History of Psychoactive Medication a Risk Factor for Neurocognitive Decline After Cardiac Surgery.

INTRODUCTION: Neurocognitive decline (NCD) is a common complication after cardiac surgery with implications for outcomes and quality of life. Identifying risk factors can help surgeons implement preventative measures, optimize modifiable risk factors, and counsel patients about risk and prognosis. METHODS: Prospective cohort study at a single academic center. 104 patients planned to undergo cardiac surgery were enrolled. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was used to measure neurocognitive function preoperatively, on postoperative day four, and postoperative day 30. NCD is defined as a change in RBANS scaled score of < -8 from baseline to postoperative day 4. Patient charts were reviewed for medication history: beta-blockers, angiotensin-converting enzyme and angiotensin receptor blockers, calcium channel blockers, statins, oral hypoglycemic agents, and psychoactive medications. Charts were also reviewed to calculate postoperative opioid usage. RESULTS: NCD was detected in 42.9% of patients. Incidence of NCD was significantly higher in patients taking a psychoactive medication (56.8%) than patients not (31.9%), P < 0.03. There was no relationship between historical use of beta-blocker, calcium-channel blocker, statin, or oral hypoglycemic medications and incidence of NCD. Simple linear regression showed no relationship between change in RBANS total scaled score and opioid usage. There was no difference in incidence of NCD at 1 mo. CONCLUSIONS: Patients with a history of taking psychoactive medications prior to cardiac surgery have an increased risk of acute postoperative NCD.

Association Between Marijuana Use and Clinical Outcomes After Coronary Artery Bypass Grafting.

INTRODUCTION: Though marijuana use has been linked to an increase in heart failure admissions, no prior study has explored the association between its use and outcomes after coronary artery bypass grafting (CABG). This study examines the relationship between marijuana use and postoperative outcomes in CABG patients. METHODS: We utilized data from the National Inpatient Sample database from 2008 to 2018 for CABG patients ≥18 y old. Patients were divided into two groups based on marijuana use (abuse/dependency versus nonuse). Primary outcomes include in-hospital mortality, favorable discharge, and length of stay (LOS). Secondary outcomes include acute kidney injury (AKI), acute myocardial infarction (AMI), and transient ischemic attack (TIA)/stroke. A multivariable model, adjusted for confounding variables, was utilized for each outcome. RESULTS: A total of 343,796 patients met inclusion criteria for the study, 590 of which were marijuana users. In both marijuana user and nonuser groups, most patients were male and White with an average age of 56.0 and 66.3 y, respectively. There was a nonsignificant decreased odds of in-hospital mortality among marijuana users (odds ratio [OR] = 0.41, [0.141-1.124]). Marijuana users exhibited significantly decreased odds of home discharge (OR = 1.50, [1.24-1.81]), and increased odds of longer LOS (mean 10.4 d versus 9.8 d; OR = 1.14, [1.09-1.20]), AKI (OR = 1.40, [1.11-1.78]), AMI (OR = 1.56, [1.32-1.84]), and TIA/stroke (OR = 1.64, [1.21-2.22]). CONCLUSIONS: Marijuana use and dependency are associated with increased nonhome discharge, AKI, AMI, TIA/stroke, and longer LOS. Further studies are needed to delineate the pathophysiologic derangements that contribute to these unfavorable post-CABG outcomes.

Increased Coronary Contraction to Thromboxane A2 in Cardiac Surgery Patients With Poorly Controlled Hypertension.

INTRODUCTION: Cardioplegia and cardiopulmonary bypass (CP/CPB) alters coronary arteriolar response to thromboxane A2 (TXA2) in patients undergoing cardiac surgery. Comorbidities, including hypertension (HTN), can further alter coronary vasomotor tone. This study investigates the effects of HTN on coronary arteriolar response to TXA2 pre and post-CP/CPB and cardiac surgery. MATERIALS AND METHODS: Coronary arterioles pre and post-CP/CPB were dissected from atrial tissue samples in patients with no HTN (NH, n = 9), well-controlled HTN (WC, n = 12), or uncontrolled HTN (UC, n = 12). In-vitro coronary microvascular reactivity was examined in the presence of TXA2 analog U46619 (10-9-10-4M). Protein expression of TXA2 receptor in the harvested right atrial tissue samples were measured by immunoblotting. RESULTS: TXA2 analog U46619 induced dose-dependent contractile responses of coronary arterioles in all groups. Pre-CPB contractile responses to U46619 were significantly increased in microvessels in the UC group compared to the NH group (P < 0.05). The pre-CP/CPB contractile responses of coronary arterioles were significantly diminished post-CP/CPB among the three groups (P < 0.05), but there remained an increased contractile response in the microvessels of the UC group compared to the WC and NH groups (P < 0.05). There were no significant differences in U46619-induced vasomotor tone between patients in the NH and WC groups (P > 0.05). There were no differences in expression of TXA2R among groups. CONCLUSIONS: Poorly controlled HTN is associated with increased contractile response of coronary arterioles to TXA2. This alteration may contribute to worsened recovery of coronary microvascular function in patients with poorly controlled HTN after CP/CPB and cardiac surgery.

Prosthetic valve endocarditis after transcatheter aortic valve replacement in low-risk patients.

OBJECTIVES: We sought to report details of the incidence, organisms, clinical course, and outcomes of prosthetic valve endocarditis (PVE) after transcatheter aortic valve replacement (TAVR) in low-risk patients. BACKGROUND: PVE remains a rare but devastating complication of aortic valve replacement. Data regarding PVE after TAVR in low-risk patients are lacking. METHODS: We performed a detailed review of all patients in the low-risk TAVR trials who underwent TAVR from 2016 to 2020 and were adjudicated to have definitive PVE by the independent Clinical Events Committee. RESULTS: We analyzed 396 low-risk patients who underwent TAVR (including 72 with bicuspid valves). PVE occurred in 11 patients at a median 379 days (210, 528) from TAVR. The incidence within the first 30 days was 0%; days 31-365, 1.5%; and after day 365, 2.8%. The most common organism identified was Streptococcus (n = 4/11). Early PVE (≤ 365 days) occurred in five patients, of whom three demonstrated evidence of embolic stroke and two underwent surgical aortic valve re-intervention. Late PVE (> 365 days) occurred in six patients, of whom thee demonstrated evidence of embolic stroke and only one underwent surgical aortic valve re-intervention. Of the six patients with evidence of embolic stroke, two died, two were discharged to rehabilitation, and two were discharged home with home care. CONCLUSIONS: PVE was infrequent following TAVR in low-risk patients but was associated with substantial morbidity and mortality. Embolic stroke complicated the majority of PVE cases, contributing to worse outcomes in these patients. Efforts must be undertaken to minimize PVE in TAVR.

Glycemic control is not associated with neurocognitive decline after cardiac surgery.

BACKGROUND: Whether perioperative glycemic control is associated with neurocognitive decline (NCD) after cardiac surgery was examined. METHODS: Thirty patients undergoing cardiac surgery utilizing cardiopulmonary bypass (CPB) were screened for NCD preoperatively and on postoperative day 4 (POD4). Indices of glucose control were examined. Serum cytokine levels were measured and human transcriptome analysis was performed on blood samples. Neurocognitive data are presented as a change from baseline to POD4 in a score standardized with respect to age and gender. RESULTS: A decline in neurocognitive function was identified in 73% (22/30) of patients on POD4. There was no difference in neurocognitive function between patients with elevated HbA1c levels preoperatively (p = .973) or elevated fasting blood glucose levels the morning of surgery (>126 mg/dl, p = .910), or a higher maximum blood glucose levels during CPB (>180 mg/dl, p = .252), or higher average glucose levels during CPB (>160 mg/dl, p = .639). Patients with postoperative leukocytosis (WBC ≥ 10.5) had more NCD when compared to their baseline function (p = .03). Patients with elevated IL-8 levels at 6 h postoperatively had a significant decline in NCD at POD4 (p = .04). Human transcriptome analysis demonstrated unique and differential patterns of gene expression in patients depending on the presence of DM and NCD. CONCLUSIONS: Perioperative glycemic control does not have an effect on NCD soon after cardiac surgery. The profile of gene expression was altered in patients with NCD with or without diabetes.

Transcatheter aortic valve replacement in low-risk patients: 2-year results from the LRT trial.

BACKGROUND: Previous studies from the Low Risk TAVR (LRT) trial demonstrated that transcatheter aortic valve replacement (TAVR) is safe and feasible in low-risk patients, with excellent 30-day and 1-year outcomes. The objective of this study was to report clinical outcomes and the impact of 30-day hypoattenuated leaflet thickening (HALT) on structural valve deterioration (SVD) 2 years after TAVR. METHODS: The LRT trial was the first Food and Drug Administration-approved Investigational Device Exemption trial in the United States to evaluate the safety and feasibility of TAVR in low-risk patients with symptomatic severe tricuspid aortic stenosis (AS). Valve hemodynamics and SVD by echo were recorded 30 days, 1 year, and 2 years post-TAVR. RESULTS: The LRT trial enrolled 200 low-risk patients to receive TAVR. Their mean age was 73.6 years and 61.5% were men. At 2-year follow-up, the mortality rate was 4.2%; the cardiovascular death rate was 1.6%. The disabling stroke rate was 1.1%, permanent pacemaker implantation rate was 8.6%, and 4 patients (2.2%) presented with endocarditis (2 between years 1 and 2). Of the 14% of TAVR subjects who had evidence of HALT at 30 days, there was no impact on valve hemodynamics, endocarditis or stroke at 2 years. CONCLUSIONS: TAVR for low-risk patients with symptomatic severe tricuspid AS is safe at 2 years. The presence of HALT at 30 days did not impact the early hemodynamic improvements nor the durability of the valve structure.

Medical malpractice in heart transplantation from 1994 to 2019.

BACKGROUND: Heart transplantation is a unique clinical intervention because it involves two separate parties, the donor and the recipient. This increases the potential for the legal liability of heart teams involved with heart transplantation, but there is no research that exists to date that analyzes the etiology of medical malpractice litigations relating to heart transplantation. METHODS: The Westlaw legal database was queried for all medical malpractice litigations concerning heart transplantation from 1994 to 2019 in the United States. Individual litigations were reviewed for inclusion, resulting in 41 included cases, and then analyzed for legal and clinical data. Statistical analyses were performed with the Fisher exact test and Mann-Whitney U tests. RESULTS: The mean age of patients involved in these litigations was 38.88 years, with female patients being younger on average. Female patients received a significantly larger average award than male counterparts (p = .03). Alleged failure to diagnose was significantly associated with settlements (p = .047). An alleged failure to obtain informed consent as presented by the plaintiff was significantly associated with defendant verdicts (p = .03). Incidence of stroke and infection were each significantly associated with nondefendant verdicts (p = .02 and p = .02). CONCLUSIONS: There should be an emphasis on documenting informed consent from all involved parties in heart transplantation to limit litigations filed against clinicians. As technologies and growing donor pools increase the prevalence of heart transplantation, clinicians would be well-served to be aware of legally tenable practices that will allow them to adopt a higher transplant volume without simultaneously adopting added legal exposure.

Seasonality of postoperative pneumonia after coronary artery bypass grafting: A national inpatient sample study.

BACKGROUND: The development of postoperative pneumonia following cardiac surgery is associated with significant morbidity and mortality. However, seasonal variation as a risk factor for the development of postoperative pneumonia remains to be investigated. We sought to investigate whether patients undergoing coronary artery bypass grafting (CABG) during "flu season" (Fall and Winter months) at increased risk of postoperative pneumonia. MATERIALS AND METHODS: A retrospective cohort study of patients undergoing CABG in the National Inpatient Sample between 2005 and 2015 was completed. Concomitant diagnosis of pneumonia was defined as the primary outcome. Secondary outcomes were defined to include pneumonia secondary to several known pathogens. Outcomes with significant differences between Fall/Winter and Spring/Summer groups were further analyzed with additive time series decomposition. Odds ratios were generated and adjusted for age, sex, elective status, and 29 other Agency for Healthcare Research and Quality comorbidity measures. RESULTS: A total of 238 757 and 277 941 patients undergoing CABG during Fall/Winter and Spring/Summer, respectively, were identified. A significantly increased risk of postoperative pneumonia (adjusted odds ratio [aOR] = 1.15) and infection with influenza (aOR = 4.08), Haemophilus influenzae (aOR = 1.40), and Streptococcus pneumoniae (aOR = 1.47) was observed among patients receiving CABG in Q1 (January-March) compared to Q3 (July-September). CONCLUSIONS: There is a strong seasonality in the incidence of postoperative pneumonia after CABG which may persist across other cardiothoracic surgeries. In addition to optimizing infection control and perioperative care, cardiac surgeons should consider preoperative vaccination against seasonal influenza, H. influenzae, and S. pneumoniae to improve outcomes among high-risk patients.

Utilization of Left Ventricular Assist Devices in Vulnerable Adults Across Medicaid Expansion.

BACKGROUND: Continuous-flow left ventricular assist device (LVAD) implantation is a payor sensitive procedure influenced by preoperative comorbidities and social factors. Whether expansion in insurance coverage will further influence device utilization is unknown. This study sought to assess the effects of Medicaid expansion on vulnerable populations (namely racial-ethnic minorities and those with low-income status) undergoing continuous-flow LVAD implantation after the enactment of the 2014 Affordable Care Act (ACA). METHODS: Data from the 2012 to Q3 2015 State Inpatient Database were used to examine a cohort of 624 nonelderly adults (aged 18-64 y) who were given a continuous-flow LVAD in three expansion states (Kentucky, New Jersey, and Maryland) and two nonexpansion states (North Carolina and Florida). The cohort excluded patients who had a heart transplant, heart-lung transplant, or noncontinuous-flow LVAD. Poisson Interrupted Time Series was used with three-way interactions and change of slope and intercept parameters at 2014 to determine the impact of the ACA expansion on utilization of continuous-flow LVAD by race and insurance strata. RESULTS: Poisson Interrupted Time Series models show that within expansion states, the population of Medicaid and uninsured patients saw an increase in the utilization of LVAD's immediately after ACA expansion, from 2.8 in Q4 2013 to 9.83 Q1 2014 (incidence rate ratio [IRR] 5.26, P = 0.02). Utilization eventually declined to pre-ACA levels, however, ending with 3.04 LVADs in Q3 2015 (IRR 0.84, 95% confidence interval 0.58-1.20). Models testing for racial effect showed no statistically preferential or disparate effects (immediate effect IRR 1.608, P = 0.506; marginal effect IRR 0.897, P = 0.512). CONCLUSIONS: These findings show that despite expanded insurance coverage, the utilization of continuous-flow LVADs was not increased in nonelderly racial and ethnic minorities following the ACA Medicaid expansion. Although these findings are preliminary and require further long-term evaluation, they suggest that insurance coverage alone does not play a significant role in increased utilization of continuous-flow LVAD. These findings point toward the importance of further exploring social, medical, and hospital drivers of these disparities.

Predictors of patient radiation exposure during transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) exposes patients to radiation. OBJECTIVES: We sought to identify factors associated with higher radiation exposure and to quantify their relative influence, which may inform reduction of this hazard. METHODS: All TAVR procedures at Rhode Island Hospital between March 20, 2012 and February 12, 2017 were included. Procedures were performed by two co-primary operators using a Siemens Artis Zeego system. Radiation metrics were generated by the imaging system. The primary metric was dose-area product (DAP, Gy*cm2 ), and secondary metrics were reference point air kerma (mGy) and fluoroscopy time (minutes). Data collected for the STS/ACC TVT Registry were utilized to develop a multivariable linear regression model predicting DAP. RESULTS: In 294 TAVRs, median DAP was 169 Gy*cm2 [interquartile range (IQR) 106-238]. The r2 values for the full 27-variable DAP model and reduced eight-variable model were 0.457 and 0.420, respectively. Valve area, aortic insufficiency, and procedure year (suggesting absence of a learning curve) were non-significant predictors in the full model, while increasing weight, cutdown transfemoral access, higher pre-procedure creatinine and hemoglobin, and vascular complications predicted higher DAP in both models. Results were unchanged when DAP was log-transformed. Secondary models for air kerma and fluoroscopy time revealed similar predictors. CONCLUSION: Factors associated with increased procedural complexity and duration as well as radiation attenuation and scatter predict increased patient radiation exposure during TAVR. Modification of procedural technique, especially using percutaneous femoral vascular access, may facilitate reduction in exposure.

Decreased coronary arteriolar response to KCa channel opener after cardioplegic arrest in diabetic patients.

We have recently found that diabetes is associated with the inactivation of the calcium-activated potassium channels (KCa) in endothelial cells, which may contribute to endothelial dysfunction in diabetic patients at baseline. In the current study, we further investigated the effects of diabetes on coronary arteriolar responses to the small (SK) and intermediate (IK) KCa opener NS309 in diabetic and non-diabetic patients and correlated that data with the changes in the SK/IK protein expression/distribution in the setting of cardioplegic ischemia and reperfusion (CP) and cardiopulmonary bypass (CPB). Coronary arterioles from the harvested right atrial tissue samples from diabetic and non-diabetic patients (n = 8/group) undergoing cardiac surgery were dissected pre- and post-CP/CPB. The in vitro relaxation response of pre-contracted arterioles was examined in the presence of the selective SK/IK opener NS309 (10-9-10-5 M). The protein expression/localization of KCa channels in the harvested atrial tissue samples, coronary microvessels, and primary cultured human coronary endothelial cells were assayed by Western blotting and immunohistochemistry. The relaxation response to NS309 post-CP/CPB was significantly decreased in diabetic and non-diabetic groups compared to their pre-CP/CPB responses, respectively (P < 0.05). Furthermore, this decrease was greater in the diabetic group than that of the non-diabetic group (P < 0.05). There were no significant differences in the total protein expression/distribution of SK/IK in the human myocardium, coronary microvessels or coronary endothelial cells between diabetic and non-diabetic groups or between pre- and post-CP/CPB (P > 0.05). Our results suggest that diabetes further inactivates SK/IK channels of coronary microvasculature early after CP/CPB and cardiac surgery. The lack of diabetic changes in SK/IK protein abundances in the setting of CP/CPB suggests that the effect is post-translational. This alteration may contribute to post-operative endothelial dysfunction in the diabetic patients early after CP/CPB and cardiac surgery.

Impact of Packed Red Blood Cell and Platelet Transfusions in Patients Undergoing Dissection Repair.

BACKGROUND: Transfusion of blood products commonly occur in patients undergoing repair of acute type A aortic dissection (AADA). MATERIALS AND METHODS: The medical records of 102 AADA patients were retrospectively reviewed and stratified into cohorts by packed red blood cell (PRBC) and platelet units received: PRBC ≤2 units (n = 68) versus PRBC >2 units (n = 34); platelets ≤1 unit (n = 74) versus platelets >1 unit (n = 28). Continuous and categorical variables were assessed by analysis of variance testing and chi-square or Fisher's testing as appropriate. Multivariate logistic regression was applied to derive P values for post-transfusion complications. Kaplan-Meier survival analyses were used to compare the hospital length of stay (LOS) and survival rate at 1 mo and 1 y. RESULTS: Patients receiving >2 units of PRBC had a median LOS of 14 d versus 9 d for those receiving ≤2 units (P < 0.002). Transfusion of >2 units of PRBC was a risk factor for postoperative infection (odds ratio [OR] = 5.4, 95% confidence interval [CI]: 1.5-19.0, P = 0.009). Survival at 1 mo was 91% versus 94% (P = 0.783) and 1 y survival was 82% versus 93% (P = 0.269) between the two groups. Patients receiving >1 unit of platelets had a median LOS of 15 d versus 10 d for those receiving ≤1 unit (P = 0.005). Transfusion of >1 unit of platelets was a risk factor for postoperative atrial fibrillation and acute kidney injury (OR = 2.9, 95% CI: 1.1-7.6, P = 0.031; OR = 3.3, 95% CI: 1.2-9.4, P = 0.025, respectively). Survival at 1 mo was 93% versus 93% (P = 0.872) and 1 y survival was 81% versus 92% (P = 0.582) between the two groups. CONCLUSIONS: Transfusion of PRBC and platelets above a threshold increases the incidence of postoperative complications and hospital LOS among patients undergoing repair of AADA.

Cyclooxygenase 2 contributes to bradykinin-induced microvascular responses in peripheral arterioles after cardiopulmonary bypass.

BACKGROUND: Diabetic patients are associated with impaired peripheral microvascular function after cardiopulmonary bypass (CPB) and cardiac surgery. We hypothesized that upregulation of the inducible cyclooxygenase 2 (COX-2) contributes to altered microvascular reactivity of peripheral arterioles in diabetic patients undergoing CPB and cardiac surgery. METHODS: Skeletal muscle samples of nondiabetic (ND) patients and patients with diabetes mellitus (DM; n = 8 per group) undergoing cardiac surgery were harvested before and after CPB. The protein expression/localization of COX-2 was assayed by Western blotting and immunohistochemistry. Peripheral arterioles were dissected from the harvested skeletal muscle tissue samples, the isolated arterioles (80-180 µm) were cannulated and pressurized, and changes in diameter were measured with video microscopy. In-vitro relaxation responses of precontracted arterioles were examined in the presence of the endothelium-dependent vasodilator bradykinin (10-10 to 10-6M) and in the presence or absence of the selective COX-2 inhibitor NS398 (10-5M). RESULTS: The post-CPB protein levels of the inducible COX-2 were significantly increased compared with pre-CPB values in both the ND and DM groups (P < 0.05), whereas, this increase was higher in DM than that of ND (P < 0.05). In the DM arterioles, not the ND vessels, bradykinin-induced relaxation response was inhibited in the presence of the specific COX-2 inhibitor NS398 at baseline (P < 0.05). After CPB, bradykinin-induced relaxation response of the ND and DM arterioles was inhibited in the presence of the specific COX-2 inhibitor NS398, but this effect was more pronounced in the diabetic patients (P < 0.05). CONCLUSIONS: Diabetes and CPB are associated with upregulation in COX-2 expression/activation in human peripheral microvasculature. This alteration may lead to altered peripheral microvascular reactivity in diabetic patients undergoing cardiac surgery.

Vascular complications associated with transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) is now an accepted pathway for aortic valve replacement for patients who are at prohibitive, severe and intermediate risk for traditional aortic valve surgery. However, with this rising uptrend and adaptation of this new technology, vascular complications and their management remain an Achilles heel for percutaneous aortic valve replacement. The vascular complications are an independent predictor of mortality for patients undergoing TAVR. Early recognition of these complications and appropriate management is paramount. In this article, we review the most commonly encountered vascular complications associated with currently approved TAVR devices and their optimal percutaneous management techniques.

Patients with uncontrolled hypertension subjected to cardiopulmonary bypass have altered coronary vasomotor responses to serotonin.

BACKGROUND: We previously found that cardioplegic arrest and cardiopulmonary bypass are associated with altered coronary arteriolar response to serotonin in patients undergoing cardiac surgery. In this study, we investigated the effects of hypertension on coronary microvascular vasomotor tone in response to serotonin and alterations in serotonin receptor protein expression in the setting of cardioplegic arrest and cardiopulmonary bypass. METHODS: Coronary arterioles were dissected from harvested pre- and post-cardioplegic arrest and cardiopulmonary bypass right atrial tissue samples of patients undergoing cardiac surgery with normotension, well-controlled hypertension, and uncontrolled hypertension. Vasomotor tone was assessed by video-myography, and protein expression was measured with immunoblotting. RESULTS: Pre-cardioplegic arrest and cardiopulmonary bypass, serotonin induced moderate relaxation responses of coronary arterioles in normotension and well-controlled hypertension patients, whereas serotonin caused moderate contractile responses in uncontrolled hypertension patients. Post-cardioplegic arrest and cardiopulmonary bypass, serotonin caused contractile responses of coronary arterioles in all 3 groups. The post-cardioplegic arrest and cardiopulmonary bypass contractile response to serotonin was significantly higher in the uncontrolled hypertension group compared with the normotension or well-controlled hypertension groups (P < .05). Pre-cardioplegic arrest and cardiopulmonary bypass, expression of the serotonin 1A receptor was significantly lower in the uncontrolled hypertension group compared with the well-controlled hypertension and normotension groups (P = .01 and P < .001). Serotonin 1B receptor expression was higher in the uncontrolled hypertension group compared with the normotension or well-controlled hypertension groups post-cardioplegic arrest and cardiopulmonary bypass (P = .03 and P = .046). CONCLUSION: Uncontrolled hypertension is associated with an increased coronary contractile response of coronary microvessels to serotonin and altered serotonin receptor protein expression after cardioplegic arrest and cardiopulmonary bypass. These findings may contribute to a worse postoperative coronary spasm and worsened recovery of coronary perfusion in patients with uncontrolled hypertension after cardioplegic arrest and cardiopulmonary bypass and cardiac surgery.

Self-expanding and balloon-expandable valves in low risk TAVR patients.

BACKGROUND: Recent randomized studies have broadened the indication of transcatheter aortic valve replacement (TAVR) to also include low-surgical-risk patients. However, the data on self-expanding (SE) and balloon-expandable (BE) valves in low-risk patients remain sparse. METHODS: The current study is a post hoc analysis of combined data from both LRT 1.0 and 2.0 trials comparing BE and SE transcatheter heart valves. RESULTS: A total of 294 patients received a BE valve, and 102 patients received an SE valve. The 30-day clinical outcomes were similar across both groups except for stroke (4.9% vs. 0.7%, p = 0.014) and permanent pacemaker implantation (17.8% vs. 5.8%, p < 0.001), which were higher in the SE cohort than the BE cohort. No difference was observed in terms of paravalvular leak (≥moderate) between the groups (0% vs. 1.5%, p = 0.577). SE patients had higher aortic valve area (1.92 ± 0.43 mm2 vs. 1.69 ± 0.45 mm2, p < 0.001) and lower mean gradient (8.93 ± 3.53 mmHg vs. 13.41 ± 4.73 mmHg, p < 0.001) than BE patients. In addition, the rate of subclinical leaflet thrombosis was significantly lower in SE patients (5.6% vs. 13.8%, p = 0.038). CONCLUSION: In this non-randomized study assessing SE and BE valves in low-risk TAVR patients, SE valves are associated with better hemodynamics and lesser leaflet thrombosis, with increased rates of stroke and permanent pacemaker implantation at 30 days; however, this could be due to certain patient-dependent factors not fully evaluated in this study. The long-term implications of these outcomes on structural valve durability remain to be further investigated. CLINICAL TRIAL REGISTRY: LRT 1.0: NCT02628899 LRT 2.0: NCT03557242.

Risk Factors for Heart Failure Readmission After Cardiac Surgery.

Background: Heart failure (HF) is a leading cause of readmission after cardiac surgery, yet risk factors for HF readmission after cardiac surgery remain poorly characterized. Objectives: This study aimed to identify risk factors associated with 30-day HF-specific readmissions after cardiac surgery using a national database. Methods: We queried the 2016 to 2018 National Readmissions Database to identify U.S. patients who underwent coronary artery bypass grafting (CABG), mitral valve repair/replacement, and/or aortic valve repair/replacement. Exclusion criteria included history of ventricular assist device or heart transplant, dialysis-dependent renal insufficiency, and death during index admission. Clinical variables were defined using International Classification of Diseases-10th Revision codes. The primary outcome was a 30-day readmission for HF following discharge. Multivariable logistic regression was used to account for relevant clinical and demographic covariates and identify independent risk factors for HF readmissions following cardiac surgery. Results: Our study included 394,050 patients who underwent cardiac surgery (mean age 66 ± 12 years, 63% isolated CABG, 27% isolated valve, 11% CABG + valve). Of these patients, 7,318 were readmitted within 30 days of discharge for a principal diagnosis of HF. Independent risk factors of HF-specific readmission included older age, female sex, prolonged length of stay, comorbid congestive HF, nondialysis dependent chronic kidney disease, chronic obstructive pulmonary disease, chronic liver disease, obesity, atrial fibrillation, and acute kidney injury. Prior CABG was marginally protective for HF-specific readmission. Conclusions: Using a national registry, we identified risk factors associated with HF readmission after cardiac surgery. Further analysis of these risk factors and their association with HF readmission is warranted.

Effect of Patient Sex on Neurocognitive Decline after Cardiac Surgery.

BACKGROUND: Neurocognitive decline (NCD) is a common complication of cardiac surgery. Understanding risk factors helps surgeons counsel patients pre- and perioperatively about risk, prevention, and treatment. STUDY DESIGN: Patients undergoing cardiac surgery using cardiopulmonary bypass underwent pre- and postoperative neurocognitive testing. Neurocognitive data are presented as a change from baseline to either postoperative day 4 or to 1 month. The score is standardized with respect to age. RESULTS: Eighty-four patients underwent surgery and completed postoperative neurocognitive testing. There was no significant difference in baseline neurocognitive function. NCD was more common in female patients (71%) than male patients (26.4%) on postoperative day 4. By 1 month, the incidence of NCD is similar between female (15.0%) and male patients (14.3%). Of note, female patients differed from male patients in preoperative hematocrit, preoperative creatinine, and type of surgery. CONCLUSIONS: In the acute postoperative period, female patients are both more likely to experience NCD and experience a more severe change from baseline cognitive function. This difference between male and female patients resolves by the 1 month follow-up point. Female patients had a lower preoperative hematocrit and were more likely to receive intraoperative and perioperative blood transfusion. Lower preoperative hematocrit appears to mediate the difference in NCD between male and female patients.