Publications by authors named "Christina Vassileva"

55 Publications

Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations.

Ann Thorac Surg 2021 Apr 9. Epub 2021 Apr 9.

Duke University, Durham, North Carolina.

Background: The STS Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting surgery (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations +/- CABG procedures.

Methods: Using July 2011 to June 2019 STS Adult Cardiac Surgery Database (ACSD) data, risk models for AVR+MVRR (n=31,968) and AVR+MVRR+CABG (n=12,650) were developed with the following endpoints: operative mortality, major morbidity (any one or more of the following: cardiac reoperation; deep sternal wound infection/mediastinitis; stroke; prolonged ventilation; and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 - June 2017, n=35,109) and validation (July 2017 - June 2019, n=9,509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration.

Results: C-statistics for the overall population of multiple valve +/- CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample.

Conclusions: New STS-ACSD risk models have been developed for multiple valve +/- CABG operations, and these models will be used in subsequent STS performance metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.089DOI Listing
April 2021

Volume-Outcome Association of Mitral Valve Surgery in the United States.

JAMA Cardiol 2020 Oct;5(10):1092-1101

Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston.

Importance: Early surgery for severe primary degenerative mitral regurgitation is recommended, provided optimal outcomes are achievable. Contemporary national data defining mitral valve surgery volume and outcomes are lacking.

Objective: To assess national 30-day and 1-year outcomes of mitral valve surgery and define the hospital- and surgeon-level volume-outcome association with mitral valve repair or replacement (MVRR) in patients with primary mitral regurgitation.

Design, Setting, And Participants: This multicenter cross-sectional observational study used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to identify patients undergoing isolated MVRR for primary mitral regurgitation in the United States. Operative data were collected from July 1, 2011, to December 31, 2016, and analyzed from March 1 to July 1, 2019, with data linked to the Centers for Medicare and Medicaid Services.

Main Outcomes And Measures: The primary outcome was 30-day in-hospital operative mortality after isolated MVRR for primary mitral regurgitation. Secondary outcomes were 30-day composite mortality plus morbidity (any occurrence of bleeding, stroke, prolonged ventilation, renal failure, or deep wound infection), rate of successful mitral valve repair of primary mitral regurgitation (residual mitral regurgitation of mild [1+] or better), and 1-year mortality, reoperation, and rehospitalization for heart failure.

Results: A total of 55 311 patients, 1094 hospitals, and 2410 surgeons were identified. Increasing hospital and surgeon volumes were associated with lower risk-adjusted 30-day mortality, lower 30-day composite mortality plus morbidity, and higher rate of successful repair. The lowest vs highest hospital volume quartile had higher 1-year risk-adjusted mortality (hazard ratio [HR], 1.61, 95% CI, 1.31-1.98), but not mitral reoperation (odds ratio [OR], 1.51; 95% CI, 0.81-2.78) or hospitalization for heart failure (HR, 1.25; 95% CI, 0.96-1.64). The surgeon-level 1-year volume-outcome associations were similar for mortality (HR, 1.60; 95% CI, 1.32-1.94) but not significant for mitral reoperation (HR, 1.14; 95% CI, 0.60-2.18) or hospitalization for heart failure (HR, 1.17; 95% CI, 0.91-1.50).

Conclusions And Relevance: National hospital- and surgeon-level inverse volume-outcome associations were observed for 30-day and 1-year mortality after mitral valve surgery for primary mitral regurgitation. These findings may help to define access to experienced centers and surgeons for the management of primary mitral regurgitation.
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http://dx.doi.org/10.1001/jamacardio.2020.2221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330833PMC
October 2020

Mitral Valve Repair Versus Replacement in Elderly With Degenerative Disease: Analysis of the STS Adult Cardiac Surgery Database.

Ann Thorac Surg 2019 03 26;107(3):747-753. Epub 2018 Oct 26.

Division of Cardiac Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts; Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts. Electronic address:

Background: It has been postulated that mitral valve repair in the elderly does not confer short-term benefits over mitral valve replacement with complete preservation of the chordal apparatus. Our purpose was to test this hypothesis using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD).

Methods: Patients aged 70 years or more undergoing primary isolated elective mitral valve repair or mitral valve replacement for degenerative disease were obtained from the STS ACSD versions 2.73 and 2.81. Patients with a concomitant tricuspid procedure, atrial fibrillation surgery, or atrial septal defect/patent foramen ovale repair were included. The two treatment groups were further stratified by age in years (70 to 74, 75 to 79, and 80 or more). Adjusted 30-day mortality rates were analyzed by mitral procedure and chordal preservation strategy.

Results: The study included 12,043 patients, of whom 71% underwent mitral valve repair. Observed 30-day mortality after repair was lower than after replacement (2.2% versus 4.8%, respectively; p < 0.0001). Using repair as reference, adjusted operative mortality was higher for replacement in the overall cohort (odds ratio 1.83, 95% confidence interval: 1.45 to 2.31). There was no significant difference in mortality between complete versus partial chordal preservation in repair (odds ratio 1.24, 95% confidence interval: 0.80 to 1.93). Mitral valve replacement with chordal preservation remained inferior to repair (odds ratio 1.66, 95% confidence interval: 1.28 to 2.14). The failed repair rate was 7.9%, with a 30-day mortality of 6%.

Conclusions: In patients aged 70 years or more, degenerative mitral repair was associated with lower operative mortality compared with replacement, irrespective of chordal preservation strategy. Failed repairs reduced this short-term benefit compared with chordal-sparing replacement as evidenced by the similar operative mortality on an intention to treat analysis.
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http://dx.doi.org/10.1016/j.athoracsur.2018.09.018DOI Listing
March 2019

Racial Comparisons of the Outcomes of Transcatheter and Surgical Aortic Valve Implantation Using the Medicare Database.

Am J Cardiol 2018 08 1;122(3):440-445. Epub 2018 May 1.

Division of Cardiac Surgery, University of Massachusetts Medical School, University Campus, Worcester, Massachusetts.

Racial disparities in the outcomes after intervention for aortic valve disease remain understudied. We stratified patients by race who underwent surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) in the Medicare database. The TAVI cohort consisted of 17,973 patients (3.9% were black and 1.0% were Hispanic). The SAVR cohort consisted of 95,078 patients, (4.8% were black and 1.3% were Hispanic). Most comorbidities were more common in blacks. After TAVI, 30-day mortality was not significantly different in races with both unadjusted and adjusted data. There were no significant racial differences in readmission rates or discharge to home after TAVI. After SAVR, black patients had worse unadjusted 30-day and 1-year mortality than whites or Hispanics (30-day mortality, 4.7% vs 6.2% vs 4.7% for whites, blacks, and Hispanics, respectively, p = 0.0001; 1-year mortality 11.7% vs 16.1% vs 12.5%, respectively, p = 0.0001); however, after adjustment, there were no differences in mortality. Black patients had higher 30-day readmission rates after SAVR (20.1% vs 25.2% vs 21.7% for whites, blacks, and Hispanics, respectively, p = 0.0001), which persisted after adjustment for comorbidities. Minorities were underrepresented in both SAVR and TAVI relative to what would be predicted by population prevalence. In conclusion, while blacks have worse outcomes in SAVR compared with whites or Hispanics, race did not impact mortality, readmission, or discharge to home in TAVI. Both blacks and Hispanics were underrepresented compared with what would be predicted by population prevalence.
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http://dx.doi.org/10.1016/j.amjcard.2018.04.019DOI Listing
August 2018

The Society of Thoracic Surgeons 2018 Adult Cardiac Surgery Risk Models: Part 1-Background, Design Considerations, and Model Development.

Ann Thorac Surg 2018 05 22;105(5):1411-1418. Epub 2018 Mar 22.

Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.

Background: The last published version of The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) risk models were developed in 2008 based on patient data from 2002 to 2006 and have been periodically recalibrated. In response to evolving changes in patient characteristics, risk profiles, surgical practice, and outcomes, the STS has now developed a set of entirely new risk models for adult cardiac surgery.

Methods: New models were estimated for isolated coronary artery bypass grafting surgery (CABG [n = 439,092]), isolated aortic or mitral valve surgery (n = 150,150), and combined valve plus CABG procedures (n = 81,588). The development set was based on July 2011 to June 2014 STS ACSD data; validation was performed using July 2014 to December 2016 data. Separate models were developed for operative mortality, stroke, renal failure, prolonged ventilation, reoperation, composite major morbidity or mortality, and prolonged or short postoperative length of stay. Because of its low occurrence rate, a combined model incorporating all operative types was developed for deep sternal wound infection/mediastinitis.

Results: Calibration was excellent except for the deep sternal wound infection/mediastinitis model, which slightly underestimated risk because of higher rates of this endpoint in the more recent validation data; this will be recalibrated in each feedback report. Discrimination (c-index) of all models was superior to that of 2008 models except for the stroke model for valve patients.

Conclusions: Completely new STS ACSD risk models have been developed based on contemporary patient data; their performance is superior to that of previous STS ACSD models.
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http://dx.doi.org/10.1016/j.athoracsur.2018.03.002DOI Listing
May 2018

The Society of Thoracic Surgeons 2018 Adult Cardiac Surgery Risk Models: Part 2-Statistical Methods and Results.

Ann Thorac Surg 2018 05 22;105(5):1419-1428. Epub 2018 Mar 22.

Department of Surgery and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: The Society of Thoracic Surgeons (STS) uses statistical models to create risk-adjusted performance metrics for Adult Cardiac Surgery Database (ACSD) participants. Because of temporal changes in patient characteristics and outcomes, evolution of surgical practice, and additional risk factors available in recent ACSD versions, completely new risk models have been developed.

Methods: Using July 2011 to June 2014 ACSD data, risk models were developed for operative mortality, stroke, renal failure, prolonged ventilation, mediastinitis/deep sternal wound infection, reoperation, major morbidity or mortality composite, prolonged postoperative length of stay, and short postoperative length of stay among patients who underwent isolated coronary artery bypass grafting surgery (n = 439,092), aortic or mitral valve surgery (n = 150,150), or combined valve plus coronary artery bypass grafting surgery (n = 81,588). Separate models were developed for each procedure and endpoint except mediastinitis/deep sternal wound infection, which was analyzed in a combined model because of its infrequency. A surgeon panel selected predictors by assessing model performance and clinical face validity of full and progressively more parsimonious models. The ACSD data (July 2014 to December 2016) were used to assess model calibration and to compare discrimination with previous STS risk models.

Results: Calibration in the validation sample was excellent for all models except mediastinitis/deep sternal wound infection, which slightly underestimated risk and will be recalibrated in feedback reports. The c-indices of new models exceeded those of the last published STS models for all populations and endpoints except stroke in valve patients.

Conclusions: New STS ACSD risk models have generally excellent calibration and discrimination and are well suited for risk adjustment of STS performance metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2018.03.003DOI Listing
May 2018

Outcomes of Early Mitral Valve Reoperation in the Medicare Population.

Ann Thorac Surg 2017 Nov 29;104(5):1516-1521. Epub 2017 Jul 29.

Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois; Division of Cardiac Surgery, University of Massachusetts Medical School, Worcester, Massachusetts. Electronic address:

Background: Surgical series on mitral valve reoperation are limited by small numbers and lack of national representation. Large-scale outcomes of reoperation for mitral valve surgery remain uncertain.

Methods: This is a descriptive analysis of 1,627 Medicare beneficiaries who underwent mitral valve reoperation within a 3-year follow-up period after an initial mitral operation (repair or replacement) that took place between 2000 and 2006. The primary outcomes were hospital mortality and long-term survival.

Results: The 1,627 patients included in the study comprise 1.6% of patients who underwent operation between 2000 and 2006. The initial surgery was repair in 49.9%, bioprosthetic replacement in 22.0%, and mechanical replacement in 28.1%. Re-repair was performed in 15.4%. Hospital mortality was 12.0% and was similar for repair and bioprosthetic or mechanical replacement. Reoperative mortality was similar for men and women and for patients aged 75 years or less versus more than 75 years; and was significantly higher for nonelective than for elective operations (15.6% versus 5.5%, p = 0.0001), for patients with endocarditis than without endocarditis (21.4% versus 11.0%, p = 0.0001), and for patients with heart failure than without heart failure (14.2% versus 9.9%, p = 0.0080). Cumulative long-term survival rates were 58.6% at 5 years.

Conclusions: The incidence of mitral valve reoperation within 3 years after initial repair or replacement is low but carries high surgical risk, which is significantly increased by certain preoperative characteristics, such as urgent status, endocarditis, and heart failure.
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http://dx.doi.org/10.1016/j.athoracsur.2017.05.001DOI Listing
November 2017

Improving coronary artery bypass grafting readmission outcomes from 2000 to 2012 in the Medicare population.

J Thorac Cardiovasc Surg 2017 10 10;154(4):1288-1297. Epub 2017 Jun 10.

Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Ill; Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC. Electronic address:

Objective: The study objective was to examine trends in 30-day readmission after coronary artery bypass grafting in the Medicare population over 13 years.

Methods: The study included isolated coronary artery bypass grafting procedures in the Medicare population from January 2000 to November 2012. Comorbidities and causes of readmission were determined using Internal Classification of Diseases, 9th Revision, Clinical Modification diagnostic codes.

Results: The cohort included 1,116,991 patients. Readmission rates decreased from 19.5% in 2000 to 16.6% in 2012 (P = .0001). There was significant improvement across all categories of admission status, age, race, gender, and hospital annual coronary artery bypass grafting volume that were analyzed. Adjusted odds of readmission in 2000 compared with 2012 was 1.28 (95% confidence interval, 1.24-1.32). Median length of stay for the readmission episode was 5 days, which improved to 4 days by 2012. Hospital mortality during the readmission episode was 2.8% overall and declined to 2.4% in 2012 (P = .0001). The most common primary readmission diagnoses were heart failure (12.6%), postoperative wound infection/nonhealing wound (8.9%), arrhythmias (6.4%), and pleural effusions (3.7%). Readmission for wound infections/nonhealing wounds decreased significantly over time, from 9.8% to 6.5% (P = .0001).

Conclusions: In a large cohort of Medicare patients undergoing coronary artery bypass grafting over 13 years, there was a significant decrease in 30-day readmission rates, a reduction in readmission for wound infections, and reduced mortality during the readmission episode, despite an increase in patient comorbidities. The improvement in readmission rates was seen regardless of patient variables examined.
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http://dx.doi.org/10.1016/j.jtcvs.2017.04.085DOI Listing
October 2017

Transcatheter Aortic Valve Replacement Outcomes in Nonagenarians Stratified by Transfemoral and Transapical Approach.

Ann Thorac Surg 2017 Jun 24;103(6):1808-1814. Epub 2017 Apr 24.

Division of Cardiac Surgery, University of Massachusetts Medical School, Worcester, Massachusetts. Electronic address:

Background: Survival and other outcomes of nonagenarians undergoing transcatheter aortic valve replacement (TAVR) in the Medicare population are unclear.

Methods: Patients aged 65 years and older who underwent TAVR from November 2011 through 2013 were considered for inclusion.

Results: The study consisted of 18,283 patients and 19.3% were aged 90 years or older. Compared with patients younger than 90 years, patients 90 years or older were less likely to have a number of comorbidities, including previous myocardial infarction (17.5% versus 21.8%), previous coronary artery bypass grafting (20.0% versus 35.0%), and chronic obstructive pulmonary disease (25.4% versus 39.0%) among others. The 30-day and 1-year mortality rates were 8.4% versus 5.9% (p = 0.0001) and 25.4% versus 21.5% (p = 0.0001) in the older and younger groups, respectively (odds ratio [OR] 1.47, 95% confidence interval [CI]: 1.28 to 1.70, p = 0.0001). Patients 90 years and older were more likely to undergo pacemaker insertion (11.1% versus 8.3%, p = 0.0001). Among nonagenarians, compared with the transapical group, patients undergoing transfemoral TAVR had lower 30-day (7.2% versus 13.6%, p = 0.0001) and 1-year (23.8% versus 31.6%, p = 0.0001) mortality rates, were more likely to be discharged home (54.4% versus 34.1%, p = 0.0001), and had lower 30-day readmission rates (23.8% versus 31.8%, p = 0.0001). After adjustment for patient characteristics, transapical TAVR was an independent predictor of 30-day mortality rate (OR 1.94, 95% CI: 1.48 to 2.56, p = 0.0001) and readmission (OR 1.46, 95% CI: 1.19 to 1.80, p = 0.0003).

Conclusions: In patients undergoing TAVR, although 30-day and 1-year mortality rates were slightly worse for nonagenarians than their younger counterparts, long-term survival was still encouraging, with 75% of nonagenarians living to 1 year. Transapical TAVR was associated with worse outcomes in nonagenarians.
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http://dx.doi.org/10.1016/j.athoracsur.2017.02.056DOI Listing
June 2017

Hospital Readmission after Aortic Valve Replacement: Impact of Preoperative Heart Failure.

J Heart Valve Dis 2016 07;25(4):430-436

Department of Surgery, Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA. Electronic correspondence:

Background And Aim Of The Study: Large-scale data of heart failure (HF) readmission after aortic valve replacement (AVR) are limited.

Methods: A total of 40,751 Medicare beneficiaries >65 years who underwent primary isolated AVR between 2000 and 2004 were included in the study. Preoperative HF was defined using ICD-9-CM diagnostic codes from the index admission and any hospitalization during the preceding year. Cumulative readmission incidences over five years were computed for those patients with and without preoperative HF, while adjusting for propensity scores.

Results: The median patient age was 76 years. At 30 days, all-cause readmission was 21.5% and HF readmission was 3.9%. Patients with preoperative HF had higher postoperative HF readmission rates compared to those without (30 days, 6.3% versus 2.2%; one year, 13.9% versus 4.4%; five years, 6.6% versus 10.3%, p = 0.0001). The incremental risk of HF on readmission was >2 following adjustment. In patients with preoperative HF, the number of admissions was associated with increased postoperative HF readmissions. At 30 days, patients with no preoperative HF admissions had a HF readmission rate of 5.3%, while those with one, two, three and four or more preoperative HF admissions had rates of 8.2%, 11.9%, 13.8% and 17.4%, respectively. This trend persisted over the five-year follow up period.

Conclusions: Postoperative HF readmission accounted for about one-fifth of all-cause readmissions after AVR in Medicare beneficiaries. Preoperative HF significantly contributed to postoperative readmission, both all-cause and HF-specific, which likely limits the symptomatic benefit of surgery. These data support early aortic valve intervention prior to the development of clinically apparent HF.
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July 2016

Mitral Valve Surgery in The Elderly: Should We Treat Atrial Fibrillation Too?

J Heart Valve Dis 2015 Nov;24(6):736-743

Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA.

Background: The study aim was to examine whether concomitant atrial fibrillation (AF) surgery at the time of mitral valve surgery in the elderly results in increased operative mortality (OM).

Methods: Medicare beneficiaries aged ≥65 years undergoing primary mitral valve repair or replacement between 2004 and 2006 were included. The cohort was divided into three groups: Group 1, AF- (n = 2,705); group 2, AF+AF surgery- (n = 2,119), and group 3, AF+AF surgery+ (n = 1,832). The primary outcomes were OM and long-term survival. A secondary outcome was the association between hospital annual mitral procedure volume and OM.

Results: The unadjusted OM was 6.4% for group 1 (AF-), 10.3% for group 2 (AF+AF surgery-), and 7.1% for group 3 (AF+AF surgery+) (p = 0.0001). Adjusted OM for AF+AF surgery+ patients was not significantly different from that of AF- patients (OR 1.16, 95% CI 0.90-1.48), or from AF+AF surgery patients (OR 0.83, 95% CI 0.66-1.06). When comparisons were adjusted for differences in baseline characteristics, AF+AF surgery- patients were more likely to experience long-term mortality than AF- patients (HR 1.30, 95% CI 1.17-1.45), as well as AF+AF surgery+ patients (HR 1.17, 95% CI 1.05-1.31). An annual average mitral procedure volume ≤40 was independently predictive of OM (OR 1.42, 95% CI 1.13-1.78). The effect of institutional volume on mortality was strongest in those who received AF surgery (AF+AF surgery+) (HR 1.75, 95% CI 1.15-2.65), compared to those who did not undergo surgery (AF+AF surgery-) (OR 1.20, 95% CI 0.86-1.67).

Conclusions: Elderly patients undergoing mitral valve surgery do not appear to have an increased mortality when clinical judgment favored the performance of concomitant AF surgery.
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November 2015

MY APPROACH to the surgeon's view on degenerative mitral regurgitation.

Trends Cardiovasc Med 2017 01 7;27(1):76-79. Epub 2016 Sep 7.

Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC. Electronic address:

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http://dx.doi.org/10.1016/j.tcm.2016.05.015DOI Listing
January 2017

Readmission after inpatient percutaneous coronary intervention in the Medicare population from 2000 to 2012.

Am Heart J 2016 09 14;179:195-203. Epub 2016 Jul 14.

Southern Illinois University School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Springfield, IL. Electronic address:

Background: Since year 2000, reducing hospital readmissions has become a public health priority. In addition, there have been major changes in percutaneous coronary intervention (PCI) during this period.

Methods: The cohort consisted of 3,250,194 patients admitted for PCI from January 2000 through November 2012.

Results: Overall, 30-day readmission was 15.8%. Readmission rates declined from 16.1% in 2000 to 15.4% in 2012 (adjusted odds ratio for readmission 1.33 in 2000 compared with 2012). Of all readmissions after PCI, the majority were for cardiovascular-related conditions (>60%); however, only a small percentage (<8%) of total readmissions were for acute myocardial infarction, unstable angina, or cardiac arrest/cardiogenic shock. A much larger percentage of patients were readmitted with chest pain/angina (7.9%), chronic ischemic heart disease (26.6%), and heart failure (12%). A small proportion was due to procedural complications and gastrointestinal (GI) bleeding. The use of PCI with stenting during readmissions was variable, increasing from 14.2% in 2000 to 23.7% in 2006 and then declining to 12.1% in 2012. Hospital mortality during readmission was 2.5% overall and varied over time (2.8% in 2000, decreasing to 2.2% in 2006 and then rising again to 3.1% in 2012). Patients who were readmitted had >4× higher 30-day mortality than those who were not.

Conclusions: Among Medicare beneficiaries, readmission after PCI declined over time despite patients having more comorbidities. This translated into a 33% lower likelihood of readmission in 2012 compared with 2000. A small proportion of readmissions were for acute coronary syndromes.
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http://dx.doi.org/10.1016/j.ahj.2016.07.002DOI Listing
September 2016

Failure to Rescue Rates After Coronary Artery Bypass Grafting: An Analysis From The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

Ann Thorac Surg 2016 Aug 22;102(2):458-64. Epub 2016 Jun 22.

Department of Surgery/Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts.

Background: Failure to rescue (FTR) is increasingly recognized as an important quality indicator in surgery. The Society of Thoracic Surgeons National Database was used to develop FTR metrics and a predictive FTR model for coronary artery bypass grafting (CABG).

Methods: The study included 604,154 patients undergoing isolated CABG at 1,105 centers from January 2010 to January 2014. FTR was defined as death after four complications: stroke, renal failure, reoperation, and prolonged ventilation. FTR was determined for each complication and a composite of the four complications. A statistical model to predict FTR was developed.

Results: FTR rates were 22.3% for renal failure, 16.4% for stroke, 12.4% for reoperation, 12.1% for prolonged ventilation, and 10.5% for the composite. Mortality increased with multiple complications and with specific combinations of complications. The multivariate risk model for prediction of FTR demonstrated a C index of 0.792 and was well calibrated, with a 1.0% average difference between observed/expected (O/E) FTR rates. With centers grouped into mortality terciles, complication rates increased modestly (11.4% to 15.7%), but FTR rates more than doubled (6.8% to 13.9%) from the lowest to highest terciles. Centers in the lowest complication rate tercile had an FTR O/E of 1.14, whereas centers in the highest complication rate tercile had an FTR O/E of 0.91.

Conclusions: CABG mortality rates vary directly with FTR, but complication rates have little relation to death. FTR rates derived from The Society of Thoracic Surgeons data can serve as national benchmarks. Predicted FTR rates may facilitate patient counseling, and FTR O/E ratios have promise as valuable quality metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2016.04.051DOI Listing
August 2016

Trends in Patient Characteristics and Outcomes of Coronary Artery Bypass Grafting in the 2000 to 2012 Medicare Population.

Ann Thorac Surg 2016 Jul 2;102(1):132-8. Epub 2016 Mar 2.

Department of Surgery, Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois. Electronic address:

Background: The purpose of this analysis was to examine the trends in patient characteristics and outcomes in patients who underwent coronary artery bypass grafting (CABG) over a 12-year period in the Medicare database.

Methods: The study included 1,264,265 isolated CABG procedures in the Medicare population from January 2000 through November 2012. Comorbidities were determined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes. Trends in patient characteristics and hospital outcomes were assessed with Cochran-Armitage trend tests. Long-term survival was examined with Kaplan-Meier survival curves.

Results: The median age was 74 years. Comorbidity profiles increased significantly over time. The number of patients undergoing CABG decreased from 131,385 in 2000 to 71,086 in 2012. The majority of patients underwent multivessel revascularization (13.5% single-vessel CABG, 35.2% 2-vessel CABG, 32.1% 3-vessel CABG, and 15.7% ≥4-vessel CABG). The percentage of patients undergoing 1- and 2-vessel revascularization increased over time, whereas that of ≥3-vessel CABG decreased. Single internal mammary artery (IMA) use increased from 75.6% to 88.6%. Median length of stay (LOS) was 8 days. Thirty-day mortality decreased from 4.2% to 3.0%. Hospital mortality fell from 4.0% in 2000 to 2.7% in 2012 (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.69-0.77). Survival was 93% at 6 months, 91% at 1 year, 84% at 3 years, and 76% at 5 years. Five-year survival changed little over time (range, 75%-77%).

Conclusions: Despite rising comorbidities in Medicare patients undergoing CABG, hospital mortality fell significantly from 2000 to 2012. When adjusted for comorbidities, this signified a 27% reduction in hospital mortality. IMA use increased during the study period, and there was a trend of decreased use of 3 or more grafts.
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http://dx.doi.org/10.1016/j.athoracsur.2016.01.016DOI Listing
July 2016

Mitral Valve Surgery in Women: Another Target for Eradicating Sex Inequality.

Circ Cardiovasc Qual Outcomes 2016 Feb;9(2 Suppl 1):S94-6

From the Department of Medicine, Washington University School of Medicine, Saint Louis, MO (C.M.); and Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield (C.V.).

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http://dx.doi.org/10.1161/CIRCOUTCOMES.115.002603DOI Listing
February 2016

Minimally invasive mitral repair: The cost is the same, but what is the price?

J Thorac Cardiovasc Surg 2016 Feb 20;151(2):389-90. Epub 2015 Oct 20.

Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Ill. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2015.09.134DOI Listing
February 2016

Effect of Hospital Volume on Prosthesis Use and Mortality in Aortic Valve Operations in the Elderly.

Ann Thorac Surg 2016 Feb 1;101(2):585-90. Epub 2015 Oct 1.

Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois. Electronic address:

Background: This study was designed to examine the effect of hospital procedural volume on outcomes in aortic valve replacement (AVR) in the elderly.

Methods: The study included 277,928 Medicare beneficiaries who underwent AVR from 2000 through 2009 at one of 1,255 participating hospitals. Operative mortality and the use of mechanical prostheses were analyzed according to hospital annual procedural volume. Annual AVR volume was divided into 5 different categories: the smallest volume group with less than 10 AVRs per year to the largest group averaging more than 70 AVRs per year.

Results: The overall observed operative mortality rate was 7.3%; for isolated AVR it was 5.5%. Lower-volume hospitals exhibited increased adjusted operative mortality: 10 cases or fewer per year--odds ratio (OR), 1.55; 95% confidence interval (CI), 1.39 to 1.72; 11 to 20 cases per year--OR, 1.35; 95% CI, 1.23 to 1.47; 21 to 40 cases per year--OR, 1.15; 95% CI, 1.06 to 1.25; 41 to 70 cases per year--OR, 1.10; 95% CI, 1.01 to 1.20 relative to those hospitals performing more than 70 cases per year. The discrepancy in operative mortality between low- and high-volume hospitals diverged during the study. Mechanical valve use decreased with increasing hospital volume (p = 0.0001). Mechanical valves were used in 64.5% of AVRs in hospitals with an annual AVR volume less than 10 in contrast to only 25.4% in hospitals with an annual AVR volume more than 70. After adjustment, the use of mechanical valves was independently associated with increased operative mortality (OR, 1.15; 95% CI, 1.11-1.19).

Conclusions: Low-volume centers were characterized by increased adjusted operative mortality and greater use of mechanical prostheses, a trend that persisted during the 10-year course of the study. These data would support the center-of-excellence concept for AVR and may be particularly relevant in the elderly population.
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http://dx.doi.org/10.1016/j.athoracsur.2015.07.010DOI Listing
February 2016

Outcomes of Patients With Severe Chronic Lung Disease Who Are Undergoing Transcatheter Aortic Valve Replacement.

Ann Thorac Surg 2015 Dec 29;100(6):2136-45; discussion 2145-6. Epub 2015 Aug 29.

Mayo Clinic, Rochester, Minnesota.

Background: In this study, we sought to determine the clinical outcomes after transcatheter aortic valve replacement (TAVR) among patients with chronic lung disease (CLD) and to evaluate the safety of transaortic versus transapical alternate access approaches in patients with varying severities of CLD.

Methods: Clinical records for patients undergoing TAVR from 2011 to 2014 in The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry were linked to Medicare hospital claims (n = 11,656). Clinical outcomes were evaluated across strata of CLD severity, and the risk-adjusted association between access route and post-TAVR mortality was determined among patients with severe CLD.

Results: In this cohort (median age, 84 years; 51.7% female), moderate to severe CLD was present in 27.7% (14.3%, moderate; 13.4%, severe). Compared with patients with no or mild CLD, patients with severe CLD had a higher rate of post-TAVR mortality to 1-year (32.3% versus 21.0%; adjusted hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.31 to 1.66), as did those with moderate CLD (25.5%; adjusted HR, 1.16; 95% CI, 1.03 to 1.30). The adjusted rate of mortality was similar for transapical versus transaortic approaches to 1 year (adjusted HR, 1.17; 95% CI, 0.83 to 1.65).

Conclusions: Moderate or severe CLD is associated with an increased risk of death to 1-year after TAVR, and among patients with severe CLD, the risk of death appears to be similar with either transapical or transaortic alternate-access approaches. Further study is necessary to understand strategies to mitigate risk associated with CLD and the long-term implications of these findings.
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http://dx.doi.org/10.1016/j.athoracsur.2015.05.075DOI Listing
December 2015

Evaluation of The Society of Thoracic Surgeons Online Risk Calculator for Assessment of Risk in Patients Presenting for Aortic Valve Replacement After Prior Coronary Artery Bypass Graft: An Analysis Using the STS Adult Cardiac Surgery Database.

Ann Thorac Surg 2015 Dec 30;100(6):2109-15; discussion 2115-6. Epub 2015 Jul 30.

Division of Cardiac Surgery, Northwestern University, Chicago, Illinois.

Background: Accurate risk assessment in patients presenting for aortic valve replacement (AVR) after prior coronary artery bypass grafting (CABG) is essential for appropriate selection of surgical versus percutaneous therapy.

Methods: We included 6,534 patients in The Society for Thoracic Surgeons (STS) Adult Cardiac Surgery Database (October 2009 through December 2013) who underwent elective, isolated reoperative AVR for aortic stenosis after prior CABG. Case-specific PROM was calculated and observed-to-expected ratios were inspected across the spectrum of risk. A cohort-specific recalibration equation was derived using logistic regression: = expit(-0.6453+0.6147*logit(PROM) -0.0709*logit(PROM)(ˆ)2), where PROM is the predicted risk of mortality. The proportion of patients reclassified as low (PROM < 4%), intermediate (4% to < 8%), high (8% to < 12%), and very high risk (≥ 12%) was calculated using the recalibration equation. The performance of the cohort-specific recalibration equation was then compared with the generic recalibration for quarterly STS reports.

Results: The STS online risk calculator overestimates risk for low, intermediate, and high risk categories. Using the recalibrated risk equation, a substantial proportion of patients were reclassified as the following: 25.5% from intermediate to low risk; 39.7% from high to intermediate risk; and 41.5% from very high to high risk. Comparison of the cohort-specific recalibration equation to the generic quarterly STS recalibration demonstrated very similar results.

Conclusions: In patients presenting for AVR after prior CABG, the STS online risk calculator overestimates risk for all but the highest risk patients. Using a cohort-specific recalibration equation, a substantial proportion of patients would be downgraded to lower risk categories. The cohort-specific recalibration correlates well with the existing generic quarterly STS recalibration. The findings of this study support recommendations for periodic recalibration of the online risk calculator in order to facilitate clinical decision making in real time.
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http://dx.doi.org/10.1016/j.athoracsur.2015.04.149DOI Listing
December 2015

Contemporary Outcomes of Repeat Aortic Valve Replacement: A Benchmark for Transcatheter Valve-in-Valve Procedures.

Ann Thorac Surg 2015 Oct 21;100(4):1298-304; discussion 1304. Epub 2015 Jul 21.

Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts. Electronic address:

Background: Reoperative aortic valve replacement (re-AVR) after previous AVR is a complex procedure involving redo sternotomy and removal of a previous prosthesis. With increasing use of valve-in-valve transcatheter aortic valve replacement for failed aortic bioprostheses, an evaluation of contemporary outcomes of re-AVR in patients with bioprostheses is warranted.

Methods: The study included 3,380 patients from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (July 2011 to September 2013) who underwent elective, isolated re-AVR after a previous AVR. Outcomes in these patients were compared with those of 54,183 patients with isolated primary AVR during the same period. A subgroup analysis of explanted bioprostheses in re-AVR (previous bioprosthetic valve: n = 2,213) was performed.

Results: Re-AVR patients were younger (66 vs 70 years, p < 0.001) compared with primary AVR patients. Re-AVR was associated with higher operative mortality (4.6% vs 2.2%, p < 0.0001), composite operative mortality and major morbidity (21.6% vs 11.8%, p < 0.0001), postoperative stroke (1.9% vs 1.4%, p = 0.02), postoperative aortic insufficiency mild or greater (2.8% vs 1.7%, p < 0.0001), pacemaker requirement (11.0% vs 4.3%, p < 0.0001), and vascular complications (0.06% vs 0.01%, p = 0.04). For the explanted previous bioprosthetic valve group, operative mortality was 4.7%, composite outcome was 21.9%, stroke rate was 1.8%, and pacemaker requirement was 11.5%.

Conclusions: Re-AVR is now performed with an acceptable operative mortality, which is higher than primary AVR. The overall incidence of stroke, vascular complication, and postoperative aortic insufficiency was low although higher than primary AVR. These results may serve as a benchmark for future analysis of valve-in-valve transcatheter aortic valve replacement and may have an effect on future choice of transcatheter aortic valve replacement vs re-AVR.
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http://dx.doi.org/10.1016/j.athoracsur.2015.04.062DOI Listing
October 2015

Magnitude of negative impact of preoperative heart failure on mortality during aortic valve replacement in the medicare population.

Ann Thorac Surg 2015 May 1;99(5):1503-09; discussion 1509-10. Epub 2015 Apr 1.

Department of Surgery, Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois.

Background: In patients with severe aortic stenosis, the development of heart failure (HF) prior to aortic valve replacement (AVR) is associated with worse prognosis. We sought to quantify the effect of progressive HF on mortality during AVR in the Medicare population over a 10-year period.

Methods: Medicare beneficiaries 65 or greater years of age who underwent primary isolated AVR from 2000 through 2009 were included (n = 114,135). Logistic regression and Cox proportional hazards were used to model adjusted operative mortality (OM) and long-term survival, according to the presence of preoperative HF and its duration (≤ 3 vs > 3 months).

Results: The incidence of preoperative comorbidities was high, and it was higher in patients with preoperative HF, compared with those without. Preoperative HF dramatically increased adjusted OM, odds ratio (OR) 1.57 (95% confidence interval [CI], 1.48 to 1.67). Preoperative HF greater than 3 months conferred a significant increase in adjusted OM compared with HF 3 months or less, OR 1.43 (95% CI, 1.32 to 1.55). Similarly, preoperative HF increased the likelihood of long-term mortality by 50%, hazard ratio (HR) 1.48 (95% CI, 1.45 to 1.51). Long-term mortality was higher for patients with longer duration of preoperative HF as compared with those without preoperative HF, HR 1.81 (95% CI, 1.75 to 1.87) and compared with patients with HF 3 months or less, HR 1.26 (95% CI, 1.23 to 1.30).

Conclusions: The magnitude of the negative impact of preoperative HF on operative mortality and long-term survival of elderly patients undergoing primary isolated AVR is significant with 50% increased likelihood of adverse outcome. Duration of preoperative HF is also significantly related to mortality. These data support AVR in the elderly prior to the development of HF.
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http://dx.doi.org/10.1016/j.athoracsur.2014.12.106DOI Listing
May 2015

Hospital volume, mitral repair rates, and mortality in mitral valve surgery in the elderly: an analysis of US hospitals treating Medicare fee-for-service patients.

J Thorac Cardiovasc Surg 2015 Mar 18;149(3):762-8.e1. Epub 2014 Sep 18.

Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Ill.

Background: The volume-outcome relationship has been suggested as a quality metric in mitral valve surgery and would be particularly relevant in the elderly because of their greater burden of comorbidities and higher perioperative risk.

Methods And Results: The study included 1239 hospitals performing mitral valve surgery on Medicare beneficiaries from 2000 through 2009. Only 9% of hospitals performed more than 40 mitral operations per year, 29% performed 5 or less, and 51% performed 10 or less. Mitral repair rates were low; 22.7% of hospitals performed 1 or less, 65.1% performed 5 or less, and only 5.6% performed more than 20 mitral repairs per year in those aged 65 years or more. Repair rates increased with increasing volume of mitral operations per year: 5 or less, 30.5%; 6 to 10, 32.9%; 11 to 20, 34.9%; 21 to 40, 38.8%; and more than 40, 42.0% (P = .0001). Hospitals with lower volume had significantly higher adjusted operative mortality compared with hospitals performing more than 40 cases per year: 5 or less cases per year, odds ratio (OR) 1.58 (95% confidence interval [CI], 1.40-1.78); 6 to 10 cases per year, OR 1.29 (95% CI, 1.17-1.43); 11 to 20 cases per year, OR 1.17 (95% CI, 1.07-1.28); 21 to 40 cases per year, OR 1.15 (95% CI, 1.05-1.26). Hospitals with lower mitral repair rates had an increased likelihood of operative mortality relative to the top quartile: lowest quartile, OR 1.31 (95% CI, 1.20-1.44); second quartile, OR 1.18 (95% CI, 1.09-1.29); and third quartile, OR 1.14 (95% CI, 1.05-1.24). Long-term mortality beyond 6 months was also higher in low-volume hospitals: 5 or less cases year, hazard ratio (HR) 1.11 (95% CI, 1.06-1.18); 6 to 10 cases per year, OR 1.06 (95% CI, 1.02-1.10) compared with hospitals performing more than 40 cases per year.

Conclusions: Most hospitals perform few mitral valve operations on elderly patients. Greater volume of mitral procedures was associated with higher repair rates. Both greater volume of mitral procedures and increasing mitral repair rates were associated with decreased mortality.
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http://dx.doi.org/10.1016/j.jtcvs.2014.08.084DOI Listing
March 2015

Heart failure readmission after mitral valve repair and replacement: five-year follow-up in the Medicare population.

Ann Thorac Surg 2014 Nov 22;98(5):1544-50. Epub 2014 Sep 22.

Southern Illinois University School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Springfield, Illinois.

Background: Readmission rates are well established as a quality indicator for heart failure (HF). We analyzed HF readmission rates after mitral valve repair (MVP) and replacement (MVR).

Methods: We included 21,138 Medicare beneficiaries with primary isolated MVP (n=6,896) or MVR (n=14,242) from 2000 through 2004. Readmission rates were identified using MedPar records subsequent to the index procedure during a 5-year follow-up. Treating death as a competing risk, cumulative readmission incidences were analyzed and stratified by presence or absence of preoperative HF.

Results: Preoperative HF was present in 61.0% of the patients. All-cause readmission rates were 24.9% at 30 days and 78.0% at 5 years. The cumulative incidence of readmission for HF remained almost 3 times higher in patients with preoperative HF compared with those without for MVP (2.1% vs 5.9% in 30 days and 10.3% vs 26.3% in 5 years) and 2 times higher for MVR (3.6% vs 7.4% in 30 days and 15.8% vs 30.4% in 5 years). Regardless of procedure type, patients without preoperative HF had significantly lower HF readmission rates (3.0% vs 7.0% in the first 30 days and 13.6% vs 29.2% after 5 years) (p=0.0001).

Conclusions: Hospital readmission after mitral surgery is high. Preoperative heart failure is associated with higher postoperative readmission rates. Because admission for heart failure accounts for a significant proportion of these readmissions, close follow-up of patients with known mitral valve disease and referral to surgery prior to development of heart failure may decrease postoperative readmission rates.
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http://dx.doi.org/10.1016/j.athoracsur.2014.07.040DOI Listing
November 2014

Long-term outcomes of mitral valve repair versus replacement for degenerative disease: a systematic review.

Curr Cardiol Rev 2015 ;11(2):157-62

1000 N. 5th Street, Springfield, IL 62702, USA.

The short-term advantage of mitral valve repair versus replacement for degenerative disease has been extensively documented. These advantages include lower operative mortality, improved survival, better preservation of leftventricular function, shorter post-operative hospital stay, lower total costs, and fewer valve-related complications, including thromboembolism, anticoagulation-related bleeding events and late prosthetic dysfunction. More recent written data are available indicating the long-term advantage of repair versus replacement. While at some institutions, the repair rate for degenerative disease may exceed 90%, the national average in 2007 was only 69%. Making direct comparisons between mitral valve repair and replacement using the available studies does present some challenges however, as there are often differences in baseline characteristics between patient groups as well as other dissimilarities between studies. The purpose of this review is to systematically summarize the long-term survival and reoperation data of mitral valve repair versus replacement for degenerative disease. A PubMed search was done and resulted in 12 studies that met our study criteria for comparing mitral valve repair versus replacement for degenerative disease. A systematic review was then conducted abstracting survival and reoperation data.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4356723PMC
http://dx.doi.org/10.2174/1573403x10666140827093650DOI Listing
July 2015

Does mitral valve repair offer an advantage over replacement in patients undergoing aortic valve replacement?

Ann Thorac Surg 2014 Aug 10;98(2):598-603; discussion 604. Epub 2014 Jun 10.

Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland.

Background: Concomitant aortic and mitral valve (MV) operations have more than doubled over the past decade. We utilized the Society of Thoracic Surgeons Adult Cardiac Surgery Database (ACSD) to evaluate outcomes for patients undergoing combined aortic valve replacement (AVR) and MV repair or replacement.

Methods: From 1993 to 2007, 23,404 patients undergoing concomitant AVR+MV surgery were identified. Patients with mitral stenosis, emergent or salvage status, and endocarditis were excluded. Outcomes were expressed as unadjusted operative mortality, adjusted odds ratio (OR) for mortality, and a composite of mortality and major complications.

Results: The MV repair was performed in 46.0% and replacement in 54.0% of AVR patients. The rate of MV repair increased from 22.5% in 1993 to 59.1% in 2007 (p<0.0001). Compared with the AVR+MV replacement group, the AVR+MV repair group was older (69.7±11.5 vs 67.2±12.7 years, p<0.0001), had worse ejection fraction (0.449±0.153 vs 0.495±0.139, p<0.0001), and more concomitant coronary artery bypass grafting (CABG) (50.5% vs 40.9%, p<0.0001). Unadjusted operative mortality was lower in the AVR+MV repair group (8.2% vs 11.6%, p<0.0001). Predictors of operative mortality by multivariable analysis included the following: age (OR 1.21, p<0.0001); concomitant CABG (OR 1.49, p<0.0001); diabetes mellitus (OR 1.56, p<0.0001); reoperation (OR 1.53, p<0.0001); and renal failure with dialysis (OR 3.57, p<0.0001). Patients undergoing MV repair had a lower independent risk of operative mortality (OR 0.61, p<0.0001), and mortality also independently improved over time (2003 to 2007 vs 1993 to 1997, OR 0.79, p<0.002).

Conclusions: When feasible, MV repair remains the most optimal method of correcting mitral regurgitation during concomitant AVR. Continued efforts to improve MV repair rates in this setting seem warranted.
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http://dx.doi.org/10.1016/j.athoracsur.2014.01.031DOI Listing
August 2014

Preoperative heart failure in the Medicare population undergoing mitral valve repair and replacement: an opportunity for improvement.

J Thorac Cardiovasc Surg 2014 Oct 1;148(4):1393-9. Epub 2014 Jan 1.

Department of Surgery, Southern Illinois University School of Medicine, Springfield, Ill.

Background: Elderly patients are under-represented in most surgical series of mitral valve surgery. The impact of preoperative heart failure (HF) on the outcomes of this subset has not been extensively studied.

Methods And Results: The study included 45,082 Medicare beneficiaries who underwent primary isolated mitral valve repair (MVP) (n=16,850) or replacement (MVR) (n=28,232) from 2000 to 2009. Medicare claims from the year before and the year of the index hospitalization were reviewed for documentation of HF to examine the operative mortality and long-term survival of patients with and without preoperative HF. Preoperative HF was present in 52.5% and 64.8% of patients who underwent repair and replacement, respectively. Duration of HF greater than 3 months was present in a significant proportion of patients (18.2% for MVP and 22.7% for MVR). Adjusted operative mortality was higher for patients with preoperative HF (MVP odds ratio [OR], 1.46; 95% confidence interval [CI], 1.21-1.78; MVR OR, 1.36; 95% CI, 1.23-1.51). Patients without preoperative HF had better long-term survival (MVP hazard ratio [HR], 2.23 [95% CI, 2.09-2.36]; MVR HR, 1.80 [95% CI, 1.73-1.86]). After adjustment, a preoperative HF diagnosis was still associated with 52% and 36% increased risk of death over the 10-year follow-up period for patients who underwent MVP and MVR, respectively. Preoperative HF duration greater than 3 months conferred an excess 28% higher risk of death on long-term follow-up compared with patients with HF less than 3 months.

Conclusions: Preoperative HF is present in a large number of elderly patients undergoing primary isolated mitral valve surgery and adversely affects their short-term and long-term survival, irrespective of procedure type (repair or replacement). The study supports the early identification of elderly patients with mitral valve disease and referral to surgery before the onset of HF.
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http://dx.doi.org/10.1016/j.jtcvs.2013.12.010DOI Listing
October 2014

Outcome characteristics of multiple-valve surgery: comparison with single-valve procedures.

Innovations (Phila) 2014 Jan-Feb;9(1):27-32

From the *Southern Illinois University School of Medicine, Springfield, IL USA; †Duke University and Duke Clinical Research Institute, Durham, NC USA; ‡Emory University School of Medicine, Atlanta, GA USA; §Mayo Clinic, Rochester, MN USA; ∥University of Louisville, Louisville, KY USA; ¶St. Louis University School of Medicine, St. Louis, MO USA; and #Vanderbilt University, Nashville, TN USA.

Objective: Multiple-valve (MUV) procedures currently exhibit higher operative mortality than do single-valve procedures, but a paucity of scientific information exists to explain the observation. This topic was examined using The Society of Thoracic Surgeons Database.

Methods: All patients in the The Society of Thoracic Surgeons data set undergoing valve surgery (except pulmonary valve and aortic root operations) from 1993 through 2007 were identified (N = 623,039). Baseline characteristics and postoperative outcomes were contrasted between all seven combinations of single-valve and MUV procedures involving aortic, mitral, and tricuspid valves. Seven independent logistic regression analyses were performed, based on the seven procedures, and multivariable risk factors for mortality were compared, with emphasis on single-valve versus MUV procedures.

Results: Baseline characteristics for MUV procedures (n = 67,926) shared many similarities to those for single-valve procedures (n = 555,113), including age, ejection fraction, and comorbidities. Preoperative renal failure, New York Heart Association class III to IV, nonelective presentation, and reoperation were slightly more common in MUV subsets, and coronary bypass was less frequent. Operative mortality was almost double for MUV as compared with single-valve procedures (10.7% vs 5.7%, P = 0.0001). Categorical predictors with the largest odds ratios for mortality were emergency status, renal failure, and second reoperation. However, predictors for mortality were generally consistent in order and magnitude between the single-valve and MUV subgroups.

Conclusions: Despite similarities in preoperative profiles of the patients undergoing single-valve and MUV procedures, mortality for MUV surgery remains considerably higher. Determinants of operative mortality and morbidity differ little across the procedural groups, and these findings serve as a benchmark for future studies, as well as suggest a continued search for explanations of poorer MUV outcomes.
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http://dx.doi.org/10.1097/IMI.0000000000000028DOI Listing
November 2014

Mitral subvalvular plasty for chronic ischemic mitral regurgitation: a preliminary experimental model.

J Heart Valve Dis 2013 Jul;22(4):538-42

Institute of Cardiology, Siberian Branch, Russian Academy of Medical Sciences, Tomsk, Russia.

Background And Aim Of The Study: Restrictive annuloplasty remains the most widespread technique for the correction of chronic ischemic mitral regurgitation (IMR). However, this technique only partially corrects the underlying pathophysiology and does not address the restricted leaflet motions during systole that result from progressive left ventricular (LV) remodeling.

Methods: A novel experimental model of IMR was developed using an isolated pig heart placed on a hydrodynamic test-stand. A T-shaped LV patch was sutured onto the posterior wall of the left ventricle to simulate LV dilatation secondary to post-MI remodeling.

Results: Using this model, a novel technique of subvalvular mitral valvuloplasty was described that reduces the distance between the posterior mitral annulus and the papillary muscle base and appears to be effective in eliminating IMR. Pledgetted 2-0 non-absorbable sutures were placed at the base of one papillary muscle, then through the other papillary muscle and then brought to the posterior mitral annulus. The same sequence was repeated in the other direction. A specific formula was then used to calculate the length of the subvalvular support prior to suture tying.

Conclusion: Subvalvular support of the mitral apparatus in chronic IMR can be achieved using this simple method, which appears to be effective in eliminating IMR. Further data relating to the use of this technique in the clinical setting as an adjunct to mitral annuloplasty are forthcoming.
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July 2013