2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

AIM: The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Balloon assisted translocation of the mitral anterior leaflet to prevent left ventricular outflow obstruction (BATMAN): A novel technique for patients undergoing transcatheter mitral valve replacement.

INTRODUCTION: Transcatheter mitral valve replacement (TMVR) is an option for patients at high risk for mitral valve replacement or repair via sternotomy or left thoracotomy approach. TMVR carries up to 22% risk of left ventricular outflow tract (LVOT) obstruction. Severe LVOT obstruction can have devastating hemodynamic and clinical consequences. HYPOTHESIS: We previously presented a novel technique to prevent LVOT obstruction during transapical retrograde mitral valve replacement, by penetrating and ballooning the anterior mitral leaflet (AML), resulting in creation of a "hole" and posterior translocation of AML, then deploying the valve. METHODS: Three patients underwent TMVR at Saint Louis University for severe mitral regurgitation after being deemed too high risk for surgery, and not candidates for a Mitra-clip procedure. These patients were deemed to be at risk for LVOT obstruction based on the preprocedural evaluation. Via transapical approach, a needle was advanced "through," perforating the AML and wire was placed in the left atrium. Over the wire, an 20-mm valvuloplasty balloon was positioned "within" the anterior leaflet and inflated leading to translocation of the AMVL. Then the valve was deployed. RESULTS: This novel technique has been performed on three patients at our institution. Sapien S3 transcatheter valves were used in all three patients, with 100% procedural success rate. Intraoperative TEE demonstrated no significant LVOT obstruction, cardiopulmonary bypass time was 42-44 min. CONCLUSION: The balloon assisted translocation of the mitral anterior leaflet to prevent left ventricular outflow obstruction technique described here may offer the option of transcatheter mitral valve implantation in patients at high risk of LVOT obstruction. A variation of this technique to allow application in cases with transseptal approach is under investigation.

Correction to: Patient selection and methods of surgical left atrial appendage exclusion.

In the original version of the article copyright information of Figure 2 was not included in the figure legend.

Patient selection and methods of surgical left atrial appendage exclusion.

The left atrial appendage (LAA) is a major source of thromboembolism, particularly in patients with atrial fibrillation (AF). LAA exclusion has arisen as a method of stroke prophylaxis in high-risk patients who have failed medical management, in whom medical management is contraindicated, and in those undergoing concomitant cardiac surgery. Percutaneous LAA exclusion with devices such as the Watchman has been described extensively in the cardiology literature, but surgical exclusion is less often discussed. Several techniques exist for surgical LAA exclusion, including appendage excision (removal), internal ligation from within the left atrium (LA), and external occlusion without opening the LA. The decision of which surgical technique to employ is dependent upon individual patient characteristics including risk factors, surgical history, and appendage anatomy. This paper discusses patient selection for surgical LAA exclusion and methods of surgical exclusion for the non-cardiac surgery medical practitioner.

Multi-functional derivatization of amine, hydroxyl, and carboxylate groups for metabolomic investigations of human tissue by electrospray ionization mass spectrometry.

Metabolomics, the study of small molecules involved in cellular processes, offers the potential to reveal insights into the pathophysiology of disease states. Analysis of metabolites by electrospray mass spectrometry is complicated by their structural diversity. Amine, hydroxyl, and carboxylate groups all affect signal responses differently based on their polarity and proton affinity. This heterogeneity of signal response, sensitivity, and resistance to competing ionization complicates metabolite quantitation. Such limitations can be mitigated by a dual derivatization scheme. In this work, primary amine and hydroxyl groups are tagged with a linear acyl chloride head containing a tertiary amine tail, followed by carboxylate groups coupled to a linear amine tag with a tertiary amine tail. This tagging scheme increases analyte proton affinity and hydrophobicity. In the case of carboxylate groups, the inherent anionic charge is inverted to a cationic charge. This dual tagging is completed within 2.5 hours, diminishes adduct formation, and improves sensitivity by >75-fold. The average limit of detection for 23 metabolites was 38 nM and the R2 was 0.97. This process was used to investigate metabolite changes from human tissue. Examination of diabetic and non-diabetic human tissue showed marked changes in both energy metabolites and amino acids. Further examination of the tissue showed that HbA1C value is inversely correlated with fumarate levels. This technique potentially allows for the analysis of virtually all metabolites in a single analytical run. Thus, it may lead to a more complete picture of metabolic dysfunction in human disease.

Atrial fibrillation: A major risk factor for cognitive decline.

Atrial fibrillation is a common disease of the elderly, conferring considerable morbidity and mortality related to cardiovascular effects and thromboembolic risks. Anticoagulation, antiarrhythmic medications, and rate control are the cornerstone of contemporary management, whereas ablation and evolving surgical techniques continue to play important secondary roles. Growing evidence shows that atrial fibrillation is also a risk factor for significant cognitive decline through a multitude of pathways, further contributing to morbidity and mortality. At the same time, cognitive decline associated with cryptogenic strokes may be the first clue to previously undiagnosed atrial fibrillation. These overlapping associations support the concept of cognitive screening and rhythm monitoring in these populations. New research suggests modulating effects of currently accepted treatments for atrial fibrillation on cognition; however, there remains the need for large multicenter studies to examine the effects of novel oral anticoagulants, rhythm and rate control, and left atrial appendage occlusion on long-term cognitive function.

Managing Career Transitions in Cardiothoracic Surgery.

Transitions during a career in cardiothoracic surgery include transition to practice following residency, multiple transitions over the course of the career, and transition to retirement. Each carries some degree of uncertainty and stress, and early preparation for each transition is key to success. A clear understanding of both professional and personal goals drives decisions and choices along the course of a career. It is crucial to seek legal counsel with expertise in physician employment contracts. Developing collegial and collaborative relationships should be a focus throughout one's career. This article outlines the key elements to successful career progression.

The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation.

The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation incorporate the most recent evidence for surgical ablation and left atrial appendage occlusion in different clinical scenarios. Substantial new evidence regarding the risks and benefits of surgical left atrial appendage occlusion and the long-term benefits of surgical ablation has been produced in the last 5 years. Compared with the 2017 clinical practice guideline, the current update has an emphasis on surgical ablation in first-time, nonemergent cardiac surgery and its long-term benefits, an extension of the recommendation to perform surgical ablation in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery, and a new class I recommendation for left atrial appendage occlusion in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery. Further guidance is provided for patients with structural heart disease and atrial fibrillation being considered for transcatheter valve repair or replacement, as well as patients in need of isolated left atrial appendage management who are not candidates for surgical ablation. The importance of a multidisciplinary team assessment, treatment planning, and long-term follow-up are reiterated in this clinical practice guideline with a class I recommendation, along with the other recommendations from the 2017 guidelines that remained unchanged in their class of recommendation and level of evidence.

Whole Exome Sequencing Uncovers the Genetic Complexity of Bicuspid Aortic Valve in Families with Early Onset Complications.

Bicuspid Aortic Valve (BAV) is the most common adult congenital heart lesion with an estimated population prevalence of 1%. We hypothesize that early onset complications of BAV (EBAV) are driven by specific impactful genetic variants. We analyzed whole exome sequences (WES) to identify rare coding variants that contribute to BAV disease in 215 EBAV families. Predicted pathogenic variants of causal genes were present in 111 EBAV families (51% of total), including genes that cause BAV (8%) or heritable thoracic aortic disease (HTAD, 17%). After appropriate filtration, we also identified 93 variants in 26 novel genes that are associated with autosomal dominant congenital heart phenotypes, including recurrent deleterious variation of FBN2, MYH6, channelopathy genes, and type 1 and 5 collagen genes. These findings confirm our hypothesis that unique rare genetic variants contribute to early onset complications of BAV disease.

Bicuspid Aortic Valve Disease With Early Onset Complications: Characteristics And Aortic Outcomes.

Bicuspid aortic valve (BAV) is the most common congenital heart malformation in adults but can also cause childhood-onset complications. In multicenter study, we found that adults who experience significant complications of BAV disease before age 30 are distinguished from the majority of BAV cases that manifest after age 50 by a relatively severe clinical course, with higher rates of surgical interventions, more frequent second interventions, and a greater burden of congenital heart malformations. These observations highlight the need for prompt recognition, regular lifelong surveillance, and targeted interventions to address the significant health burdens of patients with early onset BAV complications.

Surgical and Transcatheter Mitral Valve Therapy: Medicare Utilization and Reimbursement.

BACKGROUND: We aimed to examine trends in the utilization and reimbursement of surgical and transcatheter mitral valve therapies and their changing relationship. METHODS: A query of administrative data on US Medicare beneficiaries undergoing mitral valve therapy was conducted from 2015 to 2020 using the Centers for Medicare and Medicaid Services Part B National Summary Data File. Inflation adjustment was to the 2020 Consumer Price Index. Trend analysis was quantified with growth rate and simple linear regression calculations. RESULTS: The annual number of all mitral valve procedures remained constant. Transcatheter mitral valve therapies increased by 313% with an increase of 1552 cases per year (P < .001), whereas surgical mitral valve therapies decreased by 31.4% with a decline of 1446 procedures per year (P = .004). As a proportion of all mitral valve therapies, surgical therapies decreased from 91.8% to 65.0%. Annual Medicare reimbursements for transcatheter and surgical mitral valve therapies mirrored the annual procedural trends. For transcatheter mitral valve therapies, per-case reimbursement decreased by 14.1% ($1283.18 to $1102.88), and for surgical mitral valve therapies, per-case reimbursement decreased by 3.8% ($1480.65 to $1424.57). CONCLUSIONS: Medicare utilization of mitral valve therapies has been stable in recent years, with growth of transcatheter volumes offset by a decrease in surgical volumes. This suggests that transcatheter therapy availability has not expanded the pool of patients with access to therapy. Nonetheless, case reimbursements decreased for both modalities.

Two Decades of Declining Medicare Reimbursement in Cardiac Surgery.

BACKGROUND: Given the uncertainty of US health care finances, an understanding of reimbursement trends has become increasingly important in the field of cardiac surgery. We aimed to assess Medicare reimbursement trends for common cardiac surgical procedures from 2000 to 2022. METHODS: Reimbursement data were extracted from the Centers for Medicare and Medicaid Services Physician Fee Schedule Look-Up Tool during the study period for 6 common cardiac operations: aortic valve replacement, mitral valve repair and replacement, tricuspid valve replacement, Bentall procedure, and coronary artery bypass grafting. Reimbursement rates were adjusted for inflation to 2022 US dollars using the Consumer Price Index. Total percentage change and compound annual growth rate were calculated. A split-time analysis was performed to assess trends before and after 2015. Least squares and linear regressions were performed. The R2 value was calculated for each procedure, and slope was used to determine change in reimbursements over time. RESULTS: Inflation-adjusted reimbursement decreased by 34.1% during the study period. The overall compound annual growth rate was -1.8%. Reimbursement trends differed by procedure (P < .001), with all reimbursements trending down (R2 > 0.62), except for mitral valve replacement (P = .21) and tricuspid valve replacement (P = .43). Coronary artery bypass grafting decreased the most (-44.4%), followed by aortic valve replacement (-40.1%), mitral valve repair (-38.5%), mitral valve replacement (-29.8%), Bentall procedure (-28.5%), and tricuspid valve replacement (-25.3%). In split-time analysis, reimbursement rates did not significantly change from 2000 to 2015 (P = .24) but decreased significantly from 2016 to 2022 (P = .001). CONCLUSIONS: Medicare reimbursement significantly decreased for most cardiac surgical procedures. These trends justify further advocacy by The Society of Thoracic Surgeons to maintain access to quality cardiac surgical care.

Rare Genomic Copy Number Variants Implicate New Candidate Genes for Bicuspid Aortic Valve.

Bicuspid aortic valve (BAV), the most common congenital heart defect, is a major cause of aortic valve disease requiring valve interventions and thoracic aortic aneurysms predisposing to acute aortic dissections. The spectrum of BAV ranges from early onset valve and aortic complications (EBAV) to sporadic late onset disease. Rare genomic copy number variants (CNVs) have previously been implicated in the development of BAV and thoracic aortic aneurysms. We determined the frequency and gene content of rare CNVs in EBAV probands (n = 272) using genome-wide SNP microarray analysis and three complementary CNV detection algorithms (cnvPartition, PennCNV, and QuantiSNP). Unselected control genotypes from the Database of Genotypes and Phenotypes were analyzed using identical methods. We filtered the data to select large genic CNVs that were detected by multiple algorithms. Findings were replicated in cohorts with late onset sporadic disease (n = 5040). We identified 34 large and rare (< 1:1000 in controls) CNVs in EBAV probands. The burden of CNVs intersecting with genes known to cause BAV when mutated was increased in case-control analysis. CNVs intersecting with GATA4 and DSCAM were enriched in cases, recurrent in other datasets, and segregated with disease in families. In total, we identified potentially pathogenic CNVs in 8% of EBAV cases, implicating alterations of candidate genes at these loci in the pathogenesis of BAV.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

AIM: The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

AIM: The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS: A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

A survey of critical care training amongst surgical residents: will they be ready?

BACKGROUND: Residents' duty-hour limitations and the trends towards closed-staffing for surgical critical care (SCC) have reshaped educational paradigms. No study has yet addressed the impact of these changes on resident SCC training. In our study, we investigated residents' experiences and perceptions of SCC education and practice. METHODS: At the end of the academic year 2007-2008, we distributed anonymous surveys to categorical general surgery residents in a large, university-based residency. All dedicated SCC rotations are currently completed by the end of PGY3. The survey measured residents' ratings of teaching, experiences, satisfaction, and self-assessed comfort with common SCC diseases and procedures. RESULTS: The response rate was 78% (n = 52/67). At the time of the survey, the 52 respondents had completed 9.3 +/- 4.5 wk of SCC rotations. Despite no rotations beyond PGY3, senior residents (PGYs 4/5) reported significantly greater SCC training time (13.1 versus 7.8 wk) and comfort managing SCC diseases and procedures than juniors (PGY 3). Attendings were rated the most effective didactic teachers, and senior residents the most effective procedural teachers. The mean education satisfaction score was 3.9 +/- 0.9 (5 = extremely satisfied). Residents anticipated performing minimal SCC management of their own patients, but most felt that SCC-trained surgeons should manage critically ill surgery patients. Seniors reported greater SCC fellowship interest (19% versus 0%). The addition of acute care surgery increased interest in 30% of respondents. CONCLUSIONS: Senior residents reported greater comfort with SCC management despite the lack of senior SCC rotations, whilst dedicated training time for junior residents appears to be declining. Residents wish subspecialist care for their critically ill patients, but the low interest in SCC fellowships suggests future physician shortages in this subspecialty.

Surgical Decision Making for Left Ventricular Aneurysmectomy.

Left ventricular aneurysms may be repaired by the linear technique or endoventricular circular patch plasty technique. Choice of technique should be based on the individual patient, including cavity and aneurysm geometry. In this article, we describe the principles underlying decision making with 2 illustrative cases.

Disparity between recent graduates' and experienced surgeons' assessment of time to operative independence.

BACKGROUND: In cardiothoracic surgery, little data exist on the transition to operative independence. We aimed to compare current perceptions of operative autonomy of junior cardiothoracic surgeons and senior colleagues who oversee transitional years. METHODS: An anonymous online survey was sent to currently practicing North American board-certified/eligible cardiothoracic surgeons to assess reported time to operative independence and comfort with cardiothoracic operations. The χ2 test, Fisher exact test, and Mann-Whitney U test were used to compare junior surgeons' self-reported experience to the junior experience as reported by the midcareer and senior surgeons with whom they practiced. Logistic regression was performed to assess factors associated with operative independence. RESULTS: Responses from 436 completed surveys were analyzed (82 juniors and 354 midcareer/seniors). Two hundred fifty-four midcareer/senior surgeons reported on the experience of 531 junior partners. Juniors reported high immediate posttraining comfort with basic cardiac cases and moderate comfort with all other categories. Time to operative independence was significantly different between juniors' self-report and midcareer/senior reports of junior partners except for complex thoracic cases. In multivariable logistic regression analysis, senior, and not midcareer, surgeon status was independently associated with junior operative independence status for cardiac cases and for basic thoracic cases. CONCLUSIONS: Most junior surgeons perceived operative independence with basic thoracic, basic cardiac, and complex cardiac operations earlier in their surgical career than that reported by senior colleagues. Objective measures of operative independence may clarify this discrepancy. This study establishes a baseline by which to compare the effects of integrated 6-year programs on operative independence. The discrepant perceptions may have implications for how training programs prepare graduates for the transition to independent practice.