Impact of waitlist weight change on outcomes in heart transplant recipients: a UNOS database analysis.

BACKGROUND: While the effect of pre-transplant weight on patient outcomes following heart transplantation (HTx) has previously been studied, data regarding the impact of dynamic weight change prior to HTx are extremely limited. OBJECTIVES: We sought to elucidate the interaction between HTx listing weight and weight change while waitlisted, and explore how that interaction impacts post-HTx survival in a continuous manner. METHODS: Adult patients listed for HTx from 1987 to 2020 were identified from UNOS database. Three-dimensional restricted cubic spline analysis explored post-HTx survival relative to both changes in BMI/weight and BMI at time of HTx listing. Continuous predictor variables were analyzed with Cox proportional hazards method. RESULTS: 9,628 included patients underwent HTx. Median recipient age was 55 [IQR 46-62] years, and 21% were females. 53% of patients lost while 47% gained weight on the waitlist. Median BMI (27.6 kg/m2 [24.3-31.3] vs. 27.4 kg/m2 [24.2-30.9], paired p < 0.001) and weight (84.8 kg [73.0-98.0] kg vs. 84.4 kg [72.6-96.6], p < 0.001) were similar at listing and transplant. One-year survival was 89.3%. Weight loss over 3 BMI points or 10 kg was associated with higher hazard of death irrespective of listing BMI. In non-obese patients, some weight gain (1-4 BMI points or 5-15 kg) was associated with improved survival. In cachectic patients (BMI < 18.5), failure to gain weight was associated with worse survival. CONCLUSIONS: Impact of weight change varies depending on listing BMI. While a survival benefit is seen in non-obese patients who gain some weight, significant weight loss is associated with poorer survival.

Preemptive temporary right ventricular assist device implantation for severe biventricular heart failure: A case series.

PURPOSE: We sought to investigate the clinical results of preemptive temporary right ventricular assist device (RVAD) placement with left ventricular assist device (LVAD) implantation for anticipated right ventricular failure. METHODS: Patients at risk for right ventricular failure were identified by the heart team. After median sternotomy, Protekduo (LivaNova, London, UK) dual-stage cannula was inserted from the right internal jugular vein under fluoroscopy guidance, and advanced into the pulmonary artery to the bifurcation of the main pulmonary artery. This was then connected to the venous drainage from the right atrium for cardiopulmonary bypass (CPB). After LVAD implantation, we connected the Protekduo cannula to the RVAD with oxygenator, and weaned CPB. RESULTS: A total of 17 patients have received BiVAD implantation with this technique. The median age of patients was 55 years [Interquartile range (IQR): 51-63.5] and 94% (16/17) patients were male. 63.6% (7/11) of the patients were INTERMACS profile 1 or 2. Preoperatively, the median pulmonary artery pulsatility index was 4.0 [1.5-4.9] and median right ventricular stroke work index was 454.1 g/m/beat/m2 [436.5-530.2]. Postoperatively, the oxygenators were removed on median postoperative day (POD) 3.5 [3 - 5]. Patients received mechanical ventilation for a median of 4 days [1.5-12] and RVADs were explanted on median POD 8 [7-19] at bedside with local anesthesia. Median ICU stay was 15 days [11.4-24]. Perioperative complications included delayed sternal closure [54.5% (6/11)], re-exploration for bleeding [18% (2/11)], acute kidney injury [36% (4/11)], and heparin induced thrombocytopenia [18% (2/11)]. 30-day mortality was 0% (0/11) and 1 year survival was 85.9%. CONCLUSION: Preemptive temporary RVAD implantation strategy for right heart failure post-LVAD showed acceptable clinical outcomes without any 30-day mortality.

Supra-Annular Self-Expanding Versus Balloon-Expandable Valves for Valve-in-Valve Transcatheter Aortic Valve Replacement.

Self-expanding (SE) and balloon-expandable (BE) transcatheter heart valves (THVs) have not been extensively studied in valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). We compared outcomes of supra-annular SE and BE THVs used for ViV-TAVR through a retrospective analysis of institutional data (2013 to 2023) including all patients who underwent ViV-TAVR (TAVR in previous surgical aortic valve replacement). Unmatched and propensity-matched (1:1) comparisons of clinical and echocardiographic outcomes were undertaken in SE and BE THVs along with Kaplan-Meier survival analysis. A total of 315 patients who underwent ViV-TAVR were included, of whom 73% received an SE THV. Median age was 77 years, and women comprised 42.5% of the population. Propensity-score matching (1:1) yielded 81 matched pairs. Implanted aortic valve size was comparable in the groups (23 mm [23 to 26] vs 23 mm [23 to 26], p = 0.457). At 30 days after ViV-TAVR, the SE group had a lower mean aortic valve gradient (14 mm Hg [11 to 18] vs 17.5 mm Hg [13 to 25], p = 0.007). A greater number of patients with BE THV had severe prosthesis-patient mismatch (16% vs 6.2%, p = 0.04). At 1-year follow-up, the SE THV group had a lower aortic valve gradient (14.0 mm Hg [9.6 to 19] vs 17 mm Hg [13 to 25], p = 0.04) than that of the BE THV group; 30-day mortality was 2.7%, whereas 1-year mortality was 7.5% and comparable in the groups. Survival and stroke incidence were similar in the groups up to 5 years. In conclusion, SE and BE THVs had comparable survival after ViV-TAVR. The higher residual aortic valve gradients in BE THVs are likely due to valve design and warrant long-term evaluation for potential structural valve degeneration.

Natural History of Mitral Regurgitation After Transcatheter Aortic Valve Implantation.

BACKGROUND: This study sought to determine the impact of mitral regurgitation (MR) on outcomes after transcatheter aortic valve implantation (TAVI). METHODS: This was an observational study of TAVI for aortic stenosis (AS) from November 2012 to December 2021; 25% of patients were excluded because post-TAVI echocardiograms were unavailable. Excluded patients had a higher Society of Thoracic Surgeons predicted risk of mortality score than included patients (5.6% vs 4.9%). Patients were dichotomized according to the severity of pre-TAVI MR: < moderate vs ≥ moderate. RESULTS: A total of 2250 patients underwent TAVI, of whom 329 (14.6%) had MR ≥ moderate before TAVI. Baseline MR ≥ moderate was associated with reduced survival (46.2% for MR ≥ moderate vs 58.7% for MR < moderate; P < .001) and a higher incidence of heart failure readmission at 5 years after TAVI; 11% of patients had progression or persistence of MR ≥ moderate at 1 year after TAVI, which was also associated with reduced survival. On multivariable logistic regression, increasing age, women, lower ejection fraction, prior acute coronary syndrome, concomitant aortic insufficiency ≥ moderate, low-flow low-gradient AS, pulmonary hypertension, baseline tricuspid regurgitation ≥ moderate, and lower mean pre-TAVI aortic transvalvular pressure gradient were associated with progression or persistence of MR ≥ moderate at 1 year after TAVI, whereas procedural variables and postprocedural complications were not. CONCLUSIONS: Significant MR before and after TAVI was associated with reduced survival. Whereas various clinical variables were associated with significant MR after TAVI, periprocedural variables were not. Evolution of MR must be carefully surveilled after TAVI, and more data are needed to establish guidelines for managing mixed AS and MR.

Six-Year Outcomes of Total Arch Replacement vs Debranching With TEVAR for Aortic Arch Pathologies: Meta-Analysis of Kaplan-Meier-Derived Data From Propensity Score-Matched Studies.

BACKGROUND: Total arch replacement (TAR) and debranching plus thoracic endovascular aortic repair (TEVAR) serve as significant therapeutic options for aortic arch pathologies. It remains unclear whether one of these approaches should be considered preferable. Our study aimed to compare the long-term outcomes of these 2 approaches. METHODS: We carried out a pooled meta-analysis of time-to-event data extracted from studies published by December 2023. Eligibility criteria included populations with any aortic arch pathology who underwent debranching plus TEVAR or TAR, propensity score-matched (PSM) studies (prospective/retrospective; single-center/multicentric), and the outcomes included follow-up for overall survival/mortality and/or reinterventions. RESULTS: Eleven PSM studies met our eligibility criteria, including a total of 1142 patients (571 matched pairs). We did not observe any statistically significant difference in the risk of all-cause death between the groups (hazard ratio [HR]=1.20, 95% confidence interval [CI]=0.91-1.56, p=0.202), but patients who underwent TAR had a significantly lower risk of late aortic reinterventions compared with patients who underwent debranching plus TEVAR (HR=0.38, 95% CI=0.23-0.64, p<0.001). Our meta-regression analyses for all-cause mortality identified statistically significant coefficients for age (coefficient=-0.047; p=0.012) and type A aortic dissections (coefficient=0.012; p=0.010). CONCLUSIONS: Debranching plus TEVAR and TAR demonstrate no statistically significant differences in terms of survival in patients with aortic arch pathologies, but TAR is associated with lower risk of late aortic reinterventions over time. Although older patients may benefit more from debranching plus TEVAR rather than from TAR, patients with dissections may benefit more from TAR. CLINICAL IMPACT: Although the 2 strategies seem to be equally valuable in terms of survival, total aortic arch replacement (when compared with debranching plus TEVAR to treat patients with aortic arch pathologies) is associated with reduction of late aortic reinterventions over time in patients with and without aortic dissections. However, we should consider debranching plus TEVAR in older patients as it is associated with lower risk of death in this population. The novelty of our study lies in the fact that, instead of comparing study-level effect estimates, we analyzed the outcomes with reconstructed time-to-event data. This offered us the opportunity of performing our analyses with a mathematically appropriate model which consider events and time; however, these findings might be under the influence of treatment allocation bias.

Transcatheter Aortic Valve Replacement in Patients With Small Aortic Annuli: A Propensity-Matched Analysis of Gender-Based Outcomes.

Patients with small aortic annuli (SAAs) are predominantly women. We sought to compare gender-based and propensity-matched outcomes of index transcatheter aortic valve replacement (TAVR) in patients with SAAs. In this retrospective institutional analysis (2012 to 2023), primary stratification was by gender. SAA was defined as an aortic valve annulus diameter <23 mm and the 30-day and 1-year outcomes were compared between the groups. A total of 3,911 patients underwent TAVR. Of those, 661 patients had an SAA, of whom 23.8% were men and 76.2% were women. Propensity matching (1:1) identified 152 pairs. The mean age was 81 years. History of surgical or percutaneous coronary intervention was more prevalent in men (72.4% vs 48%, p <0.001). Men had a higher incidence of postoperative pacemaker implantation (8.6% vs 3.3%, p = 0.05), whereas only women had iliofemoral dissections (4.6% vs 0%, p = 0.007). The rates of moderate (23.0% vs 25.7%) and severe (2.6% vs 0.7%) prosthesis-patient mismatch was not statistically significantly different between the groups (p = 0.364). The 30-day mortality was 0%, whereas the 1-year mortality was 4.3%, with no difference between the groups. An increase in preoperative creatinine was associated with higher risk of death (hazard ratio 1.206, 95% confidence interval 1.025 to 1.418, p = 0.02), whereas gender was not. Kaplan-Meier survival estimates (Log rank, p = 0.768) and cumulative incidence of stroke readmission (p = 0.842) were similar in both groups. In conclusion, the outcomes of TAVR in SAAs do not differ by gender, with safety and efficacy evident in men and women.

Comparative Outcomes of Surgical and Transcatheter Aortic Valve Replacement: A Meta-analysis and Parametric Extrapolation of Clinical Trials.

INTRODUCTION: We aimed to pool randomized clinical trials (RCTs) comparing surgical aortic valve replacement (SAVR) with transcatheter aortic valve replacement (TAVR) and extrapolate pooled time-to-event data to compare long-term outcomes. METHODS: An electronic database search was performed for RCTs comparing SAVR with TAVR. The most current longest follow-up data for each RCT were included. Data were pooled using a random-effects model. Survival data were pooled for Kaplan-Meier analysis as well as parametric modeling with extrapolation. RESULTS: Seven RCTs comprising 7774 patients were included. Mean valve gradient at 5 y was comparable between SAVR [11 mmHg (3.7; 18.3)] and TAVR [8.1 mmHg (1.9; 14.3)] (P = 0.38). TAVR had a higher mean valve area at 30 d, 1 y, and 2 y [1.68 cm2 (1.22; 2.13) versus 1.8 cm2 (1.35; 2.25), P = 0.02]. SAVR had a higher freedom from any paravalvular leak at 30 d and 1 y [86% (81; 90) versus 39% (36; 41), P < 0.01]. All-cause death was lower in the SAVR group at 5 y [39% (29; 50) versus 43% (31; 57), P < 0.01]. Although no differences were seen between SAVR and TAVR in the pooled Kaplan-Meier analysis of all-cause mortality and composite of all-cause mortality or stroke, parametric modeling with extrapolation showed significant divergence for both outcomes. CONCLUSIONS: Pooled all-cause mortality as well as pooled composite of all-cause mortality or stroke indicated better survival with SAVR at 5 y. Long-term parametric extrapolation also indicated superior survival with SAVR.

Long-Term Outcomes of Mechanical Versus Bioprosthetic Aortic Valve Replacement in Patients Aged Under 50 Years: Meta-Analysis of Reconstructed Time-to-Event Data.

To compare the long-term outcomes of mechanical versus bioprosthetic aortic valve replacement (AVR) in patients aged <50 years, we performed a study-level meta-analysis with reconstructed time-to-event data including studies published by December of 2023. The primary outcome was overall survival. Secondary outcomes included reoperation, major bleeding, and stroke. A total of 5 studies met our inclusion criteria, with a total of 4,245 patients (2,311 mechanical and 1,934 bioprosthetic). All studies were observational and the mean age of groups across the studies ranged from 38.2 to 43.0 years. The median follow-up time was 11.4 years (interquartile range 6.9 to 15.0). Bioprosthetic AVR was associated with reduced overall survival and higher risk of all-cause death (hazard ratio [HR] 1.170 95% confidence interval [CI] 1.002 to 1.364, p = 0.046), increased risk of reoperation over time (HR 2.581, 95% CI 2.102 to 3.168, p <0.001), decreased risk of major bleeding (HR 0.500, 95% CI 0.367 to 0.682, p <0.001), and decreased risk of stroke (HR 0.751, 95% C, 0.565 to 0.998, p = 0.049) compared with mechanical AVR in patients aged <50 years. In conclusion, for patients aged <50 years, bioprosthetic AVR is associated with increased mortality and risk of reoperation compared with mechanical valves. In contrast, mechanical AVR is associated with an increased risk of major bleeding events and stroke. These aspects should be carefully considered during the selection of valve type in this age group; however, we should keep in mind that the statistically significant differences in the risk of all-cause death and stroke might not be clinically relevant (because of marginal statistical significance).

Age-Based Outcomes After Surgical Aortic Valve Replacement With Bioprosthetic Versus Mechanical Valves.

Recommendations for prosthesis type in older patients who underwent surgical aortic valve replacement (SAVR) are established, albeit undervalidated. The purpose of this study is to compare outcomes after bioprosthetic versus mechanical SAVR across various age groups. This was a retrospective study using an institutional SAVR database. All patients who underwent isolated SAVR were compared across valve types and age strata (<65 years, 65 to 75 years, >75 years). Patients who underwent concomitant operations, aortic root interventions, or previous aortic valve replacement were excluded. Objective survival and aortic valve reinterventions were compared. Kaplan-Meier survival estimation and multivariate regression were performed. A total of 1,847 patients underwent SAVR from 2010 to 2023. A total of 1,452 patients (78.6%) received bioprosthetic valves, whereas 395 (21.4%) received mechanical valves. Of those who received bioprosthetic valves, 349 (24.0%) were aged <65 years, 627 (43.2%) were 65 to 75 years, and 476 (32.8%%) were older than 75 years. For patients who received mechanical valves, 308 (78.0%) were aged <65 years, 84 (21.3%) were between 65 and 75 years, and 3 (0.7%) were >75 years. The median follow-up in the total cohort was 6.2 (2.6 to 8.9) years. No statistically significant differences were observed in early-term Kaplan-Meier survival estimates between SAVR valve types in all age groups. However, the cumulative incidence estimates of aortic valve reintervention were significantly higher in patients aged under 65 years who received bioprosthetic than those who received mechanical valves, with 5-year reintervention rates of 5.8% and 3.1%, respectively (p = 0.002). On competing risk analysis for valve reintervention, bioprosthetic valves were significantly associated with an increased hazard of aortic valve reintervention (hazard ratio 3.35, 95% confidence interval 1.73 to 6.49, p <0.001). In conclusion, SAVR with bioprosthetic valves (particularly, in patients aged <65 years) was comparable in survival to mechanical valve SAVR but significantly associated with increased valve reintervention rates.

Long-Term Outcomes of Tricuspid Valve Replacement With Mechanical Versus Tissue Valves: Meta-Analysis of Reconstructed Time-to-Event Data.

Tricuspid valve replacement (TVR) with mechanical versus tissue valves remains a controversial subject. To evaluate the long-term effects of types of valves on patient-relevant outcomes, we performed a systematic review with meta-analysis of reconstructed time-to-event data of studies published by March 15, 2024 (according to referred the Reporting Items for Systematic Reviews and Meta-analyses guidelines). A total of 21 studies met our eligibility criteria and included 7,166 patients (mechanical: 2,495 patients, 34.8%). Patients who underwent mechanical TVR had a lower risk of death than those who received a tissue valve (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.70 to 0.84, p <0.001). Mechanical TVR was associated with lifetime gain, as evidenced by the restricted mean survival time, which was 2.2 years longer in patients who underwent TVR with mechanical valves (12.4 vs 10.2 years, p <0.001). Our landmark analysis for reoperations revealed the following: from the time point 0 to 7 years, we found no difference in the risk of reoperation between mechanical and tissues valves (HR 0.98, 95% CI 0.60 to 1.61, p = 0.946); however, from the time point 7 years onward, we found that mechanical TVR had a lower risk of reoperation in the follow-up (HR 0.24, 95% CI 0.08 to 0.72, p = 0.001). The meta-regression analysis demonstrated a modulating effect of atrial fibrillation on the association between mechanical valves and mortality; the HRs for all-cause death tended to decrease in the presence of populations with a larger proportion of atrial fibrillation (p = 0.018). In conclusion, our results suggest that TVR with mechanical valves, whenever considered clinically reasonable and accepted by patients as an option, can offer a better long-term survival and lower risk of reoperation in the long run.

Surgeon and Hospital Factors Associated With Outcomes in the New York State Database.

INTRODUCTION: We sought to explore the relationship between various surgeon-related and hospital-level characteristics and clinical outcomes among patients requiring cardiac surgery. METHODS: We searched the New York State Cardiac Data Reporting System for all coronary artery bypass grafting (CABG) and valve cases between 2015 and 2017. The data were analyzed without dichotomization. RESULTS: Among CABG/valve surgeons, case volume was positively correlated with years in practice (P = 0.002) and negatively correlated with risk-adjusted mortality ratio (P = 0.014). For CABG and CABG/valve surgeons, our results showed a negative association between teaching status and case volume (P = 0.002, P = 0.018). Among CABG surgeons, hospital teaching status and presence of cardiothoracic surgery residency were inversely associated with risk-adjusted mortality ratio (P = 0.006, P = 0.029). CONCLUSIONS: There is a complex relationship between case volume, teaching status, and surgical outcomes suggesting that balance between academics and volume is needed.

The Society of Thoracic Surgeons Clinical Practice Guidelines on the Management of Neonates and Infants With Coarctation.

BACKGROUND: Although coarctation of the aorta without concomitant intracardiac pathology is relatively common, there is lack of guidance regarding aspects of its management in neonates and infants. METHODS: A panel of experienced congenital cardiac surgeons, cardiologists, and intensivists was created, and key questions related to the management of isolated coarctation in neonates and infants were formed using the PICO (Patients/Population, Intervention, Comparison/Control, Outcome) Framework. A literature search was then performed for each question. Practice guidelines were developed with classification of recommendation and level of evidence using a modified Delphi method. RESULTS: For neonates and infants with isolated coarctation, surgery is indicated in the absence of obvious surgical contraindications. For patients with risk factors for surgery, medical management before intervention is reasonable. For those stable off prostaglandin E1, the threshold for intervention remains unclear. Thoracotomy is indicated when arch hypoplasia is not present. Sternotomy is preferable when arch hypoplasia is present that cannot be adequately addressed through a thoracotomy. Sternotomy may also be considered in the presence of a bovine aortic arch. Antegrade cerebral perfusion may be reasonable when the repair is performed through a sternotomy. Extended end-to-end, arch advancement, and patch augmentation are all reasonable techniques. CONCLUSIONS: Surgery remains the standard of care for the management of isolated coarctation in neonates and infants. Depending on degree and location, arch hypoplasia may require a sternotomy approach as opposed to a thoracotomy approach. Significant opportunities remain to better delineate management in these patients.

The impact of the OPTN policy change on patients with a durable left ventricular assist device and chronic kidney disease: Analysis of the UNOS database.

BACKGROUND: The Organ Procurement and Transplantation Network (OPTN) implemented modifications in 2018 to the adult heart transplant allocation system to better stratify the most medically urgent transplant candidates. We evaluated the impact of these changes on patients supported by a durable left ventricular assist device (LVAD) with chronic kidney disease (CKD). OBJECTIVE: To evaluate the impact of the OPTN policy change on patients supported by durable left ventricular assist devices (LVAD) with chronic kidney disease (CKD). METHODS: We performed an analysis of patients from the United Network of Organ Sharing Database supported by durable LVAD listed for a heart transplant (HT) between October 17, 2016 and September 30, 2021. Patients were divided into two groups: pre- and postpolicy, depending on whether they were listed on or prior to October 17, 2018. Patients who were on dialysis prior to surgery or discharge were excluded from the analysis. Patients with simultaneous heart and kidney transplants were excluded. Patients who were listed for transplant prepolicy change but transplanted postpolicy change were excluded. This cohort was then subdivided into degrees of CKD based on estimated glomerular filtration rate (eGFR), which resulted in 678 patients (23.7%) in Stage 1 (GFR ≥89.499) (Prepolicy: 345, Postpolicy: 333), 1233 (43.1%) in Stage 2 (89.499 > GFR ≥ 59.499) (Prepolicy: 618, Postpolicy: 615), 613 (21.4%) in Stage 3a (59.499 > GFR ≥ 44.499) (Prepolicy: 291, Postpolicy: 322), 294 (10.3%) in Stage 3b (44.499 > GFR ≥ 29.499) (Prepolicy: 143, Postpolicy: 151), 36 (1.3%) in Stage 4 (29.499 > GFR ≥ 15) (Prepolicy: 21, Postpolicy: 15), and 9 (0.3%) in Stage 5 (15 > GFR) (Prepolicy: 4, Postpolicy: 5). The primary outcome was 1-year and 2-year post-HT survival. RESULTS: There were 2863 patients who met the study criteria (1422 prepolicy, 1441 postpolicy). Overall survival, regardless of CKD stage, was lower following the policy change (p < 0.01). There was a similar risk of primary graft failure (PGF) in the pre- and postpolicy period (1.8% vs. 1.2%, p = 0.26). 1-year overall survival was 93% (91, 94) and 89% (87, 91) in the pre- and postpolicy periods, respectively. 2-year overall survival was 89% (88, 91) and 85% (82, 87) in the pre- and postpolicy periods, respectively. For CKD Stages 1, 2, 3a, 3b, 4, and 5, 1 -year survival was 93% (91, 95), 92% (90,93), 89% (86, 91), 89% (86, 93), 80% (68, 94), and 100% (100, 100), respectively. For CKD Stages 1, 2, 3a, 3b, 4, and 5, 2-year survival was 91% (88, 93), 88% (86, 90), 84% (81, 88), 84% (80, 89), 73% (59, 90), and 100% (100, 100), respectively. Patients with CKD 1 and 2 had better survival compared to those with CKD 3 (p < 0.01) and CKD 4 and 5 (p = 0.03) in the pre- and postpolicy periods. Patients with CKD 3 did not have a survival advantage over those with CKD 4 and 5 (p = 0.25). On cox regression analysis, advancing degrees of CKD were associated with an increased risk of mortality. CONCLUSIONS: Patients with LVAD support had decreased overall survival after the OPTN policy change. Patients with more advanced CKD had lower survival than patients without advanced CKD, though they were not impacted by the OPTN policy change.

External validation of the ARCH score in patients undergoing aortic arch reconstruction under circulatory arrest.

BACKGROUND: Aortic arch surgery with hypothermic circulatory arrest (HCA) carries a higher risk of morbidity and mortality compared to routine cardiac surgical procedures. The newly developed ARCH (arch reconstruction under circulatory arrest with hypothermia) score has not been externally validated. We sought to externally validate this score in our local population. METHODS: All consecutive open aortic arch surgeries with HCA performed between 2014 and 2023 were included. Univariable and multivariable analyses were performed. Model discrimination was assessed by the C-statistic with 95% confidence intervals as part of the receiver operating characteristic (ROC) curve analysis. Model performance was visualized by a calibration plot and quantified by the Brier score. RESULTS: A total of 760 patients (38.3% females) were included. The mean age was 61 (±13.6) years, with 56.4% of patients' age >60 years. The procedures were carried out mostly emergently or urgently (59.6%). Total arch replacement was performed in 32.5% of the patients, and aortic root procedures were carried out in 74.6%. In-hospital death occurred in 64 patients (8.4%), and stroke occurred in 5.4%. The C-statistic revealed a low discriminatory ability for predicting in-hospital mortality (area under the ROC curve, 0.62; 95% confidence interval, 0.54-0.69; P = .002); however, model calibration was found to be excellent (Brier score of 0.07). CONCLUSIONS: The ARCH score for in-hospital mortality showed low discriminatory ability in our local population, although with excellent ability for prediction of mortality.

Characterizing Adaptive Changes and Patient Survival After 2018 Donor Allocation Restructuring: A UNOS Database Analysis.

PURPOSE: We sought to characterize adaptive changes to the revised United Network for Organ Sharing donor heart allocation policy and estimate long-term survival trends for heart transplant (HTx) recipients. METHODS: Patients listed for HTx between October 17, 2013 and September 30, 2021 were identified from the United Network for Organ Sharing database, and stratified into pre- and postpolicy revision groups. Subanalyses were performed to examine trends in device utilization for extracorporeal membranous oxygenation (ECMO), durable left ventricular assist device (LVAD), intra-aortic balloon pump (IABP), microaxial support (Impella), and no mechanical circulatory support (non-MCS). Survival data post-HTx were fitted to parametric distributions and extrapolated to 5 years. RESULTS: We identified 27,523 HTx waitlist candidates during the study period, most of whom (n = 16,376) were waitlisted in the prepolicy change period. Overall, 19,554 patients underwent HTx during the study period (pre: 12,037 and post: 7517). Listings increased after the policy change for ECMO ( P < 0.01), Impella ( P < 0.01), and IABP ( P < 0.01) patients. Listings for LVAD ( P < 0.01) and non-MCS ( P < 0.01) patients decreased. HTx increased for ECMO ( P < 0.01), Impella ( P < 0.01), and IABP ( P < 0.01) patients after the policy change and decreased for LVAD ( P < 0.01) and non-MCS ( P < 0.01) patients. Waitlist survival increased for the overall ( P < 0.01), ECMO ( P < 0.01), IABP ( P < 0.01), and non-MCS ( P < 0.01) groups. Waitlist survival did not differ for the LVAD ( P = 0.8) and Impella ( P = 0.1) groups. Post-transplant survival decreased for the overall ( P < 0.01), LVAD ( P < 0.01), and non-MCS ( P < 0.01) populations. CONCLUSIONS: Allocation policy revisions have contributed to greater utilization of ECMO, Impella, and IABP, decreased utilization of LVADs and non-MCS, increased waitlist survival, and decreased post-HTx survival.

Acute Aortic Dissection After Transcatheter Aortic Valve Replacement.

Acute aortic dissection (AAD) is a rare and potentially fatal complication associated with transcatheter aortic valve replacement (TAVR). Owing to the paucity of existing institutional data, we sought to assess the incidence of postimplant AAD in patients who underwent TAVR at a single institution. All patients who underwent TAVR from 2013 to 2022 were retrospectively reviewed to identify those who possessed clinical or radiologic evidence of AAD after TAVR. Follow-up and survival data were retrieved for all included patients. A total of 4,317 patients underwent TAVR, of whom 9 (0.2%) sustained an AAD. These patients had a mean age of 80 years (range 53 to 92), mean Society of Thoracic Surgeons 30-day mortality risk of 5.7% (2.4% to 16.7%), and mean effective aortic valve area of 0.8 cm2 (0.4 to 1.5 cm2). Preoperative maximum aortic diameter was 3.9 cm (2.6 to 4 cm). Of these 9 patients, 6 (67%) showed evidence of Stanford type A dissection, whereas 3 (33%) were diagnosed with Stanford type B dissection. The most common causes of dissection were posterior annular rupture by the transcatheter valve (THV) (44%) and THV embolization or "pop-out" into the ascending aorta (22%). A total of 6 patients (66.7%), comprising 5 type A (55.6%) and 1 type B (11.1%) aortic dissections, died within 30 days of AAD. The median time to follow-up in those surviving TAVR with intraoperative AAD was 1,042 days (range: 648 to 2,666). Surviving patients were managed through thoracic endovascular aortic repair and medical management. In conclusion, in this highly selected cohort of patients, our experience indicates that AAD after TAVR is a rare but often lethal intraprocedural sequela of THV implantation, especially in cases of type A aortic dissection.

Diffusion Tensor Imaging in Determining Atypical Peripheral Nerve Neuroma in a Patient with a Painless Mass.

Cite this article as: Fikri Ahmad Saad F, Syamim Fathinul Fikri R, Danial Ahmad Shahrir A. Diffusion tensor imaging in determining atypical peripheral nerve neuroma in a patient with a painless mass. Eurasian J Med., Published online May 9, 2024. doi:10.5152/eurasianjmed.2024.23149.

Outcomes of outflow graft stenting in HeartMate 3 left ventricular assist devices: A systematic review and individual patient data meta-analysis.

PURPOSE: LVAD outflow graft stenosis continues to remain prevalent with a high complication rate. We sought to pool the existing evidence on indications, utilization patterns, and outcomes of transcatheter interventions for outflow graft stenosis in the HeartMate 3 LVAD. METHODS: An electronic search was performed to identify all studies in the English literature reporting on HeartMate 3 LVAD outflow graft stenting. Patient-level data were extracted for analysis. RESULTS: Thirteen published reports and one unpublished case comprising a total of 28 patients were included. Median patient age was 68.5 years [Interquartile range: 58, 71] and 25.9% (7/27) were female. Dyspnea [60.7% (17/28)] was the most common presenting symptom. Low flow alarms were present in 60% (15/25) of patients. Findings included external compression [35.7% (10/28)], graft twist [21.4% (6/28)], graft twist and external compression [14.3% (4.28)], intraluminal thrombus [10.7% (3/28)], graft twist and intraluminal thrombus [3.6% (1/28)], and pseudoaneurysm of outflow graft [3.6% (1/28)]. Median time from LVAD implantation to stenting was 2.1 years [1.4, 3]. Immediate flow normalization after stenting was observed in 85.7% (24/28). The 30-day mortality was 12% (3/25). Overall mortality was 12% (3/25) at a median follow-up of 3.9 months [1, 17]. CONCLUSION: Outflow graft stenting in the HeartMate 3 LVAD appears to be a reasonable treatment option for outflow graft stenosis, with low overall rates of complications and mortality. Further refinement of indications and approaches may improve outcomes.

Sided Stimulation of Endothelial Cells Modulates Neutrophil Trafficking in an In Vitro Sepsis Model.

While the role of dysregulated polymorphonuclear leukocyte (PMN) transmigration in septic mediated tissue damage is well documented, strategies to mitigate aberrant transmigration across endothelium have yet to yield viable therapeutics. Recently, microphysiological systems (MPS) have emerged as novel in vitro mimetics that facilitate the development of human models of disease. With this advancement, aspects of endothelial physiology that are difficult to assess with other models can be directly probed. In this study, the role of endothelial cell (EC) apicobasal polarity on leukocyte trafficking response is evaluated with the µSiM-MVM (microphysiological system enabled by a silicon membrane - microvascular mimetic). Here, ECs are stimulated either apically or basally with a cytokine cocktail to model a septic-like challenge before introducing healthy donor PMNs into the device. Basally oriented stimulation generated a stronger PMN transmigratory response versus apical stimulation. Importantly, healthy PMNs are unable to migrate towards a bacterial peptide chemoattractant when ECs are apically stimulated, which mimics the attenuated PMN chemotaxis seen in sepsis. Escalating the apical inflammatory stimulus by a factor of five is necessary to elicit high PMN transmigration levels across endothelium. These results demonstrate that EC apicobasal polarity modulates PMN transmigratory behavior and provides insight into the mechanisms underlying sepsis.

Microaxial mechanical circulatory support after orthotopic heart transplantation.

AIM: Use of microaxial mechanical circulatory support (MCS) has been reported for severe graft rejection or dysfunction after heart transplantation (HTx). We aimed to assess utilization patterns of microaxial MCS after HTx in adolescents (ages 18 and younger) and adults (ages 19 and older). METHODS: Electronic search was performed to identify all relevant studies on post-HTx use of microaxial support in adults and adolescents. A total of 18 studies were selected and patient-level data were extracted for statistical analysis. RESULTS: All patients (n=23), including adults (n=15) and adolescents (n=8), underwent Impella (Abiomed, Danvers, MA) microaxial MCS after HTx. Median age was 36 [IQR 18-56] years (Adults, 52 [37-59]; adolescents, 16 [15-17]). Primary right ventricular graft dysfunction was an indication exclusively seen in the adults 40% (6/15), while acute graft rejection was present in 46.7% (7/15) of adults. Median time after transplant was 9 [0-32] months (Adults, 4 [0-32]; adolescents, 11 [4.5, 45]). Duration of Impella support was comparable between adults and adolescents (5 [2.5-8] vs 6 [5-8] days, p = 0.38). Overall improvement was observed both in median LV ejection fraction (23.5% [11.3-28] to 42% [37.8-47.3], p < 0.01) and cardiac index (1.8 [1.2-2.6] to 3 [2.5-3.1], p < 0.01). Retransplantation was required in four adolescents (50%, 4/8). Survival to discharge was achieved by 60.0% (9/15) of adults and 87.5% (7/8) of adolescents respectively (p = 0.37). CONCLUSION: Indications for microaxial MCS appear to vary between adult and adolescent patients. Overall improvement in LVEF and cardiac index was observed, however, with suboptimal survival to discharge.