Cardiac Surgery After Transcatheter Aortic Valve Replacement: Trends and Outcomes.

BACKGROUND: Reports of cardiac operations after transcatheter aortic valve replacement (TAVR) and early TAVR explantation are increasing. The purpose of this report is to document trends and outcomes of cardiac surgery after initial TAVR. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for all adult patients undergoing cardiac surgery after a previously placed TAVR between January 2012 and March 2023. This identified an overall cohort and 2 subcohorts: nonaortic valve operations and surgical aortic valve replacement (SAVR) after previous TAVR. Cohorts were examined with descriptive statistics, trend analyses, and 30-day outcomes. RESULTS: Of 5457 patients who were identified, 2485 (45.5%) underwent non-SAVR cardiac surgery, and 2972 (54.5%) underwent SAVR. The frequency of cardiac surgery after TAVR increased 4235.3% overall and 144.6% per year throughout the study period. The incidence of operative mortality and stroke were 15.5% and 4.5%, respectively. Existing The Society of Thoracic Surgeons risk models performed poorly, because observed-to-expected mortality ratios were significantly >1.0. Among those undergoing SAVR after TAVR, increasing preoperative surgical urgency, age, dialysis, need for SAVR, and concomitant procedures were associated with increased mortality, whereas type of TAVR explant was not. CONCLUSIONS: The need for cardiac surgery, including redo SAVR after TAVR, is increasing rapidly. Risks are higher, and outcomes are worse than predicted. These data should closely inform heart team decisions if TAVR is considered at lowering age and risk profiles in the absence of longitudinal evidence.

Surgery and transcatheter intervention for degenerative mitral regurgitation in the United States.

OBJECTIVES: We evaluated practice trends and 3-year outcomes of transcatheter edge-to-edge repair (TEER) and surgical repair for degenerative mitral regurgitation in the United States. METHODS: From the Centers for Medicare and Medicaid Services data (2012-2019), 53,117 mitral valve interventions (surgery or TEER) were performed for degenerative mitral regurgitation, identified by excluding rheumatic and congenital disease, endocarditis, myocardial infarction, cardiomyopathy, and concomitant or prior coronary revascularizations. Median follow-up was 2.9 years (interquartile range, 1.2-5.1 years). End points were 3-year survival, stroke, mitral reinterventions, and heart failure readmissions. RESULTS: Volume of total annual mitral interventions did not significantly change (P = .18) between 2012 and 2019. However, surgical cases decreased by one-third, whereas TEER increased. Among 27,170 patients (52.5% men; mean age, 73.5 years) who underwent TEER (n = 7755) or surgical repair (n = 19,415), surgical patients were younger (71.8 vs 80.8 years; P < .001), with less comorbidity and frailty. In 4532 patient pairs matched for age, frailty, and comorbidity, 3-year survival after TEER was 65.9% (95% CI, 64.3%-67.6%) and 85.7% (95% CI, 84.5%-86.9%) after surgery (P < .001). Three years after TEER or surgery, stroke rates were 1.8% (95% CI, 1.5%-2.2%) and 2.0% (95% CI, 1.6%-2.4%) (P = .49); heart failure readmission rates were 17.8% (95% CI, 16.7%-18.9%) and 11.2% (95% CI, 10.3%-12.2%) (P < .001); and mitral reintervention rates were 6.1% (95% CI, 5.5%-6.9%) and 1.3% (95% CI, 1.0%-1.7%) (P < .001), respectively. CONCLUSIONS: Among Medicare beneficiaries with degenerative mitral regurgitation, an increase in TEER utilization was associated with worse survival, increased heart failure readmissions, and more mitral reinterventions. Randomized trials are needed to better inform treatment choice.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2023 Update on Procedure Data and Research.

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database is one of the largest and most comprehensive contemporary clinical databases in use. It now contains >9 million procedures from 1010 participants and 3651 active surgeons. Using audited data collection, it has provided the foundation for multiple risk models, performance metrics, health policy decisions, and a trove of research studies to improve the care of patients in need of cardiac surgical procedures. This annual report provides an update on the current status of the database and summarizes the development of new risk models and the STS Online Risk Calculator. Further, it provides insights into current practice patterns, such as the change in the demographics among patients undergoing aortic valve replacement, the use of minimally invasive techniques for valve and bypass surgery, or the adoption of surgical ablation and left atrial appendage ligation among patients with atrial fibrillation. Lastly, an overview of the research conducted using the STS Adult Cardiac Surgery Database and future directions for the database are provided.

Prospective Study of Risk Factors for Postoperative Atrial Fibrillation After Cardiac Surgery.

INTRODUCTION: To examine risk factors for new-onset postoperative atrial fibrillation (POAF) after cardiac surgery. METHODS: Patients enrolled in the Cardiothoracic Surgical Trials Network multicenter, randomized trial of rate control versus rhythm control for POAF were included. Predictors of POAF were determined using multivariable logistic regression. RESULTS: Among the 2104 patients who were enrolled preoperatively, 695 developed POAF (33.0%). Rates of POAF were 28.1% after isolated coronary artery bypass grafting (CABG), 33.7% after isolated valve repair or replacement, and 47.3% after CABG plus valve repair or replacement. Baseline characteristics associated with an increased risk of POAF identified on multivariable analysis included older age (odds ratio [OR] 1.57; 95% confidence interval [CI] 1.42-1.73, per 10 y), White race or non-Hispanic ethnicity (OR 1.52; CI: 1.11-2.07), history of heart failure (OR 1.55; CI: 1.16-2.08), and history of hypothyroidism (OR 1.42; CI 1.04-1.94). The type of cardiac procedure was associated with an increased risk of POAF with both isolated valve repair or replacement (OR 1.33, CI 1.08-1.64) and combined CABG plus valve repair or replacement (OR 1.64, CI 1.24-2.17) having increased risk of POAF compared to isolated CABG. No preoperative cardiac medication was associated with POAF. CONCLUSIONS: In this prospective cohort of patients, older age, a history of hypothyroidism, a history of heart failure, and valve repair or replacement, with or without CABG, and White non-Hispanic race were associated with an increased risk of POAF.

Limited cumulative experience with ex vivo lung perfusion is associated with inferior outcomes after lung transplantation.

OBJECTIVE: Ex vivo lung perfusion (EVLP) allows for prolonged preservation and evaluation/resuscitation of donor lungs. We evaluated the influence of center experience with EVLP on lung transplant outcomes. METHODS: We identified 9708 isolated, first-time adult lung transplants from the United Network for Organ Sharing database (March 1, 2018-March 1, 2022), 553 (5.7%) involved using donor lungs after EVLP. Using the total volume of EVLP lung transplants per center during the study period, centers were dichotomized into low- (1-15 cases) and high-volume (>15 cases) EVLP centers. RESULTS: Forty-one centers performed EVLP lung transplants, including 26 low-volume and 15 high-volume centers (median volume, 3 vs 23 cases; P < .001). Recipients at low-volume centers (n = 109) had similar baseline comorbidities compared with high-volume centers (n = 444). Low-volume centers used numerically more donation after circulatory death donors (37.6 vs 28.4%; P = .06) and more donors with Pao2/Fio2 ratio <300 (24.8 vs 9.7%; P < .001). After EVLP lung transplants, low-volume centers had worse 1-year survival (77.8% vs 87.5%; P = .007), with an adjusted hazard ratio of 1.63 (95% CI, 1.06-2.50, adjusting for recipient age, sex, diagnosis, lung allocation score, donation after circulatory death donor, donor Pao2/Fio2 ratio, and total annual lung transplant volume per center). When compared to non-EVLP lung transplants, 1-year survival of EVLP lung transplants was significantly worse at low-volume centers (adjusted hazard ratio, 2.09; 95% CI, 1.47-2.97) but similar at high-volume centers (adjusted hazard ratio, 1.14; 95% CI, 0.82-1.58). CONCLUSIONS: The use of EVLP in lung transplantation remains limited. Increasing cumulative EVLP experience is associated with improved outcomes of lung transplantation using EVLP-perfused allografts.

Bicuspid aortic stenosis: National three-year outcomes of transcatheter versus surgical aortic valve replacement among Medicare beneficiaries.

OBJECTIVE: Randomized trials of transcatheter versus surgical aortic valve replacements have excluded bicuspid anatomy. We compared 3-year outcomes of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients aged more than 65 years with bicuspid aortic stenosis. METHODS: The Centers for Medicare and Medicaid data were used to identify 6450 patients undergoing isolated surgical aortic valve replacement (n = 3771) or transcatheter aortic valve replacement (n = 2679) for bicuspid aortic stenosis (2012-2019). Propensity score matching with 21 baseline characteristics including frailty created 797 pairs. RESULTS: Unmatched patients undergoing transcatheter aortic valve replacement were older than patients undergoing surgical aortic valve replacement (78 vs 70 years), with more comorbidities and frailty (all P < .001). After matching, transcatheter aortic valve replacement was associated with a similar mortality risk compared with surgical aortic valve replacement within the first 6 months (hazard ratio [HR], 1.08, 95% CI, 0.67-1.69) but a higher mortality risk between 6 months and 3 years (HR, 2.16, 95% CI, 1.22-3.83). Additionally, transcatheter aortic valve replacement was associated with a lower risk of heart failure readmissions before 6 months (HR, 0.51, 95% CI, 0.31-0.87) but a higher risk between 6 months and 3 years (HR, 4.78, 95% CI, 2.21-10.36). The 3-year risks of aortic valve reintervention (HR, 1.03, 95% CI, 0.30-3.56) and stroke (HR, 1.21, 95% CI, 0.75-1.96) were similar. CONCLUSIONS: Among matched Medicare beneficiaries undergoing transcatheter aortic valve replacement or surgical aortic valve replacement for bicuspid aortic stenosis, 3-year mortality was higher after transcatheter aortic valve replacement. However, transcatheter aortic valve replacement was associated with a similar risk of mortality and a lower risk of heart failure readmissions during the first 6 months after the intervention. Randomized comparative data are needed to best inform treatment choice.

Coronary Artery Aneurysms, Arteriovenous Malformations, and Spontaneous Dissections-A Review of the Evidence.

BACKGROUND: Coronary artery aneurysms (CAAs), coronary arteriovenous malformations (CAVMs), and spontaneous coronary artery dissections (SCADs) are rare clinical entities, and much is unknown about their natural history, prognosis, and management. METHODS: A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed in March 2023 to identify published papers related to CAAs, CAVMs, and SCADs. RESULTS: CAAs are found in 0.3% to 12% of patients undergoing angiography and are often associated with coronary atherosclerosis. They are usually asymptomatic but can be complicated by thrombosis in up to 4.8% of patients and rarely by rupture (0.2%). CAAs can be managed medically, percutaneously with stents or coil embolization, and surgically. The most common surgical procedure is ligation of the aneurysm, followed by coronary artery bypass grafting. The incidence of CAVMs is 0.1% to 0.2% in patients undergoing angiography, and they are most likely associated with congenital abnormal development of the coronary vessels. The diagnosis of CAVMs is usually incidental. Surgical or percutaneous intervention is indicated for patients with large CAVMs, which carry a potential risk of myocardial infarction. SCADs represent 1% to 4% of all acute coronary syndromes and typically affect young women. SCADs are strongly correlated with pregnancy, suggesting the role of sex hormones in their pathogenesis. Conservative management of SCAD is preferred for stable patients without signs of ischemia as spontaneous resolution is frequently reported. Unstable patients should undergo revascularization either percutaneously or with coronary artery bypass grafting. CONCLUSIONS: Further evidence regarding the management of these rare diseases is needed and can ideally be derived from multicenter collaborations.

Socioeconomic disparities in midterm outcomes after repair for degenerative mitral regurgitation.

OBJECTIVE: The influence of socioeconomic disparities on survival after mitral repair is poorly defined. We examined the association between socioeconomic disadvantage and midterm outcomes of repair in Medicare beneficiaries with degenerative mitral regurgitation. METHODS: US Centers for Medicare and Medicaid Services data were used to identify 10,322 patients undergoing isolated first-time repair for degenerative mitral regurgitation between 2012 and 2019. Zip code-level socioeconomic disadvantage was dichotomized with the Distressed Communities Index, which incorporates education level, poverty, unemployment, housing security, median income, and business growth; those with Distressed Communities Index score ≥80 were classified as distressed. The primary outcome was survival, censored at 3 years. Secondary outcomes included cumulative incidences of heart failure readmission, mitral reintervention, and stroke. RESULTS: Of the 10,322 patients undergoing degenerative mitral repair, 9.7% (n = 1003) came from distressed communities. Patients from distressed communities underwent surgery at lower volume centers (11 vs 16 cases/year) and traveled further for surgical care (40 vs 17 miles) (both P values < .001). At 3 years, unadjusted survival (85.4%; 95% CI, 82.9%-87.5% vs 89.7%; 95% CI, 89.0%-90.4%) and cumulative incidence of heart failure readmission (11.5%; 95% CI, 9.6%-13.7% vs 7.4%; 95% CI, 6.9%-8.0%) were worse in patients from distressed communities (all P values < .001), whereas mitral reintervention rates were similar (2.7%; 95% CI, 1.8%-4.0% vs 2.8%; 95% CI, 2.5%-3.2%; P = .75). After adjustment, community distress was independently associated with 3-year mortality (hazard ratio, 1.21; 95% CI, 1.01-1.46) and heart failure readmissions (hazard ratio, 1.28; 95% CI, 1.04-1.58). CONCLUSIONS: Community-level socioeconomic distress is associated with worse outcomes in degenerative mitral repair among Medicare beneficiaries.

Simultaneous Lung-Kidney Transplantation in the United States.

BACKGROUND: Simultaneous lung-kidney transplantation is rarely performed. Contemporary national practice trends and outcomes are unclear. METHODS: From the United Network for Organ Sharing database, we identified 108 lung-kidney transplant recipients (2005-2022). They were compared with isolated lung recipients with pretransplantation dialysis or estimated glomerular filtration rate (eGFR) ≤30 mL/min per 1.73 m2 (n = 372) and isolated non-dialysis-dependent lung recipients with 30 < eGFR < 50 mL/min per 1.73 m2 (n = 1416), respectively. Lung-kidney recipients were also compared with recipients of the contralateral kidney from the same donors (n = 90). RESULTS: Lung-kidney transplantation was performed by 36 centers, with increasing annual volume (1 in 2005, 16 in 2022; P < .01). Forty percent (44/108) of lung-kidney recipients received pretransplantation dialysis, and of those without pretransplantation dialysis, median eGFR was 30.7 mL/min per 1.73 m2. Lung-kidney recipients had improved survival compared with isolated lung recipients with eGFR ≤30 mL/min per 1.73 m2 or pretransplantation dialysis (adjusted hazard ratio, 0.59; 95% CI, 0.38-0.92). However, no survival benefit was observed when lung-kidney recipients were compared with isolated lung recipients with 30 < eGFR < 50 mL/min per 1.73 m2 and no pretransplantation dialysis (adjusted hazard ratio, 0.88; 95% CI, 0.55-1.41). Compared with isolated kidney recipients using the contralateral kidney from the same donors, lung-kidney recipients had a higher risk of kidney allograft loss (adjusted hazard ratio, 3.27; 95% CI, 1.22-8.78), a difference largely accounted for by patient death with a functioning kidney allograft. CONCLUSIONS: Recipients of lung-kidney transplants had improved survival compared with isolated lung recipients with eGFR ≤30 mL/min per 1.73 m2 or pretransplantation dialysis. However, lung-kidney recipients had a higher rate of kidney allograft loss than recipients of the contralateral kidney allograft from the same donors.

Simultaneous heart-kidney transplant in patients with borderline estimated glomerular filtration rate without dialysis dependency.

BACKGROUND: Appropriate patient selection for simultaneous heart-kidney transplantation (sHK) in patients with moderate renal dysfunction remains challenging. METHODS: From the United Network for Organ Sharing database (2003-2020), we identified 5678 adults with an estimated pre-transplant glomerular filtration rate (eGFR) between 30 and 45 mL/min/1.73 m2 and no pre-transplant dialysis. Patients undergoing sHK (n = 293) were compared with those undergoing heart transplantation alone (n = 5385) using 1:3 propensity score matching. RESULTS: The sHK utilization rate increased from 1.8% in 2003 to 12.2% in 2020 (p < .001). After matching, 1 and 5-year survival was 87.7% (95% confidence interval [CI] 83.3-91.0) and 80.0% (95% CI 74.2-84.6) after sHK, and 87.3% (95% CI 85.2-89.1) and 71.8% (95% CI 68.4-74.9) after heart transplant alone (p = .04). In the subgroup analysis, sHK was associated with a 5-year survival benefit only in patients with 30 < eGFR ≤ 35 mL/min/1.73 m2 (p = .05) but not in those with 35 < eGFR < 45 mL/min/1.73 m2 (p = .45). Patients who underwent heart transplants alone also had a higher incidence of becoming chronic dialysis-dependent after transplant within 5-year follow-up (10.2%, 95% CI 8.0-12.6 vs. 3.8%, 95% CI 1.7-7.1, p = .004). The 5-year incidence of subsequent kidney waitlisting and transplants after heart transplants alone was 5.6% and 1.9%, respectively. CONCLUSION: Among propensity-matched patients without pre-transplant dialysis, compared to heart transplants alone, sHK had improved 5-year survival in those with 30 < eGFR ≤ 35 but not in those with 35 < eGFR < 45 mL/min/1.73 m2 . One-year survival was similar irrespective of eGFR. Receiving a kidney after a heart transplant alone is rare under the current allocation system.

Heart transplantation for COVID-19 myopathy in the United States.

Evidence on characteristics and outcomes of patients undergoing heart transplantation for coronavirus disease 2019 (COVID-19) associated cardiomyopathy is limited to case reports. Of all 6,332 patients aged ≥18 years undergoing heart transplantation from July 2020 through May 2022 in the United Network for Organ Sharing database, 12 (0.2%) patients had COVID-19 myocarditis and 98 (1.6%) patients with the same level of care had non-COVID-19 myocarditis. Their median age was 49 (range 19-74) years. All patients were hospitalized in the intensive care unit and 92.7% (n = 102) were on life support prior to transplantation. No patients with COVID-19 myocarditis required ventilation while waitlisted. Survival free from graft failure was 100% among COVID-19 patients and 88.5% among non-COVID-19 patients at a median of 257 (range 0-427) days post-transplant. These findings indicate that transplantation is rarely performed for COVID-19 related cardiomyopathy in the United States, yet early outcomes appear favorable in select patients.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2022 Update on Outcomes and Research.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It is one of the most respected clinical data registries in health care, providing accurate risk-adjusted benchmarks, a foundation for quality measurement and improvement activities, and the ability to perform novel research. This report encompasses data from the years 2020 and 2021 and is the seventh in a series of reports that provide updated volumes, outcomes, database-related developments, and research summaries using the Adult Cardiac Surgery Database.

Risk of Surgical Mitral Valve Repair for Primary Mitral Regurgitation.

BACKGROUND: Risk estimation for surgical intervention is an essential component of heart team shared decision-making. However, current mitral valve (MV) surgery risk models used in practice lack etiologic or procedural specificity. OBJECTIVES: The purpose of this study was to establish a comprehensive method for assessment of operative risk of MV repair of primary mitral regurgitation (MR). METHODS: A novel etiology and procedure-specific algorithm identified 53,462 consecutive (July 2014 to June 2020) intention-to-treat MV repair patients with primary MR from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Risk models were fit for 30-day operative mortality, mortality and/or major morbidity, and conversion-to-replacement (CONV). As-treated mortality and morbidity models were derived separately. RESULTS: Event rates for mortality (n = 619; 1.16%), mortality plus morbidity (n = 4,746; 8.88%), and CONV (n = 3,399; 6.36%) were low. Mortality was higher in CONV patients vs repair (3.18% vs 1.02%). All event rates were lower with increasing program volumes. The mortality risk model had excellent discrimination (AUC: 0.807) and calibration and confirmed very low mortality risk for isolated MV repair for primary MR, with mean mortality risk of 1.16% and median of 0.55% (IQR: 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 1 in 4 patients age 75 or older had >3% estimated risk of mortality. CONCLUSIONS: This etiologic and procedure-specific risk model establishes that the contemporary mortality risk of MV repair for primary MR is <1% for the vast majority of patients.

Risk of Surgical Mitral Valve Repair for Primary Mitral Regurgitation.

BACKGROUND: Risk estimation for surgical intervention is an essential component of heart team shared decision-making. However, current mitral valve (MV) surgery risk models used in practice lack etiologic or procedural specificity. The purpose of this study was to establish a comprehensive method for assessment of operative risk of MV repair of primary mitral regurgitation (MR). METHODS: A novel etiology and procedure-specific algorithm identified 53,462 consecutive (July 2014 to June 2020) intention-to-treat MV repair patients with primary MR from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Risk models were fit for 30-day operative mortality, mortality and/or major morbidity, and conversion-to-replacement (CONV). As-treated mortality and morbidity models were derived separately. RESULTS: Event rates for mortality (n = 619; 1.16%), mortality plus morbidity (n = 4746; 8.88%), and CONV (n = 3399; 6.36%) were low. Mortality was higher in CONV patients vs repair (3.18% vs 1.02%). All event rates were lower with increasing program volumes. The mortality risk model had excellent discrimination (AUC: 0.807) and calibration and confirmed very low mortality risk for isolated MV repair for primary MR, with mean mortality risk of 1.16% and median of 0.55% (interquartile range: 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 1 in 4 patients age 75 or older had >3% estimated risk of mortality. CONCLUSIONS: This etiologic and procedure-specific risk model establishes that the contemporary mortality risk of MV repair for primary MR is <1% for the vast majority of patients.

Isolated Tricuspid Operations: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis.

BACKGROUND: Population-level data are limited regarding contemporary practice and outcomes of isolated tricuspid operations. We evaluated this using The Society of Thoracic Surgeons Adult Cardiac Surgery Database. METHODS: We identified 14,704 isolated tricuspid operations from The Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 1, 2011 to June 30, 2020. After excluding patients with endocarditis, tricuspid stenosis, emergent/emergent salvage status, previous heart transplants, and missing tricuspid operation type, 6507 patients remained. Endpoints were operative mortality and composite major comorbidities (permanent stroke, renal failure, prolonged ventilation > 24 hours, deep sternal wound infection, cardiac reoperations, and new permanent pacemaker implantation). RESULTS: Isolated tricuspid operations increased from 2012 (983 cases) to 2019 (2155 cases, P < .001). Median annual center volume was 2 cases (range, 1-81). In the final cohort (n = 6507; median age, 65 years; 38.5% men), 40% had New York Heart Association class III/IV heart failure and 24% had nonelective operations. The operative mortality was 7.3% (1.7% in patients without these risk factors), and new permanent pacemaker implant rate was 10.8%. In the multivariable analysis, factors associated with operative mortality included New York Heart Association class III/IV heart failure (odds ratio [OR], 1.57), nonelective operations (OR, 1.91), tricuspid replacement (OR, 1.56), annual center volume ≤ 5 cases (OR, 1.37), and higher model for end-stage liver disease scores (all P < .05). Beating heart operation was associated with a lower adjusted risk of pacemaker implant (OR, 0.69), renal failure (OR, 0.75), and blood transfusions (OR, 0.8) compared with full cardioplegic arrest (all P < .05). CONCLUSIONS: Isolated tricuspid repair was associated with lower adjusted mortality and morbidities than replacement. Beating heart operation was associated with lower adjusted major morbidities. The preoperative model for end-stage liver disease scores may identify high-risk patients, and early referral to higher volume centers may help improve outcomes.