Long-term Stroke and Mortality Risk in Nonagenarians After Transcatheter Aortic Valve Insertion.

BACKGROUND: Limited data exist on the long-term outcomes of transcatheter aortic valve insertion (TAVI) in nonagenarian patients. This study investigated the relationship between patient baseline comorbidity and frailty on the long-term outcome of the nonagenarian population. METHODS: A retrospective analysis was conducted of 187 consecutive nonagenarian patients who underwent TAVI from 2009 to 2020. Multivariable models were used to analyze the association between baseline patient and frailty variables and mortality, stroke, and repeat hospitalization. Long-term survival was compared with an age- and sex-matched United States population. RESULTS: The median Society of Thoracic Surgeons predicted risk of mortality was 10% (interquartile range, 7%-17%). Frailty was met in 72% of patients based on the 5-meter walk test, 13% based on the Kansas City Cardiomyopathy Questionnaire 12-item instrument score, 12% based on Katz Index of Independence in Activities of Daily Living, and 8% based on serum albumin levels. Procedure-related death occurred in 3 patients (2%) and stroke in 8 (4%). The median duration of follow-up was 3.4 years. Outcomes included death in 150 patients (80%), stroke in 15, and repeat hospitalization in 114. Multivariable analysis identified no association between any of the baseline patient variables with mortality, stroke, repeat hospitalization, or the combined outcomes (all P > .05). The 1- and 5-year survival rates in TAVI-treated nonagenarians were similar to age- and sex-matched controls (P = .27). CONCLUSIONS: Long-term death or stroke is independent of The Society of Thoracic Surgeons predicted risk of mortality and frailty risk variables in this nonagenarian patient population who received TAVI. Furthermore, survival is similar to age- and sex-matched controls.

The interaction of forced expiratory volume in 1 s and N-terminal pro-B-type natriuretic peptide with outcomes after transcatheter aortic valve replacement.

OBJECTIVES: Low forced expiratory volume in 1 s (FEV1) and elevated N-terminal pro-B-type natriuretic peptide (NT-Pro-BNP) have been individually associated with poor outcomes after transcatheter aortic valve replacement (TAVR). We hypothesized a combination of the 2 would provide prognostic indication after TAVR. METHODS: We categorized 871 patients who received TAVR from 2008 to 2018 into 4 groups according to baseline FEV1 (<60% or ≥60% predicted) and NT-Pro-BNP (<1601 or ≥1601 pg/ml): group A (n = 312, high FEV1, low NT-Pro-BNP), group B (n = 275, high FEV1, high NT-Pro-BNP), group C (n = 123 low FEV1, low NT-Pro-BNP) and group D (n = 161, low FEV1, high NT-Pro-BNP). The primary end point was survival at 1 and 5 years. RESULTS: Patients in group A had more severe aortic stenosis and achieved the best long-term survival at 1 [93% (95% CI: 90-96)] and 5 [45.3% (95% CI: 35.4-58)] years. Low FEV1 and high NT-Pro-BNP (group D) patients had more severe symptoms, higher Society of Thoracic Surgeons predicted risk of operative mortality, lower ejection fraction and aortic valve gradient at baseline. Patients in group D had the worst survival at 1 [76% (95% CI: 69-83)] and 5 years [13.1% (95% CI: 7-25)], hazard ratio compared to group A: 2.29 (95% CI: 1.6-3.2, P < 0.001) with 25.7% of patients in New York Heart Association class III-IV. Patients in groups B and C had intermediate outcomes. CONCLUSIONS: The combination of FEV1 and NT-Pro-BNP stratifies patients into 4 groups with distinct risk profiles and clinical outcomes. Patients with low FEV1 and high NT-Pro-BNP have increased comorbidities, poor functional outcomes and decreased long-term survival after TAVR.

Characterization of Blood Outgrowth Endothelial Cells (BOEC) from Porcine Peripheral Blood.

The endothelium is a dynamic integrated structure that plays an important role in many physiological functions such as angiogenesis, hemostasis, inflammation, and homeostasis. The endothelium also plays an important role in pathophysiologies such as atherosclerosis, hypertension, and diabetes. Endothelial cells form the inner lining of blood and lymphatic vessels and display heterogeneity in structure and function. Various groups have evaluated the functionality of endothelial cells derived from human peripheral blood with a focus on endothelial progenitor cells derived from hematopoietic stem cells or mature blood outgrowth endothelial cells (or endothelial colony-forming cells). These cells provide an autologous resource for therapeutics and disease modeling. Xenogeneic cells may provide an alternative source of therapeutics due to their availability and homogeneity achieved by using genetically similar animals raised in similar conditions. Hence, a robust protocol for the isolation and expansion of highly proliferative blood outgrowth endothelial cells from porcine peripheral blood has been presented. These cells can be used for numerous applications such as cardiovascular tissue engineering, cell therapy, disease modeling, drug screening, studying endothelial cell biology, and in vitro co-cultures to investigate inflammatory and coagulation responses in xenotransplantation.

Do Right Heart Hemodynamic Improvements Persist After Pulmonary Thromboendarterectomy?

The survival benefits of pulmonary thromboendarterectomy (PTE) for the treatment of chronic thromboembolic pulmonary hypertension have been well described. However, the significance of right heart hemodynamic changes and their impact on survival remains poorly understood. We sought to characterize the effects of these changes. We conducted a single center, retrospective review of 159 patients who underwent PTE between 1993 and 2015. Echocardiographic and right heart catheterization data were compared longitudinally before and after PTE in order to establish the extent of hemodynamic response to surgery. Kaplan Meier estimates were used to characterize patient survival over time. Univariable and multivariable Cox proportional hazards regression models were used to assess factors associated with long-term mortality. Among the 159 patients studied, 74 (46.5%) were male with a median age of 55 (IQR: 42-66). One-, 5-, 10-, and 15-year survival was 91.0% (95% CI: 86.6-95.6), 79.6% (73.5-86.3), 66.5% (59.2-74.7), and 56.2% (48.1-65.8). Of the 9 candidate risk factors that were evaluated, only advanced age and increased cardiopulmonary bypass time were found to be significantly associated with increased risk of mortality. Pre- and postsurgical echocardiographic imaging data, when available, revealed a median reduction in right ventricular systolic pressure of 29.0 mm Hg (P < 0.0001) and improvement of tricuspid regurgitation (P < 0.0001), both of which appeared to be sustained across long-term follow-up. Improvements in right heart hemodynamics and tricuspid valvular regurgitation persist on long term surveillance following PTE. While patient selection is often driven by the distribution of disease, close postoperative follow up may improve outcomes.

Remote robotic percutaneous coronary intervention: An animal feasibility study.

OBJECTIVES: The purpose of this study was to explore the feasibility and safety of robotic PCI performed using an off-siteremote-control system in an animal model. BACKGROUND: Access to primary percutaneous coronary intervention (PCI) remains a challenge in acute myocardial infarction management. The combination of telemedicine and robotic PCI allow the potential delivery of primary PCI to remote locations without the delay of transfer. METHODS: This single-center prospective pilot preclinical feasibility study compared robotic PCI with remote PCI on swine across three stages (adjacent room, different floor of the same building, two different buildings). Latency up to 1,000 ms was introduced into the operating environment to simulate decreased network quality (blinded to operator). The primary outcome measures were technical success and acute safety. The secondary outcome measures included lesion wiring time, procedural time and qualitative scoring of the PCI experience by the operator. RESULTS: Across 52 experiments in 15 animals, technical success was 100%. No procedural complications occurred during the study. No significant difference in lesion treatment time was detected between stages (p = .11) and between time per target vessel when latency up to 1,000 ms was introduced (p = .58). Injected delay >250 ms had the greatest impact on procedure perceived lag. Longer procedure time was associated with lower procedure impact score, regardless of injected latency. CONCLUSIONS: Remote robotic PCI was feasible and safe in an animal model. Procedural duration was acceptable and unaffected by network latency. Future studies are needed to determine the safety and feasibility of remote PCI in humans.

Characteristics and Long-Term Outcomes of Patients With Prior Coronary Artery Bypass Grafting Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction.

Limited data are available on characteristics and long-term outcomes of patients with coronary artery bypass grafts (CABG) undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI). Between January 2000 to December 2014, we identified STEMI patients with prior CABG undergoing primary percutaneous coronary intervention from 3 sites. Kaplan-Meier methods to estimate survival and major adverse cardiac events (MACE) were employed and compared to a propensity matched cohort of non-CABG STEMI patients. Independent predictors of outcomes were analyzed with Cox modeling. Of the 3,212 STEMI patients identified, there were 296 (9.2%) CABG STEMI patients, having nearly similar frequencies of culprit graft (47.6%) versus culprit native (52.4%) as the infarct-related artery (IRA). At 10 years, the adjusted survival was 44% in CABG STEMI versus 55% in non-CABG STEMI (HR 1.26; 95%CI 0.86 to 1.87; p = 0.72). Survival free of MACE was lower for CABG STEMI (graft IRA, 37%; native IRA, 46%) as compared to non-CABG STEMI controls (63%) (p = 0.02). Neither CABG history nor IRA (native vs graft) was independently associated with death or MACE in multivariable analysis. Temporal trends showed no significant change in death or MACE rates of CABG STEMI patients over time. In conclusion, long term survival of CABG STEMI patients is not significantly different than matched STEMI patients without prior CABG; however, CABG STEMI patients were at significantly higher risk for MACE events.

Acute Myocardial Infarction Due to Fixed Coronary Artery Stenosis From Myocardial Bridging.

Myocardial bridging is a common coronary abnormality often associated with left ventricular hypertrophy. It can be noted incidentally on coronary angiography by findings of systolic narrowing of the involved coronary artery. We present the case of a 59-year-old woman that presented with a non-ST elevation myocardial infarction. She had a history of angina and workup 9-months prior with CT coronary angiography that revealed an intra-myocardial course of the left anterior descending coronary artery (LAD) with minimal stenosis and no concomitant coronary artery disease. Invasive coronary angiography now demonstrated apparent myocardial bridging associated with a severe fixed stenosis of the LAD without change in diameter with nitroglycerin injection. Due to persistent symptoms, surgical myotomy was attempted and then aborted because of difficulty unroofing the LAD due to surrounding fibrosis. Coronary artery bypass grafting (CABG) was then successfully performed using a left internal mammary artery graft. The patient had complete resolution of her chest pain and was without functional limitation at 3-month follow-up. This case highlights possible sequelae of myocardial bridging and suggests that, in rare cases, fixed obstruction of the involved coronary artery may occur in the setting of fibrosis of the bridged segment. In such cases, surgical myotomy may not be feasible and CABG may be required.

Acute myocardial infarction-cardiogenic shock in patients with prior coronary artery bypass grafting: A 16-year national cohort analysis of temporal trends, management and outcomes.

BACKGROUND: There are limited data on the outcomes of acute myocardial infarction with cardiogenic shock (AMI-CS) in patients with prior coronary artery bypass grafting (CABG). METHODS: A retrospective cohort of AMI-CS admissions during 2000-2016 from the National Inpatient Sample was created and prior CABG status was identified. Outcomes of interest included in-hospital mortality and resource utilization in the two cohorts. Temporal trends of prevalence, in-hospital mortality, and cardiac procedures were evaluated. RESULTS: In 513,288 AMI-CS admissions, prior CABG was performed in 22,832 (4.4%). Adjusted temporal trends showed a 2-fold increase in CS in both cohorts. There was a temporal increase in coronary angiography and percutaneous coronary intervention (PCI) across both cohorts. The cohort with prior CABG was on average older, of male sex, of white race, and with higher comorbidity. The cohort with prior CABG received coronary angiography (50% vs. 75%), PCI (32% vs. 49%), right heart catheterization/pulmonary artery catheterization (15% vs. 20%), mechanical circulatory support (26% vs. 46%) less frequently compared to those without (all p < 0.001). The cohort with CABG had higher in-hospital mortality (53% vs. 37%; adjusted odds ratio 1.41 [95% confidence interval 1.36-1.46]), greater use of do not resuscitate status (13% vs. 6%), shorter lengths of hospital stay (7 ± 8 vs. 10 ± 12 days), lower hospitalization costs ($92,346 ± 139,565 vs. 138,508 ± 172,895) and fewer discharges to home (39% vs. 43%) (all p < 0.001). CONCLUSIONS: In AMI-CS, admission with prior CABG was older and had lower use of cardiac procedures and higher in-hospital mortality compared to those without prior CABG.

Incidence, Mechanisms, and Predictors of Mean Systolic Gradients ≥20 mm Hg after Transcatheter Aortic Valve Implantation.

There is a significant increase in transvalvular gradients after transcatheter aortic valve implantation (TAVI) in some patients; however, mechanisms underlying the greater than expected gradients are unknown. We sought to determine the incidence and mechanisms of greater than expected gradients post-TAVI. A total of 424 patients who underwent TAVI at our institution between November 2008 and August 2015 and had at least 1 follow-up echocardiogram were included in the study. Greater than expected gradients were defined as mean systolic Doppler gradients ≥20 mm Hg. The primary end-point was incidence and mechanisms of mean systolic Doppler gradients ≥20 mm Hg. A total of 36 (8%) patients had mean systolic Doppler gradients ≥20 mm Hg. The mechanisms of mean systolic Doppler gradients ≥20 mm Hg were: patient prosthesis mismatch in 15 (42%) patients, high cardiac output in 13 (36%), prosthetic and periprosthetic regurgitation in 11 (31%), stenosis in 5 (14%), and multiple mechanisms in 8 (22%). Patients with mean systolic Doppler gradients ≥20 mm Hg had higher cardiac re-hospitalization rate, but no difference in mortality or major cardiovascular events when compared with the normal gradient group. Smaller prosthetic valve size (p <0.0001) and larger body mass index (p = 0.02) were associated with mean systolic Doppler gradients ≥20 mm Hg; warfarin therapy at discharge had no effect on gradients. In conclusion, about 8% patients had mean systolic Doppler gradients ≥20 mm Hg following TAVI, and patient-prosthesis mismatch was the most common mechanism. The mean systolic Doppler gradients ≥20 mm Hg after TAVI are not benign and warrant careful surveillance.

Effect of Transcatheter Aortic Valve Replacement on Right Ventricular-Pulmonary Artery Coupling.

OBJECTIVES: The aim of this study was to test the hypothesis that the acute left ventricular (LV) unloading effect of transcatheter aortic valve replacement (TAVR) would improve right ventricular (RV) function and RV-pulmonary artery (PA) coupling in patients with severe aortic stenosis (AS). BACKGROUND: RV dysfunction is an ominous prognostic marker in patients undergoing TAVR, suggesting that relief of obstruction might be less beneficial in this cohort. However, the left ventricle and right ventricle influence each other through ventricular interaction, which could lead to improved RV function through LV unloading. METHODS: Prospective invasive hemodynamic measurements with simultaneous echocardiography were performed in symptomatic patients with severe AS before and immediately after TAVR. RESULTS: Forty-four patients (mean age 81 ± 8 years, 27% women) with severe AS underwent TAVR. At baseline, right atrial, PA mean (27 ± 7 mm Hg), and pulmonary capillary wedge (16 ± 4 mm Hg) pressures were mildly elevated, with a low normal cardiac index (2.3 l/min/m2). Pulmonary vascular resistance was mildly elevated (222 ± 133 dynes · s/cm5) and PA compliance mildly reduced (3.4 ± 01.4 ml/mm Hg). Following TAVR, aortic valve area increased (from 0.8 ± 0.3 to 2.7 ± 1.1 cm2; p < 0.001) with a reduction in mean aortic gradient (from 37 ± 11 to 7 ± 4 mm Hg; p < 0.001) and an increase in cardiac index (from 2.3 ± 0.5 to 2.5 ± 0.6 l/min/m2; p = 0.03). LV stroke work, end-systolic wall stress, and systolic ejection period decreased by 23% to 27% (p < 0.001 for all), indicating substantial LV unloading. RV stroke work (from 16 ± 7 to 18 ± 7 mm Hg · ml; p = 0.04) and tricuspid annular systolic velocities (from 9.5 ± 2.0 to 10.4 ± 3.5 cm/s; p = 0.01) increased, along with a decrease in PVR (194 ± 113 dynes · s/cm5; p = 0.03), indicating improvement in RV-PA coupling. Increased RV stroke work following TAVR directly correlated with the magnitude of increase in aortic valve area (r = 0.58; p < 0.001). CONCLUSIONS: Acute relief in obstruction to LV ejection with TAVR is associated with improvements in RV function and RV-PA coupling. These findings provide new insights into the potential benefits of LV unloading with TAVR on RV dysfunction in patients with severe AS.

Outcomes of Patients With Severe Symptomatic Aortic Valve Stenosis After Chest Radiation: Transcatheter Versus Surgical Aortic Valve Replacement.

Background Patients with symptomatic severe aortic stenosis and a history of chest radiation therapy represent a complex and challenging cohort. It is unknown how transcatheter aortic valve replacement ( TAVR ) compares with surgical aortic valve replacement in this group of patients, which was the objective of this study. Methods and Results We retrospectively reviewed all patients with severe aortic stenosis who underwent either TAVR or surgical aortic valve replacement at our institution with a history of mediastinal radiation (n=55 per group). End points were echocardiographic and clinical outcomes in-hospital, at 30 days, and at 1 year. Inverse propensity weighting analysis was used to account for intergroup baseline differences. TAVR patients had a higher STS score than surgical aortic valve replacement patients (5.1% [3.2, 7.7] versus 1.6% [0.8, 2.6], P<0.001) and more often ( P<0.01 for all) a history of atrial fibrillation (45.5% versus 12.7%), chronic lung disease (47.3% versus 7.3%), peripheral arterial disease (38.2% versus 7.3%), heart failure (58.2% versus 18.2%), and pacemaker therapy (23.6% versus 1.8%). Postoperative atrial fibrillation was less frequent (1.8% versus 27.3%; P<0.001) and hospital stay was shorter in TAVR patients (4.0 [2.0, 5.0] versus 6.0 [5.0, 8.0] days; P<0.001). The ratio of observed-to-expected 30-day mortality was lower after TAVR as was 30-day mortality in inverse propensity weighting-adjusted Kaplan-Meier analyses. Conclusions In patients with severe aortic stenosis and a history of chest radiation therapy, TAVR performs better than predicted along with less adjusted 30-day all-cause mortality, postoperative atrial fibrillation, and shorter hospitalization compared with surgical aortic valve replacement. These data support further studies on the preferred role of TAVR in this unique patient population.

Transcatheter Valve-in-Valve Vs Surgical Replacement of Failing Stented Aortic Biological Valves.

BACKGROUND: This study directly compared outcomes of transcatheter aortic valve-in-valve insertion (TAVI-in-valve) with repeat surgical aortic valve replacement (SAVR) for failing stented aortic biological prostheses. METHODS: We retrospectively reviewed the records of 350 consecutive patients who underwent repeat aortic valve replacement of failing stented aortic biological valve prostheses at our institution between November 2008 and May 2018. Operations included TAVI-in-valve in 90 patients (26%) and repeat SAVR in 260 patients (74%). RESULTS: Patient age was 74 years (interquartile range [IQR], 65-79 years), 100 patients (29%) were women, aortic valve internal diameter was 21 mm (IQR, 19-22), Society of Thoracic Surgeons predicted operative mortality risk was 4.1% (IQR, 2.3%-6.8%), and the interval to repeat operation was 7 years (IQR, 5-11 years). A 23-mm or smaller valve was inserted in 57 patients (63%) in the TAVI-in-valve group and in 170 (65%) in the SAVR group (P = .725). Aortic root enlargement was done in 45 patients (17%) in the SAVR group. Procedure-related complications were less in the TAVI-in-valve group (23% vs SAVR 59%, P < .001), whereas operative mortality was similar in both groups (2.2% vs SAVR 2.6%, P = 1.000). Severe patient-to-prosthesis mismatch was more common after TAVI-in-valve (44% vs SAVR 12%, P < .001). Median duration of follow-up was 2.1 years (IQR, 1.2-4.2 years). Multivariable analysis demonstrated no association between TAVI-in-valve and intermediate-term mortality (hazard ratio, 1.18; 95% confidence interval, 0.62 to 2.22; P = .612). CONCLUSIONS: TAVI-in-valve and repeat SAVR can be done with similar operative and intermediate-term mortality. SAVR results in better hemodynamic function and thus appears the preferred option.

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.

Transcatheter aortic valve insertion in patients with hostile ascending aorta calcification.

OBJECTIVE: Calcification of the ascending aorta complicates aortic valve replacement. Transcatheter aortic valve replacement is an alternative procedure in this situation, but it requires manipulation through the hostile area in the ascending aorta. We reviewed our transcatheter aortic valve insertion experience to better understand the surgical mortality risk of valve insertion in patients with extensive calcification of the ascending aorta. METHODS: We retrospectively reviewed the records of 665 consecutive patients who received transcatheter aortic valve insertion from November 2008 through December 2015. We defined a hostile ascending aorta on the basis of preoperative computed tomography scan documenting significant aortic calcification that the surgeon believed precluded safe aortic cross-clamp application. There were 36 patients (5%) who met our definition of a hostile ascending aorta (hostile aorta group) and 629 (95%) who did not (control group). RESULTS: Surgical mortality occurred in 2 patients (6%) in the hostile aorta group and in 18 (3%) in the control group (P = .296). There were no strokes in the hostile aorta group, whereas there were 15 (2%) in the control group (P = 1.00). There was no difference in mortality at 3 years for patients in the hostile aorta (48.5% ± 9.0%) and control groups (35.9% ± 2.3%; P = .484). Alternative access was associated with an increased risk of mortality (hazard ratio, 1.41; 95% confidence interval, 1.09-1.82; P = .009). CONCLUSIONS: Transcatheter aortic valve insertion can be performed with low procedure-related morbidity and mortality in patients with hostile calcification of the ascending aorta. Our data support a transfemoral-first paradigm in this patient population.

Predictors of 1-year mortality after transcatheter aortic valve replacement.

OBJECTIVE: To identify variables predictive of increased mortality within 1 year of transcatheter aortic valve replacement (TAVR). METHODS: We retrospectively reviewed the records of 723 consecutive patients who received TAVR from November 2008 through April 2016. Patient and procedure-related characteristics were analyzed with logistic regression for an association with death within 1 year of TAVR. RESULTS: Patient mean age was 81 ± 9 years, male sex was present in 428 patients (59%), and STS predicted risk of mortality was 9.2 ± 6.2%. There were 107 deaths (15%) within 1 year of operation. Multivariable analysis identified increased risk of death with severe chronic lung disease (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.23-3.29; P = 0.006), severe tricuspid valve regurgitation (OR 2.35; 95%CI 1.17-4.30; P = 0.017), vascular injury (OR 2.23; 95%CI 1.15-4.30; P = 0.017), and new-onset dialysis (OR 8.49; 95%CI 3.00-24.03; P < 0.001) (Area under the curve 0.687). When stratified by arterial access, there was increased risk of death following severe tricuspid valve regurgitation, vascular injury, or new-onset dialysis for transfemoral access and severe chronic lung disease or new-onset dialysis for alternative access. CONCLUSION: Patient characteristics and procedure-related complications are both significantly associated with increased risk of death within 1 year of TAVR. Patients with the baseline findings of severe chronic lung disease or severe tricuspid valve regurgitation may not experience mortality benefit from TAVR, and they should be assessed and counselled accordingly. Avoiding procedure-related complications is paramount to a good outcome. The findings have important implications for health care delivery services.

Coronary artery bypass grafting in patients treated with thoracic radiation: a case-control study.

Background and aim: Thoracic radiation therapy (XRT) for cancer is associated with the development of significant coronary artery disease that may require coronary artery bypass grafting surgery (CABG). Contemporary acute surgical outcomes and long-term postoperative survival of patients with prior XRT have not been well characterised. Methods: This was a retrospective, single-centre study of patients with a history of thoracic XRT who required CABG and who were propensity matched against 141 controls who underwent CABG over the same time period. The objectives were to assess early CABG outcomes and long-term survival in patients with prior XRT. Results: Thirty-eight patients with a history of previous thoracic XRT underwent CABG from 1994 to 2013. The median time from XRT exposure to surgery was 7.9 years (IQR: 2.5-18.4 years). Perioperative adverse events were similar in the XRT group and controls; however, there was a trends lower utilisation of internal mammary artery (IMA) grafts in the XRT group (89%vs98%, P=0.13). After a median postoperative follow-up of 5.4 years (IQR 0.9-9.4 years), no difference in long-term all-cause mortality was observed. Conclusion: Patients with prior thoracic XRT who undergo CABG have similar long-term all-cause mortality compared with controls. Isolated CABG after thoracic XRT is not associated with higher perioperative complications, but IMA graft use may be limited by prior XRT.

Transcatheter aortic valve insertion after previous mitral valve operation.

OBJECTIVE: There are limited data on transcatheter aortic valve insertion after previous mitral valve operation. To better understand the associated procedural risks, we reviewed our single-center experience. METHODS: We retrospectively reviewed the records of 772 consecutive patients who received transcatheter aortic valve insertion from November 2008 through August 2016. There were 18 (2%) patients who had previous mitral valve operation that included valve repair in 4 patients (22%) and replacement in 14 (78%). RESULTS: Baseline characteristics included age of 77 years (interquartile range 68, 84), female sex in 11 patients (61%), New York Heart Association functional class III/IV in 14 (78%), and Society of Thoracic Surgeons predicted risk of mortality of 7.0% (5.3, 12.0). Access was transfemoral in 14 patients (78%). Valve insertion was successful in all patients and involved a balloon expandable device in 10 (56%). No patient experienced acute mitral valve dysfunction or procedure-related mortality. Follow-up echocardiography demonstrated mean systolic aortic valve gradient of 9 mm Hg (8, 12), no grade moderate or greater aortic paravalvular regurgitation, and stable mitral valve function. Kaplan-Meier estimated survival was 90.9% ± 9.1% at 1 year. CONCLUSIONS: Transcatheter aortic valve insertion appears to be a safe and effective operation after previous mitral valve operation. Procedure success was achieved with both balloon expandable and self-expanding devices and was independent of arterial access method. Transcatheter valve insertion should not be denied strictly on the basis of a previous mitral valve operation.

Percutaneous revascularization in patients treated with thoracic radiation for cancer.

OBJECTIVES: To assess coronary revascularization outcomes in patients with previous thoracic radiation therapy (XRT). BACKGROUND: Previous chest radiation has been reported to adversely affect long term survival in patients with coronary disease treated with percutaneous coronary interventions (PCI). METHODS: Retrospective, single center cohort study of patients previously treated with thoracic radiation and PCI. Patients were propensity matched against control patients without radiation undergoing revascularization during the same time period. RESULTS: We identified 116 patients with radiation followed by PCI (XRT-PCI group) and 408 controls. Acute procedural complications were similar between groups. There were no differences in all-cause and cardiac mortality between groups (all-cause mortality HR 1.31, P=.078; cardiac mortality 0.78, P=.49). CONCLUSION: Patients with prior thoracic radiation and coronary disease treated with PCI have similar procedural complications and long term mortality when compared to control subjects.

Voice and swallowing outcomes for adults undergoing reconstructive surgery for laryngotracheal stenosis.

PURPOSE OF REVIEW: Adult laryngotracheal stenosis is a rare, multifactorial condition which carries a significant physical and psychosocial burden. Surgical approaches have developed in recent years, however, voice and swallowing function can be affected prior to treatment, in the immediate postoperative phase, and as an ongoing consequence of the condition and surgical intervention. In this study we discuss: the nature of the problem; surgical interventions to address airway disorders; optimal patterns of care to maximize voice and swallowing outcomes. RECENT FINDINGS: Studies in this field are limited and focused on surgical outcomes and airway status with voice and swallowing a secondary consideration. Retrospective studies of swallowing have focused on factors such as the duration of dysphagia symptoms following airway surgery and made comparisons between type of surgery, use of stent, and length of swallowing problems. The literature suggests that patients are likely to return to their preoperative diet. There has been a focus on voice outcomes following cricotracheal resection which results in a postoperative decrease in the fundamental frequency. However, study comparisons are limited by the use of inconsistent outcome measures (for both voice and swallowing) which are often not validated, with heterogeneous groups and varying surgical techniques. SUMMARY: The limited literature suggests that swallowing function is more likely to recover to presurgical status than voice function. Further prospective studies incorporating consistent instrumental, clinician, and patient-reported outcome measurement are required to understand the nature and extent of dysphagia and dysphonia resulting from this condition and its treatment.