Publications by authors named "Hiroo Takayama"

390 Publications

Prolene or Products - When Is the Right Time to Bite the Bullet and Takeback?

Ann Thorac Surg 2022 Aug 10. Epub 2022 Aug 10.

Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, Division of Cardiothoracic Surgery, 177 Ft. Washington Avenue - MHB 7GN-435, New York, NY 10032. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2022.08.003DOI Listing
August 2022

Optimizing Perioperative Renal Replacement Therapy for Patients Undergoing Cardiac Surgical Procedures Requiring Cardiopulmonary Bypass.

Blood Purif 2022 Jul 25:1-7. Epub 2022 Jul 25.

Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.

Coronary artery disease is highly prevalent in patients with end-stage renal disease (ESRD), and cardiovascular complications remain the most common cause of death in this patient population. Accordingly, many cardiac surgical procedures requiring cardiopulmonary bypass support are performed on these patients each year, with morbidity and mortality rates far exceeding patients without ESRD. Anuric patients lack the normal renal homeostatic functions which typically allow for physiologic protection from challenges during the operation, such as volume overload, hyperkalemia, and acidemia. Careful preoperative planning and coordination to provide pre-, intra-, and postoperative renal replacement therapies for such patients are imperative. Many different strategies have been reported in the literature. Zero-balance ultrafiltration is a newer strategy which utilizes convective ultrafiltration much like pre-filter continuous renal replacement therapy and utilizes pre-existing connections on the cardiopulmonary bypass pump performed by the perfusion team. This allows for control of potassium concentration throughout the operation with existing personnel and minimal additional equipment. Here, we describe the unique challenges caring for patients receiving renal replacement therapy undergoing cardiac surgical procedures requiring cardiopulmonary bypass.
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http://dx.doi.org/10.1159/000525837DOI Listing
July 2022

Concomitant tricuspid annuloplasty in patients with mild to moderate tricuspid valve regurgitation undergoing mitral valve surgery: meta-analysis.

J Cardiovasc Surg (Torino) 2022 Jul 13. Epub 2022 Jul 13.

Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA -

Objective: Clinical effects of concomitant tricuspid annuloplasty (TA) in patients with mild to moderate tricuspid regurgitation at the time of mitral valve surgery (MVS) remains indefinite. We aimed to perform a meta-analysis to determine the long-term clinical and echocardiographic effects of concomitant TA in patients undergoing MVS.

Evidence Acquisition: MEDLINE and EMBASE were searched through January 2022 to identify randomized controlled trials (RCT) and observational studies with adjusted outcomes that investigated outcomes of concomitant TA versus conservative management for mild to moderate tricuspid regurgitation in patients undergoing MVS.

Evidence Synthesis: Two RCT and 11 observational studies included in the meta-analysis with a total of 3,953 patients underwent MVS with (n = 1,837) or without (n = 2,166) concomitant TA. Mean follow-up period ranged from 24 to 115.5 months. MVS with concomitant TA was associated with all-cause mortality (hazard ration [HR] 1.15; 95% confidence interval [CI]: 0.81-1.55; p = 0.34, I2=0%) compared with MVS alone. Similarly, heart failure events (HR 0.74; 95% CI: 0.46-1.20; p = 0.22, I2=0%) as well as rates of tricuspid reoperation (HR 0.55; 95% CI: 0.27-1.10; p = 0.09, I2=1%) were comparable between the groups. However, MVS with concomitant TA was associated with a significant reduction in TR progression (HR 0.30; 95% CI: 0.17-0.53; p < 0.00001, I2=11%).

Conclusions: Concomitant TA for patients undergoing MVS was associated with similar long-term clinical outcomes compared to MVS alone. However, concomitant TA was associated with a significant reduction in TR progression. Longer follow-up is necessary to assess the effect on further clinical outcomes.
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http://dx.doi.org/10.23736/S0021-9509.22.12354-2DOI Listing
July 2022

A novel dosing strategy of del Nido cardioplegia in aortic surgery.

JTCVS Open 2022 Jun 23;10:39-61. Epub 2022 Apr 23.

Division of Cardiothoracic Surgery, New York Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY.

Objective: While del Nido (DN) cardioplegia is increasingly used in cardiac surgery, knowledge is limited in its safety profile for operations with prolonged crossclamp time (CCT). We have introduced a unique redosing strategy for aortic surgery: all operations use DN with a 1000-mL initiation dose (750 mL antegrade, 250 mL retrograde) composed of 1:4 blood:DN crystalloid. At 90 minutes CCT and every 30 minutes thereafter, a 250-mL dose was introduced retrograde in a 4:1 ("reverse") ratio. Additionally, at 90 minutes CCT and every 90 minutes thereafter, a reverse ratio dose of approximately 100 to 400 mL was introduced via the right coronary artery. Here, we analyze the outcomes of our unique redosing strategy used.

Methods: In total, 440 patients underwent aortic surgery between January 2015 and March 2021 under a single surgeon and received DN. Our primary end points were change in left ventricular ejection fraction (LVEF) and right ventricular systolic function based on echocardiography. Multivariable linear regression was used to analyze the relationship between CCT and outcomes.

Results: The median was 61 years old (interquartile range, 51-69), and 23% were female. Indication was aneurysm in 65% and dissection in 24%. Median preoperative LVEF was 60% (55%-62%). Median CCT and cardiopulmonary bypass times were 135 minutes (93-165 minutes) and 181 minutes (142-218 minutes), respectively. In-hospital mortality occurred in 3%. Multivariable linear regression showed CCT was not associated with change in LVEF or change in right ventricular systolic function.

Conclusions: Our unique method of redosing DN cardioplegia appears to provide safe and effective myocardial protection for aortic surgery.
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http://dx.doi.org/10.1016/j.xjon.2022.04.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9255383PMC
June 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

Quantifying the effects of circulatory arrest on acute kidney injury in aortic surgery.

J Thorac Cardiovasc Surg 2022 Apr 6. Epub 2022 Apr 6.

Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY; Columbia Aortic Center, New York, NY. Electronic address:

Objectives: We aim to investigate the association between parameters surrounding circulatory arrest and postoperative acute kidney injury in aortic surgery.

Methods: This is a single-center retrospective study of 1118 adult patients who underwent aortic repair with median sternotomy between January 2010 and May 2019. Acute kidney injury was defined on the basis of a modified version of the 2012 Kidney Disease Improving Global Outcomes Scale that excluded urine output. The primary outcome of interest was any stage of acute kidney injury.

Results: Circulatory arrest was required in 369 patients, and 307 patients (27.5%) developed acute kidney injury: stage 1 in 241 patients, stage 2 in 38 patients, and stage 3 in 28 patients. Lower-body ischemia (the period during circulatory arrest without blood flow to kidneys) duration was not associated with acute kidney injury after multivariable logistic regression (1-40 minutes, odds ratio, 0.67; 95% confidence interval, 0.43-1.04; P = .075; >40 minutes, odds ratio, 0.67; 95% confidence interval, 0.29-1.55; P = .356). Hypertension (odds ratio, 1.65; 95% confidence interval, 1.09-2.54; P = .020), preoperative estimated glomerular filtration rate (odds ratio, 0.99; 95% confidence interval, 0.98-1.00; P = .010), packed red blood cell transfusion volume (odds ratio, 1.00; 95% confidence interval, 1.00-1.00; P = .028), and nadir temperature (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P = .013) were independently associated with acute kidney injury after multivariable analysis. Although there was a positive association between lower-body ischemia duration and development of acute kidney injury with univariable cubic spline, the positive curve was flattened after adjustment for the described variables.

Conclusions: Within the range of our clinical practice, prolonged lower-body ischemia duration was not independently associated with postoperative acute kidney injury, whereas nadir temperature was.
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http://dx.doi.org/10.1016/j.jtcvs.2022.03.024DOI Listing
April 2022

Deep vein thrombosis and pulmonary embolism after heart transplantation.

Clin Transplant 2022 Jul 20;36(7):e14705. Epub 2022 May 20.

Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA.

Introduction: Venous thromboembolism (VTE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important and serious postoperative complication after heart transplantation. We sought to characterize in-hospital VTE after heart transplantation and its association with clinical outcomes.

Method: Adult (≧18 years) patients undergoing heart transplantation from 2015 to 2019 at our center were retrospectively reviewed. Post-transplant VTE was defined as newly diagnosed venous system thrombus by imaging studies.

Results: There were 254 patients. The cohort's median age was 55 years. A total of 61 patients were diagnosed with VTE, including one with right atrial thrombus, 54 with upper extremity DVT in which one patient subsequently developed PE, four with lower extremity DVT, and two with upper and lower extremity DVT. The cumulative incidence of VTE was 42% at 60-days of post heart transplant. Patients with VTE had longer hospital stay (P < .001), higher in-hospital mortality (P = .010), and worse 5-year survival (P = .009). On the multivariable Cox analysis, history of DVT/PE and intubation for more than 3 days were associated with an increased risk of in hospital VTE.

Conclusion: The incidence of VTE in heart transplant recipients is high. Post-transplant surveillance, and appropriate preventive measures and treatment strategies after diagnosis are warranted.
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http://dx.doi.org/10.1111/ctr.14705DOI Listing
July 2022

Plight or Potential in Overengineering?

Ann Thorac Surg 2022 Apr 16. Epub 2022 Apr 16.

Division of Cardiothoracic and Vascular Surgery New York Presbyterian Hospital Columbia University Medical Center 177 Fort Washington Avenue, NY, NY 10032. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2022.03.074DOI Listing
April 2022

Predictors of Survival and Ventricular Recovery Following Acute Myocardial Infarction Requiring Extracorporeal Membrane Oxygenation Therapy.

ASAIO J 2022 06 19;68(6):800-807. Epub 2022 Jan 19.

Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) following acute myocardial infarction with cardiogenic shock (AMI-CS) is increasing, but the ability to predict favorable outcomes with support remains limited. We retrospectively reviewed all patients with AMI-CS supported with VA-ECMO between December 2008 and June 2018. One hundred twenty-six patients received VA-ECMO for AMI-CS during the study period; of these, 39 (31.0%) experienced ventricular recovery and were discharged while 87 (69.0%) did not recover, with 71 (56.3%) dying in the hospital and 16 (12.7%) surviving to discharge with either left ventricular assist device or heart transplant. TIMI 3 flow in culprit artery (OR, 4.01; 95% CI, 1.25-12.77; p = 0.02), serum lactate (OR, 0.89; 95% CI, 0.80-0.99; p = 0.04), and prompt revascularization (OR, 3.39; 95% CI, 1.18-9.81; p = 0.02) were independent predictors of ventricular recovery. Four variables emerged as independent predictors of in-hospital mortality and were used to create the AMI-ECMO Risk Score: age >70 years, creatinine >1.5 mg/dL, serum lactate > 4.0 mmol/L, and lack of TIMI 3 flow in culprit artery. In patients supported with VA-ECMO for AMI-CS, prompt, successful revascularization, and lower serum lactate were associated with ventricular recovery while younger age, lower serum lactate, and creatinine, and successful revascularization were associated with survival to discharge. The AMI-ECMO risk score is a simple tool that can help risk stratify patients with AMI-CS being considered for VA-ECMO support.
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http://dx.doi.org/10.1097/MAT.0000000000001570DOI Listing
June 2022

Recovery With Temporary Mechanical Circulatory Support While Waitlisted for Heart Transplantation.

J Am Coll Cardiol 2022 03;79(9):900-913

Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA.

Background: The 2018 U.S. heart allocation system offers an accelerated pathway for heart transplantation to the most urgent patients.

Objectives: This study sought to determine whether the new allocation system resulted in lower likelihood of candidate recovery.

Methods: Adult patients waitlisted for heart transplantation with temporary mechanical circulatory support at the time of initial listing between 2010 and 2020 in the United Network for Organ Sharing registry were included. Competing events of heart transplantation, waitlist death or delisting for deteriorating condition, and delisting for improved condition (candidate recovery) were analyzed in the new vs old heart allocation system.

Results: A total of 688 patients were waitlisted with venoarterial extracorporeal membrane oxygenation or a surgical nondischargeable biventricular assist device (status 1 or old 1A). Overall, 2,237 patients were waitlisted with an intra-aortic balloon pump, a percutaneous left ventricular assist device (LVAD), or a surgical nondischargeable LVAD (status 2 or old 1A). Patients waitlisted with venoarterial extracorporeal membrane oxygenation or a nondischargeable biventricular assist device had significantly shorter median waitlist times (5 vs 31 days), higher incidence for cardiac transplantation (81.5% vs 43.0%), and lower incidence of candidate recovery (1.5% vs 7.9%) in the new vs old heart allocation system (all P < 0.05). Patients waitlisted with an intra-aortic balloon pump or percutaneous or a nondischargeable LVAD also had significantly shorter median waitlist times (8 vs 35 days), higher incidence of transplantation (88.9% vs 64.9%), and lower incidence of candidate recovery (0.2% vs 1.6%) in the new vs old heart allocation system (all P < 0.05).

Conclusions: Current practice of the new allocation system may not offer select temporary mechanical circulatory support patients the opportunity and adequate time to recover to the point of waitlist removal. Further research will determine which patients would benefit from urgent transplantation vs recovery strategy.
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http://dx.doi.org/10.1016/j.jacc.2021.12.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8928585PMC
March 2022

Not So Stable Angina: Single Coronary Artery Disease.

Cureus 2022 Jan 26;14(1):e21625. Epub 2022 Jan 26.

Department of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, USA.

A single coronary artery (SCA) is a rare congenital anomaly that can be incidentally found as a part of ischemic heart disease or angina workup. A modified Lipton classification is used to categorize the disease. The majority of diseases do not need surgical correction, with the exception of a few conditions. This report presented the case of a 49-year-old man who presented with stable angina with a single coronary artery arising from the right coronary sinus with an intraseptal course of the left main coronary artery. This is categorized as RII-S in the modified Lipton classification and is considered a high-risk anomaly. He underwent an unroofing procedure to decompress the left coronary artery with a resolution of symptoms.
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http://dx.doi.org/10.7759/cureus.21625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8876090PMC
January 2022

Long-term outcome of hemiarch replacement in a proximal aortic aneurysm repair: analysis of over 1000 patients.

Eur J Cardiothorac Surg 2022 Jun;62(1)

Department of Surgery, Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.

Objectives: The aim of this study was to investigate the impact of hemiarch replacement in patients undergoing an open repair of proximal thoracic aortic aneurysm without arch aneurysm.

Methods: A retrospective review was performed on 1132 patients undergoing proximal aortic aneurysm repair at our Aortic Center between 2005 and 2019. Inclusion criteria were all patients undergoing root or ascending aortic aneurysm repair with or without hemiarch replacement. Exclusion criteria were age <18 years, aortic arch diameter ≥4.5 cm, type A aortic dissection, previous ascending aortic replacement, ruptured aneurysm and endocarditis. Propensity score matching in a 2:1 ratio (573 non-hemiarch: 288 hemiarch) on 19 baseline characteristics was performed. The median follow-up time was 46.8 months (range 0.1-170.4 months).

Results: Hemiarch patients had significantly lower 10-year survival in the matched cohort (hemiarch 73.8%; 66.9-81.4%; vs non-hemiarch 86.5%; 81.1-92.3%; P < 0.001), driven by higher in-hospital mortality rate (4% vs 1%; P < 0.001). Cumulative incidence of aortic arch reintervention rates at 10 years was similarly low (hemiarch 1.0%; 0-2.5% vs non-hemiarch 1.3%; 0-2.6%, P = 0.615). Multivariate analysis with hazard ratios of the overall cohort showed hemiarch as an independent factor associated with long-term mortality (2.16; 1.42-3.27; P < 0.001) but not with aortic arch reintervention (0.76; 0.14-4.07, P = 0.750).

Conclusions: Hemiarch repair may be associated with higher short-term mortality compared to non-hemiarch. Arch reintervention was rare after a repair of proximal thoracic aortic aneurysm without arch aneurysm. Our data call for larger and prospective studies to further delineate the utility of hemiarch repair in proximal aortic surgery.
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http://dx.doi.org/10.1093/ejcts/ezab571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9257789PMC
June 2022

Three-year survival of transcatheter versus surgical aortic valve replacement in dialysis.

Catheter Cardiovasc Interv 2022 03 27;99(4):1206-1213. Epub 2022 Jan 27.

Division of Cardiothoracic Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, New York, USA.

To highlight the trends of surgical (open) aortic valve replacement (SAVR) as well as to compare the outcome between transcatheter aortic valve replacement (TAVR) and SAVR in elderly dialysis patients. TAVR has evolved as an effective alternative to surgery (SAVR) for aortic stenosis. We identified dialysis-dependent patients who underwent SAVR or TAVR from 2000 to 2015 from the United States Renal Data System using ICD-9 codes. We defined high-risk surgical patients as age over 70 or older. The primary endpoint was survival at 3 years and we compared the outcome between SAVR and TAVR groups using inverse probability of treatment weighting (IPTW). A total of 4332 and 1280 dialysis patients underwent SAVR and TAVR, respectively, during the study period. Among SAVR cohort, 3312 patients underwent SAVR before June 2012 and 1020 after June 2012. In-hospital mortality was significantly worse before 2012 (14.6% vs. 11.3% after 2012, p = 0.007) as well as estimated 3-year mortality (69.1% vs. 60.3% after 2012, p < 0.001). After June 2012, the TAVR cohort was older and had more comorbidities including coronary artery disease and congestive heart failure compared to the SAVR cohort. After IPTW, in-hospital mortality was significantly lower after TAVR versus SAVR (odds ratio 0.38 [95% confidence interval [CI], 0.27-0.52], p < 0.001). However, TAVR had a significantly higher risk of 3-year mortality than SAVR (hazard ratio 1.24 [95% CI 1.1-1.39], p < 0.001). TAVR may be a reasonable and potentially preferable alternative to SAVR in the elderly dialysis population in the short-term period.
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http://dx.doi.org/10.1002/ccd.30045DOI Listing
March 2022

Five-year Outcomes of the COMMENCE Trial Investigating Aortic Valve Replacement with RESILIA Tissue.

Ann Thorac Surg 2022 Jan 20. Epub 2022 Jan 20.

Department of Cardiovascular Surgery, Mount Sinai Saint Luke's, New York, New York.

Background: The COMMENCE trial was conducted to evaluate the safety and effectiveness of aortic valve replacement using a bioprosthesis with novel RESILIA tissue (Edwards Lifesciences). RESILIA tissue is incorporated in the INSPIRIS RESILIA aortic valve (Edwards Lifesciences).

Methods: Patients underwent clinically indicated surgical aortic valve replacement with a bovine pericardial bioprosthesis (model 11000A; Edwards Lifesciences) in a prospective, multinational, multicenter (n = 27), US Food and Drug Administration Investigational Device Exemption trial. Events were adjudicated by an independent clinical events committee, and echocardiograms were analyzed by an independent core laboratory. Outcomes through an observational period of 5 years are reported.

Results: Between January 2013 and March 2016, 689 patients received the study valve. Mean patient age was 66.9 ± 11.6 years; Society of Thoracic Surgeons Predicted Risk of Mortality was 2.0% ± 1.8%; and 23.8%, 49.9%, and 24.4% of patients were New York Heart Association functional class I, II, and III at baseline, respectively. Through December 11, 2020 the follow-up duration was 4.3 ± 1.4 years, and the completeness of follow-up over the observational period was 95.5%. Early (<30 days) all-cause mortality was 1.2%, stroke 1.6%, and major paravalvular leak 0.1%. Five-year actuarial freedom from all-cause mortality, structural valve deterioration, and all-cause reintervention were 89.2%, 100%, and 98.7%, respectively. At 5 years the effective orifice area was 1.6 ± 0.5 cm, mean gradient was 11.5 ± 6.0 mm Hg, 97.8% of patients were class I/II, and 97.8% and 96.3% of patients had none/trace paravalvular and transvalvular regurgitation, respectively.

Conclusions: The safety and hemodynamic performance of this aortic bioprosthesis with RESILIA tissue through 5 years are encouraging, with clinically stable hemodynamics, minimal regurgitation, and no evidence of structural valve deterioration.
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http://dx.doi.org/10.1016/j.athoracsur.2021.12.058DOI Listing
January 2022

Commentary: What's a girl like you doing with a heart like this?

J Thorac Cardiovasc Surg 2021 Dec 9. Epub 2021 Dec 9.

Hypertrophic Cardiomyopathy Center; Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center/NewYork-Presbyterian, New York, NY. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.12.011DOI Listing
December 2021

Re-dosing of del Nido cardioplegia in adult cardiac surgery requiring prolonged aortic cross-clamp.

Interact Cardiovasc Thorac Surg 2022 03;34(4):556-563

Department of Surgery, Columbia University Medical Center, New York, NY, USA.

Objectives: Few data exist on the use of del Nido cardioplegia in adults, specifically during operations requiring prolonged aortic cross-clamp. In this pilot study, we evaluate outcomes of patients undergoing surgery with cross-clamp time >3 h based on re-dosing strategy, using either full dose (FD; 1:4 blood to crystalloid ratio) or dilute (4:1 blood to crystalloid ratio) solution.

Methods: Consecutive adult patients (>18 years) undergoing cardiac surgery from 2012 to 2018 with cross-clamp time >3 h were reviewed. Patients were excluded if del Nido cardioplegia was not used. Patients were categorized into FD or dilute groups based on re-dosing solution. Propensity score matching was used to control for baseline differences between groups. The primary endpoint was in-hospital mortality. Other outcomes examined included: postoperative mechanical support, arrhythmia, stroke, dialysis and cardiac function.

Results: Included for analysis were 173 patients (115 male) with median age of 63.8 (interquartile range 53.9-73.1). Major comorbidities included diabetes (45), cerebrovascular disease (34), hypertension (131), atrial fibrillation (52) and previous cardiac surgery (83). There were 108 patients (62%) who received FD re-dosing, while 65 (38%) received dilute. A greater proportion of patients in the dilute group received retrograde delivery, for both induction (32/108 vs 39/65, P < 0.001) and re-dose (50/108 vs 53/65, P < 0.001). After propensity score matching, in-hospital mortality was not different between groups (6/48 vs 1/48, P = 0.131). There were no differences in rates of postoperative mechanical circulatory support, stroke, left ventricular ejection fraction or right ventricle dysfunction.

Conclusions: Del Nido cardioplegia has been used in complex cardiac surgery requiring prolonged cross-clamp. Re-dosing can be performed with either FD or dilute del Nido solution with no statistical difference in outcomes.
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http://dx.doi.org/10.1093/icvts/ivab310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8972223PMC
March 2022

The Association Between Preoperative Independent Ambulatory Status and Outcomes After Open Abdominal Aortic Aneurysm Repairs.

Ann Vasc Surg 2022 Apr 14;81:70-78. Epub 2021 Nov 14.

Department of Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center, New York, NY.

Background: Preoperative functional status is appreciated as a key determinant of decision-making when evaluating patients for complex elective surgeries. We used the Vascular Quality Initiative to analyze the effect of being able to independently ambulate on outcomes after open abdominal aortic aneurysm (AAA) repairs.

Methods: We identified all patients who underwent elective or urgent open AAA repairs from January 2013 to August 2019 in the Vascular Quality Initiative registry. We recorded demographic variables, comorbidities, and operative factors such as approach, operative ischemia time, proximal clamp site, and presence of iliac aneurysms. Short-term and long-term outcomes included 30-day mortality, any perioperative complications, failure to rescue (defined as death after a complication), and 1-year all-cause mortality. We dichotomized patients based on their ability to independently ambulate (Ambulatory) or inability to ambulate independently (Non-Ambulatory) and used both multivariable logistic regressions and cox-proportional hazards models to evaluate outcomes.

Results: Of 5,371 patients, 328 (6.1%) could not ambulate independently and were more likely to be older (median age 69 vs. 72), female (25% vs. 38%), and have greater comorbidities. Overall outcomes were: 4.3% for 30-day mortality, 38.7% for complications, 10.2% for failure-to-rescue, and 6.9% for 1-year mortality. Univariate analysis showed higher rates of all adverse outcomes in non-ambulatory patients. On adjusted analysis, non-ambulatory patients had increased odds of complications by 46% (OR 1.46 [95%-CI 1.11-1.91]) and 1-year mortality by 46% (HR 1.46 [95%-CI 1.06-1.99]), but not failure to rescue (OR 1.05 [95%-CI 0.67-1.62]) or 30-day mortality (OR 1.22 [95%-CI 0.82-1.81]). Increased hospital volume, age, and increased operative renal ischemia time were independently associated with adverse outcomes.

Conclusions: Non-ambulatory status was observed in a small percentage of patients undergoing open AAA repair but was associated with higher rates of post-operative complications and 1-year mortality. Ambulatory capacity is one of the key determinants of outcomes following open AAA repair. In patients with poor ambulatory function, a conservative approach is highly recommended over invasive open surgical intervention.
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http://dx.doi.org/10.1016/j.avsg.2021.10.050DOI Listing
April 2022

Sizable valve implantation may lead to sizable pacemaker risk.

Ann Thorac Surg 2021 Nov 8. Epub 2021 Nov 8.

Department of Surgery, Columbia University Irving Medical Center, Milstein Hospital Building, Suite 7-435, New York, NY, 10032. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2021.09.064DOI Listing
November 2021

Stroke patterns and cannulation strategy during veno-arterial extracorporeal membrane support.

J Artif Organs 2021 Nov 9. Epub 2021 Nov 9.

Department of Surgery, Division of Cardiothoracic Surgery, 177 Fort Washington Avenue, New York, NY, 10032, USA.

Stroke has potentially devastating consequences for patients receiving veno-arterial extracorporeal membrane support (VA-ECMO). Arterial cannulation sites for VA-ECMO include the ascending aorta, axillary artery, and femoral artery. However, the influence of cannulation site on stroke risk has not been well described. The purpose of this study was to investigate the association between occurrence and patterns of stroke with ECMO arterial cannulation sites. We retrospectively reviewed 414 consecutive patients who received VA-ECMO support for cardiogenic shock between March 2007 and May 2018. Patients were categorized by cannulation strategy. The rates, subtype and location of strokes as assessed by neuroimaging during and after VA-ECMO support were analyzed. Median age was 61 years (IQR 50-69); 67% were men. 77 patients were cannulated via the ascending aorta (17%), 31 via the axillary artery (7%), and 306 (69%) via the femoral artery. In total, 26 patients (6.3%) developed 30 stroke lesions at a median of 6.0 (IQR 3.1-8.7) days after ECMO cannulation. Ischemic stroke was the most common subtype (64%), followed by hemorrhagic transformation (20%) and hemorrhagic stroke (16%). Location by CT was right hemispheric in 38%, left hemispheric in 24%, bilateral in 21%, and vertebrobasilar in 17%. The incidence of stroke was similar across cannulation strategies: aorta (n = 5, 6.5%), axillary artery (n = 2, 6.5%), and femoral artery (n = 19, 6.2%), (p = 0.99). Incidence of stroke does not appear to differ among patients cannulated via the ascending aorta, axillary artery, or femoral artery. Ischemic stroke was the most common subtype of stroke.
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http://dx.doi.org/10.1007/s10047-021-01300-5DOI Listing
November 2021

Commentary: Are coronary aneurysms surgical disease?

JTCVS Tech 2021 Oct 1;9:80-81. Epub 2021 Jul 1.

Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Columbia University Medical Center/New York-Presbyterian, New York, NY.

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http://dx.doi.org/10.1016/j.xjtc.2021.06.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8501202PMC
October 2021

Effects of Septal Reduction Therapy on Acute Cardiovascular Events and All-Cause Mortality in Patients with Hypertrophic Cardiomyopathy.

Int Heart J 2021 Sep 17;62(5):1035-1041. Epub 2021 Sep 17.

Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center.

Septal reduction therapy (SRT) -i.e. septal myectomy and alcohol septal ablation-has been performed to treat medically refractory hypertrophic cardiomyopathy (HCM) for decades. However, it is largely unknown whether SRT prevents HCM-related cardiovascular events or death. The objective was to examine the effects of SRT on acute cardiovascular events and all-cause mortality in HCM. We performed a propensity score (PS) -matched study using databases that capture all hospitalizations and outpatient visits in New York state. We identified patients with HCM who underwent SRT between 2007 and 2014 (i.e. the SRT group) and those who had never had SRT but had at least one hospitalization for HCM during the same period (i.e. the control group). We performed PS matching at a 1:1 ratio. The primary outcome was a composite of acute cardiovascular events and all-cause mortality during 0-180 days and 181-360 days. The secondary outcome was 180- and 360-day all-cause mortality. We included 846 patients with HCM (423 PS-matched pairs). Patients who underwent SRT had a lower risk of the primary outcome event (0-180 days: odds ratio [OR], 0.54; 95% confidence intervals (CI), 0.37-0.80; P = 0.002 and 181-360 days: OR, 0.33; 95% CI, 0.22-0.51; P < 0.0001). Furthermore, the risk of all-cause mortality was lower at 180 days (OR, 0.37; 95% CI, 0.22-0.63; P = 0.0003) and 360 days post-SRT (OR, 0.32; 95% CI, 0.20-0.51; P < 0.0001). In conclusion, our PS-matched study using population-based datasets demonstrated that SRT was associated with a reduced risk of a composite of acute cardiovascular events and all-cause mortality in HCM during the first post-SRT year.
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http://dx.doi.org/10.1536/ihj.21-095DOI Listing
September 2021

Postdischarge Functional Capacity, Health-Related Quality of Life, Depression, Anxiety, and Post-traumatic Stress Disorder in Patients Receiving a Long-term Left Ventricular Assist Device.

J Card Fail 2022 01 20;28(1):83-92. Epub 2021 Aug 20.

Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York. Electronic address:

Background: There is a paucity of data on depression, anxiety and post-traumatic stress disorder after left ventricular assist device (LVAD) implantation. We designed an observational study to integrate these with functional capacity and health-related quality of life (HR-QOL) in surviving LVAD patients.

Methods And Results: Consenting patients between 1 month and 9 years after LVAD implantation (n = 121) were screened for functional capacity (World Health Organization Disability Assessment Schedule 2.0 [WHODAS 2.0)]); HR-QOL (European Quality of Life [EQ-5D] and Visual Assessment Scales [EQ-VAS]), depression (Patient Health Questionnaire [PHQ-9], anxiety (Generalized Anxiety Disorder Scale [GAD-7]) and post-traumatic stress disorder (Impact of Event Scale Revised [IES-R]). Of the 94% of patients who consented, 34.7% reported impaired functional capacity (WHODAS 2.0 score of ≥25%), 23.1%-34.7% HR-QOL problems (domain EQ-5D of ≥3), 10.7% "poor health" (EQ-VAS of ≤40), 14.9% depression (PHQ-9 of >14), 11.7% suicidal ideation and 17.5% anxiety (GAD-7 of >10). Among these patients, 23.5% had a positive screen for post-traumatic stress disorder (IES-R of ≥24). An EQ-VAS of 80 or greater predicted good functional capacity (P < .001).

Conclusions: One-third of discharged LVAD patients reported impaired function, HR-QOL, and psychological issues. A standardized evaluation before and after LVAD implantation could facilitate psychologic prehabilitation, inform decision-making, and identify indications for mental health intervention.
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http://dx.doi.org/10.1016/j.cardfail.2021.07.019DOI Listing
January 2022

A case series analysis on the clinical experience of Impella 5.5® at a large tertiary care centre.

ESC Heart Fail 2021 10 17;8(5):3720-3725. Epub 2021 Aug 17.

Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, 161 Fort Washington Avenue, New York, NY, 10032, USA.

Aims: We aimed to detail the early clinical experience with pVAD 5.5 at a large academic medical centre. Impella® 5.5 (Abiomed) is a temporary peripherally inserted left ventricular assist device (pVAD) used for the treatment of cardiogenic shock (CS). This system has several modifications aimed at improving deliverability and durability over the pVAD 5.0 system, but real-world experience with this device remains limited.

Methods And Results: We collected clinical and outcome data on all patients supported with pVAD 5.5 at our centre between February and December 2020, including procedural and device-related complications. Fourteen patients with pVAD 5.5 were included. Aetiology of CS was acute myocardial infarction (n = 6), decompensated heart failure (n = 6), suspected myocarditis (n = 1), and post-cardiotomy CS (n = 1). Four patients received pVAD 5.5 after being on inotropes alone, two were escalated from intra-aortic balloon pump, two were escalated from pVAD CP, and six patients were transitioned to pVAD 5.5 from extracorporeal membrane oxygenation. Median duration of pVAD 5.5 support was 12 (interquartile range 7, 25) days. Complications included axillary insertion site haematoma (n = 3), acute kidney injury (n = 3), severe thrombocytopenia (n = 1), and stroke (n = 1). No valve injury or limb complications occurred. Survival to device explant for recovery or transition to another therapy was 11/14 (79%) patients.

Conclusions: In this early experience of the pVAD 5.5, procedural and device-related complications were observed but were manageable, and overall survival was high in this critically ill cohort, particularly when the device was used as a bridge to other therapies.
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http://dx.doi.org/10.1002/ehf2.13512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497328PMC
October 2021

Commentary: The second cut is the deepest.

JTCVS Tech 2021 Aug 14;8:73-74. Epub 2021 May 14.

Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center/New York-Presbyterian, New York, NY.

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http://dx.doi.org/10.1016/j.xjtc.2021.05.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8350883PMC
August 2021

Impact of Venoarterial Extracorporeal Membrane Oxygenation Flow on Outcomes in Cardiogenic Shock.

ASAIO J 2022 02;68(2):239-246

From the Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York.

Venoarterial extracorporeal membrane oxygenation (VA ECMO) is used to provide cardiopulmonary support in cardiogenic shock; however, high extracorporeal flow may increase left ventricular (LV) afterload leading to LV distention and intracardiac stasis. It is unclear how ECMO flow affects patient outcomes and complications related to ECMO. Retrospective review of patients at a single institution placed on VA ECMO from 2007 to 2018 was performed. Patients were divided into full flow (flow index > 2.2 L/min/m2) and partial flow (flow index < 2.2 L/min/m2) groups. In-hospital mortality and markers of end-organ perfusion were compared between groups balanced for risk factors using propensity score inverse probability of treatment weighting. ECMO-related complications such as LV distention, limb ischemia, and bleeding were recorded. There were 488 patients included, 405 (83%) in the partial flow group, and 83 (17%) in the full flow group. No major differences in age, gender, or comorbidities were found. There was no difference in in-hospital mortality between groups (51% vs. 55%, p = 0.59). At 72 hours post-ECMO initiation, there was no difference in the change in renal, hepatic function, or lactate from baseline nor in the rates of continuous venoveno hemofiltration initiation (p = 0.41). There was a trend towards the decreased incidence of LV distention requiring LV vent placement in the partial flow group (12% vs. 7%, p = 0.16). Compared with full flow VA ECMO, partial flow VA ECMO in carefully selected patients results in similar in-hospital mortality and provides similar end-organ perfusion for the treatment of refractory cardiogenic shock.
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http://dx.doi.org/10.1097/MAT.0000000000001462DOI Listing
February 2022

Long-Term Outcomes of Transcatheter Aortic Valve Replacement in Patients With End-Stage Renal Disease.

J Am Heart Assoc 2021 08 13;10(16):e019930. Epub 2021 Aug 13.

Division of Cardiothoracic Surgery New York Presbyterian HospitalColumbia University Medical Center New York NY.

Background Aortic stenosis is prevalent in end-stage renal disease. Transcatheter aortic valve replacement (TAVR) is a plausible alternative for surgical aortic valve replacement. However, little is known regarding long-term outcomes in patients with end-stage renal disease who undergo TAVR. Methods and Results We identified all patients with end-stage renal disease who underwent TAVR from 2011 through 2016 using the United States Renal Data System. The primary end point was 5-year mortality after TAVR. Factors associated with 1- and 5-year mortality were analyzed. A total of 3883 TAVRs were performed for patients with end-stage renal disease. Mortality was 5.8%, 43.7%, and 88.8% at 30 days, 1 year, and 5 years, respectively. Case volumes increased rapidly from 17 in 2011 to 1495 in 2016. Thirty-day mortality demonstrated a dramatic reduction from 11.1% in 2012 to 2.5% in 2016 (=0.01). Age 75 or older (hazard ratio [HR], 1.14; 95% CI, 1.05-1.23 [=0.002]), body mass index <25 (HR, 1.18; 95% CI, 1.08-1.28 [<0.001]), chronic obstructive pulmonary disease (HR, 1.25; 95% CI, 1.1-1.35 [<0.001]), diabetes mellitus as the cause of dialysis (HR, 1.22; 95% CI, 1.11-1.35 [<0.001]), hypertension as the cause of dialysis (HR, 1.17; 95% CI, 1.06-1.29 [=0.004]), and White race (HR, 1.17; 95% CI, 1.06-1.3 [=0.002]) were independently associated with 5-year mortality. Conclusions Short-term outcomes of TAVR in patients with end-stage renal disease have improved significantly. However, long-term mortality of patients on dialysis remains high.
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http://dx.doi.org/10.1161/JAHA.120.019930DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8475055PMC
August 2021

Commentary: Axillary or femoral cannulation-Which is the lesser of 2 evils?

JTCVS Tech 2021 Feb 7;5:74-75. Epub 2020 Dec 7.

Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY.

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http://dx.doi.org/10.1016/j.xjtc.2020.11.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8300040PMC
February 2021

Commentary: SVC syndrome: Venous stenting is the mainstay but may not stay open.

JTCVS Tech 2020 Dec 10;4:181-182. Epub 2020 Oct 10.

Aortic Center, Columbia University Medical Center, New York, NY.

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http://dx.doi.org/10.1016/j.xjtc.2020.10.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8307341PMC
December 2020

Commentary: An arteriovenous bridge over novel, troubled water.

JTCVS Tech 2020 Sep 21;3:223-224. Epub 2020 Jul 21.

Division of Cardiac and Thoracic Surgery, Columbia University Medical Center, New York, NY.

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http://dx.doi.org/10.1016/j.xjtc.2020.07.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8304487PMC
September 2020

Pseudoaneurysm as a Late Complication of Chronic Stanford Type A Intramural Hematoma Requiring Endovascular Repair.

JACC Case Rep 2020 Dec 16;2(15):2470-2475. Epub 2020 Dec 16.

Columbia Aortic Center, New York-Presbyterian/Columbia University Medical Center, New York, New York, USA.

Aortic intramural hematoma accounts for 5% to 20% of patients with acute aortic syndrome. Endovascular grafts have evolved as minimally invasive alternatives for treatment in some highly selected patients. We present the case of a patient who had late complications of a chronic Stanford type A intramural hematoma requiring thoracic endovascular aortic repair. ().
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http://dx.doi.org/10.1016/j.jaccas.2020.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8305071PMC
December 2020
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