Novel heat shock protein 90 inhibitor improves cardiac recovery in a rodent model of donation after circulatory death.

OBJECTIVE: Organ donation after circulatory death (DCD) is a potential solution for the shortage of suitable organs for transplant. Heart transplantation using DCD donors is not frequently performed due to the potential myocardial damage following warm ischemia. Heat shock protein (HSP) 90 has recently been investigated as a novel target to reduce ischemia/reperfusion injury. The objective of this study is to evaluate an innovative HSP90 inhibitor (HSP90i) as a cardioprotective agent in a model of DCD heart. METHODS: A DCD protocol was initiated in anesthetized Lewis rats by discontinuation of ventilation and confirmation of circulatory death by invasive monitoring. Following 15 minutes of warm ischemia, cardioplegia was perfused for 5 minutes at physiological pressure. DCD hearts were mounted on a Langendorff ex vivo heart perfusion system for reconditioning and functional assessment (60 minutes). HSP90i (0.01 µmol/L) or vehicle was perfused in the cardioplegia and during the first 10 minutes of ex vivo heart perfusion reperfusion. Following assessment, pro-survival pathway signaling was evaluated by western blot or polymerase chain reaction. RESULTS: Treatment with HSP90i preserved left ventricular contractility (maximum + dP/dt, 2385 ± 249 vs 1745 ± 150 mm Hg/s), relaxation (minimum -dP/dt, -1437 ± 97 vs 1125 ± 85 mm Hg/s), and developed pressure (60.7 ± 5.6 vs 43.9 ± 4.0 mm Hg), when compared with control DCD hearts (All P = .001). Treatment abrogates ischemic injury as demonstrated by a significant reduction of infarct size (2,3,5-triphenyl-tetrazolium chloride staining) of 7 ± 3% versus 19 ± 4% (P = .03), troponin T release, and mRNA expression of Bax/Bcl-2 (P < .05). CONCLUSIONS: The cardioprotective effects of HSP90i when used following circulatory death might improve transplant organ availability by expanding the use of DCD hearts.

Expert Consensus Paper: Lateral Thoracotomy for Centrifugal Ventricular Assist Device Implant.

BACKGROUND: The increasing prevalence of heart failure has led to the expanded use of left ventricle assist devices (VADs) for end-stage heart failure patients worldwide. Technological improvements witnessed the development of miniaturized VADs and their implantation through less traumatic non-full sternotomy approaches using a lateral thoracotomy (LT). Although adoption of the LT approach is steadily growing, a lack of consensus remains regarding patient selection, details of the surgical technique, and perioperative management. Furthermore, the current literature does not offer prospective randomized studies or evidence-based guidelines for LT-VAD implantation. METHODS: A worldwide group of LT-VAD experts was convened to discuss these key topics openly. After a PubMed search and review with all authors, a consensus was reached and an expert consensus paper on LT-VAD implantation was developed. RESULTS: This document aims to guide clinicians in the selection of patients suitable for LT approaches and preoperative optimization. Details of operative techniques are described, with an overview of hemisternotomy and bilateral thoracotomy approaches. A review of the best surgical practices for placement of the pump, inflow cannula, and outflow graft provides advice on the best surgical strategies to avoid device malpositioning while optimizing VAD function. Experts' opinions on cardiopulmonary bypass, postoperative management, and approaches for pump exchange and explant are presented. This review also emphasizes the critical need for multidisciplinary teams and specific training. CONCLUSIONS: This expert consensus review provides a compact guide to LT for VAD implantation, from patient selection through intraoperative tips and postoperative management.

Preoperative left atrial volume index is associated with postoperative outcomes in mitral valve repair for chronic mitral regurgitation.

OBJECTIVE: To assess determinants of left atrial reverse remodeling after mitral valve repair and to evaluate the impact of preoperative left atrial volume on postoperative outcomes. METHODS: We reviewed the records of 720 patients who underwent mitral valve repair from September 2008 to July 2015 and had preoperative measurement of left atrial volume index. We analyzed the association of preoperative left atrial volume index on early and late outcomes, and determined which baseline characteristics are associated with left atrial reverse remodeling, as measured by changes in left atrial volume index in 512 patients who had at least 1 postoperative measurement. RESULTS: The median (interquartile range) preoperative left atrial volume index was 54.0 (44.0-66.0) mL/m2. Preoperative left atrial volume index, age, body mass index, and atrial fibrillation were independently associated with the degree of left atrial reverse remodeling over the follow-up period. Reverse remodeling was greatest in patients with higher baseline left atrial volume index (P < .001), but less reverse remodeling was observed in patients with advanced age (P < .001), preoperative atrial fibrillation (P < .001), and extreme values of body mass index (P = .004), although these effects were moderately attenuated when limiting the analysis to 6-month follow-up. Secondary analysis demonstrated marginally significant effects of preoperative left atrial volume index on risks of early postoperative atrial fibrillation (P = .030) and late mortality (P = .077) after adjusting for age and sex. CONCLUSIONS: In patients with degenerative mitral valve regurgitation who had mitral valve repair, preoperative left atrial volume index was associated with extent of left atrial reverse remodeling, risk of early postoperative atrial fibrillation, and late mortality. The majority of reverse remodeling occurs within the first month after operation and is greatest in younger patients.

Active clearance of chest tubes is associated with reduced postoperative complications and costs after cardiac surgery: a propensity matched analysis.

BACKGROUND: Chest tubes are routinely used to evacuate shed mediastinal blood in the critical care setting in the early hours after heart surgery. Inadequate evacuation of shed mediastinal blood due to chest tube clogging may result in retained blood around the heart and lungs after cardiac surgery. The objective of this study was to compare if active chest tube clearance reduces the incidence of retained blood complications and associated hospital resource utilization after cardiac surgery. METHODS: Propensity matched analysis of 697 consecutive patients who underwent cardiac surgery at a single center. 302 patients served as a baseline control (Phase 0), 58 patients in a training and compliance verification period (Phase 1) and 337 were treated prospectively using active tube clearance (Phase 2). The need to drain retained blood, pleural effusions, postoperative atrial fibrillation, ICU resource utilization and hospital costs were assessed. RESULTS: Propensity matched patients in Phase 2 had a reduced need for drainage procedures for pleural effusions (22% vs. 8.1%, p < 0.001) and reduced postoperative atrial fibrillation (37 to 25%, P = 0.011). This corresponded with fewer hours in the ICU (43.5 [24-79] vs 30 [24-49], p = < 0.001), reduced median postoperative length of stay (6 [4-8] vs 5 [4-6.25], p < 0.001) median costs reduced by $1831.45 (- 3580.52;82.38, p = 0.04) and the mean costs reduced by an average of $2696 (- 6027.59;880.93, 0.116). CONCLUSIONS: This evidence supports the concept that efforts to actively maintain chest tube patency in early recovery is useful in improving outcomes and reducing resource utilization and costs after cardiac surgery. TRIAL REGISTRATION: Clinicaltrial.gov, NCT02145858, Registered: May 23, 2014.

Robotic Mitral Valve Repair: Indication for Surgery Does Not Influence Early Outcomes.

OBJECTIVE: To evaluate the outcomes of robotic mitral valve repair (MVr) by primary indication per American Heart Association guidelines for surgery: class I vs class IIa. PATIENTS AND METHODS: From January 1, 2008, through September 30, 2016, 603 patients underwent robotic MVr for severe primary mitral regurgitation. Medical records of 576 consenting patients were retrospectively reviewed to determine the primary indication for surgery. Patients were stratified into class I or class IIa, and preoperative, intraoperative, and postoperative variables were compared. RESULTS: Of 516 patients, 428 (83%) had class I indication and 88 (17%) had class IIa indication for surgery. Preoperatively, no significant differences were observed between both cohorts. Importantly, a significantly higher number of patients with class I indication underwent MVr for bileaflet prolapse (172 of 428 [40%] vs 21 of 88 [25%]; P=.03). Early MVr outcomes indicated recurrent mitral regurgitation (moderate or greater) in only 12 of 576 (2%), and no significant differences were observed between classes (P=.23). Apart from parameters for ventricular size, all other intraoperative and postoperative variables were comparable between both cohorts. CONCLUSION: Comparable outcomes were indicated across all classes of indications for MVr surgery. These results continue to support the use of this surgical technique, even in less sick patients. Early referral along with more extensive robotic MVr experience will likely result in further improvements in long-term outcomes.

Acute renal failure due to bilateral renal vein thromboses: A rare complication of heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia type II is a rare but devastating complication of heparin exposure. We review a case of a 66-year-old female who underwent aortic valve surgery requiring venoarterial extracorporeal membranous oxygenation (ECMO) support postoperatively. She subsequently developed acute renal failure due to bilateral renal vein thromboses and thrombocytopenia and was found to have platelet factor 4/heparin antibodies and was diagnosed with heparin-induced thrombocytopenia (HIT). She was transitioned to nonheparin anticoagulation and her thrombocytopenia improved. Although a rare complication of anticoagulation, diagnosing HIT in a patient on ECMO requires a high index of suspicion and should be considered.

Evaluation of a lateral thoracotomy implant approach for a centrifugal-flow left ventricular assist device: The LATERAL clinical trial.

BACKGROUND: The HeartWare centrifugal-flow ventricular assist device system (HVAD) is a viable option for treatment of advanced heart failure. There is a growing trend toward the use of less invasive techniques in cardiac surgery, and the thoracotomy technique for HVAD implantation may provide benefits not available with conventional approaches. METHODS: The LATERAL trial is a multicenter, prospective, non-randomized, single-arm trial that utilized data from 144 patients enrolled in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database at 26 centers in the United States and Canada. The primary composite end-point was success at 180 days defined as alive on the originally implanted device and free from disabling stroke (modified Rankin Scale score >3), transplanted or explanted for recovery. The key secondary end-point was mean length of initial hospital stay. RESULTS: The primary end-point was successfully achieved in 88.1% of patients and was significantly greater than the pre-defined performance goal of 77.5% set from historical sternotomy data (p = 0.0012). The key secondary end-point-mean length of initial hospital stay -was 18 days and was significantly shorter than the pre-defined performance goal of 26.1 days obtained from historical sternotomy data (p < 0.0001). The adverse event profile further demonstrated the safety of the thoracotomy approach. The overall patient survival was good, and bleeding requiring reoperation was significantly less frequent than that observed in previous studies using the sternotomy approach. CONCLUSIONS: This prospective clinical trial provides validation that implantation of the HVAD system via the thoracotomy approach used in the LATERAL study represents a safe and effective alternative to median sternotomy in selected patients intended for a bridge-to-transplant indication.

Long-term outcomes of patients undergoing tricuspid valve surgery†.

OBJECTIVES: Limited literature is available on the best management strategy for tricuspid valve (TV) disease in adults. We sought to review our long-term outcomes of TV surgery with regard to survival and reoperation. METHODS: A retrospective analysis of all patients ≥18 years of age [n = 2541, aged 67 ± 13years, 1433 (56%) females] who underwent first-time TV surgery between January 1993 and December 2013 was done. There were 1735 patients who received TV repair and 806 patients underwent replacement. A gradient boosting machine model was used to derive a propensity score for predicting replacement using 27 preoperative characteristics. Four hundred and eighteen propensity-matched pairs of TV repair and replacement were identified. Cox proportional hazard regression was used on the matched subset to determine the effect of replacement. RESULTS: Functional TV regurgitation was present in 54% (n = 1369). A bioprosthesis was used in 84% (n = 680) of replacements, while 54% (n = 934) of TV repairs were ring annuloplasties. Operative mortality was 8% (n = 212). Overall survival was 54%, 29% and 13% at 5, 10 and 15 years, respectively. After propensity score matching, replacement was significantly associated with increased mortality [hazard ratio (HR) 1.54, 95% confidence interval (CI) 1.18-2.00; P = 0.001]. The cumulative incidence of TV reoperation was similar between the 2 groups when accounting for the competing risk of death [Fine-Gray HR 1.56, 95% CI 0.9-2.8; P = 0.144]. CONCLUSIONS: TV surgery is associated with poor outcomes due to multiple patient comorbidities. TV repair results in better survival compared to replacement in patients with similar comorbidities with no increased risk of getting a reoperation.

Intramyocardial Injection of Mesenchymal Precursor Cells and Successful Temporary Weaning From Left Ventricular Assist Device Support in Patients With Advanced Heart Failure: A Randomized Clinical Trial.

Importance: Left ventricular assist device (LVAD) therapy improves myocardial function, but few patients recover sufficiently for explant, which has focused attention on stem cells to augment cardiac recovery. Objective: To assess efficacy and adverse effects of intramyocardial injections of mesenchymal precursor cells (MPCs) during LVAD implant. Design, Setting, and Participants: A randomized phase 2 clinical trial involving patients with advanced heart failure, undergoing LVAD implant, at 19 North American centers (July 2015-August 2017). The 1-year follow-up ended August 2018. Interventions: Intramyocardial injections of 150 million allogeneic MPCs or cryoprotective medium as a sham treatment in a 2:1 ratio (n = 106 vs n = 53). Main Outcomes and Measures: The primary efficacy end point was the proportion of successful temporary weans (of 3 planned assessments) from LVAD support within 6 months of randomization. This end point was assessed using a Bayesian analysis with a predefined threshold of a posterior probability of 80% to indicate success. The 1-year primary safety end point was the incidence of intervention-related adverse events (myocarditis, myocardial rupture, neoplasm, hypersensitivity reactions, and immune sensitization). Secondary end points included readmissions and adverse events at 6 months and 1-year survival. Results: Of 159 patients (mean age, 56 years; 11.3% women), 155 (97.5%) completed 1-year of follow-up. The posterior probability that MPCs increased the likelihood of successful weaning was 69%; below the predefined threshold for success. The mean proportion of successful temporary weaning from LVAD support over 6 months was 61% in the MPC group and 58% in the control group (rate ratio [RR], 1.08; 95% CI, 0.83-1.41; P = .55). No patient experienced a primary safety end point. Of 10 prespecified secondary end points reported, 9 did not reach statistical significance. One-year mortality was not significantly different between the MPC group and the control group (14.2% vs 15.1%; hazard ratio [HR], 0.89; 95%, CI, 0.38-2.11; P = .80). The rate of serious adverse events was not significantly different between groups (70.9 vs 78.7 per 100 patient-months; difference, -7.89; 95% CI, -39.95 to 24.17; P = .63) nor was the rate of readmissions (0.68 vs 0.75 per 100 patient-months; difference, -0.07; 95% CI, -0.41 to 0.27; P = .68). Conclusions and Relevance: Among patients with advanced heart failure, intramyocardial injections of mesenchymal precursor cells, compared with injections of a cryoprotective medium as sham treatment, did not improve successful temporary weaning from left ventricular assist device support at 6 months. The findings do not support the use of intramyocardial mesenchymal stem cells to promote cardiac recovery as measured by temporary weaning from device support. Trial Registration: clinicaltrials.gov Identifier: NCT02362646.

Mitochondrial Morphology, Dynamics, and Function in Human Pressure Overload or Ischemic Heart Disease With Preserved or Reduced Ejection Fraction.

BACKGROUND: The FOXO3a (forkhead box O3a)-BNIP3 (B-cell lymphoma 2/adenovirus E1B 19kDa interacting protein 3) pathway modulates mitochondrial dynamics and function and contributes to myocardial remodeling in rodent models of heart failure. We sought to investigate the expression of this pathway along with the expression of mitochondrial biogenesis (PGC-1α [peroxisome proliferator-activated receptor-γ coactivator-1α]), dynamics (DRP-1 [dynamin-related protein 1], OPA-1 [optic atrophy 1], and MFN 2 [mitofusin 2]), and oxidative phosphorylation (citrate synthase and electron transport chain complexes) markers and COX IV (cytochrome C oxidase) activity in myocardium from patients with valvular or ischemic heart disease and heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS: Subepicardial left ventricular biopsies (10×1×1 mm3) were obtained at aortic valve replacement (HFpEFAVR, n=5; and HFrEFAVR, n=4), coronary artery bypass grafting (HFpEFCABG, n=5; and HFrEFCABG, n=5), or left ventricular assist device implantation (HFrEFLVAD, n=4). Subepicardial biopsies from patients with normal left ventricular function (n=2) and from donor hearts (n=3) served as controls (normal). Relative to normal, mitochondrial fragmentation and cristae destruction were evident, and mitochondrial area was decreased in HFpEF; 1.00±0.09 versus 0.71±0.08; P=0.016. These mitochondrial morphological changes were more pronounced in HFrEF (0.54±0.06); P=0.002 HFpEF versus HFrEF. BNIP3 (monomer+dimer) expression was increased in HFpEF (3.99±2.44) and in HFrEF (5.19±1.70) relative to normal; P=0.004 and P<0.001, respectively. However, BNIP3 monomer was increased in HFrEF (4.32±1.43) compared with normal (0.99±0.06) and HFpEF (1.97±0.90); P=0.001 and 0.004, respectively. The HFrEF group uniquely showed increase in DRP-1 expression (1.94±0.38) and decreases in PGC-1α expression (0.61±0.07) and COX IV activity (0.70±0.10) relative to normal; P=0.013, P<0.001, and P<0.001, respectively, with no significant change in electron transport chain complexes expression. CONCLUSIONS: These findings in human myocardium confirm studies in rodents where contractile dysfunction is associated with activation of the FOXO3a-BNIP3 pathway and altered mitochondrial dynamics, biogenesis, and function.

Repeat aortic valve replacement for failing aortic root homograft.

OBJECTIVE: Published data are limited in comparison of transcatheter aortic valve replacement with surgical aortic valve replacement for the failing aortic root homograft. We reviewed our experience with repeat aortic valve replacement in failing aortic root homografts to compare outcomes of transcatheter aortic valve replacement and surgical aortic valve replacement. METHODS: We retrospectively reviewed the records of 51 patients with failing aortic root homografts who received repeat aortic valve replacement between October 2000 and May 2018. Operation included transcatheter aortic valve replacement in 11 patients between June 2014 and May 2018. Surgical aortic valve replacement was performed in 40 patients between October 2000 and January 2018, and operation included repeat composite aortic valve/root replacement in 30 patients (75%). RESULTS: Patient age was 59 years (interquartile range, 50-72 years), sex was female in 9 patients (18%), and time to repeat aortic valve replacement was 12 years (interquartile range, 8-13). Procedure-related complications occurred in 37 patients (73%): vascular injury (any) more commonly in the transcatheter aortic valve replacement group (36% vs 5%; P = .015), bleeding (major or life-threatening) more commonly in the surgical aortic valve replacement group (58% vs 0%; P < .001), and sternal reentry injury only in the surgical aortic valve replacement group (n = 6, 15%). There were 3 procedure-related deaths in the surgical aortic valve replacement group (8%) and 1 (9%) in the transcatheter aortic valve replacement group (P = 1.000). Subsequent cardiac operation occurred in no patients in the transcatheter aortic valve replacement group and in 5 patients in the surgical aortic valve replacement group. CONCLUSIONS: Repeat aortic valve replacement for failing aortic root homograft is associated with notable risk of morbidity and mortality regardless of replacement technique. Avoidance of vascular injury could lead to improved outcomes in the transcatheter aortic valve replacement group.

Medical Therapy As Compared To Surgical Device Exchange for Left Ventricular Assist Device Thrombosis: A Systematic Review and Meta-Analysis.

Pump thrombosis is a major adverse event in patients supported on continuous-flow left ventricular assist devices (CF-LVAD). The aim of this systematic review and meta-analysis was to determine the outcomes of various treatment approaches for pump thrombosis, including surgical as compared to medical therapy. Electronic search was performed to identify all studies in the English literature addressing surgical and medical management of pump thrombosis in the modern CF-LVAD era. All identified articles were systematically assessed for inclusion and exclusion criteria. In the meta-analysis, because of significant overlap of the data, reports based on trials, registries, and individual cohort studies were analyzed separately. Forty-three studies were included in the analysis (2 trials, 4 registry reports, and 37 individual cohort studies). 2,281/28,728 (10.6%) patients developed pump thrombosis, of which 44.4% and 55.1% were supported on the HeartWare and HeartMate II, respectively. To avoid overlap in studies and to seek more granular data, pooled individual cohort studies were found to be representative of the entire population, and further in-depth analysis of this category was performed. Of the 610/5,545 (11.8%) patients with pump thrombosis in these individual cohort studies, 225 patients had surgical pump exchange, and 186 were treated medically. Surgical therapy resulted in higher success as compared to medical therapy (81.3% vs. 45.4%; p < 0.001), lower 30 day mortality rate (16.7% vs. 34.5%; p = 0.013) and recurrence rate (11.8% vs. 38.3%; p < 0.001). Meta-regression of all studies demonstrates a possible temporal increase of pump thrombosis rate (p = 0.040). Surgical pump exchange is superior to medical therapy with a higher success rate of pump thrombosis resolution, lower mortality rate, and lower recurrence rate. Randomized controlled prospective studies are needed to compare these clinical approaches and their resultant outcomes to guide decision-making for the management of CF-LVAD thrombosis.

Coexistent bicuspid aortic valve and mitral valve prolapse: epidemiology, phenotypic spectrum, and clinical implications.

AIMS: Bicuspid aortic valve (BAV) and mitral valve prolapse (MVP) are common but the prevalence and significance of coexistent conditions are unknown. This study investigated the prevalence, phenotypic expression, and clinical significance of coexistent MVP-BAV. METHODS AND RESULTS: Retrospective comparison of MVP-BAV and MVP-tricuspid aortic valve (TAV) prevalence including de novo echocardiographic analysis of all MVP-BAV patients between 2005 and 2015 was performed. The community prevalence of MVP-BAV was 2.7% vs. 3.4% for MVP-TAV (P = 0.45). Posterior mitral leaflet (PML)-MVP was the most common phenotype in both BAV and TAV (P = 0.38), but anterior mitral leaflet (AML)-MVP was twice more prevalent in BAV (31% vs. 15%, P < 0.0001). Among 130 subjects with coexistent MVP-BAV (81% men, 51 ± 16 years old), 31 (24%) exhibited AML:PML length ratio ≥3:1, termed large-AML prolapse (LAP-BAV), who had predominant BAV regurgitation when compared with those with non-LAP-BAV (P ≤ 0.001). An extreme phenotype of LAP-BAV with giant-AML prolapse and diminutive PML (GAP-BAV) was identified in 18/130 (14%) subjects. Compared with posterior-MVP-BAV, GAP-BAV patients were younger (42 ± 15 vs. 64 ± 12 years, P < 0.0001), had larger aortic annulus (28 ± 3 vs. 26 ± 2 mm, P = 0.01), and 61% had ≥ moderate BAV regurgitation (vs. 16%, P = 0.0007). Mitral repair occurred in 37/130 (28%) subjects. After median follow-up 5.5 months (4-83), 4/5 (80%) GAP-BAV patients required redo surgery for recurrent mitral regurgitation vs. 2/31 (6%) for non-LAP-BAV (P = 0.001). CONCLUSION: The community prevalence of coexistent MVP-BAV is comparable to MVP-TAV and their most common phenotype is posterior-MVP. However, anterior-MVP is twice as prevalent in MVP-BAV. A large-AML phenotype (LAP-BAV) with predominant BAV regurgitation affects 24% of MVP-BAV patients. An extreme phenotype of anterior-MVP (GAP-BAV) affects 14% of BAV patients; characterized by exceptionally large AML, diminutive PML, high mitral and aortic regurgitation prevalence, and high mitral repair failure rate.

Burden of Tricuspid Regurgitation in Patients Diagnosed in the Community Setting.

OBJECTIVES: This study sought to analyze patients with tricuspid regurgitation (TR) diagnosed in the community setting (Olmsted County) by Doppler echocardiography to define the prevalence, characteristics, and implications of clinically significant (greater or equal to moderate) TR. BACKGROUND: The prevalence, cause distribution, and significance of TR are mostly unknown. METHODS: All adult residents of Olmsted County, Minnesota, who underwent clinically indicated Doppler echocardiography between 1990 and 2000 were evaluated for presence of greater or equal to moderate TR. The characteristics and outcome of TR carriers was then analyzed. RESULTS: During the study period, 417 community residents were diagnosed with greater or equal to moderate TR corresponding to an U.S. age- and sex-adjusted prevalence of 0.55% with 95% confidence interval (0.50 to 0.60). TR adjusted prevalence was higher in women (p < 0.01) and strongly linked to age (p < 0.0001). Isolated TR (without significant comorbidities, structural left valve disease, pulmonary hypertension, or overt cardiac cause) represented 8.1% of patients with greater or equal to moderate TR. Isolated TR adjusted for age, sex, ejection fraction, atrial fibrillation, and Charlson comorbidity index independently predicted higher mortality (adjusted risk ratio: 1.68; 95% confidence interval: 1.04 to 2.60; p = 0.03) for qualitative definition. Mortality in patients with greater or equal to moderate isolated TR was higher than in the matched cases with trivial TR (p = 0.0014; matching for age, sex, atrial fibrillation, ejection fraction, comorbidity index). Only 2.6% of patients ever had tricuspid valve surgery during follow-up. CONCLUSIONS: Clinically significant (greater or equal to moderate) TR is common in community residents diagnosed by Doppler echocardiography and increases with age. Isolated TR is associated with excess mortality, thus TR represents an important public health problem.

Degenerative Mitral Regurgitation After Nonmitral Cardiac Surgery: MitraClip Versus Surgical Reconstruction.

BACKGROUND: Surgical mitral valve repair is the conventional treatment for severe degenerative mitral regurgitation (MR). MitraClip therapy has emerged as a viable option in high-risk surgical patients. We sought to compare conventional surgery to MitraClip therapy in patients with severe degenerative mitral valve prolapse (MVP) and previous cardiac interventions. METHODS: From January 2012 to May 2016, 131 patients with previous cardiac surgery and subsequent intervention for degenerative MVP were included in this analysis: 75 (57.3%) underwent surgical repair and 56 (42.7%) underwent MitraClip placement. Follow-up was available in all early survivors at median of 11 (interquartile range, 0 to 32) months for surgery and 11 (interquartile range, 3 to 21) months for MitraClip patients. RESULTS: MitraClip patients were older (75.7 ± 8.6 years of age versus 68.6 ± 13.1 of age; p < 0.001), and had higher Society of Thoracic Surgeons risk scores (5.8 ± 2.4 versus 2.7 ± 2.3; p < 0.001). Median length-of-stay was 7 (interquartile range, 5 to 11) days for surgery and 2 (interquartile range, 2 to 4) days for MitraClip patients (p < 0.001), but 30-day mortality was comparable between the 2 groups (2.7% versus 3.6%; p = 0.77). Recurrent MR (moderate or severe) was significantly higher for MitraClip patients, both at discharge (43.1% versus 5.4%; p < 0.001) and at 1-year follow-up (66.7% versus 33.3%; p = 0.02). At 1 year postintervention, freedom from mitral reintervention was significantly higher for surgical patients (100.0% versus 87.5%; p = 0.006). CONCLUSIONS: In patients with previous cardiac interventions and severe degenerative MVP, a repeat conventional surgery is safe and durable. Percutaneous MitraClip repair is effective but associated with higher risk of residual MR, and should only be considered in selected patients. Careful patient selection using a heart team approach is recommended.

Does Mitral Valve Calcium in Patients Undergoing Mitral Valve Replacement Portend Worse Survival?

BACKGROUND: Mitral annular calcification (MAC) is associated with worse outcomes after mitral valve replacement (MVR). With limited data available on long-term outcomes, we reviewed our experience of MVR in presence of MAC. METHODS: A retrospective review of 1,710 consecutive patients who underwent MVR between January 2000 and December 2015 was performed. Patients with isolated primary MVR (n = 496) were included, whereas patients with concomitant cardiac surgery (n = 1,068), previous MVR (n = 110), and mitral valve (MV) endocarditis (n = 36) were excluded. MV calcification was classified as MAC present in anterior/posterior annulus and vertically at the level of leaflets/subvalvular apparatus. A conservative approach towards annular debridement was followed. RESULTS: Our sample's mean age was 64.4 ± 14.1 years, and included 279 (56%) women. MV calcification was observed in 169 (34%) patients with MAC in 115 (23%). Older age, higher ejection fraction, peripheral vascular disease, diabetes, dialysis, and previous aortic valve surgery were associated with increased prevalence of MAC. Patients with MV calcification had higher stroke rate (p = 0.040), patients with anterior leaflet and commissural calcification had higher pacemaker implantation (p = 0.010, p = 0.001, respectively), and patients with circumferential MAC had higher postoperative dialysis (p = 0.006). Operative mortality was not significantly different (p = 0.466) between MAC (n = 1, 1%) and non-MAC (n = 9, 2%) patients. MAC was associated with late mortality (unadjusted hazard ratio, 1.62; 95% confidence interval, 1.20 to 2.18), though on multivariable analysis age, diabetes, dialysis, hypertension, previous aortic valve surgery, previous coronary artery bypass grafting, and MVR with a bioprosthetic valve were found to be independent risk factors for mortality whereas MAC was not. CONCLUSIONS: A conservative approach to treat MAC achieves satisfactory results. Patients with MAC have significant comorbidities contributing to a worse survival, though MAC in itself is not a risk factor for mortality.

Patient Experience After Cardiac Surgery: Identifying Areas for Improvement.

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a publicly reported survey of patient experience with in-hospital care. We reviewed institutional HCAHPS survey data to assess our patients' experiences after cardiac surgery and to identify targets for practice improvement. METHODS: We reviewed data from patients undergoing the most common cardiac operations, with dismissal from October 1, 2012 to September 30, 2015. We used top-box methodology to combine survey results into nine domains, including the global (composite) hospital rating, dichotomized as high versus low. Multivariable logistic regression analysis was used to evaluate the independent associations of variables with low global ratings. Key driver analysis using domain means and Spearman correlation between the global rating and the eight other domains identified targets for quality improvement. RESULTS: Among 1,315 surveyed patients a low global hospital rating was independently associated with low perceived overall health (fair or poor vs excellent; odds ratio [OR], 5.4; p = 0.001), younger age (18 to 59 vs ≥70 years; OR, 1.6; p = 0.048), prolonged length of stay (OR, 1.6; p = 0.02), and robotic mitral valve (MV) repair (robotic vs open repair; OR, 2.4; p = 0.045). Patients undergoing transcatheter aortic valve replacement (TAVR) reported global ratings similar to that of patients with open aortic valve operations (OR, 0.9; p = 0.64). Key drivers of patient experience were care transitions and communication regarding medications. CONCLUSIONS: The primary targets of improvement for our institution are care transitions and communications regarding medications. The less-invasive procedures (robotic MV repair, TAVR) were not independently associated with higher patient-experience scores.