The axis of local cardiac endogenous Klotho-TGF-ß1-Wnt signaling mediates cardiac fibrosis in human.

BACKGROUND: Cardiovascular fibrosis is a major contributor to cardiovascular disease, the primary cause of death in patients with chronic kidney disease (CKD). We previously reported expression of endogenous Klotho in human arteries, and that CKD is a state of Klotho deficiency, resulting in vascular calcification, but myocardial expression of Klotho is poorly understood. This study aimed to further clarify endogenous Klotho's functional roles in cardiac fibrosis in patients with underlying CKD. METHODS AND RESULTS: Human atrial appendage specimens were collected during cardiac surgery from individuals with or without CKD. Cardiac fibrosis was quantified using trichrome staining. For endogenous Klotho functional studies, primary human cardiomyocytes (HCMs) were treated with uremic serum from CKD patients or recombinant human TGF-ß1. The effects of endogenous Klotho in HCMs were studied using Klotho-siRNA and Klotho-plasmid transfection. Both gene and protein expression of endogenous Klotho are found in human heart, but decreased Klotho expression is clearly associated with the degree of cardiac fibrosis in CKD patients. Moreover, we show that endogenous Klotho is expressed by HCMs and cardiac fibroblasts (HCFs) but that HCM expression is suppressed by uremic serum or TGF-ß1. Klotho knockdown or overexpression aggravates or mitigates TGF-ß1-induced fibrosis and canonical Wnt signaling in HCMs, respectively. Furthermore, co-culture of HCMs with HCFs increases TGF-ß1-induced fibrogenic proteins in HCFs, but overexpression of endogenous Klotho in HCMs mitigates this effect, suggesting functional crosstalk between HCMs and HCFs. CONCLUSIONS: Our data from analysis of human hearts as well as functional in vitro studies strongly suggests that the loss of cardiac endogenous Klotho in CKD patients, specifically in cardiomyocytes, facilitates intensified TGF-ß1 signaling which enables more vigorous cardiac fibrosis through upregulated Wnt signaling. Upregulation of endogenous Klotho inhibits pathogenic Wnt/ß-catenin signaling and may offer a novel strategy for prevention and treatment of cardiac fibrosis in CKD patients.

Surgical pulmonary embolectomy and catheter-directed thrombolysis for treatment of submassive pulmonary embolism.

BACKGROUND: Acute pulmonary embolism (PE) with preserved hemodynamics but right ventricular dysfunction, classified as submassive PE, carries a high risk of mortality. We report the results for patients who did not qualify for medical therapy and required treatment of submassive PE with surgical pulmonary embolectomy and catheter-directed thrombolysis (CDT). METHODS: Between October 1999 and May 2015, 133 submassive PE patients underwent treatment with pulmonary embolectomy (71) and CDT (62). A multidisciplinary PE response team helped to determine the most appropriate treatment strategy on a case-by-case basis. The EkoSonic ultrasound-facilitated thrombolysis system (EKOS) was used for CDT, which was introduced in 2010. RESULTS: The mean age of submassive PE patients was 57.3 years, which included 36.8% females. PE risk factors included previous deep venous thrombosis (46.6%), immobility (36.1%), recent surgery (30.8%), and cancer (22.6%), P < 0.05. The most common indication for advanced treatment was right ventricular strain (42.9%), P = 0.03. The frequency of surgical pulmonary embolectomy remained stable even after incorporating the EKOS procedure into our treatment algorithm, with statistically similar operative mortality. Bleeding was observed in six CDT patients and one pulmonary embolectomy patient (P < 0.05). Follow-up echocardiography was available for 61% of the overall cohort, of whom 76.5% had no residual moderate or severe right ventricular dysfunction. CONCLUSIONS: Pulmonary embolectomy and CDT are important contemporary advanced treatment options for selected high-risk patients with submassive PE, who do not qualify for medical therapy.

Current state-of-the-art of device therapy for advanced heart failure.

Heart failure remains one of the most common causes of morbidity and mortality worldwide. The advent of mechanical circulatory support devices has allowed significant improvements in patient survival and quality of life for those with advanced or end-stage heart failure. We provide a general overview of past and current mechanical circulatory support devices encompassing options for both short- and long-term ventricular support.

Prediction of operative mortality for patients undergoing cardiac surgical procedures without established risk scores.

OBJECTIVE: Current cardiac surgery risk models do not address a substantial fraction of procedures. We sought to create models to predict the risk of operative mortality for an expanded set of cases. METHODS: Four supervised machine learning models were trained using preoperative variables present in the Society of Thoracic Surgeons (STS) data set of the Massachusetts General Hospital to predict and classify operative mortality in procedures without STS risk scores. A total of 424 (5.5%) mortality events occurred out of 7745 cases. Models included logistic regression with elastic net regularization (LogReg), support vector machine, random forest (RF), and extreme gradient boosted trees (XGBoost). Model discrimination was assessed via area under the receiver operating characteristic curve (AUC), and calibration was assessed via calibration slope and expected-to-observed event ratio. External validation was performed using STS data sets from Brigham and Women's Hospital (BWH) and the Johns Hopkins Hospital (JHH). RESULTS: Models performed comparably with the highest mean AUC of 0.83 (RF) and expected-to-observed event ratio of 1.00. On external validation, the AUC was 0.81 in BWH (RF) and 0.79 in JHH (LogReg/RF). Models trained and applied on the same institution's data achieved AUCs of 0.81 (BWH: LogReg/RF/XGBoost) and 0.82 (JHH: LogReg/RF/XGBoost). CONCLUSIONS: Machine learning models trained on preoperative patient data can predict operative mortality at a high level of accuracy for cardiac surgical procedures without established risk scores. Such procedures comprise 23% of all cardiac surgical procedures nationwide. This work also highlights the value of using local institutional data to train new prediction models that account for institution-specific practices.

Cardiac angiosarcoma management and outcomes: 20-year single-institution experience.

PURPOSE: To identify the clinicopathologic characteristics, treatments, and outcomes of a series of patients with primary cardiac angiosarcoma (AS). METHODS: This retrospective case series was set in a tertiary referral center with a multidisciplinary clinic. Consecutive patients with institutionally confirmed pathologic diagnosis of cardiac AS from January 1990 to May 2011 were reviewed. Main outcome measures included patient demographics, tumor characteristics, management strategies, disease response, and survival. RESULTS: Data from 18 patients (78 % male) were reviewed. Sixteen patients (89 %) had AS originating in the right atrium. At diagnosis, eight patients (44 %) had localized/locally advanced disease and ten patients (56 %) had metastatic disease. Initial treatment strategies included resection (44 %), chemotherapy (39 %), and radiotherapy (11 %). Of the eight patients with localized/locally advanced AS, two underwent macroscopically complete resection with negative microscopic margins, one underwent macroscopically complete resection with positive microscopic margins, one underwent macroscopically incomplete resection, two received chemotherapy followed by surgery and intraoperative radiotherapy, one received chemotherapy alone, and one died before planned radiotherapy. Median follow-up was 12 months. Median overall survival (OS) was 13 months for the entire cohort; median OS was 19.5 months for those presenting with localized/locally advanced AS and 6 months for those with metastatic disease at presentation (p = 0.08). Patients who underwent primary tumor resection had improved median OS compared with patients whose tumors remained in situ (17 vs. 5 months, p = 0.01). CONCLUSIONS: Cardiac AS is associated with poor prognosis. Resection of primary tumor should be attempted when feasible, as OS may be improved. Nevertheless, most patients die of disease progression.

Defective DNA replication impairs mitochondrial biogenesis in human failing hearts.

RATIONALE: Mitochondrial dysfunction plays a pivotal role in the development of heart failure. Animal studies suggest that impaired mitochondrial biogenesis attributable to downregulation of the peroxisome proliferator-activated receptor gamma coactivator (PGC)-1 transcriptional pathway is integral of mitochondrial dysfunction in heart failure. OBJECTIVE: The study sought to define mechanisms underlying the impaired mitochondrial biogenesis and function in human heart failure. METHODS AND RESULTS: We collected left ventricular tissue from end-stage heart failure patients and from nonfailing hearts (n=23, and 19, respectively). The mitochondrial DNA (mtDNA) content was decreased by >40% in the failing hearts, after normalization for a moderate decrease in citrate synthase activity (P<0.05). This was accompanied by reductions in mtDNA-encoded proteins (by 25% to 80%) at both mRNA and protein level (P<0.05). The mRNA levels of PGC-1alpha/beta and PRC (PGC-1-related coactivator) were unchanged, whereas PGC-1alpha protein increased by 58% in the failing hearts. Among the PGC-1 coactivating targets, the expression of estrogen-related receptor alpha and its downstream genes decreased by up to 50% (P<0.05), whereas peroxisome proliferator-activated receptor alpha and its downstream gene expression were unchanged in the failing hearts. The formation of D-loop in the mtDNA was normal but D-loop extension, which dictates the replication process of mtDNA, was decreased by 75% in the failing hearts. Furthermore, DNA oxidative damage was increased by 50% in the failing hearts. CONCLUSIONS: Mitochondrial biogenesis is severely impaired as evidenced by reduced mtDNA replication and depletion of mtDNA in the human failing heart. These defects are independent of the downregulation of the PGC-1 expression suggesting novel mechanisms for mitochondrial dysfunction in heart failure.

Descending aortic calcification increases renal dysfunction and in-hospital mortality in cardiac surgery patients with intraaortic balloon pump counterpulsation placed perioperatively: a case control study.

INTRODUCTION: Acute kidney injury (AKI) after cardiac surgery increases length of hospital stay and in-hospital mortality. A significant number of patients undergoing cardiac surgical procedures require perioperative intra-aortic balloon pump (IABP) support. Use of an IABP has been linked to an increased incidence of perioperative renal dysfunction and death. This might be due to dislodgement of atherosclerotic material in the descending thoracic aorta (DTA). Therefore, we retrospectively studied the correlation between DTA atheroma, AKI and in-hospital mortality. METHODS: A total of 454 patients were retrospectively matched to one of four groups: -IABP/-DTA atheroma, +IABP/-DTA atheroma, -IABP/+DTA atheroma, +IABP/+DTA atheroma. Patients were then matched according to presence/absence of DTA atheroma, presence/absence of IABP, performed surgical procedure, age, gender and left ventricular ejection fraction (LVEF). DTA atheroma was assessed through standard transesophageal echocardiography (TEE) imaging studies of the descending thoracic aorta. RESULTS: Basic patient characteristics, except for age and gender, did not differ between groups. Perioperative AKI in patients with -DTA atheroma/+IABP was 5.1% versus 1.7% in patients with -DTA atheroma/-IABP. In patients with +DTA atheroma/+IABP the incidence of AKI was 12.6% versus 5.1% in patients with +DTA atheroma/-IABP. In-hospital mortality in patients with +DTA atheroma/-IABP was 3.4% versus 8.4% with +DTA atheroma/+IABP. In patients with +DTA atheroma/+IABP in hospital mortality was 20.2% versus 6.4% with +DTA atheroma/-IABP. Multivariate logistic regression identified DTA atheroma>1 mm (P=*0.002, odds ratio (OR)=4.13, confidence interval (CI)=1.66 to 10.30), as well as IABP support (P=*0.015, OR=3.04, CI=1.24 to 7.45) as independent predictors of perioperative AKI and increased in-hospital mortality. DTA atheroma in conjunction with IABP significantly increased the risk of developing acute kidney injury (P=0.0016) and in-hospital mortality (P=0.0001) when compared to control subjects without IABP and without DTA atheroma. CONCLUSIONS: Perioperative IABP and DTA atheroma are independent predictors of perioperative AKI and in-hospital mortality. Whether adding an IABP in patients with severe DTA calcification increases their risk of developing AKI and mortality postoperatively cannot be clearly answered in this study. Nevertheless, when IABP and DTA are combined, patients are more likely to develop AKI and to die postoperatively in comparison to patients without IABP and DTA atheroma.

Ventricular Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy (Analysis Spanning 60 Years Of Practice): AJC Expert Panel.

Surgical myectomy remains the time-honored primary treatment for hypertrophic cardiomyopathy patients with drug refractory limiting symptoms due to LV outflow obstruction. Based on >50 years experience, surgery reliably reverses disabling heart failure by permanently abolishing mechanical outflow impedance and mitral regurgitation, with normalization of LV pressures and preserved systolic function. A consortium of 10 international currently active myectomy centers report about 11,000 operations, increasing significantly in number over the most recent 15 years. Performed in experienced multidisciplinary institutions, perioperative mortality for myectomy has declined to 0.6%, becoming one of the safest currently performed open-heart procedures. Extended myectomy relieves symptoms in >90% of patients by ≥ 1 NYHA functional class, returning most to normal daily activity, and also with a long-term survival benefit; concomitant Cox-Maze procedure can reduce the number of atrial fibrillation episodes. Surgery, preferably performed in high volume clinical environments, continues to flourish as a guideline-based and preferred high benefit: low treatment risk option for adults and children with drug refractory disabling symptoms from obstruction, despite prior challenges: higher operative mortality/skepticism in 1960s/1970s; dual-chamber pacing in 1990s, alcohol ablation in 2000s, and now introduction of novel negative inotropic drugs potentially useful for symptom management.

Current Management of Sternal Wounds.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the pathogenesis, classification, and risk factors of sternal wound infection. 2. Discuss options for sternal stabilization for the prevention of sternal wound infection, including wiring and plating techniques. 3. Discuss primary surgical reconstructive options for deep sternal wound infection and the use of adjunctive methods, such as negative-pressure wound therapy. SUMMARY: Poststernotomy sternal wound infection remains a life-threatening complication of open cardiac surgery. Successful treatment relies on timely diagnosis and initiation of multidisciplinary, multimodal therapy.

Ventricular assist device in patients with prosthetic heart valves.

Ventricular assist device (VAD) support inpatients with a prosthetic heart valve had previously been considered a relative contraindication due to an increased risk of thromboembolic complications. We report our clinical experience of VAD implantation in patients with prosthetic heart valves, including both mechanical and bioprosthetic valves. The clinical records of 133 consecutive patients who underwent VAD implantation at a single institution from January 2002 through June 2009 were retrospectively reviewed. Six of these patients had a prosthetic valve in place at the time of device implantation. Patient demographics,operative characteristics, and postoperative complications were reviewed.Of the six patients,four were male.The mean age was 57.8 years (range 35­66 years). The various prosthetic cardiac valves included a mechanical aortic valve (n = 2), a bioprosthetic aortic valve (n = 3), and a mechanical mitral valve (n = 1).The indications for VAD support included bridge to transplantation (n = 2), bridge to recovery (n = 1), and postcardiotomy ventricular failure(n = 3). Three patients underwent left ventricular assist device placement and three received a right ventricular assist device. Postoperatively, standard anticoagulation management began with a heparin infusion (if possible)followed by oral anticoagulation.The 30-day mortality was50% (3/6). The mean duration of support among survivors was 194.3 days (range 7­369 days) compared with 16.0 days(range 4­29 days) for nonsurvivors. Of the three survivors,two were successfully bridged to heart transplantation and one recovered native ventricular function.Among the three nonsurvivors,acute renal failure developed in each case, and two developed heparin-induced thrombocytopenia. This study suggests that VAD placement in patients with a prosthethic heart valve, either mechanical or bioprosthetic,appears to be a reasonable option.

Cardiac Surgery in Patients With Opioid Use Disorder: An Analysis of 1.7 Million Surgeries.

BACKGROUND: Adverse repercussions associated with the current opioid epidemic have been documented in many surgical specialties. This study evaluated the impact of opioid use disorder (OUD) on in-hospital cardiac surgery outcomes by using a large national database. METHODS: Using the National Inpatient Sample, this study isolated patients undergoing coronary artery bypass grafting, valve repair, or valve replacement from 2009 to 2014. Patients were stratified by OUD status. Multivariable analysis was performed to evaluate the association between opioid use and postoperative outcomes. Patients were further stratified by surgery type. RESULTS: Overall, 1,743,161 patients underwent cardiac surgery, and 6960 patients had OUD (0.4%). Mean age was 47.2 and 65.8 years among those with and without OUD, respectively. Although in-hospital mortality did not differ among these groups, patients with OUD had a significantly higher incidence of stroke (8.3% vs 2.8%) and acute kidney injury (21.4% vs 16.2%), longer hospital stays (18 days vs 10 days), and higher hospitalization costs ($81,238 vs $58,654; all P < .01). However, after adjusting for patient and hospital-level factors, OUD was associated only with a longer hospital length of stay (2.2 days; 95% confidence interval, 1.19 to 3.20) compared with non-opioid users. CONCLUSIONS: OUD among cardiac surgery patients is associated with prolonged hospitalization and increased risk of postoperative morbidity, mainly driven by the patient's preoperative risk factors. Strategies to minimize these risk factors at the prehospitalization level is warranted to curb the opioid epidemic and improve overall outcomes in this vulnerable population.

Sex-based differences in mitral valve Re-operation after mitral valve repair: Truth or myth?

BACKGROUND: Outcomes after mitral valve (MV) repair are known to be worse in women. Less is known about sex-based differences in MV repair durability. METHODS: All adult patients undergoing MV repair from 2002 to 2016 were reviewed. Of 2463 cases, 947 (39%) were women. Re-operation risk was defined as any intervention for repair failure or MV disease progression. Median follow-up was 8.2 years. RESULTS: Women were older with higher STS-risk scores and were more likely to have rheumatic disease (RHD). Operative mortality was clinically higher in women (2.7% vs 1.7%; P = 0.09). Although women had significantly higher 10-year re-operation risk (7% vs 4%), adjusted longitudinal analysis showed that this was associated with RHD in women (HR 4.04; P = 0.001). Female sex alone was not a significant predictor (P = 0.21). CONCLUSIONS: Re-operation following MV repair was infrequent. Women had increased re-operation risk that was largely attributable to their worse preoperative profiles rather than female sex alone.

Significance of Interstitial Lung Disease on Outcomes Following Cardiac Surgery.

Interstitial lung disease (ILD) is a known risk factor for noncardiac surgery due to acute pulmonary exacerbations but its impact after cardiac surgery is not known. We examined perioperative outcomes and risk factors for long-term survival in ILD patients who underwent cardiac surgery. From January 2002 to June 2017, 294 cardiac surgery patients with a previous ILD diagnosis, including 75 patients with idiopathic pulmonary fibrosis (IPF), were identified. A comparison cohort of 1,481 non-ILD patients was selected based on a priori variables. Long-term survival was evaluated using Cox proportional hazard modeling. Median follow-up was 6.4 years. ILD patients had higher postoperative mortality, reintubation rates, longer intensive care unit stay, and higher 30-day readmission rates (all p <0.05). Kaplan-Meier estimates of survival at 1, 5, and 10 years were 89%, 62%, and 37% for the non-IPF ILD cohort, 89%, 50%, and 13% for the IPF cohort, and 95%, 82%, and 67% for the comparison cohort, respectively (overall p <0.001). These significant differences in survival persisted in our risk-adjusted survival analysis. Adjusted survival analysis identified IPF (hazard ratio 3.04) and ILD (non-IPF; hazard ratio 1.78) as significant contributors to all-cause mortality. However, there were no changes in pulmonary function tests after 48 months postprocedure. In conclusion, ILD patients who underwent cardiac surgery have increased operative mortality, reintubation rates, longer intensive care unit, and higher 30-day readmissions compared with non-ILD patients. Moreover, severity of ILD, especially in IPF, appears to be associated with shorter long-term survival. In these patients, pulmonary risk stratification and multidisciplinary team approach are crucial.

Early and late outcomes of 1000 minimally invasive aortic valve operations.

OBJECTIVE: Minimal access cardiac valve surgery is increasingly utilized. We report our 11-year experience with minimally invasive aortic valve surgery. METHODS: From 07/96 to 12/06, 1005 patients underwent minimally invasive aortic valve surgery. Early and late outcomes were analyzed. RESULTS: Median patient age was 68 years (range: 24-95), 179 patients (18%) were 80 years or older, 130 patients (13%) had reoperative aortic valve surgery, 86 (8.4%) had aortic root replacement, 62 (6.1%) had concomitant ascending aortic replacement, and 26 (2.6%) had percutaneous coronary intervention on the day of surgery (hybrid procedure). Operative mortality was 1.9% (19/1005). The incidences of deep sternal wound infection, pneumonia and reoperation for bleeding were 0.5% (5/1005), 1.3% (13/1005) and 2.4% (25/1005), respectively. Median length of stay was 6 days and 733 patients (72%) were discharged home. Actuarial survival was 91% at 5 years and 88% at 10 years. In the subgroup of the elderly (> or =80 years), operative mortality was 1.7% (3/179), median length of stay was 8 days and 66 patients (37%) were discharged home. Actuarial survival at 5 years was 84%. There was a significant decreasing trend in cardiopulmonary bypass time, the incidence of bleeding, and operative mortality over time. CONCLUSIONS: Minimal access approaches in aortic valve surgery are safe and feasible with excellent outcomes. Aortic root replacement, ascending aortic replacement, and reoperative surgery can be performed with these approaches. These procedures are particularly well-tolerated in the elderly.

Early and late outcomes of multiple coronary endarterectomy.

OBJECTIVES: Coronary endarterectomy has been shown to be an effective adjunctive technique of revascularization for diffuse coronary artery disease. However, outcomes of multiple coronary endarterectomy (MCE) have not been well investigated. We sought to examine early and late results of this technique. METHODS: Between January 1992 and June 2006, 58 consecutive patients underwent coronary endarterectomy in more than one coronary artery territories, representing 6.5% of total coronary endarterectomy during the same period. Early and late outcomes were retrospectively analyzed. RESULTS: The mean age was 64 years. Forty-one patients (70.7%) had coronary endarterectomy in the left anterior descending artery and right coronary artery territories; five (8.6%) in the left anterior descending artery and circumflex artery territories; eight (13.8%) in the circumflex artery and right coronary artery territories; and four (6.9%) in the left anterior descending artery, circumflex artery, and right coronary artery territories. Operative mortality was 12.1% (7/58). The incidence of perioperative myocardial infarction was 25.9% (15/58). The median length of hospital stay was seven days. Actuarial five- and 10-year survivals were 64% and 36%, respectively. CONCLUSIONS: MCE may be a reasonable option for revascularization of multiple diffuse coronary artery disease. However, early and late outcomes are relatively poor and the indication should be carefully considered.

Minimally invasive versus full sternotomy aortic valve replacement in low-risk patients: Which will stand against transcatheter aortic valve replacement?

BACKGROUND: Minimally invasive aortic valve replacement using upper-hemisternotomy has been associated with improved results compared to full sternotomy aortic valve replacement. Given the likely expansion of transcatheter aortic valve replacement to low-risk patients, we examine contemporary outcomes after full sternotomy and minimally invasive aortic valve replacement in low-risk patients using our 15-year experience. METHODS: Two thousand ninety-five low-risk patients (Society of Thoracic Surgeons Predicted Risk of Mortality score <4) underwent elective isolated aortic valve replacement, including 1,029 (49%) minimally invasive and 1,066 (51%) full sternotomy, from 2002 to 2015. RESULTS: Compared to minimally invasive aortic valve replacement patients, full sternotomy aortic valve replacement patients had a greater burden of comorbidities, including diabetes, stroke, congestive heart failure, and predicted risk of mortality (all P ≤ .05). Operative mortality, stroke, and reoperation rates for bleeding were similar. There was a clinical trend toward shorter median intensive care unit stay and significantly shorter hospital length of stay among minimally invasive aortic valve replacement patients. Adjusted survival analysis identified age, chronic kidney disease, prior sternotomy, and congestive heart failure as predictors of decreased survival (all P ≤ .05), while type of intervention approach was nonsignificantly different. CONCLUSION: In low-risk patients, minimally invasive aortic valve replacement results in similar mortality, stroke, reoperation rates for bleeding, and midterm survival (after adjusting for confounders), but shorter hospital length of stay and a trend (P = .075) toward shorter intensive care unit stay, compared to full sternotomy aortic valve replacement. Therefore, minimally invasive aortic valve replacement should stand as a benchmark against transcatheter aortic valve replacement in these patients.

Outcomes of repeat mitral valve replacement in patients with prior mitral surgery: A benchmark for transcatheter approaches.

OBJECTIVES: With the emergence of transcatheter mitral valve-in-valve/ring replacement for deteriorated bioprostheses or failed repair, comparative clinical benchmarks for surgical repeat mitral valve replacement (re-MVR) are needed. We present in-hospital and survival outcomes of a 24-year experience with re-MVR. METHODS: From January 1992 to June 2015, 520 adult patients underwent re-MVR; 273 had undergone prior mitral valve repair (pMVP) and 247 had undergone prior MVR (pMVR). A benchmark cohort of isolated re-MVR was defined based on potential eligibility for transcatheter mitral valve-in-valve/ring replacement, resulting in 73 pMVPs with previous annuloplasty rings and 74 pMVRs with previous bioprosthetic valves for comparison. RESULTS: For the entire cohort, mean age was 64 ± 12 years for pMVP patients and 63 ± 15 years for pMVR patients (P = .281), which was similar for the benchmark cohort. Overall operative mortality was 14 out of 273 (5%) for pMVP versus 23 out of 247 (9%) for pMVR (P = .087). There were 3 operative deaths (4.1%) in both groups of the benchmark cohort (P = 1.0). For the benchmark cohort, median time to reoperation was 9.8 years for pMVP and 9.1 years for pMVR. Cox proportional hazard analysis showed that chronic kidney disease (hazard ratio [HR], 2.47; 95% CI, 1.77-3.44), endocarditis (HR, 1.49; 95% CI, 1.07-2.07), pMVR (HR, 1.45; 95% CI, 1.12-1.89), early reoperation ≤ 1 year (HR, 1.49; 95% CI, 1.02-2.17), and age (HR, 1.04/y; 95% CI, 1.03-1.05) were associated with decreased survival after re-MVR. CONCLUSIONS: A re-MVR is a high-risk operation, but in carefully selected patients such as our benchmark population, it can be performed with acceptable results. Patients undergoing pMVP also have better long-term survival compared with patients undergoing pMVR. These results will serve as a benchmark for transcatheter mitral valve-in-valve/ring replacement.

Surgical management of tricuspid stenosis.

Tricuspid valve stenosis (TS) is rare, affecting less than 1% of patients in developed nations and approximately 3% of patients worldwide. Detection requires careful evaluation, as it is almost always associated with left-sided valve lesions that may obscure its significance. Primary TS is most frequently caused by rheumatic valvulitis. Other causes include carcinoid, radiation therapy, infective endocarditis, trauma from endomyocardial biopsy or pacemaker placement, or congenital abnormalities. Surgical management of TS is not commonly addressed in standard cardiac texts but is an important topic for the practicing surgeon. This paper will elucidate the anatomy, pathophysiology, and surgical management of TS.

Those who do not remember the past are condemned to repeat it.

Transcatheter aortic valve replacement (TAVR) for aortic valve stenosis has rapidly progressed from its initial application in the inoperable or high-risk patients to those determined to be intermediate and low risk. It is our concern this has occurred without adequate knowledge or examination of the long-term durability of TAVR valves and the impact on subsequent aortic valve surgery, should it be required. In this editorial, we provide insight and reflect upon lessons learned from past surgical techniques and their subsequent abandonment.