Transcatheter heart valve explant with infective endocarditis-associated prosthesis failure and outcomes: the EXPLANT-TAVR international registry.

BACKGROUND AND AIMS: Surgical explantation of transcatheter heart valves (THVs) is rapidly increasing, but there are limited data on patients with THV-associated infective endocarditis (IE). This study aims to assess the outcomes of patients undergoing THV explant for IE. METHODS: All patients who underwent THV explant between 2011 and 2022 from 44 sites in the EXPLANT-TAVR registry were identified. Patients with IE as the reason for THV explant were compared to those with other mechanisms of bioprosthetic valve dysfunction (BVD). RESULTS: A total of 372 patients from the EXPLANT-TAVR registry were included. Among them, 184 (49.5%) patients underwent THV explant due to IE and 188 (50.5%) patients due to BVD. At the index transcatheter aortic valve replacement, patients undergoing THV explant for IE were older (74.3 ± 8.6 vs. 71 ± 10.6 years) and had a lower Society of Thoracic Surgeons risk score [2.6% (1.8-5.0) vs. 3.3% (2.1-5.6), P = .029] compared to patients with BVD. Compared to BVD, IE patients had longer intensive care unit and hospital stays (P < .05) and higher stroke rates at 30 days (8.6% vs. 2.9%, P = .032) and 1 year (16.2% vs. 5.2%, P = .010). Adjusted in-hospital, 30-day, and 1-year mortality was 12.1%, 16.1%, and 33.8%, respectively, for the entire cohort, with no significant differences between groups. Although mortality was numerically higher in IE patients 3 years postsurgery (29.6% for BVD vs. 43.9% for IE), Kaplan-Meier analysis showed no significant differences between groups (P = .16). CONCLUSIONS: In the EXPLANT-TAVR registry, patients undergoing THV explant for IE had higher 30-day and 1-year stroke rates and longer intensive care unit and hospital stays. Moreover, patients undergoing THV explant for IE had a higher 3-year mortality rate, which did not reach statistical significance given the relatively small sample size of this unique cohort and the reduced number of events.

Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association.

Acute pulmonary embolism is the third leading cause of cardiovascular death, with most pulmonary embolism-related mortality associated with acute right ventricular failure. Although there has recently been increased clinical attention to acute pulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams, mortality of patients with pulmonary embolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed. Because historical data and practice patterns affect current consensus treatment recommendations, surgical embolectomy has largely been relegated to patients who have contraindications to other treatments or when other treatment modalities fail. Despite a selection bias toward patients with greater illness, a growing body of literature describes the safety and efficacy of the surgical management of acute pulmonary embolism, especially in the hemodynamically compromised population. The purpose of this document is to describe modern techniques, strategies, and outcomes of surgical embolectomy and venoarterial extracorporeal membrane oxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.

Minimalist transcatheter aortic valve replacement misses paravalvular regurgitation: Incidence and echocardiographic distribution of missed paravalvular regurgitation.

BACKGROUND: Paravalvular regurgitation (PVR) may be missed intraoperatively with transthoracic echocardiography (TTE) guided minimalist TAVR. We sought to determine the incidence and echocardiographic distribution of PVR missed on intra-op TTE, but detected on predischarge TTE. METHODS: From July 2015 to 2020, 475 patients with symptomatic severe native aortic stenosis underwent TTE-guided minimalist TAVR. Missed PVR was defined as predischarge PVR that was ≥1 grade higher than the corresponding intra-op PVR severity. PVR was classified as anterior or posterior on the four standard TTE views; parasternal short-axis (PSAX), parasternal long-axis (PLAX), apical 3-chamber (A3C), and 5-chamber (A5C). Location-specific risk of missed PVR was then determined. RESULTS: Mild or greater PVR was seen in 55 (11.5%) cases intra-op and 91 (19.1%) at predischarge, with no severe PVR. Among the 91 patients with ≥mild predischarge PVR, missed PVR was present in 42 (46.2%). Compared to the corresponding anterior jets, missed PVR rate was significantly higher for posterior jets in PLAX (62.5% vs. 25.0%, p = 0.005), A5C (56.9% vs. 25.0%, p = 0.009), PSAX (66.7% vs. 24.3%, 0.001), but not A3C (58.5% vs. 40.0%, p = 0.28). CONCLUSIONS: Intraoperative TTE-guided minimalist TAVR either misses nearly half of ≥mild PVR or underestimates PVR by ≥1 grade when compared to predischarge TTE. Posterior PVR jets are more likely to be missed. Transesophageal echo guidance may help minimize missing PVR. Further studies are warranted.

Practical approach to confirm femoral artery patency after percutaneous closure for veno-arterial extracorporeal membrane oxygenation decannulation.

BACKGROUND: We describe a technique to assess blood flow distal to the decannulation site after deployment of Perclose ProGlide (Abbott Vascular, Abbott Park, Ill) in patients on femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. TECHNIQUE: An antegrade distal perfusion catheter was placed in all patients, and decannulation was primarily performed at bedside (N = 11/12). With the VA-ECMO circuit switched off, a needle was inserted into the arterial tubing, passed through the femoral arterial cannula into the artery. The arterial cannula was removed over a wire and the previously placed Proglide Perclose sutures were secured. Back bleeding from the antegrade distal perfusion catheter, confirmed using a three-way connector, indicated blood flow to the superficial femoral artery. This was followed by confirmation of blood flow to the lower leg using a Doppler ultrasound. Hemostasis of the antegrade perfusion catheter was achieved through manual compression. RESULTS: We implemented this technique in 12 patients with a technical success rate of 100%. There were no ipsilateral leg ischemia, bleeding, pseudoaneurysm, or infection after decannulation. CONCLUSIONS: This technique allows prompt assessment of blood flow to the distal leg immediately following arterial decannulation.

Outcomes and feasibility of redo-TAVR after Sapien 3 Ultra TAVR in extremely-undersized versus nominally-sized annuli.

OBJECTIVES: To compare outcomes in Sapien 3 Ultra (S3U) transcatheter aortic valve replacement (TAVR) with extreme annular undersizing (EAU) versus nominal annular sizing (NAS). BACKGROUND: The Edwards S3U valve has reduced paravalvular leak (PVL) in TAVR but outcomes remain unknown in extremely undersized anatomy. Implanting a smaller S3U valve may facilitate future redo-TAVR but risk compromising hemodynamics. METHODS: From December 2019 to July 2021, 366 patients with native aortic stenosis underwent S3U TAVR. Patients with EAU (annular areas >430 mm2 for 23 mm or >546 mm2 for 26 mm) were compared to NAS (338-430 mm2 for 23 mm or 430-546 mm2 for 26 mm). In-hospital and 30-day outcomes, and redo-TAVR feasibility were determined. RESULTS: There were 79 (21.6%) EAU patients, with more bicuspid (p = 0.0014) and ≥moderate annular/left ventricular outflow tract calcification (p < 0.001). The EAU group had less annular oversizing than NAS group (23 mm: -8.2 ± 2.6% vs. 4.0 ± 7.0%, p < 0.001; 26 mm: -8.9 ± 2.2% vs. 6.7 ± 6.9%, p < 0.001), more balloon overfilling (71.3% vs. 11.6%, p < 0.001), and postdilatation (15.0% vs. 5.8%, p = 0.016). No differences were found in in-hospital or 30-day mortality and stroke (p > 0.05). Mild PVL (13.4% EAU vs. 11.5% NAS, p = 0.56) and mean gradients (23 mm: 13.0 ± 4.5 vs. 14.1 ± 5.4 mmHg, p = 0.40; 26 mm: 11.4 ± 4.1 vs. 11.5 ± 3.9 mmHg, p = 1.0) were similar at 30 days. Had the EAU group undergone NAS with the larger Sapien 3/S3U, by computed tomography analysis simulating 80:20 or 90:10 target implant depth, 33.3%-60.9% (vs. 4.3%-23.2%) would not be feasible for redo-TAVR due to high risk of coronary obstruction. CONCLUSIONS: In this first report of EAU with S3U TAVR, similar excellent short-term outcomes can be achieved compared to NAS, and may preserve future redo-TAVR option.

High flow from Impella 5.5 with partial veno-arterial extracorporeal membrane oxygenation support: Case series.

Optimal flow balance between Impella 5.5 and veno-arterial extracorporeal membrane oxygenation (ECMO) support in the setting of EC-PELLA (ECMO+Impella) is unknown. Outcomes of high Impella 5.5 flow in the setting of EC-PELLA support were reviewed (N = 7). EC-PELLA was successfully explanted in 6 patients (bridge-to-transplant, N = 1; bridge-to-recovery, N = 5). The median duration of EC-PELLA support in explanted patients was 6 days. Survival at discharge was 71.4% (5 patients). In terms of device-related events, either VA-ECMO or Impella-related complications were not experienced. The median performance level of Impella 5.5 was P5 at the time of starting EC-PELLA support and then increased with time up to the median of P8 with increment of the Impella flow, and index (L/min/m2 ). The percentage of Impella flow per total EC- PELLA flow reached 50% after 48 h of support. The vasoactive-inotropic score and serum lactate level improved after institution of EC-PELLA support as well as the pulmonary artery pressures and central venous pressure. In conclusion, a high pump flow from Impella 5.5 with partial VA-ECMO support in the setting of EC-PELLA provided great support with favorable survival and device-related complications rate.

Evaluating Changes in del Nido Cardioplegia Practices in Adult Cardiac Surgery.

There has been a rapid adoption of the use of del Nido cardioplegia (DC) among adults undergoing cardiac surgery. We leveraged a multicenter database to evaluate differences over time in the choice and impact of cardioplegia type (DC vs. blood) among patients undergoing cardiac surgery. We evaluated 26,373 patients undergoing non-emergent coronary artery bypass and/or valve surgery between 2014-2015 (early period) and 2017-2018 (late period) at 31 centers. DC was compared with blood-based cardioplegia (BC: 1:1, 2:1, 4:1, 8:1, and variable ratio). We evaluated whether treatment choice differed across prespecified patient characteristics, procedure type, and perfusion practices by time period. We evaluated increased DC use with clinical outcomes (major morbidity and mortality, prolonged intubation, and renal failure), after adjusting for baseline characteristics, procedure type, center, and year. DC use increased from 19.6% in 2014-2015 to 41.5% in 2017-2018, p < .001. Increased DC use occurred among coronary artery bypass grafting (CABG), valve, and CABG + valve procedures, all p < .001. Differences in median procedural duration increased over time (DC vs. BC): 1) bypass duration was 11.0 minutes shorter with DC in the early period and 27.0 minutes shorter in the late period, and 2) cross-clamp duration was 7.0 minutes shorter with DC in the early period and 17.0 minutes shorter in the late period, all p < .001. There were no statistical differences in adjusted odds of major morbidity and mortality (odds ratio [OR]adj: 1.01), prolonged intubation (ORadj: .99), or renal failure (ORadj: .80) by DC use (p > .05). In this large multicenter experience, DC use increased over time and was associated with reduced bypass and ischemic time absent any significant differences in adjusted outcomes.

Is Conventional Bypass for Coronary Artery Bypass Graft Surgery a Misnomer?

Although recent trials comparing on vs. off-pump revascularization techniques describe cardiopulmonary bypass (CPB) as "conventional," inadequate description and evaluation of how CPB is managed often exist in the peer-reviewed literature. We identify and subsequently describe regional and center-level differences in the techniques and equipment used for conducting CPB in the setting of coronary artery bypass grafting (CABG) surgery. We accessed prospectively collected data among isolated CABG procedures submitted to either the Australian and New Zealand Collaborative Perfusion Registry (ANZCPR) or Perfusion Measures and outcomes (PERForm) Registry between January 1, 2014, and December 31, 2015. Variation in equipment and management practices reflecting key areas of CPB is described across 47 centers (ANZCPR: 9; PERForm: 38). We report average usage (categorical data) or median values (continuous data) at the center-level, along with the minimum and maximum across centers. Three thousand five hundred sixty-two patients were identified in the ANZCPR and 8,450 in PERForm. Substantial variation in equipment usage and CPB management practices existed (within and across registries). Open venous reservoirs were commonly used across both registries (nearly 100%), as were "all-but-cannula" biopassive surface coatings (>90%), whereas roller pumps were more commonly used in ANZCPR (ANZCPR: 85% vs. PERForm: 64%). ANZCPR participants had 640 mL absolute higher net prime volumes, attributed in part to higher total prime volume (1,462 mL vs. 1,217 mL) and lower adoption of retrograde autologous priming (20% vs. 81%). ANZCPR participants had higher nadir hematocrit on CPB (27 vs. 25). Minimal absolute differences existed in exposure to high arterial outflow temperatures (36.6°C vs. 37.0°C). We report substantial center and registry differences in both the type of equipment used and CPB management strategies. These findings suggest that the term "conventional bypass" may not adequately reflect real-world experiences. Instead of using this term, authors should provide key details of the CPB practices used in their patients.

The Relationship between Intra-Operative Transfusions and Nadir Hematocrit on Post-Operative Outcomes after Cardiac Surgery.

Uncertainty exists regarding the optimal strategy for the management of anemia in the setting of cardiac surgery. We sought to improve our understanding of the role of intra-operative hematocrit (HCT) and transfusions on peri-operative outcomes following cardiac surgery. A total of 18,886 patients undergoing on-pump cardiac surgery were identified from a multi-institutional registry including surgical and perfusion data. Patients were divided into four groups based on their intra-operative nadir HCT (<21 or ≥21) and whether or not they received intra-operative red blood cell (+RBC or -RBC) transfusions. Outcomes were adjusted for the Society of Thoracic Surgeons predicted risk of mortality (PROM), pre-operative HCT, and medical center. Regardless of nadir HCT cohort, those who received a transfusion had higher PROM relative to patients who did not receive a transfusion. The mean PROM was significantly higher among those HCT ≥21 + RBC (5.3%) vs. HCT ≥ 21 - RBC (1.9%), p < .001. Similarly, the PROM was significantly higher among HCT <21 + RBC (5.1%) vs. those HCT <21 - RBC (3.1%), p < .001. Adjusted outcomes demonstrated an increased impact of RBC transfusions on adverse outcomes irrespective of nadir HCT including stroke (p < .001), renal failure (p < .001), prolonged ventilation (p < .001), and mortality (p < .001). This study demonstrates that transfusions have a more profound effect on post-operative cardiac surgery outcomes than anemia.

Stroke After Acute Type A Dissection Repair Using Right Axillary Cannulation First Approach.

BACKGROUND: This study sought to analyze the details of strokes after acute type A dissection repair (ATAD) using a right axillary artery (RAX) first approach. METHODS: A total of 356 consecutive ATAD repairs from 2005 to 2022 were analyzed on the basis of arterial cannulation site. Strokes were evaluated by head computed tomography. RESULTS: The rate of RAX cannulation was 82.6% (n = 294), with a 38.2% rate of antegrade cerebral perfusion use, both of which had increased over the years. The non-RAX group had more cardiogenic shock (RAX, 16.3% vs non-RAX, 37.1%; P < .001), cerebral malperfusion (8.8% vs 25.8%, respectively; P < .001), and innominate artery dissection (45.9% vs 69.2%, respectively; P = .007). Eight patients died before undergoing a full neurologic assessment. The overall stroke rate was 8.4% (n = 30), and it was lower in the RAX group (5.1% vs 24.2%; P < .001). All strokes were ischemic, with concomitant hemorrhagic strokes occurring in 6 patients. Strokes diagnosed immediately after surgery (perioperative stroke) accounted for 70% (n = 21 of 30) of cases. Strokes predominantly affected the right anterior circulation (right anterior, 80% vs left anterior, 46.7% vs left posterior, 26.7%; P = .013), independent of arterial cannulation site. The proposed mechanism of perioperative strokes was not uniform (embolism, 33.3%; hypoperfusion, 42.8%; embolism and hypoperfusion, 14.3%; lacunar infarct, 10%), whereas most postoperative strokes were embolic (77.8%). The mean National Institutes of Health Stroke Scale score was 20.6 ± 9.9, and the modified Rankin score at discharge was 4.1±2.2. CONCLUSIONS: Most strokes in ATAD occurred perioperatively from various mechanisms predominantly affecting the right anterior circulation irrespective of the arterial cannulation site. This complication is most likely the result of unstable hemodynamics and dissection of the innominate artery (IA) or its downstream vessels.

Perfusion Measures and Outcomes (PERForm) registry: First annual report.

BACKGROUND: The Perfusion Measures and Outcomes (PERForm) registry was established in 2010 to advance cardiopulmonary bypass (CPB) practices and outcomes. The registry is maintained through the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative and is the official registry of the American Society of Extracorporeal Technology. METHODS: This first annual PERForm registry report summarizes patient characteristics as well as CPB-related practice patterns in adult (≥18 years of age) patients between 2019 and 2022 from 42 participating hospitals. Data from PERForm are probabilistically matched to institutional surgical registry data. Trends in myocardial protection, glucose, anticoagulation, temperature, anemia (hematocrit), and fluid management are summarized. Additionally, trends in equipment (hardware/disposables) utilization and employed patient safety practices are reported. RESULTS: A total of 40,777 adult patients undergoing CPB were matched to institutional surgical registry data from 42 hospitals. Among these patients, 54.9% underwent a CABG procedure, 71.6% were male, and the median (IQR) age was 66.0 [58.0, 73.0] years. Overall, 33.1% of the CPB procedures utilized a roller pump for the arterial pump device, and a perfusion checklist was employed 99.6% of the time. The use of conventional ultrafiltration decreased over the study period (2019 vs. 2022; 27.1% vs. 24.9%) while the median (IQR) last hematocrit on CPB has remained stable [27.0 (24.0, 30.0) vs. 27.0 (24.0, 30.0)]. Pump sucker termination before protamine administration increased over the study period: (54.8% vs. 75.9%). CONCLUSION: Few robust clinical registries exist to collect data regarding the practice of CPB. Although data submitted to the PERForm registry demonstrate overall compliance with published perfusion evidence-based guidelines, noted opportunities to advance patient safety and outcomes remain.

Aortic Reoperation After Prior Acute Type A Aortic Dissection Repair: Don't Despair the Repair.

BACKGROUND: There is paucity of data regarding reoperation after acute type A aortic dissection (ATAD) repair. METHODS: From October 2006 to March 2022, 75 patients received 123 reoperations after ATAD (proximal, n = 17; distal, n = 103; and both, n = 3) utilizing redo sternotomy (RS, n = 68), left thoracotomy (LT, n = 44), and endovascular approach (TEVAR, n = 11). The axillary artery cannulation was utilized in 97.1% of the RS cases. A classic elephant trunk technique was used as a 2-staged procedure for distal pathology. Most LT repairs (95.5%) were completed above the celiac axis. RESULTS: Index ATAD repairs were predominantly ascending/hemiarch repair (73.3%). The median duration from the index repair was 2.0 years. Most reoperations were elective procedures (82.1%). Hospital mortality was 2.4% (RS, 1.5%; LT, 4.5%; TEVAR, 0%), and the stroke rate was 1.6%. There was no spinal cord ischemia. The 5-year overall survival and freedom from aortic mortality or procedure were 85.2% ± 5.6% and 80.6% ± 6.1%, respectively. There were 7 distal reinterventions (prior TEVAR, n = 3; prior LT, n = 4). Two patients required LT repair after prior TEVAR and 3 patients received infrarenal aortic repair after prior LT repair. Computed tomography after completion of the distal repair (n = 45) showed an increase of distal aorta at each level as follows: celiac axis 1.2 mm/y; renal artery 1.0 mm/y; and terminal aorta 1.2 mm/y. CONCLUSIONS: Reoperation after ATAD repair can be safely performed as an elective procedure at experienced centers. Staged distal interventions utilizing classic elephant trunk insertion and open repair above the celiac axis showed durable outcomes.

Zone 2 arch repair for acute type A dissection: Evolution from arch-first to proximal-first repair.

Objective: With growing experience of acute type A aortic dissection repair, Zone 2 arch repair has been advocated. The aim of this study is to compare the outcome between "proximal-first" and "arch-first" Zone 2 repair. Methods: From January 2015 to March 2023, 45 patients underwent Zone 2 arch repair out of 208 acute type A aortic dissection repairs: arch-first, N = 19, and proximal-first technique, N = 26, since January 2021. Indications were aortic arch or descending tear, complex dissection in neck vessels, cerebral malperfusion, or aneurysm of the aortic arch. Results: The lowest bladder temperature was higher in the proximal-first technique (24.9 °C vs 19.7 °C, P < .001). Cardiopulmonary bypass (230 vs 177.5 minutes, P < .001), myocardial ischemic (124 vs 91 minutes, P < .001), and lower-body circulatory arrest (87 vs 28 minutes, P < .001) times were shorter in the proximal-first technique. The arch-first group required more packed red blood cells (arch-first, 2 units vs proximal-first, 0 units, P = .048), platelets (arch-first, 4 units vs proximal-first, 2 units, P = .003), and cryoprecipitates (arch-first, 2 units vs proximal-first, 1 unit, P = .024). Operative mortality and major morbidities were higher in the arch-first group (57.9% vs 11.5%, P = .001). One-year survival was comparable (arch-first, 89.5% ± 7.0% vs proximal-first, 92.0% ± 5.5%, P = .739). Distal intervention was successfully performed in 5 patients (endovascular, N = 3, and open repair, N = 2). Conclusions: Zone 2 arch repair using the proximal-first technique for acute type A aortic dissection repair yields shorter lower-body ischemic time with a warmer core temperature, resulting in shorter cardiopulmonary bypass time, less blood product use, and fewer morbidities when compared with the arch-first technique.

Dispelling the Saddle Pulmonary Embolism Myth (from a Comparison of Saddle Versus Non-Saddle Pulmonary Embolism).

In the setting of an acute pulmonary embolism (PE), there is often an assumed association between a saddle PE (SPE) and increased clinical severity. We aimed to determine the magnitude of SPE proximal pulmonary artery (PA) flow obstruction and its impact on right ventricular (RV) function in the setting of acute PE in a single-center series. From 2005 to 2022, patients with acute PE presenting with acute RV dysfunction requiring intervention were classified as SPE and non-SPE based on presenting computed tomography (CT) scans. SPE flow obstruction was determined by the ratio of the orthogonal cross-sectional surface area measurements of clot and native PA at the location of maximum clot burden in the right PA and left PA. Presenting RV function based on clinical and imaging parameters (CT and transthoracic echocardiography) were compared between SPE and non-SPE cohorts. A total of 174 patients were identified (SPE 92 [52.9%] and non-SPE 82 [47.1%]). Demographics and co-morbidities were similar. In patients with SPE, there was a mean 25.9% total flow obstruction (right PA 26.9% and left PA 25.5%). Non-SPE had greater clinical RV dysfunction on presentation as reflected by more high-risk PE (43.9% vs 26.1%, p = 0.01), need for venoarterial extracorporeal membrane oxygenation (21.9% vs 10.9%, p = 0.05), and more preoperative cardiopulmonary resuscitation (16.7% vs 7.8%, p = 0.08). RV:left ventricular ratio (CT and transthoracic echocardiography) and RV fractional area change were statistically similar between groups. In-hospital mortality was statistically similar between cohorts (4.9% non-SPE vs 2.1% SPE, p = 0.32). In conclusion, in a single-center series of patients with acute PE with RV dysfunction, SPE did not cause proximal flow-limiting obstruction. Non-SPE was associated with more clinical RV dysfunction than SPE. Thus, it should not be assumed that a non-SPE is a marker of patient stability.

Extracorporeal membrane oxygenation in COVID-19 compared to other etiologies of acute respiratory failure: A single-center experience.

BACKGROUND: The COVID-19 pandemic has led to a boom in the use of V-V ECMO for ARDS secondary to COVID. Comparisons of outcomes of ECMO for COVID to ECMO for influenza have emerged. Very few comparisons of ECMO for COVID to ECMO for ARDS of all etiologies are available. OBJECTIVES: To compare clinically important outcome measures in recipients of ECMO for COVID to those observed in recipients of ECMO for ARDS of other etiologies. METHODS: V-V ECMO recipients between March 2020 and March 2022 consisted exclusively of COVID patients and formed the COVID ECMO group. All patients who underwent V-V ECMO for ARDS between January 2014 and March 2020 were eligible for analysis as the non-COVID ECMO comparator group. The primary outcome was survival to hospital discharge. Secondary outcomes included ECMO decannulation, ECMO duration >30 days, and serious complications. RESULTS: Thirty-six patients comprised the COVID ECMO group and were compared to 18 non-COVID ECMO patients. Survival to hospital discharge was not significantly different between the two groups (33% in COVID vs. 50% in non-COVID; p = 0.255) nor was there a significant difference in the rate of non-palliative ECMO decannulation. The proportion of patients connected to ECMO for >30 days was significantly higher in the COVID ECMO group: 69% vs. 17%; p = 0.001. There was no significant difference in serious complications. CONCLUSION: This study could not identify a statistically significant difference in hospital survival and rate of successful ECMO decannulation between COVID ECMO and non-COVID ECMO patients. Prolonged ECMO may be more common in COVID. Complications were not significantly different.

Explant vs Redo-TAVR After Transcatheter Valve Failure: Mid-Term Outcomes From the EXPLANTORREDO-TAVR International Registry.

BACKGROUND: Valve reintervention after transcatheter aortic valve replacement (TAVR) failure has not been studied in detail. OBJECTIVES: The authors sought to determine outcomes of TAVR surgical explantation (TAVR-explant) vs redo-TAVR because they are largely unknown. METHODS: From May 2009 to February 2022, 396 patients in the international EXPLANTORREDO-TAVR registry underwent TAVR-explant (181, 46.4%) or redo-TAVR (215, 54.3%) for transcatheter heart valve (THV) failure during a separate admission from the initial TAVR. Outcomes were reported at 30 days and 1 year. RESULTS: The incidence of reintervention after THV failure was 0.59% with increasing volume during the study period. Median time from index-TAVR to reintervention was shorter in TAVR-explant vs redo-TAVR (17.6 months [IQR: 5.0-40.7 months] vs 45.7 months [IQR: 10.6-75.6 months]; P < 0.001], respectively. TAVR-explant had more prosthesis-patient mismatch (17.1% vs 0.5%; P < 0.001) as the indication for reintervention, whereas redo-TAVR had more structural valve degeneration (63.7% vs 51.9%; P = 0.023), with a similar incidence of ≥moderate paravalvular leak between groups (28.7% vs 32.8% in redo-TAVR; P = 0.44). There was a similar proportion of balloon-expandable THV failures (39.8% TAVR-explant vs 40.5% redo-TAVR; P = 0.92). Median follow-up was 11.3 (IQR: 1.6-27.1 months) after reintervention. Compared with redo-TAVR, TAVR-explant had higher mortality at 30 days (13.6% vs 3.4%; P < 0.001) and 1 year (32.4% vs 15.4%; P = 0.001), with similar stroke rates between groups. On landmark analysis, mortality was similar between groups after 30 days (P = 0.91). CONCLUSIONS: In this first report of the EXPLANTORREDO-TAVR global registry, TAVR-explant had a shorter median time to reintervention, with less structural valve degeneration, more prosthesis-patient mismatch, and similar paravalvular leak rates compared with redo-TAVR. TAVR-explant had higher mortality at 30 days and 1 year, but similar rates on landmark analysis after 30 days.

The effect of risk and race on lower extremity amputations among Medicare diabetic patients.

OBJECTIVE: The effect of national quality initiatives aiming at limiting lower extremity amputations in diabetic patients remains uncertain. We therefore explored trends in amputation among Medicare diabetic patients with a focus on those at highest risk. METHODS: The Diabetes Analytical File, an enhanced sample of all diabetic patients from the Medicare 5% sample, was used to study the national incidence of amputation in diabetic patients. Within a cohort of ∼5 million diabetic patients between 1999 and 2006, we compared the incidence of amputation in high-risk (end-stage renal disease or more than three comorbidities) and low-risk groups and by race. RESULTS: Between 1999 and 2006, 23,976 amputations were performed, comprising 11,558 in high-risk and 12,418 in low-risk patients. The amputation rate declined over time from 4.8/1000 in 1999 to 4.4/1000 in 2006 (P<.001). High-risk patients represented a growing proportion of all amputations (33% in 1999, 50% in 2006; P<.001) despite representing 4% of diabetic patients in 1999 and 10% in 2006 (P<.001). The incidence of amputation was 29.6/1000 in the high-risk group vs 2.7/1000 in low-risk patients (P<.001). African Americans had higher rates of amputation in high-risk and low-risk groups. CONCLUSIONS: High-risk patients represent a minority of Medicare diabetic patients but account for 50% of all amputations, and this effect is magnified in African Americans. Future quality improvement efforts should focus on high-risk patients and African Americans.

Simultaneous Real-Time Intravascular Ultrasound-Guided Transcatheter Pulmonary Embolectomy Improves Procedural Accuracy, Efficacy, and Safety.

Percutaneous catheter-directed interventions for pulmonary embolism is a rapidly evolving field. We present the first case report of simultaneous intravascular ultrasound (IVUS) use during transcatheter pulmonary embolectomy. Real-time IVUS guidance offers the advantage of better clot visualization and precise suction catheter localization while minimizing contrast medium exposure and wire exchanges. (Level of Difficulty: Advanced.).

Successful Heart Transplantation Recovered From a Brain-Dead Donor on Veno-Arterial Extracorporeal Membrane Oxygenation Support.

We describe the successful transplantation of a brain-dead donor supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) after cardiac arrest secondary to pulmonary embolism. The donor was a 50-year-old female who developed massive pulmonary embolism complicated by cardiac arrest requiring initiation of VA-ECMO. An initial echocardiogram revealed severe right ventricular dysfunction which recovered after 6 days of VA-ECMO confirmed by transthoracic echocardiogram and right heart catheterization. The heart was transplanted to a 56-year-old male on a left ventricular assist device. At 1-year posttransplant, he continues to have normal graft function. The present case reports the successful transplantation of a brain-dead donor heart recently recovered from pulmonary embolism induced acute right ventricular failure supported by VA-ECMO and represents a potential source of increased donor organs that would otherwise not be utilized.

Direct Axillary Artery Cannulation for Aortic Surgery: Lessons From Contemporary Experiences.

BACKGROUND: This study seeks to assess the outcomes of direct axillary artery (AX) cannulation for thoracic aortic surgery. METHODS: From October 2009 to November 2021 direct AX cannulation was planned in 515 patients for thoracic aortic pathology. An important aspect of our technique is that the cannula is not inserted deeper than 3 cm. AX cannulation-related events included shift of cannulation site from the initial site, vascular injury, and iatrogenic dissection. RESULTS: Half of the patients had acute type A dissection (ATAD). An angled cannula was used in 442 patients and a straight cannula in 73 patients (14.2%) after August 2020. A previously cannulated AX was reused in 36 patients (7.0%). Mortality and stroke rates were 5.4% (ATAD vs non-ATAD: 8.0% vs 2.8%, P = .008) and 2.7% (ATAD vs non-ATAD: 4.6% vs 0.8%, P = .034), respectively. AX cannulation-related events were observed in 2.7% of patients. There was no difference in the vascular injury rate between ATAD and non-ATAD cases (1.6% vs 0.4%, respectively; P = .385), between different cannula types (angled vs straight: 0.9% vs 1.4%, P = 1.00), or between primary and redo AX cannulation cases (0.8% vs 2.8%, respectively; P = .791). On multidetector computed tomography analysis using automated 3-dimensional images, the mean distance from the thoracoacromial artery to the vertebral artery on the right and left sides was 8.70 cm and 8.69 cm, respectively. CONCLUSIONS: Direct AX cannulation for thoracic aortic repair is safe and carries a low rate of vascular injury, especially in elective cases. Our direct cannulation technique, which includes not inserting a cannula deeper than 3 cm, seems to be safe in not occluding the vertebral artery.