Mechanical or Biological Prosthesis for Aortic Valve Replacement in Patients Aged 45 to 74 Years.

OBJECTIVE: The selection of valve prostheses for patients undergoing surgical aortic valve replacement (SAVR) remains controversial. In this study, we compared the long-term outcomes of patients undergoing aortic valve replacement with biological or mechanical aortic valve prostheses. METHODS: We evaluated late results among 5,762 patients aged 45-74 years who underwent biological or mechanical aortic valve replacement with or without concomitant coronary artery bypass from 1989 to 2019 at four medical centers. The Cox proportional hazards model was used to compare late survival; the age-dependent effect of prosthesis type on long-term survival was evaluated by an interaction term between age and prosthesis type. Incidences of stroke, major bleeding, and reoperation on the aortic valve following the index procedure were compared between prosthesis groups. RESULTS: Overall, 61% (n=3,508) of patients received a bioprosthesis. The 30-day mortality rate was 1.7% (n=58) in the bioprosthesis group and 1.5% (n=34) in the mechanical group (P=0.75). During a mean follow-up of 9.0 years, the adjusted risk of mortality was higher in the bioprosthesis group (HR=1.30, P<0.001). The long-term survival benefit associated with mechanical prosthesis persisted until 70 years of age. Bioprosthesis (vs mechanical prosthesis) was associated with a similar risk of stroke (P=0.20), lower risk of major bleeding (P<0.001), and higher risk of reoperation (P<0.001). CONCLUSIONS: Compared to bioprostheses, mechanical aortic valves are associated with a lower adjusted risk of long-term mortality in patients aged 70 years or younger. Patients <70 years old undergoing SAVR should be informed of the potential survival benefit of mechanical valve substitutes.

Adult Congenital Heart Disease Transplantation: Does Univentricle Physiology Impact Early Mortality?

BACKGROUND: With congenital heart disease patients increasingly living into adulthood, there is a growing population of adult congenital heart disease (ACHD) patients suffering from heart failure. Limited data exist evaluating heart transplant in this population. METHODS: Retrospective review was performed of ACHD patients undergoing heart transplantation 11/1990-1/2023. Kaplan-Meier, cumulative incidence accounting for competing risk of death, and subgroup analyses comparing those with biventricular (BiV) and univentricular (UniV) physiology were performed. Data are presented as median (interquartile range) or counts (%). RESULTS: 77 patients with a median age of 36 years (27, 45) were identified, including 57 (74%) BiV and 20 (26%) UniV. Preoperatively, UniV patients were more likely to have cirrhosis (9/20 [45.0%] vs 4/57 [7.0%], p<0.001) and protein losing enteropathy (4/20 [20.0%] vs 1/57 [1.8%], p=0.015). Multiorgan transplantation was performed in 23 patients (30%) and more frequently in UniV patients (10 [50%] vs. 13[23%], p=0.04). Operative mortality was 6.5%, 2/20 (10%) among UniV and 2/57 (4%) among BiV patients, p=0.276. Median clinical follow-up was 6.0 (1.4, 13.1) years. Survival tended to be lower among UniV patients compared to BiV patients, particularly within the first year (p=0.09), but was similar for survivors beyond one year. At 5 years, incidence of rejection was 28% (17%, 38%) and coronary allograft vasculopathy was 16% (7%, 24%). CONCLUSIONS: Underlying liver disease and need for heart/liver transplantation were significantly higher among UniV patients. Survival tended to be lower among UniV, particularly within the first year, but was similar for survivors beyond one year.

Simultaneous Tricuspid Valve Repair at the Time of Mitral Valve Surgery: Determinants of Postoperative Pacemaker Implantation.

OBJECTIVE: Guidelines recommend tricuspid valve (TV) repair for patients with severe tricuspid valve regurgitation (TR) undergoing surgery for degenerative mitral valve (MV) disease, but management of ≤ moderate TR is controversial. This study examines the incidence and causes of bradyarrhythmias leading to PPM implantation. METHODS: Review of patients undergoing simultaneous TV repair and MV surgery for degenerative MV disease from 2001 to 2022 (N=404). Primary endpoint was the incidence of postoperative PPM implantation. Secondary endpoints included the incidence of high-degree AV block and overall survival. RESULTS: All patients underwent TV repair at the time of MV surgery; 332 (82%) underwent MV repair and 72 (18%) MV replacement. Tricuspid valve repair techniques included flexible band (n=258, 63.8%), DeVega annuloplasty (n=78, 19.3%), complete flexible ring (n=49, 12.1%), and incomplete rigid ring (n=19, 4.7%). The 30-day mortality was 0.5% (n=2). A total of 35 (8.7%) patients had a PPM implanted postoperatively, 26 (6.4%) for high-degree AV block. On multivariable analysis, only older age was associated with PPM implantation. Patients who received a PPM due to high-degree AV block had reduced overall survival (Figure, p=0.01). CONCLUSIONS: Need for permanent pacing following TV repair at the time of MV surgery is not uncommon, but there are few modifiable factors that might reduce this risk. Careful selection of patients with less-than-severe TR and surgical techniques may reduce PPM-related risks and complications.

Delayed Sternal Closure vs Emergency Sternal Reopening in Adults With Congenital Heart Disease.

BACKGROUND: Limited data exist regarding outcomes of delayed sternal closure (DSC) in adults with congenital heart disease (ACHD). METHODS: We reviewed 159 ACHD patients undergoing cardiac operation from 1993 to 2023 who required DSC (open sternum at the end of operation, n = 112) or sternum emergently reopened (n = 47). Regression models were performed to determine factors associated with outcomes. RESULTS: Of 112 patients undergoing DSC, 87 patients (77.6%) underwent DSC ≤4 days and 25 patients (22.3%) >4 days. The most common operations were valve (n = 35 [31.2%]), aortic (n = 33 [29.4%]), and right ventricular outflow tract procedures (n = 23 [20.5%]). Median time to chest closure was 2 days (interquartile range, 1-5 days). Apart from sex, baseline characteristics were similar between DSC groups. A stepwise increase in early mortality was observed from DSC ≤4 days to DSC >4 days (6.8% vs 32%), as well as the incidence of early complications, except sternal infection. Risk factors associated with early mortality were age (P = .02), DSC >4 days (P < .001), hemodynamic indication (P = .03), and single ventricle (P = .02). On multivariable analysis, lower ejection fraction (P = .04), hemodynamic indication (P = .02), single ventricle (P = .004), and diabetes mellitus (P = .03) were predictors of prolonged time to chest closure. Among hospital survivors, late survival was similar between patients undergoing DSC ≤4 days vs >4 days (P = .48). CONCLUSIONS: A brief duration of DSC in ACHD patients is associated with low morbidity and mortality. Higher early mortality and complications were observed among patients who did not achieve chest closure within 4 days.

Single-Center Prospective Study of Cross-Clamp vs Balloon Occlusion in Robotic Mitral Surgery.

BACKGROUND: Transthoracic aortic cross-clamp and endoaortic balloon occlusion have both been shown to have comparable safety profiles for aortic occlusion. Because most surgeons use only one technique, we sought to compare the outcomes when a homogeneous group of surgeons changed their occlusion technique from aortic cross-clamp to balloon occlusion. METHODS: We changed our technique from aortic cross-clamp to balloon occlusion in November 2022. This allowed us to conduct a prospective treatment comparison study in the same group of surgeons. Propensity score matching was used to match cases (balloon occlusion) 1:3 to controls (aortic cross-clamp) based on age, sex, body mass index, concomitant maze procedure, and tricuspid valve repair. RESULTS: Total of 411 patients underwent robotic mitral surgery from 2020 through 2023. Propensity score matching was used to match 56 balloon occlusion patients to 168 aortic cross-clamp patients. The 224 patients were a median age of 65 years (interquartile range, 55.6-70.0 years), and 119 (53%) were men. All valves were successfully repaired. Balloon occlusion had a shorter median cardiopulmonary bypass (CPB) time compared with aortic cross-clamp (84.0 vs 94.5 minutes, P = .006). Median cross-clamp time (64.0 vs 64.0 minutes, P = .483) and total surgery time (5.9 vs 6.1 hours, P = .495) did not differ between groups. There were no in-hospital deaths. There were 5 surgeons who performed various combinations of console and bedside roles. CPB, cross-clamp, and surgery durations were not significantly affected by the different surgeon combinations. CONCLUSIONS: Compared with aortic cross-clamp, balloon occlusion has similar perioperative and early postoperative outcomes. Additionally, it likely introduces a 10-minute reduction in total CPB time.

A Case Series of Minimally Invasive Robotic-Assisted Resection of Cardiac Papillary Fibroelastoma: The Mayo Clinic Experience.

Papillary fibroelastomas (PFEs) are small, slowly growing benign cardiac tumors with clinically significant risk of embolization. Surgical excision is the definitive treatment of symptomatic PFE and is conventionally performed through a median sternotomy. In this study, we report a series of 12 patients, who underwent robotic-assisted PFE removal at the Mayo Clinic. PFE involved the mitral valve, left atrium, and tricuspid valve. No major complications occurred after the procedure, and most patients were discharged 4 days after the surgery. On follow-up, 1 patient demonstrated pericarditis.

Navigating missing link: innovative cannulation for robotic mitral valve repair in the absence of inferior vena cava.

Cardiac surgeries often require the use of cardiopulmonary bypass to allow visualization and manipulation of tissues. Vascular anomalies may impose challenges with access configuration. A patient was evaluated for robot-assisted mitral valve repair and found to have an atretic inferior vena cava secondary due to chronic occlusion. The patient was cannulated arterially through the left common femoral artery, and two cannulation sites were applied for venous drainage: the right intrajugular vein and a second percutaneous access site directly into the right atrium through the chest wall. The procedure was completed without immediate complications, and the patient's perioperative course was unremarkable.

Outcomes of aortic surgery in patients with Takayasu arteritis.

OBJECTIVE: To investigate the presentation, aortic involvement, and surgical outcomes in patients with Takayasu arteritis undergoing aortic surgery. METHODS: We queried our surgical database for patients with Takayasu arteritis who underwent aortic surgery from 1994 to 2022. RESULTS: There were a total of 31 patients with Takayasu arteritis who underwent aortic surgery. Patients' median age at the time of diagnosis was 35.0 years (interquartile range, 25.0-42.0). The majority were female (n = 27, 87.0%). Most patients (n = 28, 90.3%) were diagnosed before surgery, and 3 patients (9.6%) were diagnosed perioperatively. The median time interval from diagnosis to surgery was 2.8 years (interquartile range, 0.5-13.9). The most common presentation was ascending aorta aneurysm (n = 22, 70.9%), and severe aortic regurgitation was the most common valve insufficiency (n = 17, 54.8%). The most common operation was ascending aorta replacement (n = 20, 64.5%), and aortic valve replacement was the most common valve intervention (n = 17, 54.8%). Active vasculitis was identified in 2 (11.7%) aortic valve specimens. Early mortality was 6.5% (n = 2). A total of 6 deaths occurred over a median follow-up of 13.1 years (interquartile range, 6.1-25.2). Survival at 10 years was 86.7% (95% CI, 75.4-99.7). A total of 5 patients (16.1%) required a subsequent operation in a median of 1.9 years (interquartile range, 0.2-7.4). Freedom from reoperation was 96.9% (95% CI, 90.1-100) at 1 year, 89.4% (95% CI, 78.7-100.0) at 5 years, and 77.5% (95% CI, 61.2-98.1) at 10 and 15 years. CONCLUSIONS: Ascending aorta aneurysm and aortic valve regurgitation are the most frequent presentations in patients with Takayasu arteritis requiring aortic surgery. Surgery in these individuals is safe, with acceptable short- and long-term results.

Case Report: A myxoma with a far reach.

A 73-year-old woman presented to the emergency department with a syncopal episode and a history of dizzy spells. A transthoracic echocardiogram demonstrated a large left atrial mass extending into the right upper pulmonary veins. Subsequently, cardiac magnetic resonance imaging and coronary computed tomography angiography with three-dimensional reconstruction and printing of the heart and mass were performed, which demonstrated a high index of suspicion for an atypical left atrial myxoma. The mass was excised robotically, and the pathology report confirmed a diagnosis of myxoma.

Diagnosis and surgical management of pericardial constriction after cardiac surgery.

OBJECTIVES: Previous cardiac surgery is an increasingly common etiology of constrictive pericarditis, but there is a paucity of data on clinical presentation and outcome of surgical treatment. METHODS: We reviewed data of 263 patients who underwent pericardiectomy for postoperative constriction from January 1, 1993, through July 1, 2017. Outcomes of interest were early and late mortality, as well as features of clinical presentation. RESULTS: Median patient age was 64 (56-72) years, and the median interval between previous operation and pericardiectomy was 2.7 years (range, 0-54 years). Previous operations included coronary artery bypass grafting in 114 (43%), valve surgery in 85 (32%), combined coronary artery bypass grafting and valve surgery in 33 (13%), and other procedures in 31 (12%). Common presentations were symptoms of right heart failure in 221 (84%) or dyspnea in 42 (16%). Moderate-to-severe tricuspid valve regurgitation was present in 108 (41%) patients. There were 14 (5.5%) deaths within 30 days postoperatively, and survival at 5 and 10 years postoperatively was 61% and 44%. On multivariate analysis, older age (P = .013), diabetes (P = .019), and nonelective pericardiectomy within 2 years of cardiac surgery (P < .001) were associated with decreased long-term survival. CONCLUSIONS: Pericardial constriction after cardiac surgery can present at any interval postoperatively. Symptoms and signs of right heart failure in patients with previous cardiac surgery should alert physicians to the possibility of pericardial constriction followed by a correct diagnosis. Pericardiectomy performed urgently following cardiac operation has poor long-term outcomes.

Cardiac Transplantation: Physiology and Natural History of the Transplanted Heart.

Heart transplantation (HT) is one of the prodigious achievements in modern medicine and remains the cornerstone in the treatment of patients with advanced heart failure. Advances in surgical techniques, immunosuppression, organ preservation, infection control, and allograft surveillance have improved short- and long-term outcomes thereby contributing to greater clinical success of HT. However, prolonged allograft and patient survival following HT are still largely restricted by the development of late complications, including allograft rejection, infection, cardiac allograft vasculopathy (CAV), and malignancy. The introduction of mTOR inhibitors early after HT has demonstrated multiple protective effects against CAV progression, renal dysfunction, and tumorigenesis. Therefore, several HT programs increasingly use mTOR inhibitors with partial or complete withdrawal of calcineurin inhibitor (CNI) in stable HT patients to reduce complications risk and improve long-term outcomes. Furthermore, despite a substantial improvement in exercise capacity and health-related quality of life after HT as compared to advanced heart failure patients, most HT recipients remain with a 30% to 50% lower peak oxygen consumption (Vo 2 ) than that of age-matched healthy subjects. Several factors, including alterations in central hemodynamics, HT-related complications and alterations in the musculoskeletal system, and peripheral physiological abnormalities, presumably contribute to the reduced exercise capacity following HT. Cardiac denervation and subsequent loss of sympathetic and parasympathetic regulation are responsible for various physiological alterations in the cardiovascular system, which contributes to restricted exercise tolerance. Restoration of cardiac innervation may improve exercise capacity and quality of life, but the reinnervation process is only partial even several years after HT. Multiple studies have shown that aerobic and strengthening exercise interventions improve exercise capacity by increasing maximal heart rate, chronotropic response, and peak Vo 2 after HT. Novel exercise modalities, such as high-intensity interval training (HIT), have been proven as safe and effective for further improvement in exercise capacity, including among de novo HT recipients. Further developments have recently emerged, including donor heart preservation techniques, noninvasive CAV and rejection surveillance methods, and improvements in immunosuppressive therapies, all aiming at increasing donor availability and improving late survival after HT. © 2023 American Physiological Society. Compr Physiol 13:4719-4765, 2023.

Heart Transplantation from COVID-19-Positive Donors: A Word of Caution.

BACKGROUND: During the COVID-19 pandemic, efforts to maintain solid-organ transplantation have continued, including the use of SARS-CoV-2-positive heart donors. METHODS: We present our institution's initial experience with SARS-CoV-2-positive heart donors. All donors met our institution's Transplant Center criteria, including a negative bronchoalveolar lavage polymerase chain reaction result. All but 1 patient received postexposure prophylaxis with anti-spike monoclonal antibody therapy, remdesivir, or both. RESULTS: A total of 6 patients received a heart transplant from a SARS-CoV-2-positive donor. One heart transplant was complicated by catastrophic secondary graft dysfunction requiring venoarterial extracorporeal membrane oxygenation and retransplant. The remaining 5 patients did well postoperatively and were discharged from the hospital. None of the patients had evidence of COVID-19 infection after surgery. CONCLUSION: Heart transplants from SARS-CoV-2 polymerase chain reaction-positive donors are feasible and safe with adequate screening and postexposure prophylaxis.

Does Minimally Invasive Mitral Valve Repair Mean Less Postoperative Pain?

BACKGROUND: Rapid recovery after minimally invasive mitral valve (MV) repair has been demonstrated in many studies, but the issue of postoperative pain has not been fully elucidated. We evaluated pain scores and medication use in patients undergoing MV repair by minimally invasive surgery (MIS) and open sternotomy (OS). METHODS: Between 2008 and 2019, 1332 patients underwent isolated MV repair by OS, and 913 underwent minimally invasive MV repair. After 1:1 propensity score matching, the study included 709 patients in each group. Opioid use was quantified as oral morphine equivalents in milligrams for each hospital day. The highest pain scores were collected from a visual analogue scale at 6-hour intervals. Predictive modeling was employed to compare pain medications and pain scores between the groups. RESULTS: The postoperative median length of stay was 3 (3-4) and 5 (4-5) days for the MIS and OS groups, respectively (P < .001). The predicted geometric mean oral morphine equivalents demonstrated lower opioid use for the MIS group compared with the OS group for the first 4 days. However, the predicted mean pain score was higher in the first 24 hours for the MIS group compared with the OS group (4.7 [4.5-4.8] vs 4.4 [4.3-4.5], respectively, on a visual analogue scale of 0 to 10). CONCLUSIONS: MV repair by MIS methods was associated with decreased opioid use but not with decreased postoperative pain scores. Possible explanations include the difference in incision site pain and subjective differences in postoperative pain expectations.

Excess Reintervention With Mitroflow Prosthesis for Aortic Valve Replacement: Ten-Year Outcomes of a Randomized Trial.

BACKGROUND: Current bioprostheses are considered to have improved durability and better hemodynamic performance compared with previous designs, but there are limited comparative data on late outcomes. METHODS: From 2009 through 2011, 300 adults with severe aortic valve stenosis undergoing aortic valve replacement (AVR) were randomly assigned to receive Edwards Magna, St Jude Epic, or Sorin Mitroflow bioprostheses (n = 100, n = 101, n = 99, respectively). Overall survival was analyzed using Kaplan-Meier and Cox proportional hazards methods, whereas competing risk analysis was used for all time-to-event outcomes. Serial echocardiographic data were fitted with longitudinal models stratified by implant valve size. RESULTS: During median follow-up of 9.8 years (interquartile range, 8.7-10.2), 10-year survival was 50% for the Magna group, 42% for the Epic group, and 41% for the Mitroflow group (P = .415). Cumulative risk of stroke was 9% at 10 years, and rates were comparable for the three groups. Indexed aortic valve area and mean gradients were similar among the three groups receiving 19 mm and 21 mm valves, but in larger (23 mm or more) prostheses, gradients were lower (P < .001) and indexed aortic valve areas were higher in the Magna group (P < .001). The 10-year risk of endocarditis differed by group (P = .033), with higher incidence in the Mitroflow vs the Magna group (7% vs 0%, P = .019). Late risk of reinterventions in the Mitroflow group was 22%, compared with 0% in the Magna group (P < .001) and 5% in the Epic group (P = .008). CONCLUSIONS: The Magna valve had the lowest gradients and largest indexed aortic valve area with larger implant sizes. The Mitroflow bioprosthesis is associated with an increased rate of reintervention and possible increased risk of infection compared with Magna and Epic valves.

Apixaban for Anticoagulation After Robotic Mitral Valve Repair.

BACKGROUND: There is no consensus regarding postoperative anticoagulation after mitral valve repair (MVRep). We compared the outcomes of post-MVRep anticoagulation with apixaban compared to warfarin. METHODS: We reviewed data of 666 patients who underwent isolated robotic MVRep between January 2008 and October 2019. We excluded patients who had conversion to sternotomy and those discharged without anticoagulation or on clopidogrel (n = 40). Baseline and intraoperative characteristics and antiplatelet/anticoagulation records were collected. In-hospital and post-discharge complications and overall survival were compared. RESULTS: Among the 626 studied patients the median age was 58 years (interquartile range, 51-66), 71% were male, and 1% (n = 9) had atrial fibrillation. Eighty percent (n = 499) were discharged on warfarin and 20% on apixaban (n = 127). Almost all patients (126 of 127, 99%) in the apixaban group were also on aspirin at discharge, whereas in the warfarin group only 79% (n = 395) were also on aspirin at discharge. Baseline characteristics were similar, except that the apixaban group had more female patients (46 of 127, 36% vs 136 of 499, 27%, P = .047). There were no differences in in-hospital complications, including stroke. Readmission rate was higher in the apixaban group (15 of 127, 12% vs 30 of 499, 6%, P = .02), driven mostly by postoperative atrial fibrillation (6 of 127 [5%] vs 5 of 499 [1%], respectively; P = .01). There was no difference in other complications (including bleeding and thromboembolic events), or overall mortality within 3 years. Exclusion of patients who did not receive aspirin at discharge did not affect the results. CONCLUSIONS: Anticoagulation with apixaban after minimally invasive robotic MVRep is safe and has similar rates of bleeding and thromboembolism compared to patients treated with warfarin.

Impact of tricuspid valve regurgitation on intermediate outcomes of degenerative mitral valve surgery.

BACKGROUND: In patients undergoing mitral valve surgery, optimal management of less-than-severe concomitant tricuspid valve regurgitation (TR) is unclear, as there are few long-term data. This study examines progression of TR, patient survival, and reoperations in patients undergoing mitral valve surgery. METHODS: There were 1588 patients who underwent degenerative mitral valve surgery and had pre- and postoperative echocardiograms for assessment of TR severity and tricuspid annulus diameter. Analysis used repeated-measures ordinal regression to model the longitudinal trends in TR grade and proportional hazards regression for long-term survival and reoperation outcomes. RESULTS: Concomitant tricuspid valve (TV) surgery was performed in 235 (14.8%) patients. In response to surgery, TR grades improved more in patients with concomitant TV intervention regardless of the severity of preoperative TR, and these early trends were sustained over long-term follow-up. Risk of progression to severe TR was not influenced by tricuspid annulus diameter (P = .226). After we adjusted for underlying health characteristics, survival following mitral valve surgery was similar in patients with and without TV intervention. Late TV reoperation was observed in 22 patients (5-year cumulative risk 1.5%), but among these, only 6 patients had severe TR as the primary indication for reoperation; preoperative TR grade and initial concomitant TV surgery were not associated with incidence of reoperation. CONCLUSIONS: Concomitant TV surgery for moderate TR reduces progression of TR but did not influence survival or incidence of reoperation. Among patients with less-than-severe preoperative TR, tricuspid annular diameter was not associated with progression to severe TR.

Mitral valve surgery after failed transcatheter edge-to-edge repair.

Objective: Mitral valve operations for failed transcatheter edge-to-edge repair (TEER) are increasing. This study investigated the indications, surgical procedures, and outcomes after surgery for failed TEER. Methods: We analyzed records of patients who underwent mitral valve operations after TEER between January 2013 and September 2021. Patient characteristics, clip number and location, indications, timing, surgery type, and outcomes were evaluated. Results: A total of 41 patients (median age, 77 years; 14 women; median Society of Thoracic Surgeons predicted risk of mortality score, 9.4% [5.6%-12.6%]; and previous cardiac surgery in 21 patients) underwent mitral valve surgery at a median of 8 months (range, 4-16 months) after TEER. One clip was implanted in 24 patients and 2 or more in 17 patients. Indications for surgery were severe mitral regurgitation in 33, severe mitral stenosis in 1 patient, and both in 7 patients. Operations were performed via sternotomy in 37 patients and lateral thoracotomy in 4 patients. The mitral valve was replaced in all patients (bioprosthesis in 35 patients and a mechanical valve in 6 patients). Concomitant procedures were performed in 30 patients. Operative mortality was 5% (observed to expected ratio, 0.53) and did not differ for primary procedures versus reoperations. Echocardiographic follow-up demonstrated no or trivial mitral regurgitation in 34 patients, mild mitral regurgitation in 5 patients, and moderate perivalvular mitral regurgitation in 1 patient with severe mitral annular calcification. At a median follow-up of 1.5 years (interquartile range, 4.7 months-2.7 years), the actuarial survival was 79%. Conclusions: Mitral valve replacement can be performed safely after failed TEER with operative mortality lower than expected even in high-risk patients.

Robotic vs. minimally invasive mitral valve repair: A 5-year comparison of surgical outcomes.

BACKGROUND: Minimally invasive mitral valve repair (MVr) is commonly performed. Data on the outcomes of robotic MVr versus nonrobotic minimally invasive MVr are lacking. We sought to compare the short-term and mid-term outcomes of robotic and nonrobotic MVr. METHODS: We reviewed all patients who underwent robotic MVr (n = 424) or nonrobotic MVr via right mini-thoracotomy (n = 86) at Mayo Clinic, Rochester, MN, from January 2015 to February 2020. Data on baseline and operative characteristics, operative and long-term outcomes were analyzed. Patients were matched 1:1 using propensity scores. RESULTS: Sixty-nine matched pairs were included in the study. The median age was 59 years (interquartile range [IQR]: 54-69) and 75% (n = 103) were male. Baseline characteristics were similar after matching. Robotic and nonrobotic MVr had similar operative characteristics, except that robotic had longer cross-clamp times (57 [48-67] vs. 47 [37-58] min, p < .001) and more P2 resections (83% vs. 68%, p = .05) compared to nonrobotic MVr. There was no difference in operative outcomes between groups. Hospital stay was shorter after robotic MVr (4 [3-4] vs. 4 [4-6] days, p = .003). After a median follow-up of 3.3 years (IQR, 2.1-4.5), there was no mortality in either group, and there was no difference in freedom from mitral valve reoperations between robotic and nonrobotic MVr (5 years: 97.1% vs. 95.7%, p = .63). Follow-up echocardiogram analysis predicted excellent freedom from recurrent moderate-or-severe mitral regurgitation at 3 years after robotic and nonrobotic MVr (90% vs. 92%, p = .18, respectively). CONCLUSIONS: Both short-term and mid-term outcomes of robotic and nonrobotic minimally invasive mitral repair surgery are comparable.

Lung transplantation long-term survival is worse in patients who have undergone previous cardiac surgery.

OBJECTIVES: Approximately 10% of lung transplant recipients have had previous cardiothoracic surgery. We sought to determine if previous surgery affects outcomes after lung transplant at a national level. METHODS: The United Network for Organ Sharing database was analysed from 2005 to 2019 to include adult patients who underwent lung transplant who had previous cardiac surgery and previous thoracic surgery. T-test and chi-squared analysis were used to compare perioperative outcomes. Long-term survival comparison was performed using the Kaplan-Meier method in an unadjusted and propensity-matched analysis. RESULTS: Out of 24 784 lung transplants, 691 (2.7%) had previous cardiac surgery and 1321 (6.5%) had previous thoracic surgery. Operative mortality was worse in previous cardiac surgery [42 (6.1%)] versus no previous cardiac surgery [740 (3.1%), P < 0.001] and in previous thoracic surgery [65 (4.9%)] versus no previous thoracic surgery [717 (3.1%), P < 0.001]. The previous thoracic surgery group had more primary graft failure and treated rejection during the first-year post-transplant. There was no difference in stroke, dialysis, intubation and extracorporeal membrane oxygenation at 72 h. Long-term survival was significantly worse for lung transplant patients who had undergone previous cardiac surgery (median 3.8 vs 6.3 years, P < 0.001) due to an increase in cardiovascular deaths (P = 0.008) and malignancy (P = 0.043). However, there was no difference in previous thoracic surgery (median 6.6 vs 6.1 years, P = 0.337). CONCLUSIONS: Previous cardiac surgery prior to lung transplant results in worse survival related to cardiovascular death and malignancies. Previous thoracic surgery worsens perioperative outcomes but does not affect long-term survival.

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes.

OBJECTIVES: There is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes. METHODS: We reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients. RESULTS: The median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time. CONCLUSIONS: Mechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.