Trends in Infective Endocarditis in California and New York State, 1998-2013.

IMPORTANCE: Prophylaxis and treatment guidelines for infective endocarditis have changed substantially over the past decade. In the United States, few population-based studies have explored the contemporary epidemiology and outcomes of endocarditis. OBJECTIVE: To quantify trends in the incidence and etiologies of infective endocarditis in the United States. DESIGN, SETTING, AND PARTICIPANTS: Retrospective population epidemiology study of patients hospitalized with a first episode of endocarditis identified from mandatory state databases in California and New York State between January 1, 1998, and December 31, 2013. EXPOSURE: Infective endocarditis. MAIN OUTCOMES AND MEASURES: Outcomes were crude and standardized incidence of endocarditis and trends in patient characteristics and disease etiology. Trends in acquisition mode, organism, and mortality were analyzed. RESULTS: Among 75 829 patients with first episodes of endocarditis (mean [SD] age, 62.3 [18.9] years; 59.1% male), the standardized annual incidence was stable between 7.6 (95% CI, 7.4 to 7.9) and 7.8 (95% CI, 7.6 to 8.0) cases per 100 000 persons (annual percentage change [APC], -0.06%; 95% CI, -0.3% to 0.2%; P = .59). From 1998 through 2013, the proportion of patients with native-valve endocarditis decreased (from 74.5% to 68.4%; APC, -0.7%; 95% CI, -0.9% to -0.5%; P < .001). Prosthetic-valve endocarditis increased (from 12.0% to 13.8%; APC, 1.3%; 95% CI, 0.8% to 1.7%; P < .001), and cardiac device-related endocarditis increased (from 1.3% to 4.1%; APC, 8.8%; 95% CI, 7.8% to 9.9%; P < .001). The proportion of patients with health care-associated nosocomial endocarditis decreased (from 17.7% to 15.3%; APC, -1.0%; 95% CI, -1.4% to -0.7%; P < .001). The proportion of patients with health care-associated nonnosocomial endocarditis increased (from 32.1% to 35.9%; APC, 0.8%; 95% CI, 0.5% to 1.1%; P < .001). The incidence of oral streptococcal endocarditis did not increase (unadjusted: APC, -0.1%; 95% CI, -0.8% to 0.6%; P = .77; adjusted: APC, -1.3%; 95% CI, -1.8% to -0.7%; P < .001). Crude 90-day mortality was unchanged (from 23.9% to 24.2%; APC, -0.3%; 95% CI, -1.0% to 0.4%; P = .44); adjusted risk of 90-day mortality decreased (adjusted hazard ratio per year, 0.982; 95% CI, 0.978 to 0.986; P < .001). CONCLUSIONS AND RELEVANCE: In California and New York State, the overall standardized incidence of infective endocarditis was stable from 1998 through 2013, with changes in patient characteristics and etiology over this time.

Intracardiac migration of vena caval stent: decision-making and treatment considerations.

Migration and embolization of intravenously placed devices has been described previously with inferior vena cava (IVC) filters but not stents. While patients with intracardiac embolization of venous devices may be asymptomatic, we present a patient with symptomatic migration of an IVC stent to the heart and discuss the treatment considerations and decision-making involved.

Incidence, Outcomes, and Opportunity for Left Ventricular Assist Device Weaning for Myocardial Recovery.

BACKGROUND: Myocardial recovery occurs in patients with advanced heart failure on left ventricular assist device (LVAD) support, but there is the premise that it is rare with uncertain results. OBJECTIVES: The goal of this study was to investigate the incidence and consequence of LVAD explant after myocardial recovery. METHODS: Using the United Network for Organ Sharing registry, LVAD implants in the United States between 2005 and 2020 were tracked until death, transplantation, or explant for myocardial recovery. The cohort undergoing explant was followed up for heart failure relapse (defined as relisting followed by delisting due to death, being too ill, or transplantation; or second durable LVAD implant). RESULTS: Of 15,728 LVAD implants, 126 patients underwent explant for recovery, which only occurred in 55 (38%) of 145 implanting centers. The crude cumulative incidence was 0.7% at 2 years, whereas the incidence reached 4.7% among designated centers in the selected young nonischemic cohort. Of 126 explanted patients, 76 (60%) were subsequently delisted for sustained recovery. Heart failure relapsing had a relatively higher hazard in the early phase, with a 30-day incidence of 6% (7 of 126) but tapered following with the freedom rate of 72.5% at 4 years. CONCLUSIONS: In the United States, LVAD explant for myocardial recovery was underutilized, leading to a very low incidence at the national level despite a realistic rate being achieved in designated centers for selected patients. With follow-up extending up to 4 years after explant, more than one-half were successfully removed and stayed off the waitlist, and approximately 70% were free from heart failure relapse events.

Total artificial heart implantation as a bridge to transplantation in the United States.

OBJECTIVES: Although the SynCardia total artificial heart (SynCardia Systems, LLC) was approved for use as a bridge to transplantation in 2004 in the United States, most centers do not adopt the total artificial heart as a standard bridging strategy for patients with biventricular failure. This study was designed to characterize the current use and outcomes of patients placed on total artificial heart support. METHODS: The United Network of Organ Sharing Standard Transplant Research File was queried to identify total artificial heart implantation in the United States between 2005 and 2018. Multivariable Cox regression models were used for risk prediction. RESULTS: A total of 471 patients (mean age, 49 years; standard deviation, 13 years; 88% were male) underwent total artificial heart implantation. Of 161 transplant centers, 11 centers had cumulative volume of 10 or more implants. The 6-month cumulative incidence of mortality on the total artificial heart was 24.6%. The 6-month cumulative incidence of transplant was 49.0%. The 1-year mortality post-transplantation was 20.0%. Cumulative center volume less than 10 implants was predictive of both mortality on the total artificial heart (hazard ratio, 2.2, 95% confidence interval, 1.5-3.1, P < .001) and post-transplant mortality after a total artificial heart bridge (hazard ratio, 1.5, 95% confidence interval, 1.0-2.2, P = .039). CONCLUSIONS: Total artificial heart use is low, but the total artificial heart can be an option for biventricular bridge to transplant with acceptable bridge to transplant and post-transplant survival, especially in higher-volume centers. The observation of inferior outcomes in lower-volume centers raises questions as to whether targeted training, center certifications, and minimum volume requirements could improve outcomes for patients requiring the total artificial heart.

Ross Procedure Versus Mechanical Versus Bioprosthetic Aortic Valve Replacement: A Network Meta-Analysis.

Background The Ross operation appears to restore normal survival in young and middle-aged adults with aortic valve disease. However, there are limited data comparing it with conventional aortic valve replacement. Herein, we compared outcomes of the Ross procedure with mechanical and bioprosthetic aortic valve replacement (M-AVR and B-AVR, respectively). Methods and Results MEDLINE and EMBASE were searched through March 2022 to identify randomized controlled trials and propensity score-matched studies that investigated outcomes of patients aged ≥16 years undergoing the Ross procedure, M-AVR, or B-AVR. The systematic literature search identified 2 randomized controlled trials and 8 propensity score-matched studies involving a total of 4812 patients (Ross: n=1991; M-AVR: n=2019; and B-AVR: n=802). All-cause mortality was significantly lower in the Ross procedure group compared with M-AVR (hazard ratio [HR] [95% CI], 0.58 [0.35-0.97]; P=0.035) and B-AVR (HR [95% CI], 0.32 [0.18-0.59]; P<0.001) groups. The reintervention rate was lower after the Ross procedure and M-AVR compared with B-AVR, whereas it was higher after the Ross procedure compared with M-AVR. Major bleeding rate was lower after the Ross procedure compared with M-AVR. Long-term stroke rate was lower following the Ross procedure compared with M-AVR and B-AVR. The rate of endocarditis was also lower after the Ross procedure compared with B-AVR. Conclusions Improved long-term outcomes of the Ross procedure are demonstrated compared with conventional M-AVR and B-AVR options. These results highlight a need to enhance the recognition of the Ross procedure and revisit current guidelines on the optimal valve substitute for young and middle-aged patients.

Outcomes of Simultaneous Heart and Kidney Transplantation.

BACKGROUND: Simultaneous heart-kidney transplantation has been increasingly performed in end-stage heart failure patients with concurrent kidney dysfunction despite limited evidence supporting its indications and utility. OBJECTIVES: The purpose of this study was to investigate the effects and utility of simultaneously implanted kidney allografts with various degrees of kidney dysfunction during heart transplantation. METHODS: Using the United Network for Organ Sharing registry, long-term mortality was compared in recipients with kidney dysfunction who underwent heart-kidney transplantation (n = 1,124) vs isolated heart transplantation (n = 12,415) in the United States between 2005 and 2018. In heart-kidney recipients, contralateral kidney recipients were compared for allograft loss. Multivariable Cox regression was used for risk adjustment. RESULTS: Long-term mortality was lower among heart-kidney recipients than among heart-alone recipients when recipients were on dialysis (26.7% vs 38.6% at 5 years; HR: 0.72; 95% CI: 0.58-0.89) or had a glomerular filtration rate (GFR) of <30 mL/min/1.73 m2 (19.3% vs 32.4%; HR: 0.62; 95% CI: 0.46-0.82) and GFR of 30 to 45 mL/min/1.73 m2 (16.2% vs 24.3%; HR: 0.68; 95% CI: 0.48-0.97) but not in GFR of 45 to 60 mL/min/1.73 m2. Interaction analysis showed that the mortality benefit of heart-kidney transplantation continued up to GFR 40 mL/min/1.73 m2. The incidence of kidney allograft loss was higher among heart-kidney recipients than among contralateral kidney recipients (14.7% vs 4.5% at 1 year; HR: 1.7; 95% CI: 1.4-2.1). CONCLUSIONS: Heart-kidney transplantation relative to heart transplantation alone provided superior survival for dialysis-dependent recipients and non-dialysis-dependent recipients up to a GFR of approximately 40 mL/min/1.73 m2 but at the cost of almost twice the risk of kidney allograft loss than contralateral kidney allograft recipients.

Propensity-Matched Comparison of the Ross Procedure and Prosthetic Aortic Valve Replacement in Adults.

BACKGROUND: There has recently been renewed interest in the Ross procedure in adults. OBJECTIVES: The goal of this study was to compare long-term outcomes after the Ross procedure vs biological and mechanical aortic valve replacement (AVR) in adults (aged 18-50 years) undergoing aortic valve surgery. METHODS: Mandatory California and New York databases were queried between 1997 and 2014. Exclusion criteria included: ≥1 concomitant procedure, reoperations, infective endocarditis, intravenous drug use, hemodialysis, and out-of-state residency. Propensity matching (1:1:1) was used, resulting in 434 patients per group. The primary endpoint was all-cause mortality. Secondary endpoints were stroke, major bleeding, reoperation, and endocarditis. Median follow-up was 12.5 years (IQR: 9.3-15.7 years). RESULTS: At 15 years, actuarial survival after the Ross procedure was 93.1% (95% CI: 89.1%-95.7%), similar to that of the age-, sex-, and race-matched U.S. general population. It was significantly lower after biological AVR (HR: 0.42; 95% CI: 0.23-0.075; P = 0.003) and mechanical AVR (HR: 0.45; 95% CI: 0.26-0.79; P = 0.006). At 15 years, the Ross procedure was associated with a lower cumulative risk of reintervention (P = 0.008) and endocarditis (P = 0.01) than biological AVR. In contrast, at 15 years, the Ross procedure was associated with a higher cumulative incidence of reoperation (P < 0.001) but lower risks of stroke (P = 0.03) and major bleeding (P = 0.016) than mechanical AVR. Thirty-day mortality after valve-related complications was lowest after a reintervention. CONCLUSIONS: In young adults, the Ross procedure is associated with better long-term survival and freedom from valve-related complications compared with prosthetic AVR. This confirms the notion that a living valve substitute in the aortic position translates into improved clinically relevant outcomes.

Effects of hot­water extracts from 26 herbs on α­glucosidase activity.

α­glucosidase is a key enzyme that plays a role in glucose absorption in the gastrointestinal tract, and the inhibition of its activity induces the prevention of postprandial hyperglycemia. Several α­glucosidase inhibitors have been used as medicines for type 2 diabetes, but a similar effect is observed in natural resources, including traditional herbs and their phytochemicals. To identify the presence of the α­glucosidase inhibitory activity in herbs, in which various functional effects have been known to occur, the present study investigated the effects of hot­water extracts of 26 types of herbs on α­glucosidase activity in an in vitro assay. The results indicated significant increases in the inhibition of α­glucosidase activity in 1,000 µg/ml olive (P<0.01), white willow (P<0.01) and red rooibos hot­water extracts. Furthermore, ≥50% inhibition of α­glucosidase activity was determined to be significant in 1,000 µg/ml coltsfoot, green tea and bearberry hot­water extracts. In addition, the effects of bearberry, green tea and coltsfoot hot­water extracts on α­glucosidase activity in vivo were evaluated according to the blood glucose levels (BGLs) in maltose and glucose load model rats. It was indicated that the administration of these three herb extracts significantly reduced the increasing BGLs after maltose loading until 0.5 h compared with the control group. However, only coltsfoot extract significantly reduced the increasing BGLs after glucose loading until 0.5 h compared with the control group. Thus, the present results may facilitate the understanding of a novel functionality in traditional herbs, which could be useful for the prevention of disease onset and progression, such as in hyperglycemia and type 2 diabetes.

Impact of Cerebral Perfusion on Outcomes of Aortic Surgery: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis.

BACKGROUND: Limited data inform cerebral protection during circulatory arrest. This study was designed to identify optimal approaches from a national clinical registry. METHODS: A total of 7830 adults (mean age, 63.1 years, SD 13.1 years) who underwent hemiarch (n = 6891; 88.0%) or total arch (n = 939; 12.0%) replacement with hypothermic circulatory arrest between 2014 and 2016 were identified from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (version 2.81). Aortic dissections were excluded from the analysis. Multivariable logistic regression was used to adjust for 29 baseline and operative variables, including demographics, comorbidity, surgery, and nadir temperature, comparing outcomes according to protection strategy. The primary end point was a composite of 30-day and in-hospital mortality or major permanent neurologic complications. RESULTS: The rate of death or permanent neurologic complication was 10.9% (n = 850). Antegrade cerebral perfusion was most commonly used (n = 3369; 43%; median nadir temperature 23°C; median arrest time 30 minutes) compared with retrograde cerebral perfusion (n = 1898; 24%; 20°C; 24 minutes) and no cerebral perfusion (n = 2563; 33%; 20°C, 22 minutes). In multivariable analysis, deep hypothermia with antegrade (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52 to 0.81) or retrograde (OR, 0.57; 95% CI, 0.45 to 0.71) perfusion and moderate hypothermia with antegrade perfusion (OR, 0.61; 95% CI, 0.46 to 0.79) were associated with significant reductions in death and stroke compared with deep hypothermia without cerebral perfusion. Risk reduction was greatest in circulatory arrest lasting longer than 30 minutes. CONCLUSIONS: For patients without aortic dissection and who require more than 30 minutes of circulatory arrest, optimal cerebral protection strategies are deep hypothermia with either antegrade or retrograde cerebral perfusion and moderate hypothermia with antegrade cerebral perfusion.

Endothelial cell-derived bone morphogenetic proteins regulate glial differentiation of cortical progenitors.

Gliogenesis is an important component of cortical development during the postnatal period. Two macroglial cells are generated in a particular order, i.e. astrocytes first and oligodendrocytes later. The mechanisms underlying this sequence of glial differentiation are unknown but interactions with blood vessels are postulated to play a role. We show, using a mouse in-vitro coculture system, that endothelial cells promote astrocyte differentiation but inhibit oligodendrocyte differentiation of postnatal cortical progenitors. Endothelial cells produce bone morphogenetic proteins (BMPs) to activate Sma- and Mad-related protein (Smad) signalling in progenitors and the effects of endothelial cells on glial differentiation are blocked by the BMP antagonist Noggin. Differentiation of progenitors into astrocytes results in the inhibition of endothelial cell growth, accompanied by changes in gene expression of angiogenic factors, indicating bidirectional interactions between progenitors and endothelial cells. In vivo, Smad signalling is activated in various types of cortical cells including progenitors in association with astrogenesis but is inactivated before the peak of oligodendrogenesis. Capillary vessels isolated from the developing cortex express high levels of BMPs. Together, these results demonstrate that endothelial cells regulate glial differentiation by secreting BMPs in vitro and suggest a similar role in cortical gliogenesis in vivo.

Bioprosthetic Versus Mechanical Valve Replacement for Infective Endocarditis: Focus on Recurrence Rates.

BACKGROUND: Consensus guidelines for prosthesis selection in infective endocarditis recommend bioprosthetic or mechanical valve replacement based on life expectancy and comorbidity. However, contemporary outcome data are limited to institution series. METHODS: The outcomes of 3,447 patients identified from mandatory discharge databases in California and New York who had either primary isolated mitral (n = 1,603) or aortic (n = 1,844) valve replacement for active endocarditis between 1998 and 2010 were compared according to whether they received bioprosthetic (n = 1,673, 48.5%) or mechanical (n = 1,774, 51.5%) valves. Drug abusers were analyzed as a separate cohort. The primary outcome was endocarditis recurrence. Median follow-up time was 6.8 years (range, 0 to 12). Last follow-up for survival was December 31, 2015. RESULTS: Patients receiving bioprosthetic valves were older (60.4 ± 14.9 versus 53.4 ± 14.3 years, p < 0.001), with more comorbidity. There was no significant difference in 12-year survival with bioprosthetic versus mechanical valves after mitral (adjusted hazard ratio 1.14, 95% confidence interval [CI]: 0.98 to 1.34, p = 0.10) or aortic (adjusted hazard ratio 1.10, 95% CI: 0.93 to 1.29, p = 0.26) valve replacement. Bioprosthetic and mechanical valves were associated with similar recurrence rates at 12 years: 10.4% (95% CI: 8.0% to 13.1%) versus 8.8% (95% CI: 6.9% to 10.9%), adjusted Cox p = 0.79 after mitral replacement; and 9.4% (95% CI: 7.5% to 11.6%) versus 10.0% (95% CI: 8.0% to 12.4%), adjusted Cox p = 0.81 after aortic valve replacement. CONCLUSIONS: Bioprosthetic and mechanical valves are associated with similar survival and freedom from endocarditis recurrence. These data support guideline recommendations that patient factors guide prosthesis choice in infective endocarditis.

Survival and long-term outcomes after mitral valve replacement in patients aged 18 to 50 years.

OBJECTIVE: To provide long-term data on survival and major morbidity after mitral valve replacement in patients aged 18 to 50 years. METHODS: Retrospective analysis of 2727 patients aged 18 to 50 years who underwent isolated mitral replacement in California and New York from 1997 to 2006. Median follow-up time was 12.4 years (maximum 15.0 years). The primary endpoint was mortality; secondary endopoints were stroke, major bleeding, and reoperation. Propensity matching yielded 373 patient pairs. RESULTS: Bioprosthetic valve use increased from 10% to 34% between 1997 and 2014 (P < .001). Among propensity score-matched patients, actuarial 15-year survival was 74.3% (95% confidence interval [CI], 69.0%-78.7%) after bioprosthetic versus 80.8% (95% CI, 75.1%-85.3%) mechanical valve replacement (hazard ratio [HR], 1.67; 95% CI, 1.21-2.32, P = .002). At 15 years after mitral valve replacement, the cumulative incidence of stroke was similar (9.1% [95% CI, 6.0%-13.0%] vs 9.7% [95% CI, 6.7-13.4]; HR, 0.95 [95% CI, 0.57-1.59]); the cumulative incidence of major bleeding events was similar (7.9% [95% CI, 5.0%-11.5%] vs 11.5% [95% CI, 7.6%-16.2%]; HR, 0.78 [95% CI, 0.46-1.32]); and the cumulative incidence of reoperation after bioprosthetic valve replacement was greater (19.9% [95% CI, 15.4%-24.8%] vs 5.7% [95% CI, 3.5%-8.7%]; HR, 20.3 [95% CI, 4.0-102.8]), respectively. CONCLUSIONS: The significant survival benefit associated with mechanical mitral valve replacement in adults ≤50 years may be due to the practice of implanting bioprostheses in sicker patients or those judged less likely to comply with long-term medication despite adjustment for baseline characteristics in propensity score matching.

Bioprosthetic aortic valve replacement: Revisiting prosthesis choice in patients younger than 50 years old.

OBJECTIVE: Aortic prosthesis choice is controversial in young adults because robust comparative outcome data are lacking. We therefore compared mortality and morbidity in young adults after bioprosthetic versus mechanical aortic valve replacement. METHODS: This was a retrospective analysis of 5111 patients aged 18 to 50 years undergoing primary aortic valve replacement in California and New York State from 1997 to 2006. Median follow-up time was 11.8 years (maximum 18.9 years). The primary endpoint was mortality; secondary endpoints were stroke, bleeding, and reoperation. Propensity score matching yielded 1175 patient pairs. RESULTS: Bioprosthetic valves increased from 14% to 47% of aortic valve replacements between 1997 and 2014 (P < .001). There was no survival difference with bioprosthetic versus mechanical aortic valves in the propensity score-matched cohort: actuarial 15-year survival was 79.0% (95% confidence interval [CI], 75.8%-81.8%) versus 81.5% (95% CI, 78.5%-84.2%) respectively (hazard ratio [HR], 1.14; 95% CI, 0.93-1.40, P = .20). No interaction was found between age and prosthesis choice on survival (Pinteraction = 0.16). After bioprosthetic valve replacement, stroke rates were lower (5.4% [95% CI, 3.8%-7.2%] vs 8.1% [95% CI, 6.3%-10.2%], HR 0.62 [95% CI 0.43-0.91]), bleeding rates were lower (4.2% [95% CI, 3.0-5.6%] vs 8.4% [95% CI, 6.6-10.4%], HR 0.48 [95% CI, 0.33-0.69]), but reoperation rates were greater (24.5% [95% CI, 21.3%-27.8%] vs 9.3% [95% CI, 7.2%-11.7%], HR 5.9 [95% CI 3.2-11.0]) at 15 years versus mechanical valve replacement. CONCLUSIONS: Although lifetime risks are represented incompletely, these findings suggest that in adults aged 18-50 years, bioprostheses are a reasonable alternative to mechanical valves for aortic valve replacement.

SYNTAX score may predict the severity of atherosclerosis of the ascending aorta.

BACKGROUND: The objective of this study was to investigate the association of the coronary SYNTAX score with the degree of atherosclerosis of the ascending aorta in patients who underwent coronary artery bypass grafting (CABG). METHODS: A total of 152 patients (mean age 65 years, 66% male) were analyzed who underwent isolated CABG with both SYNTAX score and the intraoperative 5-point scale grading of the severity of atherosclerosis in the ascending aorta available. The patient were stratified into low, intermediate, and high SYNTAX score groups [≤22 (n=36), 22-33 (n=42), and ≥33 (n=76)]. RESULTS: The mean SYNTAX score was 31±11. Patient demographics and comorbidity were comparable in each group. The prevalence of severe atherosclerosis (Grade ≥III) in the ascending aorta was 17.5% (n=27) in the whole population and was different in each group with higher prevalence in higher score groups (8.3% vs. 9.5% vs. 26.3%, P=0.018). After adjusting for age, sex and other relevant comorbidity, SYNTAX score remained a predictor of severe atherosclerosis [adjusted OR 1.63, 95% CI: 1.01-2.62, P=0.046 (per 10 point increase); adjusted OR 5.20, 95% CI: 1.15-23.5, P=0.032 (high vs. low score)]. CONCLUSIONS: SYNTAX score was associated with the severity of atherosclerosis in the ascending aorta. Patients with high scores have a 5 times higher chance of severe disease compared to patients with low scores and should warrant preoperative and intraoperative comprehensive assessment of the ascending aorta.

Real-world outcomes of surgery for native mitral valve endocarditis.

BACKGROUND: Consensus guidelines recommend repair over replacement for the surgical treatment of active native mitral valve infective endocarditis. However, contemporary practice and long-term outcome data are limited. METHODS: Multivariable Cox regression was used to compare outcomes of 1970 patients undergoing isolated primary mitral valve repair (n = 367, 19%) or replacement (n = 1603, 81%) for active infective endocarditis between 1998 and 2010 in New York and California states. The primary outcome was long-term survival. Secondary outcomes were recurrent endocarditis and mitral reoperation. Median follow-up time was 6.6 years (range 0-12), and last follow-up date was December 31, 2015. RESULTS: Mitral valve repair rates increased from 10.7% to 19.4% over the study period (P < .001). Patients undergoing mitral repair were younger (55 ± 15 vs 57 ± 15 years, P = .005), less likely to have congestive heart failure (46.3% vs 57.1%, P < .001), and less likely to have staphylococcal infections (21.3% vs 32.0%, P < .001). Twelve-year survival was 68.8% (95% confidence interval [CI], 62.5%-74.3%) after mitral repair, versus 53.5% (95% CI, 50.6%-56.4%) after replacement (adjusted hazard ratio, 0.71; 95% CI, 0.57-0.88; P = .002). Mitral repair was associated with lower rate of recurrent endocarditis at 12 years than replacement (4.7% [95% CI, 2.8%-7.2%] vs 9.5% [95% CI, 8.0-11.1%]; P = .03), and similar rate of reoperation (9.1% [95% CI, 6.2%-12.8%] vs 8.6% [95% CI, 7.1%-10.4%]; P = .12). CONCLUSIONS: In active endocarditis, mitral valve repair is associated with better survival and lower risk of recurrent infection compared with valve replacement and should be the surgery of choice when feasible.

Relation of Mitral Valve Surgery Volume to Repair Rate, Durability, and Survival.

BACKGROUND: Degenerative mitral valve repair rates remain highly variable, despite established benefits of repair over replacement. The contribution of surgeon-specific factors is poorly defined. OBJECTIVES: This study evaluated the influence of surgeon case volume on degenerative mitral valve repair rates and outcomes. METHODS: A mandatory New York State database was queried and 5,475 patients were identified with degenerative mitral disease who underwent mitral valve operations between 2002 and 2013. Mitral repair rates, mitral reoperations within 12 months of repair, and survival were analyzed using multivariable Cox modeling and restricted cubic spline function. RESULTS: Median annual surgeon volume of any mitral operations was 10 (range 1 to 230), with a mean repair rate of 55% (n = 20,797 of 38,128). In the subgroup of patients with degenerative disease, the mean repair rate was 67% (n = 3,660 of 5,475), with a range of 0% to 100%. Mean repair rates ranged from 48% (n = 179 of 370) for surgeons with total annual volumes of ≤10 mitral operations to 77% (n = 1,710 of 2,216) for surgeons with total annual volumes of >50 mitral operations (p < 0.001). Higher total annual surgeon volume was associated with increased repair rates of degenerative mitral valve disease (adjusted odds ratio [OR]: 1.13 for every additional 10 mitral operations; 95% confidence interval [CI]: 1.10 to 1.17; p < 0.001); a steady decrease in reoperation risk until 25 total mitral operations annually; and improved 1-year survival (adjusted hazard ratio: 0.95 for every additional 10 operations; 95% CI: 0.92 to 0.98; p = 0.001). For surgeons with a total annual volume of ≤25 mitral operations, repair rates were higher (63.8%; n = 180 of 282) if they operated in the same institution as a surgeon with total annual mitral volumes of >50 and degenerative mitral valve repair rates of >70%, compared with surgeons operating in the other institutions (51.3%; n = 580 of 1,130) (adjusted OR: 1.79; 95% CI: 1.24 to 2.60; p < 0.001). CONCLUSIONS: This study suggests that individual surgeon volume is a determinant of not only mitral repair rates, but also freedom from reoperation, and survival. The data from this study support the guideline's concept of reference referral to experienced mitral surgeons to improve outcomes in patients with degenerative mitral valve disease.

Totally Endoscopic Robotic Left Atrial Appendage Closure Demonstrates High Success Rate.

OBJECTIVE: In patients with atrial fibrillation, 90% of embolic strokes originate from the left atrial appendage (LAA). Successful exclusion of the LAA is associated with a lower stroke rate in patients with atrial fibrillation. Surgical oversewing of the LAA is often incomplete when evaluated with transesophageal echocardiogram (TEE). External closure techniques of suturing and stapling have also demonstrated high failure rates with persistent flow and large stumps. We hypothesized that the precise visualization of a robotic LAA closure (RLAAC) would result in superior closure rates. METHODS: Before robotic mitral repair, patients underwent RLAAC; the base of the LAA was oversewn using a running 4-0 polytetrafluoroethylene suture in two layers. Postoperatively, the LAA was interrogated in multiple TEE views. Incomplete closure was defined as any flow across the LAA suture line or a residual stump of greater than 1 cm. RESULTS: Seventy-nine consecutive patients underwent RLAAC; no injuries occurred. On postrepair TEE, 73 of 79 patients had LAAs visualized well enough to thoroughly evaluate. Successful ligation was confirmed in 64 (87.7%) of 73 patients. Seven patients (9.6%) had small jet flow into the LAA; no residual stumps were noted. Two patients (2.7%) had undetermined flow. CONCLUSIONS: We have demonstrated excellent success with RLAAC; we postulate that this may be due to improved intracardiac visualization. Robotic LAA closure was more successful (87.7%) than previously reported results from the Left Atrial Appendage Occlusion Study for suture exclusion (45.5%) and staple closure (72.7%). With success rates equivalent to transcatheter device closures, RLAAC should be considered for robotic mitral valve surgical patients.

Extracorporeal Membrane Oxygenation in New York State: Trends, Outcomes, and Implications for Patient Selection.

BACKGROUND: Utilization of extracorporeal membrane oxygenation (ECMO) is expanding despite limited outcome data defining appropriate use. METHODS AND RESULTS: To quantify determinants of early and 1-year survival after ECMO in adult patients, we conducted a retrospective cohort analysis of 1286 patients aged ≥18 years who underwent ECMO in New York State from 2003 to 2014. Median follow-up time was 4.9 months (range, 0-12 months). ECMO utilization increased from 13 patients in 8 hospitals in 2003 to 330 patients in 30 hospitals in 2014. Compared with patients undergoing ECMO before 2009, later patients were older (54.4 versus 52.3 years; P=0.013) and more likely to have major comorbidity including chronic kidney disease (25.2% versus 13.2%; P=0.02) and liver disease (20.0% versus 10.7%; P=0.001). In the overall cohort, 30-day mortality was 52.2% (95% confidence interval, 49.5-54.9). Mortality at 30 days was 65.2% for patients aged ≥75 years (n=73/112) and 74.6% in patients who required cardiopulmonary resuscitation (n=91/122). Survival at 1 year was 38.4% (95% confidence interval, 35.7-41.0). The 30-day mortality and 1-year survival improved across the study period. In multivariable analysis, earlier year of ECMO, lower hospital volume, indication for ECMO after a cardiac procedure, cardiopulmonary resuscitation before ECMO placement, and age >65 years were independent predictors of worse survival. CONCLUSIONS: Outcomes of ECMO have improved despite increasing comorbidity. Extreme mortality after ECMO in elderly patients and patients requiring cardiopulmonary resuscitation indicates that less invasive therapeutic or palliative modalities may be more appropriate in this end-of-life setting.