratifies the majority of indications related to CHD, future documents should consider the unclassifiable CHD indications and the non-CHD indications.<br /><br />Copyright © 2022 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Soc Echocardiogr: 01 Oct 2022; 35:1084-1090.e19</small></div>

<div><h4>22nd Annual Feigenbaum Lecture: Right Heart, Right Now: The Role of Three-Dimensional Echocardiography.</h4><i>Muraru D</i><br /><AbstractText>Three-dimensional echocardiography is the only ultrasound technique that offers the ability to image the complex right heart in its complete dimensionality. Over the years, the benefits of three-dimensional echocardiography to improve our understanding of right heart pathologies and ultimately patients\' care have emerged from numerous publications. The aims of this review article are to highlight the importance of three-dimensional echocardiography for a more accurate evaluation of the right heart structures, to discuss the most important recent developments in the field and highlight future directions and needs.</AbstractText><br /><br />Copyright © 2022 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Soc Echocardiogr: 01 Oct 2022; 35:893-909</small></div>

<div><h4>Mathematical analysis of hemoglobin target in univentricular parallel circulation.</h4><i>Ahmed M, Acosta SI, Hoffman GM, Tweddell JS, Ghanayem NS</i><br /><b>Objective</b><br />The hemoglobin threshold for a decision to transfuse red blood cells in univentricular patients with parallel circulation is unclear. A pediatric expertise initiative put forth a \"weak recommendation\" for avoiding reflexive transfusion beyond a hemoglobin of 9 g/dL. We have created a mathematical model to assess the impact of hemoglobin thresholds in patients with parallel circulation.<br /><b>Methods</b><br />A univentricular circulation was mathematically modeled. We examined the impact on oxygen extraction ratios and systemic and venous oxygen saturations by varying hemoglobin levels, pulmonary to systemic blood flow ratios, and total cardiac output.<br /><b>Results</b><br />Applying a total cardiac index of 6 L/m<sup>2</sup>/min, oxygen consumption of 150 mL/min/m<sup>2</sup>, and a Q<sub>p</sub>/Q<sub>s</sub> ∼ 1, we found a hemoglobin level of 9 g/dL would lead to severe arterial (arterial oxygen saturation <70%) and venous (systemic venous oxygen saturation <40%) hypoxemia. To operate above the critical oxygen economy boundary (systemic venous oxygen saturation ∼40%) and maintain arterial oxygen saturation >70% would require either increasing the cardiac index to ∼ 9 L/m<sup>2</sup>/min or increasing the hemoglobin to greater than 13 g/dL. Further, we found a greater improvement in arterial and venous saturation arises when hemoglobin is augmented from levels below 12 g/dL.<br /><b>Conclusions</b><br />Based on our model, a hemoglobin level of 9 g/dL would require a constricted set of features to sustain arterial saturations >70% and systemic venous saturations >40% and would risk unfavorable oxygen economy with elevations in oxygen consumption. Further prospective clinical studies are needed to delineate the impact of restrictive transfusion practices in univentricular circulation.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 30 Sep 2022; epub ahead of print</small></div>

<div><h4>Aerobic fitness change with time in children with congenital heart disease: A retrospective controlled cohort study.</h4><i>Gavotto A, Ladeveze M, Avesani M, Huguet H, ... Matecki S, Amedro P</i><br /><b>Background</b><br />To evaluate the change in aerobic fitness (VO<sub>2max</sub>), measured by cardio-pulmonary exercise test (CPET), in children with congenital heart disease (CHD), compared to matched healthy controls, and identify predictors of VO<sub>2max</sub> change with time in this specific population.<br /><b>Method</b><br />This longitudinal retrospective multicentre cohort study was carried out from 2010 to 2020. We included CHD paediatric patients from the cohort of a previous cross-sectional study, who had a second CPET at least 1 year after the first one, during their follow-up.<br /><b>Results</b><br />We included 936 children, 296 in the CHD group and 640 controls. Mean time between baseline and final CPET was 4.4 ± 1.7 years. After matching on age and gender and adjustment for age and BMI, the mean VO2<sub>max</sub> group difference was 10.5% ± 1.0% of percent-predict VO<sub>2max</sub> at baseline and increased to 19.1% ± 1.3% at final assessment. In the CHD group, the proportion of children with impaired aerobic fitness was significantly higher at final than at baseline CPET assessment (51.4% vs 20.3%; P < 0.01). The mean annual VO<sub>2max</sub> decrease was significantly worse in the CHD group than in controls (-1.88% ± 0.19% of percent-predict VO<sub>2max</sub>/year vs. -0.44% ± 0.27% of percent-predict VO<sub>2max</sub>/year, P < 0.01, respectively). In multivariate analyse, male gender, a high initial VO<sub>2max</sub>, a high BMI, and the number of cardiac surgical procedures ≥2, were predictors of the VO<sub>2max</sub> decrease with time.<br /><b>Conclusion</b><br />The VO<sub>2max</sub> decrease with time is more pronounced in children with CHD compared to healthy matched controls. This study highlighted the importance of serial CPET assessment in children with CHD. Trial registrationNCT04815577.<br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 28 Sep 2022; epub ahead of print</small></div>

<div><h4>Transbronchial real-time lung tumor localization with folate receptor-targeted near-infrared molecular imaging: A proof of concept study in animal models.</h4><i>Ishiwata T, Hiraishi Y, Bernards N, Sata Y, ... Aragaki M, Yasufuku K</i><br /><b>Objective</b><br />The diagnostic yield of bronchoscopy is not satisfactory, even with recent navigation technologies, especially for tumors located outside of the bronchial lumen. Our objective was to perform a preclinical assessment of folate receptor-targeted near-infrared imaging-guided bronchoscopy to detect peribronchial tumors.<br /><b>Methods</b><br />Pafolacianine, a folate receptor-targeted molecular imaging agent, was used as a near-infrared fluorescent imaging agent. An ultra-thin composite optical fiberscope was used for laser irradiation and fluorescence imaging. Subcutaneous xenografts of KB cells in mice were used as folate receptor-positive tumors. Tumor-to-background ratio was calculated by the fluorescence intensity value of muscle tissues acquired by the ultra-thin composite optical fiberscope system and validated using a separate spectral imaging system. Ex vivo swine lungs into which pafolacianine-laden KB tumors were transplanted at various sites were used as a peribronchial tumor model.<br /><b>Results</b><br />With the in vivo murine model, tumor-to-background ratio observed by ultra-thin composite optical fiberscope peaked at 24 hours after pafolacianine injection (tumor-to-background ratio: 2.56 at 0.05 mg/kg, 2.03 at 0.025 mg/kg). The fluorescence intensity ratios between KB tumors and normal mouse lung parenchyma postmortem were 6.09 at 0.05 mg/kg and 5.08 at 0.025 mg/kg. In the peribronchial tumor model, the ultra-thin composite optical fiberscope system could successfully detect fluorescence from pafolacianine-laden folate receptor-positive tumors with 0.05 mg/kg at the carina and those with 0.025 mg/kg and 0.05 mg/kg in the peripheral airway.<br /><b>Conclusions</b><br />Transbronchial detection of pafolacianine-laden folate receptor-positive tumors by near-infrared imaging was feasible in ex vivo swine lungs. Further in vivo preclinical assessment is needed to confirm the feasibility of this technology.<br /><br />Copyright © 2022 The American Association for Thoracic Surgery. All rights reserved.<br /><br /><small>J Thorac Cardiovasc Surg: 28 Sep 2022; epub ahead of print</small></div>

<div><h4>Metoprolol Improves Left Ventricular Longitudinal Strain at Rest and during Exercise in Obstructive Hypertrophic Cardiomyopathy.</h4><i>Dybro AM, Rasmussen TB, Nielsen RR, Pedersen ALD, ... Jensen MK, Poulsen SH</i><br /><b>Background</b><br />Patients with obstructive hypertrophic cardiomyopathy (HCM) often experience symptoms of heart failure upon exertion despite having normal left ventricular (LV) ejection fractions. Longitudinal strain (LS) may be a more sensitive marker of systolic dysfunction in patients with LV hypertrophy. The aims of this study were to characterize LV segmental LS and global LS (GLS) at rest and during exercise and to assess if first-line treatment with β-blockers improves LV systolic performance.<br /><b>Methods</b><br />Twenty-nine patients with obstructive HCM and New York Heart Association functional class ≥ II symptoms were enrolled in a double-blind, placebo-controlled, randomized crossover trial. Patients received metoprolol 150 mg or placebo for two consecutive 2-week periods in random order. Echocardiographic assessment with speckle-tracking-derived LS was performed at rest and during peak exercise at the end of each treatment period.<br /><b>Results</b><br />During placebo treatment, resting values of segmental LS showed an apical-basal difference of -10.3% (95% CI, -12.7% to -7.8%; P < .0001), with a severely abnormal value of the basal segment of -9.3 ± 4.2%. Treatment with metoprolol was associated with more negative LS values of the apical segment (-2.8%; 95% CI, -4.2% to -1.3%; P < .001) and the mid segment (-1.1%; 95% CI, -2.0% to -0.3%; P = .007). During peak exercise there was a deterioration in LV GLS, but treatment with metoprolol was associated with more negative peak exercise LV GLS (-1.3 %; 95% CI, -2.6% to -0.1%; P = .03).<br /><b>Conclusions</b><br />Systolic performance assessed by LV GLS showed impaired values at rest and during exercise, with severely depressed values of the basal and mid segments. Treatment with metoprolol improved LV GLS upon exercise, indicating a beneficial effect of β-blocker treatment on LV systolic function.<br /><br />Copyright © 2022 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.<br /><br /><small>J Am Soc Echocardiogr: 19 Sep 2022; epub ahead of print</small></div>

<div><h4>Prognostic implications of weight gain and weight loss in adults with congenital heart disease.</h4><i>Egbe AC, Miranda WR, Anderson JH, Connolly HM</i><br /><b>Background</b><br />There are conflicting data about the association between obesity and clinical outcomes in adults with congenital heart disease (CHD), and the effects of weight gain or weight loss remain unclear. The purpose of this study was to determine whether a temporal change in body mass index (BMI) was associated with clinical outcomes independent of baseline BMI in adults with CHD.<br /><b>Methods</b><br />Retrospective cohort study of adults with CHD that had clinical assessments at baseline and 5 years afterwards. Weight gain and weight loss were defined as ≥5% change from baseline BMI. Atherosclerotic cardiovascular disease (ASCVD) risk profile (blood pressure [BP], low density lipoprotein cholesterol [LDL-C] and hemoglobin A1C [HBA1c]) and cardiovascular events (heart failure hospitalization, transplant, death) were ascertained.<br /><b>Results</b><br />Of the 3407, 1804 (53%) had stable weight, 1291 (38%) had weight gain, and 312 (9%) had weight loss at follow-up assessment. The median change in BMI (∆ BMI) was +3% (1-5). The baseline BMI and ∆ BMI were associated with worsening ASCVD risk profile (higher BP, LDL-C and HBA1C), and an increase in cardiovascular events in patients with obesity at baseline.<br /><b>Conclusions</b><br />Collectively, the results provide evidence to support lifestyle interventions aimed at weight maintenance in patients with normal weight, and to promote weight loss in patients that are overweight or obese. Further studies are required to determine the optimal type of lifestyle interventions that will be most effective in this population.<br /><br />Copyright © 2022. Published by Elsevier B.V.<br /><br /><small>Int J Cardiol: 18 Sep 2022; epub ahead of print</small></div>