2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.

BACKGROUND: The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS: The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS: Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS: The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

World's first en bloc heart-lung transplantation using the paragonix lungguard donor preservation system.

We present the first en bloc heart-lung donor transplant procurement using the Paragonix LUNGguard™ donor preservation system. This system offers reliable static hypothermic conditions designed to prevent major complications such as cold ischemic injury, uneven cooling and physical damage. While this represents a single case, the encouraging results warrant further investigation.

Relation of Length of Survival After Orthotopic Heart Transplantation to Age of the Donor.

We aim to evaluate the impact of donor age on the outcomes in orthotropic heart transplantation recipients. The United Network for Organ Sharing database was queried for adult patients (age; ≥60) underwent first-time orthotropic heart transplantation between 1987 and 2019 (n = 18,447). We stratified the cohort by donor age; 1,702 patients (9.2%) received a heart from a donor age of <17 years; 11,307 patients (61.3%) from a donor age of 17 ≥, < 40; 3,525 patients (19.1%) from a donor age of 40 ≥, < 50); and 1,913 patients (10.4%) from a donor age of ≥50. There was a significant difference in the survival likelihood (p < 0.0001) based on donor's age-based categorized cohort, however, the median survival was 10.5 years in the cohort in whom the donor was <17, 10.3 years in whom the donor was 17 ≥, < 40, 9.4 years in whom the donor was 40 ≥, < 50, and 9.0 years in whom the donor was ≥ 50. Additionally, there was no significant difference in the episode of acute rejection (p = 0.19) nor primary graft failure (p = 0.24). In conclusion, this study demonstrated that patients receiving hearts from the donor age of ≥50 years old showed slight inferior survival likelihood, but appeared to be equivalent median survival.

Impact of Surgical Approach in Double Lung Transplantation: Median Sternotomy vs Clamshell Thoracotomy.

BACKGROUND: Double lung transplantation (DLT) remains the gold standard for end-stage lung disease. Although DLT was historically performed via clamshell thoracotomy, recently the median sternotomy has emerged as a viable alternative. As the ideal surgical approach remains unclear, the aim of our study was to compare the short- and long-term outcomes of these 2 surgical approaches in DLT. METHODS: We retrospectively reviewed 192 consecutive adult patients who underwent primary DLT at our institution between 2012 and 2017 (sternotomy, n = 147; clamshell, n = 45). The impact of each surgical approach on post-transplant morbidity was investigated, and the overall survival probability analyses were performed. RESULTS: There were no significant differences in recipients' baseline and donors' characteristics and bilateral allograft ischemic time. Freedom from primary graft dysfunction, acute rejection episodes, postoperative prolonged ventilator support, tracheostomy, postoperative stroke, and airway dehiscence were comparable between these 2 groups. The duration of cardiopulmonary bypass and operative time were significantly longer in the clamshell thoracotomy group. Postoperative extracorporeal membrane oxygenation usage tended to be more frequent in the clamshell thoracotomy group than the median sternotomy group, despite no statistical significance. Length of hospital and intensive care unit stay were not influenced by the type of incision. There was no significant difference in overall survival between these 2 procedure groups (P = .61, log-rank test). CONCLUSIONS: The median sternotomy approach in DLT decreases operative time and more importantly leads to a shorter duration of cardiopulmonary bypass. The type of surgical approach did not show any statistically significant impact on adult DLT recipients' morbidity and survival.

The role of visual and direct force feedback in robotics-assisted mitral valve annuloplasty.

BACKGROUND: The objective of this work was to determine the effect of both direct force feedback and visual force feedback on the amount of force applied to mitral valve tissue during ex vivo robotics-assisted mitral valve annuloplasty. METHODS: A force feedback-enabled master-slave surgical system was developed to provide both visual and direct force feedback during robotics-assisted cardiac surgery. This system measured the amount of force applied by novice and expert surgeons to cardiac tissue during ex vivo mitral valve annuloplasty repair. RESULTS: The addition of visual (2.16 ± 1.67), direct (1.62 ± 0.86), or both visual and direct force feedback (2.15 ± 1.08) resulted in lower mean maximum force applied to mitral valve tissue while suturing compared with no force feedback (3.34 ± 1.93 N; P < 0.05). CONCLUSIONS: To achieve better control of interaction forces on cardiac tissue during robotics-assisted mitral valve annuloplasty suturing, force feedback may be required.

Augmented Reality System for Ultrasound Guidance of Transcatheter Aortic Valve Implantation.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) relies on fluoroscopy and nephrotoxic contrast medium for valve deployment. We propose an alternative guidance system using augmented reality (AR) and transesophageal echocardiography (TEE) to guide TAVI deployment. The goals of this study were to determine how consistently the aortic valve annulus is defined from TEE using different aortic valve landmarks and to compare AR guidance with fluoroscopic guidance of TAVI deployment in an aortic root model. METHODS: Magnetic tracking sensors were integrated into the TAVI catheter and TEE probe, allowing these tools to be displayed in an AR environment. Variability in identifying aortic valve commissures and cuspal nadirs was assessed using TEE aortic root images. To compare AR guidance of TAVI deployment with fluoroscopic guidance, a TAVI stent was deployed 10 times in the aortic root model using each of the two guidance systems. RESULTS: Commissures and nadirs were both investigated as features for defining the valve annulus in the AR guidance system. The commissures were identified more consistently than the nadirs, with intraobserver variability of 2.2 and 3.8 mm, respectively, and interobserver variability of 3.3 and 4.7 mm, respectively. The precision of TAVI deployment using fluoroscopic guidance was 3.4 mm, whereas the precision of AR guidance was 2.9 mm, and its overall accuracy was 3.4 mm. This indicates that both have similar performance. CONCLUSIONS: Aortic valve commissures can be identified more reliably than cuspal nadirs from TEE. The AR guidance system achieved similar deployment accuracy to that of fluoroscopy while eliminating the use and consequences of nephrotoxic contrast and radiation.

Phantom study of an ultrasound guidance system for transcatheter aortic valve implantation.

A guidance system using transesophageal echocardiography and magnetic tracking is presented which avoids the use of nephrotoxic contrast agents and ionizing radiation required for traditional fluoroscopically guided procedures. The aortic valve is identified in tracked biplane transesophageal echocardiography and used to guide stent deployment in a mixed reality environment. Additionally, a transapical delivery tool with intracardiac echocardiography capable of monitoring stent deployment was created. This system resulted in a deployment depth error of 3.4mm in a phantom. This was further improved to 2.3mm with the custom-made delivery tool. In comparison, the variability in deployment depth for traditional fluoroscopic guidance was estimated at 3.4mm.

Dual antiplatelet therapy use by Canadian cardiac surgeons.

BACKGROUND: Dual antiplatelet therapy is the cornerstone treatment for patients with acute coronary syndrome. Recent Canadian Guidelines recommend the use of dual antiplatelet therapy for 1 year after coronary artery bypass grafting in patients with acute coronary syndrome, but considerable variability remains. METHODS: We performed a survey of 75 Canadian cardiac surgeons to assess the use of dual antiplatelet therapy. RESULTS: Whereas 58.6% of respondents indicated that the benefits of dual antiplatelet therapy were seen irrespective of how patients were managed after acute coronary syndrome, 36.2% believed that the benefits of dual antiplatelet therapy were limited to those treated medically or percutaneously. In regard to the timing of dual antiplatelet therapy administration, 57% of respondents indicated that dual antiplatelet therapy should be given upstream in the emergency department, whereas 36.2% responded that dual antiplatelet therapy should be given only once the coronary anatomy has been defined. The majority surveyed (81%) weighed bleeding risk as being more important than ischemic risk reduction. In stable patients after acute coronary syndrome, the majority of surgeons would wait approximately 4 days after the last dose of P2Y12 antagonist before coronary artery bypass grafting. Only 44.6% indicated that they routinely use dual antiplatelet therapy postrevascularization in the setting of acute coronary syndrome. Rather, most surgeons use dual antiplatelet therapy for select patients, such as those with a stented vessel without a bypass graft, endarterectomy, or off-pump coronary artery bypass grafting. CONCLUSIONS: Cardiac surgeons exhibit variation in their attitudes and practice patterns toward dual antiplatelet therapy after coronary artery bypass grafting, and in approximately half of cases, their practice does not adhere to current guideline recommendations. New trials focusing on coronary artery bypass grafting cases in their primary analysis and educational initiatives for surgeons that focus on guideline recommendations may be warranted.

Recalcitrant prosthetic valve endocarditis requiring repeated reconstruction: running out of options.

In this report we describe a previously healthy 36-year-old man who presented with septic shock secondary to bacterial endocarditis with multiple cerebral, mesenteric, and peripheral embolic phenomena. He underwent emergent porcine prosthetic valve replacement with aortic annular reconstruction. Subsequently, he developed recalcitrant Candida parapsilosis endocarditis requiring treatment with multiple antifungal agents and 4 repeated complex reconstructions of the aortic root and fibrous trigones over 3 years, before the infection was successfully controlled. This case underscores the significant morbidity associated with fungal endocarditis and importance of an early combined medical and surgical approach.

Myocardium at risk is associated with adverse clinical events in women but not in men, after coronary artery bypass grafting.

BACKGROUND: Women undergoing coronary artery bypass grafting (CABG) are at increased risk for morbidity and mortality. Factors responsible for this observation include smaller coronary size and delayed presentation. To date, no studies have examined the effect of the degree of myocardium at risk (MAR) on the relationship between female sex and adverse postoperative events. METHODS: Consecutive patients undergoing first-time isolated CABG at a single institution from 2002-2007 were identified. MAR was calculated using the weighted Duke Index and was categorized as low, moderate, or high. Multivariable logistic regression models were created to compare the impact of MAR on adverse clinical events. RESULTS: We identified 3741 patients, 3325 (89%) of whom had complete angiographic data. Women (n = 755) were older (P = 0.0001) and presented more often with hypertension (P = 0.0001), diabetes (P = 0.0001), heart failure (P = 0.0001), and an urgent/emergent situation (P = 0.002). After surgery, women experienced greater rates of adverse events (15.2% vs 9.3%; P = 0.0001). In a fully adjusted logistic regression model, the nested interaction of sex in MAR showed that women had a significantly greater risk of major adverse cardiovascular events (MACE) when MAR was high (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3-2.6; P = 0.0004). Greater severity of MAR emerged as an independent predictor of adverse events among women (high: OR, 2.9; 95% CI, 1.2-7.3; moderate: OR, 2.2; 95% CI, 0.8-5.7; low: OR, 1.0), but not among men. CONCLUSIONS: MAR was independently associated with higher rates of adverse events among women but not in men undergoing CABG. This finding may help explain differences in outcomes seen between women and men after revascularization.

Evaluating the effect of three-dimensional visualization on force application and performance time during robotics-assisted mitral valve repair.

OBJECTIVE: The purpose of this study was to determine the effect of three-dimensional (3D) binocular, stereoscopic, and two-dimensional (2D) monocular visualization on robotics-assisted mitral valve annuloplasty versus conventional techniques in an ex vivo animal model. In addition, we sought to determine whether these effects were consistent between novices and experts in robotics-assisted cardiac surgery. METHODS: A cardiac surgery test-bed was constructed to measure forces applied during mitral valve annuloplasty. Sutures were passed through the porcine mitral valve annulus by the participants with different levels of experience in robotics-assisted surgery and tied in place using both robotics-assisted and conventional surgery techniques. RESULTS: The mean time for both the experts and the novices using 3D visualization was significantly less than that required using 2D vision (P < 0.001). However, there was no significant difference in the maximum force applied by the novices to the mitral valve during suturing (P = 0.7) and suture tying (P = 0.6) using either 2D or 3D visualization. The mean time required and forces applied by both the experts and the novices were significantly less using the conventional surgical technique than when using the robotic system with either 2D or 3D vision (P < 0.001). CONCLUSIONS: Despite high-quality binocular images, both the experts and the novices applied significantly more force to the cardiac tissue during 3D robotics-assisted mitral valve annuloplasty than during conventional open mitral valve annuloplasty. This finding suggests that 3D visualization does not fully compensate for the absence of haptic feedback in robotics-assisted cardiac surgery.

Knowledge, attitudes, and practice patterns in surgical management of bicuspid aortopathy: a survey of 100 cardiac surgeons.

OBJECTIVE: Clinical practice guidelines have been established for surgical management of the aorta in bicuspid aortic valve disease. We hypothesized that surgeons' knowledge of and attitudes toward bicuspid aortic valve aortopathy influence their surgical approaches. METHODS: We surveyed cardiac surgeons to probe the knowledge of, attitudes toward, and surgical management of bicuspid aortopathy. A total of 100 Canadian adult cardiac surgeons participated. RESULTS: Fifty-two percent of surgeons believed that the mechanism underlying aortic dilation in those with bicuspid aortic valve was due to an inherent genetic abnormality of the aorta, whereas only 2% believed that altered valve-related processes were involved in this process. Only a minority (15%) believed that bicuspid valve leaflet fusion type is associated with a unique pattern of aortic dilatation aortic phenotype. Sixty-five percent of surgeons recommended echocardiographic screening of first-degree relatives of patients with bicuspid aortic valve. Most surgeons (61%) elected to replace the aorta when the diameter is 45 mm or greater at the time of valve surgery. Fifty-five percent of surgeons surveyed suggested that in the absence of concomitant valvular disease, they would recommend ascending aortic replacement at a threshold of 50 mm or greater. Approximately one third of surgeons suggested that they would elect to replace a mildly dilated ascending aorta (40 mm) at the time of valve surgery. The most common surgical approach (61%) for combined valve and aortic surgery was aortic valve replacement and supracoronary replacement of the ascending aorta, and only a minority suggested the use of deep hypothermic circulatory arrest and open distal anastomosis. More aggressive approaches were favored with greater surgeon experience, and when circulatory arrest was chosen, the majority (68%) suggested they would use antegrade cerebral perfusion. In the setting of aortic insufficiency and a dilated aorta, 42% of surgeons suggested that they would perform valve-sparing surgery. Of note, 40% of respondents used an index measure of aortic size to body surface area in addition to absolute aortic diameter in assessing the threshold for intervention. CONCLUSIONS: This large survey uncovered significant gaps in the knowledge and attitudes of surgeons toward the diagnosis and management of bicuspid aortopathy, many of which were at odds with current guideline recommendations. Efforts to promote knowledge translation in this area are strongly encouraged.

Augmented reality image guidance improves navigation for beating heart mitral valve repair.

OBJECTIVE: Emerging off-pump beating heart valve repair techniques offer patients less invasive alternatives for mitral valve (MV) repair. However, most of these techniques rely on the limited spatial and temporal resolution of transesophageal echocardiography (TEE) alone, which can make tool visualization and guidance challenging. METHODS: Using a magnetic tracking system and integrated sensors, we created an augmented reality (AR) environment displaying virtual representations of important intracardiac landmarks registered to biplane TEE imaging. In a porcine model, we evaluated the AR guidance system versus TEE alone using the transapically delivered NeoChord DS1000 system to perform MV repair with chordal reconstruction. RESULTS: Successful tool navigation from left ventricular apex to MV leaflet was achieved in 12 of 12 and 9 of 12 (P = 0.2) attempts with AR imaging and TEE alone, respectively. The distance errors of the tracked tool tip from the intended midline trajectory (5.2 ± 2.4 mm vs 16.8 ± 10.9 mm, P = 0.003), navigation times (16.7 ± 8.0 seconds vs 92.0 ± 84.5 seconds, P = 0.004), and total path lengths (225.2 ± 120.3 mm vs 1128.9 ± 931.1 mm, P = 0.003) were significantly shorter in the AR-guided trials compared with navigation with TEE alone. Furthermore, the potential for injury to other intracardiac structures was nearly 40-fold lower when using the AR imaging for tool navigation. The AR guidance also seemed to shorten the learning curve for novice surgeons. CONCLUSIONS: Augmented reality-enhanced TEE facilitates more direct and safe intracardiac navigation of the NeoChord DS tool from left ventricular apex to MV leaflet. Tracked tool path results demonstrate fourfold improved accuracy, fivefold shorter navigation times, and overall improved safety with AR imaging guidance.

Can internal thoracic arteries be used for both coronary artery bypass and breast reconstruction?

OBJECTIVES: Recently, the internal thoracic arteries have been preferentially used in autologous breast reconstruction at the levels of the third or fourth intercostal spaces. This may compromise future treatment of occult coronary disease. We hypothesized that internal thoracic artery length at the fourth intercostal space would allow both breast reconstruction and future coronary artery bypass grafting (CABG). METHODS: Anatomic analysis of 20 female patients undergoing CABG was performed examining internal thoracic artery length from its origin to the third, fourth, fifth intercostal spaces and the left anterior descending (LAD) artery target. RESULTS: The left internal thoracic artery was anastamosed to the LAD target at a mean length of 11.4 ± 1.4 cm. The mean lengths of the pedicled left internal thoracic artery from its origin to the third, fourth and fifth intercostal space were 8.5 ± 1.0, 10.9 ± 1.2 and 13.0 ± 1.4 cm, respectively. Therefore, the left internal thoracic artery length was adequate at the fourth intercostal space in 6 of 20 (30%) patients. CONCLUSIONS: Dissection of the left internal thoracic artery to the fourth intercostal space would allow for concomitant use in CABG and breast reconstruction in one-third of cases. However, skeletonization of the internal thoracic artery at the level of the fourth intercostal space would be sufficient for CABG in all cases following autologous breast reconstruction.

Long-term angiographic follow-up of robotic-assisted coronary artery revascularization.

BACKGROUND: Robotic-assisted coronary artery bypass grafting (CABG) has been shown in short-term studies to increase patient satisfaction and to reduce surgical morbidity and recovery times. However, the long-term patency rate of robotic-assisted CABG is unknown. Therefore, the objective of this study was to assess the long-term patency rate of robotic-assisted coronary artery bypass grafts. METHODS: The study cohort included all patients who underwent robotic-assisted conduit dissection for CABG at London Health Sciences Centre between September 1999 and December 2003. These patients had selective graft patency assessment using cardiac catheterization or computed tomography angiography (CTA), or both, and stress myocardial perfusion scintigraphy (MPS) 5 to 10 years after surgery to evaluate graft patency and to give functional information on the hemodynamic significance of any graft stenosis. Patients also completed quality of life questionnaires. RESULTS: From a total of 160 patients who underwent robotic-assisted CABG, 82 eligible patients were followed with graft patency assessments for a mean period of 8 years±16.3 months. The patency rate of all robotic-assisted CABG grafts in this patient cohort was 92.7%. The patency rate of left internal thoracic artery grafts to the left anterior descending artery after robotic-assisted CABG in this patient cohort was 93.4%. Patients consistently attained high scores on quality of life questionnaires after surgery. CONCLUSIONS: The long-term patency rate of grafts after robotic-assisted CABG was 92.7% at a mean follow-up period of 95.8±16.3 months. Specifically, the patency rate of left internal thoracic artery grafts to the left anterior descending artery after robotic-assisted CABG was 93.4%.