Racial and Ethnic Variations in Patients Undergoing Mitral and Tricuspid Valve Surgery.

INTRODUCTION: Prior investigations assessing the impact of race/ethnicity on outcomes after mitral valve (MV) surgery have reported conflicting findings. This analysis aimed to examine the association between race/ethnicity and operative presentation and outcomes of patients undergoing MV and tricuspid valve (TV) surgery. METHODS: We retrospectively analyzed 5984 patients (2730 female, median age 63 y) who underwent MV (n = 4,534, 76%), TV (n = 474, 8%) or both MV and TV (n = 976, 16%) surgery in a statewide collaborative from 2012 to 2021. The influence of race/ethnicity on preoperative characteristics, MV and TV repair rates, and postoperative outcomes was assessed for White (n = 4,244, 71%), Black (n = 1,271, 21%), Hispanic (n = 144, 2%), Asian (n = 171, 3%), and mixed/other race (n = 154, 3%) patients. RESULTS: Black patients, compared to White patients, had higher Society of Thoracic Surgeons predicted risk of morbidity/mortality (24.5% versus 13.1%; P < 0.001) and more comorbid conditions. Compared to White patients, Black and Hispanic patients were less likely to undergo an elective procedure (White 71%, Black 55%, Hispanic 58%; P < 0.001). Degenerative MV disease was more prevalent in White patients (White 62%, Black 41%, Hispanic 43%, Asian 51%, mixed/other 45%; P < 0.05), while rheumatic disease was more prevalent in non-White patients (Asian 28%, Hispanic 26%, mixed/other 25%, Black 17%, White 10%;P < 0.05). After multivariable adjustment, repair rates and adverse postoperative outcomes, including mortality, did not differ by racial/ethnic group. CONCLUSIONS: Patient race/ethnicity is associated with a higher burden of comorbidities at operative presentation and MV disease etiology. Strategies to improve early detection of valvular heart disease and timely referral for surgery may improve outcomes.

Characterizing the Racial Discrepancy in Hypoxemia Detection in Venovenous Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis.

PURPOSE: Skin pigmentation influences peripheral oxygen saturation (SpO2) compared to arterial saturation of oxygen (SaO2). Occult hypoxemia (SaO2 ≤ 88% with SpO2 ≥ 92%) is associated with increased in-hospital mortality in venovenous-extracorporeal membrane oxygenation (VV-ECMO) patients. We hypothesized VV-ECMO cannulation, in addition to race/ethnicity, accentuates the SpO2-SaO2 discrepancy due to significant hemolysis. METHODS: Adults (≥ 18 years) supported with VV-ECMO with concurrently measured SpO2 and SaO2 measurements from over 500 centers in the Extracorporeal Life Support Organization Registry (1/2018-5/2023) were included. Multivariable logistic regressions were performed to examine whether race/ethnicity was associated with occult hypoxemia in pre-ECMO and on-ECMO SpO2-SaO2 calculations. RESULTS: Of 13,171 VV-ECMO patients, there were 7772 (59%) White, 2114 (16%) Hispanic, 1777 (14%) Black, and 1508 (11%) Asian patients. The frequency of on-ECMO occult hypoxemia was 2.0% (N = 233). Occult hypoxemia was more common in Black and Hispanic patients versus White patients (3.1% versus 1.7%, P < 0.001 and 2.5% versus 1.7%, P = 0.025, respectively). In multivariable logistic regression, Black patients were at higher risk of pre-ECMO occult hypoxemia versus White patients (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.18-2.02, P = 0.001). For on-ECMO occult hypoxemia, Black patients (aOR = 1.79, 95% CI = 1.16-2.75, P = 0.008) and Hispanic patients (aOR = 1.71, 95% CI = 1.15-2.55, P = 0.008) had higher risk versus White patients. Higher pump flow rates (aOR = 1.29, 95% CI = 1.08-1.55, P = 0.005) and on-ECMO 24-h lactate (aOR = 1.06, 95% CI = 1.03-1.10, P < 0.001) significantly increased the risk of on-ECMO occult hypoxemia. CONCLUSION: SaO2 should be carefully monitored if using SpO2 during ECMO support for Black and Hispanic patients especially for those with high pump flow and lactate values at risk for occult hypoxemia.

Center Variation in Use of Preoperative Dual Antiplatelet Therapy and Platelet Function Testing at the Time of Coronary Artery Bypass Grafting in Maryland.

BACKGROUND: Patients presenting with acute coronary syndrome are administered a P2Y 12 inhibitor and aspirin before coronary catheterization to prevent further myocardial injury from thrombosis. Guidelines recommend a standard waiting period between the time patients are administered dual antiplatelet therapy (DAPT) and elective cardiac surgery. Since 25% to 30% of the population may be considered nonresponders to clopidogrel, platelet function testing can be utilized for timing of surgery and to assess bleeding risks. The extent to which a standard waiting period or platelet function testing is used across centers is not established, representing an important opportunity to standardize practice. METHODS: We conducted a retrospective cohort study from 2011 to 2020 using data from the Maryland Cardiac Surgical Quality Initiative, a consortium of all 10 hospitals in the state performing cardiac surgery. The proportion of patients administered DAPT within 5 days of surgery was examined by hospital over the time period. Mixed-effects multivariable logistic regressions were used to examine the association of preoperative DAPT with ischemic and bleeding outcomes. Centers were surveyed on use or nonuse of preoperative platelet function testing, and bleeding outcomes were compared. RESULTS: There was significant heterogeneity of preoperative DAPT usage across centers ranging from 2% to 54% ( P < .001). DAPT within 5 days of isolated coronary artery bypass grafting (CABG) was associated with higher odds of reoperation for bleeding (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.19-2.01; P = .001), >2 units of red blood cells (RBCs) transfused (OR, 1.62; 95% CI, 1.44-1.81; P < .001), and >2 units of non-RBCs transfused (OR, 1.79; 95% CI, 1.60-2.00; P < .001). In the 5 hospitals using preoperative platelet function testing to guide timing of surgery, there were greater odds for DAPT within 5 days (OR, 1.33; 95% CI, 1.22-1.45; P < .001), fewer RBCs >2 units transfusions (22% vs 33%; P < .001), and non-RBCs >2 units (17% vs 28%; P < .001) transfusions within DAPT patients. CONCLUSIONS: There is significant variability in DAPT usage within 5 days of CABG between hospital centers. Preoperative platelet function testing may allow for earlier timing of surgery for those on DAPT without increased bleeding risks.

Red Blood Cell Transfusion and Postoperative Infection in Patients Having Coronary Artery Bypass Grafting Surgery: An Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database.

BACKGROUND: Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure in the world and up to one-third of patients are transfused red blood cells (RBCs). RBC transfusion may increase the risk for health care-associated infection (HAI) after CABG, but previous studies have shown conflicting results and many did not establish exposure temporality. Our objective was to explore whether intraoperative RBC transfusion is associated with increased odds of postoperative HAI. We hypothesized that intraoperative RBC transfusion would be associated with increased odds of postoperative HAI. METHODS: We performed an observational cohort study of isolated CABG patients in the Society of Thoracic Surgeons adult cardiac surgery database from July 1, 2017, to June 30, 2019. The exposure was intraoperative RBC transfusion modeled as 0, 1, 2, 3, or 4+ units. The authors focused on intraoperative RBC transfusion as a risk factor, because it has a definite temporal relationship before postoperative HAI. The study's primary outcome was a composite HAI variable that included sepsis, pneumonia, and surgical site infection (both deep and superficial). Mixed-effects modeling, which controlled for hospital as a clustering variable, was used to explore the relationship between intraoperative RBC transfusion and postoperative HAI. RESULTS: Among 362,954 CABG patients from 1076 hospitals included in our analysis, 59,578 patients (16.4%) received intraoperative RBCs and 116,186 (32.0%) received either intraoperative or postoperative RBCs. Risk-adjusted odds ratios for HAI in patients who received 1, 2, 3, and 4+ intraoperative RBCs were 1.11 (95% confidence interval [CI], 1.03-1.20; P = .005), 1.13 (95% CI, 1.05-1.21; P = .001), 1.15 (95% CI, 1.04-1.27; P = .008), and 1.14 (95% CI, 1.02-1.27; P = .02) compared to patients who received no RBCs. CONCLUSIONS: Intraoperative RBC transfusion is associated with a small increase in odds of HAI in CABG patients. Future studies should explore whether reductions in RBC transfusion can also reduce HAIs.

Effectiveness of telemedicine in a mitral valve center of excellence.

BACKGROUND: The COVID-19 pandemic necessitated a drastic increase in the use of telemedicine. There is little information about the effectiveness of telemedicine in cardiac surgery. We examined clinical outcomes and patient satisfaction among patients who had in-person versus telemedicine preoperative appointments in a subspecialized mitral valve surgical practice. METHODS: We retrospectively reviewed all patients who had elective mitral valve operations between January 2019 and February 2021. Patients were categorized into 2 groups based on the format of the preoperative appointment (telemedicine or in-person). Preoperative characteristics and clinical outcomes were compared between the two groups. All patients who had a telemedicine appointment were sent an online survey to assess their satisfaction with the process. RESULTS: Among 286 patients analyzed, 197 (69%) had in-person preoperative evaluations and 89 (31%) had telemedicine evaluations. The in-person and telemedicine groups had similar preoperative and operative characteristics. Outcomes did not differ between the 2 groups, including ventilation time (3.7 vs. 4.1 h, p = .399), total length of stay (5 vs. 5 days, p = .949), 30-day mortality (0% vs. 1%, p = .311), and readmissions within 30 days (13% vs. 8%, p = .197). Among patients who completed the survey, 91% were "satisfied" or "very satisfied" with the telemedicine preoperative appointment. CONCLUSION: Patients who had telemedicine preoperative appointments before mitral valve operations during the COVID-19 pandemic had similarly excellent clinical outcomes to patients who had in-person preoperative appointments before the pandemic. Patients had relatively high levels of satisfaction with telemedicine and almost half preferred telemedicine for future visits.

Lung transplantation and Affordable Care Act Medicaid expansion in the era of lung allocation score - a retrospective study.

This study evaluated the impact of Medicaid eligibility expansion (ME) on lung transplant (LT) listings and Medicaid coverage. Data on LT candidates aged 18-64 were obtained from the Scientific Registry of Transplant Recipients (N = 9153). The impact of ME was evaluated by comparing LT listings in 2011-2013 with listings in 2014-2016, as well as comparing states that had and had not adopted ME in 2014. LT listings increased by 7.7% nationally post-ME. In ME states, LT listings increased by 15.2%, whereas nonexpansion states decreased by 1.5%. LT candidates with Medicaid increased after ME nationally (8.3% vs. 9.9%, P = 0.006) and in ME states (9.7% vs. 11.5%, P = 0.036), but not in nonexpansion states (6.6% vs. 7.7%, P = 0.170). Following multivariable adjustment, LT listings in ME states had 58% greater odds for Medicaid compared to nonexpansion states (P < 0.001). Expansion of Medicaid provided greater healthcare access and increased LT listings, but only within states that adopted eligibility expansion.

Development of the Cardiac Surgery Patient Expectations Questionnaire (C-SPEQ).

PURPOSE: Some variability in recovery and outcomes after cardiac surgery may be influenced by psychosocial aspects not routinely captured. Preliminary evidence suggests patient expectations impact health status, but there is no specific measure of expectations for cardiac surgery. The purpose of this study was to adapt an expectations scale to cardiac surgery and assess the psychometric properties of the scale. METHODS: Before surgery, 93 patients awaiting non-emergent cardiac surgery completed questionnaires, including the adapted Cardiac Surgery Patient Expectations Questionnaire (C-SPEQ). At 1 year after surgery, 68 patients completed questionnaires. RESULTS: Mean C-SPEQ score was 39.4 ± 9.02, and scores were normally distributed (Cronbach's alpha = 0.86). Higher score indicated negative expectations. Higher presurgery C-SPEQ score was correlated with greater depression (r = 0.32, p = 0.01) and perceived stress (r = 0.36, p = 0.003), but not state anxiety (r = 0.18, p = 0.14), at one-year post-surgery. Higher C-SPEQ was associated with longer recovery time (B = 0.14, p = 0.006) and lower physical HRQL after surgery (B = -0.31, p = 0.005). Higher C-SPEQ was not related to greater odds for perioperative complications (OR 1.01, p = 0.68) or readmissions <30 days (OR 1.05, p = 0.31). C-SPEQ score was not related to survival. CONCLUSIONS: Adaptation of an expectations questionnaire to cardiac surgery patients was successful with acceptable reliability and validity. Negative expectations had a detrimental impact on recovery and HRQL following cardiac surgery but were not related to clinical outcomes. Although focus is mainly on improving clinical outcomes, there are opportunities to improve non-clinical aspects of the patient experience. Presurgical education might better prepare patients, reduce negative expectations, and improve psychosocial outcomes after cardiac surgery.

The Effects of Frailty in Patients Undergoing Elective Cardiac Surgery.

BACKGROUND: The Society of Thoracic Surgeons (STS) recommends using gait speed as a marker of frailty to identify cardiac surgery patients at risk for adverse outcomes. However, a single marker of frailty may not provide consistently reliable risk information. We evaluated the impact of frailty and gait speed on patient outcomes after elective cardiac surgery. METHODS: This was a prospective study of 167 older (≥65 years) coronary artery bypass grafting (CABG) and/or valve surgery patients. Patients were assessed using Cardiovascular Health Study (CHS) Frailty Index criteria: weight loss, exhaustion, physical activity, gait speed, and grip strength. RESULTS: Frailty was identified in 39 patients (23%) using CHS criteria. Frail patients had longer median intensive care unit stays (54 vs. 28 h, p = 0.003), longer median length of stay (8 vs. 5 days, p < 0.001), and greater likelihood of STS-defined complications (54% vs. 32%, p = 0.011) and discharge to an intermediate-care facility (45% vs. 12%, p < 0.001) but were not different from nonfrail patients on major outcome, operative mortality, or readmissions. After multivariate adjustment, frail and nonfrail patients were similar on perioperative outcomes. Absolute gait speed and slow gait speed using a cutoff were not related to incidence of STS-defined complications or major outcome in multivariate analyses. However, higher body mass index was correlated with slower gait speed (rs = 0.30, p < 0.001). CONCLUSIONS: The CHS index did not identify "frail" patients at increased risk for adverse outcomes. No relationship was found between gait speed and outcome. There is a need for alternative multidimensional measures to assess frailty in cardiac surgical patients. doi: 10.1111/jocs.12699 (J Card Surg 2016;31:187-194).

Preoperative hematocrit as a predictor of perioperative morbidities following nonemergent coronary artery bypass surgery.

BACKGROUND: Preoperative hematocrit (HCT) has predicted inferior outcome following cardiac surgery. However, the potential for preoperative HCT to be a marker for sicker patients was not well explored. This study examined the impact of HCT on outcome following nonemergent coronary artery bypass grafting (CABG) and whether the association is modified by operative risk or intraoperative blood transfusion. METHODS: Nonemergent isolated CABG surgery patients were included (N = 2306). Logistic regressions were conducted to assess the effect of HCT on major perioperative morbidities. Separate analyses were conducted on tertiles of STS score (<0.55%, n = 768; 0.55% to 1.15%, n = 771; >1.15%, n = 767). RESULTS: Mean age was 63.1 ± 10.1, preoperative HCT was 38.9 ± 4.8, and STS score was 1.4 ± 2.0% (median = 0.79%). In univariate (OR = 0.89, p < 0.001) and multivariate (OR = 0.93, p < 0.001) analyses, lower HCT predicted major morbidity. Lower HCT predicted major morbidity only in the highest risk tertile (OR = 0.93, p < 0.001) and the same result was found after multivariate adjustment (OR = 0.92, p < 0.001). Following inclusion of intraoperative transfusion in a multivariate model, preoperative HCT remained an independent predictor for major morbidity (OR = 0.95, p = 0.01), while transfusion was also a strong predictor (OR = 4.86, p < 0.001). Addition of transfusion to multivariate models by STS risk tertiles revealed preoperative HCT remained predictive only in the highest risk group (OR = 0.95, p = 0.03) while transfusion was a strong predictor in all three risk tertiles (OR = 3.97 to 10.36; p-values < 0.001). CONCLUSIONS: Lower preoperative HCT was associated with higher odds for perioperative morbidity in nonemergent CABG patients with higher STS risk. Additionally, intraoperative blood transfusion negatively impacted all STS risk groups. Preoperative strategies to mitigate anemia may reduce transfusions and improve outcome in CABG patients.

Right ventricular sizing and pulmonary vascular resistance: How much mass do you need?

OBJECTIVE: Right ventricular (RV) donor-recipient sizing has been demonstrated to be a sensitive predictor for mortality after heart transplantation. We sought to understand the relationship between donor-recipient RV mass (RVM) ratio and pulmonary vascular resistance (PVR) on outcomes after heart transplantation. METHODS: Adult heart transplant recipients from the United Network for Organ Sharing database were included (N = 42,594). The influence of RVM ratio and PVR on 1-year mortality was assessed by logistic regression after multivariable adjustment. RESULTS: Among transplant recipients, median PVR was 2.4 Wood units (WU) (range, 1.7-3.3 WU) and median RVM ratio was 1.2 (1.0-1.3). Without considering PVR, RVM ratio was highly associated with postoperative dialysis (odds ratio [OR], 0.49; P < .001) and 1-year mortality (OR, 0.64; P < .001). Without considering RVM ratio, PVR was highly associated with 1-year mortality (OR, 1.05; P < .001), but not postoperative dialysis (OR, 0.98; P = .156). When considering both RVM ratio and PVR, the risk associated with each remained significant, but PVR did not modify the effect of RVM ratio on 1-year mortality (RVM ratio × PVR: OR, 0.99; P = .858). To maintain a consistent predicted 1-year mortality, RVM ratio would need to increase by 0.12 for each WU increase in PVR. Secondary analyses found that a 1 WU change in PVR was associated with an 11% increase in mortality risk in RVM ratio mismatched patients (RVM ratio < 1; P = .001), but only a 5% increase in RVM ratio matched patients (RVM ratio ≥ 1; P = .003). CONCLUSIONS: RVM ratio and recipient PVR are independent predictors of 1-year mortality. Still, a larger RV mass may be utilized to mediate the effects of an elevated PVR.

Statewide data on surgical ablation for atrial fibrillation: The data provide a path forward.

OBJECTIVE: Atrial fibrillation (AF), if left untreated, is associated with increased intermediate and long-term morbidity/mortality. Surgical treatment for AF is lacking standardization in patient selection and lesion set, despite clear support from multi-society guidelines. The aim of this study was to analyze a statewide cardiac surgery registry to establish whether or not there is an association between center volume and type of index procedure with performance of surgical ablation (SA) for AF, the lesion set chosen, and ablation technology used. METHODS: Adult, first-time, nonemergency patients with preoperative AF between 2014 and 2022 excluding standalone SA procedures from a statewide registry of Society of Thoracic Surgeons data were included (N = 4320). AF treatment variability by hospital volume (ordered from smallest to largest) and surgery type were examined with χ2 analyses. Hospital-level Spearman correlations compared hospital volume with proportion of AF patients treated with SA. RESULTS: Overall, 37% of patients with AF were ablated at the time of surgery (63% of mitral procedures, 26% of non-mitrals) and 15% had left atrial appendage management only. There was a significant temporal trend of increasing performance of SA for AF over time (Cochran-Armitage = 27.8; P < .001). Hospital cardiac surgery volume did not correlate with the proportion of AF patients treated with SA (rs = 0.19; P = .603) with a rate of SA below the state average for academic centers. Of cases with SA (n = 1582), only 43% had a biatrial lesion set. Procedures that involved mitral surgery were more likely to include a biatrial lesion set (χ2 = 392.3; P < .001) for both paroxysmal and persistent AF. Similarly, ablation technology use was variable by type of concomitant operation (χ2 = 219.0; P < .001) such that radiofrequency energy was more likely to be used in non-mitral procedures. CONCLUSIONS: These results indicate an increase in adoption of SA for AF over time. No association between greater hospital volume or academic status and performance of SA for AF was established. Similar to national data, the type of index procedure remains the most consistent factor in the decision to perform SA with a disconnect between AF pathophysiology and decision making on the type of SA performed. This analysis demonstrates a gap between evidence-based guidelines and real-world practice, highlighting an opportunity to confer the benefits of concomitant SA to more patients.

Non-resectional cordal repair for Barlow mitral valve disease.

BACKGROUND: The redundant leaflet tissue and annular pathology of Barlow disease can make surgical repair challenging. We examined perioperative and late outcomes of a large cohort of patients with Barlow disease undergoing surgical repair. METHODS: Patients included in this analysis underwent mitral valve repair from 01/2004-11/2021 by a single surgeon. RESULTS: Of 2798 patients undergoing mitral valve operations, 46% (N.=1292) had degenerative pathology and 7% (N.=184) had Barlow disease. Of the 179 Barlow patients, median age at surgery was 62 (51-70) years; 64% were male (115/179). Rates of non-resectional cordal repair and resectional repair were 86% (154/179) and 14% (25/179). Among patients undergoing non-resectional repair, the median number of cordal pairs inserted on the anterior and posterior leaflets was 2 (2-3) and 4 (3-4). Incidence of return to bypass for systolic anterior motion of the mitral valve, perioperative death, stroke, and renal failure was 2% (4/179), 1% (2/179), 0% (0/179), and 0% (0/179). Rates of clinical and echocardiographic follow-up were 93% (165/177) and 89% (157/177). Median time to latest postoperative clinical and echocardiographic follow-up was 2.4 (0.8-6.1) and 2.1 (0.6-4.7) years. Mitral regurgitation grade at latest follow-up or time of repair failure was none/trace, mild, mild to moderate, and severe in 63% (98/157), 26% (41/157), 8% (12/157), and 4% (6/157); five of six patients with severe MR underwent reoperation. Since 2011 97% (139/144) of patients underwent cordal repair without resection. CONCLUSIONS: Non-resectional artificial cordal repair is safe and feasible in almost all patients with Barlow valves and is associated with excellent mid-term results.

American Association of Plastic Surgeons Consensus on Breast Implant-Associated Anaplastic Large-Cell Lymphoma.

BACKGROUND: In the absence of high-quality evidence, there is a need for guidelines and multidisciplinary consensus recommendations on breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). The purpose of this expert consensus conference was to evaluate the existing evidence regarding the diagnosis and management of BIA-ALCL caused by textured implants. This article aims to provide evidence-based recommendations regarding the management and prevention of BIA-ALCL. METHODS: A comprehensive search was conducted in the MEDLINE, Cochrane Library, and Embase databases, and supplemented by manual searches of relevant English-language articles and "related articles" sections. Studies focusing on breast surgery and lymphoma associated with breast implants were included for analysis. Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons using a Delphi consensus method. RESULTS: A total of 840 articles published between January of 2011 and January of 2023 were initially identified and screened. The full text of 188 articles was assessed. An additional 43 articles were excluded for focus, and 145 articles were included in the synthesis of results, with 105 of them being case reports or case series. The analysis encompassed a comprehensive examination of the selected articles to determine the incidence, risk factors, clinical presentation, diagnostic approaches, and treatment modalities related to BIA-ALCL. CONCLUSIONS: Plastic surgeons should be aware of the elevated risks by implant surface type, implement appropriate patient surveillance, and follow the recommendations outlined in this statement to ensure patient safety and optimize outcomes. Ongoing research on the pathogenesis, genetic drivers, and preventative and prophylactic measures for BIA-ALCL is crucial for improving patient care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, V.

The state of surgical ablation for atrial fibrillation in patients with mitral valve disease.

PURPOSE OF REVIEW: Atrial fibrillation has been shown to be associated with less favorable short and long-term outcomes in patients having mitral valve surgery. Despite the growing evidence related to the potential benefits of surgical ablation for atrial fibrillation at the time of the mitral valve operation, there is a significant variability among surgeons in their approaches to atrial fibrillation. The purpose of this review is to discuss the current state of surgical ablation for atrial fibrillation as reported in the literature, as well as to discuss the significance of atrial fibrillation and the different surgical approaches to treat patients with mitral valve disease who may also concurrently suffer from tricuspid valve disease and atrial fibrillation. RECENT FINDINGS: Increased mortality and morbidity are expected when atrial fibrillation is left untreated in patients undergoing mitral valve surgery. Modern surgical ablations resulted in a shift from the cut and sew maze procedure to the vast majority of cases being performed using different ablation technologies. The use of ablation technology simplifies the procedure. The expectation is that the vast majority of patients with atrial fibrillation will be ablated at the time of their mitral valve surgery. SUMMARY: Patients who have mitral valve with or without tricuspid valve disease with a significant history of atrial fibrillation may benefit from surgical ablation to eliminate atrial fibrillation. No increased perioperative morbidity or mortality has been documented with an improved long-term survival and very low incidence of thromboembolic events.

Health-related quality of life following isolated aortic valve surgery: is earlier intervention better?

BACKGROUND AND AIM OF THE STUDY: The study aim was to determine the health-related quality of life (HRQL) in conjunction with clinical outcomes following aortic valve replacement (AVR) surgery. In these times of healthcare change, quality measures of the success of a procedure go beyond clinical outcomes, with patient reports of HRQL considered important. METHODS: All patients who had undergone AVR surgery were followed prospectively through the authors' valve registry and the local Society of Thoracic Surgery (STS) database. The HRQL (Short-Form 12 and Minnesota Living with Heart Failure Questionnaire) was collected preoperatively, and at six and 12 months after surgery. RESULTS: Since 2005, a total of 459 patients have undergone isolated AVR surgery. The mean age, ejection fraction and STS risk score were 65.8 +/- 13.6 years, 57.7 +/- 11.0%, and 2.8 +/- 3.5 (range: 0.4-47.9), respectively. The median (IQR) length of hospital stay was 5 (3-7) days. Compared to the STS national norms, all clinical outcomes were excellent. A Kaplan-Meier analysis showed the two year cumulative survival as 92.0%. After 12 months the physical and mental HRQL had improved significantly, surpassing age and heart disease norms (p < 0.001 and p = 0.02, respectively). Multivariate analysis determined that a higher 12-month physical HRQL was predicted by a lower STS risk score (B = -1.3, p < 0.001) and a lower perioperative morbidity (B = -5.5, p = 0.02) after adjustment for baseline HRQL, age, and gender. In a subset of patients classified as 'symptomatic', as determined by higher MLHF scores, the HRQL scores were increased to age norms and surpassed the heart disease norms. CONCLUSION: Patients who undergo AVR can expect excellent clinical and HRQL outcomes, with greater benefits the earlier the surgery is carried out. The tracking of HRQL is valuable in understanding the success of a procedure from the patients' perspective.

Indexed donor cardiac output for improved size matching in heart transplantation: A United Network for Organ Sharing database analysis.

Objective: Implantation of an appropriately sized donor heart is critical for optimal outcomes after heart transplantation. Although predicted heart mass has recently gained consideration, there remains a need for improved granularity in size matching, particularly among small donor hearts. We sought to determine if indexed donor cardiac output is a sensitive metric to assess the adequacy of a donor heart for a given recipient. Methods: A retrospective analysis was performed (2003-2021) in isolated orthotopic heart transplant recipients from the United Network for Organ Sharing database. Donor cardiac output was divided by recipient body surface area to compute cardiac index (donor cardiac index). Predicted heart mass ratio was computed as donor/recipient predicted heart mass. The primary outcome was mortality 1 year after transplant. Results: Among transplant recipients, median donor cardiac output was 7.3 (5.8-9.0) liters per minute and donor cardiac index was 3.7 (3.0-4.6) liters per minute/m2. Predicted heart mass ratio was 1.01 (0.91-1.13). After multivariable adjustment, higher donor cardiac index was associated with lower 1-year mortality risk (odds ratio, 0.92, P = .042). Recipients with predicted heart mass ratio less than 0.80 (n = 255) had a lower median donor cardiac index than those with a predicted heart mass ratio of 0.80 or greater (3.2 vs 3.7, P < .001). As predicted, heart mass ratio became smaller and the association between donor cardiac index and 1-year mortality became progressively stronger. Conclusions: Higher donor cardiac index was associated with a lower probability of 1-year mortality among patients undergoing heart transplantation and served to further quantify mortality risk among those with a small predicted heart mass ratio. Donor cardiac index appears to be an effective tool for size matching and may serve as an adjunctive strategy among small donor hearts with a low predicted heart mass ratio.

Institutional Variability in Red Blood Cell Transfusion With Coronary Bypass in a Statewide Database.

BACKGROUND: The decision to perform transfusion is common but varies among centers and surgeons. This study looked at variables associated with red blood cell (RBC) transfusion in a statewide database. The study aimed to understand discrepancies in transfusion rates among hospitals and to establish whether the hospital itself was a significant variable in transfusion, independent of variables known to affect transfusion in patients undergoing cardiac surgical procedures. METHODS: The Maryland Cardiac Surgery Quality Initiative is a consortium of centers in the state. Patients undergoing isolated coronary artery bypass grafting from January 2018 to June 2020 from 10 centers in Maryland were included. Multivariable logistic regression was used to determine probability of RBC transfusion with covariates, including age, preoperative hemoglobin value, The Society of Thoracic Surgeons predicted risk of mortality, emergency status, preoperative adenosine diphosphate receptor blocker use, sex, body mass index, and off-pump status. RESULTS: A total of 5343 patients were included and had an overall RBC transfusion rate of 30.3% (range, 11.3%-55.8%). There was significant variability in the incidence of RBC transfusion among hospitals (χ2 = 604.7; P < .001). After covariate adjustment, a significant effect of hospital on transfusion remained (Wald = 547.3; P < .001). Hospital variation in RBC transfusion was not correlated with hospital variation in median age (P = .467), hemoglobin (P 0 855), The Society of Thoracic Surgeons predicted risk of mortality (P = .855), or sex (P = .726). CONCLUSIONS: In a statewide analysis, wide variability in transfusion rates was observed, with hospital-specific management strongly associated with RBC transfusion. This study suggests that RBC transfusion may be affected by the culture and practices of an institution independent of clinical and demographic variables.

Unexpected impact of preoperative anemia in low-risk isolated coronary artery bypass grafting or single-valve surgical patients: Do not overlook these patients in anemia management!

OBJECTIVE: Preoperative anemia is prevalent in cardiac surgery and independently associated with increased risk for short-term and long-term mortality. The purpose of this study was to examine the effect of preoperative hematocrit (Hct) on outcomes in cardiac surgical patients and whether the effect is comparable across levels of Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM). METHODS: The study consisted of adult, isolated coronary artery bypass grafting (CABG) or single-valve surgical patients in a statewide registry from 2011 to 2022 (N = 29,828). Regressions were used to assess effect of preoperative Hct on STS-defined major morbidity/mortality including the interaction of Hct and STS PROM as continuous variables. RESULTS: Median age was 66 years (58-73 years), STS PROM was 1.02% (0.58%-1.99%), and preoperative Hct was 39.5% (35.8%-42.8%). The sample consisted of 78% isolated CABG (n = 23,261), 10% isolated mitral valve repair/replacement (n = 3119), 12% isolated aortic valve replacement (n = 3448), and 29% were female (n = 8646). Multivariable analyses found that greater Hct was associated with reduced risk of STS-defined morbidity/mortality (odds ratio, 0.96; P < .001). These effects for Hct persisted even after adjustment for intraoperative blood transfusion. The interaction of Hct and STS PROM was significant for morbidity/mortality (odds ratio, 1.01; P < .001). There was a stronger association between Hct levels and morbidity/mortality risk in the patients with the lowest STS risk compared with patients with the greatest STS risk. CONCLUSIONS: Patients with lower risk had a greater association between preoperative Hct and major morbidity and mortality compared with patients with greater risk. Preoperative anemia management is essential across all risk groups for improved outcomes.