The Impact of Frailty on Outcomes of Proximal Aortic Aneurysm Surgery: A Nationwide Analysis.

(1) Background: This study examines frailty's impact on proximal aortic surgery outcomes. (2) Methods: All patients with a thoracic aortic aneurysm who underwent aortic root, ascending aorta, or arch surgery from the 2016-2017 National Inpatient Sample were included. Frailty was defined by the Adjusted Clinical Groups Frailty Indicator. Outcomes of interest included in-hospital mortality and a composite of death, stroke, acute kidney injury (AKI), and major bleeding (MACE). (3) Results: Among 5745 patients, 405 (7.0%) met frailty criteria. Frail patients were older, with higher rates of chronic pulmonary disease, diabetes, and chronic kidney disease. There was no difference in in-hospital death (4.9% vs. 2.4%, p = 0.169); however, the frail group exhibited higher rates of stroke and AKI. Frail patients had a longer length of stay (17 vs. 8 days), and higher rates of non-home discharge (74.1% vs. 54.3%) than non-frail patients (both p < 0.001). Sensitivity analysis confirmed increased morbidity and mortality in frail individuals. After adjusting for patient comorbidities and hospital characteristics, frailty independently predicted MACE (OR 4.29 [1.88-9.78], p = 0.001), while age alone did not (OR 1.00 [0.99-1.02], p = 0.568). Urban teaching center status predicted a lower risk of MACE (OR 0.27 [0.08-0.94], p = 0.039). (4) Conclusions: Frailty is associated with increased morbidity in proximal aortic surgery and is a more significant predictor of mortality than age. Coordinated treatment in urban institutions may enhance outcomes for this high-risk group.

Comparison of Postdischarge Outcomes Between Valve-in-Valve Transcatheter Mitral Valve Replacement and Reoperative Surgical Mitral Valve Replacement.

Limited data are available comparing the postdischarge perioperative outcomes of isolated valve-in-valve transcatheter mitral valve replacement (VIV-TMVR) versus surgical reoperative mitral valve replacement (re-SMVR) on a nationwide scale. The objective of this study was to perform a robust head-to-head assessment of contemporary postdischarge outcomes between isolated VIV-TMVR and re-SMVR using a large national multicenter longitudinal database. Adult patients aged ≥18 years with failed/degenerated bioprosthetic mitral valves who underwent either isolated VIV-TMVR or re-SMVR were identified in the 2015 to 2019 Nationwide Readmissions Database. The risk-adjusted differences in 30-, 90-, and 180-day outcomes were compared using propensity score weighting with overlap weights to mimic the results of a randomized controlled trial. The differences between a transeptal and transapical VIV-TMVR approach were also compared. A total of 687 patients with VIV-TMVR and 2,047 patients with re-SMVR were included. After the overlap weighting to attain balance between treatment groups, VIV-TMVR was associated with significantly lower major morbidity within 30 (odds ratio [95% confidence interval (CI)] 0.0.31 [0.22 to 0.46]), 90 (0.34 [0.23 to 0.50]), and 180 (0.35 [0.24 to 0.51]) days. The differences in major morbidity were primarily driven by less major bleeding (0.20 [0.14 to 0.30]), new onset complete heart block (0.48 [0.28 to 0.84]) and need for permanent pacemaker placement (0.26 [0.12 to 0.55]). The differences in renal failure and stroke were not significant. VIV-TMVR was also associated with shorter index hospital stays (median difference [95% CI] -7.0 [4.9 to 9.1] days) and an increased ability for patients to be discharged home (odds ratio [95% CI] 3.35 [2.37 to 4.72]). There were no significant differences in total hospital costs; in-hospital or 30-, 90-, and 180-day mortality; or readmission. The findings remained similar when stratifying the VIV-TMVR access using a transeptal versus a transapical approach. The changes in outcomes over time suggest marked improvements for patients with VIV-TMVR relative to stagnant results for patients with re-SMVR from 2015 to 2019. In this large nationally representative cohort of patients with failed/degenerated bioprosthetic mitral valves, VIV-TMVR appears to confer a short-term advantage over re-SMVR in terms of morbidity, discharge home, and length of stay. It yielded equivalent outcomes for mortality and readmission. Longer-term studies are needed to assess further follow-up beyond 180 days.

Efficacy of opioid-sparing analgesia after median sternotomy with continuous bilateral parasternal subpectoral plane blocks.

OBJECTIVES: Regional anesthetic techniques, traditionally underutilized in cardiac surgery, may play a role in multimodal analgesia, effectively improving pain control and reducing opioid consumption. We investigated the efficacy of continuous bilateral ultrasound-guided parasternal subpectoral plane blocks following sternotomy. METHODS: We reviewed all opioid-naïve patients who underwent cardiac surgery via median sternotomy under our enhanced recovery after surgery protocol between May 2018 and March 2020. Patients were grouped based on postoperative pain management strategy-those who received standard Enhanced Recovery After Surgery (ERAS) multimodal analgesia alone (no nerve block group) versus those receiving ERAS multimodal analgesia plus continuous bilateral parasternal subpectoral plane blocks (block group). In the block group, parasternal subpectoral plane catheters were placed under ultrasound-guidance on each side of the sternum with initial 0.25% ropivacaine bolus, followed by continuous 0.125% bupivacaine infusions. Postoperative patient-reported numerical rating scale pain scores and opioid consumption in morphine milligram equivalents were compared through postoperative day 4. RESULTS: Of 281 patients included in the study, the block group comprised 125 (44%) patients. Although baseline characteristics, type of surgery, and length of stay were similar between groups, average numerical rating scale pain scores and opioid consumption were significantly lower in the block group through postoperative day 4 (all P values < .05). We also observed a 44% reduction in total opioid consumption after surgery in the block group (75.1 vs 133.1 MME; P = .001) and 1 less hospital day requiring opioids (4.2 vs 3 days; P = .001). CONCLUSIONS: Continuous bilateral parasternal subpectoral plane blocks may further reduce poststernotomy pain and opioid consumption within the context ERAS multimodal analgesia.

Outcomes of procedural complications in transfemoral transcatheter aortic valve replacement.

OBJECTIVES: As the application of transcatheter aortic valve replacement (TAVR) expands, the longitudinal implications of periprocedural complications are increasingly relevant. We examine the influence of TAVR complications on midterm survival. METHODS: Patients undergoing transfemoral TAVR at our institution between November 2011 and June 2018 were reviewed. Stroke severity was classified according to the National Institutes of Health stroke score. Kaplan-Meier analysis was used to assess survival, and a Cox proportional hazards model was created to examine independent associations with survival. The median follow-up time was 36 months for a total of 2789 patient-years. RESULTS: Overall, 866 patients were included. The mean age was 80 ± 9.5 years and mean Society of Thoracic Surgeons score was 4.8% ± 2.7%. The mortality rate at 30-days was 2.8% and 11.8% at 1 year. In-hospital left bundle branch block and 30-day permanent pacemaker insertion occurred in 14.8% and 7.9%, respectively. Postprocedural greater-than-mild paravalvular leak was present in 4.4% and stroke occurred in 3.8% at 30-days. Greater-than-mild paravalvular leak was associated with decreased survival at 2 years (P = .02), but not at 5 years. Severe stroke was independently associated with decreased survival at 5 years (hazard ratio, 5.73; 95% confidence interval, 2.29-14.36; P ≤ .001); however, the effect of nonsevere stroke did not reach significance (hazard ratio, 1.69; 95% confidence interval, 0.82-3.47; P = .152). CONCLUSIONS: Severe stroke was independently associated with decreased 5-year survival and initial risks associated with paravalvular leak may be attenuated over the midterm following transfemoral TAVR. Strategies to minimize the incidence of stroke and paravalvular leak must be prioritized to improve longitudinal outcomes after TAVR.

Outcomes of Mitral Valve Repair Among High- and Low-Volume Surgeons Within a High-Volume Institution.

BACKGROUND: Volume-outcome relationships have been described for mitral valve repair at the institution and surgeon level. We aimed to assess whether this relationship is mitigated at high-volume (HV) mitral repair centers between HV and low-volume (LV) surgeons. METHODS: All mitral repair cases at an HV mitral center (mean, 192 annual repairs) from 1992 to 2018 were considered. Cases with concomitant procedures other than tricuspid and atrial fibrillation procedures were excluded. Surgeons who performed ≥25 repairs per year were considered HV. The primary outcome was operative mortality; secondary outcomes were operative complications, long-term mortality, and reoperation. RESULTS: In total, 2653 mitral repairs from 19 surgeons were included. The mean age of the patients in the HV and LV groups was 59.6 years and 61.8 years, respectively (P = .005), with no difference in other baseline characteristics. HV surgeons had significantly shorter median aortic cross-clamp times (80 vs 87 minutes; P < .001) compared with LV surgeons; however, there was no significant difference in operative mortality (0.9% vs 1.6%; P = .19), reoperation, perioperative complications, or length of stay. LV surgeons had higher repair conversion to replacement than HV surgeons did (9.0% vs 3.4%; P < .001). In the risk-adjusted analyses, surgeon volume group did not have an impact on longitudinal survival or reoperation. CONCLUSIONS: At an HV mitral repair institution, LV surgeons appear to have short- and long-term outcomes similar to those of HV surgeons despite increased conversion rates. These findings suggest that institutional volume may mitigate the surgeon volume outcome. However, complex repairs may benefit from referral to HV surgeons, given the lower conversion rate.

Postdischarge Pain and Opioid Use After Cardiac Surgery: A Prospective Cohort Study.

BACKGROUND: The rate of chronic opioid use after cardiac surgery is high compared with other surgical specialties; however evidence regarding optimal prescribing is limited. The purpose of this study was to evaluate patterns of opioid consumption after cardiac surgery to guide prescribing practices. METHODS: Consecutive patients undergoing sternotomy-based cardiac operations were considered for enrollment. Patients with opioid use within 3 months of surgery and those discharged to a nonhome facility were excluded. A patient diary and researcher-directed pill count was used to track pain and opioid use for 10 days after discharge. RESULTS: One hundred four patients were included in the final analysis. Of the 63 patients discharged with an opioid, 22 (34.9%) used none and 12 (19.0%) used fewer than half of the pills prescribed. Overall, pain and opioid consumption decreased significantly throughout the discharge period (P < .001). In those who used opioids after discharge, median total consumption was 64 morphine milligram equivalents (interquartile range, 38-128), or the equivalent of 9 oxycodone 5-mg tablets. Patients who used opioids were younger (60.9 vs 70.0, P < .001), but there were no differences based on sex, history of substance use, smoking, or procedure. After risk adjustment the mean pain score ≥ 3 on the day of discharge was predictive of opioid use (odds ratio, 2.9; 95% confidence interval, 1.8-4.8; P < .001). Most patients (88.5%) were satisfied or very satisfied with pain management. CONCLUSIONS: Fewer than half of all patients used opioids after discharge in this study. These data support the need for the development of prescription recommendations after cardiac surgery.

Aortic root management in acute type A aortic dissection: A nationwide analysis.

OBJECTIVE: Acute type A aortic dissection (ATAAD) is a life-threatening condition and surgical repair often includes aortic valve replacement (AVR). Aortic valve repair (AVr) is increasingly being reported with favorable outcomes from single-center experiences. This study examined national trends and outcomes of AVr in patients with ATAAD. METHODS: Adults with a primary diagnosis of acute thoracic aortic dissection who underwent proximal aortic surgery from January 2016 to December 2017 were obtained from the National Inpatient Sample. Patients were stratified into an isolated aortic surgery group (no aortic valve procedure), concomitant AVR, or concomitant AVr groups. The primary outcome was in-hospital mortality and secondary outcomes included stroke, acute kidney injury, heart block, and bleeding. Propensity score matching was used to address patient and hospital-level confounders between AVR and AVr groups. RESULTS: In total, 5115 patients underwent surgery for ATAAD and were included. Overall, 3220 (63%) underwent isolated ATAAD repair, while 1120 (22%) had concomitant AVR, and 775 (15%) had concomitant AVr. In 455 propensity-matched pairs, there was no difference in mortality or stroke between AVr and AVR groups, however, heart block (1.1% vs. 7.5%, p < .001) and bleeding (65.9% vs. 81.3%, p < .001) were significantly less common among those who underwent AVr. Patients who underwent AVr had shortest LOS (11.9 vs. 13.5 days, p < .001). There were no differences in outcomes of AVr in ATAAD based on hospital size or teaching status. CONCLUSION: In selected patients, AVr is being performed safely in the setting of ATAAD with mortality and composite outcomes comparable to AVR.

Marital Status and Sex-Based Differences in Outcomes After Transcatheter Aortic Valve Implantation.

Studies have shown improved outcomes among married patients who underwent cardiovascular surgery; however, this has not been well studied in transcatheter aortic valve implantation (TAVi). We examined the impact of marital status and patient sex on outcomes after TAVi. Patients who underwent TAVi from January 2015 to June 2018 were reviewed and stratified into 3 groups: single, married, and widowed. The impact of marital status and sex on 30-day outcomes was assessed using a stepwise logistic regression analysis. Cumulative survival was estimated using Kaplan-Meier analysis and adjusted survival with multivariable Cox proportional hazards modeling. A total of 785 patients were included: 149 single, 413 married, and 223 widowed. Widowed patients were older (84 vs 79 years) with higher Society of Thoracic Surgeons risk scores (6.79% vs 5.51%, both p ≤0.001) than married patients. Neither marital status nor sex was associated with 30-day mortality or home discharge. However, 1-year survival revealed a differential survival penalty, with married females (p = 0.041) having lower survival and married males (p = 0.007) having higher survival than their single counterparts. This survival penalty persisted in the adjusted analyses (married females hazard ratio [HR] 2.24, p = 0.009; widowed males HR 2.42, p = 0.057). For patients who were readmitted in the first year, adjusted analysis showed widowed status was associated with higher 30-day readmissions (HR 1.91, p = 0.012) in both sexes. In conclusion, these findings suggest that marital status does not impact both sexes equally after TAVi; identifying at-risk patients and targeted interventions, such as adjusting discharge planning to ensure adequate home social support, may help improve outcomes.

Surgical Aortic Valve Replacement Outcomes in Non-Transcatheter Aortic Valve Replacement Centers: Implications for Tier-Based Systems of Care.

BACKGROUND: With wide expansion of transcatheter aortic valve replacement (TAVR) and dissemination of multidisciplinary-based approaches to care, societies are discussing the implementation of a tier system to valve centers. This study explores the impact of tier-based systems of care on surgical aortic valve replacement (SAVR) outcomes at institutions that perform SAVR only. METHODS: Medicare beneficiaries undergoing SAVR procedures from 2012 to 2015 were included. The SAVR hospitals were stratified into either tier A, valve centers with a TAVR program; or tier B, valve centers without a TAVR program. Adjusted survival, assessed by multivariable Cox regression, controlled for program type and patient risk profile. Time-dependent analysis accounted for hospitals that initiated a TAVR program during the study period. RESULTS: Overall, there were 562 tier A and 485 tier B SAVR hospitals. Tier A hospitals had significantly higher comorbidity burden compared with tier B hospitals (all P < .05) but had significantly lower rates of 30-day mortality (3.2% vs 4.1%) and 1-year mortality (8.1% vs 9.4%; both P < .05). After risk stratification, tier B hospitals had significantly worse 30-day mortality compared with tier A hospitals for all patient risk-profiles, except for the low-risk patients (P < .01). These findings persisted in the time-dependent analysis. Adjusted midterm survival was higher in tier A vs tier B hospitals. CONCLUSIONS: Low-risk patients can safely undergo SAVR in both tier level hospitals without compromising outcomes. Establishment of quality of care measures, especially in the SAVR-only hospitals, remains paramount and should be closely integrated when designing tier-based systems for aortic valve replacement care.

Enhanced Recovery After Cardiac Surgery: A Propensity-Matched Analysis.

Enhanced Recovery After Surgery (ERAS) pathways have improved clinical outcomes, cost-effectiveness, and patient satisfaction across multiple non-cardiac surgical specialties. Since the adaptation of ERAS in cardiac surgery is rapidly increasing yet still evolving, herein, we demonstrate early results of our implementation of ERAS cardiac guidelines. We retrospectively reviewed all patients who were managed with our institutional ERAS Cardiac Surgery guidelines between 5/2018 and 6/2019(N = 102). Postoperative primary outcomes (total ventilation times(hours), intensive-care unit(ICU) stay, and postoperative hospital length of stay (LOS)) were compared to 1:1 propensity matched controls from the pre ERAS era between January 2017 and March 2019. A total of 76 propensity-matched pairs were identified. Compared to the matched controls, ERAS patients had significantly shorter median ventilation times(3.5 vs. 5.3 hours, p = .01), ICU stays(median 28 vs 48 hours, p=.005) and postoperative hospital LOS (median 5 vs. 6 days, p = .03). There were no operative mortalities and no significant differences in 30-day readmission rates. There were also no significant differences in post-operative stroke, acute kidney injury, atrial fibrillation, and reoperation rates for bleeding. Two-year survival was also not statistically different between the two cohorts (p = .22). Our initial experience with implementation of ERAS protocols in cardiac surgery appear to demonstrate that these protocols are associated with shorter ventilation times, ICU stay, and hospital LOS without compromising patient outcomes. While these results are promising yet preliminary, further studies are warranted to demonstrate whether ERAS algorithms in cardiac surgery can consistently expedite postoperative recovery and improve outcomes.

Debunking the July Effect in Transcatheter Interventions in Structural Heart Disease: Truth or Myth?

Background: The "July effect", the perception of worse outcomes in the first month of training, has been previously demonstrated in critical care medicine and general surgery. However, the July effect in the context of structural heart interventions (i.e., transcatheter aortic valve replacement [TAVR] and MitraClip) remains unknown. Methods: All adult patients undergoing TAVR or MitraClip in the 2012-2016 National Inpatient Sample were included. Outcomes were compared by procedure month and academic year quartiles (i.e., between the first academic year quartile [Q1] vs. the fourth quartile [Q4]). Outcomes between teaching and nonteaching hospitals were compared using risk-adjusted logistic difference-in-difference regression. Results: During the study period, 94,170 TAVR (Q1: 25,250; Q4: 23,170) and 8750 MitraClip (Q1: 2220; Q4: 2150) procedures were performed. In-hospital mortality did not vary as per academic year quartiles for either procedure, even after risk adjustment. These findings persisted in sensitivity analysis by procedure month and newer device era (2015-2016; all p > 0.05). In the subgroup analysis, the unadjusted and adjusted Q1 vs. Q4 in-hospital mortality between teaching and nonteaching hospitals were similar for either procedure. In-hospital mortality also did not vary by procedure month when stratified by hospital teaching status for both procedures. However, postprocedural complication rates appeared to be improving among the TAVR teaching hospitals for stroke, major bleeding, and vascular complications (all p < 0.05). Conclusions: In this large, nationwide study, the July effect was not evident for structural heart interventions. With increasing interest and growth in transcatheter procedures, early resident and fellow teaching can be achieved with appropriate supervision.

Transcatheter Compared With Surgical Aortic Valve Replacement in Patients With Previous Chest-Directed Radiation Therapy.

BACKGROUND: Cardiac surgery for radiation-induced valvular disease is associated with adverse outcomes. Transcatheter aortic valve replacement (TAVR) is increasingly used in patients with a history of chest-directed radiation therapy and aortic stenosis (CRT-AS). OBJECTIVES: We examined outcomes of TAVR compared with surgical aortic valve replacement (SAVR) for patients with CRT-AS. METHODS: We identified 69 patients with CRT-AS who underwent TAVR from January 2012 to September 2018. Operative mortality, postoperative morbidities, and length of hospitalization were compared with 117 contemporaneous patients with CRT-AS who underwent isolated SAVR. Age-adjusted survival was evaluated by means of Cox proportional hazards modeling. RESULTS: Compared with SAVR patients, TAVR patients were older (mean age 75 ± 11.5 vs 65 ± 11.5 years), with more comorbidities, such as chronic obstructive pulmonary disease, atrial fibrillation, and peripheral vascular disease (all P < 0.050). Operative mortality was 4.3% for SAVR vs 1.4% for TAVR (P = 0.41). Most SAVR deaths (4 of 5) occurred in the intermediate-/high-risk group (Society for Thoracic Surgeons predicted risk of operative mortality >3%; P = 0.026). The ratio of observed to expected mortality was better for low-risk SAVR patients and all TAVR patients (0.72 [95% confidence interval [CI]: 0.59-0.86] and 0.24 [95% CI: 0.05-0.51], respectively) compared with intermediate-/high-risk SAVR patients (2.52 [95% CI: 0.26-4.13]). SAVR patients had significantly longer median intensive care unit and overall length of stay and higher blood transfusion requirements but similar rates of stroke and pacemaker implantation. CONCLUSIONS: TAVR was associated with excellent in-hospital outcomes and better survival compared with intermediate-/high-risk SAVR in patients with CRT-AS. While SAVR still has a role in low-risk patients or those for whom TAVR is unsuitable for technical or anatomical reasons, TAVR is emerging as the standard of care for intermediate-/high-risk CRT-AS patients.

Early outcomes of transatrial mitral valve replacement in severe mitral annular calcification.

OBJECTIVE: Mitral valve replacement (MVR) in the setting of severe mitral annular calcification is a technically challenging operation with increased morbidity and mortality. Transseptal/apical transcatheter MVR (TMVR) in mitral annular calcification has emerged as an option for these cases, although may not be feasible due to anatomical reasons. Transatrial TMVR is a potential treatment option for this subgroup of patients. METHODS: Patients who underwent transatrial TMVR between June 2018 and November 2020 at a single institution were included. Patients were selected by a structural heart team based on their surgical risk, pattern of mitral annular calcification, risk of valve migration, left ventricular outflow obstruction, and paravalvular leak. RESULTS: A total of 11 patients underwent transatrial TMVR. Mean patient age was 74.2 years and mean Society of Thoracic Surgeons predicted risk of mortality score was 9.1%. All patients had the presence of both mitral stenosis and regurgitation-dominant etiology-was mitral stenosis in 81.2%, and mitral regurgitation in 18.8%. Among patients, 54.5% had a concomitant cardiac procedure. There was no in-hospital or 30-day mortality. Technical success defined by the Mitral Valve Academic Research Consortium was achieved in 90.9% of patients. Postoperative paravalvular leak was mild or less in all patients. CONCLUSIONS: In this series, transatrial TMVR was shown to be a safe and effective treatment option for patients who are high risk for surgical MVR and should be in surgeons' armamentarium in the treatment of this high-risk patient population. Dissemination of safe technique will be critical in the successful conduct of this surgery.

Nationally Representative Repeat Transcatheter Aortic Valve Replacement Outcomes: Report From the Centers for Medicare and Medicaid Services.

OBJECTIVES: The aim of this study was to examine real-world experience with repeat transcatheter aortic valve replacement (TAVR) in a population-based national database. BACKGROUND: Repeat TAVR is a growing option in patients requiring reintervention for TAVR. However, large-scale studies with longitudinal follow-up are limited. METHODS: All Medicare beneficiaries who underwent TAVR from 2012 to 2017 were included. Outcomes included 30-day and longitudinal mortality and major adverse cardiovascular events, defined as death, stroke, pacemaker insertion, major bleeding, acute kidney injury, or cardiac arrest. Outcomes of repeat TAVR were compared with surgical explantation after TAVR (TAVR explantation) in a matched analysis. RESULTS: Of 133,250 patients who underwent TAVR, 617 (0.46%) underwent subsequent repeat TAVR at a median interval of 154 days (interquartile range: 58-537 days). Mortality at 30 days and 1 year was 6.0% and 22.0%, respectively. Rates of 30-day stroke and pacemaker insertion were 1.8% and 4.2%. Mortality at 30 days was lower in those who underwent their first TAVR during the later era (2015-2017) compared with earlier years (2012-2014) (4.6% vs 8.7%; P = 0.049). Repeat TAVR was associated with lower 30-day mortality compared with a matched group undergoing TAVR explantation (6.2% vs 12.3%; P = 0.05), although 1-year mortality was similar (21.0% vs 20.8%; P = 1.000). The incidence of 30-day major adverse cardiovascular events was higher with TAVR explantation compared with repeat TAVR (risk ratio: 2.92; 95% CI: 1.88-4.99; P ≤ 0.001). CONCLUSIONS: Repeat TAVR was performed with acceptable 30-day mortality in this high-risk population. Short-term outcomes were superior to surgical explantation, but 1-year outcomes were similar. Repeat TAVR will likely be an important option for aortic valve reintervention after TAVR.