Prevalence of Cardiovascular Risk Factors in Women With Obstructive Coronary Disease Requiring Revascularization: A Meta-analysis.

Background: Cardiovascular disease continues to be the primary cause of premature mortality in women, who previously have been overlooked in clinical trials. Several studies showed that women undergoing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) present more cardiovascular risk factors at baseline, develop more postprocedural complications, and have a higher mortality rate than men. The goal of this review is to analyze the difference between men and women in terms of the prevalence of individual cardiovascular risk factors. Methods: A meta-analysis was conducted of original investigations with adult subjects who underwent surgical intervention or PCIs in which cardiovascular risk factors were evaluated, using the MEDLINE, Cochrane, Evidence-Based Medicine Reviews (EBMR), Ovid Embase, Google Scholar, and PubMed databases. Results: Of the 4567 identified records found, 18 were retained for qualitative analysis. Prevalence of hypertension (CABG: 71% (95% confidence interval [CI] 64%, 78%]); PCI: (59% [95% CI 48%,70%]), and diabetes (CABG: 48% [95% CI 38%, 57%]); PCI 43% (95% CI 27%, 59%]) was high in women. Women who underwent either CABG or PCI had higher odds of having hypertension (CABG: odds ratio [OR] 1.92 [95% CI 1.47-2.50], P < 0.05); PCI: OR 1.86 [95% CI 1.76-1.97], P < 0.05]), and diabetes (CABG: OR 1.94 [95% CI 1.55-2.42], P < 0.05; PCI: OR 1.97 [95% CI 1.54-2.53], P < 0.05)). However, the prevalence of smoking among women, compared to men, was lower (CABG: 0.17 [95% CI 0.06-0.52], P < 0.05; PCI: 0.22 [95% CI 0.06-0.86], P < 0.03). Conclusion: The review shows that women who underwent either surgical or percutaneous revascularization had higher odds of hypertension and diabetes, compared to men.

Contexte: Les maladies cardiovasculaires demeurent la principale cause de décès prématurés chez les femmes, qui ont antérieurement été négligées dans les essais cliniques. Or, plusieurs études ont révélé que les femmes qui subissent un pontage aortocoronarien (PAC) ou une intervention coronarienne percutanée (ICP) présentent initialement plus de facteurs de risque cardiovasculaire, connaissent plus de complications postopératoires et affichent un taux de mortalité plus élevé que les hommes. Cette analyse visait à dégager les différences entre les hommes et les femmes quant à la prévalence de chacun des facteurs de risque cardiovasculaire. Méthodologie: Une méta-analyse a été menée sur des enquêtes originales auprès d'adultes ayant subi une intervention chirurgicale ou des ICP chez qui les facteurs de risque cardiovasculaire ont été évalués. Les bases de données interrogées étaient les suivantes : MEDLINE, Cochrane, Evidence-Based Medicine Reviews (EBMR), Ovid Embase, Google Scholar et PubMed. Résultats: Parmi les 4567 dossiers recensés, 18 ont été retenus pour une analyse qualitative. La prévalence de l'hypertension (PAC : 71 % [intervalle de confiance {IC} à 95 % : 64 %; 78 %]); ICP : 59 % [IC à 95 % : 48 %; 70 %]) et du diabète (PAC : 48 % [IC à 95 % : 38 %; 57 %]); ICP : 43 % (IC à 95 % : 27 %; 59 %]) était élevée chez les femmes. Les femmes qui ont subi un PAC ou une ICP présentaient un risque accru d'hypertension (PAC : rapport de cotes [RC] de 1.92 [IC à 95 % : 1,47-2,50], p < 0,05); ICP : RC de 1,86 [IC à 95 % : 1,76-1,97], p < 0,05]) et de diabète (PAC : RC de 1,94 [IC à 95 % : 1,55-2,42], p < 0,05; ICP : RC de 1,97 [IC à 95 % : 1,54-2,53], p < 0,05). Cependant, le tabagisme était moins prévalent chez les femmes que chez les hommes (PAC : 0,17 [IC à 95 % : 0,06-0,52], p < 0,05; ICP : 0,22 [IC à 95 % : 0,06-0,86], p < 0,03). Conclusion: L'analyse révèle que, par rapport aux hommes, les femmes qui ont subi une revascularisation chirurgicale ou percutanée présentaient plus de risque d'hypertension et de diabète.

Anterolateral territory coronary artery bypass grafting strategies: a non-inferiority randomized clinical trial: the AMI-PONT trial.

OBJECTIVES: The main objective was to assess whether a composite coronary artery bypass grafting strategy including a saphenous vein graft bridge to distribute left internal mammary artery outflow provides non-inferior patency rates compared to conventional grafting surgery with separated left internal mammary artery to left anterior descending coronary graft and aorto-coronary saphenous vein grafts to other anterolateral targets. METHODS: All patients underwent isolated grafting surgery with cardiopulmonary bypass and received ≥2 grafts/patients on the anterolateral territory. The graft patency (i.e. non-occluded) was assessed using multislice spiral computed tomography at 1 year. RESULTS: From 2012 to 2021, 208 patients were randomized to a bridge (n = 105) or conventional grafting strategy (n = 103). Patient characteristics were comparable between groups. The anterolateral graft patency was non-inferior in the composite bridge compared to conventional grafting strategy at 1 year [risk difference 0.7% (90% confidence interval -4.8 to 6.2%)]. The graft patency to the left anterior descending coronary was no different between groups (P = 0.175). Intraoperatively, the bridge group required shorter vein length for anterolateral targets (P < 0.001) and exhibited greater Doppler flow in the mammary artery pedicle (P = 0.004). The composite outcome of death, myocardial infarction or target vessel reintervention at 30 days was no different (P = 0.164). CONCLUSIONS: Anterolateral graft patency of the composite bridge grafting strategy is non-inferior to the conventional grafting strategy at 1 year. This novel grafting strategy is safe, efficient, associated with several advantages including better mammary artery flow and shorter vein requirement, and could be a valuable alternative to conventional grafting strategies. Ten-year clinical follow-up is underway. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01585285.

Growth Differentiation Factor-15 as a Predictor of Functional Capacity, Frailty, and Ventricular Dysfunction in Patients With Aortic Stenosis and Preserved Left Ventricular Ejection Fraction.

In aortic stenosis (AS), left ventricular (LV) remodeling often occurs before symptom onset, and early intervention may be beneficial. Risk stratification remains challenging and identification of biomarkers may be useful. We evaluated the association between growth differentiation factor-15 (GDF-15) and soluble suppression of tumorigenicity 2 (sST2) and known markers of poor prognosis in AS. Baseline plasma GDF-15 and sST2 levels were measured in 70 patients with moderate-severe AS (aortic valve area <1.5 cm2) and preserved LV ejection fraction (>45%). Patients were categorized into "low GDF-15" versus "high GDF-15" and "low sST2" versus "high sST2" groups. Groups were compared for differences in cardiovascular risk factors, 6-minute walk test, 5 m gait speed, cognitive function (Montreal Cognitive Assessment), and echocardiographic parameters. Overall, 44% of patients were deemed asymptomatic by New York Heart Association class, 61% had severe AS (aortic valve area <1 cm2) and all patients had preserved LV ejection fraction. GDF-15 levels were not predictive of AS severity. However, high GDF-15 (>1,050 pg/ml) was associated with LV dysfunction as shown by lower indexed stroke volume (p <0.01), worse LV global longitudinal strain (p = 0.04), greater mean E/e' (p = 0.02) and indexed left atrial volume (p <0.01). It was also associated with decreased functional capacity with shorter 6-minute walk test (p = 0.01) and slower 5 m gait speed (p = 0.02). Associations between sST2 levels and markers of poor prognosis were less compelling. In this study of patients with moderate to severe AS, elevated GDF-15 levels are associated with impaired functional capacity, poorer performance on fragility testing, and LV dysfunction. In conclusion, GDF-15 may integrate these markers of adverse outcomes into a single biomarker of poor prognosis.

Amyloid Deposits in a Functionally Unicuspid Stenotic Aortic Valve.

Amyloidosis concomitant to aortic stenosis usually occurs with myocardial infiltration by the transthyretin protein. To our knowledge, this is the first report of localized amyloidosis of indeterminate type in a severely calcified and functionally unicuspid aortic valve. Isolated dystrophic valvular amyloidosis is believed to be related to fibrocalcific valve disease. In light of the literature on this topic, the present case raises new hypotheses on pathophysiology and further supports the contributory role of unusual non-tricuspid valve morphology in the development of dystrophic amyloid, likely secondary to altered hemodynamic stress.

Une amyloïdose associée à une sténose aortique survient généralement avec infiltration du myocarde par la protéine transthyrétine. Le cas que nous décrivons est, à notre connaissance, le premier cas rapporté d'amyloïdose localisée de type indéterminé dans une valve aortique sévèrement calcifiée et fonctionnellement unicuspide. L'amyloïdose valvulaire dystrophique isolée serait liée à l'atteinte fibrocalcique de la valve. À la lumière de la littérature à ce sujet, le cas décrit ici permet de soulever de nouvelles hypothèses physiopathologiques et appuie le lien entre une morphologie valvulaire inhabituelle (non tricuspide) et l'apparition de substances amyloïdes dystrophiques, probablement secondaire à une altération des contraintes hémodynamiques.

Three-year outcomes of the Dissected Aorta Repair Through Stent Implantation trial.

OBJECTIVE: The study objective was to evaluate the clinical and radiographic outcomes of the Ascyrus Medical Dissection Stent in a prospective, nonrandomized, international study (Dissected Aorta Repair Through Stent Implantation) of patients with acute DeBakey type I aortic dissection. METHODS: The Ascyrus Medical Dissection Stent was used in combination with the standard surgical management of acute DeBakey type I aortic dissection I to treat patients with (56.5%, 26/46) and without (43.5%, 20/46) preoperative clinical and radiographic malperfusion. All patients had a primary entry tear in the ascending aorta, and 97.8% (45/46) were treated with a hemiarch repair. Median follow-up was 3 years. RESULTS: All 47 patients underwent emergency surgical repair with successful Ascyrus Medical Dissection Stent implantation. One patient was excluded from analysis due to use in iatrogenic dissection. Overall mortality at 30 days and 3 years was 13.0% (6/46) and 21.7% (10/46), respectively. Overall new stroke rate at 30 days was 15.2% (7/46). No devices were explanted at any time during the 3-year median follow-up. At 3 years, the total aortic diameter in zones 0, 1, and 2 decreased or remained stable in 91.7%, 72.7%, and 75.0%, respectively. The false lumen was completely or partially thrombosed in 90.5% in zone 0, 60.0% in zone 1, and 68.2% in zone 2 at 3 years. CONCLUSIONS: The use of the Ascyrus Medical Dissection Stent in the treatment of acute DeBakey type I aortic dissection I holds promise as a simple technology that enables repair of the aortic arch and proximal descending aorta, while promoting positive aortic remodeling. Ongoing follow-up of the Dissected Aorta Repair Through Stent Implantation trial will provide long-term, prospective, clinical outcomes and radiographic data on positive remodeling of the aortic arch.

Transcatheter occlusion of a left ventricular outflow tract pseudoaneurysm using a "plug and coil" strategy.

Left ventricular outflow tract pseudoaneurysm is a rare and potentially fatal complication of aortic valve replacement. Surgical repair is the most common treatment and is particularly suitable for large pseudoaneurysms. Recently, there has been significant breakthroughs in the management of postoperative pseudoaneurysms via endovascular techniques. We report a case of a large postoperative pseudoaneurysm of the left ventricular outflow tract that occurred 1 year following a redo mechanical aortic valve replacement in a patient with previous valve sparing procedure performed 5 years earlier. The pseudoaneurysm was anatomically located antero-laterally between the right atrium and the ascending aorta. Successful occlusion was achieved with an Amplatzer Vascular Plug 2 (Abbott) and several coils (Terumo) via a transapical approach.

Less invasive treatments for pure aortic insufficiency: Are we there yet?

The gold standard for the treatment of pure aortic insufficiency (PAI) is surgical valve repair or replacement. With the newest transcatheter heart valve technologies and the accumulating years of experience of heart teams with the current transcatheter aortic valve replacement (TAVR) prostheses, implanters have pushed the envelope with off-label use of those valves designed and approved for aortic stenosis, in patients with PAI especially those at higher risks or for compassionate use. However, new prostheses are currently under investigation in clinical use and evidence is provided on the safety and efficacy of those latter. Will be discussed in this commentary, the actual clinical evidence and the use of transcatheter heart valves, in- and off-label, for the treatment of PAI.

Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic. METHODS: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. RESULTS: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies. CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

Daytime Variation of Clinical Outcome in Cardiac Surgery: A Propensity-Matched Cohort Study.

OBJECTIVE: The purpose of the present study was to investigate the hypothesis of a nychthemeral variation in the tolerance to ischemia and reperfusion injury in adult cardiac surgeries. DESIGN: Retrospective cohort study. SETTING: A single academic center. PARTICIPANTS: All patients undergoing nonemergent aortic valve replacement (AVR) ± coronary artery bypass graft between January 2012 and May 2018 were included. They were divided into two groups (morning and afternoon) according to the time of the day at the beginning of surgery. Propensity score matching estimated by multivariate logistic regression with a 1:1 matching ratio was performed to ensure that the two groups were comparable. This allowed obtaining 269 pairs, for a total of 538 patients. INTERVENTION: The objective of the study was to assess whether there were differences in perioperative and postoperative outcomes between the morning and the afternoon groups. RESULTS: There was no between-group difference in the primary composite endpoints, namely the occurrence of death, myocardial infarction, low cardiac output, and stroke during the 30 days following the surgery. Regarding cardiac biomarkers, there were no between-group differences for both postoperative evolution of troponin T plasma levels and the maximum postoperative troponin T plasma level. CONCLUSION: These results did not support the hypothesis that the timing of the surgery could influence the tolerance to ischemia and reperfusion injury, at least in patients undergoing nonemergent AVR or a combined AVR with coronary artery bypass graft.

SAVR contemporary outcomes in TAVI era: Still a valid option for the future.

The advent of transcatheter aortic valve implantation (TAVI) has changed the way aortic stenosis (AS) is treated. In the last decade, the improvement of techniques and the development of more performing devices helped in granting TAVI approval for its use in high- and intermediate-risk patients and more recently in low-risk patients. With the majority of surgical aortic valve replacement (SAVR) procedures being done on low-risk patients, recent results from the PARTNER 3 and Evolut Low Risk trials have ignited the question of TAVI use in patient category as well as an alternative to SAVR. The paper by a group from the Royal Papworth Hospital from the University of Cambridge, UK, published in the Journal of Cardiac Surgery, should serve as concrete proof that SAVR remains an excellent option with favorable outcomes in the treatment of AS. It is a wake-up call to the entire surgical community to push forward to ameliorate outcomes and reduce complications through innovation and experience, newer surgical techniques, better equipment, and improved valves to adapt to the changing world of heart valve diseases.

The International Society for Minimally Invasive Cardiothoracic Surgery Expert Consensus Statement on Transcatheter and Surgical Aortic Valve Replacement in Low- and Intermediate-Risk Patients: A Meta-Analysis of Randomized and Propensity-Matched Studies.

OBJECTIVE: There is an increasing amount of evidence supporting use of transcatheter aortic valve replacement (TAVR) for treatment of aortic stenosis in patients at low or intermediate risk for surgical aortic valve replacement (SAVR). TAVR is now approved for use in all patient cohorts. Despite this, there remains debate about the relative efficacy of TAVR compared with SAVR in lower-risk cohorts and various subgroups of patients. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and propensity-matched trials to guide a consensus among expert cardiologists and surgeons. METHODS: Studies comparing TAVR and SAVR in low- and intermediate-risk patients were identified by a thorough search of the major databases. Mortality, stroke, and other perioperative outcomes were assessed at 30 days and 1 year. RESULTS: Early mortality was lower in TAVR compared to SAVR in RCTs, but not propensity-matched studies in low-risk cohorts (0.66% vs 1.5%; odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.20 to 0.98, I2 = 0%). No difference in mortality between TAVR and SAVR was identified in intermediate-risk patients at early or later time points. Incidence of perioperative stroke in 3 low-risk RCTs was significantly lower in TAVR (0.4%) than SAVR (1.4%; OR = 0.33, 95% CI 0.13 to 0.81, I2 = 0%). There was no difference in stroke for intermediate-risk patients between TAVR and SAVR. The expert panel of cardiologists and cardiac surgeons provided recommendations for TAVR and SAVR in various clinical scenarios. CONCLUSIONS: In RCTs comparing TAVR and SAVR in low-risk patients, early mortality and stroke were lower in TAVR, but did not differ at 1 year. There was no difference in mortality and stroke in intermediate-risk patients. The Multidisciplinary Heart Team must consider individual patient characteristics and preferences when recommending TAVR or SAVR. The decision must consider the long-term management of each patient's aortic valve disease.

60 Years After the First Woman Cardiac Surgeon: We Still Need More Women in Cardiac Surgery.

In 1960, Dr Nina Starr Braunwald became the first woman to perform open heart surgery. Sixty years later, despite the fact that women outnumbered men in American medical school in 2017, men still dominate the field of cardiac surgery. Women surgeons remain underrepresented in cardiac surgery; 11% of practicing cardiac surgeons in Canada were women in 2015, and 6% of practicing adult cardiac surgeons in the US were women in 2019. Although women remain a minority in other surgical specialties also, cardiothoracic surgery remains one of the most unevenly-gender distributed specialties. Why are there so few women cardiac surgeons, and why does it matter? Evidence is emerging regarding the benefits of diversity for a variety of industries, including healthcare. In order to attract and retain the best talent, we must make the cardiac surgery environment more diverse, equitable, and inclusive. Some causes of perpetuation of the gender gap have been documented in the literature-these include uneven compensation and career advancement opportunities, outdated views on family dynamics, and disproportionate scrutiny of women surgeons, causing additional workplace frictions for women. Diversity is an organizational strength, and gender-diverse institutions are more likely to outperform their non-gender-diverse counterparts. Modifiable issues perpetuate the gender gap, and mentorship is key in helping attract, develop, and retain the best and brightest within cardiac surgery. Facilitating mentorship opportunities is key to reducing barriers and bridging the gap.

En 1960, la Dre Nina Starr Braunwald est devenue la première femme à pratiquer une chirurgie à cœur ouvert. Soixante ans plus tard, malgré le fait que les femmes étaient plus nombreuses que les hommes dans les facultés de médecine américaines en 2017, les hommes dominent toujours le domaine de la chirurgie cardiaque. Les chirurgiennes restent sous-représentées en chirurgie cardiaque; 11 % des chirurgiens praticiens en cardiologie au Canada étaient des femmes en 2015, et 6% des chirurgiens praticiens en cardiologie pour adultes aux États-Unis étaient des femmes en 2019. Bien que les femmes restent également minoritaires dans d'autres spécialités chirurgicales, la chirurgie cardiothoracique reste l'une des spécialités où la répartition des sexes est la plus inégale. Pourquoi y a-t-il si peu de chirurgiennes en cardiologie, et pourquoi est-ce important? Des données émergent au sujet des avantages de la diversité pour une variété de secteurs, y compris les soins de santé. Afin d'attirer et de retenir les meilleurs talents, nous devons rendre le milieu de la chirurgie cardiaque plus diversifié, équitable et inclusif. Certaines causes expliquant la persistance de l'écart entre les sexes ont été documentées dans la littérature : il s'agit notamment de l'inégalité de la rémunération et des possibilités d'avancement, de points de vue dépassés sur la dynamique familiale et de l'attention disproportionnée portée aux chirurgiennes, ce qui entraîne des frictions supplémentaires pour les femmes en milieu de travail. La diversité est une force au sein d'une organisation, et les établissements où la diversité des genres est présente sont plus susceptibles d'obtenir de bons résultats que les autres. Des problèmes modifiables perpétuent l'écart entre les sexes, et le mentorat est essentiel pour attirer, perfectionner et retenir les meilleurs éléments dans le domaine de la chirurgie cardiaque. Il est essentiel de faciliter les possibilités de mentorat pour réduire les obstacles et combler le fossé.

Changes in outcomes over time in intermediate-risk patients treated for severe aortic stenosis.

BACKGROUND: The advent of transcatheter aortic valve replacement (TAVR) has changed the practice of treating patients with severe aortic stenosis (AS). Heart-Teams have improved their decision-making process to refer patients to the best and safest treatment. The evidence allowed centers to increase funding and TAVR volume and extend indications to different risk categories of patients. This study evaluates the outcomes of intermediate-risk patients treated for severe AS in an academic center. METHODS: Between 2012 and 2019, 812 patients with AS underwent TAVR or surgical aortic valve replacement (SAVR). A propensity score-matching analytic strategy was used to balance groups and adjust for time periods. Outcomes were recorded according to the Society of Thoracic Surgeons Guidelines; the primary outcome being 30-day mortality and the secondary outcomes being perioperative course and complications. RESULTS: No difference in mortality was seen but complications differed: more postoperative transient ischemic attacks, permanent pacemaker implantations, and perivalvular leaks in the transcatheter group, while more acute kidney injuries, atrial fibrillation, delirium, postoperative infections and bleeding, tamponade and need for reoperation in the surgical group as well as a longer hospital length-of-stay. However, over the years, morbidities/mortality decreased for all patients treated for AS. CONCLUSIONS: Data showed an improvement in morbidities/mortality for intermediate-risk patients treated with SAVR or TAVR. Increased funding allowed for a higher TAVR volume by increasing access to this technology. Also, the difference in complications could impact healthcare costs. By incorporating important metrics such as length-of-stay, readmission rates, and complications into decision-making, the Heart-Team can improve clinical outcomes, healthcare economics, and resource utilization.

Transcatheter Aortic Valve Replacement After Prior Mitral Valve Surgery: Results From the Transcatheter Valve Therapy Registry.

BACKGROUND: Due to perceived technical challenges, patients with previous surgical mitral valve repair or replacement (SMVR) have been excluded from most transcatheter aortic valve replacement (TAVR) trials. Our objective was to compare the 30-day and 1-year outcomes of TAVR for patients with and without prior SMVR. METHODS: In a retrospective review of The Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) Transcatheter Valve Therapy (TVT) Registry, we compared 1097 patients with prior SMVR to 46,327 patients without prior SMVR who underwent TAVR between November 2011 and September 2015 at 394 US centers. Preoperative characteristics, procedural details, and clinical outcomes were analyzed. RESULTS: Patients with previous SMVR were younger, more often female, and had higher STS predicted risk of mortality (8.6% vs 6.8%, P < .001). However, there was no difference in 30-day mortality (4.6% vs 5.5%, P = .293), myocardial infarction, stroke, reintervention, new dialysis, or readmission. Moderate/severe paravalvular leak at discharge was also similar (5.8% vs 4.9%, P = .343). At 1 year, morbidity was similar with slightly higher mortality among patients with prior SMVR (20% vs 17.5%, P = .087) that was significant after adjustment (hazard ratio 1.18, P = .043). The type of prior SMVR (repair, bioprosthetic replacement, or mechanical replacement) had no impact on 30-day or 1-year survival. CONCLUSIONS: Patients with prior SMVR undergoing TAVR had similar 30-day outcomes, slightly higher 1-year mortality, and no increase in early paravalvular leak compared with patients who did not have previous SMVR. Prior SMVR should not preclude TAVR for appropriately selected patients.

Making cardiac surgery feasible in African countries: Experience from Namibia, Uganda, and Zambia.

OBJECTIVES: Few African countries have the resources to provide optimal cardiac surgery care. We explored needs at cardiac surgery centers in Namibia, Zambia, and Uganda. Our objectives were (1) to determine the key variables to be included in a cardiac surgery needs assessment tool and (2) to highlight the current initiatives, challenges and opportunities, and future goals for cardiac surgery in these 3 countries. METHODS: We conducted in-depth interviews with stakeholders in each country as well as surveys of surgical facilities. We synthesized our findings using a health systems conceptual framework. Each program's current capacity was compared with a standardized definition of "adequate" surgical capacity. On the basis of these findings, we developed a formal needs assessment questionnaire for use in resource-constrained countries. RESULTS: Although each of these countries has adequate facilities and surgical expertise, they still lack key support staff and material resources. Training and mentorship programs are being built, and the sites participate in cardiovascular research. Yet a comprehensive, multidisciplinary approach-including palliative care and rehabilitation-is lacking, and patients in remote areas are not being served. These observations allowed us to define the variables in our needs assessment tool. CONCLUSIONS: Our study demonstrates the great potential that exists to expand cardiac surgery in Africa and highlights some of the major resource bottlenecks that may hinder the scale-up of surgical programs. Our needs assessment questionnaire will assist ministries of health in building sustainable cardiac surgery programs using innovative Afro-centric solutions.

The train has left: Can surgeons still get a ticket to treat structural heart disease?

With the disruptive advancement of catheter-based technologies and minimally invasive techniques in structural heart disease, surgeons must obtain necessary skills to continue to serve this large patient population. We believe that surgeons are uniquely positioned to offer the full spectrum of therapy in structural heart disease (transcatheter, minimally invasive, and complex redo interventions), making them comprehensive valve specialists. Given the variability in structural heart training, we urgently recommend the establishment of a standardized curriculum and pathways for surgical trainees to gain proficiency in transcatheter technologies.