Publications by authors named "Gorav Ailawadi"

365 Publications

Barriers to atrial fibrillation ablation during mitral valve surgery.

J Thorac Cardiovasc Surg 2021 Mar 17. Epub 2021 Mar 17.

Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.

Background: Nearly 40% of patients with atrial fibrillation (AF) undergoing mitral valve surgery do not receive concomitant ablation despite societal guidelines. We assessed barriers to implementation of this evidence-based practice through a survey of cardiac surgeons in 2 statewide quality collaboratives.

Methods: Adult cardiac surgeons across 2 statewide collaboratives were surveyed on their knowledge and practice regarding AF ablation. Questions concerning experience, clinical practice, case scenarios, and barriers to implementation were included.

Results: Among 66 respondents (66 of 135; 48.9%), the majority reported "very comfortable/frequently use" cryoablation (53 of 66; 80.3%) and radiofrequency (55 of 66; 83.3%). Only 12.1% (8/66) were not aware of the recommendations. Approximately one-half of the respondents reported learning AF ablation in fellowship (50.0%; 33 of 66) or attending courses (47.0%; 31 of 66). Responses to clinical scenarios demonstrated wide variability in practice patterns. One-half of the respondents reported no barriers; others cited increased cross-clamp time, excessive patient risk, and arrhythmia incidence as obstacles. Desired interventions included cardiology/electrophysiology support, protocols, pacemaker rate information, and education in the form of site visits, videos and proctors.

Conclusions: Knowledge of evidence-based recommendations and practice patterns vary widely. These data identify several barriers to implementation of concomitant AF ablation and suggest specific interventions (mentorship/support, protocols, research, and education) to overcome these barriers.
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http://dx.doi.org/10.1016/j.jtcvs.2021.03.039DOI Listing
March 2021

Commentary: The reality of The Society of Thoracic Surgeons risk calculators at high volume centers.

J Thorac Cardiovasc Surg 2021 Mar 16. Epub 2021 Mar 16.

Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.035DOI Listing
March 2021

Minimally Invasive Versus Sternotomy for Mitral Surgery in the Elderly: A Systematic Review and Meta-Analysis.

Innovations (Phila) 2021 Mar 30:15569845211000332. Epub 2021 Mar 30.

622170384 Western University, London, ON, Canada.

Objective: The safety of minimally invasive mitral valve surgery (MIMVS) in elderly patients is still debated. Our objective was to perform a systematic review and meta-analysis of studies comparing MIMVS with conventional sternotomy (CS) in elderly patients (≥65 years old).

Methods: We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for trials and observational studies comparing MIMVS with CS in patients ≥65 years old presenting for mitral valve surgery. We performed a random-effects meta-analysis of all outcomes.

Results: The MIMVS group had lower odds of acute renal failure (odds ratio [OR] 0.27; 95% CI 0.10 to 0.78), prolonged intubation (>48 h; OR 0.47; 95% CI 0.31 to 0.70), less blood product transfusion (weighted mean difference [WMD] -0.82 units; 95% CI -1.29 to -0.34 units), shorter ICU length of stay (LOS; WMD -2.57 days; 95% CI -3.24 to -1.90 days) and hospital LOS (WMD -4.06 days; 95% CI -5.19 to -2.94 days). There were no significant differences in the odds of mortality, stroke, respiratory infection, reoperation for bleeding, and postoperative atrial fibrillation. MIMVS was associated with longer cross-clamp (WMD 11.8 min; 95% CI 3.5 to 20.1 min) and cardiopulmonary bypass times (WMD 23.0 min; 95% CI 10.4 to 35.6 min).

Conclusions: MIMVS in elderly patients is associated with lower postoperative complications, blood transfusion, shorter ICU, and hospital LOS, and longer cross-clamp and bypass times.
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http://dx.doi.org/10.1177/15569845211000332DOI Listing
March 2021

Prediction of Prolonged Intensive Care Unit Length of Stay Following Cardiac Surgery.

Semin Thorac Cardiovasc Surg 2021 Mar 6. Epub 2021 Mar 6.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Intensive care unit (ICU) costs comprise a significant proportion of the total inpatient charges for cardiac surgery. No reliable method for predicting intensive care unit length of stay following cardiac surgery exists, making appropriate staffing and resource allocation challenging. We sought to develop a predictive model to anticipate prolonged ICU length of stay (LOS). All patients undergoing coronary artery bypass grafting (CABG) and/or valve surgery with a Society of Thoracic Surgeons (STS) predicted risk score were evaluated from an institutional STS database. Models were developed using 2014-2017 data; validation used 2018-2019 data. Prolonged ICU LOS was defined as requiring ICU care for at least three days postoperatively. Predictive models were created using lasso regression and relative utility compared. A total of 3283 patients were included with 1669 (50.8%) undergoing isolated CABG. Overall, 32% of patients had prolonged ICU LOS. Patients with comorbid conditions including severe COPD (53% vs 29%, P < 0.001), recent pneumonia (46% vs 31%, P < 0.001), dialysis-dependent renal failure (57% vs 31%, P < 0.001) or reoperative status (41% vs 31%, P < 0.001) were more likely to experience prolonged ICU stays. A prediction model utilizing preoperative and intraoperative variables correctly predicted prolonged ICU stay 76% of the time. A preoperative variable-only model exhibited 74% prediction accuracy. Excellent prediction of prolonged ICU stay can be achieved using STS data. Moreover, there is limited loss of predictive ability when restricting models to preoperative variables. This novel model can be applied to aid patient counseling, resource allocation, and staff utilization.
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http://dx.doi.org/10.1053/j.semtcvs.2021.02.021DOI Listing
March 2021

Longitudinal analysis of National Institutes of Health funding for academic thoracic surgeons.

J Thorac Cardiovasc Surg 2021 Feb 3. Epub 2021 Feb 3.

Department of Cardiac Surgery, University of Michigan School of Medicine, Ann Arbor, Mich. Electronic address:

Objective: National Institutes of Health (NIH) funding for academic (noncardiac) thoracic surgeons at the top-140 NIH-funded institutes in the United States was assessed. We hypothesized that thoracic surgeons have difficulty in obtaining NIH funding in a difficult funding climate.

Methods: The top-140 NIH-funded institutes' faculty pages were searched for noncardiac thoracic surgeons. Surgeon data, including gender, academic rank, and postfellowship training were recorded. These surgeons were then queried in NIH Research Portfolio Online Reporting Tools Expenditures and Results for their funding history. Analysis of the resulting grants (1980-2019) included grant type, funding amount, project start/end dates, publications, and a citation-based Grant Impact Metric to evaluate productivity.

Results: A total of 395 general thoracic surgeons were evaluated with 63 (16%) receiving NIH funding. These 63 surgeons received 136 grants totaling $228 million, resulting in 1772 publications, and generating more than 50,000 citations. Thoracic surgeons have obtained NIH funding at an increasing rate (1980-2019); however, they have a low percentage of R01 renewal (17.3%). NIH-funded thoracic surgeons were more likely to have a higher professorship level. Thoracic surgeons perform similarly to other physician-scientists in converting K-Awards into R01 funding.

Conclusions: Contrary to our hypothesis, thoracic surgeons have received more NIH funding over time. Thoracic surgeons are able to fill the roles of modern surgeon-scientists by obtaining NIH funding during an era of increasing clinical demands. The NIH should continue to support this mission.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.088DOI Listing
February 2021

Valve-sparing aortic root replacement after neonatal arterial switch operation.

J Card Surg 2021 Feb 27. Epub 2021 Feb 27.

Department of Cardiac Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan, USA.

Arterial switch operations (ASO) are lifesaving procedures performed on neonates to treat transposition of the great arteries. However, future operations on the neoaorta may be required due to dilation. We present a case of a 25-year-old female who presented with dilation of her neoaorta and required a David procedure. Her previous ASO resulted in an anterior lie of the pulmonary artery in front of the neoaorta, with both coronary arteries coming off anteriorly. We describe our approach to performing a David procedure on this patient with this unique anatomy.
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http://dx.doi.org/10.1111/jocs.15466DOI Listing
February 2021

Edge-to-edge repair: will it still be mainstream repair therapy in 2030?

Ann Cardiothorac Surg 2021 Jan;10(1):158-160

Advanced Cardiac Valve Center, University of Virginia, Charlottesville, VA, USA.

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http://dx.doi.org/10.21037/acs-2020-mv-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867422PMC
January 2021

Surgical versus transcatheter mitral valve replacement in functional mitral valve regurgitation.

Ann Cardiothorac Surg 2021 Jan;10(1):75-84

Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA.

Surgical mitral valve intervention for severe functional, or secondary mitral regurgitation is a viable option for patients deemed to be operative candidates and can be performed via traditional sternotomy or by minimally invasive techniques with similar outcomes. Transcatheter mitral valve replacement is an emerging technology with a potential role in the treatment of functional mitral valve regurgitation. A plethora of devices are currently in development and in various stages of clinical investigation. Operative approach to transcatheter mitral valve replacement varies from a percutaneous transseptal approach to a hybrid percutaneous/surgical apical approach. The Tendyne, Intrepid and Evoque systems show promising results from their early feasibility studies in treatment of patients with mitral regurgitation that were too high risk for surgery. In this review, we describe considerations for surgical and transcatheter mitral valve replacement for functional mitral valve regurgitation.
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http://dx.doi.org/10.21037/acs-2020-mv-217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867424PMC
January 2021

Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation.

J Am Coll Cardiol 2021 Feb;77(6):713-724

Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background: Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.

Objectives: The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.

Methods: Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.

Results: Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).

Conclusions: After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).
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http://dx.doi.org/10.1016/j.jacc.2020.11.066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953587PMC
February 2021

Surgical Explantation of Transcatheter Aortic Bioprostheses: Balloon Versus Self-Expandable Devices.

Ann Thorac Surg 2021 Feb 2. Epub 2021 Feb 2.

Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI.

Background: Despite the rapid adoption of transcatheter aortic replacement (TAVR), surgical TAVR valve explantation (TAVR-explant) and the clinical impact of explanted TAVR device type is not well-described.

Methods: TAVR-explant from 2016 to 2019 was queried using the Society of Thoracic Surgeons (STS) National Database. A total of 483 patients with documented explanted valve type, consisting of 330 (68%) with balloon-expandable and 153 (32%) patients with self-expandable devices, were identified. The primary outcome was 30-day mortality. The secondary outcome was the need for any simultaneous procedures with TAVR-explant.

Results: The mean age was 72.8, 38% were female, and 51% demonstrated NYHA class 3-4 symptoms. During TAVR-explant, 63% required other simultaneous procedures including aortic repair (27%), mitral (22%), coronary artery bypass grafting (15%), and tricuspid (7%) procedures. Patients with a self-expandable device underwent more frequent ascending aortic replacement (22% vs. 9%; p<0.001) than those with a balloon-expandable device, whereas the aortic root replacement rate was similar (19% vs. 24%; p=0.22). The overall 30-day mortality was 18% without difference regarding the mortality or other major complications between groups. Of the 157 patients with isolated surgical aortic valve replacement and available STS predicted risk of mortality score, the observed-to-expected (O/E) mortality ratio was 2.2.

Conclusions: The TAVR-explant outcomes were comparable between patients with balloon-expandable and self-expandable devices, while ascending aortic replacement was observed more frequently with self-expandable devices. Younger patients undergoing a TAVR should be informed of the future TAVR-explant risk which may accompany a higher O/E ratio and frequent morbid concurrent procedures.
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http://dx.doi.org/10.1016/j.athoracsur.2021.01.041DOI Listing
February 2021

Characteristics and outcomes of surgically ineligible patients with multivessel disease treated with percutaneous coronary intervention.

Catheter Cardiovasc Interv 2021 Feb 3. Epub 2021 Feb 3.

The Cardiovascular Division and Division of Cardiothoracic Surgery, University of Virginia Health Systems, Charlottesville, Virginia.

Objectives: In this study we evaluated the clinical characteristics and outcomes of surgically ineligible patients with coronary artery disease (CAD) who underwent multivessel percutaneous coronary intervention (PCI).

Background: Patients with multivessel CAD who are surgically ineligible and undergo PCI are not well represented in large trials.

Methods: Out of 1,061 consecutive patients who underwent a non-emergent PCI for unprotected left main or multivessel CAD at the University of Virginia Medical Center, 137 patients were determined to be surgically ineligible for coronary artery bypass graft (CABG) surgery by a heart team. The clinical characteristics and reasons for surgical ineligibility were collected. The coronary angiograms were reviewed and the SYNTAX score calculated. The Society of Thoracic Surgeons (STS) score was calculated. Outcomes were determined at 30 days and 1-year.

Results: The mean age of the cohort was 71 and 59% were women. Hypertension, hyperlipidemia, tobacco abuse, and diabetes were common comorbidities. The average SYNTAX score was 22. The most commonly cited reasons for surgical ineligibility were advanced age, frailty, severe lung disease, ejection fraction ≤ 30% and STS score ≥ 8%. Outcomes at 30 days were excellent and better than those predicted by STS for surgery. Frailty and STS score predicted one-year outcomes.

Conclusions: Patients undergoing PCI for multivessel disease who are surgically ineligible have multiple risk factors and comorbidities. Frailty, lung disease, poor left ventricular function, and high STS score represent common reasons for surgical ineligibility. Frailty and the STS score better predict one-year outcomes after PCI compared to the SYNTAX score.
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http://dx.doi.org/10.1002/ccd.29508DOI Listing
February 2021

Time for a More Sophisticated Approach for Young Aortic Stenosis Patients.

Authors:
Gorav Ailawadi

Innovations (Phila) 2021 Jan-Feb;16(1):22-23. Epub 2021 Feb 1.

21614 Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA.

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http://dx.doi.org/10.1177/1556984521991529DOI Listing
February 2021

First in human experience with an epicardial beating heart device for secondary mitral regurgitation.

J Thorac Cardiovasc Surg 2021 Mar 14;161(3):949-958.e4. Epub 2020 Dec 14.

Baylor Scott & White Heart and Vascular Hospital, Plano, Tex.

Objective: We describe a novel, off-pump, epicardial implant that is intended to reshape both the mitral valve annulus and the left ventricle (LV) in those with secondary mitral regurgitation (MR).

Methods: Five patients underwent an epicardial implant with the Mitral Touch device (Mitre Medical Corp, Morgan Hill, Calif), during concomitant off-pump coronary artery bypass for secondary MR. The median age was 71.2 years; 4 patients had severe MR and 1 moderate. Patients were followed for 1 year with transthoracic echocardiography and computed tomography. Safety, cardiac remodeling, and MR were assessed by an independent core laboratory.

Results: One patient died within 30 days from nondevice-related organ failure and the remaining 4 survived through 1-year follow-up. Implant technical success was 100% and took an average of 52 minutes. Paired computed tomography showed mean left ventricular end-systolic volume remodeling at 1 and 12 months of -35% and -31%, respectively. They averaged left atrial end-systolic volume remodeling of -12% and -15% at 1 and 12 months. Right ventricular end-systolic volume changes of -19% and -8% and right atrial end-systolic volume remodeling of -5% and 1%, at the 1- and 12-month time points were noted. Regurgitant volume by transthoracic echocardiography decreased by 46% and 44% and the ejection fraction from 34.6% to 32.1% and 39.5%, at 1 and 12 months, respectively. There were no device-related complications reported to 1 year.

Conclusions: The Epicardial Mitral Touch System for Mitral Regurgitation (ENRAPT-MR) study demonstrates a first-in-man, off-pump, epicardial repair of secondary MR. Procedural safety and geometric correction of the mitral valve apparatus and LV was achieved. Further studies in the United States are underway.
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http://dx.doi.org/10.1016/j.jtcvs.2020.11.169DOI Listing
March 2021

Aortic Annular Enlargement in the Elderly: Short and Long-Term Outcomes in the United States.

Ann Thorac Surg 2021 Jan 6. Epub 2021 Jan 6.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA. Electronic address:

Background: Patient prosthesis mismatch (PPM) is associated with significant long-term morbidity and mortality after aortic valve replacement, but the role and outcomes of annular enlargement (AE) remains poorly defined. We hypothesized that increasing rates of AE may lead to improved outcomes for patients at risk for severe PPM.

Methods: Patients over age 65 undergoing surgical aortic valve replacement (SAVR) with or without coronary artery bypass grafting from 2008-2016 in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD) with matching Center for Medicare Services data were included (n=189,268). Univariate, multivariate, and time-to-event analysis was used to evaluate the association between AE and early and late outcomes. Patients were stratified by projected degree of PPM based on calculated effective orifice area index (EOAi).

Results: A total of 5,412 (2.9%) patients underwent AE. STS predicted mortality was similar between AE and non-AE groups (2.97% vs 2.99%, p=0.052). Patients undergoing AE had higher risk-adjusted rates of 30-day complications and death (5.4% vs 3.4%, p<0.0001), but no differences in long-term rates of stroke, heart failure re-hospitalizations or aortic valve reoperation. Survival analysis demonstrated a higher risk of mortality with AE during the first 3 years after which the survival curves cross, favoring AE.

Conclusions: These data suggest annular enlargement during SAVR is associated with increased short-term risk in a Medicare population. Survival curves crossed after three years, which may portend a benefit in select patients. However, annular enlargement is still only done in the minority of patients who are at risk for PPM.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.023DOI Listing
January 2021

Imaging for Native Mitral Valve Surgical and Transcatheter Interventions.

JACC Cardiovasc Imaging 2021 Jan;14(1):112-127

Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA.

There has been rapid progress in transcatheter therapies for mitral regurgitation. These developments have elevated the need for the imager to have a core understanding of the functional mitral valve anatomy. Pre- and intraoperative echocardiography for surgical mitral valve repair for mitral regurgitation has defined contemporary interventional imaging in many ways. The central tenets of these principles apply to interventional imaging of transcatheter mitral valve interventions. However, the heightened emphasis on procedural planning and procedural imaging is one of the new challenges posed by transcatheter interventions. This need for accurate and reliable information has required the imager to be agnostic to the imaging modality. Cardiac computed tomography has become critical in procedural planning in this new paradigm. The expanded use of pre-procedural cardiac magnetic resonance to quantify mitral regurgitation and characterize the left ventricle is another illustration of this newer approach. Other illustrations of the new world of interventional imaging include the expanded use of 3-dimensional (3D) transesophageal echocardiography and real-time fusion of echocardiography and fluoroscopy images. Imaging data are also the basis for computational modeling, 3D printing, and artificial intelligence. These technologies are being increasingly explored to improve therapy selection and prediction of procedural outcomes. This review provides an update of the essentials in present interventional imaging for surgical and transcatheter interventions for mitral regurgitation.
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http://dx.doi.org/10.1016/j.jcmg.2020.11.021DOI Listing
January 2021

Lower Survival After Coronary Artery Bypass in Patients Who Had Atrial Fibrillation Missed by Widely Used Definitions.

Mayo Clin Proc Innov Qual Outcomes 2020 Dec 10;4(6):630-637. Epub 2020 Dec 10.

Department of Cardiac Surgery, Washington University School of Medicine and Barnes-Jewish Hospital, St Louis, MO.

Objective: To investigate the impact of limiting the definition of post-coronary artery bypass graft (CABG) atrial fibrillation (AF) to AF/flutter requiring treatment-as in the Society of Thoracic Surgeons' (STS) database- on the association with survival.

Patients And Methods: We assessed in-hospital incidence of post-CABG AF in 7110 consecutive isolated patients with CABG without preoperative AF at 4 hospitals (January 1, 2004 to December 31, 2010). Patients with ≥1 episode of post-CABG AF detected via continuous in-hospital electrocardiogram (ECG)/telemetry monitoring documented by physicians were assigned to the following: Group 1, identified as having post-CABG AF in STS data and Group 2, not identified as having post-CABG AF in STS data. Patients without documented post-CABG AF constituted Group 3. Survival was compared via a Cox model, adjusted for STS risk of mortality and accounting for site differences.

Results: Over 7 years' follow-up, 16.0% (295 of 1841) of Group 1, 18.7% (79 of 422) of Group 2, and 7.9% (382 of 4847) of Group 3 died. Group 2 had a significantly greater adjusted risk of death than both Group 1 (hazard ratio [HR]: 1.16; 95% confidence interval [CI], 1.02 to 1.33) and Group 3 (HR: 1.94; 95% CI, 1.69 to 2.22).

Conclusions: The statistically significant 16% higher risk of death for patients with AF post-CABG missed vs captured in STS data suggests treatment and postdischarge management should be investigated for differences. The historical misclassification of "missed" patients as experiencing no AF in the STS data weakens the ability to observe differences in risk between patients with and without post-CABG AF. Therefore, STS data should not be used for research examining post-CABG AF.
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http://dx.doi.org/10.1016/j.mayocpiqo.2020.07.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749274PMC
December 2020

Sex-Based Differences Among Experimental Swine Abdominal Aortic aneurysms.

J Surg Res 2021 Apr 17;260:488-498. Epub 2020 Dec 17.

Department of Surgery, University of Florida, Gainesville, Florida. Electronic address:

Background: Female sex protects against abdominal aortic aneurysms (AAAs); however, the mechanisms behind these sex-based differences remain unknown. The purpose of this study was to explore the role of sex and sex hormones in AAA formation among swine.

Materials And Methods: Using a previous validated model, infrarenal AAA were surgically created in uncastrated male (n = 8), female (n = 5), and castrated male (n = 4) swine. Aortic dilation was measured on postoperative day 28 during the terminal procedure and compared to initial aortic diameter measured during the index procedure. Tissue was analyzed for immunohistochemistry, cytokine array, gelatin zymography, serum 17β-estradiol, and testosterone assay.

Results: Uncastrated males had significantly larger maximal aortic dilation compared to castrated males (113.5% ± 11.4% versus 38.1% ± 4.5%, P = 0.0012). Females had significantly higher mean aortic dilation compared to castrated males (96.2% ± 7.5% versus 38.1% ± 4.5%, P = 0.0004). Aortic diameters between females and uncastrated males were not significantly different on day 28. Female swine had significantly higher concentrations of 17β-estradiol compared with uncastrated males (1590 ± 873.3 ng/mL versus 95.2 ± 2.3 ng/mL, P = 0.047), with no significant difference between females and castrated males. Uncastrated male AAA demonstrated significantly more elastin degradation compared with female and castrated males (P = 0.01 and <0 .01, respectively). No differences existed for T-cells or smooth muscle cells between groups. Multiple proinflammatory cytokines were elevated within uncastrated male aortic walls compared to females and castrated males.

Conclusions: Sex hormones, specifically 17β-estradiol and testosterone, influence experimental swine AAA formation as demonstrated by increased aneurysm size, collagen turnover, and elastolysis in uncastrated males in processes reflective of human disease.
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http://dx.doi.org/10.1016/j.jss.2020.11.061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946779PMC
April 2021

Effect of Cardiac Surgery on One-Year Patient-Reported Outcomes: A Prospective Cohort Study.

Ann Thorac Surg 2020 Dec 9. Epub 2020 Dec 9.

Department of Surgery, Washington University School of Medicine, St. Louis, MO. Electronic address:

Background: Current cardiac surgery risk algorithms and quality measures focus on perioperative outcomes. However, delivering high-value, patient-centered cardiac care will require a better understanding of long-term patient-reported quality of life after surgery. Our objective was to prospectively assess the effect of cardiac surgery on long-term patient-reported outcomes.

Methods: Patients undergoing cardiac surgery at an academic medical center (2016-2017) were eligible for enrollment. Patient-reported outcomes were measured using the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) preoperatively and one year postoperatively across five domains: mental health, physical health, physical functioning, social satisfaction, and applied cognition. Baseline data and perioperative outcomes were obtained from the Society of Thoracic Surgeons database. The effect of cardiac surgery on long-term patient-reported quality of life was assessed.

Results: Ninety-eight patients were enrolled and underwent cardiac surgery, with 92.9% (91/98) successful follow-up. The most common operation was CABG (63.3% [62/98]), with 60.2% (59/98) undergoing an elective operation. One-year all-cause mortality was 5.1% (5/98). Rate of major morbidity was 11.2% (11/98). Cardiac surgery significantly improved patient-reported outcomes at one year across four domains: mental health (Preop: 47.3±7.7 vs. Postop: 51.1±8.9, p=0.0004), physical health (41.2±8.2 vs. 46.3±9.3, p=0.0003), physical functioning (39.8±8.6 vs. 44.8±8.5, p<0.0001), and social satisfaction (46.8±10.9 vs. 50.7±10.8, p=0.023). Hospital discharge to a facility did not impact one-year patient-reported outcomes.

Conclusions: Cardiac surgery improves long-term patient-reported quality of life. Mental, physical, and social well-being scores were significantly higher one year postoperatively. Data collection with NIH PROMIS provides meaningful, quantifiable results that may improve delivery of patient-centered care.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.061DOI Listing
December 2020

Transcatheter Mitral Valve Repair With Leaflet-to-Ring Technique in the Presence of a Radiolucent Prosthetic Ring.

JACC Cardiovasc Interv 2021 Jan 9;14(1):e1-e4. Epub 2020 Dec 9.

Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan, USA.

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http://dx.doi.org/10.1016/j.jcin.2020.10.051DOI Listing
January 2021

Early Versus Delayed Pacemaker for Heart Block After Valve Surgery: A Cost-Effectiveness Analysis.

J Surg Res 2021 Mar 3;259:154-162. Epub 2020 Dec 3.

Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia.

Background: A significant percentage of patients who acutely develop high-grade atrioventricular block after valve surgery will ultimately recover, yet the ability to predict recovery is limited. The purpose of this analysis was to evaluate the cost-effectiveness of two different management strategies for the timing of permanent pacemaker implantation for new heart block after valve surgery.

Methods: A cost-effectiveness model was developed using costs and probabilities of short- and long-term complications of pacemaker placement, short-term atrioventricular node recovery, intensive care unit stays, and long-term follow-up. We aggregated the total expected cost and utility of each option over a 20-y period. Quality-adjusted survival with a pacemaker was estimated from the literature and institutional patient-reported outcomes. Primary decision analysis was based on an expected recovery rate of 36.7% at 12 d with timing of pacemaker implantation: early placement (5 d) versus watchful waiting for 12 d.

Results: A strategy of watchful waiting was more costly ($171,798 ± $45,695 versus $165,436 ± $52,923; P < 0.0001) but had a higher utility (9.05 ± 1.36 versus 8.55 ± 1.33 quality-adjusted life years; P < 0.0001) than an early pacemaker implantation strategy. The incremental cost-effectiveness ratio of watchful waiting was $12,724 per quality-adjusted life year. The results are sensitive to differences in quality-adjusted survival and rates of recovery of atrioventricular node function.

Conclusions: Watchful waiting for pacemaker insertion is a cost-effective management strategy compared with early placement for acute atrioventricular block after valve surgery. Although this is cost-effective from a population perspective, clinical risk scores predicting recovery will aid in personalized decision-making.
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http://dx.doi.org/10.1016/j.jss.2020.11.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897291PMC
March 2021

Commentary: A Strained or Depressed Heart: When Should Mitral Regurgitation Be Addressed?

Semin Thorac Cardiovasc Surg 2020 Nov 9. Epub 2020 Nov 9.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2020.10.026DOI Listing
November 2020

Outcomes of surgical mitral valve replacement: A benchmark to assess transcatheter technologies.

J Card Surg 2021 Jan 1;36(1):69-73. Epub 2020 Nov 1.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia, USA.

Background: Clinical trials are underway to evaluate the safety and efficacy of transcatheter mitral valve replacement in intermediate and high surgical risk patients. We analyzed outcomes of surgical mitral valve replacement in a regional consortium to provide benchmark data for emerging alternative therapies.

Methods: All patients undergoing mitral replacement with a Society of Thoracic Surgeons predicted risk of mortality (STS PROM) in a regional consortium from 2001 to 2017 were analyzed. Patients with endocarditis were excluded. Patients were stratified by STS PROM into low (<4%), moderate (4%-8%), and high risk (>8%) cohorts. Mortality, postoperative complications, and resource utilization were evaluated for each group.

Results: A total of 1611 patients were analyzed including 927 (58%) low, 370 (23%) moderate, and 314 (20%) high-risk patients. The mean STS PROM was 2%, 5.6%, and 15.4% for each group. Mortality was adequately predicted for all groups while the most common complications included prolonged ventilation, reoperation, and renal failure. Higher risk patients had longer intensive care unit and hospital lengths of stay (2 vs. 3 vs. 5 days, p < .0001 and 7 vs. 8 vs. 10 days, p < .0001) and higher total hospital costs ($38,029 vs. $45,075 vs. $59,171 p < .0001).

Conclusions: Mitral valve replacement is associated with acceptable morbidity and mortality, particularly for low and intermediate-risk patients. These outcomes also serve as a benchmark with which to compare forthcoming results of transcatheter mitral valve replacement trials.
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http://dx.doi.org/10.1111/jocs.15157DOI Listing
January 2021

Electronic Glycemic Management System and Endocrinology Service Improve Value in Cardiac Surgery.

Am Surg 2020 Oct 29:3134820950685. Epub 2020 Oct 29.

2358 Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Virginia, USA.

Background: Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery.

Methods: All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care-related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs.

Results: A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL ( < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care-related value by 38%.

Conclusion: Implementation of a protocol consisting of an eGMS paired with a cardiac surgery-specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care-related value increased as a result of eGMS implementation.
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http://dx.doi.org/10.1177/0003134820950685DOI Listing
October 2020

Safety of Intravenous Heparin for Cardiac Surgery in Patients With Alpha-Gal Syndrome.

Ann Thorac Surg 2020 Oct 5. Epub 2020 Oct 5.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.

Background: Alpha-gal syndrome is a tick-acquired disease caused by immunoglobulin E (IgE) to the oligosaccharide galactose-alpha-1,3-galactose (alpha-gal), causing allergic reactions to meat and products sourced from nonprimate mammals. As heparin is porcine-derived, we hypothesized that patients with alpha-gal syndrome who received high-dose heparin for cardiac surgery would have increased risk of anaphylaxis.

Methods: All cardiac surgery patients at an academic medical center from 2007 to 2019 were cross-referenced with research and clinical databases for the alpha-gal IgE blood test. Clinical data were obtained through the institutional Society of Thoracic Surgeons Adult Cardiac Database and chart review. Patients were stratified by development of an allergic reaction for univariate statistical analysis.

Results: Of the 8819 patients, 17 (0.19%) had a positive alpha-gal test before cardiac surgery. Of these 17 patients, 4 (24%) had a severe allergic reaction. The median alpha-gal titer was significantly higher in patients with a reaction (75 [interquartile range, 61-96] IU/mL vs 8 [interquartile range, 3-18] IU/mL; P = .006). There were no differences in median heparin loading dose, total dose, or maximum activated clotting time (all P > .05). In a subgroup of 8 patients with recent alpha-gal IgE level, 4 (50%) developed an allergic reaction.

Conclusions: Although alpha-gal is rare in patients undergoing cardiac surgery, there is up to a 50% risk of serious allergic reaction to heparin for cardiopulmonary bypass. Higher preoperative alpha-gal titers may confer a higher risk of severe allergic reaction. For patients with a clinical suspicion of alpha-gal syndrome, we recommend prescreening with IgE levels and premedicating before receiving high doses of intravenous heparin.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019687PMC
October 2020

Transcatheter Mitral Valve Repair and Replacement: What's on the Horizon?

Semin Thorac Cardiovasc Surg 2020 Sep 24. Epub 2020 Sep 24.

Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

There are more than 4 million people affected by mitral regurgitation in both the United States and Europe. Prior to the last decade the only options for treatment of MR were medical therapy and open-heart surgery which left many high risk patients with little option once medically optimized. However, we saw a flood in innovative transcatheter mitral valve interventions. As the technologies are refined these new approaches are considerably less invasive and for some high-risk patients may represent a superior option to conventional open-heart surgery. There are 3 main approaches currently being considered for transcatheter mitral valve repair, edge to edge repair, indirect annuloplasty and direct annuloplasty. There have also been large advancements in recent years in transcatheter replacement of the mitral valve. Although many of these devices are under investigation still, we sought to examine the current state of innovative transcatheter mitral valve technologies.
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http://dx.doi.org/10.1053/j.semtcvs.2020.09.018DOI Listing
September 2020

Endovascular repair of left ventricular assist device outflow graft defect.

J Card Surg 2020 Nov 24;35(11):3235-3238. Epub 2020 Sep 24.

Division of Cardiac Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.

Outflow graft complications after left ventricular assist device placement are infrequent but highly morbid. In this case report, we describe endovascular repair of multiple outflow graft defects with external hemorrhage in a complex patient using overlapping stent grafts. This approach successfully stopped the outflow graft hemorrhage and temporized the patient for subsequent cardiac transplantation.
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http://dx.doi.org/10.1111/jocs.15005DOI Listing
November 2020

Minimally Invasive vs Open Coronary Surgery: A Multiinstitutional Analysis of Cost and Outcomes.

Ann Thorac Surg 2020 Sep 19. Epub 2020 Sep 19.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.

Background: Limited multiinstitutional data evaluating minimally invasive cardiac surgery (MICS) coronary artery bypass surgery (CABG) outcomes have raised concern for increased resource utilization compared with standard sternotomy. The purpose of this study was to assess short-term outcomes and resource utilization with MICS CABG in a propensity-matched regional cohort.

Methods: Isolated CABG patients (2012-2019) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by MICS CABG vs open CABG via sternotomy, propensity-score matched 1:2 to balance baseline differences, and compared by univariate analysis.

Results: Of 26,255 isolated coronary artery bypass graft patients, 139 MICS CABG and 278 open CABG patients were well balanced after matching. There was no difference in the operative mortality rate (2.2% open vs 0.7% MICS CABG, P = .383) or major morbidity (7.9% open vs 7.2% MICS CABG, P = .795). However, open CABG patients received more blood products (22.2% vs 12.2%, P = .013), and had longer intensive care unit (45 vs 30 hours, P = .049) as well as hospital lengths of stay (7 vs 6 days, P = .005). Finally, median hospital cost was significantly higher in the open CABG group ($35,011 vs $27,906, P < .001) compared with MICS CABG.

Conclusions: Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.136DOI Listing
September 2020

How Big Is Too Big?: Donor Severe Obesity and Heart Transplant Outcomes.

Circ Heart Fail 2020 10 16;13(10):e006688. Epub 2020 Sep 16.

Department of Surgery, University of Virginia Health System, Charlottesville, VA (E.D.K., J.P.B., J.H.M., M.R.T., G.A., L.T.Y.).

Background: As the population becomes increasingly obese, so does the pool of potential organ donors. We sought to investigate the impact of donors with body mass index ≥40 (severe obesity) on heart transplant outcomes.

Methods: Single-organ first-time adult heart transplants from 2003 to 2017 were evaluated from the United Network for Organ Sharing database and stratified by donor severe obesity status (body mass index ≥40). Demographics were compared, and univariate and risk-adjusted analyses evaluated the relationship between severe obesity and short-term outcomes and long-term mortality. Further analysis evaluated the prevalence of severe obesity within the pool of organ donation candidates.

Results: A total of 26 532 transplants were evaluated, of which 939 (3.5%) had donors with body mass index ≥40, with prevalence increasing over time (2.2% in 2003, 5.3% in 2017). Severely obese donors more likely had diabetes mellitus (10.4% versus 3.1%, <0.01) and hypertension (33.3% versus 14.8%, <0.01), and 67.4% were size mismatched (donor weight >130% of recipient). Short-term outcomes were similar, including 1-year survival (10.6% versus 10.7%), with no significant difference in unadjusted and risk-adjusted long-term survival (log-rank =0.67, hazard ratio, 0.928, =0.30). Organ donation candidates also exhibited an increase in severe obesity over time, from 3.5% to 6.8%, with a lower proportion of hearts from severely obese donors being transplanted (19.5% versus 31.6%, <0.01).

Conclusions: Donor severe obesity was not associated with adverse post-transplant outcomes. Increased evaluation of hearts from obese donors, even those with body mass index ≥40, has the potential to expand the critically low donor pool.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006688DOI Listing
October 2020

Transcatheter tricuspid valve repair: Bringing the forgotten valve into the spotlight.

J Thorac Cardiovasc Surg 2020 Dec 26;160(6):1467-1473. Epub 2020 Jun 26.

Department of Surgery, University of Virginia School of Medicine, Charlottesville, Va. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.04.184DOI Listing
December 2020

A 30-year analysis of National Institutes of Health-funded cardiac transplantation research: Surgeons lead the way.

J Thorac Cardiovasc Surg 2020 Jul 5. Epub 2020 Jul 5.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va. Electronic address:

Objectives: Obtaining National Institutes of Health funding for heart transplant research is becoming increasingly difficult, especially for surgeons. We sought to determine the impact of National Institutes of Health-funded cardiac transplantation research over the past 30 years.

Methods: National Institutes of Health Research Portfolio Online Reporting Tools Expenditures and Results was queried for R01s using 10 heart transplant-related terms. Principal Investigator, total grant funding amount, number of publications, and citations of manuscripts were collected. A citation-based Grant Impact Metric was assigned to each grant: sum of citations for each manuscript normalized by the funding of the respective grant (per $100K). The department and background degree(s) (MD, PhD, MD/PhD) for each funded Principal Investigator were identified from institutional faculty profiles.

Results: A total of 321 cardiac transplantation R01s totaling $723 million and resulting in 6513 publications were analyzed. Surgery departments received more grants and more funding dollars to study cardiac transplantation than any other department (n = 115, $249 million; Medicine: n = 93, $208 million; Pathology: 26, $55 million). Surgeons performed equally well compared with all other Principal Investigators with respect to Grant Impact Metric (15.1 vs 20.6; P = .19) and publications per $1 million (7.5 vs 6.8; P = .75). Finally, all physician-scientists (MDs) have a significantly higher Grant Impact Metric compared with nonclinician researchers (non-MDs) (22.3 vs 16.3; P = .028).

Conclusions: Surgeon-scientists are equally productive and impactful compared with nonsurgeons despite decreasing funding rates at the National Institutes of Health and greater pressure from administrators to increase clinical productivity.
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http://dx.doi.org/10.1016/j.jtcvs.2020.06.076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7782209PMC
July 2020