Programmatic approach to patients with advanced ischemic cardiomyopathy: Integrating microaxial support into strategies for the modern era.

Patients with advanced ischemic cardiomyopathy manifesting as left ventricular dysfunction exist along a spectrum of severity and risk, and thus decision-making surrounding optimal management is challenging. Treatment pathways can include medical therapy as well as revascularization through percutaneous coronary intervention or coronary artery bypass grafting. Additionally, temporary and durable mechanical circulatory support, as well as heart transplantation, may be optimal for select patients. Given this spectrum of risk and the complexity of treatment pathways, patients may not receive appropriate therapy given their perceived risk, which can lead to sub-satisfactory outcomes. In this review, we discuss the identification of high-risk ischemic cardiomyopathy patients, along with our programmatic approach to patient evaluation and perioperative optimization. We also discuss our strategies for therapeutic decision-making designed to optimize both short- and long-term patient outcomes.

The Relation of Neighborhood Racial and Income Polarity to Preterm Birth Rates in Chicago.

OBJECTIVES: To investigate the extent to which spatial social polarization is associated with preterm birth among urban African-American and non-Latinx white women, and whether prenatal care modifies this relationship. METHODS: We performed multilevel logistic regression analyses on a 2013-2017 dataset of Chicago vital records (N = 29,179) with appended Index of Concentration at the Extremes (ICE) values for race and income. RESULTS: Women who resided in the bottom ICE quintile neighborhoods had a preterm birth rate of 11.5%, compared to 7.3% for those who live in the top ICE quintile areas; adjusted odds ratio (aOR) equaled 1.72 (95% confidence interval [CI] = 1.39, 2.12). This disparity widened for early (< 34 weeks) preterm birth rates, aOR = 2.60 (1.77, 3.81). These associations persisted among women with adequate prenatal care utilization. CONCLUSIONS FOR PRACTICE: Spatial polarization of race and income in urban African-American and non-Latinx white women's residential environment is strongly associated with preterm birth rates, even among those who receive adequate prenatal care. These findings highlight the benefit of using ICE to contextualize the impact of urban neighborhood-level characteristics on preterm birth rates.

Two-year outcomes after transcatheter aortic valve-in-valve implantation in degenerated surgical valves.

BACKGROUND: Transcatheter aortic valve-in-valve implantation (ViV-TAVI) has emerged in recent years as a safe alternative to redo surgery in high-risk patients. Although early results are encouraging, data beyond short-term outcomes are lacking. Herein, we aimed to assess the 2-year outcomes after ViV-TAVI. METHODS: Patients undergoing ViV-TAVI for degenerated surgical valves between 2013 and 2019 at the Cleveland Clinic were reviewed. The coprimary endpoints were all-cause mortality and congestive heart failure (CHF) hospitalizations. We used time-to-event analyses to assess the primary outcomes. Further, we measured the changes in transvalvular gradients and the incidence of structural valve deterioration (SVD). RESULTS: One hundred and eighty-eight patients were studied (mean age = 76 years; 65% males). At 2 years of follow-up, all-cause mortality and CHF hospitalizations occurred in 15 (8%) and 28 (14.9%) patients, respectively. On multivariable analysis, the postprocedural length of stay was a significant predictor for both all-cause mortality (hazard ratio [HR] = 1.1; 95% confidence interval [CI]: 1.01, 1.19) and CHF hospitalization (HR = 1.16; 95% CI: 1.07, 1.27). However, the internal diameter of the surgical valve was not associated with significant differences in both primary endpoints. For hemodynamic outcomes, nine patients (4.8%) developed SVD. The mean and peak transvalvular pressure gradients remained stable over the follow-up period. CONCLUSION: ViV-TAVI for degenerated surgical valves was associated with favorable 2-year clinical and hemodynamic outcomes. Further studies are needed to better understand the role of ViV-TAVI as a treatment option in the life management of aortic valve disease.

Using near-infrared spectroscopy myocardial oximetry to monitor myocardial oxygen balance in a swine model of cardiac surgery: a descriptive study.

Monitoring of the adequacy of myocardial protection with cardioplegia is nearly non-existent in clinical cardiac surgical practice and instead relies on well-defined protocols for delivery of cardioplegia often resulting in inadequate protection. We hypothesized that Near Infrared Spectroscopy technology could be useful in the monitoring of the myocardial oxygen state by attaching the monitors to the epicardium in a porcine model of cardiac surgery. The experiments were conducted with 3 different protocols of 2 pigs each for a total of 6 pigs. The objective was to induce episodic, oxygen supply-demand mismatch. Methods for decreased supply included decreasing coronary blood flow, coronary blood hypoxemia, coronary occlusion, hypovolemia, and hypotension. Methods for increase demand included rapid ventricular pacing and the administration of isoproterenol. Changes in myocardial tissue oximetry were measured and this measurement was then correlated with blood hemoglobin saturations of oxygen from coronary sinus blood samples. We found that decreases in myocardial oxygen supply or increases in demand due to any of the various experimental conditions led to decreases in both myocardial tissue oximetry and hemoglobin oxygen saturation of coronary sinus blood with recovery when the conditions were returned to baseline. Correlation between myocardial tissue oximetry and hemoglobin oxygen saturation of coronary sinus blood was moderate to strong under all tested conditions. This may have translational applications as a monitor of adequacy of myocardial protection and the detection of coronary occlusion.

Temporal improvements in perioperative stroke rates following coronary artery bypass grafting.

PURPOSE OF REVIEW: Perioperative stroke remains one of the most dreaded complications following coronary artery bypass grafting. In this review, we highlight the significant advances in understanding and preventing stroke in patients undergoing bypass surgery and offer our center's current best-practice recommendations to help avoid this debilitating outcome. RECENT FINDINGS: The incidence of stroke has significantly reduced since the advent of coronary artery bypass graft surgery. Improvements in our understanding of the cause, mechanisms, risk factors, and diagnosis of stroke as well as refinements in medical optimization, surgical technique, and perioperative care all have contributed to making coronary artery bypass grafting safer even as patients have become increasingly complex. SUMMARY: The field of cardiothoracic surgery endures in its quest to eliminate the risk of perioperative stroke. By incorporating the lessons of the past into our innovations of the future, cardiac surgeons will continue to strive for safer coronary artery bypass grafting and afford patients to not only live longer but better as well.

Ross Procedure Following a Dislodged Transcatheter Aortic Valve Replacement.

A 36-year-old pregnant woman with a history of rheumatic heart disease and prior aortic valve replacement and mitral valve repair presented to an outside hospital with severe aortic stenosis. The patient had a cardiac arrest upon labor induction and underwent a transcatheter aortic valve replacement (TAVR), which dislodged two days later. Five months later, the patient underwent removal of the dislodged TAVR and a Ross procedure at the authors' institution. The patient was stable upon discharge, with minimal aortic and pulmonary regurgitation. To the authors' knowledge, the present report is the first of the Ross procedure being used under such circumstances. It is suggested that caution be taken when using bioprosthetic and transcatheter aortic valves in young patients, and primary use of the Ross procedure is encouraged at experienced centers.

Multidisciplinary approach to long-standing left bundle branch block with dyssynchrony and aortic stenosis: case report.

Background: Cardiac resynchronization therapy (CRT) is recommended for patients with symptomatic heart failure in sinus rhythm with left ventricular ejection fraction (LVEF) ≤ 35%, QRS duration ≥ 150 ms, and left bundle branch block (LBBB) morphology. However, when severe left ventricular dysfunction and cardiogenic shock are present, treatment paradigms are often limited to palliative medical therapy or advanced therapies with durable left ventricular assist device or heart transplant as the functional and survival benefit of CRT in these patients remains uncertain. Case summary: A 77-year-old white man with long-standing LBBB with dyssynchrony, severely reduced LVEF of 4%, and severe bicuspid aortic stenosis (AS) presented with worsening heart failure symptoms. After multidisciplinary heart team evaluation and pre-operative optimization, the patient underwent a surgical aortic valve replacement with simultaneous intraoperative initiation of CRT with pacemaker (CRT-P) and temporary mechanical circulatory support. Echocardiography at 44 days and 201 days post-discharge showed an LVEF of 29% and 40%, respectively. Discussion: This case demonstrates that reverse remodelling and native heart recovery were successfully achieved in a patient with advanced structural heart disease, presenting with cardiogenic shock, through an early and aggressive approach involving multidisciplinary heart team evaluation, treatment of severe AS with surgical aortic valve replacement, prophylactic intraoperative initiation of temporary mechanical circulatory support, and early initiation of CRT-P.

Outcomes After Left Atrial Appendage Clip Placement During Cardiac Surgery: A Nationwide Analysis.

This study evaluated the nationwide associations between concomitant left atrial appendage clip (LAAC) placement during cardiac surgery and postoperative outcomes. We identified 1,260,999 patients who underwent coronary artery bypass grafting, valve, and aortic surgeries in the 2016 to 2020 Nationwide Readmissions Database and stratified by concomitant LAAC versus no LAAC placement. Patients who underwent surgical ablation were excluded. Mortality and complications were compared during index admissions and for patients readmitted within 30 and 90 days of the index discharge date for unmatched and propensity score-matched groups. Overall, 6.7% (84,293) of patients underwent cardiac surgery and concomitant LAAC placement without surgical ablation. After propensity score matching, the index admission mortality and overall complications were not different in patients with LAAC versus patients without LAAC. LAAC placement was associated with increased any-cause 30-day readmissions (15% vs 13%, p <0.01). In patients with LAAC, within 30 days, there were no differences in mortality (3.9% vs 3.8%, p = 0.60) or overall complications (64% vs 63%, p = 0.20), whereas stroke was lower (5.3% vs 6.5%, p <0.01) and heart failure was higher (35% vs 30%, p <0.01). For patients readmitted within 90 days, similar findings were observed for any-cause readmissions, mortality, overall complications, stroke, and heart failure. In conclusion, concomitant LAAC placement during cardiac surgery was associated with lower early postdischarge incidence of stroke and a favorable overall risk-benefit profile. Given these short-term findings in a real-world population of all patients who underwent cardiac surgery, longer-term studies with more granular data are needed to evaluate the potential benefit of this practice.

Efficacy and safety of a transaortic approach to midventricular and apical septal myectomy.

OBJECTIVE: The study objective was to evaluate the safety and efficacy of a transaortic approach to midventricular and apical septal myectomy in patients with hypertrophic cardiomyopathy with left ventricular outflow tract or midventricular obstruction. METHODS: From January 2018 to August 2023, 940 patients underwent transaortic septal myectomy at the Cleveland Clinic, of whom 682 (73%) had midventricular or apical resection. Patients who underwent isolated basal myectomies were excluded. Templated operative reports designated septal regions resected as basal (opposition to mitral valve up to the leaflet tips), midventricular (leaflet tips to just beyond the papillary muscle heads), and apical (apical third of the ventricle). Myocardial resection specimen weights, intraventricular gradients, and clinical outcomes were assessed. RESULTS: Of the 682 patients, 582 (85%) had basal plus midventricular resection and 78 (11%) had basal, midventricular, and apical resection. Mean preoperative intraventricular gradient was 102 ± 41 mm Hg. Median resection weight was 10 g (15th, 85th percentiles: 7, 15), and mean postoperative intraventricular gradient was 16 ± 10 mm Hg, with 625 (96%) patients achieving gradients 36 mm Hg or less. There were no iatrogenic mitral or aortic valve injuries. Permanent pacemaker placement was required in 38 patients (5.6%), of whom 8 (1.2%) had normal preoperative conduction. Operative mortality occurred in 1 patient (0.1%) after an intraoperative ventricular septal defect. CONCLUSIONS: Most patients undergoing septal myectomy for relief of obstruction required resection beyond the basal septum. With specialized instrumentation, detailed imaging and knowledge of variable septal anatomy, resecting midventricular and apical septal muscle can be safely and effectively achieved through a transaortic approach.

Heart Transplant Using a Donor Heart With Only a Persistent Left Superior Vena Cava: A Case Report.

A persistent left superior vena cava (PLSVC) is a congenital anomaly wherein the left superior cardinal vein fails to regress. We describe the case of a successful orthotopic heart transplant using a donor heart with a PLSVC and congenital absence of a right superior vena cava (SVC) in a recipient with normal anatomy. After donor cardiectomy, the donor organ's PLSVC was ligated near the insertion site into the coronary sinus. The recipient underwent cardiectomy such that the native SVC was left with a long right atrial cuff. A modified bicaval technique was used to anastomose the recipient's right atrial cuff directly to the donor's right atrial appendage. This technique restored the recipient's normal anatomy, and we demonstrated that donor hearts with a PLSVC and absent right SVC might be used for transplant. Without other disqualifying abnormalities, surgeons should consider accepting these organs for life-saving transplant operations.

Extensive Spontaneous Coronary Artery Dissection Associated With Thrombosis: A Surgical Challenge.

Spontaneous coronary artery dissection is an uncommon cause of myocardial ischemia. Conservative management is the mainstay, although a few patients will require revascularization. We present a case of a 31-year-old woman whose extensive dissection necessitated coronary artery bypass grafting requiring an extended arteriotomy for excision of the thrombus and dissection flap. (Level of Difficulty: Advanced.).

Desperate Times Call for Desperate Measures: Bridging to Transplant in the Face of Central Device Infection.

Patients with durable left ventricular assist devices (LVAD) that develop central device infections can prove prohibitively challenging to treat and may require device explant for source control. In bridge to transplant (BTT) LVAD patients, the management of mediastinal infection is further complicated by changes in the 2018 United Network of Organ Sharing (UNOS) allocation system, which resulted in a comparatively lower listing status than in its previous iteration. We present the case of a 36-year-old male with nonischemic cardiomyopathy status post Heartmate 3 (HM3) implantation as BTT who after a year of stable HM3 support, developed a severe bacterial infection along the outflow graft. Despite attempts at finding a suitable donor at his current listing, his clinical status continued to deteriorate. To obtain infection source control, he underwent LVAD explant and insertion of a left axillary artery Impella 5.5 ventricular assist device for necessary hemodynamic support. The patient's listing was upgraded to Status 2, and following the identification of a suitable donor, underwent successful heart transplantation. This case highlights the limitation of the updated UNOS heart allocation system for patients with central device infections and describes the successful use of salvage temporary mechanical circulatory support to bridge to transplantation.

Machine learning using institution-specific multi-modal electronic health records improves mortality risk prediction for cardiac surgery patients.

Background: The Society of Thoracic Surgeons risk scores are widely used to assess risk of morbidity and mortality in specific cardiac surgeries but may not perform optimally in all patients. In a cohort of patients undergoing cardiac surgery, we developed a data-driven, institution-specific machine learning-based model inferred from multi-modal electronic health records and compared the performance with the Society of Thoracic Surgeons models. Methods: All adult patients undergoing cardiac surgery between 2011 and 2016 were included. Routine electronic health record administrative, demographic, clinical, hemodynamic, laboratory, pharmacological, and procedural data features were extracted. The outcome was postoperative mortality. The database was randomly split into training (development) and test (evaluation) cohorts. Models developed using 4 classification algorithms were compared using 6 evaluation metrics. The performance of the final model was compared with the Society of Thoracic Surgeons models for 7 index surgical procedures. Results: A total of 6392 patients were included and described by 4016 features. Overall mortality was 3.0% (n = 193). The XGBoost algorithm using only features with no missing data (336 features) yielded the best-performing predictor. When applied to the test set, the predictor performed well (F-measure = 0.775; precision = 0.756; recall = 0.795; accuracy = 0.986; area under the receiver operating characteristic curve = 0.978; area under the precision-recall curve = 0.804). eXtreme Gradient Boosting consistently demonstrated improved performance over the Society of Thoracic Surgeons models when evaluated on index procedures within the test set. Conclusions: Machine learning models using institution-specific multi-modal electronic health records may improve performance in predicting mortality for individual patients undergoing cardiac surgery compared with the standard-of-care, population-derived Society of Thoracic Surgeons models. Institution-specific models may provide insights complementary to population-derived risk predictions to aid patient-level decision making.

Association of timing of percutaneous left ventricular assist device insertion with outcomes in patients undergoing cardiac surgery.

Objectives: The aim of this study was to explore the associations between percutaneous ventricular assist device (pVAD) insertion timing relative to cardiac surgery and patient outcomes. Methods: The Nationwide Inpatient Sample was queried for patients undergoing cardiac surgery and pVAD insertion in the same admission from 2016 to 2019. Patients were stratified by timing of pVAD insertion. Preoperative characteristics, postoperative complications, and mortality were compared among groups. Results: Overall, 3695 patients underwent cardiac surgery and pVAD insertion during the same hospitalization (pre: 1130, intra: 1690, and post: 875). The distribution of cardiac surgery procedures was similar across groups. Median Elixhauser Comorbidity Index was 13 for pre-, 15 for intra-, and 17 for postoperative pVAD patients (P = .021). Patients who received a postoperative pVAD were associated with increased mortality (pre: 18%, intra: 39%, and post: 54%; P < .01). Increased complication rates were also associated with postoperative pVAD insertion (pre: 61%, intra: 55%, and post: 75%; P < .01). Preoperative pVAD insertion was associated with increase rates of sepsis (pre: 18%, intra: 9.8%, and post: 17%; P = .01) and pneumonia (pre: 38%, intra: 23%, and post: 31%; P < .01). Postoperative pVAD insertion was associated with increased rates of gastrointestinal bleeding (pre: 2.2%, intra: 3.0%, and post: 7.4%; P = .01), renal failure (pre: 10%, intra: 9.2%, and post: 17%; P = .01), and prolonged ventilation (pre: 44%, intra: 41%, and post: 54%; P = .02). Conclusions: Postoperative pVAD insertion following cardiac surgery was associated with increased complications and mortality compared with preoperative or intraoperative insertion. Further studies should explore optimal utilization and timing of pVAD insertion in patients undergoing cardiac surgery.

Trends in surgical ablation at the time of cardiac surgery among patients with atrial fibrillation.

Background: The 2017 American Association for Thoracic Surgery (AATS) guidelines support surgical ablation in patients undergoing cardiac surgery with preoperative atrial fibrillation (AF) owing to a reduction in early mortality and improved overall safety. We explored practice patterns changes and outcomes in patients undergoing concomitant surgical ablation following the guideline change. Methods: We identified 19,246 patients with preoperative AF who underwent cardiac surgery between 2016 and 2019 from the Florida and Maryland State Inpatient Databases. Rates of surgical ablation by procedure type were temporally trended across years. Secondary outcomes included complications, inpatient mortality, and hospital readmissions. Using multivariable logistic regression, we identified patient variables associated with concomitant surgical ablation. Results: A total of 2738 patients (14.3%) with AF underwent a concomitant surgical ablation. The rate of surgical ablation increased from 2.1% to 17.4% (P < .001) from 2016 to 2017 but remained unchanged thereafter. Postoperative mortality was lower in the surgical ablation cohort (2.7% vs 3.7%; P = .006), although with a higher rate of pacemaker insertion (11.8% vs 7.2%; P < .0001). Patients with a high-risk Elixhauser score (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.73-0.95), lower income (OR, 0.66; 95% CI, 0.57-0.75), or African American or Hispanic race/ethnicity (OR, 0.80; 95% CI, 0.67-0.96 and OR, 0.82; 95% CI, 0.71-0.96, respectively) had lower odds of undergoing concomitant surgical ablation. Conclusions: Despite a class I-2a recommendation by the AATS, surgical ablation continues to be underutilized in clinical practice, especially in patients with high-risk comorbidities, with lower incomes, or from minority populations. Surgeons should be mindful of guideline-directed AF management in these vulnerable populations.

Value of psychosocial evaluation for left ventricular assist device candidates.

OBJECTIVE: Left ventricular assist devices require a psychosocial assessment to determine candidacy despite limited data correlating with outcome. Our objective is to determine whether the Stanford Integrated Psychosocial Assessment for Transplant, a tool validated for transplant and widely used by left ventricular assist device programs, predicts left ventricular assist device program hospital readmissions and death. METHODS: We performed a retrospective analysis of adults at the Cleveland Clinic with Stanford Integrated Psychosocial Assessment for Transplant scores before primary left ventricular assist device program implantation from April 1, 2013, to December 31, 2018. The primary outcome was unplanned hospital readmissions censored at death, transplantation, and transfer of care. The secondary outcome was death. RESULTS: There were 263 patients in the left ventricular assist device program with a median (Q1, Q3) Stanford Integrated Psychosocial Assessment for Transplant score of 16 (8, 28). During a median follow-up 1.2 years, 56 died, 65 underwent transplantation, and 21 had transferred care. There were 640 unplanned hospital readmissions among 250 patients with at least 1 outpatient visit at our center. In a multivariable analysis, Stanford Integrated Psychosocial Assessment for Transplant components but not total Stanford Integrated Psychosocial Assessment for Transplant score was associated with readmissions. Psychopathology (Stanford Integrated Psychosocial Assessment for Transplant C-IX) was associated with hemocompatibility (coefficient 0.21 ± standard error 0.11, P = .040) and cardiac (0.15 ± 0.065, P = .02) readmissions. Patient readiness was associated with noncardiac (Stanford Integrated Psychosocial Assessment for Transplant A-III, 0.24 ± 0.099, P = .016) and cardiac (Stanford Integrated Psychosocial Assessment for Transplant A-low total, 0.037 ± 0.014, P = .007) readmissions. Poor living environment (Stanford Integrated Psychosocial Assessment for Transplant B-VIII) was associated with device-related readmissions (0.83 ± 0.34, P = .014). Death was associated with organic psychopathology or neurocognitive impairment (Stanford Integrated Psychosocial Assessment for Transplant C-X, 0.59 ± 0.21, P = .006). CONCLUSIONS: Total Stanford Integrated Psychosocial Assessment for Transplant score was not associated with left ventricular assist device program readmission or mortality. However, we identified certain Stanford Integrated Psychosocial Assessment for Transplant components that were associated with outcome and could be used to create a left ventricular assist device program specific psychosocial tool.