Re-repair for mitral insufficiency.

BACKGROUND: Mitral valve repair provides superior outcomes to replacement for primary MR. Whether this is true following previous repair is unknown. We present the results of a strategy of re-repair for failed mitral valve repair. We examine patients who were brought to the operating room for an intended mitral valve re-repair. METHODS: We reviewed the last one decade of our institutional mitral valve databases at The University of Pennsylvania and Plano Heart Hospital and identified patients undergoing repeat mitral valve repair, in whom the index operation was mitral valve repair. We analyzed their operative details, clinical and echocardiographic outcomes. RESULTS: Between 2008 and 2021, 71 patients (aged 61.5 ±10.7 years, 20% female) underwent mitral valve reoperation at an mean of 6.24 ±7.62 years following index mitral repair. 20% of patients presented with NYHA class III/IV symptoms. At index operation, 34 (47.9%) had repair through a right mini-thoracotomy. 15 patients (21.1%) required the reoperation within one year. There were 0 early and 8 late deaths. One patient who underwent mitral replacement instead of repair, required reoperation for paravalvular leak during the follow-up period. Three patients required mitral valve replacement at an average of 2.28 ±2.03 years following initial mitral valve re-repair. CONCLUSIONS: Mitral re-repair can be performed with acceptable results at a valve reference center. Durability and functional advantages of this approach remain to be proven.

A comprehensive deep venous thrombosis prophylaxis regimen in isolated coronary artery bypass grafting.

Objectives: Deep venous thrombosis (DVT) is a known surgical complication that can lead to pulmonary embolism with subsequent morbidity and mortality. The incidence of DVT following coronary artery bypass grafting is unclear. Prophylaxis regimens vary and some guidelines advocate against use of routine chemoprophylaxis in patients at low-moderate risk for venous thromboembolism. We utilized postoperative lower extremity venous ultrasound to determine the incidence of DVT following coronary artery bypass grafting in patients with low- to moderate-risk of venous thromboembolism receiving aggressive postoperative DVT prophylaxis. Methods: This is a single-center, retrospective study of all patients who underwent coronary artery bypass grafting between April 2022 and January 2023. All patients who completed postoperative venous ultrasound of the bilateral lower extremities were initially included. Patients who underwent concurrent valve or aortic surgery, were at high risk of venous thromboembolism, or were receiving anticoagulation therapy for nonvenous thromboembolism indications were excluded. The primary outcome was in-hospital incidence of DVT. Secondary outcomes were rates of mortality, postoperative bleeding, and thromboembolic events from discharge to 30 days postoperatively and from 30 days to 3 months postoperatively. Results: No DVTs were observed in 211 included patients. In hospital, there were 3 significant bleeding events and 1 stroke. Following discharge there were 3 additional bleeding events, 1 death, 1 transient ischemic attack, and 1 pulmonary embolism. Conclusions: We observed a 0% rate of DVT in low- to moderate-risk patients undergoing isolated coronary artery bypass grafting and receiving a comprehensive DVT prophylaxis regimen. In hospital bleeding and other thromboembolic event rates were 2.84% and 0.47% respectively.

Predicting risk of tracheostomy after cardiac surgery: a decade of insights from nearly 10,000 patients.

Objective: Studies have shown that requiring tracheostomy following cardiac surgery has significant implications on outcomes. This study proposes a risk stratification model to predict the likelihood of requiring a tracheostomy after cardiac surgery. Methods: Patients who underwent cardiac surgery between January 2010 and December 2019 were analyzed. Kaplan-Meier analysis and log-rank test were used to estimate and compare survival between cohorts. A prediction model for the need for postoperative tracheostomy was developed with logistic regression combined with undersampling analysis. Results: A total of 9849 patients underwent cardiac surgery, and 176 (1.8%) required postoperative tracheostomy. Tracheostomy patients were older (mean age 68.4 ± 12.3 vs 65.9 ± 11.2 years; P < 0.01) and more likely female (43.8% vs 28.5%; P < 0.01). Predictors for requiring tracheostomy included hypertension (odds ratio [OR] 1.91; P = 0.05), New York Heart Association III/IV (OR 2.68; P < 0.001), chronic lung disease (OR 3.27; P < 0.001), and history of prior myocardial infarction (OR 3.32; P < 0.001). Three-year Kaplan-Meier survival was worse in patients who received tracheostomy (log-rank P < 0.001). Conclusions: A risk prediction model for requiring tracheostomy after cardiac surgery is proposed in this study. A history of New York Heart Association III/IV, chronic lung disease, and myocardial infarction as well as undergoing valve surgeries were associated with increased risk of requiring a tracheostomy.

App-Based Mindfulness for Attenuation of Subjective and Physiological Stress Reactivity in a Population With Elevated Stress: Randomized Controlled Trial.

BACKGROUND: Stress-related mental health disorders have steadily increased and contributed to a worldwide disease burden with up to 50% experiencing a stress-related mental health disorder worldwide. Data suggest that only approximately 20%-65% of individuals receive treatment. This gap in receiving treatment may be attributed to barriers such as limited treatment access, negative stigma surrounding mental health treatment, approachability (ie, not having a usual treatment plan or provider), affordability (ie, lack of insurance coverage and high treatment cost), and availability (ie, long waits for appointments) leaving those who need treatment without necessary care. To mitigate the limited access mental health treatment, there has been a rise in the application and study of digital mental health interventions. As such, there is an urgent need and opportunity for effective digital mental health interventions to alleviate stress symptoms, potentially reducing adverse outcomes of stress-related disorders. OBJECTIVE: This study examined if app-based guided mindfulness could improve subjective levels of stress and influence physiological markers of stress reactivity in a population with elevated symptoms of stress. METHODS: The study included 163 participants who had moderate to high perceived stress as assessed by the Perceived Stress Scale (PSS-10). Participants were randomly allocated to 1 of 5 groups: a digital guided program designed to alleviate stress (Managing Stress), a digital mindfulness fundamentals course (Basics), digitally delivered breathing exercises, an active control intervention (Audiobook), and a Waitlist Control group. The 3 formats of mindfulness interventions (Managing Stress, Basics, and Breathing) all had a total duration of 300 minutes spanning 20-30 days. Primary outcome measures were perceived stress using the PSS-10, self-reported sleep quality using the Pittsburgh Sleep Quality Index, and trait mindfulness using the Mindful Attention Awareness Scale. To probe the effects of physiological stress, an acute stress manipulation task was included, specifically the cold pressor task (CPT). Heart rate variability was collected before, during, and after exposure to the CPT and used as a measure of physiological stress. RESULTS: The results showed that PSS-10 and Pittsburgh Sleep Quality Index scores for the Managing Stress (all P<.001) and Basics (all P≤.002) groups were significantly reduced between preintervention and postintervention periods, while no significant differences were reported for the other groups. No significant differences among groups were reported for Mindful Attention Awareness Scale (P=.13). The physiological results revealed that the Managing Stress (P<.001) and Basics (P=.01) groups displayed reduced physiological stress reactivity between the preintervention and postintervention periods on the CPT. There were no significant differences reported for the other groups. CONCLUSIONS: These results demonstrate efficacy of app-based mindfulness in a population with moderate to high stress on improving self-reported stress, sleep quality, and physiological measures of stress during an acute stress manipulation task. TRIAL REGISTRATION: ClinicalTrials.gov NCT05832632; https://www.clinicaltrials.gov/ct2/show/NCT05832632.

Outcomes of the Ross procedure in patients older versus younger than 50 years old.

OBJECTIVES: The Ross procedure is traditionally considered for young adult patients with aortic valve disease. This study compares long-term outcomes of patients undergoing the Ross procedure who are ≥50 and <50-years old. METHODS: Data were collected from 225 patients undergoing Ross procedure at a single centre from 1994 to 2019. Patients were categorized into younger (<50-years old; n = 156) and older (≥50-years old; n = 69) cohorts. Baseline demographics clinical outcomes were compared. RESULTS: The mean age was 36 ± 8.1 and 55 ± 4.2 years in the younger and older cohort, respectively. Both groups were predominantly male (58.5% vs 69.6%; P = 0.59). The younger group had a higher rate of aortic insufficiency (51% vs 26.1%; P < 0.01), and bicuspid aortic valve (81.4% vs 58.0%; P < 0.01). Aortic stenosis was more prevalent in the older cohort (25.6% vs 58.0%; P < 0.01). Operative mortality was acceptable in both groups (1.3% vs 4.3%; P = 0.15). Survival up to 10 years was not statistically different between 2 groups (96.2% vs 91.3% P = 0.16), whereas survival up to 15 years for younger patients was significantly higher (94.9% vs 85.5%; P = 0.03). After non-cardiac related deaths were excluded, survival up to 15 years (98.7% vs 91.3%; P = 0.02) was significantly lower than younger patients. In both groups, survival after the Ross procedure was similar to the age- and sex-matched US population. CONCLUSIONS: Survival up to 10 years after Ross procedure were similar, but up to 15 years was significantly higher in younger patients. The Ross procedure restored patients from both groups to expected survival. Our results suggest that at experienced centres, the Ross procedure is a safe and reasonable option for patients who are 50 years and older.

Explant vs Redo-TAVR After Transcatheter Valve Failure: Mid-Term Outcomes From the EXPLANTORREDO-TAVR International Registry.

BACKGROUND: Valve reintervention after transcatheter aortic valve replacement (TAVR) failure has not been studied in detail. OBJECTIVES: The authors sought to determine outcomes of TAVR surgical explantation (TAVR-explant) vs redo-TAVR because they are largely unknown. METHODS: From May 2009 to February 2022, 396 patients in the international EXPLANTORREDO-TAVR registry underwent TAVR-explant (181, 46.4%) or redo-TAVR (215, 54.3%) for transcatheter heart valve (THV) failure during a separate admission from the initial TAVR. Outcomes were reported at 30 days and 1 year. RESULTS: The incidence of reintervention after THV failure was 0.59% with increasing volume during the study period. Median time from index-TAVR to reintervention was shorter in TAVR-explant vs redo-TAVR (17.6 months [IQR: 5.0-40.7 months] vs 45.7 months [IQR: 10.6-75.6 months]; P < 0.001], respectively. TAVR-explant had more prosthesis-patient mismatch (17.1% vs 0.5%; P < 0.001) as the indication for reintervention, whereas redo-TAVR had more structural valve degeneration (63.7% vs 51.9%; P = 0.023), with a similar incidence of ≥moderate paravalvular leak between groups (28.7% vs 32.8% in redo-TAVR; P = 0.44). There was a similar proportion of balloon-expandable THV failures (39.8% TAVR-explant vs 40.5% redo-TAVR; P = 0.92). Median follow-up was 11.3 (IQR: 1.6-27.1 months) after reintervention. Compared with redo-TAVR, TAVR-explant had higher mortality at 30 days (13.6% vs 3.4%; P < 0.001) and 1 year (32.4% vs 15.4%; P = 0.001), with similar stroke rates between groups. On landmark analysis, mortality was similar between groups after 30 days (P = 0.91). CONCLUSIONS: In this first report of the EXPLANTORREDO-TAVR global registry, TAVR-explant had a shorter median time to reintervention, with less structural valve degeneration, more prosthesis-patient mismatch, and similar paravalvular leak rates compared with redo-TAVR. TAVR-explant had higher mortality at 30 days and 1 year, but similar rates on landmark analysis after 30 days.

Race, neighborhood disadvantage, and survival of Medicare beneficiaries after aortic valve replacement and concomitant coronary artery bypass grafting.

BACKGROUND: Race, neighborhood disadvantage, and the interaction between these 2 social determinants of health remain poorly understood with regards to survival after aortic valve replacement with concomitant coronary artery bypass grafting (AVR+CABG). METHODS: Weighted Kaplan-Meier survival analyses and Cox proportional hazards modeling were used to evaluate the association between race, neighborhood disadvantage, and long-term survival in 205,408 Medicare beneficiaries undergoing AVR+CABG from 1999 to 2015. Neighborhood disadvantage was measured using the Area Deprivation Index, a broadly validated ranking of socioeconomic contextual disadvantage. RESULTS: Self-identified race was 93.9% White and 3.2% Black. Residents of the most disadvantaged quintile of neighborhoods included 12.6% of all White beneficiaries and 40.0% of all Black beneficiaries. Black beneficiaries and residents of the most disadvantaged quintile of neighborhoods had more comorbidities compared with White beneficiaries and residents of the least disadvantaged quintile of neighborhoods, respectively. Increasing neighborhood disadvantage linearly increased the hazard for mortality for Medicare beneficiaries of White but not Black race. Residents of the most and least disadvantaged neighborhood quintiles had weighted median overall survival of 93.0 and 82.1 months, respectively, a significant difference (P < .001 by Cox test for equality of survival curves). Black and White beneficiaries had weighted median overall survival of 93.4 and 90.6 months, respectively, a nonsignificant difference (P = .29 by Cox test for equality of survival curves). A statistically significant interaction between race and neighborhood disadvantage was noted (likelihood ratio test P = .0215) and had implications on whether Black race was associated with survival. CONCLUSIONS: Increasing neighborhood disadvantage was linearly associated with worse survival after combined AVR+CABG in White but not Black Medicare beneficiaries; race, however, was not independently associated with postoperative survival.

Vein Graft Use and Long-Term Survival Following Coronary Bypass Grafting.

BACKGROUND: Although placement of at least 1 arterial graft during coronary artery bypass grafting (CABG) has a proven survival benefit, it is unknown what degree of revascularization with saphenous vein grafting (SVG) is associated with improved survival. OBJECTIVES: The authors sought to determine whether undergoing surgery performed by a surgeon who is liberal with vein graft utilization is associated with improved survival in patients undergoing single arterial graft CABG (SAG-CABG). METHODS: This was a retrospective, observational study of SAG-CABG performed in Medicare beneficiaries from 2001 to 2015. Surgeons were stratified by number of SVG utilized per SAG-CABG into conservative (≥1 SD below mean), average (within 1 SD of mean), and liberal (≥1 SD above mean). Long-term survival was estimated using Kaplan-Meier analysis and compared among surgeon groups before and after augmented inverse-probability weighting. RESULTS: There were 1,028,264 Medicare beneficiaries undergoing SAG-CABG from 2001 to 2015 (mean age 72.0 ± 7.9 years, 68.3% male). Over time, 1-vein and 2-vein SAG-CABG utilization increased, whereas 3-vein and ≥4-vein SAG-CABG utilization decreased (P < 0.001). Surgeons who were conservative vein graft users performed a mean 1.7 ± 0.2 vein grafts per SAG-CABG, whereas those who were liberal vein graft users performed a mean 2.9 ± 0.2 vein grafts per SAG-CABG. Weighted analysis demonstrated no difference in median survival among patients undergoing SAG-CABG by liberal vs conservative vein graft users (adjusted median survival difference 27 days). CONCLUSIONS: Among Medicare beneficiaries undergoing SAG-CABG, there is no association between surgeon proclivity for vein graft utilization and long-term survival, suggesting that a conservative approach to vein graft utilization is reasonable.

A path model examination: maternal anxiety and parenting mediate the association between maternal adverse childhood experiences and children's internalizing behaviors.

BACKGROUND: Children of mothers with adverse childhood experiences (ACEs) are at increased risk for developmental problems. However, the mechanisms through which a mother's experience of ACEs are transmitted to her offspring are understudied. The current study investigates potential modifiable mediators (maternal psychopathology and parenting) of the association between maternal ACEs and children's behavioral problems. METHODS: We utilized data from a pregnancy cohort study (N = 1030; CANDLE study) to investigate longitudinal associations between maternal ACEs, postpartum anxiety, observed parenting behavior, and child internalizing behaviors (meanage = 4.31 years, s.d. age = 0.38) in a racially diverse (67% Black; 33% White/Other) sample. We used structural equation modeling to test for direct associations between maternal ACEs and children's internalizing behaviors, as well as indirect associations via two simple mediations (maternal anxiety and parenting), and one serial mediation (sequence of maternal anxiety to parenting). RESULTS: Simple mediation results indicated that maternal anxiety and cognitive growth fostering behaviors independently mediated the association between maternal ACEs and child internalizing. We observed no evidence of a serial mediation from ACEs to internalizing via the effects of maternal anxiety on parenting. CONCLUSIONS: This study supports and refines extant literature by confirming the intergenerational association between maternal ACEs and child internalizing behaviors in a large, diverse sample, and identifies potential modifiable mediators: maternal anxiety and parenting behaviors related to fostering cognitive development. Findings may inform interventions targeting mothers who have experienced ACEs and suggest that providing support around specific parenting behaviors and addressing maternal anxiety may reduce internalizing behaviors in children.

Outcomes of redo operations after the Ross procedure.

BACKGROUND: The Ross procedure is not commonly performed, owing to the procedural complexity and the risk of autograft and/or homograft reoperation. This study examined outcomes of patients undergoing Ross reinterventions at a dedicated Ross center. METHODS: We retrospectively reviewed 225 consecutive patients who underwent a Ross procedure between 1994 and 2019. Index and redo operation characteristics and outcomes were compared between patients with and those without redo operations. Multivariate analysis was used to identify independent predictors of Ross-related reinterventions. Survival was estimated with Kaplan-Meier analysis. RESULTS: Sixty-six patients (29.3%) required redo Ross surgery, 41 patients (18.2%) underwent autograft reoperation only, 8 patients (3.6%) had a homograft reintervention, and 17 patients (7.6%) had both autograft and homograft reoperations (12 as a combined procedure and 5 as sequential procedures). The mean time to reintervention was 11 ± 6 years for autograft reoperations and 12 ± 7 years for homograft reoperations. Patients who underwent Ross-related reinterventions were younger (mean, 38 ± 11 years vs 43 ± 11 years; P < .01) and had a higher rate of New York Heart Association class III/IV (56% vs 38%; P = .02) at the index Ross procedure. Most patients undergoing autograft reintervention had aortic insufficiency and/or aneurysm (98.2%; 57 of 58). The primary reason for homograft reintervention was pulmonary stenosis (92%; 23 of 25). The operative mortality of Ross reintervention was 1.5% (1 of 66). Survival at 15 years was similar in patients who required a redo operation and those who did not (91.2% vs 93.9%; P = .23). CONCLUSIONS: Ross reinterventions can be performed safely and maintain patients at the normal life expectancy restored by the index Ross procedure up to 15 years at experienced centers.

Contemporary Outcomes of Isolated Tricuspid Valve Surgery.

INTRODUCTION: Isolated tricuspid valve (TV) surgery is uncommonly performed and has historically been associated with excessive operative mortality. We previously reported improved short-term outcomes at our center. Understanding contemporary outcomes of isolated TV surgery beyond the perioperative period is essential to properly benchmark outcomes of newer transcatheter interventions. METHODS: Patients who underwent isolated TV surgery from 2007 to 2021 at a single institution were retrospectively reviewed. Survival was estimated using the Kaplan-Meier method and multivariable Cox proportional hazards regression modeling identified independent risk factors for all-cause mortality. RESULTS: Among 173 patients undergoing isolated TV surgery, 103 (60%) underwent TV repair and 70 (40%) underwent TV replacement. Mean age was 60.3 ± 18.9 y and 55 (32%) were male. The most common etiology of TV disease was functional (46%). In-hospital mortality was 4.1% (7/173), with no difference between TV repair and replacement (P = 0.06). Overall survival at 1 y and 5 y was 78.3% (111/142) and 64.5% (53/82), respectively. After median (interquartile range) follow-up of 2.0 (0.6-4.4) y, patients undergoing TV repair experienced a higher unadjusted survival as compared to those undergoing TV replacement (log-rank P = 0.02). However, after adjusting for covariates, TV replacement was not an independent predictor of all-cause mortality (hazard ratio 1.40; 95% confidence interval, 0.71-2.76; P = 0.33). CONCLUSIONS: Isolated TV surgery can be performed with lower operative mortality than historically reported. Establishing survival benchmarks from TV surgery is important in the era of developing transcatheter interventions.

Drug-Coated Balloon Angioplasty for Carotid Artery In-Stent Restenosis: Case Series.

OBJECTIVES: Few case reports have demonstrated promising results of drug-coated balloons (DCBs) as an emerging management for carotid artery in-stent restenosis (CAISR). Herein, we report 6 cases of CAISR which were treated with a DCB with or without new stent deployment. BACKGROUND: Carotid artery in-stent restenosis is a high-risk condition with an estimated incidence rate that varies widely from 6% to 40%. Several strategies are available now for the management of the CAISR including conventional balloon angioplasty, plaque modification balloon angioplasty, and new stent placement. METHODS: A retrospective review of consecutive patients with a diagnosis of severe CAISR at Baylor Scott & White The Heart Hospital Plano from 2011 to 2021 was performed. This study was approved by the Baylor Scott & White Research Institute institutional review board. RESULTS: Six patients underwent DCB angioplasty with or without stent placement under an embolic protection device. Resolution of CAISR was achieved in all cases with 0% to 10% residual stenosis in all cases. Following the procedure, 1 patient had a brief episode of syncope with balloon inflation with immediate recovery on deflation of the balloon. There were otherwise no significant neurological or cardiac events prior to discharge. All patients were asymptomatic at their follow-up visit with no neurological or cardiac events reported at 12, 24, and 36 months following the procedure. CONCLUSION: While CAISR treatment remains a challenging condition, our study shows that the use of DCB with or without stent placement is a feasible and promising treatment option when compared with other conventional treatment options. CLINICAL IMPACT: Carotid artery in-stent restenosis treatment remains a challenging condition. Our study shows that the use of drug coated balloon with or without stent placement is a feasible and promising treatment option when compared with current conventional treatment options.

Bloodstream and respiratory coinfections in patients with COVID-19 on ECMO.

BACKGROUND: Although several studies have characterized the risk of coinfection in COVID pneumonia, the risk of the bloodstream and respiratory coinfection in patients with COVID-19 pneumonia on extracorporeal membrane oxygenation (ECMO) supports severe acute respiratory distress syndrome (ARDS) is poorly understood. METHODS: This is a retrospective analysis of patients with COVID-19 ARDS on ECMO at a single center between January 2020 and December 2021. Patient characteristics and clinical outcomes were compared. RESULTS: Of 44 patients placed on ECMO support for COVID-19 ARDS, 30 (68.2%) patients developed a coinfection, and 14 (31.8%) patients did not. Most patients underwent venovenous ECMO (98%; 43/44) cannulation in the right internal jugular vein (98%; 43/44). Patients with coinfection had a longer duration of ECMO (34 [interquartile range, IQR: 19.5, 65] vs. 15.5 [IQR 11, 27.3] days; p = .02), intensive care unit (ICU; 44 [IQR: 27,75.5] vs 31 [IQR 20-39.5] days; p = .03), and hospital (56.5 [IQR 27,75.5] vs 37.5 [IQR: 20.5-43.3]; p = .02) length of stay. When stratified by the presence of a coinfection, there was no difference in hospital mortality (37% vs. 29%; p = .46) or Kaplan-Meier survival (logrank p = .82). Time from ECMO to first positive blood and respiratory culture were 12 [IQR: 3, 28] and 10 [IQR: 1, 15] days, respectively. Freedom from any coinfection was 50 (95% confidence interval: 37.2-67.2)% at 15 days from ECMO initiation. CONCLUSIONS: There is a high rate of co-infections in patients placed on ECMO for COVID-19 ARDS. Although patients with coinfections had a longer duration of extracorporeal life support, and longer length of stays in the ICU and hospital, survival was not inferior.

Real-world validation of fractional flow reserve computed tomography in patients with stable angina: Results from the prospective AFFECTS trial.

BACKGROUND: Fractional flow reserve computed tomography (FFRct) allows for non-invasive assessment of hemodynamically significant coronary artery disease (CAD). Real-world data regarding the diagnostic performance of FFRct is scarce. We aim to validate the diagnostic performance of FFRct against invasive coronary angiography (ICA) in patients with stable angina and an abnormal single photon emission computed tomography (SPECT) study. METHODS: This prospective, single-cohort, real-world study enrolled consecutive adult patients with stable angina and an abnormal SPECT study who were referred for ICA. Prior to ICA, FFRct analysis was performed. Sensitivity and specificity of FFRct were evaluated at the patient and vessel level against ICA. Physician intuition-based diagnosis of hemodynamically significant CAD was also documented prior to ICA. RESULTS: A total of 66 patients were enrolled; 10 were excluded due to protocol deviation or missing studies. FFRct achieved 95% sensitivity and 83% specificity at the patient level, and 78% sensitivity and 88% specificity at the vessel level. FFRct was most accurate in the left circumflex artery (sensitivity 83%, specificity 92%) and the least in the left anterior descending artery (80% sensitivity, 78% specificity). FFRct identified hemodynamically significant CAD more accurately than physician intuition (sensitivity 95% vs 84%; specificity 83% vs 46%). If physicians had been unblinded to FFRct, ICA may have been avoided in up to 53% of patients. CONCLUSION: We performed a real-world study to validate the diagnostic performance of FFRct against gold-standard invasive imaging. FFRct has high sensitivity and specificity for the diagnosis of hemodynamically significant CAD in intermediate-to-high risk patients.

Health-Related Quality of Life Among Members Using an On Demand Behavioral Health Platform: Pilot Observational Study.

BACKGROUND: Despite the well-known adverse health conditions and negative economic outcomes associated with mental health problems, accessing treatment is difficult due to reasons such as availability and cost. As a solution, digital mental health services have flooded the industry, and new studies are quickly emerging that support their potential as an accessible and cost-effective way to improve mental health outcomes. However, many mental health platforms typically use clinical tools such as the Patient Health Questionnaire-9 (PHQ-9) or General Anxiety Disorder-7 (GAD-7). Yet, many individuals that seek out care do not have clinical symptomatology and thus, traditional clinical measures may not adequately capture symptom improvement in general well-being. As an alternative, this study used the health-related quality of life (HRQoL) tool from the Centers for Disease Control and Prevention "Healthy Days" measure. This subjective measure of well-being is an effective way to capture HRQoL and might be better suited as an outcome measure for treatments that include both clinical and subclinical individuals. OBJECTIVE: The purpose of this study was to describe changes in HRQoL in clinical and subclinical members assessing virtual care and to examine the association between text-based behavioral coaching and virtual clinical sessions with changes in HRQoL. METHODS: A total of 288 members completed the 4-item HRQoL measure at baseline and at 1 month following use of the Ginger on demand behavioral health platform. Baseline anxiety and depression levels were collected using the GAD-7 and PHQ-9, respectively. RESULTS: Members completed on average 1.92 (SD 2.16) coaching sessions and 0.91 (SD 1.37) clinical sessions during the assessment month. Paired samples t tests revealed significant reductions in the average number of unhealthy mental health days between baseline (mean 16, SD 8.77 days) and follow-up (mean 13.2, SD 9.02 days; t287=5.73; P<.001), and in the average number of days adversely impacted (meanbaseline 10.9, meanfollow-up 8.19; t287=6.26; P<.001). Both subclinical members (t103=3.04; P=.003) and clinical members (t183=5.5; P<.001) demonstrated significant improvements through reductions in adversely impacted days over a month. Clinical members also demonstrated significant improvements through reductions in unhealthy mental health days (t183=5.82; P<.001). Finally, member engagement with virtual clinical sessions significantly predicted changes in unhealthy mental health days (B=-0.96; P=.04). CONCLUSIONS: To our knowledge, this study is one of the first to use the HRQoL measure as an outcome in an evaluation of a digital behavioral health platform. Using real-world longitudinal data, our preliminary yet promising results show that short-term engagement with virtual care can be an effective means to improve HRQoL for members with subclinical and clinical symptoms. Further follow-up of reported HRQoL over several months is needed.

Association Between Care Modality and Use With Treatment Response Among Members Accessing Virtual Mental Health Services: Real-world Observational Study.

BACKGROUND: There is a growing bottleneck in mental health care, as the demand for services has outpaced the availability of mental health professionals. Consequently, many health systems have shifted to teletherapy as a scalable approach to increasing accessibility to care. Within these care models, various treatment modalities (eg, coaching and clinical care) are used to deliver support for anxiety and depression. However, more research is needed to better understand the differences in treatment responses. OBJECTIVE: The purpose of this study was to examine the association between different care modalities and the levels of use with symptom score changes for members seeking virtual care services. METHODS: We conducted an observational study of 4219 members who accessed Ginger, an on-demand mental health service, between September 2020 and September 2021. Using a mobile app, members can access text-based behavioral health coaching and virtual clinical services. This study focused on members with clinically elevated depression or anxiety levels at baseline. Logistic regressions were used to assess the association between care modalities and the levels of use with treatment response in depression and anxiety, using the Patient Health Questionnaire and Generalized Anxiety Disorder Assessment, respectively. RESULTS: Of the 4219 members, 1623 (38.47%) demonstrated a full response to depression, and 1684 (39.91%) demonstrated a full response to anxiety. Members who completed care (ie, text-based coaching, virtual clinical therapy, hybrid of coaching, and clinical care) beyond the introductory session showed significantly increased odds of a full response compared with those who completed only limited care. Members who completed a hybrid of care had the highest odds of improvement; the odds of showing a full response in depression were 2.31 times higher (95% CI 1.91-2.80; P<.001) and in anxiety were 2.23 times higher (95% CI 1.84-2.70; P<.001) compared with members who completed limited care. For members who completed only coaching or clinical care, the largest effects were observed among those with high use. For members who completed a hybrid care program, we observed similar treatment responses across all levels of use. CONCLUSIONS: Our real-world study found that members who completed text-based coaching achieved full treatment responses at similar rates compared with members who completed virtual clinical care and members who completed a hybrid of care. There were no significant differences in the predicted probabilities of full treatment response between coaching and clinical care. Generally, the odds for a full response were highest among members with high use within each care modality; however, there were no differences in full-response treatment odds across levels of use with hybrid care. The results support the utility of digital behavioral health interventions and further highlight text-based coaching protocols as an accessible and suitable option when considering virtual care for treating anxiety and depression.

Changes in Resilience Following Engagement With a Virtual Mental Health System: Real-world Observational Study.

BACKGROUND: Digital health services can serve as scalable solutions to address the growing demand for mental health care. However, more research is needed to better understand the association between engagement with care and improvements in subclinical outcomes. OBJECTIVE: This study aims to fill this research gap by examining the relationship between members' engagement with the Ginger platform and changes in their psychological resilience. METHODS: We conducted a retrospective observational study of 3272 members who accessed Ginger, an on-demand mental health service, between January 2021 and November 2021. Each member completed the 10-item Connor-Davidson Resilience Scale questionnaire, a measure of psychological resilience, at baseline and again during a 6- to 16-week follow-up window. Depression and anxiety symptoms (9-item Patient Health Questionnaire and 7-item Generalized Anxiety Disorder) were also measured. Linear regression was used to identify the association between engagement with Ginger's multiple care modalities and changes in resilience. Moderator analysis was conducted to test whether clinical depression or anxiety at baseline moderated the relationship between engagement level and changes in resilience. RESULTS: Of the 3272 members, 2683 (82%) reported low resilience at baseline. The mean change in resilience was 0.77 (SD 5.50) points. Linear regression models showed that age and census region did not predict changes in resilience; however, male members showed larger improvements (coefficient=0.58; P=.04). Baseline mental health outcomes, including resilience and depression and anxiety symptoms, were strong predictors of changes in resilience. Every point decrease in baseline resilience is associated with a 0.28-point increase in change in resilience (P<.001), and members with no or mild depression and anxiety at baseline saw changes in resilience that were 1.44 points (P<.001) larger than their clinical counterparts. Engagement with the Ginger system predicted changes in resilience. Members who engaged with Ginger coaching, clinical services, or both improved their resilience by 1.82, 1.55, and 1.40 points, respectively (P<.001), more than those who only engaged with Ginger content. Screening negative for moderate to severe depression and anxiety at baseline was associated with larger improvements in resilience (coefficient=1.30; P<.001); however, subclinical status was not shown to be a moderator for the association between level of engagement and changes in resilience. CONCLUSIONS: Engagement with Ginger services was associated with improvements in resilience. Members who engaged in coaching or clinical care had significantly larger improvements compared with those who only engaged in self-guided content, regardless of whether a member screened positive for clinical depression or anxiety at baseline.

Intergenerational Transmission of Effects of Women's Stressors During Pregnancy: Child Psychopathology and the Protective Role of Parenting.

Objective: Experiences of stress and adversity, such as intimate partner violence, confer risk for psychiatric problems across the life span. The effects of these risks are disproportionately borne by women and their offspring-particularly those from communities of color. The prenatal period is an especially vulnerable period of fetal development, during which time women's experiences of stress can have long-lasting implications for offspring mental health. Importantly, there is a lack of focus on women's capacity for resilience and potential postnatal protective factors that might mitigate these intergenerational risks and inform intervention efforts. The present study examined intergenerational associations between women's prenatal stressors and child executive functioning and externalizing problems, testing maternal parenting quality and child sex as moderators, using a large, prospective, sociodemographically diverse cohort. Methods: We used data from 1,034 mother-child dyads (64% Black, 30% White) from the Conditions Affecting Neurocognitive Development and Learning in Early Childhood (CANDLE) pregnancy cohort within the ECHO PATHWAYS consortium. Women's prenatal stressors included stressful life events (pSLE) and intimate partner violence (pIPV). Measures of child psychopathology at age 4-6 included executive functioning and externalizing problems. Parenting behaviors were assessed by trained observers, averaged across two sessions of mother-child interactions. Linear regression models were used to estimate associations between women's prenatal stressors and child psychopathology, adjusting for confounders and assessing moderation effects by maternal parenting quality and child sex. Results: Women's exposures to pSLE and pIPV were independently associated with child executive functioning problems and externalizing problems in fully-adjusted models. Maternal parenting quality moderated associations between pSLE and both outcomes, such that higher parenting quality was protective for the associations between women's pSLE and child executive functioning and externalizing problems. No moderation by child sex was found. Discussion: Findings from this large, sociodemographically diverse cohort suggest women's exposures to interpersonal violence and major stressful events-common for women during pregnancy-may prenatally program her child's executive functioning and externalizing problems. Women's capacity to provide high quality parenting can buffer this intergenerational risk. Implications for universal and targeted prevention and early intervention efforts to support women's and children's wellbeing are discussed.

Outcomes of aortic root enlargement during isolated aortic valve replacement.

OBJECTIVES: Aortic root enlargement (ARE) lowers the risk of patient prosthesis mismatch after surgical aortic valve replacement (SAVR) in patients with small annular size. Whether ARE is associated with increased operative mortality is controversial. This study compares the early and intermediate outcomes in patients undergoing SAVR with and without ARE. METHODS: All patients undergoing isolated SAVR with and without ARE from 2015 to 2020 were analyzed. Propensity-matching was used to adjust for possible confounding variables. Kaplan-Meier analysis and log-rank test were used to estimate and compare overall outcomes and survival in the study cohorts. RESULTS: Among 868 isolated SAVRs, ARE was performed in 54 (6.2%) patients. Before matching, mean age was similar but female sex (67.4% vs. 29.6%; SD: -0.82) and previous AVR (18.9% vs. 3.9%; SD: -0.48) were more common in patients undergoing SAVR + ARE versus SAVR alone. A bovine pericardial patch was used for 81.5% (44 of 54) of ARE, with a Dacron patch in the rest. After propensity matching, the average cardiopulmonary bypass (138.2 ± 34.9 vs. 102.9 ± 33.0 min; p < 0.01) and cross-clamp times (113.8 ± 26.7 vs. 83.0 ± 28.4 min; p < 0.01) were longer in the SAVR + ARE group. There were no significant differences in postoperative stroke, new-onset dialysis, pacemaker placement, reoperation for bleeding, length of hospital stay, or 30-day readmission. Thirty-day mortality (0% vs. 0.6%, p = 1.0) and 5-year survival (96.3% vs. 95.7%, p = 0.86) were also similar. CONCLUSIONS: ARE during surgical AVR can be safely performed without an increase in complications with excellent early and intermediate-term survival.