Beware of an anomalous left circumflex artery when considering aortic valve or root procedures.

Anomalous coronary arteries pose an additional challenge when contemplating surgical options for a patient with aortic valve or root pathology. We demonstrate the course of an anomalous retro-aortic left circumflex coronary artery arising from the right coronary sinus in a patient with an aortic root and ascending aortic aneurysm with severe aortic regurgitation who underwent ascending aorta and aortic valve replacements.

Type A aortic dissection in the East and West: A comparative study between two hospitals from China and the US.

BACKGROUND: In this study, we compare the clinical characteristics, intraoperative management, and postoperative outcomes of patients with acute type A aortic dissection (ATAAD) between two academic medical hospitals in the United States and China. METHODS: From January 2011 to December 2017, 641 and 150 patients from Nanjing Drum Tower Hospital (NDTH) and Massachusetts General Hospital (MGH) were enrolled. Patient demographics, clinical features, surgical techniques, and postoperative outcomes were compared. RESULTS: The annual number of patients presenting with ATAAD at MGH remained relatively stable, while the number at NDTH increased significantly over the study period. The average age was 51 years at NDTH and 61 years at MGH (P < .001). The percentage of patients with known hypertension at the two centers was similar. The time interval from onset of symptoms to diagnosis was significantly longer at NDTH than MGH (11 vs 3.5 hours; P < .001). Associated complications at presentation were more common at NDTH than MGH. More than 90% of patients (91% NDTH and 92% MGH) underwent surgery. The postoperative stroke rate was higher at MGH (12% vs 4%; P < .001); however, the 30-day mortality rate was lower (7% vs 16%; P = .006). CONCLUSIONS: There was a significant increase in the number of ATAAD at NDTH during the study period while the number at MGH remained stable. Hypertension was a common major risk factor; however, the onset of ATAAD at NDTH was nearly one decade earlier than MGH. Chinese patients tended to have more complicated preoperative pathophysiology at presentation and underwent more extensive surgical repair.

Myocardial Revascularization Trials.

This article reviews the context and evidence of recent myocardial revascularization trials that compared percutaneous coronary intervention with coronary artery bypass grafting for the treatment of left main and multivessel coronary artery disease. We develop the rationale that some of the knowledge synthesis resulting from these trials, particularly with regard to the claimed noninferiority of percutaneous coronary intervention beyond nondiabetic patients with low anatomic complexity, may have been affected by trial design, patient selection based on suitability for percutaneous coronary intervention, and end point optimization favoring percutaneous coronary intervention over coronary artery bypass grafting. We provide recommendations that include holding a circumspect interpretation of the currently available evidence, as well as suggestions for the collaborative design and conduct of future clinical trials in this and other fields.

Treatment of thoracoabdominal aortic disease in patients with connective tissue disorders.

OBJECTIVE: Aneurysmal degeneration of the entire aorta is common in patients with connective tissue disorders (CTDs). Potential treatment options of these aneurysms include open repair and endovascular repair. Our objective herein was to review available evidence for different approaches to treatment of thoracoabdominal aortic disease in patients with CTDs. METHODS: We performed a systematic literature review using PubMed and referenced manuscripts on open and endovascular treatment of thoracoabdominal aortic aneurysms and dissections in patients with CTDs. RESULTS: A total of 28 studies were identified for inclusion in this review, 8 reporting on outcomes after open thoracoabdominal aortic aneurysm repair in patients with CTD, 8 on open branched graft use, and 12 on endovascular aortic repair in this population of patients. Reported outcomes were characterized by low perioperative morbidity and mortality, good branch patency, and low rate of reintervention for open repair and significant rates of endograft-related complications and substantial need for secondary endovascular interventions and open conversions for endovascular repair. CONCLUSIONS: There is a lack of high-quality evidence to support any particular approach to aortic repair in patients with CTD and a dearth of comparative data between open repair and endovascular repair. There are distinct differences in the published lengths of follow-up between the two repair approaches as well as in the prevalence of their use in an acute vs elective setting. It is evident that endovascular interventions for aortic disease in patients with CTDs are associated with many device- and aorta-related complications both in the short term and in the long term. Despite the lack of level 1 evidence, open repair currently remains the standard approach to treatment of aortic disease due to CTDs. Open branched graft repair in particular is the preferred technique. Endovascular interventions may be cautiously used in patients with CTDs in selective circumstances.

Perioperative management of a redo aortic root replacement in a patient with severe factor XI deficiency.

Factor XI deficiency is associated with significant bleeding in the setting of trauma and surgery. We present a patient with FXI deficiency and multiple red blood cell allo-antibodies requiring repeat aortic root replacement and discuss the perioperative management of patients with FXI deficiency undergoing cardiac surgery.

Pseudoaneurysm formation after valve sparing root replacement in children with Loeys-Dietz syndrome.

BACKGROUND: Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder predisposing patients to aneurysm formation and arterial dissection. Aortic root replacement is often performed prophylactically and valve-sparing root replacement (VSRR) has become the procedure of choice. However, in these patients with connective tissue disorders, postoperative pseudoaneurysms may develop. METHODS: All children with LDS undergoing VSRR at a single institution were retrospectively reviewed to identify patients who developed postoperative pseudoaneurysms. RESULTS: Thirty-one children with LDS underwent VSRR; four of these developed pseudoaneurysms of their synthetic aortic root grafts requiring reoperation. These four children were reviewed to investigate the cause of pseudoaneurysm formation after VSRR. Each had severe subtypes of LDS. Each underwent reoperation for repair of their pseudoaneurysms and were found to have suffered pseudoaneurysms as a result of tearing of sutures from their reimplantation VSRR. CONCLUSIONS: Pseudoaneurysms following aortic root replacement with VSRR can occur in children with severe subtypes of LDS. Long-term surveillance is required to detect these potentially life-threatening lesions.

A Novel Risk Score to Predict New Onset Atrial Fibrillation in Patients Undergoing Isolated Coronary Artery Bypass Grafting.

BACKGROUND: Atrial fibrillation (AF) is common after cardiac surgery and contributes to increased morbidity and mortality. Our objective was to derive and validate a predictive model for AF after CABG in patients, incorporating novel echocardiographic and laboratory values. METHODS: We retrospectively reviewed patients at our institution without preexisting dysrhythmia who underwent on-pump, isolated CABG from 2011-2015. The primary outcome was new onset AF lasting >1 hour on continuous telemetry or requiring medical treatment. Patients with a preoperative echocardiographic measurement of left atrial diameter were included in a risk model, and were randomly divided into derivation (80%) and validation (20%) cohorts. The predictors of AF after CABG (PAFAC) score was derived from a multivariable logistic regression model by multiplying the adjusted odds ratios of significant risk factors (P < .05) by a factor of 4 to derive an integer point system. RESULTS: 1307 patients underwent isolated CABG, including 762/1307 patients with a preoperative left atrial diameter measurement. 209/762 patients (27%) developed new onset AF including 165/611 (27%) in the derivation cohort. We identified four risk factors independently associated with postoperative AF which comprised the PAFAC score: age > 60 years (5 points), White race (5 points), baseline GFR < 90 mL/min (4 points) and left atrial diameter > 4.5 cm (4 points). Scores ranged from 0-18. The PAFAC score was then applied to the validation cohort and predicted incidence of AF strongly correlated with observed incidence (r = 0.92). CONCLUSION: The PAFAC score is easy to calculate and can be used upon ICU admission to reliably identify patients at high risk of developing AF after isolated CABG.

Valve-Sparing Aortic Root Replacement in Pediatric Patients: Lessons Learned Over Two Decades.

Valve-sparing aortic root replacement has been utilized in children with aneurysms of the proximal aorta as a valid alternative to composite mechanical or biologic prostheses. While the majority of pediatric patients with aortic root aneurysms have various forms of connective tissue disorders, other diagnostic groups have emerged, such as patients with various forms of congenital heart disease and non-syndromic thoracic aortic aneurysms. We present our experience with valve-sparing procedures in pediatric patients, highlighting the technical aspects of the operation as well as some of the pitfalls and complications we have encountered over the last two decades.

Management of sickle cell disease in patients undergoing cardiac surgery.

Sickle cell disease is a life-limiting inherited hemoglobinopathy that poses inherent risk for surgical complications following cardiac operations. In this review, we discuss preoperative considerations, intraoperative decision-making, and postoperative strategies to optimize the care of a patient with sickle cell disease undergoing cardiac surgery.

Do early postoperative CT findings following type A aortic dissection repair predict early clinical outcome?

PURPOSE: The purposes of this study are to determine the prevalence of specific postoperative CT findings following Stanford type A aortic dissection repair in the early postoperative period and to determine if these postoperative findings are predictive of adverse clinical outcome. METHODS: Patients who underwent type A dissection repair between January 2012 and December 2014 were identified from our institutional cardiac surgery database. Postoperative CT exams within 1 month of surgery were retrospectively reviewed to determine sizes and attenuation of mediastinal, pericardial, and pleural fluid, and the presence or absence of pneumomediastinum, pneumothorax, or lung consolidation. Poor early clinical outcome was defined as length of stay (LOS) > 14 days. Student's t test and chi-square test were used to determine the relationship between postoperative CT features and early clinical outcome. RESULTS: Thirty-nine patients (24 M, 15 F, mean age 58.5 ± 13.7 years) underwent type A dissection repair and mean LOS was 17.3 ± 21.2 days. A subset of 19 patients underwent postoperative CTs within 30 days of surgery, and there was no significant relationship between LOS and sizes and attenuation of mediastinal, pericardial, and pleural fluid, and the presence or absence of pneumomediastinum, pneumothorax, or lung consolidation. CONCLUSIONS: CT features such as mediastinal, pericardial, and pleural fluid were ubiquitous in the early postoperative period. There was no consistent CT feature or threshold that could reliably differentiate between "normal postoperative findings" and early postoperative complications.

Blood Pressure Deviations From Optimal Mean Arterial Pressure During Cardiac Surgery Measured With a Novel Monitor of Cerebral Blood Flow and Risk for Perioperative Delirium: A Pilot Study.

OBJECTIVE: The aim of this study was to evaluate whether excursions of blood pressure from the optimal mean arterial pressure during and after cardiac surgery are associated with postoperative delirium identified using a structured examination. DESIGN: Prospective, observational study. SETTING: University hospital. PARTICIPANTS: The study included 110 patients undergoing cardiac surgery. INTERVENTIONS: Patients were monitored using ultrasound-tagged near-infrared spectroscopy to assess optimal mean arterial pressure by cerebral blood flow autoregulation monitoring during cardiopulmonary bypass and the first 3 hours in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: The patients were tested preoperatively and on postoperative days 1 to 3 with the Confusion Assessment Method or Confusion Assessment Method for the Intensive Care Unit, the Delirium Rating Scale-Revised-98, and the Mini Mental State Examination. Summative presence of delirium on postoperative days 1 through 3, as defined by the consensus panel following Diagnostic and Statistical Manual of Mental Disorders-IV-TR criteria, was the primary outcome. Delirium occurred in 47 (42.7%) patients. There were no differences in blood pressure excursions above and below optimal mean arterial pressure between patients with and without summative presence of delirium. Secondary analysis showed blood pressure excursions above the optimal mean arterial pressure to be higher in patients with delirium (mean±SD, 33.2±26.51 mmHgxh v 23.4±16.13 mmHgxh; p = 0.031) and positively correlated with the Delirium Rating Scale score on postoperative day 2 (r = 0.27, p = 0.011). CONCLUSIONS: Summative presence of delirium was not associated with perioperative blood pressure excursions; but on secondary exploratory analysis, excursions above the optimal mean arterial pressure were associated with the incidence and severity of delirium on postoperative day 2.

Predictors of Late-Onset Atrial Fibrillation Following Isolated Mitral Valve Repairs in Patients With Preserved Ejection Fraction.

BACKGROUND: We sought to determine the incidence of and risk factors for late-onset atrial fibrillation (LOAF) in patients with preserved ejection fractions undergoing mitral valve repair METHODS: We included patients undergoing isolated mitral valve repair (MVR) for degenerative disease between 1997-2014 at our institution with EF ≥60%. Patients who had AF preoperatively were excluded from the final analysis. Our primary outcome, LOAF, was defined as AF occurring after discharge following MVR (≥9 days). RESULTS: 223 patients were included in the study with a mean follow-up of 4.8 ± 4.6 years. A total of 25 patients developed LOAF, and freedom from LOAF was 93.9% at one year, and 87.3% at five years. Patients developing LOAF were of similar mean age (58 vs. 63 years in controls, p = 0.08) and had similar preoperative comorbidities, but did show a trend toward larger left atrial diameter (5.1 vs. 4.7 cm, p = 0.11). After risk adjustment with Cox regression analysis, only increasing left atrial size was associated with LOAF (HR 1.63, p = 0.04). On follow-up, 29 patients (10.8%) developed moderate or greater mitral regurgitation at a mean of 2.2 years. Using a mixed-effects model, we were unable to detect an association between recurrent mitral regurgitation following MVR and LOAF (OR 1.36, p = 0.42). CONCLUSIONS: LOAF occurs in about 13% of preserved ejection fraction patients undergoing MVR by five years. Increasing left atrial diameter is an independent predictor of LOAF. Concomitant anti-arrhythmic procedures may warrant further investigation in patients with preserved ejection fraction and enlarged left atria undergoing MVR. doi: 10.1111/jocs.12774 (J Card Surg 2016;31:486-492).

SCAI/AATS/ACC/STS operator and institutional requirements for transcatheter valve repair and replacement, Part III: Pulmonic valve.

With the evolution of transcatheter valve replacement, an important opportunity has arisen for cardiologists and surgeons to collaborate in identifying the criteria for performing these procedures. Therefore, The Society for Cardiovascular Angiography and Interventions (SCAI), American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), and The Society of Thoracic Surgeons (STS) have partnered to provide recommendations for institutions to assess their potential for instituting and/or maintaining a transcatheter valve program. This article concerns transcatheter pulmonic valve replacement (tPVR). tPVR procedures are in their infancy with few reports available on which to base an expert consensus statement. Therefore, many of these recommendations are based on expert consensus and the few reports available. As the procedures evolve, technology advances, experience grows, and more data accumulate, there will certainly be a need to update this consensus statement. The writing committee and participating societies believe that the recommendations in this report serve as appropriate requisites. In some ways, these recommendations apply to institutions more than to individuals. There is a strong consensus that these new valve therapies are best performed using a Heart Team approach; thus, these credentialing criteria should be applied at the institutional level. Partnering societies used the ACC's policy on relationships with industry (RWI) and other entities to author this document (http://www.acc.org/guidelines/about-guidelines-and-clinical-documents). To avoid actual, potential, or perceived conflicts of interest due to industry relationships or personal interests, all members of the writing committee, as well as peer reviewers of the document, were asked to disclose all current healthcare-related relationships including those existing 12 months before the initiation of the writing effort. A committee of interventional cardiologists and surgeons was formed to include a majority of members with no relevant RWI and to be led by an interventional cardiology cochair and a surgical cochair with no relevant RWI. Authors with relevant RWI were not permitted to draft or vote on text or recommendations pertaining to their RWI. RWI were reviewed on all conference calls and updated as changes occurred. Author and peer reviewer RWI pertinent to this document are disclosed in the Appendices. In addition, to ensure complete transparency, authors' comprehensive disclosure information (including RWI not pertinent to this document) is available in Appendix AII. The work of the writing committee was supported exclusively by the partnering societies without commercial support. SCAI, AATS, ACC, and STS believe that adherence to these recommendations will maximize the chances that these therapies will become a successful part of the armamentarium for treating valvular heart disease in the United States. In addition, these recommendations will hopefully facilitate optimum quality during the delivery of this therapy, which will be important to the development and successful implementation of future, less invasive approaches to structural heart disease.

Cerebral Autoregulation Monitoring with Ultrasound-Tagged Near-Infrared Spectroscopy in Cardiac Surgery Patients.

BACKGROUND: Individualizing mean arterial blood pressure (MAP) based on cerebral blood flow (CBF) autoregulation monitoring during cardiopulmonary bypass (CPB) holds promise as a strategy to optimize organ perfusion. The purpose of this study was to evaluate the accuracy of cerebral autoregulation monitoring using microcirculatory flow measured with innovative ultrasound-tagged near-infrared spectroscopy (UT-NIRS) noninvasive technology compared with transcranial Doppler (TCD). METHODS: Sixty-four patients undergoing CPB were monitored with TCD and UT-NIRS (CerOx™). The mean velocity index (Mx) was calculated as a moving, linear correlation coefficient between slow waves of TCD-measured CBF velocity and MAP. The cerebral flow velocity index (CFVx) was calculated as a similar coefficient between slow waves of cerebral flow index measured using UT-NIRS and MAP. When MAP is outside the autoregulation range, Mx is progressively more positive. Optimal blood pressure was defined as the MAP with the lowest Mx and CFVx. The right- and left-sided optimal MAP values were averaged to define the individual optimal MAP and were the variables used for analysis. RESULTS: The Mx for the left side was 0.31 ± 0.17 and for the right side was 0.32 ± 0.17. The mean CFVx for the left side was 0.33 ± 0.19 and for the right side was 0.35 ± 0.19. Time-averaged Mx and CFVx during CPB had a statistically significant "among-subject" correlation (r = 0.39; 95% confidence interval [CI], 0.22-0.53; P < 0.001) but had only a modest agreement within subjects (bias 0.03 ± 0.20; 95% prediction interval for the difference between Mx and CFVx, -0.37 to 0.42). The MAP with the lowest Mx and CFVx ("optimal blood pressure") was correlated (r = 0.71; 95% CI, 0.56-0.81; P < 0.0001) and was in modest within-subject agreement (bias -2.85 ± 8.54; 95% limits of agreement for MAP predicted by Mx and CFVx, -19.60 to 13.89). Coherence between ipsilateral middle CBF velocity and cerebral flow index values averaged 0.61 ± 0.07 (95% CI, 0.59-0.63). CONCLUSIONS: There was a statistically significant correlation and agreement between CBF autoregulation monitored by CerOx compared with TCD-based Mx.

Cohort comparison of thoracic endovascular aortic repair with open thoracic aortic repair using modern end-organ preservation strategies.

BACKGROUND: Pivotal trials showed that thoracic endovascular aortic repair (TEVAR) has improved outcomes compared with open surgery for treating descending thoracic aortic aneurysms. However, those trials included historical open controls in which modern end-organ preservation strategies were not routinely employed. To create a more level assessment, we compared our outcomes of elective TEVAR with modern open thoracic aortic repair (OTAR) controls. METHODS: A retrospective review of thoracic aortic aneurysm patients undergoing TEVAR was compared with a contemporaneous cohort of OTAR patients. Partial bypass or hypothermic circulatory arrest was used in all OTAR patients. Cerebrospinal fluid drain placement was attempted in all patients. Preoperative characteristics, operative variables, and outcomes were recorded, and the Kaplan-Meier method was used for survival estimates. RESULTS: The main outcome was mortality. Secondary outcomes included postoperative spinal cord ischemia (SCI) or stroke, and any persistent neurologic deficit 30 days following the operation. During the study period, 62 patients underwent TEVAR and 56 underwent OTAR with median follow-up of 23.7 months and 36.4 months, respectively. No difference existed between the TEVAR and OTAR with respect to overall neurologic complications (8.1% vs. 12.5%, P = 0.55) as well as any residual neurologic deficit at 30 days (0% vs. 5.4%, P = 0.10). TEVAR patients had fewer complications including pneumonia (P = 0.02), rebleeding (P = 0.02), and acute kidney injury (P = 0.001). There was no difference in 30-day mortality (1.6% vs. 8.9%, P = 0.10), 1-year mortality (12.2% vs. 14%, P = 0.80), or 5-year mortality (53.9% vs. 44%, P = 0.48) between TEVAR and OTAR, respectively. CONCLUSIONS: TEVAR continues to show improved perioperative outcomes with a trend toward decreased 30-day mortality and fewer major adverse events compared with OTAR. However, with the routine use of end-organ preservation strategies during OTAR, neurologic deficits, particularly SCI, can be safely reduced to comparable levels with those of TEVAR and 1-year all-cause mortality rates are similar between the groups. These OTAR results may serve as a benchmark as TEVAR is increasingly applied for other aortic pathologies, such as chronic dissection, wherein long-term efficacy is not proven.

A syndrome of altered cardiovascular, craniofacial, neurocognitive and skeletal development caused by mutations in TGFBR1 or TGFBR2.

We report heterozygous mutations in the genes encoding either type I or type II transforming growth factor beta receptor in ten families with a newly described human phenotype that includes widespread perturbations in cardiovascular, craniofacial, neurocognitive and skeletal development. Despite evidence that receptors derived from selected mutated alleles cannot support TGFbeta signal propagation, cells derived from individuals heterozygous with respect to these mutations did not show altered kinetics of the acute phase response to administered ligand. Furthermore, tissues derived from affected individuals showed increased expression of both collagen and connective tissue growth factor, as well as nuclear enrichment of phosphorylated Smad2, indicative of increased TGFbeta signaling. These data definitively implicate perturbation of TGFbeta signaling in many common human phenotypes, including craniosynostosis, cleft palate, arterial aneurysms, congenital heart disease and mental retardation, and suggest that comprehensive mechanistic insight will require consideration of both primary and compensatory events.

Valve-Sparing Aortic Root Replacement State of the Art Review Part II: Surgical Techniques.

Aortic valve disease is common and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement (VSRR) has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long term results vary based on underlying anatomy, pathology, and patient selection, and surgeon expertise. The purpose of Part II of this VSRR State of the Art Review article is to provide technical pearls related to VSRR.

Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part I: Anatomy and Physiology.

Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long-term results vary based on the underlying anatomy, pathology, and patient selection, as well as surgeon expertise. The first installment of this Valve-Sparing Aortic Root Replacement State-of-the-Art Review article addresses patient anatomy and physiology as it relates to candidacy for VSRR.

MDCT evaluation of aortic root surgical complications.

OBJECTIVE: CT is the primary imaging modality used after aortic root repair. Distinction of normal findings from postoperative complications is imperative and requires optimization of acquisition parameters and interpretation with advanced postprocessing tools. CONCLUSION: After aortic root surgery, findings can be categorized as complications within the aorta, complications outside the aorta, and benign postoperative changes. Distinction of normal findings from postoperative complications requires proper CT technique and an understanding of CT findings that require intervention.

Valve surgery for infective endocarditis is associated with high hospital charges.

BACKGROUND AND AIM OF THE STUDY: Half of all patients with infective endocarditis (IE) will require early surgical intervention, and another 40% will eventually undergo surgical treatment for their disease. Although the surgical management of IE is effective, the financial impact of the disease has never been assessed. METHODS: All patients who underwent valve surgery for native valve IE at the present authors' institution over a 10-year period (1996-2006) were reviewed retrospectively. Hospital charges were identified and adjusted to reflect US$ in 2006. A logistic regression analysis was performed to identify factors affecting charges and the patients' length of stay (LOS). RESULTS: A total of 369 patients (252 males, 117 females; mean age 53 +/- 15 years) underwent surgery for IE. Of these patients, 121 (33%) had preoperative renal failure and 70 (20%) were intravenous drug users. In addition, 159 patients (43%) had aortic IE, 112 (30%) had mitral IE, and 45 (12%) had both aortic and mitral valve IE. Right- and left-sided IE was identified in 42 patients (11%), and 11 (3%) had isolated right-sided IE. The median hospital charges were US$ 60,072 (interquartile range (IQR) US$ 39,386-103,960), with a median LOS of 15 days (IQR 9-29 days). Both, hospital charges and LOS were higher for patients undergoing emergent operations, or those with active IE (p < 0.001). The 30-day mortality was 2.7%. Regression analyses showed preoperative renal failure (p = 0.007), intraoperative transfusion (p = 0.028) and postoperative gastrointestinal complications (p < 0.001), renal failure (p = 0.012), heart block (p < 0.001), in-hospital mortality (p < 0.001), and patients undergoing emergent procedures (p < 0.001), or with active infection (p < 0.001) to be associated with significantly increased hospital charges. Factors that significantly affected LOS were other non-white race (p = 0.039), postoperative gastrointestinal complications (p = 0.001), stroke (p = 0.014), heart block (p < 0.001), and patients undergoing emergent procedures (p < 0.001) or with active infection (p < 0.001). CONCLUSION: The present series was among the largest to include patients with IE, and the first in which risk factors were assessed for increased hospital charges and resource utilization following surgery for endocarditis. Operations for IE are associated with a significant financial burden to the healthcare system, despite a relatively low percentage of complications. Patients with significant preoperative comorbidities, those with postoperative complications, and those who underwent emergent procedures or who had active IE, were associated with a prolonged LOS and increased hospital charges.