One-year clinical and echocardiographic outcomes of transcatheter aortic valve replacement with SAPIEN 3 Ultra versus SAPIEN 3.

BACKGROUND: The newest-generation balloon-expandable valve, SAPIEN 3 Ultra (S3U), is expected to function well with the enhanced sealing skirt compared with SAPIEN 3 (S3). However, current literature on the comparison between these two valves is limited to short-term follow-ups. Therefore, we aimed to evaluate the 1-year outcomes and echocardiographic changes of S3U compared with S3. METHODS: We retrospectively identified patients who underwent transfemoral-transcatheter aortic valve replacement with S3U or S3 (20/23/26 mm) at our institution in 2018-2020. Outcomes were 1-year clinical events and echocardiographic parameters, and were compared between S3U and S3 after adjustment with inverse probability of treatment weighting. RESULTS: The S3U and S3 groups included 297 (25.7%) and 858 (74.3%) patients, respectively. There were no significant differences between the two groups in clinical events (death 5.8% vs. 5.5%, hazard ratio [HR] 1.07, 95% confidence interval [CI] 0.81-1.90; death or heart failure hospitalization 10.3% vs. 10.1%, HR 1.04, 95% CI 0.67-1.62). The S3U group had a lower prevalence of mild paravalvular leakage (PVL) (13.7% vs. 22.3%, p = 0.044), with similar moderate PVL (0.7% vs. 1.2%, p > 0.99). No significant differences were observed in aortic valve mean gradient and Doppler velocity index at 1 year. However, the S3U group had a larger increase in mean gradient from implantation to 1 year (median +4.70 vs. +1.63 mmHg, p < 0.001). CONCLUSIONS: S3U and S3 carried similarly favorable clinical event risks. Nonetheless, S3U was associated with less frequent mild PVL but a larger increase in transprosthetic gradient. Further studies are needed to determine the prognostic impact of these hemodynamic differences.

Anomalous inferior vena cava drainage in a patient undergoing cardiac surgery.

Congenital anomalies of the inferior vena cava are rare but if unidentified may create a risk for complications during surgery. In cardiac surgery, identifying such anomalies is crucial as they may alter the normal conduct of cardiopulmonary bypass. Herein, we describe a case of a 78-year-old women with an anomalous inferior vena cava draining into the superior vena cava, who was referred for surgical management of severe mitral regurgitation. We describe the clinical implication of the inferior vena cava anomality and the surgical strategies used to obtain adequate surgical exposure and venous drainage for cardiopulmonary bypass in a patient who underwent a mitral and tricuspid annuloplasty, bi-atrial MAZE procedure and a left atrial appendage closure.

Peripheral cannulation and endoaortic balloon occlusion for management of porcelain aorta during cardiac surgery.

Porcelain aorta with extensive calcification of the ascending aorta complicates cardiac surgery and increases perioperative risk. Aortic cannulation and cross-clamping in these patients increase the risk of serious complications including perioperative embolic stroke. Although different techniques have been proposed, surgery in these patients remains a challenge. We present the clinical implications of the porcelain aorta and surgical strategies involving axillary arterial cannulation and endoaortic balloon to allow for the institution of cardiopulmonary bypass and cardioplegic arrest during surgery. The surgery included a redo sternotomy with bioprosthetic mitral valve replacement, tricuspid valve repair with an annuloplasty, and closure of the left atrial appendage. In appropriately selected patients, endoaortic balloon occlusion was a valuable tool to facilitate the safe conduct of an operation. Careful preoperative evaluation and planning by a multidisciplinary team are essential in these cases.

A Causality-guided Statistical Approach for Modeling Extreme Mei-yu Rainfall Based on Known Large-scale Modes-A Pilot Study.

Extreme Mei-yu rainfall (MYR) can cause catastrophic impacts to the economic development and societal welfare in China. While significant improvements have been made in climate models, they often struggle to simulate local-to-regional extreme rainfall (e.g., MYR). Yet, large-scale climate modes (LSCMs) are relatively well represented in climate models. Since there exists a close relationship between MYR and various LSCMs, it might be possible to develop causality-guided statistical models for MYR prediction based on LSCMs. These statistical models could then be applied to climate model simulations to improve the representation of MYR in climate models. In this pilot study, it is demonstrated that skillful causality-guided statistical models for MYR can be constructed based on known LSCMs. The relevancy of the selected predictors for statistical models are found to be consistent with the literature. The importance of temporal resolution in constructing statistical models for MYR is also shown and is in good agreement with the literature. The results demonstrate the reliability of the causality-guided approach in studying complex circulation systems such as the East Asian summer monsoon (EASM). Some limitations and possible improvements of the current approach are discussed. The application of the causality-guided approach opens up a new possibility to uncover the complex interactions in the EASM in future studies.

Centennial relationships between ocean temperature and Atlantic puffin production reveal shifting decennial trends.

The current warming of the oceans has been shown to have detrimental effects for a number of species. An understanding of the underlying mechanisms may be hampered by the non-linearity and non-stationarity of the relationships between temperature and demography, and by the insufficient length of available time series. Most demographic time series are too short to study the effects of climate on wildlife in the classical sense of meteorological patterns over at least 30 years. Here we present a harvest time series of Atlantic puffins (Fratercula arctica) that goes back as far as 1880. It originates in the world's largest puffin colony, in southwest Iceland, which has recently experienced a strong decline. By estimating an annual chick production index for 128 years, we found prolonged periods of strong correlations between local sea surface temperature (SST) and chick production. The sign of decennial correlations switches three times during this period, where the phases of strong negative correlations between puffin productivity and SST correspond to the early 20th century Arctic warming period and to the most recent decades. Most of the variation (72%) in chick production is explained by a model in which productivity peaks at an SST of 7.1°C, clearly rejecting the assumption of a linear relationship. There is also evidence supporting non-stationarity: The SST at which puffins production peaked has increased by 0.24°C during the 20th century, although the increase in average SST during the same period has been more than three times faster. The best supported models indicate that the population's decline is at least partially caused by the increasing SST around Iceland.

Projected Future Changes in Tropical Cyclones Using the CMIP6 HighResMIP Multimodel Ensemble.

Future changes in tropical cyclone properties are an important component of climate change impacts and risk for many tropical and midlatitude countries. In this study we assess the performance of a multimodel ensemble of climate models, at resolutions ranging from 250 to 25 km. We use a common experimental design including both atmosphere-only and coupled simulations run over the period 1950-2050, with two tracking algorithms applied uniformly across the models. There are overall improvements in tropical cyclone frequency, spatial distribution, and intensity in models at 25 km resolution, with several of them able to represent very intense storms. Projected tropical cyclone activity by 2050 generally declines in the South Indian Ocean, while changes in other ocean basins are more uncertain and sensitive to both tracking algorithm and imposed forcings. Coupled models with smaller biases suggest a slight increase in average TC 10 m wind speeds by 2050.

Successful management of COVID-19 and associated coagulopathy in a patient with durable left ventricular assist device.

Patients with durable left ventricular assist devices pose special problems for management in the setting of COVID-19 infection. We describe the successful management of a 44-year-old man with severe COVID-19 infection and HeartMate 3 left ventricular assist device. His course was complicated by cytokine storm and COVID-19-associated coagulopathy. We describe our institutional protocol for managing COVID-19 infection in patients on mechanical circulatory support, focusing on the need for a thoughtful, multidisciplinary approach.

Robotic trans-mitral septal myectomy and papillary muscle reorientation for HOCM combined with or without mitral valve repair: Technical aspects - How we do it.

Hypertrophic obstructive cardiomyopathy (HOCM) is one of the more common genetic disorders. The pathophysiology and natural history of the disease have been well studied. Left ventricular outflow tract obstruction (LVOTO) and systolic anterior motion (SAM) of the anterior mitral leaflet can result in sudden cardiac death, progressive heart failure and arrythmias. Surgical septal myectomy for HOCM is the standard of care and is routinely performed through a median sternotomy. Septal myectomy has also been performed using the trans-atrial, trans-mitral approach either directly or with robotic assistance. In cases with severe LVOT obstruction in the setting of only mild to moderate proximal septal hypertrophy, intrinsic problems with the mitral valve contribute. Typically, these are hypermobile papillary muscles and or excessive height of the anterior mitral leaflet. Combining septal myectomy with reorientation of hypermobile anteriorly positioned papillary muscles has shown to prevent SAM and thereby additionally decrease the subvalvular aortic outflow obstruction. Our extensive experience in both septal myectomy and robotic mitral valve repair has given us a different perspective in approaching the primary mitral regurgitation in HOCM patients where a combined septal myectomy, papillary muscle reorientation and complex mitral valve repair has been safely performed using the less invasive robotic-assisted approach.Our objective here is to discuss the technical aspects of the procedure.

Surgical ablation of atrial fibrillation in hypertrophic obstructive cardiomyopathy: Outcomes of a tailored surgical approach.

OBJECTIVE: To assess outcomes of concomitant ablation for atrial fibrillation (AF) in patients with preoperative AF undergoing septal myectomy for hypertrophic obstructive cardiomyopathy. METHODS: From 2005 to 2016, 67 patients underwent concomitant ablation for AF and septal myectomy and had a follow-up beyond a 3-month blanking period. Ablation strategy (pulmonary vein isolation [PVI], modified Cox-maze III [CM-III], or Cox-maze IV [CM-IV]) was tailored to preoperative AF burden, with high AF burden defined as persistent AF or need for cardioversion. AF recurrence was analyzed as a time-related event and predictors of recurrence identified using a random forest methodology. RESULTS: A total of 38 patients (57%) had low AF burden and 29 (43%) high burden. Patients with low AF burden most frequently underwent PVI (68%). Patients with high AF burden more frequently underwent CM-III (62%) or CM-IV (35%). Besides the preoperative AF burden, baseline characteristics were similar between patients receiving CM-III, CM-IV, and PVI. After surgery, the maximum provoked left ventricular outflow tract (LVOT) gradient decreased from 99 ± 34 to 18 ± 11mm Hg (P < .001). Eight patients (12%) required a permanent pacemaker. Cumulative AF recurrence at 1, 2, and 5 years was 11%, 22%, and 48%, respectively. Age, low preoperative resting LVOT gradient, and large left atrial diameter were predictors of AF recurrence. CONCLUSIONS: Surgical outcomes of concomitant ablation for AF and septal myectomy are good, although recurrence of AF by 5 years is frequent.

Repair of bileaflet prolapse in Barlow syndrome: The 4-chord technique.

Barlow syndrome is a form of degenerative mitral valve (MV) disease found in a subset of patients with bileaflet prolapse. The hallmark of Barlow's disease includes excessive and billowing leaflet tissue caused by myxomatous tissue proliferation, elongated chordae, and pronounced annular dilatation. Surgical repair of patients with Barlow's disease is challenging due to the extent of the leaflet and annular abnormalities. Several techniques have been described to repair Barlow's MV including currently popular "non-resectional" approaches. Repair with neochordae has been associated with excellent results and includes the advantage of preserved leaflet mobility and a large surface of coaptation. We describe a simple approach to the use of neochordae to repair bileaflet prolapse in patients with Barlow syndrome and avoid systolic anterior motion.

Surgical management of infective endocarditis complicated by ischemic stroke.

Embolism to the central nervous system is a frequent and important complication of infective endocarditis. While early surgery improves outcomes in many groups of patients with infective endocarditis, ischemic stroke secondary to septic embolism carries the risk of hemorrhagic transformation and neurological deterioration with heparinization and cardiopulmonary bypass. We review the literature regarding the surgical management of infective endocarditis in patients with cerebral emboli.

Global increase in tropical cyclone ocean surface waves.

The long-term changes of ocean surface waves associated with tropical cyclones (TCs) are poorly observed and understood. Here, we present the global trend analysis of TC waves for 1979-2022 based on the ERA5 wave reanalysis. The maximum height and the area of the TC wave footprint in the six h reanalysis have increased globally by about 3%/decade and 6%/decade, respectively. The TC wave energy transferred at the interface from the atmosphere to the ocean has increased globally by about 9%/decade, which is three times larger than that reported for all waves. The global energy changes are mostly driven by the growing area of the wave footprint. Our study shows that the TC-associated wave hazard has increased significantly and these changes are larger than those of the TC maximum wind speed. This suggests that the wave hazard should be a concern in the future.

Outcomes of aortic root replacement with tricuspid aortic valve reimplantation in patients with residual aortic regurgitation.

OBJECTIVE: To characterize residual aortic regurgitation (AR), identify its risk factors, and evaluate outcomes following aortic root replacement with aortic valve reimplantation. METHODS: From 2002 to 2020, 756 patients with a tricuspid aortic valve underwent elective reimplantation for aortic root aneurysm. AR on transthoracic echocardiograms before hospital discharge was graded as mild or greater. Machine learning was used to identify risk factors for residual AR and subsequent aortic valve reoperation. RESULTS: Sixty-five patients (8.6%) had mild (58 [7.7%]) or moderate (7 [0.93%]) residual postoperative AR. They had more severe preoperative AR (38% vs 12%; P < .0001), thickened cusps (7.7% vs 2.2%; P = .008), aortic valve repair (38% vs 23%; P = .004), and multiple returns to cardiopulmonary bypass for additional repair (11% vs 3.3%; P = .003) than those without AR. Predictors of residual AR were severe preoperative AR, smaller aortic root graft, and concomitant cusp repair. At 10 years, patients with versus without residual AR had more moderate or severe AR (48% vs 7.0%; P < .0001) and freedom from reoperation was worse (89% vs 98%; P < .0001). Residual AR was a risk factor for early reoperation. Concomitant coronary bypass, lower body mass index, and lower ejection fraction were risk factors for late reoperation. Ten-year survival was similar among patients with and without residual AR (97% vs 93%; P = .43). CONCLUSIONS: Residual AR after elective reimplantation of a tricuspid aortic valve for aortic root aneurysm is uncommon. Patients with severe preoperative AR and those who undergo valve repair have higher risk for residual AR, which can progress and increase risk of aortic valve reoperation.

Implanted size and structural valve deterioration in the Edwards Magna bioprosthesis.

Background: The desire of patients to avoid anticoagulation, together with the potential of valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR), have resulted in the increasing use of bioprosthetic valves for aortic valve replacement (AVR). While patient-prosthesis mismatch (PPM) is known to be an adverse risk after AVR, few studies have addressed the effect of PPM on valve durability. This study evaluates the role of valve size and hemodynamics on long term durability after AVR with a Magna bioprosthesis. Methods: We performed a retrospective, single-center evaluation of patients who underwent a surgical AVR procedure between June 2004 through December 2022 using the Magna bioprosthesis. Perioperative information and long-term follow-up data were sourced from the institution's Society for Thoracic Surgeons Adult Cardiac Surgery Registry and outcomes database. Cumulative incidence of freedom from reintervention were estimated accounting for competing events. Group comparisons used Gray's test. Results: Among 2,100 patients, the mean patient age was 69 years (range, 22-95 years), of whom 98% had native aortic valve disease, 32.5% had concomitant coronary bypass grafting, and 19% had mitral valve surgery. Median follow-up was 5.8 (1.9-9.4) years, during which 116 reinterventions were performed, including 74 explants and 42 VIV procedures. Nine hundred and twenty-eight patients died prior to reintervention. Incidence of all cause reintervention was 1.2%, 4.5%, and 11.7% at 5, 10, and 15 years, respectively. Smaller valve size was associated with worse survival (P<0.001), but not with reintervention. Higher mean gradient at implant was associated with increased late reintervention [sub-distribution hazard ratio: 1.016; 95% confidence interval (CI): 1.005 to 1.028; P=0.0047, n=1,661]. Conclusions: While reintervention rates are low for the Magna prosthesis at 15 years, the analysis is confounded by the competing risk of death. PPM, as reflected physiologically by elevated post-operative valve gradients, portends an increased risk of intervention. Further study is necessary to elucidate the mechanism of early stenosis in patients who progress to reintervention.

Contemporary experience with the Commando procedure for anterior mitral anular calcification.

Objective: Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. Methods: From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). Results: Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). Conclusions: The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

Moral status, justice, and the common morality: challenges for the principlist account of moral change.

The theory of principlism elaborated by Beauchamp and Childress in Principles of Biomedical Ethics has become extremely influential in bioethics. The theory employs the idea of the common morality as a foundation for the principles of autonomy, beneficence, nonmaleficence, and justice. According to this account, the content of the common morality is universal and constant, while variability in morals is due to the fact that the issue of who is included within the scope of moral status evolves over time. This suggests that issues of moral status are not part of the common morality at all, and this presents a conundrum: questions of moral status seem central to any substantive account of justice, and any conception of the common morality that excludes moral status therefore seems inadequate for supporting a robust principle of justice. We argue that proponents of common morality theory are left with four options: (1) making moral status a part of the objective common morality and ignoring evidence that views about moral status do seem to vary over time and place; (2) excluding justice from the substantive content of the common morality; (3) taking common morality to be an imperfect approximation of an independently justified and universal foundationalist ethic against which the common morality is judged; or (4) weakening claims about the universality of common morality, thereby allowing the common morality to support a variety of principles of justice applicable only within particular communities that have specified the scope of moral status. We suspect that proponents of common morality theory will not view any of these options favorably, which raises questions about the ultimate contribution of that account.

Equatorial waves as useful precursors to tropical cyclone occurrence and intensification.

Understanding and prediction of tropical cyclone (TC) activity on the medium range remains challenging. Here, we find that the pre-existing westward-moving equatorial waves can inform the risk of TC occurrence and intensification, based on a dataset obtained by synchronising objectively identified TCs and equatorial waves in a climate reanalysis. Globally, westward-moving equatorial waves can be precursors to 60-70% of pre-tropical cyclogenesis events, and to >80% of the events with the strongest vorticity, related to the favourable environmental conditions within the pouch of equatorial waves. We further find that when storms are in-phase with westward-moving equatorial waves, the intensification rate of TCs is augmented, whilst in other phases of the waves, storm intensity grows more slowly, or even decays. Coherent wave packets associated with TCs are identifiable up to two weeks ahead. Our findings show that westward-moving equatorial waves can be useful medium-range precursors to TC activity.

Survival and repair durability in patients undergoing concomitant aortic valve reimplantation and mitral valve repair.

Objective: The study objective was to determine repair durability and survival in patients with and without connective tissue disorders undergoing concomitant aortic valve reimplantation and mitral valve repair. Methods: From 2002 to 2019, 68 patients underwent concomitant aortic valve reimplantation and mitral valve repair, including 27 patients with Marfan syndrome (39.7%). Follow-up echocardiograms were analyzed using nonlinear multiphase mixed-effects cumulative logistic regression. The regurgitation grade over time was estimated by averaging patient-specific profiles. Survival and freedom from reoperation were estimated by the Kaplan-Meier method. Results: At 7 years, 11% of patients had aortic insufficiency greater than mild (severe in 2 patients). There was no difference in greater than mild aortic insufficiency between patients with or without Marfan syndrome (P = .37). Twenty percent of patients had progressed to mitral regurgitation greater than mild (severe in only 1 patient). The prevalence of recurrent mitral regurgitation was higher in those without Marfan syndrome, with greater than mild regurgitation increasing to 24% by 2 years and remaining constant thereafter (P = .04). Freedom from reoperation on the aortic valve or mitral valve was 83% at 10 years and did not differ between Marfan syndrome groups. There were no cases of perioperative mortality. Survival at 5 and 10 years was 94% and 87%, respectively, without a difference between those with and without Marfan syndrome. Conclusions: Patients can undergo a total repair strategy using combined aortic valve reimplantation and mitral valve repair procedures with a low risk of mortality and complications, with favorable freedom from both residual valve regurgitation and reoperation.