Publications by authors named "Joseph A Dearani"

612 Publications

Variation in Case-Mix Across Hospitals: An analysis of STS Congenital Heart Surgery Database.

Ann Thorac Surg 2022 Aug 5. Epub 2022 Aug 5.

Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) was queried to document variation of patient characteristics, procedure types, and programmatic case-mix.

Methods: All index cardiac operations in patients <18 years in STS-CHSD (July 2016 to June 2020) were eligible for inclusion except patients <2.5 kilograms undergoing isolated PDA closure. At the hospital level, we describe variation in patient and procedural characteristics that are known from previous analyses to be associated with outcomes. We also report variation across hospitals of programmatic case-mix.

Results: Data were analyzed from 117 sites (90,322 total operations, 87,296 total index cardiac operations eligible for STAT 2020 Mortality Score). Median annual total index cardiac operations eligible for STAT 2020 Mortality Score per hospital was 157 (interquartile range [IQR]=94-276). Wide variability was documented in total annual index cardiac operations eligible for STAT 2020 Mortality Score per hospital (ratio 90th/10th percentile=9.01), operations in neonates with weight <2.5 kg (ratio 90th/10th percentile=4.09), operations in patients with non-cardiac anatomic abnormalities (ratio 90th/10th percentile=3.46), and operations in patients with preoperative mechanical ventilation (ratio 90th/10th percentile=3.97). At the hospital level: median percentage of all index cardiac operations in STAT 2020 Mortality Category 5=3.7%(IQR=1.7%-4.9%); median percentage of all index cardiac operations in STAT 2020 Mortality Category 4 or 5= 24.4%(IQR=19.0%-28.4%); hospital-specific mean STAT Mortality Category-median=2.39(IQR=2.20-2.47); and hospital-specific mean STAT Mortality Score-median=0.86(IQR=0.73-0.91).

Conclusions: Substantial variation of patient characteristics, procedure types, and case-mix exists across pediatric and congenital cardiac surgical programs. Knowledge about programmatic case-mix augments data about indirectly standardized programmatic observed-to-expected mortality.
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http://dx.doi.org/10.1016/j.athoracsur.2022.06.053DOI Listing
August 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

Cardiac Implantable Electronic Devices in Ebstein Anomaly: Management and Outcomes.

Circ Arrhythm Electrophysiol 2022 07 28;15(7):e010744. Epub 2022 Jun 28.

Department of Cardiovascular Diseases (N.Y.T., W.R.M., H.M.C., A.E., S.J.A., M.M.), Mayo Clinic, Rochester, MN.

Background: Optimal management of cardiac implantable electronic devices (CIEDs) in patients with Ebstein anomaly during tricuspid valve (TV) surgery is unknown. Thus, we aimed to characterize CIED management/outcomes in patients with Ebstein anomaly undergoing TV surgery.

Methods: Patients at the Mayo Clinic from 1987 to 2020 with Ebstein anomaly and CIED procedure were reviewed for procedural details, complications, echocardiogram, and lead parameters. Five-year cumulative incidence of CIED complications were estimated using the Kaplan-Meier method.

Results: Ninety-three patients were included; 51 were female, and mean age was 40.7±17.5 years. A new CIED was implanted in 45 patients at the time of TV surgery with the majority receiving an epicardial (n=37) CIED. Among 34 patients who had preexisting CIED (11 epicardial, 23 transvenous) at time of TV surgery, 20 had a transvenous right ventricular lead managed by externalizing the lead to the TV (n=15) or extracting the transvenous lead with epicardial lead implantation (n=5). Fourteen patients underwent CIED implantation (4 epicardial, 10 transvenous) without concurrent surgery. Placement of lead across the TV was avoided in 85% of patients. The 5-year cumulative incidence of CIED complications was 24% with no significant difference between epicardial and transvenous CIEDs (26% versus 23%, =0.96). Performance of lead parameters was similar in epicardial and transvenous leads during median (interquartile range) follow-up of 44.5 (61.1) months.

Conclusions: In patients with Ebstein anomaly undergoing TV surgery, the use of epicardial leads and externalization of transvenous leads to the TV can avoid lead placement across the valve leaflets. Lead performance and CIED complications was similar between epicardial and transvenous CIEDs.
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http://dx.doi.org/10.1161/CIRCEP.121.010744DOI Listing
July 2022

Fontan Palliation in Patients with Heterotaxy Syndrome: A Five Decade Experience.

World J Pediatr Congenit Heart Surg 2022 07;13(4):436-442

Division of Pediatric Cardiology, 6915Mayo Clinic, Rochester, MN, USA.

Background: Patients with heterotaxy syndromes (right and left atrial isomerism) are at high risk of poor outcomes after single-ventricle palliation. However, the long-term outcomes and specific parameters associated with poor outcomes are incompletely understood.

Methods: A retrospective review was performed of all patients with atrial isomerism who had a Fontan at our institution from 1973 to 2020. Standard demographic, as well as pre-, peri-, and postoperative parameters were collected. Features and outcomes of patients with polysplenia were compared to asplenia. Outcomes were analyzed for effect during 4 eras: (1: 1973-1984; n = 27), (2: 1985-1994; n = 93), (3: 1995-2004; n = 28), and (4: 2005-2020; n = 10).

Results: Of the 1176 patients who had a Fontan operation, 158 (14%) had a heterotaxy syndrome. The median age at the time of Fontan was 8 (9) years. Early mortality was 20% and was greater in patients with asplenia compared to polysplenia (27% vs. 12%,  = .019). But it substantially improved over time (61% in era 1 vs. 7%-10% in the more recent eras ( < .001)), as did transplant-free survival (22% at 10 years in era 1 vs. 88% in era 4,  < .001). Transplant-free survival was significantly lower in patients with asplenia versus those with polysplenia ( = .014), and patients with heterotaxy had lower survival than nonheterotaxy ( = .01). This was largely due to the asplenia group ( < .001) (hazard ratio = 3.05,  = .007).

Conclusions: After Fontan operation, patients with heterotaxy, particularly asplenia, continue to demonstrate worse transplant-free survival than nonheterotaxy patients. Early mortality and long-term transplant-free survival have improved in more recent eras.
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http://dx.doi.org/10.1177/21501351221099944DOI Listing
July 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

Outcomes of Biventricular and Single Ventricle Heterotaxy Patients: A Single Center Five-Decade Experience.

Ann Thorac Surg 2022 Jun 17. Epub 2022 Jun 17.

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

Background: Surgical palliation of patients with heterotaxy syndrome has proven challenging. Long-term outcomes have historically been poor. Factors contributing to these outcomes are not completely understood.

Methods: The institutional databases were queried for patients with heterotaxy syndrome from 1973 to 2021. Comparisons were made between patients managed with single ventricle physiology and biventricular physiology.

Results: Heterotaxy syndrome was identified in 230 patients (polysplenia, 47%; asplenia, 53%). In all, 199 patients had single ventricle physiology; 180 (78%) had undergone Fontan palliation. Thirty-one patients had biventricular physiology, including 20 (9%) with surgical intervention and 11 (5%) without surgical intervention. Median age at Fontan was 7.5 years (interquartile range, 8.8). Median follow-up was 20 years (interquartile range, 21). Kaplan-Meier analysis showed decreased survival with single ventricle physiology (53% ± 4%, vs biventricular 93% ± 5% at 30 years; P = .001), as well as asplenia compared with polysplenia (49% ± 5% vs 68% ± 5% at 30 years; P < .001). Polysplenia patients with biventricular physiology demonstrated the best survival (100% alive, vs 53% ± 25% of asplenia biventricular at 30 years; P < .001). Overall, 8 patients (3.5%) underwent cardiac transplantation at a median age of 17 years. On multivariable analysis, risk factors associated with mortality included single ventricle physiology (odds ratio [OR] 7.2; 95% CI, 2.4-21.7), no prior Glenn (OR 3.6; 95% CI, 1.9-6.7), need for permanent pacemaker (OR 2.3; 95% CI, 1.2-4.6), and asplenia (OR 2.7; 95% CI, 1.5-5.0).

Conclusions: Overall, patients with asplenia demonstrated decreased survival compared with patients with polysplenia; and single ventricle physiology had decreased survival compared with biventricular. Patients with biventricular physiology and polysplenia had the best survival.
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http://dx.doi.org/10.1016/j.athoracsur.2022.05.045DOI Listing
June 2022

Ergonomics for Surgeons by Surgeons-Posture, Loupes, and Exercise.

JAMA Surg 2022 Jun 15. Epub 2022 Jun 15.

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

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http://dx.doi.org/10.1001/jamasurg.2022.0676DOI Listing
June 2022

Complexity and Outcome of Reoperations After the Ross Procedure in the Current Era.

Ann Thorac Surg 2022 May 26. Epub 2022 May 26.

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

Background: The Ross procedure has several advantages, but the need for reintervention is inevitable. The aim of this study was to examine the complexity and outcomes of reoperation after the Ross procedure.

Methods: Retrospective chart review was performed of patients with a prior Ross procedure who underwent reoperation at our institution from September 1991 to January 2021. Demographic, echocardiographic, surgical, and perioperative data were collected. Descriptive statistical and regression analyses were performed.

Results: A total of 105 patients underwent a reoperation at Mayo Clinic after the initial Ross procedure performed at our institution (n = 16; 16.2%) or elsewhere (n = 83; 83.8%). Mean age at the Ross procedure was 27 ± 17 years, and mean age at reoperation at our institution was 37 ± 19 years. Indications for surgical procedure varied, but 64% had autograft regurgitation as 1 of their indications for reoperation. Autograft interventions were performed in 78 patients (74.2%). Pulmonary valve or conduit replacement was performed in 56 patients (53.3%). Double root replacement was performed in 11 patients (10.5%). Aortic reconstruction was performed in 37 patients (38.4%). There were 5 early deaths (5%). During a median follow-up of 6.25 years (3 months-24 years), late deaths occurred in 14 patients (13.1%). Patients with ejection fraction <30% on preoperative echocardiography had shorter duration between the Ross procedure and subsequent reoperation (P = .03).

Conclusions: Reoperations after the Ross procedure are performed for a wide range of indications, with most due to autograft dysfunction. The number of early deaths is not low. Reoperation after the Ross procedure should be advised before left ventricular systolic dysfunction.
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http://dx.doi.org/10.1016/j.athoracsur.2022.05.017DOI Listing
May 2022

Ebstein Anomaly-Of Veils and Visions.

JAMA 2022 06;327(22):2173-2174

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

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http://dx.doi.org/10.1001/jama.2022.7679DOI Listing
June 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

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

Resilience. Hope. Unity. STS Presidential Address 2021.

Authors:
Joseph A Dearani

Ann Thorac Surg 2022 Jul 30;114(1):5-17. Epub 2022 Apr 30.

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

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http://dx.doi.org/10.1016/j.athoracsur.2022.01.068DOI Listing
July 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

Chasing Excellence: A Cardiac Surgeon's Life in Letters.

Authors:
Joseph A Dearani

World J Pediatr Congenit Heart Surg 2022 05;13(3):280-286

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

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http://dx.doi.org/10.1177/21501351221084889DOI 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

COVID-19 FAQs in Pediatric Cardiac Surgery: 2022 Perspective and Updates.

World J Pediatr Congenit Heart Surg 2022 05 28;13(3):287-292. Epub 2022 Mar 28.

Divisions of Infectious Diseases and Critical Care Medicine, 6567Children's Hospital of Philadelphia, PA, USA.

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http://dx.doi.org/10.1177/21501351221085966DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9024014PMC
May 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

Team Approach to Decision-Making in Pulmonary Valve Replacement.

Semin Thorac Cardiovasc Surg 2022 Mar 5. Epub 2022 Mar 5.

Department of Pediatric and Adolescent Medicine/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota.

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http://dx.doi.org/10.1053/j.semtcvs.2022.02.008DOI 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

Outcomes of Tricuspid Valve Repair With Artificial Neochordae in Pediatric and Adult Patients.

Ann Thorac Surg 2022 Feb 8. Epub 2022 Feb 8.

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

Background: There are sparse data on outcomes after expanded polytetrafluoroethylene artificial neochordae (ePTFE-AN) for tricuspid valve (TV) repair. We evaluated outcomes after TV repair with ePTFE-AN in both pediatric and adult patients.

Methods: We analyzed clinical data of 87 consecutive patients who underwent ePTFE-AN implantation at the time of TV repair from 1998 to 2020. Patients were categorized into pediatric and adult groups.

Results: There were 29 pediatric (33.3%) and 58 adult (66.7%) patients. The most common etiology of tricuspid regurgitation (TR) was congenital (pediatrics: 86.2% [25 of 29]; adults: 39.7% [23 of 59]). The median number of pairs of ePTFE-AN implanted was 2 (interquartile range [IQR], 2-5 pairs) for pediatric and 3 (IQR, 2-4 pairs) for adult patients. There was no early death. Three adult patients (5.2%) required early TV reoperation, and 4 patients (1 pediatric, 3 adults) underwent late TV reintervention. Etiology of TR was congenital in 4 of the 6 adults who required TV reintervention. The 3-year cumulative risk of TV reintervention was 0.0% for pediatric and 7.3% (95% CI, 0.4%-14.2%) for adult patients. There was significant improvement in TR grade after TV repair at dismissal and at the latest echocardiographic follow-up in each group (P < .001). Severe TR developed in 1 pediatric patient and 7 adult patients during follow-up, and 6 (1 pediatric, 5 adults) of them underwent TV reoperation.

Conclusions: ePTFE-AN implantation in the TV position can be performed safely and effectively with no early death. In adult patients with congenital TR, patient selection is critical to achieve a durable outcome after TV repair.
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http://dx.doi.org/10.1016/j.athoracsur.2022.01.027DOI Listing
February 2022

Mortality Prediction After Cardiac Surgery in Children: An STS Congenital Heart Surgery Database Analysis.

Ann Thorac Surg 2022 Feb 3. Epub 2022 Feb 3.

Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: The Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (CHSD) provides risk-adjusted operative mortality rates to approximately 120 North American congenital heart centers. Optimal case-mix adjustment methods for operative mortality risk prediction in this population remain unclear.

Methods: A panel created diagnosis-procedure combinations of encounters in the CHSD. Models for operative mortality using the new diagnosis-procedure categories, procedure-specific risk factors, and syndromes or abnormalities included in the CHSD were estimated using Bayesian additive regression trees and least absolute shrinkage and selector operator (lasso) models. Performance of the new models was compared with the current STS CHSD risk model.

Results: Of 98 825 operative encounters (69 063 training; 29 762 testing), 2818 (2.85%) STS-defined operative mortalities were observed. Differences in sensitivity, specificity, and true and false positive predicted values were negligible across models. Calibration for mortality predictions at the higher end of risk from the lasso and Bayesian additive regression trees models was better than predictions from the STS CHSD model, likely because of the new models' inclusion of diagnosis-palliative procedure variables affecting <1% of patients overall but accounting for 27% of mortalities. Model discrimination varied across models for high-risk procedures, hospital volume, and hospitals.

Conclusions: Overall performance of the new models did not differ meaningfully from the STS CHSD risk model. Adding procedure-specific risk factors and allowing diagnosis to modify predicted risk for palliative operations may augment model performance for very high-risk surgical procedures. Given the importance of risk adjustment in estimating hospital quality, a comparative assessment of surgical program quality evaluations using the different models is warranted.
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http://dx.doi.org/10.1016/j.athoracsur.2021.11.077DOI Listing
February 2022

Reevaluating Congenital Heart Surgery Center Performance Using Operative Mortality.

Ann Thorac Surg 2022 Feb 2. Epub 2022 Feb 2.

Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) provides observed-to-expected (O/E) operative mortality ratios to more than 100 congenital heart centers in North America. We compared the current approach for estimating O/E ratios to approaches incorporating information on diagnosis as moderators of procedures, other unused risk factors, and additional variation in confidence interval construction to characterize center performance.

Methods: Bayesian additive regression trees (BART) and lasso models linked operative mortality to diagnosis-procedure categories, procedure-specific risk factors, and syndromes/abnormalities. Bootstrapping accounted for variation in the STS-CHSD (STS bootstrap) and lasso CIs. We compared O/E estimates, interquartile range of CI widths, and concordance of center performance categorizations (worse-than-, as-, or better-than-expected mortality) of the new approaches to the STS-CHSD.

Results: In 110 surgical centers including 98,822 surgical operative encounters, there were 2818 (2.85%) operative mortalities (center range, 0.37%-10%). Compared with the STS-CHSD, BART- and lasso-estimated O/E ratios varied more and had narrower confidence intervals (interquartile range of confidence interval: STS-CHSD = 1.11, STS bootstrap = 0.98; lasso = 0.80; BART = 0.96). Concordance of performance categorization with the STS-CHSD ranged from 84% (lasso) to 91% (STS Bootstrap); more than 70% of discordant centers improved categories. Discordant centers had smaller volumes, fewer operative mortalities, and treated more patients with congenital lung abnormalities.

Conclusions: Relative to the STS-CHSD, up to 16% of hospitals changed performance categories, most improving performance. Given the significance of quality reports for congenital heart centers, inclusion of additional risk factors and unaddressed variation should be considered.
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http://dx.doi.org/10.1016/j.athoracsur.2021.11.076DOI Listing
February 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
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