Relation of body mass index to long-term survival and cardiac remodelling for patients undergoing mitral valve replacement surgery.

BACKGROUND AND AIMS: Studies have demonstrated that obesity is paradoxically associated with reduced mortality following cardiac surgery. However, these studies have treated various types of cardiac surgery as a single entity. With mitral valve (MV) surgeries being the fastest-growing cardiac surgical interventions in North America, the purpose of this study was to identify the impact of body mass index (BMI) on long-term survival and cardiac remodelling of patients undergoing MV replacement (MVR). METHODS AND RESULTS: In this retrospective, single-center study, 1071 adult patients who underwent an MVR between 2004 and 2018 were stratified into five BMI groups (<20, 20-24.9, 25-29.9, 30-34.9, >35). Cox proportional hazard regression models were used to determine the association between BMI and all-cause mortality. Patients who were underweight had significantly higher all-cause mortality rates at the longest follow-up (median 8.2 years) than patients with normal weight (p = 0.01). Patients who were in the obese group had significantly higher readmission rates due to myocardial infarction (MI) at the longest follow-up (p = 0.017). Subgroup analysis revealed a significant increase in long-term all-cause mortality for female patients who were underweight. Significant changes in left atrial size, mitral valve peak and mean gradients were seen in all BMI groups. CONCLUSIONS: For patients undergoing mitral valve replacement, BMI is unrelated to operative outcomes except for patients who are underweight.

Impact of Sex on Long-Term Outcomes Following Surgical Aortic Valve Replacement.

BACKGROUND: The impact of sex on outcomes following surgical aortic valve replacement (SAVR) remains unclear. It has been proposed that females experience inferior outcomes, but this has yet to be conclusively established, particularly in the long term. The objective of this study is to identify discrepancies in postoperative outcomes between males and females following SAVR to better inform consideration for surgical intervention. METHOD: We retrospectively reviewed the outcomes of 4,927 patients who underwent SAVR from 2004 to 2018 at our centre. In total, 531 propensity-matched males and females were included in the final analysis. The primary outcome was mortality at any point during the follow-up period. Secondary outcomes included various measures of postoperative morbidity. Follow-up duration was 15 years. RESULTS: In SAVR all-comers, females experienced inferior short-term mortality, but equivalent mid-term and long-term mortality. Rates of mediastinal bleeding, sternal wound infections, sepsis, heart failure, and pacemaker insertion were all equivalent between the sexes; however, males experienced a higher rate of acute kidney injury and readmission for stroke at the longest follow-up while females experienced a longer intensive care unit and hospital length of stay. In a sub-analysis of isolated SAVR, males and females experienced equivalent early, mid, and late mortality. Of note, a trend towards increased aortic valve reoperation was noted in females at the longest follow-up. CONCLUSIONS: Males and females experience equivalent long-term mortality following isolated SAVR. Sex is not an independent risk factor of poor outcomes post-SAVR; however, the increased preoperative risk profile of females requires diligent consideration.

Recellularized bovine pericardium with autologous mesenchymal stem cells reduces immune activation.

INTRODUCTION: Current bioprosthetic heart valve replacement options are limited by structural valvular deterioration (SVD) due to an immune response to the xenogenic scaffold. Autologous mesenchymal stem cell (MSC) recellularization is a method of concealing xenogenic scaffolds, preventing recipient immune recognition of xenogenic tissue heart valves, and potentially leading to reduction in SVD incidence. The purpose of this study is to examine the effects of autologous MSC recellularized tissue on the immune response of human whole blood to bovine pericardium (BP). We hypothesized that autologous MSC recellularization of BP will result in reduced pro-inflammatory cytokine production equivalent to autologous human pericardium. METHODS: Bone marrow, human pericardium, and whole blood were collected from adult patients undergoing elective cardiac surgery. Decellularized BP underwent recellularization with autologous MSCs, followed by co-incubation with autologous whole blood. Immunohistochemical, microscopic, and quantitative immune analysis approaches were used. RESULTS: We demonstrated that native BP, exposed to human whole blood, results in significant TNF-α and IL1ß production. When decellularized BP is recellularized with autologous MSCs and exposed to whole blood, there is a significant reduction in TNF-α and IL1ß production. Importantly, recellularized BP exposed to whole blood had similar production of TNF-α and IL1ß when compared to autologous human pericardium exposed to human whole blood. CONCLUSION: Our results suggest that preventing initial immune activation with autologous MSC recellularization may be an effective approach to decrease the recipient immune response, preventing recipient immune recognition of xenogeneic tissue engineered heart valves, and potentially leading to reduction in SVD incidence.

Coronary artery occlusion flap: An unusual case of spontaneous coronary artery dissection.

CASE REPORT: A 39-year-old female presented with chest pain, shortness of breath, and was diagnosed with ST-elevation myocardial infarction. Coronary angiogram revealed left main coronary artery (LMCA) spontaneous coronary artery dissection (SCAD). Following conservative treatment, the patient continued experiencing shortness of breath and chest pain. The cause of these symptoms was difficult to ascertain, even with further investigation. The patient underwent coronary artery bypass grafting, aortic valve replacement, and aortic root replacement with reimplantation of coronary buttons. Following aortotomy, a dissection flap formed by the SCAD was identified, intermittently occluding the LMCA. This was thought to cause their intermittent and severe heart failure symptoms as the flap would intermittently occlude the LMCA causing severe myocardial ischemia. CONCLUSION: This patient's presentation of a dissection flap intermittently occluding the LMCA demonstrates an abnormal manifestation of SCAD. Increased awareness of this presentation is imperative to ensure future cases are correctly identified and managed.

Mortality and morbidity of surgical and transcatheter mitral valve repair in octogenarians: A systematic review.

BACKGROUND: Valvular heart disease (VHD) is a prominent problem in healthcare today with mitral regurgitation (MR) being the leading cause of VHD in the elderly population. While mitral valve repair (MVr) surgery is one of the only options for the end-stage disease, octogenarians are often denied MVr due to concerns with operative mortality and postoperative morbidity. To provide information on this underrepresented group of surgical patients, a systematic approach was taken to review the mortality and morbidity rates of octogenarians who received MVr. METHODS: Pubmed and Medline were searched for articles containing outcomes of octogenarians receiving surgical mitral valve repair (SMVr) or transcatheter mitral valve repair (TMVr) published after 2000. Ten articles met the inclusion criteria for a total of 7968 patients included in the analysis using Microsoft Excel, Version 2105. RESULTS: Short-term mortality rates for SMVr and TMVr were 2.6% and 1.4% for in-hospital, and 7.8% and 3.3% for 30 days, respectively. The average incidence of stroke, acute kidney injury, infection, and major bleeding for SMVr were 3.2%, 11.2%, 7.7%, and 24%, respectively, and 0.3%, 6.7%, 2.7%, and 7.9% for TMVr, respectively. CONCLUSION: Octogenarians receiving SMVr or TMVr experienced similar rates of short-term mortality and morbidity as younger populations, and when considering life expectancy, midterm mortality was also similar. With these results, denying octogenarians MVr operations based on age alone should be reconsidered. Depending on risk factors and comorbidities, either SMVr or TMVr is a viable and relatively safe option for octogenarians with severe MR.

The effects of body mass index on long-term outcomes and cardiac remodeling following mitral valve repair surgery.

BACKGROUND: Previous literature has demonstrated equivalent or improved survival post mitral valve (MV) surgery amongst patients with obesity when compared to their normal-weight counterparts. This relationship is poorly understood and the impact of body mass index (BMI) on cardiac remodeling has not been established. METHODS: In this retrospective, single-center study, we sought to identify the impact that BMI may have on long-term outcomes and cardiac remodeling post-MV repair. Outcomes were compared between patients of varying BMI undergoing MV repair between 2004 and 2018. The primary outcome was mortality and secondary outcomes included stroke, myocardial infarction, reoperation of the MV, rehospitalization, and cardiac remodeling. RESULTS: A total of 32 underweight, 249 normal weight, 249 overweight, 121 obese, and 50 morbidly obese patients were included in this study. Underweight patients had increased mortality at longest follow-up. Patients with morbid obesity were found to have higher rates of readmission for heart failure. Only underweight patients did not demonstrate a significant reduction in LVEF. Patients with normal weight and overweight had a significant reduction in left atrial size, and patients with obesity had a significant reduction in MV area. CONCLUSIONS: An obesity paradox has been identified in cardiac surgery. While patients with obesity have higher rates of comorbidities preoperatively, their rates of mortality are equivalent or even superior to those with lower BMI. The results of our study confirm this finding with patients of high BMI undergoing MV repair demonstrating equivalent rates of morbidity to their normal BMI counterparts. While the obesity paradox has been relatively consistent in the literature, the understanding of its cause and long-term impacts are not well understood. Further focused investigation is necessary to elucidate the cause of this relationship.

A review of the immune response stimulated by xenogenic tissue heart valves.

Valvular heart disease continues to afflict millions of people around the world. In many cases, the only corrective treatment for valvular heart disease is valve replacement. Valve replacement options are currently limited, and the most common construct utilized are xenogenic tissue heart valves. The main limitation with the use of this valve type is the development of valvular deterioration. Valve deterioration results in intrinsic permanent changes in the valve structure, often leading to hemodynamic compromise and clinical symptoms of valve re-stenosis. A significant amount of research has been performed regarding the incidence of valve deterioration and determination of significant risk factors for its development. As a result, many believe that the underlying driver of valve deterioration is a chronic immune-mediated rejection process of the foreign xenogenic-derived tissue. The underlying mechanisms of how this occurs are an area of ongoing research and active debate. In this review, we provide an overview of the important components of the immune system and how they respond to xenografts. A review of the proposed mechanisms of xenogenic heart valve deterioration is provided including the immune response to xenografts. Finally, we discuss the role of strategies to combat valve degeneration such as preservation protocols, epitope modification and decellularization.

Impact of sex on cardiac remodeling and long-term outcomes, following mitral valve replacement.

BACKGROUND: Differences in cardiac remodeling after mitral valve (MV) surgery between the sexes is poorly understood. Inferior outcomes for females undergoing MV surgery compared with males have been suggested in the literature, although causative factors behind this discrepancy have not been identified. MATERIALS AND METHODS: In this propensity-matched, retrospective, single-center study, we sought to identify the impact that sex may have on cardiac remodeling and long-term outcomes to better inform clinical decision-making in MV surgical intervention. Outcomes were compared between males and females undergoing MV replacement (MVR) between 2004 and 2018. The primary outcome was cardiac remodeling 1 year postoperatively. Secondary outcomes included mortality, stroke, myocardial infarction (MI), reoperation of the MV, and rehospitalization. RESULTS: A total of 311 males and 311 females were included after propensity matching. Both groups demonstrated significant improvement in left atrial remodeling, although only males demonstrated a significant degree of improved left ventricular remodeling while their female counterparts did not. Mortality rates were relatively equivalent between the two groups, although males were more likely to develop sepsis and require rehospitalization due to MI. CONCLUSIONS: There has been little research exploring the differences in cardiac remodeling between the sexes after MVR. The results of this study have suggested that MVR is equally safe for both sexes and has demonstrated a difference in the heart's ability to remodel after MVR. The significance of this difference has the potential to result in largely different clinical outcomes for males and females. Further study is necessary to fully elucidate this relationship.

The effects of body mass index on outcomes for patients undergoing surgical aortic valve replacement.

BACKGROUND: Most of the studies of obesity and postoperative outcome have looked predominantly at coronary artery bypass grafting with fewer focused on valvular disease. The purpose of this study was to compare the outcomes of patients undergoing aortic valve replacement stratified by body mass index (BMI, kg/m^2). METHODS: The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry captured 4780 aortic valve replacements in Alberta, Canada from January 2004 to December 2018. All recipients were stratified by BMI into five groups (BMI: < 20, 20-24.9, 25-29.9, 30-34.9, and > = 35). Log-rank test and Cox regression were used to examine the crude and adjusted survival differences. RESULTS: Intra-operative clamp time and pump time were similar among the five groups. Significant statistical differences between groups existed for the incidence of isolated AVR, AVR and CABG, hemorrhage, septic infection, and deep sternal infection (p < 0.05). While there was no significant statistical difference in the mortality rate across the BMI groups, the underweight AVR patients (BMI < 20) were associated with increased hazard ratio (1.519; 95% confidence interval: 1.028-2.245) with regards to all-cause mortality at the longest follow-up compared with normal weight patients. CONCLUSION: Overweight and obese patients should be considered as readily for AVR as normal BMI patients.

Outcomes following bioprosthetic valve replacement in prior non-cardiac transplant recipients.

BACKGROUND: We report on overall survival and valve-related outcomes after bioprosthetic valve replacement in prior transplant recipients. METHODS: From January 2004 to December 2018, 20 consecutive patients (mean age 65.7-years, 90% male) with prior non-cardiac transplantation underwent bioprosthetic aortic (n = 18) or combined aortic and mitral (n = 2) valve replacement. Patients consisted of kidney (n = 14), lung (n = 2), liver (n = 3), and bone-marrow (n = 2) transplants with the most common indication for valve replacement being calcific degeneration (n = 12). Outcomes were measured over a 12-year span, with a median follow-up duration of 3.9 years. RESULTS: Overall survival at 30 days was 100% and at median follow-up was 60%. Acute kidney injury occurred in 50% (n = 10) with temporary dialysis required in 5% (n = 1) and 15% (n = 3) suffered respiratory failure. No patients experienced major bleeding, heart failure, or sternal wound infection. No patients required redo valve replacement during the study period. CONCLUSIONS: Our results provide contemporary data demonstrating that patients with prior transplant can undergo bioprosthetic valve replacement with acceptable inhospital mortality rates and long-term survival, with a low rate of major morbidity. Furthermore, bioprosthetic valve replacement is a viable option in this group of patients with no redo valve replacement and acceptable long-term hemodynamic valvular function.

The Use of the Ascyrus Medical Dissection Stent in Acute Type A Aortic Dissection Repair Reduces Distal Anastomotic New Entry Tear.

BACKGROUND: A distal anastomotic new entry tear (DANE) can occur at the time of surgical repair for acute type A aortic dissection (ATAAD). This study aimed to compare the occurrence of DANE following a standard hemiarch repair with that following a hemiarch repair with an uncovered arch dissection stent. METHODS: All patients who received a hemiarch repair or a hemiarch repair with an Ascyrus Medical Dissection Stent (AMDS) for ATAAD from 2017 to 2021 were included. Baseline and intra- and postoperative characteristics were collected. All available pre- and postoperative computed tomographic scans were analysed. The primary outcome measures were the incidence of DANE, positive aortic remodelling, mortality, and aortic reintervention rates at last follow-up. RESULTS: A total of 114 patients underwent repair of Debakey I ATAAD during the study period with either an isolated hemiarch (n = 77) or a hemiarch with AMDS (n = 37). There was no significant difference in mortality (P = 0.768) or other in-hospital adverse events. During the follow-up period, DANE occurred in 43.3% (n = 26) of the isolated hemiarch group and in 11.8% (n = 4) of the hemiarch with AMDS group (P = 0.002). The incidence of false lumen thrombosis and obliteration favoured the AMDS group in the aortic arch (P = 0.029), the proximal descending thoracic aorta (P = 0.031), and level of pulmonary artery bifurcation (P = 0.044). CONCLUSIONS: The incidence of DANE is significantly reduced with the addition of an AMDS at the time of hemiarch repair for ATAAD repair. Further follow-up is necessary to identify late aortic complications that may have been prevented by reducing the incidence of postoperative DANE.

Aortic remodelling based on false lumen communications in patients undergoing acute type I dissection repair with AMDS hybrid prosthesis: a substudy of the DARTS trial.

OBJECTIVES: The Dissected Aorta Repair Through Stent (DARTS) Implantation trial demonstrated positive proximal aortic remodelling following aortic dissection repair with the AMDS hybrid prosthesis. In this study, we look to identify predictors of aortic remodelling following aortic dissection repair with AMDS including whether communications between branch vessels and the false lumen (FL) predict aortic growth. METHODS: The DARTS implantation trial included patients who underwent acute DeBakey type I aortic dissection (ATAD I) repair with the AMDS from March 2017 to January 2019. Anatomic measurements were collected from original computerized tomography scans. Measurements were taken at zones 2, 3, 6 and 9. Patients were grouped based on the number of FL communications with the supra-aortic branch vessels or visceral branch vessels. RESULTS: Forty-seven patients were included in the original DARTS implantation trial. Patients with FL communications with the supra-aortic branch vessels tended to have significant growth at zone 3 (P = 0.02-0.0018), while greater numbers of visceral FL communications tended to predict aortic growth at zones 3 (P = 0.003), 6 (P = 0.017-0.0087) and 9 (P = 0.0016-0.0003). CONCLUSIONS: Aortic remodelling following ATAD I repair using the AMDS may be predicted by local FL communications with branch vessels. Patients undergoing ATAD I repair were more likely to experience significant aortic growth in zone 3 with more head vessel communications and in zones 3, 6 and 9 with more visceral FL communications. Predictors of aortic remodelling may help to guide initial surgical management for aortic dissection patients.

Hybrid noncovered open stents in repair of DeBakey type 1 acute aortic dissections.

OBJECTIVES: The indications for use, evidence base and experience with the novel noncovered open hybrid surgical stents for acute type A aortic dissection repair for concurrent stabilization of the 'downstream' aorta remains limited. We review the evidence base and the development of these stents. METHODS: Data were collected from Pubmed/Medline literature search to develop and review the evidence base for safety and efficacy of non-covered surgical stents. Existing guidelines for use and developments were reviewed. RESULTS: A single randomized control trial and 4 single-centre studies were included in the review with a total worldwide experience of 241 patients. The deployment was easy and did not add significantly to the primary operation. The mortality and new stroke ranged from 6.3-18.7%. Safe and complete deployment was accomplished in 92-100%. There was no device-related reintervention. There was a significant improvement in malperfusion in over 90% of the cases with varying degrees of remodelling (60-90%) of the downstream aorta. CONCLUSIONS: Open noncovered stent grafts represent a major technical advancement as an adjunct procedure for acute dissection repairs, e.g. hemiarch repair. It has potential for wider use by non-aortic surgeons due to simplicity of technique. Limited safety and efficacy data confirm the device to be safe, feasible and reproducible with potential for wider adoption. However, long-term trial and registry data are required before recommendations for standard use outside of high-volume experienced aortic centres.

The Ascyrus Medical Dissection Stent: A One-Fits-All Strategy for the Treatment of Acute Type A Aortic Dissection?

The treatment of DeBakey type I aortic dissection remains a major challenge in the field of aortic surgery. To upgrade the standard of care hemiarch replacement, a novel device called an "Ascyrus Medical Dissection Stent" (AMDS) is now available. This hybrid device composed of a proximal polytetrafluoroethylene cuff and a distal non-covered nitinol stent is inserted into the aortic arch and the descending thoracic aorta during hypothermic circulatory arrest in addition to hemiarch replacement. Due to its specific design, it may result in a reduced risk for distal anastomotic new entries, the effective restoration of branch vessel malperfusion and positive aortic remodeling. In this narrative review, we provide an overview about the indications and the technical use of the AMDS. Additionally, we summarize the current available literature and discuss potential pitfalls in the application of the AMDS regarding device failure and aortic re-intervention.

Minimally Invasive Approaches to Mitral Valve Surgery: Where Are We Now? A Narrative Review.

Minimally invasive mitral valve surgery (MiMVS) has been increasing in prevalence. This review focuses on the approaches, clinical outcomes, and patient selection for MiMVS. There are 4 minimally invasive approaches to the mitral valve: right mini-thoracotomy (including video-assisted and fully endoscopic), robotic mitral surgery, and transapical beating heart off-pump neochordal repair. Advantages over conventional surgery include less blood loss and transfusion, improved postoperative mobility, shorter length of stay, less postoperative atrial fibrillation, fewer surgical site infections, and improved cosmesis. This range of minimally invasive techniques will continue to evolve, providing options that are tailored for different patient populations.

Assessment of a Novel, Adjustable Task Trainer for Cardiac Surgical Skills.

INTRODUCTION: A recent needs assessment in Canadian cardiac surgery programs identified the desire for a coronary artery bypass (CABG) and aortic valve replacement (AVR) simulation model for home practice. We aimed to develop and assess a portable, adjustable task trainer for cardiac surgical skills with high functional task alignment. METHODS: Intraoperative measurements were taken from patients undergoing elective CABG and AVR (N = 30). Measurements were taken in 3 axes and used to create a chest cavity that resembles the mediastinal constraints of a patient undergoing CABG and AVR. The task trainer is adjustable on the following 3 levels: (1) size of the incision, (2) depth of the chest, and (3) relative position of coronary artery or aortic valve model within the chest. Three groups (novices, intermediates, and experts) of cardiac surgery members evaluated the task trainer for functional task alignment and construct validity. RESULTS: The CABG and AVR model had high functional task alignment. There was a high satisfaction for both models and all participants would recommend the AVR and CABG model as an educational tool. Performance time significantly differed between the groups for both models (CABG: P = 0.032 and AVR: P = 0.001), as well as number of errors (CABG: P = 0.04 and AVR: P = 0.043). CONCLUSIONS: Using real patient data, we were able to develop an adjustable task trainer for training principles of CABG and AVR. Our pilot study provides preliminary sources of evidence for validity and future study will look to assess transferability of skill to the operating room.

Enterococcus faecalis endocarditis resulting in annular rupture: a case report.

Enterococcus faecalis is the third most common organism to cause infective endocarditis and is associated with high rates of morbidity and mortality. E. faecalis infective endocarditis often presents with a subacute course and with nonspecific constitutional symptoms. Complications related to E. faecalis infective endocarditis are common and include embolic events, abscess formation and pseudoaneurysm formation. Contained annular rupture is a complication of E. faecalis infective endocarditis that, to the authors knowledge, has not been previously described in the literature. Herein, we present an unusual case of a 62-year-old male presenting with classical symptoms of E. faecalis infective endocarditis which resulted in an unusual complication of this condition, a contained annular rupture and the surgical management undertaken to correct this condition.

Enterococcus faecalis is the third most common organism to cause infection of the heart and heart valves and is associated with high rates of complications and death. Complications related to E. faecalis heart infections are common and include dislodging of infected material, abscess formation and injury to blood vessel walls. Contained rupture of the aortic valve annulus is a complication of E. faecalis infections that, to the authors knowledge, has not been previously described in the literature. Herein, we present an unusual case of a 62-year-old male presenting with classical symptoms of E. faecalis infection of the heart which resulted in an unusual complication of this condition, a contained annular rupture and the surgical management undertaken to correct this condition.

Quantifying the immune response to a tissue-engineered porcine extracellular matrix.

Aim: Structural valvular deterioration of xenogenic heart valve replacements is thought to be due to a chronic immune response. We sought to engineer porcine extracellular matrix that elicits minimal inflammatory immune response. Materials & methods: Whole blood, bone marrow and pericardium were collected from patients undergoing elective cardiac surgery. Porcine extracellular matrix was decellularized, reseeded with homologous mesenchymal stem cells and exposed to whole blood. Results: DAPI stain confirmed the absence of cells after decellularization, and presence of mesenchymal stem cells after recellularization. There was a significant reduction in IL-1ß and TNF-α production in the recellularized matrix. Conclusion: Recellularization of porcine matrix is successful at attenuating the xenogenic immune response and may provide a suitable scaffold to address the current limitations of prosthetic heart valve replacements.

Deterioration of tissue heart valve replacements is thought to be due to a chronic immune response. We sought to remove cells from a pig derived tissue and replace those cells with human stem cells to create a scaffold that results in a reduced immune response. Whole blood, bone marrow and pericardium were collected from patients undergoing elective cardiac surgery. The pig derived tissue had the cells removed, were replaced with human stem cells and exposed to whole blood. Tissue stain confirmed the absence of cells after removal, and presence of stem cells after replacement of cells. There was a significant reduction in markers of immune response in the recellularized tissue. Removal of cells from pig derived tissue and replacement with human stem cells is successful at reducing the immune response to animal tissue and may provide a suitable scaffold to address the current limitations of heart valve replacement options.

The influence of renal disease on outcomes and cardiac remodeling following surgical mitral valve replacement.

OBJECTIVES: Chronic kidney disease (CKD) is increasingly prevalent in patients undergoing mitral valve replacement (MVR). While CKD is known to result in suboptimal outcomes for patients with mitral valve disease, there is limited literature evaluating the long-term outcomes and cardiac remodeling of patients with CKD undergoing MVR. We present the first analysis coupling long-term outcomes of combined morbidity, mortality, and cardiac remodeling post-MVR in patients with CKD. METHODS: Patients with varying degrees of CKD undergoing MVR from 2004 to 2018 were compared. Patients were grouped by estimated glomerular filtration rate (eGFR) > 90 mL/min/1.73m2 (n = 109), 60-89 mL/min/1.73m2 (450), 30-59 mL/min/1.73m2 (449), < 30 mL/min/1.73m2 (60). The primary outcome was mortality. Secondary outcomes included measures of postoperative morbidity and cardiac remodeling. RESULTS: One-year mortality was significantly increased in patients with eGFR < 30 (p = 0.023). Mortality at 7 years was significantly increased in patients with eGFR < 30 mL/min/1.73m2 (p < 0.001). Multivariable regression analysis of 7-year all-cause mortality indicated an eGFR of 15 mL/min/1.73m2 (HR 4.03, 95% CI 2.54-6.40) and 30 mL/min/1.73m2 (HR 2.17 95% CI 1.55-3.05) were predictive of increased mortality. Reduced eGFR predicted the development of postoperative sepsis (p = 0.002), but not other morbidities. Positive cardiac remodeling of the left ventricle, left atrium, and valve gradients were identified postoperatively for patients with eGFR > 30 mL/min/1.73m2 while patients with eGFR < 30 mL/min/1.73m2 did not experience the same changes. CONCLUSIONS: CKD is predictive of inferior clinical and echocardiographic outcomes in patients undergoing MVR and consequently requires careful preoperative consideration and planning. Further investigation into optimizing the postoperative outcomes of this patient population is necessary.

Thoracic Endovascular Aortic Repair Stent Deployed in the Ascyrus Medical Dissection Stent.

The Ascyrus Medical Dissection Stent (AMDS) has proved to promote false lumen closure at the distal anastomosis in type A dissection repairs. During the past 20 years, open techniques have developed into endovascular repairs. We report a case of thoracic endovascular aortic repair (TEVAR) landed inside an AMDS. A 63-year-old man with hypertension presented with type A aortic dissection. After initial repair with AMDS, he returned for TEVAR to fix residual type B dissection. A proper seal was created between the AMDS and TEVAR stents, demonstrating a successful off-label use of the AMDS stent.