Minimally invasive approach associated with lower resource utilization after aortic and mitral valve surgery.

Objective: To investigate the effect of minimally invasive cardiac surgery (MICS) on resource utilization, cost, and postoperative outcomes in patients undergoing left-heart valve operations. Methods: Data were retrospectively reviewed for patients undergoing single-valve surgery (eg, aortic valve replacement, mitral valve replacement, or mitral valve repair) at a single center from 2018 to 2021, stratified by surgical approach: MICS vs full sternotomy (FS). Baseline characteristics and postoperative outcomes were compared. Primary outcome was high resource utilization, defined as direct procedure cost higher than the third quartile or either postoperative LOS ≥7 days or 30-day readmission. Secondary outcomes were direct cost, length of stay, 30-day readmission, in-hospital and 30-day mortality, and major morbidity. Multiple regression analysis was conducted, controlling for baseline characteristics, operative approach, valve operation, and lead surgeon to assess high resource utilization. Results: MICS was correlated with a significantly lower rate of high resource utilization (MICS, 31.25% [n = 115] vs FS 61.29% [n = 76]; P < .001). Median postoperative length of stay (MICS, 4 days [range, 3-6 days] vs FS, 6 days [range, 4 to 9 days]; P < .001) and direct cost (MICS, $22,900 [$19,500-$28,600] vs FS, $31,900 [$25,900-$50,000]; P < .001) were lower in the MICS group. FS patients were more likely to experience postoperative atrial fibrillation (P = .040) and renal failure (P = .027). Other outcomes did not differ between groups. Controlling for stratified Society of Thoracic Surgeons predicted risk of mortality, cardiac valve operation, and lead surgeon, FS demonstrated increased likelihood of high resource utilization (P < .001). Conclusions: MICS for left-heart valve pathology demonstrated improved postoperative outcomes and resource utilization.

Ambulatory Electrocardiography Monitoring for Early Discharge After Minimally Invasive Valve Surgery.

INTRODUCTION: We sought to compare outcomes after early discharge in patients with and without predischarge diagnosis of arrhythmia following minimally invasive valve surgery (MIVS). MATERIALS AND METHODS: We retrospectively reviewed ambulatory electrocardiography (AECG) datasheets and medical records of patients discharged with 14-d AECG monitoring from our facility between October 2019 and March 2022 ≤ 3 d after MIVS. Baseline and clinical characteristics, arrhythmias during AECG monitoring, and 30-d adverse outcomes were reported for the population and stratified by presence or absence of predischarge arrhythmia. RESULTS: Of 41 patients discharged ≤3 d postoperatively of MIVS, 17 (41.5%) experienced predischarge arrhythmias and 24 (58.5%) did not. The population was predominantly male and White with a median age of 62 y [57, 70]. Baseline and clinical characteristics did not differ between subgroups. Most patients (92.7% [n = 38]) experienced one or more tachyarrhythmias during the AECG monitoring period. There were similar proportions of patients experiencing atrial fibrillation in both groups, but patients with predischarge arrhythmias had higher burden of atrial fibrillation on AECG monitoring (27.60% [6.57%, 100%] versus 1.65% [0.76%, 4.32%]; P = 0.004). The predischarge arrhythmia subgroup had higher proportions of patients experiencing nonsustained ventricular tachycardia but lower proportions experiencing supraventricular tachycardia. There were no mortalities within 30 d of surgery. Six (14.6%) patients were readmitted within 30 d with equal proportions of readmissions between subgroups (P = 0.662). CONCLUSIONS: Early discharge timelines and noninvasive monitoring techniques can allow patients to return to their normal activities quicker in the comfort of their own home with no increased risk of morbidity or mortality.

Is cardiopulmonary bypass standby still required for laser lead extractions?

OBJECTIVE: Over the last two decades there has been an increase in the number of cardiac implantable electronic devices and consequently, there has also been an increased need for lead extractions. Fibrotic attachments develop between the lead and the venous and cardiac structures that may require the use of a laser to mobilize the lead. Cardiothoracic surgeons (CTS) have traditionally provided backup for surgical emergencies for these extractions. This study evaluates the surgical outcomes of patients undergoing transvenous laser lead extractions (TLE) and determines if CTS are still needed for backup. METHODS: A retrospective review of consecutive patients undergoing laser lead extractions at a single academic center. Lead extractions using only laser sheaths were analyzed. The clinical characteristics, complications, and mortality of the patients were evaluated. RESULTS: One hundred and twenty-one patients underwent TLEs from January 1st, 2014 to December 31st, 2018. The majority were male (N = 80, 66.1%), and the average age was 66.48 ± 14 years. The indication for removal was either laser lead malfunction or infection. A total of 30 patients (24.8%) had complications postoperatively including wound hematomas, superficial infections, and arrhythmias. The average length of stay was 9 ± 12 for all the patients in the study. 2 patients (1.6%) had injuries that required emergency surgical repair with injuries to the posterior superior vena cava and right ventricle. Both patients survived the initial injury with one patient was discharged home on day 4 and the other succumbing to his injuries on postoperative day 20. CONCLUSION: Although the incidence of surgical emergencies is rare the morbidity and mortality for TLE require that surgical backup be available.

Early Discharge After Minimally Invasive Aortic and Mitral Valve Surgery.

BACKGROUND: We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery. METHODS: All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve surgery at a single center between 2012 and 2019 were classified by postoperative length of stay: early discharge (≤3 days) or late discharge (>3 days). The trend in early discharge was investigated over the study period, predictors of early discharge were identified using multivariate logistic regression modeling, and 1:1 propensity score matching was used to determine which patients in the late-discharge cohort had similar health to patients discharged early. Adjusted outcomes of 30-day mortality, readmission, and direct costs were analyzed. RESULTS: Among 1262 consecutive patients undergoing minimally invasive valve surgery, 618 were elective and uncomplicated, 25% (n = 162) of whom were discharged early. The proportion of early-discharge patients increased over time (P for trend < .05). A history of congestive heart failure, stroke, or smoking and higher Society of Thoracic Surgeons predictive risk of mortality score negatively predicted early discharge (P < .05). Propensity score matching identified 101 (22%) late-discharge patients comparable with early-discharge patients. Adjusted 30-day mortality and readmission rates were comparable between cohorts. The median direct costs per patient ($20,046 vs $22,124, P < .05) were significantly lower in the early-discharge cohort. CONCLUSIONS: In well-selected patients early discharge after minimally invasive valve surgery was associated with lower costs but comparable postoperative outcomes. About one-fifth of patients who remain in the hospital beyond postoperative day 3 may be candidates for earlier discharge.

Outcomes of minimally invasive aortic valve replacement in patients with obese body mass indices.

BACKGROUND: Minimally invasive heart valve surgery has previously been shown to be safe and feasible in obese patients. Within this population, we investigated the effect of obesity class on the patient outcomes of minimally invasive aortic valve replacement (mini-AVR). METHODS: A single-center retrospective cohort study of consecutive patients with obese body mass indices (BMIs) who underwent mini-AVR between 2012 and 2020. Patients were stratified into three groups according to Centers for Disease Control and Prevention adult obesity classifications: Class I (BMI: 30.0-<35.0), Class II (BMI: 35.0-<40.0), and Class III (BMI ≥ 40.0). The primary outcomes were postoperative length of stay (LOS), 30-day mortality, and direct cost. RESULTS: Among 206 obese patients who underwent mini-AVR, LOS (Class I 5 [3-7] vs. Class II 6 [5-7] vs. Class III 6 [5-7] days; p = .056), postoperative 30-day mortality (Class I 2.44% [n = 3] vs. Class II 4.44% [n = 2] vs. Class III 7.89% [n = 3]; p = .200), and costs (Class I $24,118 [$20,237-$29.591] vs. Class II $22,215 [$18,492-$28,975] vs. Class III $24,810 [$20,245-$32,942] USD; p = .683) did not differ between obesity class cohorts. CONCLUSIONS: Mini-AVR is safe and feasible to perform for obese patients regardless of their obesity class. Patients with obesity should be afforded the option of minimally invasive aortic valve surgery regardless of their obesity class.

Short-term and intermediate outcomes of cardiogenic shock and cardiac arrest patients supported by venoarterial extracorporeal membrane oxygenation.

BACKGROUND: Cardiogenic shock and cardiac arrest are life-threatening emergencies with high mortality rates. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) and extracorporeal cardiopulmonary resuscitation (e-CPR) provide viable options for life sustaining measures when medical therapy fails. The purpose of this study is to determine the utilization and outcomes of VA ECMO and eCPR in patients that require emergent cardiac support at a single academic center. METHODS: A retrospective chart review of prospectively collected data was performed at an academic institution from January 1st, 2018 to June 30th, 2020. All consecutive patients who required VA ECMO were evaluated based on whether they underwent traditional VA ECMO or eCPR. The study variables include demographic data, duration on ECMO, length of stay, complications, and survival to discharge. RESULTS: A total of 90 patients were placed on VA ECMO for cardiac support with 44.4% (40) of these patients undergoing eCPR secondary to cardiac arrest and emergent placement on ECMO. A majority of the patients were male (n = 64, 71.1%) and the mean age was 58.8 ± 15.8 years. 44.4% of patients were transferred from outside hospitals for a higher level of care and 37.8% of patients required another primary therapy such as an Impella or IABP. The most common complication experienced by patients was bleeding (n = 41, 45.6%), which occurred less often in eCPR (n = 29, 58% vs. n = 12, 30%). Other complications included infections (n = 11, 12.2%), limb ischemia (n = 13, 14.4%), acute kidney injury (n = 17, 18.9%), and cerebral vascular accident (n = 4, 4.4%). The length of stay was longer for patients on VA ECMO (32.1 ± 40.7 days vs. 17.7 ± 18.2 days). Mean time on ECMO was 8.1 ± 8.3 days. Survival to discharge was higher in VA ECMO patients (n = 23, 46% vs. n = 8, 20%). CONCLUSION: VA ECMO provided an effective rescue therapy in patients in acute cardiogenic shock with a survival greater than the expected ELSO guidelines of 40%. While the survival of eCPR was lower than expected, this may reflect the severity of patient's condition and emphasizes the importance of careful patient selection and planning.

Case report: surgical resection of right ventricular cardiac fibroma in an adult patient.

BACKGROUND: Cardiac fibromas are rare benign cardiac neoplasms, most frequently occurring in the pediatric population; with very rare cases identified in adults. The tumors are comprised of spindled cells with myofibroblastic ultrastructural features embedded in generally collagenous and elastic stroma. The tumors are intramural in the ventricles, most commonly the left ventricle. Clinical symptoms vary by location and size of tumor and some are asymptomatic. Surgical resection is curative, but rare cases require cardiac transplantation. CASE PRESENTATION: We report an asymptomatic, large, right ventricular fibroma in a 64-year-old woman. The patient underwent open incisional tumor biopsy via lower hemi-sternotomy, followed by complete tumor resection via full sternotomy a week later after confirming the tumor is benign. The tumor was resected using cardiopulmonary bypass, and the defect of right ventricular free wall was repaired using a prosthetic double-patch technique. The postoperative course was uneventful. The patient was discharged to home on day 4 post-complete tumor resection. CONCLUSION: This report expands the existing literature for better comprehension and detection of cardiac fibroma patients and also highlights the various imaging modalities, surgical management, and histological analysis.

Impact of risk factors on in-hospital mortality for octogenarians undergoing cardiac surgery.

BACKGROUND: Octogenarians undergoing cardiac surgery have higher mortality than their younger counterparts. OBJECTIVES: To determine if various risk factors have the same effect on mortality in octogenarians as in younger patients. METHODS: The National Inpatient Sample data set from 2004 to 2014 was queried to select patients aged 65 years and older who underwent either coronary artery bypass grafting (CABG), valvular heart surgery (VHS), or both (CABG + VHS) within 10 days of hospital admission. The patients were divided into two groups 65-79 years and 80 years and greater. Hospital mortality, patient demographics, comorbidities, and type of hospital admission was evaluated and compared using χ2 and multivariable logistic regressions. RESULTS: About 397,713 patients were identified including 86,345 (21.7%) aged 80 and above. Octogenarians had higher in-hospital mortality for all procedures: CABG (4.94% vs. 2.39%, p < .001), VHS (5.49% vs. 4.08%, p < .001), and CABG + VHS (7.59% vs. 5.95%, p < .001), and this relationship persisted when gender, race, comorbidities, and type of hospital admission were controlled for: CABG (odds ratio [OR] = 1.71; 95% confidence interval [CI] 1.62-1.81); VHS (OR = 1.18; 95% CI 1.11-1.27); and CABH + VHS (OR = 1.17; 95%CI 1.10-1.26). Female gender, renal, or heart failure, nonelective admission, and CABG + VHS were associated with increased risk of in-hospital mortality. Octogenarians had higher rates of these factors (p < .001). The effect size of renal and heart failure and type of surgery was smaller for octogenarians. CONCLUSIONS: Octogenarians undergoing cardiac surgery have higher rates of nonelective admissions, renal and heart failure, and female gender, which are most strongly associated with in-hospital mortality. Differing effect sizes suggest that certain risk factors, such as renal and heart failure, contribute more to mortality in younger patients.

Health and Healthcare Disparities: Impact on Resource Utilization and Costs After Transcatheter Aortic Valve Replacement.

OBJECTIVE: We investigated health and healthcare disparities in the treatment of aortic stenosis with transcatheter aortic valve replacement (TAVR) and how they affect resource utilization and costs. METHODS: We retrospectively reviewed all patients who were discharged alive after TAVR between 2012 and 2017 from the National Inpatient Sample. Patients were stratified by race and outcomes investigated were in-hospital complications, total procedural costs, and resource utilization. High resource utilization (HRU) was defined as length of stay (LOS) ≥7 days or discharge to a nonhome location. Multivariable regression models were used to identify predictors of HRU. RESULTS: TAVR patients (N = 29,464) were stratified into Caucasians (n = 25,691), others (n = 1,274), Hispanics (n = 1,267), and African Americans (AA, n = 1,232). More AA and Hispanics had TAVR at urban teaching centers (P = 0.003) and were less likely to be Medicare beneficiaries (P < 0.001). Distribution of TAVR patients in the lowest income quartile showed AA (50%) versus Caucasian (20%) versus Hispanic (33%, P < 0.001). In-hospital complications were higher among Hispanics and AA than Caucasians with prolonged LOS, procedural costs, and HRU. On multivariable analysis, independent predictors of HRU were TAVR year (P < 0.001), advanced age (P < 0.001), female sex (P < 0.001), non-Caucasian race (P = 0.038), history of coronary artery bypass grafting (P < 0.001), smoking (P < 0.001), chronic lung disease (P = 0.003), stroke (P < 0.001), and lowest income quartile (P = 0.002). CONCLUSIONS: There exist significant healthcare and health disparities among patients undergoing TAVR in the United States. Consequently, this unequal access to care and determinants of heath translate into higher resource utilization and costs.

Change in Renal Function and Its Impact on Survival in Chronic Kidney Disease Patients Bridged to Heart Transplantation With a Left Ventricular Assist Device.

The study investigates the incidence of change in renal function and its impact on survival in renal dysfunction patients who were bridged to heart transplantation with a left ventricular assist device (BTT-LVAD). BTT-LVAD patients with greater than or equal to moderately reduced renal function (estimated glomerular filtration rate [eGFR] ≤ 60 ml/min/1.73 m2) at the time of listing between 2008 and 2018 were identified from a prospectively maintained database of the United Network for Organ Sharing. Patients with a baseline eGFR less than or equal to 15 ml/min/1.73 m2 or on dialysis were excluded. Patients were divided into three groups based on percent change ([Pretransplant eGFR - listing eGFR/listing glomerular filtration rate (GFR)] × 100) in eGFR: Improvement greater than or equal to 10%, no change, decline greater than or equal to 10%, and their operative outcomes were compared. Posttransplant survival was estimated and compared among the three groups with the Kaplan-Meier survival curves and the log-rank test. Cox proportional hazards modeling was used to identify predictors of posttransplant survival. Out of 14,395 LVAD patients, 1,622 (11%) met the inclusion criteria. At the time of transplant, 900 (55%) had reported an improvement in eGFR greater than or equal to 10%, 436 (27%) had no change, and 286 (18%) experienced a decline greater than or equal to 10%. Postoperatively, the incidence of dialysis was higher in the decline than in the unchanged or improved groups (22% vs. 12% vs. 12%; p = 0.002). After a median follow-up of 5 years, there was no difference in posttransplant survival among the stratified groups (improved eGFR: 24.8%, unchanged eGFR: 23.2%, declined eGFR: 20.3%; p = 0.680). On Cox proportional hazard modeling, independent predictors of worse survival were: [hazard ratio: 95% CI; p] history of diabetes (1.43 [1.13-1.81]; p = 0.002) or tobacco use (1.40 [1.11-1.79]; p = 0.005) and ischemic time greater than 4 hours (1.36 [1.03-1.76]; p = 0.027). More than half of the patients with compromised renal function who undergo BTT-LVAD demonstrate an improvement in renal function at the time of transplant. A 10% change in GFR while listed was not associated with worse posttransplant survival.

The role of the axillary Impella 5.0 device on patients with acute cardiogenic shock.

BACKGROUND: Acute cardiogenic shock is associated with high mortality rates. The Impella device is a microaxial left ventricular assist device that can be inserted through the axillary artery. The purpose of our study is to determine the role of the Axillary Impella devices on patients with acute cardiogenic shock. METHODS: A retrospective chart review was conducted to identify patients who underwent Axillary Impella device placement for acute cardiogenic shock from January 1st, 2014 to September 30th, 2018 at a single institution. In-patient records were examined to determine duration of device, length of stay (LOS), postoperative complications, and 30-day in-hospital mortality. RESULTS: A total of 40 patients, who were primarily men (N = 29) with a mean age of 61.2 ± 10.7 years old, underwent Axillary Impella placement for cardiogenic shock. The primary reasons for implant were (1) required upgraded support from an Impella CP or intra-aortic balloon pump (iabp) to Impella 5.0, (2) to treat left ventricular (LV) distention for patients on extracorporeal mechanical oxygenation (ECMO), and (3) to provide longer term support and allow for mobilization of the patients in whom a device was already indwelling. Twenty-three of the patients had previous devices already in place including a Femoral Impella CP device or an iabp and 9 patients were on ECMO support. The duration of the device was 21.05 ± 17 days with the LOS of 40.8 ± 28 days for those patients. Seventeen of the patients went on to additional surgery including (1) Heartmate 3 device placement (N = 6), (2) other cardiac procedures such as surgical revascularization (N = 9), and orthotopic heart transplantation (N = 2). A total of 21 patients of the 40 (52%) died during their hospitalization with 7 patients (17%) having complications related to the Impella device. These complications included right arm ischemia or neuropathy (N = 3) and Impella malfunction requiring device replacement (N = 4). The majority of these devices were placed in the right axillary artery (N = 38) versus the left axillary artery (N = 2). CONCLUSIONS: A total of 58% (N = 23) of the study patients had previous mechanical support and 23% (N = 9) were on ECMO demonstrating the severity of disease and accounting for the high mortality. The Axillary Impella device allows for a minimally invasively placed device that is durable with a mean duration of 3 weeks. The Axillary artery Impella 5.0 provides upgraded full cardiac support while allowing for mobilization of the patient. In addition, it treats LV distention in patients on ECMO while avoiding sternotomy. Finally, the Axillary Impella provides time for decision making for explant, additional therapy with either long-term devices or orthotopic heart transplant.

PTEN suppresses epithelial-mesenchymal transition and cancer stem cell activity by downregulating Abi1.

The epithelial-mesenchymal transition (EMT) is an embryonic program frequently reactivated during cancer progression and is implicated in cancer invasion and metastasis. Cancer cells can also acquire stem cell properties to self-renew and give rise to new tumors through the EMT. Inactivation of the tumor suppressor PTEN has been shown to induce the EMT, but the underlying molecular mechanisms are less understood. In this study, we reconstituted PTEN-deficient breast cancer cells with wild-type and mutant PTEN, demonstrating that restoration of PTEN expression converted cancer cells with mesenchymal traits to an epithelial phenotype and inhibited cancer stem cell (CSC) activity. The protein rather than the lipid phosphatase activity of PTEN accounts for the reversal of the EMT. PTEN dephosphorylates and downregulates Abi1 in breast cancer cells. Gain- and loss-of-function analysis indicates that upregulation of Abi1 mediates PTEN loss-induced EMT and CSC activity. These results suggest that PTEN may suppress breast cancer invasion and metastasis via dephosphorylating and downregulating Abi1.

The impact of age on outcomes of coronary artery bypass grafting.

OBJECTIVE: As the population ages, increasing number of older patients are undergoing adult cardiac surgery. The purpose of the study is to assess the impact of age on postoperative outcomes in patients that undergo coronary artery bypass grafting (CABG). METHODS: Patients that are ≥70 years old who underwent CABG were selected from the Nationwide/National Inpatient Sample from 2010 to 2015 using ICD-9-CM diagnosis and procedure codes. The patients who were 70-79 years old were compared to patients aged 80-89 years old to determine if the age difference of the patients had an impact on surgical outcomes. In addition, a secondary endpoint is to compare surgical outcomes between the 2 genders of the patients 80-89 years old. The rates of postoperative complications, and mortality were compared. RESULTS: A total of 67,568 patients were identified who were ≥ 70 years old and underwent CABG. Compared to the Septuagenarians, the Octogenarians were more likely to develop cardiac complications (OR [odds ratio] =1.20, 95% CI [confidence interval] 1.12-1.23. They were also more likely to develop renal complications (P < 0001), and respiratory complications (P < 0001). The Octogenarians were also more likely to bleed postoperatively (P < 0.0001) and have a higher mortality (P < 0001). Furthermore, the female Octogenarians had a higher mortality (OR 1.25 95% CI 1.07-1.46) compared to males in the same age group. CONCLUSIONS: The patients who were ≥ 80-89 years old had worse postoperative outcomes. The Octogenarians who were females had a higher mortality compared to their male counterparts.

Delay in coronary artery bypass grafting for STEMI patients improves hospital morbidity and mortality.

OBJECTIVES: The optimal timing of coronary artery bypass grafting (CABG) in patients with ST elevated acute myocardial infarction (STEMI) is unclear. The purpose of the study is to evaluate and compare the outcomes in STEMI patients who underwent CABG within the various time intervals within the first 7 days of either emergent or urgent hospital admission. METHODS: Patients aged 30 years old and older diagnosed with STEMI who underwent CABG within first 7 days after non-elective hospital admission were selected from the National Inpatient Sample 2010-2014 using the appropriate ICD-9-CM diagnosis and procedure codes. These patients were divided into 3 cohorts based on timing of surgery: within 24 h (group A), 2nd-3rd day (group B), and 4th-7th day (group C). The rates of postoperative complications, mortality, and postoperative hospital length of stay (LOS) were compared using the Chi-square test, multivariable logistic regression analysis, and Wilcoxon rank sum test. RESULTS: A total of 5963 patients were identified: group A = 28.5%, group B = 36.1%, group C = 35.4%. Mean age overall was 63.1 ± 11.1 years; 76.9% were males and 72.9% were whites. Compared to groups B and C, patients in group A were more likely to develop cardiac complications (OR [odds ratio] =1.33, 95%CI [confidence interval] 1.12-1.59 and OR = 1.39, 95%CI 1.17-1.67, respectively) and respiratory complications (OR = 1.31, 95%CI 1.13-1.51 and OR = 1.53, 95%CI 1.32-1.78, respectively). They were also more likely to have renal complications (OR = 1.31, 95%CI 1.11-1.54) and bleeding (OR = 1.20, 95%CI 1.05-1.37) than patients in group B and had a similar tendency compared to group C. We did not find significant differences in the above complications between groups B and C. Postoperative stroke and sternal wound infection rates were similar between all three groups. In-hospital mortality was also higher in group A (8.2%) compared to group B (3.5%) and group C (2.9%, P < 0.0001 for both); differences between groups B and C were not significant. This was confirmed in the multivariable logistic regression analysis with controlling for age, gender, race, the Elixhauser Comorbidity Index, and complications (group A vs B: OR = 1.85, 95%CI 1.52-2.25; group A vs C: OR = 2.21; 95%CI 1.82-2.68). Patients in group A had a significantly longer postoperative LOS (median 7 days with IQR [interquartile range] 5-10 days) compared to those in group B (median 6 days, IQR 5-8 days) and group C (median 6 days, IQR 4-8 days; P < 0.0001 for both). CONCLUSIONS: The results of this study show that despite the urgency and severity of STEMI, patients who undergo CABG within the first 24 h after non-elective hospital admission have increased hospital morbidity and mortality. These findings suggest that a delay in surgery beyond the first 24 h may be beneficial to patient outcomes. Furthermore, there is a significant cost effectiveness when the patients delay surgery because the hospital length of stay is reduced as well as the subsequent hospital costs.

Placement of a rapid deployment aortic valve in a patient with severely calcified aortic root homograft.

Significant aortic calcification is a known sequelae of homograft aortic root replacement and creates a treatment challenge if these patients require cardiac reintervention. The standard surgical option for patients requiring an aortic valve replacement in the setting of a calcified aortic homograft has been a Bentall procedure, which is high-risk with extended cross-clamp, cardiopulmonary bypass and operative times. We present a patient with a severely calcified aortic homograft who underwent successful valve replacement using a rapid deployment aortic valve leaving the aortic root and arch intact and avoiding the more extensive redo aortic root replacement. Similar cases in the literature are rare.

Association between increased-risk donor social behaviors and recipient outcomes after heart transplantation.

BACKGROUND: This study aims to investigate the association between social behaviors of increased-risk donors (IRD) and recipient outcomes after heart transplantation. METHODS: The United Network for Organ Sharing (UNOS) database was queried to identify patients who received a heart transplant between 2004 and 2015. Patients were grouped based on donor's risk status (IRD vs standard risk donor [SRD]). Recipients of IRD were categorized based on donor social behaviors (SB), and recipient survival was assessed. Cox regression analysis was used to identify associations between SB of donors and recipient survival. RESULTS: Out of 22 333 heart transplantations performed during the study period, 2769 (12%) received an IRD graft with the following SB: Unprofessional tattoos or piercings (n = 1722) (63%), cocaine use (n = 916) (33%), heavy smoking (n = 437) (16%), and heavy alcohol abuse (n = 610) (22%). Viral screens detected 72(3%) hepatitis B virus (HBV) positive and 12 (0.4%) hepatitis C virus (HCV) positive at donation. There was no difference in recipient survival based on both donor risk and their social behaviors. Cox regression analysis found only donor HCV infection and non-identical ABO mismatch to be associated with poor recipient survival among recipients of IR grafts. CONCLUSION: Cardiac allografts from IRD, serologically negative for viruses, can safely be used. There is no association between social behaviors of IRD and recipient survival.