Publications by authors named "Hartzell V Schaff"

646 Publications

Apixaban for Anticoagulation after Robotic Mitral Valve Repair.

Ann Thorac Surg 2022 Aug 13. Epub 2022 Aug 13.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.

Background: There is no consensus regarding postoperative anticoagulation after mitral valve repair (MVRep). We compared the outcomes of post-MVRep anticoagulation with apixaban compared to warfarin.

Methods: We reviewed data of 666 patients who underwent isolated robotic MVRep between January 2008 and October 2019. We excluded patients who had conversion to sternotomy, and those discharged without anticoagulation or on clopidogrel (n=40). Baseline and intraoperative characteristics, antiplatelet/anticoagulation records were collected. In-hospital and post-discharge complications, and overall survival were compared.

Results: Among the 626 studied patients the median age was 58 years (IQR, 51-66), 71% were male and 1% (n=9) had atrial fibrillation. Eighty percent (n=499) were discharged on warfarin and 20% on apixaban (n=127). Almost all patients (126/127, 99%) in the apixaban group were also on aspirin at discharge, while in warfarin group only 79% (n=395). Baseline characteristics were similar, except that apixaban group had more females (46/127, 36% vs. 136/499, 27%, p=0.047). There were no differences in in-hospital complications, including stroke. Readmission rate was higher in the apixaban group (15/127, 12% vs. 30/499, 6%, p=0.02), driven mostly by postoperative atrial fibrillation (6/127 [5%] vs. 5/499 [1%], respectively; p=0.01). There was no difference in other complications (including bleeding and thromboembolic events), or overall mortality within 3 years. Exclusion of patients who did not receive aspirin at discharge did not affect the results.

Conclusions: Anticoagulation with apixaban after minimally invasive robotic MVRep is safe and has similar rates of bleeding and thromboembolism compared to patients treated with warfarin.
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http://dx.doi.org/10.1016/j.athoracsur.2022.07.045DOI Listing
August 2022

Mitral valve surgery after failed transcatheter edge-to-edge repair.

JTCVS Tech 2022 Aug 14;14:79-88. Epub 2022 May 14.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.

Objective: Mitral valve operations for failed transcatheter edge-to-edge repair (TEER) are increasing. This study investigated the indications, surgical procedures, and outcomes after surgery for failed TEER.

Methods: We analyzed records of patients who underwent mitral valve operations after TEER between January 2013 and September 2021. Patient characteristics, clip number and location, indications, timing, surgery type, and outcomes were evaluated.

Results: A total of 41 patients (median age, 77 years; 14 women; median Society of Thoracic Surgeons predicted risk of mortality score, 9.4% [5.6%-12.6%]; and previous cardiac surgery in 21 patients) underwent mitral valve surgery at a median of 8 months (range, 4-16 months) after TEER. One clip was implanted in 24 patients and 2 or more in 17 patients. Indications for surgery were severe mitral regurgitation in 33, severe mitral stenosis in 1 patient, and both in 7 patients. Operations were performed via sternotomy in 37 patients and lateral thoracotomy in 4 patients. The mitral valve was replaced in all patients (bioprosthesis in 35 patients and a mechanical valve in 6 patients). Concomitant procedures were performed in 30 patients. Operative mortality was 5% (observed to expected ratio, 0.53) and did not differ for primary procedures versus reoperations. Echocardiographic follow-up demonstrated no or trivial mitral regurgitation in 34 patients, mild mitral regurgitation in 5 patients, and moderate perivalvular mitral regurgitation in 1 patient with severe mitral annular calcification. At a median follow-up of 1.5 years (interquartile range, 4.7 months-2.7 years), the actuarial survival was 79%.

Conclusions: Mitral valve replacement can be performed safely after failed TEER with operative mortality lower than expected even in high-risk patients.

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http://dx.doi.org/10.1016/j.xjtc.2022.05.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9366625PMC
August 2022

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

Am J Cardiol 2022 Aug 11. Epub 2022 Aug 11.

Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA.

Surgical myectomy remains the time-honored primary treatment for hypertrophic cardiomyopathy patients with drug refractory limiting symptoms due to LV outflow obstruction. Based on >50 years experience, surgery reliably reverses disabling heart failure by permanently abolishing mechanical outflow impedance and mitral regurgitation, with normalization of LV pressures and preserved systolic function. A consortium of 10 international currently active myectomy centers report about 11,000 operations, increasing significantly in number over the most recent 15 years. Performed in experienced multidisciplinary institutions, perioperative mortality for myectomy has declined to 0.6%, becoming one of the safest currently performed open-heart procedures. Extended myectomy relieves symptoms in >90% of patients by ≥ 1 NYHA functional class, returning most to normal daily activity, and also with a long-term survival benefit; concomitant Cox-Maze procedure can reduce the number of atrial fibrillation episodes. Surgery, preferably performed in high volume clinical environments, continues to flourish as a guideline-based and preferred high benefit: low treatment risk option for adults and children with drug refractory disabling symptoms from obstruction, despite prior challenges: higher operative mortality/skepticism in 1960s/1970s; dual-chamber pacing in 1990s, alcohol ablation in 2000s, and now introduction of strong negative inotropic drugs potentially useful for symptom management.
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http://dx.doi.org/10.1016/j.amjcard.2022.06.007DOI Listing
August 2022

Role of Multimodality Imaging and Preoperative Management in Intrapericardial Paragangliomas: Experience From a Case Series.

JACC Case Rep 2022 Jul 20;4(14):871-877. Epub 2022 Jul 20.

Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.

Intrapericardial paragangliomas are rare, highly vascular tumors that frequently adhere to adjacent structures and blood vessels, making surgical resection challenging. In this case series, we discuss the role of multimodality imaging and preoperative embolization in the management of 3 patients presenting with intrapericardial paragangliomas. ().
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http://dx.doi.org/10.1016/j.jaccas.2022.04.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9334143PMC
July 2022

Aortic root replacement in the setting of a mildly dilated nonsyndromic ascending aorta.

J Thorac Cardiovasc Surg 2022 Jun 3. Epub 2022 Jun 3.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.

Objective: There is controversy on how to address mild aortic root dilation during concomitant aortic valve replacement: composite aortic valve conduit replacement or separate ascending aorta and aortic valve replacement. We reviewed our experience to address the issue.

Methods: We retrospectively reviewed 778 adult nonsyndromic patients with aortic root diameter 55 mm or less who received replacement of the ascending aorta and aortic valve from January 1994 to June 2017. Patients were divided into 2 groups based on the type of aortic root intervention: composite aortic valve conduit replacement in 406 patients (52%) and separate ascending aorta and aortic valve replacement in 372 patients (48%). Propensity matching was used to mitigate differences in baseline patient characteristics and produced 188 matched pairs.

Results: Sinus of Valsalva diameter was 43 mm (39-47). Operative mortality occurred in 3 patients (2%) in the composite aortic valve conduit replacement group and in 5 patients (3%) in the separate ascending aorta and aortic valve replacement group (P = .470). Median follow-up was 9.6 years (8.4-10.1). Long-term mortality was similar in the 2 groups (P = .083). Repeat operation was performed in 13 patients (7%) in the composite aortic valve conduit replacement group and in 19 patients (10%) in the separate ascending aorta and aortic valve replacement group (P = .365). Sinus of Valsalva diameter decreased 2 mm (-4-0; median follow-up 41 months) in the propensity-matched separate ascending aorta and aortic valve replacement group.

Conclusions: In patients with mild aortic root dilation, separate ascending aorta and aortic valve replacement results in a similar risk of repeat operation and mortality in comparison with composite aortic valve replacement. Separate ascending aorta and aortic valve replacement is not associated with subsequent aortic root dilation on medium-term echocardiography follow-up.
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http://dx.doi.org/10.1016/j.jtcvs.2022.03.044DOI Listing
June 2022

Cardiopulmonary exercise test in patients with obstructive hypertrophic cardiomyopathy.

J Thorac Cardiovasc Surg 2022 May 28. Epub 2022 May 28.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.

Objective: The study objective was to analyze performance on cardiopulmonary exercise testing and its prognostic value in patients with obstructive hypertrophic cardiomyopathy undergoing septal myectomy.

Methods: We reviewed patients with obstructive hypertrophic cardiomyopathy who had cardiopulmonary exercise testing before septal myectomy from 2005 to 2016. Causes of functional impairment and their impact on survival were analyzed.

Results: A total of 752 patients had cardiopulmonary exercise testing at a median of 16 days (interquartile range, 2-56) before myectomy. The median exercise time was 6.6 (5.3-8.0) minutes. Functional aerobic capacity was 64% (53%-75%) of predicted, and metabolic equivalent of task was 5.2 (4.1-6.4). The peak oxygen consumption was 18.0 (14.2-21.9) mL/kg/min, which was 60% (49%-72%) of the predicted value. The primary causes for low peak oxygen consumption were impaired cardiac output (73.7%), limited heart rate reserve (52.0%), and obesity (48.2%). Resting outflow tract gradient correlated poorly to peak oxygen consumption, but the use of beta-blockers was associated with reduced peak oxygen consumption. During a median (interquartile range) of 9.0 (6.8-11.7) years of follow-up, the estimated 5- and 10-year survivals were 97% and 91%, respectively. Greater adjusted peak oxygen consumption (hazard ratio, 0.98; P = .011) and abnormal pulse oxygen increase (hazard ratio, 0.44; P = .003) were independently associated with better long-term survival after myectomy.

Conclusions: Among patients with hypertrophic cardiomyopathy undergoing septal myectomy, functional capacity is severely impaired despite receiving optimal medical treatment. We identified risk factors of reduced long-term survival from preoperative cardiopulmonary exercise testing that may aid risk stratification in patients undergoing septal myectomy.
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http://dx.doi.org/10.1016/j.jtcvs.2022.05.025DOI Listing
May 2022

Impact of Hospital Volume on Outcomes of Septal Myectomy for Hypertrophic Cardiomyopathy.

Ann Thorac Surg 2022 Jun 30. Epub 2022 Jun 30.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Left ventricular outflow tract obstruction is common among symptomatic patients with hypertrophic cardiomyopathy, yet septal reduction by surgical myectomy (septal myectomy [SM]) is performed infrequently in many centers. This study examined the possible relationship between institutional case volume and early outcomes of SM.

Methods: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for patients with hypertrophic cardiomyopathy who underwent SM from January 2012 to December 2019. The study defined center case volume categories as <1, 1 to 4.99, 5 to 9.99, and ≥10 cases performed on average per year.

Results: The study population included 5935 patients at 481 centers with 933 surgeons. The range of average center volume was <1 to 138 cases per year. Overall early mortality was 2.6%, ventricular septal defect (VSD) occurred in 1.9%, and complete heart block occurred in 9.0%. Concomitant mitral valve (MV) repair was performed in 28.7%, and MV replacement was performed in 17.1%. In multivariable analysis, the lowest annual case volume (average <1 case/y) was consistently associated with greater early mortality (odds ratio [OR], 5.4; CI, 3.0-9.9; P < .001), greater risk of VSD (OR, 9.3; CI ,4.2-20.4; P < .001), increased incidence of complete heart block (OR, 2.0; CI, 1.5-2.7; P < .001), and a higher likelihood of MV replacement (OR, 9.4; CI, 7.5-11.8; P < .001).

Conclusions: Volume of SM cases varies widely among institutions reporting to the Society of Thoracic Surgeons Adult Cardiac Surgery Database. There appears to be an important association between surgical experience, as reflected by institutional case volume, and early outcomes, including mortality, as well as the occurrence of VSD, heart block, and MV replacement.
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http://dx.doi.org/10.1016/j.athoracsur.2022.05.062DOI Listing
June 2022

Anticoagulation After Bioprosthetic Aortic Valve Replacement: Are We Following the Guidelines?

Ann Thorac Surg 2022 Jun 30. Epub 2022 Jun 30.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Guideline-directed medication adherence is considered an important quality measure after cardiac surgery. We evaluated compliance with the American College of Cardiology/American Heart Association guidelines for warfarin use after surgical aortic valve replacement (sAVR) using bioprostheses and examined potential variations in anticoagulation practice over time.

Methods: Using the OptumLabs Data Warehouse, we investigated adult patients having bioprosthetic sAVR with or without coronary artery bypass (2007-2019). Early postoperative warfarin use was defined as ≥30 days of continuous prescription coverage after sAVR.

Results: Among 10 730 adult patients having sAVR, 3071 (28.6%) received warfarin early postoperatively. Median length of warfarin prescription coverage was 4.5 months (interquartile range, 3.0-8.9 months). However, only 11.1% (736/6634) had warfarin prescription coverage of 3 to 6 months in compliance with the most recent guidelines. Yearly warfarin prescription rate did not change significantly during the 13-year period (P = .386). Compared with patients from the non-warfarin group, those receiving warfarin prescriptions were older and more likely to be male and to have atrial fibrillation, congestive heart failure, chronic pulmonary disease, and CHADS-VASc score ≥2; warfarin use was also greater in patients receiving prescriptions for other cardiac medications (P < .05).

Conclusions: Anticoagulation after sAVR as reflected by warfarin prescriptions may be underused; the rates of warfarin use have not changed in the last decade. Although additional studies are needed to confirm the benefit of early anticoagulation after sAVR, these results indicate that guideline recommendations are not followed by most clinicians. The findings highlight a potentially important area for quality improvement.
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http://dx.doi.org/10.1016/j.athoracsur.2022.05.056DOI Listing
June 2022

Coronary Artery Bypass Grafting in Octogenarians-Risks, Outcomes, and Trends in 1283 Consecutive Patients.

Mayo Clin Proc 2022 07 20;97(7):1257-1268. Epub 2022 Jun 20.

Department of Cardiovascular Surgery, Rochester, MN. Electronic address:

Objective: To describe the risks, outcomes, and trends in patients older than 80 years undergoing coronary artery bypass grafting (CABG).

Methods: We retrospectively studied 1283 consecutive patients who were older than 80 years and underwent primary isolated CABG from January 1, 1993, to October 31, 2019, in our clinic. Kaplan-Meier survival probability and quartile estimates were used to analyze patients' survival. Logistic regression models were used for analyzing temporal trends in CABG cases and outcomes. A multivariable Cox proportional hazards regression model was developed to study risk factors for mortality.

Results: Operative mortality was overall 4% (n=51) but showed a significant decrease during the study period (P=.015). Median follow-up was 16.7 (interquartile range, 10.3-21.1) years, and Kaplan-Meier estimated survival rates at 1 year, 5 years, 10 years, and 15 years were 90.2%, 67.9%, 31.1%, and 8.2%, respectively. Median survival time was 7.6 years compared with 6.0 years for age- and sex-matched octogenarians in the general US population (P<.001). Multivariable Cox regression analysis identified older age (P<.001), recent atrial fibrillation or flutter (P<.001), diabetes mellitus (P<.001), smoking history (P=.006), cerebrovascular disease (P=.04), immunosuppressive status (P=.01), extreme levels of creatinine (P<.001), chronic lung disease (P=.02), peripheral vascular disease (P=.02), decreased ejection fraction (P=.03) and increased Society of Thoracic Surgeons predicted risk score (P=.01) as significant risk factors of mortality.

Conclusion: Although CABG in octogenarians carries a higher surgical risk, it may be associated with favorable outcomes and increase in long-term survival. Further studies are warranted to define subgroups benefiting more from surgical revascularization.
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http://dx.doi.org/10.1016/j.mayocp.2022.03.033DOI Listing
July 2022

Is There Still a Role for Diagnostic Direct LV Puncture?: Sir Brock Would Say Yes.

JACC Cardiovasc Interv 2022 06 25;15(12):e147-e148. Epub 2022 May 25.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1016/j.jcin.2022.03.032DOI Listing
June 2022

Controversy pro: Mechanical AVR for better long-term survival of 50-70 years old.

Prog Cardiovasc Dis 2022 May-Jun;72:26-30. Epub 2022 Jun 18.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA. Electronic address:

Selection of the most appropriate type of aortic valve prosthesis (mechanical or biologic) for patients 50-70 years of age is a matter of frequent debate. The purpose of this article is to review overlooked concepts and misconceptions in valve-related complications, prosthesis durability, and late survival to aid decision making in contemporary practice. A trend favoring improved long-term survival was found among patients who receive a mechanical prosthesis compared to a biologic substitute. Additionally, an acceptably low rate of long-term valve-related thromboembolism and hemorrhage was found among those with mechanical prostheses. Implantation of a biologic valve substitute did not appear to reduce the risk of thromboembolism, may not eliminate the need for long-term anticoagulation and may be associated with an increased risk of late mortality. These findings may aid providers (and patients) in the preoperative consultation and seem to support consideration of a mechanical heart valve substitute over a biologic valve for patients 50-70 years age.
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http://dx.doi.org/10.1016/j.pcad.2022.06.003DOI Listing
July 2022

Optimal Management of Mitral Regurgitation Due to Ruptured Mitral Chordae Tendineae in Patients With Hypertrophic Cardiomyopathy.

Semin Thorac Cardiovasc Surg 2022 May 20. Epub 2022 May 20.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

There is continued controversy regarding surgical management of patients with hypertrophic cardiomyopathy (HCM) and intrinsic mitral valve disease; some clinicians favor prosthetic replacement as this corrects left ventricular outflow tract (LVOT) obstruction and valve leakage. In this study, we investigated the management and late outcome of operation for mitral regurgitation (MR) due to ruptured chordae tendineae in patients with HCM. We analyzed 49 consecutive patients with HCM and MR due to ruptured mitral valve chordae. Echocardiograms and operative reports were reviewed to classify valve anatomy and surgical methods. Information on late outcomes was obtained from electronic medical records and follow-up surveys. The mean age of the 36 men and 13 women was 61.9 ± 12.5 years; significant resting or provoked LVOT obstruction was present at the time of surgery in 46 patients. During the index operation, mitral valve repair was performed in 45 patients, and prosthetic replacement was necessary for 4 patients. Concomitant septal myectomy was performed in 46 patients. There were no hospital deaths or deaths within 30 days of operation. Five and ten-year survival estimates (Kaplan-Meier) were 92% and 71%. During follow-up at a median of 7.9 years, 3 patients underwent reoperation for MV replacement, 5 days, 3 years, and 14 years following valve repair. Ruptured mitral chordae may result in severe mitral valve regurgitation in patients with hypertrophic cardiomyopathy. Valvuloplasty at the time of septal myectomy is safe with an acceptably low rate of recurrent MR requiring prosthetic replacement.
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http://dx.doi.org/10.1053/j.semtcvs.2022.05.008DOI Listing
May 2022

Improvement in gastrointestinal bleeding after septal myectomy for hypertrophic cardiomyopathy.

J Thorac Cardiovasc Surg 2022 Apr 20. Epub 2022 Apr 20.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.

Objective: Patients with obstructive hypertrophic cardiomyopathy may have occult gastrointestinal bleeding. In this study, we analyzed outcomes of septal myectomy in patients who had a history of gastrointestinal bleeding preoperatively to understand patient characteristics and impact of septal reduction on recurrent gastrointestinal bleeding.

Methods: We analyzed 73 adult patients who had a history of gastrointestinal bleeding before transaortic septal myectomy for obstructive hypertrophic cardiomyopathy and compared outcomes to 219 patients without gastrointestinal bleeding preoperatively.

Results: Patients with preoperative history of gastrointestinal bleeding were older (median (IQR) age, 65 (59-69) years, P < .001) and were more likely to have systemic hypertension (70% vs 53%, P = .020) and coronary artery disease (25% vs 13%, P = .026). Preoperatively, patients with gastrointestinal bleeding had a larger left atrial volume index (median, 53 mL/m; interquartile range, 42-67; P = .006) and greater right ventricular systolic pressure (median, 36 mm Hg; interquartile range, 32-49; mm Hg, P = .005) but no significant difference in severity of outflow tract obstruction (P = .368). There were no perioperative deaths. The estimated 5- and 10-year survivals were 96.6% and 81.8%, respectively. At a median of 3.4 (interquartile range, 1.9-9.1) years after septal myectomy, 11 patients (15%) had recurrence of gastrointestinal bleeding, which was attributed to angiodysplasia or unknown causes in 6 patients (8%).

Conclusions: Patients with a preoperative history of gastrointestinal bleeding have favorable short- and long-term outcomes after septal myectomy for obstructive hypertrophic cardiomyopathy. Remission of gastrointestinal bleeding was observed in 85% of patients postprocedure, and only 8% of the patients had recurrent gastrointestinal bleeding due to angiodysplasia or unknown causes.
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http://dx.doi.org/10.1016/j.jtcvs.2022.04.008DOI Listing
April 2022

Differential expansion and outcomes of ascending and descending degenerative thoracic aortic aneurysms.

J Thorac Cardiovasc Surg 2022 Apr 9. Epub 2022 Apr 9.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn.

Objective: To evaluate expansion of degenerative thoracic aortic aneurysms (TAAs) and compare results between ascending and descending TAAs.

Methods: Among patients with diagnosis of degenerative TAA (1995-2015) in Olmsted County, we studied those having at least 2 computed tomography scans of TAA throughout the follow-up. Patients were classified as ascending or descending groups according to the segment where the maximal aortic diameter was measured. Primary end points were expansion rates and factors associated with TAA growth.

Results: We investigated 137 patients, 70 (51.1%) of whom were women; 78 (56.9%) were in the ascending and 59 (43.1%) were in the descending group. Median baseline maximal aortic diameter was 48.5 mm (interquartile range, 47.0-49.9 mm) for ascending and 42.4 mm (interquartile range, 40.0-45.4 mm) for descending group (P < .001). Median expansion rate was higher in the descending than the ascending group (2.0 mm/year [interquartile range, 0.9-3.2 mm/year] vs 0.2 mm/year [IQR, 0.1-0.6 mm/year]; P < .001). Aneurysm in the descending aorta and larger baseline maximal aortic diameter were independently associated with TAA expansion. Advanced age and chronic obstructive pulmonary disease but not aneurysm size or location were independently associated with overall mortality (P < .05). Aneurysm in the descending aorta was associated with aortic-related events (P < .05).

Conclusions: Degenerative TAAs under surveillance expand slowly. Descending TAA and larger baseline maximal aortic diameter were independently associated with more rapid TAA expansion, but these factors did not influence all-cause mortality.
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http://dx.doi.org/10.1016/j.jtcvs.2022.03.032DOI Listing
April 2022

Clinical Outcomes of Mitral Valve Repair for Degenerative Mitral Regurgitation in Elderly Patients.

Eur J Cardiothorac Surg 2022 May 9. Epub 2022 May 9.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN.

Objectives: This study analyzes the safety and outcomes of mitral valve repair for degenerative mitral valve regurgitation in patients 75 years of age or older.

Methods: We retrospectively reviewed the clinical results of 343 patients aged ≥75 years who underwent mitral valve repair for degenerative mitral valve regurgitation as a primary indication between January 1998 and June 2017.

Results: The median (IQR) age of the patients was 79.4 (76.9, 82.9) years, and 132 (38.5%) patients were women. Concomitant procedures were performed in 123 patients: tricuspid surgery in 68 (19.8%) and a maze procedure or pulmonary vein isolation in 55 (16.0%). Operative mortality was 1.2%. Operative complications included atrial fibrillation in 37.9%, prolonged ventilation in 7.0%, pacemaker implantation in 3.8, renal failure requiring dialysis in 1.5, and troke in 3 (0.9%). Median follow-up was 7.4 years (IQR, 3.5-14.1 years). The cumulative incidence rates of mitral valve reoperation were 2.2%, 3.2%, and 3.2% at 1, 5, and 10 years, respectively. Overall survival at 1, 5, and 10 years were 95%, 83%, and 51%, respectively. Older age, smoking, and over and under weight were associated with increased risk of mortality, while higher left ventricular ejection fraction and hypertension were associated with reduced risk.

Conclusions: Mitral valve repair in elderly patients can be accomplished with low operative mortality and complications. Mitral valve repair in the elderly remains the preferred treatment for degenerative mitral regurgitation.
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http://dx.doi.org/10.1093/ejcts/ezac299DOI Listing
May 2022

Partial Anomalous Pulmonary Venous Connection With Intact Atrial Septum: Early and Midterm Outcomes.

Ann Thorac Surg 2022 Apr 30. Epub 2022 Apr 30.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: Partial anomalous pulmonary venous return with intact atrial septum warrants greater understanding and evaluation in the literature.

Methods: From January 1993 to December 2018, 293 patients with partial anomalous pulmonary venous return underwent surgical repair. Of these, 45 patients (15.3%) had an intact atrial septum. The median age was 36 years (interquartile range, 24-48). Direct reimplantation was used in 17 patients (38%), intracardiac baffling in 15 (33%), and caval division (Warden) technique in 13 (29%). Descriptive statistics were used to assess the data, and Kaplan-Meier analysis was used to assess survival.

Results: Anomalous veins were right-sided in 27 patients (60%), left-sided in 16 patients (36%), and bilateral in 2 patients (4%). The insertion sites were the superior vena cava in 23 patients (51%), innominate vein in 12 (27%), inferior vena cava in 6 (13%), coronary sinus in 2 (4%), right atrium in 1 patient (2%), and unknown in 1 patient (2%). Scimitar syndrome was noted in 8 patients (18%). There was no postoperative mortality or residual defects. Postoperative echocardiography excluded any obstruction of pulmonary or systemic veins. Postoperative complications included atrial fibrillation in 9 patients (20%) and pneumothorax requiring chest tube in 5 patients (11%). Survival at 1, 5, and 10 years was 100%, 95%, and 95%, respectively. Two patients underwent pulmonary vein dilation, one at 3 years and the other at 7 years.

Conclusions: Surgical repair of partial anomalous pulmonary venous connection with intact atrial septum can be performed with excellent early and midterm outcomes. The overall incidence of midterm systemic or pulmonary vein stenosis is low.
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http://dx.doi.org/10.1016/j.athoracsur.2022.04.031DOI Listing
April 2022

Survival Following Alcohol Septal Ablation or Septal Myectomy for Patients With Obstructive Hypertrophic Cardiomyopathy.

J Am Coll Cardiol 2022 05;79(17):1647-1655

Division of Cardiology, Hypertrophic Cardiomyopathy Center, Tufts Medical Center, Boston, Massachusetts, USA.

Background: There is little information regarding long-term mortality comparing the 2 most common procedures for septal reduction for obstructive hypertrophic cardiomyopathy (HCM), alcohol septal ablation (ASA), and septal myectomy.

Objectives: This study sought to compare the long-term mortality of patients with obstructive HCM following septal myectomy or ASA.

Methods: We evaluated outcomes of 3,859 patients who underwent ASA or septal myectomy in 3 specialized HCM centers. All-cause mortality was the primary endpoint of the study.

Results: In the study cohort, 585 (15.2%) patients underwent ASA, and 3,274 (84.8%) underwent septal myectomy. Patients undergoing ASA were significantly older (median age: 63.0 years [IQR: 52.7-72.8 years] vs 53.7 years [IQR: 44.9-62.8 years]; P < 0.001) and had smaller septal thickness (19.0 mm [IQR: 17.0-22.0 mm] vs 20.0 mm [IQR: 17.0-23.0 mm]; P = 0.007). Patients undergoing ASA also had more comorbidities, including renal failure, diabetes, hypertension, and coronary artery disease. There were 4 (0.7%) early deaths in the ASA group and 9 (0.3%) in the myectomy group. Over a median follow-up of 6.4 years (IQR: 3.6-10.2 years), the 10-year all-cause mortality rate was 26.1% in the ASA group and 8.2% in the myectomy group. After adjustment for age, sex, and comorbidities, the mortality remained greater in patients having septal reduction by ASA (HR: 1.68; 95% CI: 1.29-2.19; P < 0.001).

Conclusions: In patients with obstructive hypertrophic cardiomyopathy, ASA is associated with increased long-term all-cause mortality compared with septal myectomy. This impact on survival is independent of other known factors but may be influenced by unmeasured confounding patient characteristics.
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http://dx.doi.org/10.1016/j.jacc.2022.02.032DOI Listing
May 2022

Early and Late Outcomes of the Warden and Modified Warden Procedure.

Ann Thorac Surg 2022 Mar 26. Epub 2022 Mar 26.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota. Electronic address:

Background: Operative repair of partial anomalous pulmonary venous connection (PAPVC) remains challenging due to risks of sinus node dysfunction, baffle obstruction, and superior vena cava (SVC) obstruction.

Methods: Traditional or modified Warden procedures were performed in 75 of 318 consecutive patients (24%) with PAPVC repaired surgically at our institution during 1993 to 2021. Clinical characteristics, echocardiography data, operative details, and early and late outcomes were collected. Cumulative incidence of reintervention and Kaplan-Meier survival analysis are reported.

Results: Median age was 39 years (interquartile range, 21-57 years). Fifty-nine (79%) had normal sinus rhythm preoperatively. Seventeen (23%) had intact atrial septa. Traditional and modified Warden procedures were performed in 15 (20%) and 60 (80%), respectively. Frequent concomitant procedures included 15 (20%) tricuspid valve repairs and 12 (16%) atrial fibrillation procedures. There were no early deaths. Postoperative complications included atrial fibrillation in 17 (23%), sinus node dysfunction in 15 (20%), pneumothorax in 3 (4%), pleural effusion in 2 (3%), and pacemaker implantation in 1 (1%). At hospital discharge, sinus node dysfunction persisted in 8 (11%). Over a median follow-up of 6 years (interquartile range, 4-10 years), baffle obstruction developed in 1 patient and SVC obstruction developed in 7. None required reoperation and 6 were treated with SVC stents. At 1, 5, and 10 years, the cumulative incidence of reintervention was 5%, 7%, and 14%, and survival was 99%, 94%, and 94%, respectively.

Conclusions: Traditional and modified Warden procedures can be performed with satisfactory early and late survival. Persistent sinus node dysfunction and need for permanent pacing are low. Late SVC obstruction is uncommon and can often be managed nonoperatively.
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http://dx.doi.org/10.1016/j.athoracsur.2022.03.032DOI Listing
March 2022

Transapical Ventricular Remodeling for Hypertrophic Cardiomyopathy With Systolic Cavity Obliteration.

Ann Thorac Surg 2022 Mar 23. Epub 2022 Mar 23.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Background: Some patients with hypertrophic cardiomyopathy (HCM) present with reduced left ventricular (LV) stroke volume and elongated systolic cavity obliteration due to symmetric LV hypertrophy. In this report, we detail our experience with transapical septal myectomy to enlarge the LV volume and to relieve cavity obliteration in this unique subgroup of patients with HCM.

Methods: We analyzed 38 patients with HCM who had extended symmetric LV hypertrophy and underwent transapical septal myectomy to enlarge the LV cavity from February 2001 to May 2021.

Results: At the time of evaluation for operation, 84.2% (n = 32) of the patients were in New York Heart Association class III/IV. The peak oxygen consumption was 51.5% (44.0%-58.0%) of the normal predicted values on the preoperative exercise stress test (n = 16). Preoperative left atrial sizes in this cohort were enlarged (left atrial volume index, 39.0 [33.5-51.5] mL/m), despite only 4 patients with moderate or greater mitral valve regurgitation. All patients underwent transapical septal myectomy to enlarge the LV cavity size. There was no postoperative (within 30 days) death. During a median (interquartile range) follow-up of 3.4 (0.7-6.9) years, the estimated survival rates were 100%, 92%, and 87% at 1, 3, and 5 years, respectively. Follow-up surveys suggested that 16 of the 17 contacted patients experienced improvement in their heart function after the procedure.

Conclusions: Transapical myectomy to enlarge LV cavity volume can be performed safely with good early survival and functional results. This procedure is an important alternative to cardiac transplantation for HCM patients with systolic cavity obliteration and progressive heart failure.
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http://dx.doi.org/10.1016/j.athoracsur.2022.02.073DOI Listing
March 2022

Outcomes of cardiac surgery in nonagenarians.

J Card Surg 2022 Jun 14;37(6):1664-1670. Epub 2022 Mar 14.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: While advanced age can be considered by some a contraindication to open-heart surgery, there is a paucity of data regarding outcomes of cardiac surgery in nonagenarians. We, therefore, sought to investigate the outcomes of nonagenarians undergoing cardiac surgery.

Methods: A retrospective review of our institutional Society of Thoracic Surgeons database between 1993 and 2019 was performed. Among a total of 32,421 patients who underwent open-heart surgery, 134 patients (0.4%) were nonagenarians (50.7% females, median age 91.6 [interquartile range: 90.7-92.9]). A comparison was performed between nonagenarians and patients aged 80-89 years. A regression analysis was performed to evaluate factors associated with midterm mortality in nonagenarians.

Results: The incidence of cardiac surgery in nonagenarians has been stable over time, from 0.4% in (1993-2000), 0.5% in (2001-2010) to 0.4% in (2011-2019). Valve surgery and CABG+valve were higher in nonagenarians compared to octogenarians (44.8% vs. 25.6%, 39.6% vs. 30.7%, respectively), but CABG was lower (15.7% vs. 33.8%); p < .01. Urgent/emergent surgery status was similar between groups (p = .7). Operative mortality was similar in the two groups (6% vs. 4.6%, p = .5). Hospital complications were comparable between groups.

Conclusion: Cardiac surgery in nonagenarians can be achieved with acceptable morbidity and mortality. This study can be a benchmark for risk stratification for cardiac surgery in this high-risk population.
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http://dx.doi.org/10.1111/jocs.16396DOI Listing
June 2022

Durability of a simple repair method for commissural leaflet prolapse.

Eur J Cardiothorac Surg 2022 Jun;62(1)

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.1093/ejcts/ezac141DOI Listing
June 2022

Progress in Management of Mechanical Valve Thrombosis.

J Am Coll Cardiol 2022 03;79(10):990-992

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jacc.2022.01.008DOI Listing
March 2022

Surgical management of diastolic heart failure after septal myectomy for obstructive hypertrophic cardiomyopathy.

JTCVS Tech 2022 Feb 1;11:21-26. Epub 2021 Nov 1.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.

Objective: Some patients with obstructive hypertrophic cardiomyopathy may remain limited after surgical relief of the subaortic obstruction. In this report, we describe experience in surgical management of patients with advanced diastolic heart failure symptoms after adequate transaortic septal myectomy for obstructive hypertrophic cardiomyopathy.

Methods: We identified adult patients who presented with heart failure symptoms after previous transaortic septal myectomy for obstructive hypertrophic cardiomyopathy and underwent repeat sternotomy for transapical myectomy to enlarge a small left ventricular cavity. Functional recovery after hospital dismissal was assessed through a questionnaire-based survey.

Results: Six patients with previous septal myectomy presented with New York Heart Association functional class III symptoms. Preoperative transthoracic Doppler echocardiography confirmed adequate relief of subaortic outflow tract obstruction with only trivial or mild mitral valve regurgitation; left atrial volume index was increased at 46 mL/m (range, 44-47 mL/m). Following transapical myectomy, the left ventricular diameter was enlarged from 23 mm (range, 21-27 mm) to 29 mm (range, 27-31 mm) at end-systole and from 40 mm (range, 38-42 mm) to 43 mm (range, 42-50 mm) at end-diastole. All the patients were alive after a median follow-up of 0.6 years (range, 0.4-3.5 years), and 5 patients responded to a postoperative survey and indicated improvement in their heart condition compared with functional status before the repeat myectomy.

Conclusions: Patients with diastolic heart failure after septal myectomy for obstructive hypertrophic cardiomyopathy may present with systolic cavity obliteration due to excessive myocardial hypertrophy. Repeat transapical myectomy can enlarge the left ventricular chamber and augment the diastolic volume, which results in improved physical capacity and patient-perceived functional status.
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http://dx.doi.org/10.1016/j.xjtc.2021.10.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8828785PMC
February 2022

How to build a successful hypertrophic cardiomyopathy team and ensure training the next generation of myectomy surgeons.

Asian Cardiovasc Thorac Ann 2022 Jan 15;30(1):19-27. Epub 2022 Feb 15.

Department of Cardiovascular Surgery, 4352Mayo Clinic, Rochester, MN, USA.

Transaortic extended septal myectomy is the most reliable method for septal reduction for symptomatic patients with obstructive hypertrophic cardiomyopathy. In addition, surgical management of nonobstructive hypertrophic cardiomyopathy is possible for selected patients with diastolic heart failure and small left ventricular end-diastolic cavity dimensions. These procedures, however, are performed infrequently in many centers, and trainees may not be exposed to the preoperative evaluation and intraoperative management of patients with hypertrophic cardiomyopathy. In this paper, we review what we believe are the central features for creating a successful program for septal myectomy and detail our strategies to optimize instruction in these techniques for residents and fellows.
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http://dx.doi.org/10.1177/02184923211053399DOI Listing
January 2022

Surgical Management of Hypertrophic Cardiomyopathy Complicated by Infective Endocarditis.

Ann Thorac Surg 2022 Feb 1. Epub 2022 Feb 1.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Background: Infective endocarditis is a serious complication in hypertrophic cardiomyopathy. Cardiac surgery is often necessary, however, literature assessing surgical outcomes is limited.

Methods: From December 1995 to September 2018, 43 patients with a history of hypertrophic cardiomyopathy and native valve infective endocarditis underwent cardiac surgery at our institution. Relevant data were abstracted from medical records and analyzed.

Results: Median age was 57 years (interquartile range, 45 to 67); 81% (n = 35) were male. Infective endocarditis was active in 21% of patients (n = 9) at the time of surgery; of these, the suspected origin of infection was orodental in 19% (n = 8). Significant mitral valve regurgitation was detected in 54% of patients (n = 23), and aortic valve regurgitation in 7% (n = 3). Septal myectomy was performed in 95% of patients (n = 41), with concomitant valve surgery in 58% (n = 25), including prosthetic replacement in 28% (n = 12). Two patients underwent double valve replacement without septal myectomy. Outflow gradients improved from a median 67 mm Hg (interquartile range, 34 to 97 mm Hg) to 9 mm Hg (interquartile range, 6 to 22 mm Hg). One inhospital death occurred because of uncontrollable pulmonary edema. As of last follow-up, 7 patients required reoperation, and the 5-year and 10-year cumulative incidences were 11% and 26%, respectively. Ten deaths occurred; overall survival probability at 5 and 10 years was 94% and 78%, respectively.

Conclusions: Valvular complications of infective endocarditis add complexity to surgical management of hypertrophic cardiomyopathy. There is an increased need for concomitant valve repairs, prosthetic replacements, and reoperation. These data underscore the need for recognition of infection, especially after oral procedures, which preceded the majority of the active infective endocarditis cases.
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http://dx.doi.org/10.1016/j.athoracsur.2022.01.016DOI Listing
February 2022

Safety of Bariatric Surgery in Obese Patients With Hypertrophic Cardiomyopathy.

Am J Cardiol 2022 03 3;167:93-97. Epub 2022 Jan 3.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Obesity is an independent risk factor for heart failure in patients with hypertrophic cardiomyopathy (HC). In this study, we examined national trends and early outcomes of bariatric surgery for obesity in patients with HC. Using the weighted discharge data from the National Inpatient Sample, we identified adult patients with HC who underwent elective bariatric surgery for obesity between 2011 and 2017. A total of 443 obese patients with HC were identified, and 42% (n = 185) had obstructive HC. The annual number of patients increased from 18 in 2011 to 130 in 2017. Overall, the median (interquartile range) age was 50 (43 to 57) years, and 85 patients (19%) were 60 years or older. Approximately 20% (n = 90) of the patients had heart failure at the time of operation. Atrial fibrillation was present in 83 patients (19%), and 22% (n = 95) of the cohort had a pacemaker or automatic cardiac defibrillator implanted before the operation. Laparoscopic sleeve gastrectomy (72%, n = 318) and laparoscopic Roux-en-Y gastric bypass (25%, n = 110) were the most commonly performed bariatric procedures. Overall, patients stayed in the hospital for a median (interquartile range) of 2 (1 to 2) days. During the hospital stay, there were no deaths, myocardial infarctions, or documented episodes of thromboembolism. In conclusion, bariatric surgery in patients with HC is performed more frequently in recent years and is safe and associated with few perioperative complications. Because of the impact of obesity on long-term survival, clinicians should strongly consider bariatric surgery for obese HC patients who do not respond to conservative weight loss measures.
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http://dx.doi.org/10.1016/j.amjcard.2021.11.055DOI Listing
March 2022

A Blinded Randomized Trial Comparing Standard Activated Clotting Time Heparin Management to High Target Active Clotting Time and Individualized Hepcon HMS Heparin Management in Cardiopulmonary Bypass Cardiac Surgical Patients.

Ann Thorac Cardiovasc Surg 2022 Jun 22;28(3):204-213. Epub 2021 Dec 22.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.

Purpose: High-dose heparin has been suggested to reduce consumption coagulopathy.

Materials And Methods: In a randomized, blinded, prospective trial of patients undergoing elective, complex cardiac surgery with cardiopulmonary bypass, patients were randomized to one of three groups: 1) high-dose heparin (HH) receiving an initial heparin dose of 450 u/kg, 2) heparin concentration monitoring (HC) with Hepcon Hemostasis Management System (HMS; Medtronic, Minneapolis, MN, USA) monitoring, or 3) a control group (C) receiving a standard heparin dose of 300 u/kg. Primary outcome measures were blood loss and transfusion requirements.

Results: There were 269 patients block randomized based on primary versus redo sternotomy to one of the three groups from August 2001 to August 2003. There was no difference in operative bleeding between the groups. Chest tube drainage did not differ between treatment groups at 8 hours (median [25th percentile, 75th percentile] for control group was 321 [211, 490] compared to 340 [210, 443] and 327 [250, 545], p = 0.998 and p = 0.540, for HH and HC treatment groups, respectively). The percentage of patients receiving transfusion was not different among the groups.

Conclusion: Higher heparin dosing accomplished by either activated clot time or HC monitoring did not reduce 24-hour intensive care unit blood loss or transfusion requirements.
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http://dx.doi.org/10.5761/atcs.oa.21-00222DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9209891PMC
June 2022

Sex and Race Disparities in Hypertrophic Cardiomyopathy: Unequal Implantable Cardioverter-Defibrillator Use During Hospitalization.

Mayo Clin Proc 2022 03 7;97(3):507-518. Epub 2021 Dec 7.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.

Objective: To evaluate if there are sex and race disparities in use of implantable cardioverter-defibrillator (ICD) devices for prevention of sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM).

Patients And Methods: Using the National Inpatient Sample from January 2003 through December 2014, we identified all adult admissions with a diagnosis of HCM and an ICD implantation. Race was classified as White versus non-White. Trends in ICD use, predictors of ICD implantation, device-related complications, hospitalization costs, and lengths of stay were evaluated.

Results: Among a total of 23,535 adult hospitalizations for HCM, ICD implantation was performed in 3954 (16.8%) admissions. Over the study period, there was an overall increasing trend in ICD use (11.6% in 2003 to 17.0% in 2014, P<.001). Compared with admissions not receiving an ICD, those receiving an ICD had shorter median lengths of in-hospital stay but higher hospitalization costs (P<.001). Compared with men and White race, female sex (odds ratio, 0.72; 95% CI, 0.66 to 0.78; P<.001) and non-White race (odds ratio, 0.87; 95% CI, 0.79 to 0.96; P<.001) were associated with lower adjusted odds of receiving an ICD. Women and non-White hospitalizations had higher rates of device related complications, longer lengths of in-hospital stay, and higher hospitalization costs compared with men and White race, respectively (all P<.01).

Conclusion: Among HCM hospitalizations, ICD devices are underused in women and racial minorities independent of demographics, hospital characteristics, and comorbidities. Women and racial minorities also had higher rates of complications and greater resource use compared with men and those belonging to the White race, respectively.
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http://dx.doi.org/10.1016/j.mayocp.2021.07.022DOI Listing
March 2022

Mitral Annular Calcification in Obstructive Hypertrophic Cardiomyopathy: Prevalence and Outcomes.

Ann Thorac Surg 2021 Nov 22. Epub 2021 Nov 22.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.

Background: The prevalence and clinical impact of mitral annular calcification (MAC) in patients with obstructive hypertrophic cardiomyopathy (HCM) are largely unknown.

Methods: We reviewed 2113 HCM patients who underwent septal myectomy from January 2000 to April 2016. Preoperative and intraoperative echocardiograms along with operative notes were reviewed to identify MAC. Survival was estimated and compared using Kaplan-Meier analysis and the log-rank test. Cox regression analysis was used to identify factors independently associated with mortality.

Results: MAC was identified in 390 (18.5%) patients. Older age, female sex, and presence of mitral valve leaflet calcification were strongly associated with higher odds of having MAC. Patients with MAC had higher resting left ventricular outflow tract gradients, were more likely to have worse mitral regurgitation preoperatively, and were more likely to undergo a concomitant mitral valve replacement (6% vs 1%; P < .001) compared with those without MAC. Postoperatively, patients with MAC had marginally higher residual mitral regurgitation (13% vs 8%). After a median follow-up of 6.95 (interquartile range, 3.7-12.1) years, survival of patients with MAC at 1, 5, and 10 years was 99%, 92%, and 69%, respectively. Adjusted analysis identified MAC as an independent predictor of poor survival (hazard ratio, 1.46; 95% confidence interval, 1.08-1.97; P = .014).

Conclusions: MAC is a frequent finding in older patients with obstructive HCM, is more likely to be seen in females, and is associated with higher rates of concomitant mitral valve replacement. Despite the higher prevalence of comorbidities, MAC remained an independent predictor for overall mortality after septal myectomy.
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http://dx.doi.org/10.1016/j.athoracsur.2021.09.077DOI Listing
November 2021

Preoperative left ventricular longitudinal strain predicts outcome of septal myectomy for obstructive hypertrophic cardiomyopathy.

J Thorac Cardiovasc Surg 2021 Oct 6. Epub 2021 Oct 6.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.

Objective: The objective of this study was to determine the characteristics of longitudinal strain and its effect on outcomes in patients with obstructive hypertrophic cardiomyopathy (HCM) who underwent septal myectomy.

Methods: We reviewed patients with obstructive HCM who underwent septal myectomy at our clinic from 2007 to 2016. Data of those who had strain echocardiography within 6 months before isolated myectomy were analyzed.

Results: The median age of the 857 patients studied was 55 (interquartile range [IQR], 44-63) years, and 451 (52.6%) were male. Left ventricular ejection fraction was 71% (IQR, 67%-74%), and the resting peak outflow tract gradient was 58 (IQR, 27-85) mm Hg. The median global longitudinal strain (GLS) was -14.6% (IQR, -12.0% to -17.3%). Regional longitudinal strain was nonuniform as reflected by more normal values in apical segments and more abnormal in basal segments. Moreover, GLS correlated poorly with ejection fraction and outflow tract gradient. In 64 patients who had postoperative strain echocardiography, GLS was comparable before and after septal myectomy, but regional strain was more uniform after myectomy. Over a follow-up of 8.3 (IQR, 6.5-10.3) years, when patients were equally stratified according to GLS (cutoff, -14.64%), the group with worse GLS had significantly poorer survival compared with the better GLS group (P = .002). Left ventricular ejection fraction had no association with survival.

Conclusions: Left ventricular longitudinal strain is nonuniform and might be significantly reduced in patients with obstructive HCM. Septal myectomy does not impair GLS but is associated with more uniform regional strains. Most importantly, reduced GLS preoperatively is strongly and independently associated with increased all-cause mortality after septal myectomy for obstructive HCM.
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http://dx.doi.org/10.1016/j.jtcvs.2021.09.058DOI Listing
October 2021
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