Multilayer Perceptron Neural Network Analysis of Fluoroscopic Working Angle on Transcatheter Aortic Valve Implantation Complications.

BACKGROUND: We sought to determine whether there is a relationship between the fluoroscopic working angle used to achieve a co-planar view during the deployment of the prosthesis during transcatheter aortic valve implantation (TAVI) and rates of complications, including paravalvular leaks, complete heart block, annular rupture, stroke, valve embolization, discharge to a skilled nursing facility and death within thirty days. METHODS: All patients undergoing TAVI at our institution from 2015 to 2022 were retrospectively analyzed. Images were reviewed to determine the fluoroscopic working angle during deployment, and medical records were used to determine the incidence and type of complication. A multilayer perceptron was employed to evaluate the predictive ability of the fluoroscopic working angle during deployment on complications of one-day and 30-day paravalvular leak, 30-day mortality, the need for a new pacemaker, discharge to a skilled nursing facility, stroke and the requirement for emergency intervention. RESULTS: Eight hundred and thirty-four patients were included in the study. Fluoroscopic working angle had excellent predictive value for stroke (area under the receiver operating characteristic curve (AUROC) of 0.812), one-day (AUROC 0.850), and 30-day paravalvular leak (AUROC 0.801). However, feature importance and scaled weighting analysis indicated that only a working angle in the left anterior oblique/cranial quadrant was informative for the development of an outcome of interest specific to a working angle quadrant (30-day paravalvular leak). CONCLUSION: Fluoroscopic working angle may be a useful way to further refine well-established risk calculi during TAVI.

Predictors of Survival After Heart Transplant in the New Allocation System: A UNOS Database Analysis.

Clinical predictors of posttransplant graft loss since the United Network for Organ Sharing (UNOS) heart allocation system change have not been well characterized. Single organ adult heart transplants from the UNOS database were identified (n = 10,252) and divided into a test cohort (n = 6,869, 67%) and validation cohort (n = 3,383, 33%). A Cox regression analysis was performed on the test cohort to identify recipient and donor risk factors for posttransplant graft loss. Based on the risk factors, a score (max 16) was developed to classify patients in the validation cohort into risk groups of low (≤1), mid (2-3), high (≥4) risk. Recipient factors of advanced age, Black race, recipient blood group O, diabetes, etiology of heart failure, renal dysfunction, elevated bilirubin, redo-transplantation, elevated pulmonary artery pressure, transplant with a durable ventricular assist device, or transplant on extracorporeal membrane oxygenation (ECMO) or ventilator were associated with more posttransplant graft loss. Donor factors of ischemic time and donor age were also associated with outcomes. One year graft survival for the low-, mid-, high-risk groups was 94%, 91%, and 85%, respectively. In conclusion, easily obtainable clinical characteristics at time of heart transplant can predict posttransplant outcomes in the current era.

Outcomes of coronary artery bypass surgery using modified del Nido cardioplegia in patients with poor ventricular function.

BACKGROUND: del Nido cardioplegia (DN) has been shown to be safe in adult patients undergoing isolated coronary artery bypass grafting with normal left ventricular ejection fraction. We sought to determine whether it was also safe in adult patients with diminished left ventricular function. METHODS: All patients with preoperative left ventricular ejection fraction ≤ 40% undergoing isolated coronary artery bypass grafting between 1/1/2019 and 7/10/2022 were retrospectively analyzed. Off-pump and beating heart cases were excluded. Patients were divided by surgeon preference between conventional cardioplegia (CCP) and DN. Baseline and intraoperative characteristics and short-term postoperative outcomes were compared. RESULTS: Six surgeons performed 829 isolated coronary artery bypass operations during the study. Two-hundred seventy-two met study criteria. Three surgeons used exclusively CCP for the duration of the study, two used exclusively DN and one switched from CCP to DN mid-way through. Group totals were: CCP n = 181 and DN n = 91. There were no significant differences in baseline characteristics including mean left ventricular ejection fraction (CCP 32.5 ± 7.4% vs. DN 33.4 ± 7.29%, p = 0.939). Other than a significant decrease in bypass time for DN (113.20 ± 37.2 vs. 122.43 ± 34.3 min, p = 0.043) there were no intergroup differences in urgency, number of grafts, ischemic time or incidence of blood transfusion. Postoperative outcomes between CCP and DN were similar including incidence of atrial fibrillation (12.2% vs. 8.8%, p = 0.403), intensive care length of stay (3.7 ± 2.3 vs. 4.3 ± 3.7 days, p = 0.886), total length of stay (5.7 ± 3.7 vs. 6.3 ± 4.4 days, p = 0.922) and 30-day mortality (3.85% vs. 1.10%, p = 0.205). CONCLUSION: Compared to conventional cardioplegia, del Nido cardioplegia provides equivalent short-term outcomes in patients with low left ventricular ejection fraction undergoing isolated coronary artery bypass grafting.

Giant Aneurysm of Left Main Coronary Artery in a Patient With Prior Operation for 4-Valve Endocarditis.

Left main coronary artery aneurysm is an unusual complication of infective endocarditis. Although this type of aneurysm is often asymptomatic, rupture and thrombus formation that result in myocardial infarction are known complications; therefore, prompt recognition and surgical intervention are warranted. This report describes a patient who presented with a giant left main coronary artery aneurysm 3.5 years after being treated for 4-valve endocarditis. The management and technical aspects of this challenging case are discussed here.

Current status of perioperative temporary mechanical circulatory support during cardiac surgery.

OBJECTIVES: We sought to determine utilization and outcomes of perioperative temporary mechanical circulatory support (tMCS) in the current practice of cardiac surgery. BACKGROUND: tMCS is an evolving adjunct to cardiac surgery not fully characterized in contemporary practice. METHODS: Using the nationwide inpatient sample we retrospectively analyzed hospital discharge data between January 1, 2016 and December 31, 2019. ICD-10-CM procedure codes were used to identify and divide patient hospitalizations into those who had preoperative tMCS (pre-tMCS) versus tMCS instituted the day of surgery or afterwards (sd/post-tMCS). RESULTS: In all, 1,383,520 hospitalizations met inclusion criteria. 86,445 (6.25%) had tMCS. tMCS was utilized in 8.74% of coronary artery bypass grafting (CABG), 2.58% of isolated valve, and 9.71% of valve/CABG; operations. 29,325 (33.9%) had pre-tMCS while 57,120 (66.1%) had sd/post-tMCS. The use of tMCS was associated with greater inpatient mortality (15.66% vs. 1.53%, p < .001), longer length of stay (LOS) (14.4 vs. 8.5 days, p < .001), and higher mean inflation-adjusted costs ($93,040 ± 1038 vs. $51,358 ± 296, p < .001) compared to no use. Inpatient mortality (5.98% vs. 20.63%, p < .001), LOS (13.87 vs. 14.68, p < .001), and cost ($82,621 ± 1152 SEM vs. $98,381 ± 1242) were all significantly lower with pre-tMCS compared to sd/post tMCS. When analyzed separately, mortality was higher with later utilization of tMCS (5.98% pre, 17.1% sd, and 49.05% postsurgical date insertion, p < .001). CONCLUSIONS: Perioperative tMCS is utilized in 6.25% of modern cardiac surgery, with two-thirds of cases instituted on the day of surgery or afterwards. The use of tMCS is associated with significantly higher mortality, longer LOS, and higher costs. Among patients undergoing tMCS, earlier utilization is associated with better outcomes.

Atherosclerotic Coronary Artery Disease in a Younger Adult With Transseptal Anomalous Left Coronary Artery.

We present a case of extensive coronary atherosclerotic disease in a younger patient with an anomalous left coronary artery with transseptal course and show the utility of multimodality evaluation to determine the culprit lesion in patients presenting with this rare association. (Level of Difficulty: Intermediate.).

Impact of the heart transplant allocation policy change on inpatient cost of index hospitalization.

BACKGROUND: We sought to determine the financial impact of the United Network for Organ Sharing heart transplant (HT) allocation policy change of October 2018. METHODS: Using the Nationwide Inpatient Sample we retrospectively analyzed hospital discharge data between January 1, 2016 and December 31, 2019. ICD-10-CM procedure codes were used to identify hospitalizations of patients undergoing HT as well as the use of temporary mechanical circulatory support (MCS) during the HT hospitalization. Patients < 18 years old and those with missing data on costs were excluded. The primary outcome was inflation-adjusted costs. Total costs were inflated to 2019 US dollars. RESULTS: During the course of the study, temporary MCS increased significantly among 11 380 weighted patients transplanted while mean length of stay (LOS) did not. Mean inflation-adjusted costs rose about $40k per HT. On univariate analysis, transplantation year, use of temporary MCS and LOS were all significantly associated with increased cost while on multivariate analysis only temporary MCS and LOS were. CONCLUSIONS: The 2018 allocation change has resulted in more expensive inpatient costs for HT correlating with an increase in temporary MCS.

The effect of recipient BMI on waitlist and post-transplant outcomes after the 2018 heart transplant allocation policy change.

OBJECTIVE: The effects of recipient body mass index (BMI) on waitlist strategies, waitlist outcomes, and post-transplant outcomes among adult patients listed for heart transplantation under the updated 2018 allocation system have not been well characterized. METHODS: The United Network of Organ Sharing data set between October 2015 and March 2021 was analyzed, and patients were grouped based on recipient BMI and whether listing occurred in the old (pre-October 2018) or new allocation system. RESULTS: Listing strategies differed by BMI group, but trends of increased use of temporary mechanical support and decreased use of durable support remained among all BMI groups, except those with BMI > 35 kg/m2 . Waitlist outcomes improved among all BMI cohorts in the new allocation system, including among patients with BMI 30-34.9 and >35 kg/m2 , although patients with higher BMIs continued to have longer waitlist times. Post-transplant outcomes in the new allocation system are worse for patients with BMI > 30 kg/m2  (hazard ratio: 1.47; confidence interval: 1.19-1.82; p < .001). CONCLUSIONS: The 2018 change to the heart transplant allocation system was associated with similar changes in the use of mechanical support for listing strategy across BMI ranges, except in the most obese, and improved waitlist outcomes across all BMI ranges. Post-transplant outcomes in the new allocation system are worse for patients with BMI > 30 kg/m2  compared to patients with BMI < 30 kg/m2 . These findings have important clinical implications for our understanding of the ongoing influence of BMI on waitlist courses and post-transplant outcomes among patients listed for heart transplantation.

Coronary artery aneurysm, ectasia and stenosis in a 53-year-old man with HIV infection.

The impact of long-standing human immunodeficiency virus infection (HIV) and potent anti-retroviral therapy on the coronary circulation is unknown; however, scattered reports are emerging of coronary aneurysms in this population. We report what we believe to be the first described case of both coronary stenosis and coronary artery aneurysms in a person living with HIV and discuss management options.

Hemorrhagic pericardial effusion resulting in constriction in hereditary hemorrhagic telangiectasia.

BACKGROUND: We report the first ante-mortem diagnosis of hemorrhagic pericardial effusion in hereditary hemorrhagic telangiectasia resulting in constriction; the case also demonstrates the unusual but well-described complication of right-sided heart failure requiring extracorporeal membrane oxygenation (ECMO) support after pericardiectomy. CASE PRESENTATION: A previously healthy 48 year old man with a strong family history of Osler-Weber-Rendu disease presented to our institution with signs and symptoms of advance heart failure. His workup demonstrated a thickened pericardium and constrictive physiology. He was brought to the operating room where old clot and inflamed tissue were appreciated in the pericardial space and he underwent complete pericardiectomy under cardiopulmonary bypass. Separation from bypass, hampered by the development of right ventricular dysfunction and profound vasoplegia, required significant pressor and inotropic support. The right heart dysfunction and vasoplegia worsened in the early postoperative period requiring a week of ECMO after which his right ventricle recovered and he was successfully de-cannulated. CONCLUSION: Given the poor outcome of severe postoperative right ventricular failure after pericardiectomy, with high central venous pressure, a low gradient between central venous and pulmonary artery pressures and high vasopressor requirements, ECMO should be instituted promptly.

The heart transplant allocation change attenuates but does not eliminate blood group O waitlist outcome disadvantage.

BACKGROUND: Patients with blood group O have historically been disadvantaged in the United Network for Organ Sharing (UNOS) heart transplant allocation system. We sought to determine whether the new UNOS allocation system implemented in 2018 had an impact on waitlist and post-transplant outcomes among blood groups. METHODS: Using the UNOS database we included all adult patients listed and transplanted with first-time single-organ heart transplant between 10/17/15 and 10/1/21. For post-transplant outcomes, we separately evaluated all adult patients transplanted with the same time-frame. We used exclusion criteria and censoring to limit biases from changing clinical practices around the allocation change (10/18/2018), and from unequal or inadequate follow-up. We compared clinical characteristics and outcomes before and after the allocation change among each blood group. Fine-Gray and Cox regression models were used to estimate the effect of the new allocation system on competing waitlist outcomes- transplantation, death-or-removal from waitlist- and post-transplant survival, respectively. RESULTS: Of the 21,565 patients listed for transplantation 14,000 met criteria for waitlist analysis (7,035 in the old system vs. 6,965 in the new), and 7,657 met criteria for post-transplant analysis (3,519 in the old system vs. 4,138 in the new). Among each blood group, new allocation change was associated with higher transplantation rates lower waitlist days and lower waitlist mortality (except Group AB). However, despite improvements, Group O was still associated with worse waitlist outcomes for each metric compared to non-O Groups. The new allocation system did not have a significant impact on post-transplant survival among any blood groups. CONCLUSION: Changes in heart transplant allocation have attenuated but not eliminated blood group O disadvantage in access to donor hearts.

Center-Level Variation in Transplant Rates Following the Heart Allocation Policy Change.

IMPORTANCE: Wide state-level variability in waiting list outcomes have been noted for patients listed for heart transplant in the US, but little is known regarding center-level transplant rates since the heart allocation policy change. OBJECTIVE: To evaluate center-level transplant rates following the recent allocation policy change for heart transplant. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the United Network for Organ Sharing database from October 18, 2015, to March 1, 2020, for a nationwide analysis of transplant centers in the US. Transplant candidates were stratified into 2 time cohorts, with era 1 denoting the 3-year period before the policy change (October 18, 2018), and era 2 representing the 500-day period after the policy change but before the beginning of the COVID-19 pandemic. Data were analyzed from May to June 2021. EXPOSURE: The heart allocation policy change enacted on October 18, 2018. MAIN OUTCOMES AND MEASURES: Competing risk regression for waiting list outcomes was performed to calculate adjusted era 1 and era 2 center-level transplant rates. Rates were compared across regions and states, as well as within organ procurement organizations. Pearson correlation coefficient was used to assess center-level factors associated with era 2 transplant rates. RESULTS: Of 15 940 transplant candidates included for analysis, 5063 (median [IQR] age, 56 [45-63] years; 1385 women [27.4%]) comprised the era 2 cohort. The proportion of patients with temporary mechanical circulatory support increased between era 1 and era 2 (extracorporeal membrane oxygenation, 2.00% vs 3.42%; percutaneous ventricular assist device, 0.66% vs 1.86%; intra-aortic balloon pump, 5.21% vs 13.10%). The adjusted mean center-level likelihood of transplant increased after the rule change (from 48.1% in era 1 to 78.0% in era 2). Significant variation in transplant rates was observed across regions and states even among centers with shared organ procurement organizations. The largest absolute difference in transplant rates was 27.1% for 2 centers belonging to the same organ procurement organization. Centers with higher transplant volumes in era 2 and with a greater proportion of candidates with intra-aortic balloon pump were observed to have higher transplant rates. CONCLUSIONS AND RELEVANCE: Despite sharing organ supply and having a small geographical distance, these findings suggest that intercenter disparities in the likelihood of transplant have persisted following the heart allocation policy change. Further work is necessary to ensure equitable allocation of organs in heart transplant.

Experience, exposure, and attitudes regarding off-pump coronary artery bypass grafting techniques in US cardiothoracic surgical residents: Results of a survey.

Background: We sought to determine the current level of exposure to and interest in off-pump coronary artery bypass and beating heart surgery techniques regarding cardiothoracic surgical residents in the United States. Methods: An email survey consisting of 6 questions was sent to all cardiothoracic surgery residents of approved cardiothoracic training programs in the United States. The survey was emailed using the Qualtrics XM cloud-based survey platform. When the email responses were received, the answers to the survey questions were tabulated by the Qualtrics software and the resident's institution and year of graduation from their residency was noted. Results: Of 400 surveys sent, we received 99 responses for a response rate of 25%. A total of 78% of cardiothoracic surgery residents reported that they are at programs that do off-pump coronary artery bypass or beating heart surgery infrequently, noting that these cases are done in less than 5% of the coronary artery bypass graftings to which they are exposed. A total of 51% responded that they do not feel comfortable with off-pump coronary artery bypass grafting under any circumstances. A total of 49% reported some comfort with the technique with most of these respondents noting that they would do off-pump coronary artery bypass or beating heart surgery on a selective basis if the clinical situation arose and 4% plan to do off-pump coronary artery bypass routinely. Exposure to off-pump coronary artery bypass and beating heart surgery significantly correlated with future adoption of the technique by the cardiothoracic surgery residents. Cardiothoracic surgery residents in the lowest, middle, and highest terciles of exposure to off-pump coronary artery bypass and beating heart surgery plan to use these techniques 31%, 86%, and 75%, respectively, in selective cases when they are in independent practice. Conclusions: Over half of graduating cardiothoracic surgery residents do not feel comfortable with off-pump coronary artery bypass or beating heart surgery techniques. Exposure to these techniques in training correlates with comfort level and plans to use them in independent practice.

Association of donor hypertension and outcomes in orthotopic heart transplantation.

The present study examined the impact of donor hypertension on recipient survival and offer acceptance practices in the United States. This was a retrospective study of all patients undergoing OHT from 1995 to 2019 using the United Network for Organ Sharing and Potential Transplant Recipient file databases. Hypertensive donors were stratified by Short (0-5 years) and Prolonged (> 5 years) hypertension. Multivariable logistic regression was used to analyze offer acceptance practices while Cox proportional-hazards models were used to compare mortality across groups. Of 38,338 heart transplants meeting study criteria, 5662 were procured from hypertensive donors (69% Short and 31% Prolonged). After adjustment, Prolonged donor hypertension was associated with increased mortality (hazard ratio, HR, 1.31, 95% confidence interval, CI, 1.04-1.64), while recipients of Short donors experienced no decrement in post-transplant survival. Both Short and Prolonged hypertension were independently associated with decreased odds of offer acceptance (odds ratio, OR .92 95%CI: .88-.96 and OR .93 95%CI: .88-.99, respectively). While prolonged untreated hypertension in OHT donors is associated with a slight decrement in recipient survival, donors with ≤5 years of hypertension yielded similar outcomes. Donor hypertension was associated with reduced organ offer acceptance, highlighting a potential source of organ underutilization.

Impact of transplant center volume on donor heart offer utilization rates in the United States.

BACKGROUND: We tested the hypothesis that transplant centers (TCs) with higher volumes have higher donor heart (DH) offer utilization rates. METHODS: Using the Annual Data reports of the US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients (SRTR) we reviewed all adult heart transplant offers between July 1, 2016 and June 29, 2019. Unadjusted donor offer utilization rates and observed to expected (O/E) DH utilization ratios adjusted using the SRTR model were calculated for each TC for all DH offers and for the following sub-categories: DH with left ventricular ejection fraction <60%, DH >40 years, DH >500 miles from TC, "hard-to-place hearts" (defined as those offered to >50 TCs) and DH designated as increased infectious risk. Univariable linear regression was used to identify a relationship between average yearly center volume and DH utilization. RESULTS: During the study 118,841 total offers were made to 107 TCs and 8300 transplants were performed. The unadjusted utilization rate was not associated with TC volume for all donor offers (p = .517). However, among all subcategories other than DH >40 years, the unadjusted DH utilization rate was associated with TC volume (p < .05). In addition, using the adjusted SRTR O/E ratio, there was a significant impact of TC volume on utilization rate for all donor offers (for an increase TC volume of 10 transplants/year coefficient = 0.095, 95% confidence interval: 0.037-0.151, p = .001). This relationship persisted with an identifiable change for each of the subcategories (p ≤ .001). CONCLUSIONS: TC volume is significantly correlated to DH offer utilization rate.

Impact of heart transplant allocation change on competing waitlist outcomes among listing strategies.

In 2018, the United Network for Organ Sharing (UNOS) adopted a 6-tier system for heart allocation which shifted patterns in listing strategies. The effects of the change on waitlist survival and transplantation rates have yet to be substantiated by analysis of competing outcomes among various listing strategies. This study included all adult patients listed for first-time heart transplantation in UNOS between 10/17/15 and 6/12/20. Clinical characteristics were compared before and after allocation change among various listing strategies: no support, inotropes, intra-aortic balloon pump, durable left ventricular assist device (LVAD), temporary VAD, and extracorporeal membrane oxygenation. Fine-Gray proportional subhazard models were used to estimate the effect of allocation change on competing waitlist outcomes-transplantation, death, or removal from waitlist-among each strategy. During the study period, there were 17 422 patients listed for heart transplantation. Among each listing strategy, clinical characteristics were similar before and after allocation change. Subhazard models demonstrated reduced risk for waitlist mortality (p < .001) among each strategy except temporary VAD and increased transplantation rates (p < .001) among each strategy except for durable LVAD. These results validate the association of the new allocation system on waitlist outcomes across listing strategies.

Early modified primary closure for treatment of cardiac implantable electronic device pocket infections.

BACKGROUND: Guidance for wound management of the vacated generator pocket in cardiac implantable electronic device (CIED) pocket infections after removal of all hardware and tissue debridement is limited. The typical surgical technique for management of a purulent wound is to allow healing by secondary intention. An alternative approach uses negative pressure wound therapy with or without delayed primary closure. While effective in managing infection, these approaches increase hospital length of stay and costs. We present our experience with a third option: modified early primary wound closure over a suction device. METHODS: All patients with CIED pocket infections who presented to our institution between September 2018 and October 2020 underwent extraction of hardware and modified primary wound closure over a negative pressure Jackson-Pratt drain. Length of hospital and postoperative stay, complications, and recurrent infections were recorded. RESULTS: During the study period, 14 patients underwent modified primary wound closure for CIED pocket infections. Mean length of hospital stay was 6.64 days ± 4.01 days (standard deviation [SD]). Mean postoperative length of stay was 3.92 ± 2.21 days (SD). Two patients (both on intravenous heparin for mechanical valve prostheses) required re-exploration for bleeding. No patients developed recurrent infection at a mean follow up of 363 ± 245 days (SD). CONCLUSION: Based on our experience, early modified primary wound closure for CIED pocket infections appears to be safe and allows for prompt discharge with no observed re-infections.

Perioperative Individualized Goal Directed Therapy for Cardiac Surgery: A Historical-Prospective, Comparative Effectiveness Study.

INTRODUCTION: Cardiac surgery patients are at increased risk for post-operative complications and prolonged length of stay. Perioperative goal directed therapy (GDT) has demonstrated utility for non-cardiac surgery, however, GDT is not common for cardiac surgery. We initiated a quality improvement (QI) project focusing on the implementation of a GDT protocol, which was applied from the immediate post-bypass period into the intensive care unit (ICU). Our hypothesis was that this novel GDT protocol would decrease ICU length of stay and possibly improve postoperative outcomes. METHODS: This was a historical prospective, QI study for patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB). Integral to the QI project was education towards all associated providers on the concepts related to GDT. The protocol involved identifying patient specific targets for cardiac index and mean arterial pressure. These targets were maintained from the post-CPB period to the first 12 h in the ICU. Statistical comparisons were performed between the year after GDT therapy was launched to the last two years prior to protocol implementation. The primary outcome was ICU length of stay. RESULTS: There was a significant decrease in ICU length of stay when comparing the year after the protocol initiation to years prior, from a median of 6.19 days to 4 days (2017 vs. 2019, p < 0.0001), and a median of 5.88 days to 4 days (2018 vs. 2019, p < 0.0001). Secondary outcomes demonstrated a significant reduction in total administered volumes of inotropic medication(milrinone). All other vasopressors demonstrated no differences across years. Hospital length of stay comparisons did not demonstrate a significant reduction. CONCLUSION: These results suggest that an individualized goal directed therapy for cardiac surgery patients can reduce ICU length of stay and decrease amount of inotropic therapy.