Factor Eight Inhibitor Bypassing Activity as First-line Therapy for Coagulopathy in Cardiac Surgery.

OBJECTIVES: To compare the outcomes of factor eight inhibitor bypassing activity (FEIBA) versus fresh frozen plasma (FFP) as the primary treatment for postoperative coagulopathy in patients undergoing cardiac surgery. DESIGN: A retrospective, propensity-matched study. SETTING: A single, tertiary hospital. PARTICIPANTS: Patients who underwent noncoronary cardiac surgery with cardiopulmonary bypass between 2015 and 2023. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We stratified patients into 2 groups based on whether they received intraoperative FFP or FEIBA; cases using both were excluded. We analyzed 434 cases, with 197 receiving FFP and 237 receiving FEIBA. After propensity matching, there was no significant difference in the proportion of the patients who required packed red blood cell transfusions (p = 0.08). However, of those who required packed red blood cell transfusions, patients in the FEIBA group required significantly fewer units of packed red blood cells (p < 0.001). Significantly fewer patients in the FEIBA group required platelet (p < 0.001) and cryoprecipitate (p < 0.001) transfusions. The FEIBA group showed decreased prolonged postoperative intubation (p = 0.05), decreased intensive care unit length of stay (p = 0.04), and lower 30-day readmission rates (p = 0.03). There were no differences in the rates of thrombotic complications between the 2 cohorts. CONCLUSIONS: In the initial treatment of postcardiopulmonary bypass coagulopathy, FEIBA may be more effective than FFP in decreasing blood product transfusions and readmission rates. Further studies are needed to explore the potential routine use of FEIBA as first-line agent in this patient population.

Predictors of Postoperative Morphine Milligram Equivalents in Cardiac Surgery.

OBJECTIVES: Given both the short- and long-term deleterious effects of opioids, there has been an increased focused on reducing the use of postoperative opioid analgesia. As patients undergoing cardiac surgery often require high levels opioids postoperatively, understanding risk factors for increased postoperative opioid use may be helpful for the development of patient-specific opioid-sparing pain regimens for this patient population. DESIGN: A retrospective analysis of data from our electronic medical records and the Society of Thoracic Surgeon's database. SETTING: A single-institution study at an academic medical center. PARTICIPANTS: All patients undergoing open adult cardiac surgery were included. Exclusion criteria were patients with continuous intravenous narcotic drips and operative mortality. INTERVENTIONS: As this was a retrospective study, no interventions were conducted on the participants. MEASUREMENTS AND MAIN RESULTS: Data for patient postoperative opioid requirements were extracted from the electronic medical record. Total opioid use on postoperative days 0 to 3 was converted to morphine milligram equivalent (MME) via standard conversion factors. The study cohort comprised 1604 patients, including 456 females and 1066 coronary artery bypass grafting (CABG) recipients. MME was 31.0% greater in patients undergoing CABG (p < 0.001), 76.3% greater in patients with liver disease (p = 0.005), and 48.8% greater in patients with patient-controlled analgesia (p <0.001) during postoperative days 0 to 3. Younger age (p < 0.001) and higher body mass index (BMI) (p < 0.001) also were associated with increased MME prescription. CONCLUSIONS: CABG, liver disease, patient-controlled analgesia, younger age, and higher BMI are associated with increased narcotic use after cardiac surgery. Implementation of more aggressive perioperative multimodal opioid-sparing regimens should be considered for these patient groups.

Use of Bioimpedance Spectroscopy for Postoperative Fluid Management in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass.

OBJECTIVE: To assess whether bioimpedance spectroscopy analysis (BIA) can be used as a tool to guide postoperative fluid management in patients undergoing cardiac surgery. DESIGN: An observational study. SETTING: A single tertiary hospital. PARTICIPANTS: Patients who underwent cardiac surgery with cardiopulmonary bypass between June and November 2023 who were able to undergo BIA measurements. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Correlations between BIA measurements of extracellular fluid (ECF) and total body water (TBW) volumes and daily changes in weight and 24-hour net intake and output (I/O) of fluids were assessed. Correlations between predischarge ECF volume as a percentage of TBW volume (ECF%TBW) and predischarge pro-B-type natriuretic peptide (Pro-BNP) levels and readmissions were analyzed. Changes in daily ECF volume significantly correlated with daily weight changes (p < 0.01) and 24-hour I/O (p < 0 .01). TBW volume significantly correlated with daily weight changes (p < 0.01) and with 24-hour I/O (p = 0.04). Daily weight changes did not correlate with 24-hour I/O (p = 0.06). The patients with predischarge ECF%TBW(%) greater than or equal to 51 had significantly higher predischarge Pro-BNP than those with ECF%TBW(%) less than 51 (p < 0.01). Patients who had heart failure revisits or admissions after discharge had a higher predischarge ECF%TBW(%) on index admission compared with patients who did not have heart failure readmissions (p = 0.01). CONCLUSIONS: BIA measurements in postoperative cardiac surgery patients may be a valuable tool to quantitatively determine fluid status to help guide fluid management in this patient population. Further studies validating the use of BIA for postoperative care in this population are warranted.

Impact of Limited Enhanced Recovery Pathway for Cardiac Surgery: A Single-Institution Experience.

OBJECTIVES: Enhanced recovery pathway (ERP) refers to extensive multidisciplinary, evidence-based pathways used to facilitate recovery after surgery. The authors assessed the impact that limited ERP protocols had on outcomes in patients undergoing cardiac surgery at their institution. DESIGN: A retrospective cohort study. SETTING: This study was a single-institution study conducted at a university hospital. PARTICIPANTS: Patients undergoing open adult cardiac surgery. INTERVENTIONS: Enhanced recovery pathways limited to preoperative, intraoperative, and postoperative management of pain, atrial fibrillation prevention, and nutrition optimization were implemented. MEASUREMENTS AND MAIN RESULTS: A total of 1,058 patients were included in this study. There were 374 patients in each pre- and post-ERP cohort after propensity matching, with no significant baseline differences between the 2 cohorts. Compared to the matched patients in the pre-ERP group, patients in the post-ERP group had decreased total ventilation hours (6.8 v 7.8, p = 0.006), less use of postoperative opioid analgesics as determined by total morphine milligram equivalent (32.5 v 47.5, p < 0.001), and a decreased rate of postoperative atrial fibrillation (23.3% v 30.5%, p = 0.032). Post-ERP patients also experienced less subjective pain and postoperative nausea and drowsiness as compared to their matched pre-ERP cohorts. CONCLUSIONS: Limited ERP implementation resulted in significantly improved perioperative outcomes. Patients additionally experienced less postoperative pain despite decreased opioid use. Implementation of ERP, even in a limited format, is a promising approach to improving outcomes in patients undergoing cardiac surgery.

Simultaneous Heart-Kidney Transplant-Does Hospital Experience With Heart Transplant or Kidney Transplant Have a Greater Impact on Patient Outcomes?

High institutional transplant volume is associated with improved outcomes in isolated heart and kidney transplant. The aim of this study was to assess trends and outcomes of simultaneous heart-kidney transplant (SHKT) nationally, as well as the impact of institutional heart and kidney transplant volume on survival. All adult patients who underwent SHKT between 2005-2019 were identified using the United Network for Organ Sharing (UNOS) database. Annual institutional volumes in single organ transplant were determined. Univariate and multivariable analyses were conducted to assess the impact of demographics, comorbidities, and institutional transplant volumes on 1-year survival. 1564 SHKT were identified, increasing from 54 in 2005 to 221 in 2019. In centers performing SHKT, median annual heart transplant volume was 35.0 (IQR 24.0-56.0) and median annual kidney transplant volume was 166.0 (IQR 89.5-224.0). One-year survival was 88.4%. In multivariable analysis, increasing heart transplant volume, but not kidney transplant volume, was associated with improved 1-year survival. Increasing donor age, dialysis requirement, ischemic times, and bilirubin were also independently associated with reduced 1-year survival. Based on this data, high-volume heart transplant centers may be better equipped with managing SHKT patients than high-volume kidney transplant centers.

Factor eight inhibiting bypass activity for refractory bleeding in acute type A aortic dissection repair: A propensity-matched analysis.

BACKGROUND: Perioperative bleeding and transfusion have been associated with adverse outcomes after cardiac surgery. The use of factor eight inhibiting bypass activity (FEIBA) in managing bleeding after repair of acute Stanford type A aortic dissection (ATAAD) has not previously been evaluated. We report our experience in utilizing FEIBA in ATAAD repair. STUDY DESIGN AND METHODS: A retrospective review was undertaken of all consecutive patients who underwent repair of ATAAD between July 2014 and December 2019. Patients were divided into two groups, dependent upon whether or not they received FEIBA intraoperatively: "FEIBA" (n = 112) versus "no FEIBA" (n = 119). From this, 53 propensity-matched pairs of patients were analyzed with respect to transfusion requirements and short-term clinical outcomes. RESULTS: Thirty-day mortality for the entire cohort was 11.7% (27 deaths), not significantly different between patient groups. Those patients who received FEIBA demonstrated reduced transfusion requirements for all types of blood products in the first 48 h after surgery as compared with the "no FEIBA" cases, including red blood cells, platelets, plasma, and cryoprecipitate (p < .0001). There was no significant difference in major postoperative morbidity between the two groups. The FEIBA cohort did not demonstrate an increased incidence of thrombotic complications (stroke, deep venous thrombosis, pulmonary thromboembolism). DISCUSSION: When used as rescue therapy for refractory bleeding following repair of ATAAD, FEIBA appears to be effective in decreasing postoperative transfusion requirements whilst not negatively impacting clinical outcomes. These findings should prompt further investigation and validation via larger, multi-center, randomized trials.

Use of TIMP-2 and IGFBP-7 for prediction of postoperative acute kidney injury after cardiac surgery.

BACKGROUND: The following cell cycle arrest urinary biomarkers, tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP-7), have been used for early detection of acute kidney injury (AKI) in critically ill patients. The purpose of this study is to validate the use of these urinary biomarkers in patients undergoing open heart surgery. MATERIALS AND METHODS: In a single-center prospective observational study, urine samples were collected in 108 consecutive patients who underwent open heart surgery immediately after separation from cardiopulmonary bypass and on postoperative day 1, and were sent for the biomarker [TIMP-2]*[IGFBP7] analysis. Acute kidney injury was defined based on KDIGO criteria, and levels of [TIMP-2]*[IGFBP7] were analyzed for the ability to predict AKI. RESULTS: Of the 108 patients, 19 (17.6%) patients developed postoperative AKI within 48 hours of surgery. At the threshold of > 0.3 (ng/mL)2/1,000, post-cardiopulmonary bypass [TIMP-2]*[IGFBP-7] had a sensitivity of 13% and specificity of 82% for predicting postoperative AKI. Postoperative day-1 [TIMP-2]*[IGFBP-7] had a sensitivity of 47% and a specificity of 59% for predicting postoperative AKI. There were no differences in [TIMP-2]*[IGFBP-7] values at either timepoint between patients who developed postoperative AKI as compared to those who did not. CONCLUSION: Urinary [TIMP-2]*[IGFBP7] was not predictive of the risk of AKI after cardiac surgery in this single-center study population.

Contemporary national utilization of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest.

OBJECTIVE: The utilization of extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) has demonstrated promising evidence for the management of out-of-hospital cardiac arrest (OHCA). We aim to describe contemporary utilization and predictors of survival of patients receiving ECPR for OHCA. METHODS: The National Inpatient Sample (NIS) was queried to identify hospital discharge records of patients aged ≥18 years who underwent ECPR from 2012 to 2017. Patients with an International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of cardiac arrest, admitted urgently and placed on ECMO on Day 0 of hospitalization, were selected. Patients with a primary diagnosis indicative of veno-venous ECMO were excluded. Predictors of mortality were assessed using multivariable analyses. RESULTS: There were 1675 cases of ECPR, increasing from 185 cases in 2012 to 400 in 2017 (p < .001). Overall mortality was 63.3%, which remained stable over time (p = .441). Common diagnoses included ST-elevation myocardial infarction (39.1%), non-ST-elevation myocardial infarction (9.3%), and pulmonary embolism (13.7%). Percutaneous coronary intervention was performed in 495 patients (29.6%); coronary artery bypass grafting was performed in 125 patients (7.5%). In multivariable analysis, decreased age, female gender, and left ventricular (LV) decompression were associated with reduced mortality. CONCLUSION: Utilization of ECPR is increasing nationally with stable mortality rates. Younger age, female gender, and utilization of LV decompression were associated with increased survival.

Survival and readmission among patients with advanced cardiomyopathy undergoing transcatheter edge-to-edge mitral valve repair: Are we applying COAPT findings too broadly?

OBJECTIVE: Transcathether edge-to-edge mitral valve repair (TEER) has been shown to be an effective treatment for secondary mitral regurgitation (MR). However, the outcomes of TEER in patients with severe cardiomyopathy is less clear. The objective of this study is to determine the outcomes of such patients who underwent TEER at our institution. METHODS: A retrospective review of patients with severe cardiomyopathy, defined as ejection fraction ≤30% or the requirement of inotropic support preoperatively, undergoing TEER for secondary MR at our institution from 11/2016 to 11/2020 was performed. Univariate analysis associating preoperative characteristics with our primary endpoint of 1-year death or orthotopic heart transplant (OHT) was performed. Kaplan-Meier analysis was conducted for the composite outcome of death or OHT, as well as for heart failure-related readmission. Finally, an assessment of changes in MR severity from the preoperative, to immediate postoperative period, to 30-day postoperative period was conducted. RESULTS: There were 48 patients identified. Median age was 74.5 years (IQR 65.5-79.5), median ejection fraction was 21.5% (IQR 16.0-27.5), and 81.4% of patients had severe or torrential mitral regurgitation preoperatively. The composite endpoint of 1-year mortality or OHT occurred in 15 of 48 patients (31.3%, 14 deaths and 1 OHT). One-year heart failure readmission rate was 47.9%. Mortality or OHT at 2 years occurred in 45.8%. CONCLUSION: Patients at extremes of heart failure who underwent TEER had poor outcomes when assessed at 1-year. Our study may suggest that the results of cardiovascular outcomes assessment of the mitraclip percutaneous therapy for heart failure patients with secondary mitral regurgitation may not be applicable to patients with severe cardiomyopathy.

Transcatheter heart valve selection in patients with low ejection fraction and aortic stenosis.

OBJECTIVE: The aim of this study was to compare outcomes of transcatheter heart valve (THV) choice in patients with left ventricular (LV) systolic dysfunction. BACKGROUND: The management congestive heart failure with combined LV systolic dysfunction and severe aortic stenosis (AS) is challenging, yet transcatheter aortic valve replacement (TAVR) has emerged as a suitable treatment option in such patients. Head-to-head comparisons among the balloon-expandable (BEV) and self-expandable (SEV) THV remain limited in this subgroup of patients. METHODS: In this retrospective study, we included patients with severe AS with LV systolic dysfunction (LVEF ≤40%) who underwent TAVR at four high volume centers. Two thousand and twenty-eight consecutive patients were analyzed, of which 335 patients met inclusion criteria. One hundred fourty-six patients (43%) received a SEV, and 189 patients (57%) received a BEV. RESULTS: Baseline characteristics were similar except for a higher proportion of females in the SEV group. The primary composite endpoint of in-hospital mortality, moderate or greater paravalvular (PVL), stroke, conversion to open surgery, aortic valve reintervention, and/or need for permanent pacemaker (PPM) was no different among THV choice. There was more PVL in the SEV group, but higher transaortic gradients in the BEV group. Clinical outcomes and quality of life measures were similar up to 1 year follow-up. CONCLUSION: The choice of THV in patients with severe AS and systolic dysfunction must be weighed on a case-by-case basis.

Deep Versus Moderate Hypothermia in Acute Type A Aortic Dissection: A Propensity-Matched Analysis.

BACKGROUND: The ideal temperature for hypothermic circulatory arrest (HCA) during acute type A aortic dissection (ATAAD) repair has yet to be determined. We examined the clinical impact of different degrees of hypothermia during dissection repair. METHODS: Out of 240 cases of ATAAD between June 2014 and December 2019, 228 patients were divided into two groups according to lowest intraoperative temperature: moderate hypothermic circulatory arrest (MHCA) (20-28°C) versus deep hypothermic circulatory arrest (DHCA) (<20°C). From this, 74 pairs of propensity-matched patients were analysed with respect to operative data and short-term clinical outcomes. Independent predictors of a composite outcome of 30-day mortality and stroke were identified. RESULTS: Mean lowest temperature was 25.5±3.9°C in the MHCA group versus 16.0±2.9°C in DHCA. Overall 30-day mortality of matched cohort was 11.5% (17 deaths), there were no significant different between matched groups. Cardiopulmonary bypass (CPB) times were longer in DHCA (221.0±69.9 vs 190.7±74.5 mins, p=0.01). Antegrade cerebral perfusion (ACP) during HCA predicted a lower composite risk of 30-day mortality and stroke (OR 0.38). Female sex (OR 4.71), lower extremity ischaemia at presentation (OR 3.07), and CPB >235 minutes (OR 2.47), all portended worse postoperative outcomes. CONCLUSIONS: A surgical strategy of MHCA is at least as safe as DHCA during repair of acute type A aortic dissection. ACP during HCA is associated with reduced 30-day mortality and stroke, whereas female sex, lower extremity ischaemia, and longer CPB times are all predictive of poorer short-term outcomes.

Rare case of Proteus mirabilis native mitral valve endocarditis in an immunocompromised patient.

BACKGROUND: Bacterial infective endocarditis caused by Proteus mirabilis is rare and there are few cases in the literature. The natural history and treatment of this disease is not as clear but presumed to be associated with complicated urinary tract infection (cUTI). CASE PRESENTATION: A 65-year-old female with a history of rheumatoid arthritis, factor V Leiden hypercoagulability, and prior saddle pulmonary embolism presented to the emergency department following a mechanical fall. Computed Tomography showed evidence of acute/subacute splenic emboli. Complicated UTI was likely secondary to a ureteral stone. Blood and urine cultures also grew out P. mirabilis. Transthoracic echocardiography revealed a mobile echogenic density on the anterior mitral valve (MV) leaflet consistent with a vegetation. The patient underwent MV replacement, and P. mirabilis was isolated from the surgically removed valve. CONCLUSIONS: We hypothesize that the patient's immunocompromised status following steroid and Janus Kinase inhibitor usage for rheumatoid arthritis contributed to Gram-negative bacteremia following P. mirabilis UTI, ultimately seeding the native MV. Additional studies with larger numbers of Proteus endocarditis cases are needed to investigate an association between immunosuppression and Proteus species endocarditis.

Structural and functional cardiac changes in endomyocardial fibrosis treated with endomyocardial resection: Disease progression captured by multimodality imaging.

Eosinophilic myocarditis, a rare and under-recognized disease process, occurs due to cytotoxic inflammation of the endomyocardium that over time may lead to a restrictive cardiomyopathy. We report clinical, multimodality imaging, and pathologic findings in a 45-year-old woman over a 17-month period as she progressed from suspected acute eosinophilic myocarditis to phenotypic endomyocardial fibrosis resulting in recurrent ascites. Interval echocardiograms demonstrate definitive pathologic structural changes that reflect the hemodynamic consequences of the underlying cardiomyopathy. Despite a negative myocardial biopsy, characteristic findings on cardiovascular magnetic resonance imaging clarified the diagnosis which led to successful treatment with endomyocardial resection and valve replacements.

Accuracy of predicted effective orifice area in determining incidence of patient-prosthesis mismatch after transcatheter aortic valve replacement.

OBJECTIVE: Patient-prosthesis mismatch (PPM) is associated with poor outcomes after aortic valve replacement. The aim of this study was to assess the accuracy of indexed effective orifice area (EOAi) charts in predicting PPM after transcatheter aortic valve replacement (TAVR). METHODS: A retrospective review of 346 TAVR patients from January 2017 to November 2018 was performed. EOAi was predicted for patients based on published predictive tables using valve type, annulus diameter, and body surface area. Actual EOAi was calculated based on intraoperative transesophageal echocardiogram (TEE) measurements. PPM was defined by EOAi ≤ 0.85 cm2 /m2 . The accuracy of predicted PPM was assessed. Differences in clinical outcomes, including mean gradient, length of stay, mortality, complications, and change in Kansas City cardiomyopathy questionnaire score as an indicator of quality of life, were evaluated based on actual PPM. RESULTS: Of the 346 patients analyzed, 44 (12.7%) of patients had PPM on intraoperative TEE. Of the 182 patients who received Sapien 3 valves, 42 (23.1%) were predicted to have PPM while 25 (13.7%) had actual PPM. Of the 164 patients who received Evolut valves, 3 (1.8%) were predicted to have PPM while 19 (11.6%) had actual PPM. EOAi charts had poor sensitivity (40.0% for Sapien 3; 5.25% for Evolut) and positive predictive value (23.8% for Sapien 3; 33.3% for Evolut) for both valve types. CONCLUSION: Preoperative prediction of PPM in TAVR patients using tables of expected EOA demonstrates significant variation from actual PPM. The utility of EOAi charts to predict PPM in patients undergoing TAVR may be limited.

Racial and socioeconomic disparities in urgent transcatheter mitral valve repair: A National Inpatient Sample analysis.

BACKGROUND: Cardiac interventions performed urgently are known to be associated with poor outcomes compared with electively performed procedures. Transcatheter edge-to-edge mitral valve repair (TMVr) has developed as a reasonable alternative to mitral valve surgery in certain patient populations. We aimed to leverage a national database to identify predictors of urgent versus elective TMVr, as well as the association between urgency and outcomes. METHODS: The National Inpatient Sample (NIS) was queried to identify patients who underwent TMVr from 2016 to 2017. Hospitalizations were identified within the database as elective versus nonelective. Univariate and multivariable analyses were performed to identify patient characteristics associated with urgent procedures. In-hospital outcomes were assessed. RESULTS: There were 10,195 cases of TMVr in this cohort, 24.2% of which were performed urgently. In multivariable analysis, Hispanic race, Medicaid insurance, and low income were associated with increased likelihood of urgent hospital admission and TMVr. Additionally, small hospital size and Northeast region were associated with increased likelihood of urgent admission and procedure. Urgent TMVr was associated with increased mortality (4.5% vs. 1.6%, p < .001), prolonged length of stay (6.0 vs. 2.0, p < .001), and increased cost ($71,451.90 vs. $44,981.20, p < .001). CONCLUSIONS: Racial and socioeconomic disparities exist in the utilization of TMVr as an urgent versus elective procedure, suggesting differences in access to surveillance and preventive care. Urgent TMVr is associated with increased morbidity and mortality, prolonged length of stay, and increased hospital costs. Priority should be placed on mitigating such disparities to improve outcomes.

Impact of chronic lung disease on quality-of-life outcomes in patients undergoing transcatheter aortic valve replacement.

BACKGROUND: As the symptoms for both chronic lung disease (CLD) and aortic stenosis (AS) frequently overlap, it may be challenging to determine the degree of symptomatic improvement expected for a patient with CLD after correction of AS. Our aim was to determine if patients with CLD have the same degree of quality-of-life improvement following transcatheter aortic valve replacement (TAVR) as patients without CLD. METHODS: A retrospective review of 238 TAVR patients from January 2017 to November 2018 who underwent preoperative pulmonary function tests and completed 30-day follow-up was performed. Patients were identified as having CLD with FEV1 more than 75% predicted. Postoperative outcomes and changes in Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) were compared between groups. RESULTS: Of the 238 patients identified, 143 (60.0%) had CLD, 50 (35.0%) of whom had an obstructive disease pattern. Patients with CLD were more likely to be male, had higher rates of peripheral artery disease, and had lower baseline ejection fraction. There was no difference in STS Predicted Risk of Mortality, but patients with CLD were more likely to be designated as high-risk by surgeon evaluation. While initial and follow-up KCCQ-12 was lower for patients with CLD, there was no significant difference in degree of improvement (p = .900). When comparing patients with obstructive lung disease (FEV1/FVC < 0.70) to those without CLD, there was also no significant difference in the change of quality of life (p = .720). CONCLUSION: Although patients with concomitant severe AS and CLD have reduced baseline quality of life compared to patients without CLD, they experience a comparable degree of improvement following TAVR.

Marijuana: An Underappreciated Risk Factor for Acute Type A Aortic Dissection?

BACKGROUND: Stimulants such as cocaine and amphetamines are well-established risk factors for acute aortic dissection. Despite the fact that marijuana is the most commonly used illicit drug in the United States, its relationship to acute aortic syndromes has not been well studied. METHODS: A comprehensive retrospective review was undertaken of all consecutive patients who presented with acute Stanford type A aortic dissection from January 2017 to December 2019. Of 152 patients identified, 51 (33.6%) underwent comprehensive urine toxicology screening at clinical presentation. The characteristics and outcomes of the patients with urine results positive for tetrahydrocannabinol (THC) (n = 9, 17.6%) were compared with the 42 patients who had no evidence of recent marijuana consumption. RESULTS: Of the 51 dissection patients who underwent broad-spectrum urine toxicology screening upon presentation, 9 (17.6%) returned positive results for THC, a proportion higher than would be expected for the general population. All THC patients were male; 3 concurrently tested positive for cocaine, and 3 others had evidence of recent amphetamine use. The THC patients were significantly younger than the non-THC patients (mean ± standard deviation age 48 ± 11.3 versus 61.4 ± 12.3 years, respectively, P = .004). A greater proportion of the THC cohort had a known diagnosis of aortic aneurysm before the dissection (44.4% versus 4.8%, P = .006). All patients underwent expeditious surgical repair. Thirty-day mortality for the entire cohort of 51 patients was 19.6% (10 deaths); for the THC group, it was 11.1% (1 death). There was no difference in the incidence of major postoperative complications between the 2 groups. CONCLUSION: Marijuana is the third most commonly used substance in the United States, after alcohol and tobacco. Although marijuana use is understudied, our results suggest that marijuana may be a contributing risk factor for acute type A aortic dissection, particularly in patients with other predisposing risk factors. Given the recent national trend to legalize marijuana, with the concomitant potential for exponential increases in its consumption, we suggest that the diagnosis of aortic dissection be considered earlier in any younger patient who presents with suggestive symptoms, especially if there is a history of recent marijuana use.

Evaluating the Validity of Risk Scoring in Predicting Pacemaker Rates following Transcatheter Aortic Valve Replacement.

INTRODUCTION: Requirement of permanent pacemaker (PPM) implantation is a known and common postoperative consequence of transcatheter aortic valve replacement (TAVR). The Emory risk score has been recently developed to help risk stratify the need for PPM insertion in patients undergoing TAVR with SAPIEN 3 valves. Our aim was to assess the validity of this risk score in our patient population, as well as its applicability to patients receiving self-expanding valves. METHODS: We conducted a retrospective review of 479 TAVR patients without preoperative pacemakers from November 2016 through December 2018. Preoperative risk factors included in the Emory risk score were collected for each patient: preoperative QRS, preoperative right bundle branch block (RBBB), preoperative syncope, and degree of valve oversizing. Multivariable analysis of the individual variables within the scoring system to identify predictors of PPM placement was performed. The predictive discrimination of the risk score for the risk of PPM placement after TAVR was assessed with the area under the receiver operating characteristic curve (AUC). RESULTS: Our results demonstrated that, of the 479 patients analyzed, 236 (49.3%) received balloon-expandable valves and 243 (50.7%) received self-expanding valves. Pacemaker rates were higher in patients receiving self-expanding valves than those receiving balloon-expandable valves (25.1% versus 16.1%, p=0.018). The Emory risk score showed a moderate correlation with pacemaker requirement in patients receiving each valve type, with AUC for balloon-expandable and self-expanding valves of 0.657 and 0.645, respectively. Of the four risk score components, preoperative RBBB was the only predictor of pacemaker requirement with an AUC of 0.615 for both balloon-expandable and self-expanding valves. Conclusion. In our cohort, the Emory risk score had modest predictive utility for PPM insertion after balloon-expandable and self-expanding TAVR. The risk score did not offer better discriminatory utility than that of preoperative RBBB alone. Understanding the determinants of PPM insertion after TAVR can better guide patient education and postoperative management.

Risk stratification for nonagenarians undergoing transcatheter aortic valve replacement.

BACKGROUND: There are disparate data on the outcomes of nonagenarians undergoing transcatheter aortic valve replacement (TAVR) compared with younger patients. The purpose of this study is to determine whether the Society of Thoracic Surgeons (STS) score can be used to identify the subset of nonagenarians that are at a significantly higher risk for poor postoperative outcomes after TAVR. METHODS: A total of 425 patients above the age of 80 underwent elective TAVR between 12/2013 and 2/2018 and were included in this study. Patients were deemed intermediate or high risk based on an STS predicted the risk of surgical mortality score of 3% to 8% and more than 8%, respectively. Differences in postoperative outcomes and/or 6-month mortality between intermediate and high-risk octogenarians and nonagenarians were compared. RESULTS: Of the 425 patients, 112 (26.4%) patients were nonagenarians, and 313 (73.6%) patients were octogenarians. Fifty-four (48.2%) of the nonagenarians were stratified as high-risk, while 78 (24.9%) of the octogenarians were stratified as high-risk. There were no statistically significant differences in the composite outcomes between intermediate-risk nonagenarians and intermediate-risk octogenarians. In contrast, high-risk nonagenarians were significantly more likely to experience the composite outcome of major perioperative complications and/or 6-month mortality as compared to high-risk octogenarians. CONCLUSION: Intermediate-risk nonagenarians undergoing TAVR have similar postoperative outcomes compared to intermediate-risk octogenarians. However, high-risk nonagenarian patients undergoing TAVR experience significantly poorer outcomes compared to their octogenarian counterparts. Judicious patient selection for TAVR in this subgroup of patients is therefore warranted.

Incidence of Acute Kidney Injury in Patients with Chronic Renal Insufficiency: Transcatheter versus Surgical Aortic Valve Replacement.

OBJECTIVES: The objective of this study is to determine incidence of acute kidney injury (AKI) associated with transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patients with preexisting chronic kidney disease. BACKGROUND: The incidence of AKI in patients with preexisting renal insufficiency undergoing TAVR versus SAVR is not well described. METHODS: All patients with preexisting chronic kidney disease who underwent SAVR for aortic stenosis with or without concomitant coronary artery bypass grafting or TAVR from 5/2008 to 6/2017. Patients requiring preoperative hemodialysis were excluded. Chronic kidney disease was defined as an estimated glomerular filtrate rate (eGFR) of < 60 mL/min/1.73 m2. The incidence of postoperative AKI was compared using the RIFLE classification system for acute kidney injury. RESULTS: A total of 406 SAVR patients and 407 TAVR patients were included in this study. TAVR patients were older and had lower preoperative eGFR as compared to SAVR patients. Covariate adjustment using propensity score between the two groups showed that SAVR patients were more likely to have a more severe degree of postoperative AKI as compared to TAVR patients (OR = 4.75; 95% CI: 3.15, 7.17; p <.001). SAVR patients were more likely to require dialysis postoperatively as compared to TAVR patients (OR = 4.55; 95% CI: 1.29, 15.99; p <.018). CONCLUSION: In patients with preexisting chronic kidney disease, TAVR was associated with significantly less AKI as compared to SAVR.