Publications by authors named "Joseph E Bavaria"

326 Publications

Effect of Aortic Valve Type on Patients Who Undergo Type A Aortic Dissection Repair.

Semin Thorac Cardiovasc Surg 2021 May 11. Epub 2021 May 11.

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

Aortic valve replacement (AVR) is common in the setting of type A aortic dissection (TAAD) repair. Here, we evaluated the association between prosthesis choice and patient outcomes in an international patient cohort. We reviewed data from the International Registry of Acute Aortic Dissection (IRAD) interventional cohort to examine the relationship between valve choice and short- and mid-term patient outcomes. Between January 1996 and March 2016, 1290 surgically treated patients with TAAD were entered into the IRAD interventional cohort. Of those, 364 patients undergoing TAAD repair underwent aortic valve replacement (AVR; mean age, 57 years). The mechanical valve cohort consisted of 189 patients, of which 151 (79.9%) had a root replacement. The nonmechanical valve cohort consisted of 5 patients who received homografts and 160 patients who received a biologic AVR, with a total of 118 (71.5%) patients who underwent root replacements. The mean follow-up time was 2.92 ± 1.75 years overall (2.46 ± 1.69 years for the mechanical valve cohort and 3.48 ± 1.8 years for the nonmechanical valve cohort). After propensity matching, Kaplan-Meier estimates of 4-year survival rates after surgery were 64.8% in the mechanical valve group compared with 74.7% in the nonmechanical valve group (p = 0.921). A stratified Cox model for 4-year mortality showed no difference in hazard between valve types after adjusting for the propensity score (p = 0.854). A biologic valve is a reasonable option in patients with TAAD who require AVR. Although this option avoids the potential risks of anticoagulation, long-term follow up is necessary to assess the effect of reoperations or transcatheter interventions for structural valve degeneration.
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http://dx.doi.org/10.1053/j.semtcvs.2021.04.003DOI Listing
May 2021

The impact of surgeon and hospital procedural volume on outcomes after aortic root replacement in the United States.

J Card Surg 2021 May 12. Epub 2021 May 12.

Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objective: Surgeon procedural volume for complex cardiac procedures have become important quality metrics. The objective is to determine the association of surgeon and hospital case volume on patient outcomes after an aortic root replacement for aortic root aneurysms.

Methods: From 2009 to 2014, 4629 Medicare patients underwent an aortic root replacement for a root aneurysm. Procedures were performed by 1276 surgeons at 718 hospitals. Patients with endocarditis, aortic rupture, or Type-A dissection were excluded. Procedural volume was defined as mean number of cases performed each year during the study period. The impact of hospital and surgeon volume on adjusted 30-day mortality was analyzed as a continuous variable using adjusted logistic regression with cubic splines.

Results: After an aortic root replacement, we observed a nonlinear reduction in the adjusted odds ratio for 30-day mortality as surgeon and hospital volume increased. Surgeons that performed approximately five cases/year and hospitals that completed approximately five cases/year had the greatest reduction in the odds of perioperative death. Patients treated at high-volume hospitals (≥4.5 cases/year) had a lower risk for 30-day postoperative stroke (hazard ratio [HR] = 0.51, p = .008), myocardial infarction (HR = 0.49, p = .016), hemodialysis (HR = 0.44, p = .005), and reoperation (HR = 0.48, p = .003). Additionally, patients treated with high-volume surgeons (≥9 cases/year) had lower risk for stroke (HR = 0.65, p = .005), hemodialysis (HR = 0.65, p = .03), sepsis (HR = 0.62, p = .03), and reoperation (HR = 0.67, p = .004).

Conclusion: Among Medicare patients undergoing an aortic root replacement, there is a strong inverse relationship between annualized surgeon and hospital case volume and postoperative outcomes. Procedural volume is an important quality metric for this high-risk procedure.
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http://dx.doi.org/10.1111/jocs.15620DOI Listing
May 2021

A Composite Metric for Benchmarking Site Performance in TAVR: Results from the STS/ACC TVT Registry.

Circulation 2021 May 5. Epub 2021 May 5.

Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, PA.

Transcatheter aortic valve replacement (TAVR) is a transformative therapy for aortic stenosis. Despite rapid improvements in technology and techniques, serious complications remain relatively common and are not well described by single outcome measures. The purpose of this study was to determine if there is site-level variation in TAVR outcomes in the United States using a novel 30-day composite measure. We performed a retrospective cohort study using data from the STS/ACC TVT Registry to develop a novel ranked composite performance measure that incorporates mortality and serious complications. The selection and rank order of the complications for the composite was determined by their adjusted association with 1-year outcomes. Sites whose risk-adjusted outcomes were significantly more or less frequent than the national average based on a 95% probability interval were classified as performing worse or better than expected. The development cohort consisted of 52,561 patients who underwent TAVR between January 1, 2015 and December 31, 2017. Based on the associations with 1-year risk-adjusted mortality and health status, we identified four periprocedural complications to include in the composite risk model in addition to mortality. Ranked empirically according to severity, these included stroke, major, life-threatening or disabling bleeding, stage III acute kidney injury, and moderate or severe peri-valvular regurgitation. Based on these ranked outcomes, we found that there was significant site-level variation in quality of care in TAVR in the United States. Overall, better than expected site performance was observed in 25/301 (8%) of sites; performance as expected was observed in 242/301 sites (80%); and worse than expected performance was observed in 34/301 (11%) of sites. Thirty-day mortality, stroke, major, life-threatening or disabling bleeding, and moderate or severe peri-valvular leak were each substantially more common in sites with worse than expected performance as compared with other sites. There was good aggregate reliability of the model. There are substantial variations in the quality of TAVR care received in the United States, and 11% of sites were identified as providing care below the average level of performance. Further study is necessary to determine structural, process-related, and technical factors associated with high- and low-performing sites.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.051456DOI Listing
May 2021

Evaluation of the Gore TAG thoracic branch endoprosthesis in the treatment of proximal descending thoracic aortic aneurysms.

J Vasc Surg 2021 Apr 30. Epub 2021 Apr 30.

Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.

Background: Thoracic endovascular aortic repair has radically transformed the treatment of descending thoracic aortic aneurysms. However, when aneurysms involve the aortic arch in the region of the left subclavian artery, branch vessel preservation must be considered. Branched aortic endografts have provided a new option to maintain branch patency.

Methods: Six investigative sites enrolled 31 patients in a nonrandomized, prospective investigational device exemption feasibility trial of a single branched aortic endograft for the management of aneurysms that include the distal aortic arch. The Gore TAG thoracic branch endoprosthesis (W. L. Gore & Associates, Inc, Flagstaff, Ariz), an investigational device, allows for graft placement proximal to the left subclavian artery and incorporates a single side branch for left subclavian perfusion.

Results: All 31 patients (100%) had undergone successful implantation of the investigational device in landing zone 2. Men slightly outnumbered women (51.6%). Their average age was 74.1 ± 10.4 years. The aneurysm morphology was fusiform in 12 and saccular in 19 patients, with a mean maximum aortic diameter of 54.8 ± 10.9 mm. The mean follow-up period for the cohort was 25.2 ± 11.1 months. We have reported the patient outcomes at 1 month and 1 year. At 1 month, the side branch patency was 100% and the freedom from core laboratory-reported device-related endoleak (types I and III) was 96.7%, without 30-day death or permanent paraplegia. One patient experienced a procedure-related stroke. Through 1 year, five patients had died; none of the deaths were related to the device or procedure (clinical endpoint committee adjudicated). One thoracic reintervention was required. No conversions were required, and no aneurysm growth (core laboratory) was reported. One case of the loss of side branch patency was diagnosed in the left subclavian artery in an asymptomatic individual from computed tomography at 6 months, with no reported subsequent adverse events due to loss of patency. Endoleaks were reported by the core laboratory in five patients at 12 months (two, type II; and three, indeterminate).

Conclusions: The present investigational device exemption feasibility study has reported the preliminary results of the use of a single side branch endograft to treat patients with proximal descending thoracic aortic aneurysms.
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http://dx.doi.org/10.1016/j.jvs.2021.04.025DOI Listing
April 2021

First-in Human Implantation of a Novel Biologic Valved Conduit for Aortic Root Replacement.

Ann Thorac Surg 2021 Apr 8. Epub 2021 Apr 8.

Division of Cardiac Surgery, University of Pennsylvania School of Medicine, Philadelphia Pennsylvania 19104. Electronic address:

Aortic root replacement is a complex procedure. Recently, the Konect Resilia aortic valved conduit® (Edwards Lifesciences), the first prefabricated biologic valved conduit available in the United States of America, was approved for use. Here we report the initial series of three patients representing the first-in-human implantation of the novel Konect biobentall. The conduit was implanted in both supra-annular and intra-annular positions, and the unique design of the sewing ring offers several advantages. The Konect biobentall streamlines the process of root replacement and may represent an improvement in terms of ease-of-implantation and durability.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.087DOI Listing
April 2021

Long-term outcomes of aortic root operations in the United States among Medicare beneficiaries.

J Thorac Cardiovasc Surg 2021 Feb 25. Epub 2021 Feb 25.

Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC. Electronic address:

Objective: The best method of aortic root repair in older patients remains unknown given a lack of comparative effectiveness of long-term outcomes data. The objective of this study was to compare long-term outcomes of different surgical approaches for aortic root repair in Medicare patients using The Society of Thoracic Surgeons Adult Cardiac Surgery Database-Centers for Medicare & Medicaid Services-linked data.

Methods: A retrospective cohort study was performed by querying the Society of Thoracic Surgeons Adult Cardiac Surgery Database for patients aged 65 years or more who underwent elective aortic root repair with or without aortic valve replacement. Primary long-term end points were mortality, any stroke, and aortic valve reintervention. Short-term outcomes and long-term survival were compared among each root repair strategy. Additional risk factors for mortality after aortic root repair were assessed with a multivariable Cox proportional hazards model.

Results: A total of 4173 patients aged 65 years or more underwent elective aortic root repair. Patients were stratified by operative strategy: mechanical Bentall, stented bioprosthetic Bentall, stentless bioprosthetic Bentall, or valve-sparing root replacement. Mean follow-up was 5.0 (±4.6) years. Relative to mechanical Bentall, stented bioprosthetic Bentall (adjusted hazard ratio, 0.80; confidence interval, 0.66-0.97) and stentless bioprosthetic Bentall (adjusted hazard ratio, 0.70; confidence interval, 0.59-0.84) were associated with better long-term survival. In addition, stentless bioprosthetic Bentall (adjusted hazard ratio, 0.64; confidence interval, 0.47-0.80) and valve-sparing root replacement (adjusted hazard ratio, 0.51; confidence interval, 0.29-0.90) were associated with lower long-term risk of stroke. Aortic valve reintervention risk was 2-fold higher after valve-sparing root replacement compared with other operative strategies.

Conclusions: In the Medicare population, there was poorer late survival and greater late stroke risk for patients undergoing mechanical Bentall and a higher rate of reintervention for valve-sparing root replacement. Bioprosthetic Bentall may be the procedure of choice in older patients undergoing aortic root repair, particularly in the era of transcatheter aortic valve replacement.
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http://dx.doi.org/10.1016/j.jtcvs.2021.02.068DOI Listing
February 2021

Moderate vs Deep Hypothermia in Type A Acute Aortic Dissection Repair: Insights from IRAD.

Ann Thorac Surg 2021 Jan 27. Epub 2021 Jan 27.

Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA.

Background: The optimal strategy for cerebral protection during repair of type A acute aortic dissection (TAAAD) has yet to be determined. We sought to determine the impact of differing degrees of hypothermia in patients undergoing acute dissection repair.

Methods: All patients in the International Registry of Acute Aortic Dissection Interventional Cohort (IRAD-IVC) database who underwent TAAAD repair between 2010 and 2018 were identified. Data for operative temperature was available in 1962 patients, subsequently divided into 2 groups according to lowest temperature: moderate hypothermic circulatory arrest (MHCA) (20 - 28°C) vs. deep hypothermic circulatory arrest (DHCA) (< 20°C). We then propensity-matched 362 pairs of patients and analyzed operative data and short-term outcomes.

Results: The median lowest temperature was 25.0°C in the matched MHCA group, as compared with 18.0°C in DHCA. For the entire cohort of 1962 patients, in-hospital mortality was 14.2% (278 deaths), not significantly different between DHCA and MHCA. Perioperative stroke rate was comparable between groups, before and after propensity-matching. Circulatory arrest times were significantly longer in the MHCA cohort, regardless of matching. Use of antegrade or retrograde cerebral perfusion was similar in matched groups. There were no differences in 30-day survival, or in other major postoperative morbidity between the two matched cohorts.

Conclusions: A surgical strategy of MHCA + ACP is at least as safe as DHCA during repair of acute type A aortic dissection.
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http://dx.doi.org/10.1016/j.athoracsur.2021.01.027DOI Listing
January 2021

STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement.

Ann Thorac Surg 2021 Feb 16;111(2):701-722. Epub 2020 Nov 16.

Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.

The STS-ACC TVT Registry (Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry) from 2011 to 2019 has collected data on 276,316 patients undergoing transcatheter aortic valve replacement (TAVR) at sites in all U.S. states. Volumes have increased every year, exceeding surgical aortic valve replacement in 2019 (72,991 vs. 57,626), and it is now performed in all U.S. states. TAVR now extends from extreme- to low-risk patients. This is the first presentation on 8,395 low-risk patients treated in 2019. In 2019, for the entire cohort, femoral access increased to 95.3%, hospital stay was 2 days, and 90.3% were discharged home. Since 2011, the 30-day mortality rate has decreased (7.2% to 2.5%), stroke has started to decrease (2.75% to 2.3%), but pacemaker need is unchanged (10.9% to 10.8%). Alive with acceptable patient-reported outcomes is achieved in 8 of 10 patients at 1 year. The Registry is a national resource to improve care and analyze TAVR's evolution. Real-world outcomes, site performance, and the impact of coronavirus disease 2019 will be subsequently studied. (STS/ACC Transcatheter Valve Therapy Registry [TVT Registry]; NCT01737528).
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.002DOI Listing
February 2021

RESPONSE: It Is Time.

Authors:
Joseph E Bavaria

J Am Coll Cardiol 2020 11;76(21):2568

Penn Medicine, Surgical Director, Heart and Vascular Center, Vice-Chief, Division of Cardiovascular Surgery, Philadelphia, Pennsylvania. Electronic address:

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http://dx.doi.org/10.1016/j.jacc.2020.10.016DOI Listing
November 2020

STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement.

J Am Coll Cardiol 2020 11;76(21):2492-2516

Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.

The STS-ACC TVT Registry (Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry) from 2011 to 2019 has collected data on 276,316 patients undergoing transcatheter aortic valve replacement (TAVR) at sites in all U.S. states. Volumes have increased every year, exceeding surgical aortic valve replacement in 2019 (72,991 vs. 57,626), and it is now performed in all U.S. states. TAVR now extends from extreme- to low-risk patients. This is the first presentation on 8,395 low-risk patients treated in 2019. In 2019, for the entire cohort, femoral access increased to 95.3%, hospital stay was 2 days, and 90.3% were discharged home. Since 2011, the 30-day mortality rate has decreased (7.2% to 2.5%), stroke has started to decrease (2.75% to 2.3%), but pacemaker need is unchanged (10.9% to 10.8%). Alive with acceptable patient-reported outcomes is achieved in 8 of 10 patients at 1 year. The Registry is a national resource to improve care and analyze TAVR's evolution. Real-world outcomes, site performance, and the impact of coronavirus disease 2019 will be subsequently studied. (STS/ACC Transcatheter Valve Therapy Registry [TVT Registry]; NCT01737528).
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http://dx.doi.org/10.1016/j.jacc.2020.09.595DOI Listing
November 2020

Common carotid artery true lumen flow impairment in patients with type A aortic dissection.

Eur J Cardiothorac Surg 2020 Nov 3. Epub 2020 Nov 3.

Department of Cardiovascular Surgery, Jichi Medical University, Saitama Medical Centre, Saitama, Japan.

Objectives: Our aim was to evaluate clinical and neurological effects of common carotid artery (CCA) true lumen flow impairment or occlusion in patients with type A aortic dissection.

Methods: Characteristics and imaging data of patients with dissected CCA secondary to acute type A aortic dissection from 3 institutions were analysed. We defined true lumen blood flow as unimpaired when the maximum true lumen diameter exceeded 50% of the complete CCA diameter, as impaired when the true lumen was compressed to ˃50% of the complete lumen, or as occluded.

Results: Out of 440 patients, 207 presented unimpaired CCA flow, 172 impaired CCA flow and CCA occlusion was present in 61 patients. Preoperative shock (P = 0.045) or a neurological deficit (P < 0.001) were least common in patients with unimpaired CCA flow and most common in those with CCA occlusion. Non-cerebral, other-organ malperfusion was common in 37% of all patients, but the incidence was similar (P = 0.69). In patients with CCA occlusion, postoperative stroke (P < 0.001) and in-hospital mortality (0.011) were significantly higher, while the incidences were similar between patients with unimpaired and impaired CCA flow. Mixed-effects logistic regression models showed that CCA flow impairment (P = 0.23) or occlusion (P = 0.55) was not predictive for in-hospital mortality, but CCA occlusion was predictive for in-hospital stroke (odds ratio 2.166, P = 0.023).

Conclusions: Shock and non-cerebral, other-organ malperfusion are common in patients with CCA dissection. While there is a high risk for stroke in patients with CCA occlusion, CCA flow impairment and occlusion were not predictive for in-hospital mortality. Surgery should not be denied to patients with CCA flow impairment or occlusion.
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http://dx.doi.org/10.1093/ejcts/ezaa322DOI Listing
November 2020

Evolving Treatment Strategies for Arch Pathologies.

Innovations (Phila) 2020 Nov/Dec;15(6):521-524. Epub 2020 Nov 3.

1464021798 Division of Cardiac Surgery, University of Pennsylvania School of Medicine, PA, USA.

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http://dx.doi.org/10.1177/1556984520969756DOI Listing
November 2020

Dynamic volumetric assessment of the aortic root: The influence of bicuspid aortic valve competence.

Ann Thorac Surg 2020 Sep 25. Epub 2020 Sep 25.

Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA.

Background: Aortic root evaluation is conventionally based on two-dimensional measurements at a single phase of the cardiac cycle. This work presents an image analysis method for assessing dynamic three-dimensional changes in the aortic root of minimally calcified bicuspid aortic valves (BAVs) with and without moderate to severe aortic regurgitation.

Methods: The aortic root was segmented over the full cardiac cycle in three-dimensional transesophageal echocardiographic images acquired from 19 patients with minimally calcified BAVs and from 16 patients with physiologically normal tricuspid aortic valves (TAVs). The size and dynamics of the aortic root were assessed using the following image-derived measurements: absolute mean root volume and mean area at the level of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction, as well as normalized root volume change and normalized area change of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction over the cardiac cycle.

Results: Normalized volume change over the cardiac cycle was significantly greater in BAV roots with moderate to severe regurgitation than in normal TAV roots and in BAV roots with no or mild regurgitation. Aortic root dynamics were most significantly different at the mid-level of the sinuses of Valsalva in BAVs with moderate to severe regurgitation than in competent TAVs and BAVs.

Conclusions: Echocardiographic reconstruction of the aortic root demonstrates significant differences in dynamics of BAV roots with moderate to severe regurgitation relative to physiologically normal TAVs and competent BAVs. This finding may have implications for risk of future dilatation, dissection, or rupture, which warrant further investigation.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990744PMC
September 2020

A biological approach to aortic valve disease: durability and survival.

Nat Rev Cardiol 2020 Dec;17(12):754-756

Department of Cardiovascular Surgery, Mount Sinai Hospital, New York City, NY, USA.

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http://dx.doi.org/10.1038/s41569-020-00446-8DOI Listing
December 2020

Glycation and Serum Albumin Infiltration Contribute to the Structural Degeneration of Bioprosthetic Heart Valves.

JACC Basic Transl Sci 2020 Aug 5;5(8):755-766. Epub 2020 Aug 5.

Department of Surgery, Columbia University, New York, New York.

Valvular heart diseases are associated with significant cardiovascular morbidity and mortality, and often require surgical and/or percutaneous repair or replacement. Valve replacement is limited to mechanical and biological prostheses, the latter of which circumvent the need for lifelong anticoagulation but are subject to structural valve degeneration (SVD) and failure. Although calcification is heavily studied, noncalcific SVD, which represent roughly 30% of BHV failures, is relatively underinvestigated. This original work establishes 2 novel and interacting mechanisms-glycation and serum albumin incorporation-that occur in clinical valves and are sufficient to induce hallmarks of structural degeneration as well as functional deterioration.
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http://dx.doi.org/10.1016/j.jacbts.2020.06.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452200PMC
August 2020

Five-year outcomes of endovascular repair of complicated acute type B aortic dissections.

J Thorac Cardiovasc Surg 2020 May 13. Epub 2020 May 13.

Department of Vascular Surgery, Long Beach Memorial Heart and Vascular Institute, Long Beach, Calif.

Objective: Thoracic endovascular aortic repair is the standard of care for acute complicated type B aortic dissections, but long-term single-device outcomes are limited.

Methods: Fifty patients were treated with the Valiant Captivia thoracic stent graft (Medtronic Inc, Santa Rosa, Calif) for acute complicated type B aortic dissections in this prospective, nonrandomized Dissection Trial. All-cause mortality, secondary procedures, and serious adverse events were assessed, and a core lab evaluated images for aortic remodeling.

Results: Compliance for both clinical and imaging follow-up was 78% (18 out of 23) for the available patients at 5 years. Notable baseline characteristics were 86% of patients (43 out of 50) had malperfusion, 20% (10 out of 50) had ruptures, and 94% (46 out of 49) had DeBakey class IIIB dissections. The 5-year freedom from dissection-related mortality, secondary procedures related to the dissection, and endoleaks was 83%, 86%, and 85%, respectively. After 5 years, 89% of patients (16 out of 18) had a completely thrombosed false lumen in the stented segment of the aorta and the true lumen diameter over the length of stent graft was stable or increased for 94% of patients (16 out of 17) while the false lumen diameter was stable or decreased in 77% (13 out of 17) after 5 years.

Conclusions: In the Dissection Trial, patients experienced positive and sustained measures of aortic remodeling. Survival outcomes, need for secondary procedures, and adverse event rates were consistent with previous thoracic endovascular aortic repair studies. Although limitations exist with the follow-up compliance, the Valiant Captivia thoracic stent graft system was effective in the long-term management of acute complicated type B aortic dissections in this patient population with a challenging condition.
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http://dx.doi.org/10.1016/j.jtcvs.2020.03.162DOI Listing
May 2020

Recurrent aortic insufficiency after emergency surgery for acute type A aortic dissection with aortic root preservation.

J Thorac Cardiovasc Surg 2021 Jun 18;161(6):1989-2000.e6. Epub 2020 Apr 18.

Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn. Electronic address:

Objective: Patients with acute type A aortic dissection demonstrate a wide range of aortic insufficiency. Outcomes after valve resuspension and root repair are not well studied in the long term. We evaluated the long-term effects of preoperative aortic insufficiency in patients undergoing emergency root-preserving surgery for acute type A aortic dissection.

Methods: From 2002 to 2017, 558 of 776 patients with acute type A aortic dissection underwent native aortic valve resuspension and root reconstruction. Patients were stratified into 4 groups by preoperative aortic insufficiency grade (n = 539): aortic insufficiency less than 2+ (n = 348), aortic insufficiency = 2+ (n = 72), aortic insufficiency = 3+ (n = 49), and aortic insufficiency = 4+ (n = 70). Multivariable ordinal longitudinal mixed effects and multi-state transition models were used to assess risk factors for recurrent aortic insufficiency.

Results: The prevalence of cardiogenic shock in patients presenting with preoperative aortic insufficiency less than 2+, 2+, 3+, and 4+ was 53 of 348 (15.2%), 12 of 72 (16.7%), 10 of 49 (20.4%), and 24 of 70 (34.3%), respectively (P = .002). Postoperatively, 94.0% of patients had aortic insufficiency 1+ or less at discharge. Operative mortality was 34 of 348 (9.8%), 10 of 72 (13.9%), 6 of 49 (12.2%), and 12 of 70 (17.1%) (P = .303). In an ordinal mixed effects model, preoperative aortic insufficiency was associated with more severe postoperative aortic insufficiency. The multi-state transition model demonstrated that severe aortic insufficiency was associated with progression from no to mild aortic insufficiency (hazard ratio, 2.14; 95% confidence interval, 1.35-3.38), and progression from mild to moderate aortic insufficiency (hazard ratio, 5.70; 95% confidence interval, 1.88-17.30).

Conclusions: Preoperative aortic insufficiency is an important predictor of recurrent aortic insufficiency in patients undergoing valve resuspension with root reconstruction for emergency acute type A aortic dissection repair. Increased echocardiographic surveillance for recurrent aortic insufficiency may be warranted in this cohort.
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http://dx.doi.org/10.1016/j.jtcvs.2020.01.116DOI Listing
June 2021

Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians.

J Thorac Cardiovasc Surg 2020 May 4. Epub 2020 May 4.

Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn. Electronic address:

Objective: The incidence of elderly patients with acute type A aortic dissection is increasing. A recent analysis of the International Registry of Acute Aortic Dissection failed to show a mortality benefit with surgery compared with medical management in octogenarians. Therefore, we compared our institutional outcomes of emergency surgery for acute type A aortic dissection in octogenarians versus septuagenarians to understand the outcomes of surgical intervention in elderly patients.

Methods: From 2002 to 2017, 70 octogenarians (aged ≥80 years) and 165 septuagenarians (70-79 years) underwent surgery for acute type A aortic dissection (N = 235, total). Quality of life was assessed by the RAND Short Form-36 quality of life survey. Midterm clinical and functional data were obtained retrospectively.

Results: At baseline, septuagenarians had a higher prevalence of diabetes (20.6% vs 5.7%, P = .01). The prevalence of cardiopulmonary resuscitation was 4.8% versus 10.0% (P = .24) in septuagenarians and octogenarians. The prevalence of cardiogenic shock was 18.2% versus 27.1% (P = .17). Thirty-day/in-hospital mortality was 21.2% versus 28.6% (P = .29). Multivariable logistic regression identified cardiogenic shock as an independent risk factor for in-hospital mortality (odds ratio, 10.07; 95% confidence interval, 2.30-44.03) in octogenarians. Survival at 5 years was 49.7% (42.1%-58.6%) versus 34.2% (23.9%-48.8%) in septuagenarians and octogenarians, respectively. Responses to the quality of life survey were no different between septuagenarians and octogenarians across all 8 quality of life categories.

Conclusions: Clinical outcomes after surgery for acute type A aortic dissection are similar in octogenarians and septuagenarians. For discharged survivors, quality of life remains favorable and does not differ between the 2 groups.
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http://dx.doi.org/10.1016/j.jtcvs.2020.03.157DOI Listing
May 2020

Midterm outcomes and durability of sinus segment preservation compared with root replacement for acute type A aortic dissection.

J Thorac Cardiovasc Surg 2020 May 4. Epub 2020 May 4.

Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Conn. Electronic address:

Objective: The durability of root repair for acute type A aortic dissection is not well studied in the context of aortic insufficiency and stability of the sinuses of Valsalva. We compared clinical and functional outcomes in patients undergoing root repair and replacement for acute type A aortic dissection.

Methods: Of 716 patients undergoing surgery for acute type A aortic dissection, 585 (81.7%) underwent root repair and 131 (18.3%) underwent root replacement. Survival, cumulative incidence of reoperation, aortic insufficiency, and sinuses of Valsalva dilation were compared between the 2 groups.

Results: Survival at 1, 5, and 10 years was 84.1% versus 77.3%, 70.8% versus 69.2%, 57.6% versus 58.0% in the root repair and replacement groups, respectively (P = .69). Cumulative incidence of reoperation at 1, 5, and 10 years was 0.0% versus 0.8%, 1.4% versus 3.8%, and 3.4% versus 8.6% in the root repair and root replacement groups, respectively (P = .011). Multivariable Cox regression identified sinuses of Valsalva diameter 45 mm or more as a risk factor for proximal aortic reoperation (hazard ratio, 9.06; 95% confidence interval, 1.26-65.24). In a repeated-measures, linear, mixed-effects model, root replacement was associated with smaller follow-up of sinuses of Valsalva dimensions (β = -0.66, P < .001). In an ordinal longitudinal mixed model, root replacement was associated with lower severity of postoperative aortic insufficiency (β = -3.10, P < .001).

Conclusions: Survival is similar, but the incidence of aortic insufficiency and root dilation may be greater after root repair compared with root replacement for acute type A aortic dissection.
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http://dx.doi.org/10.1016/j.jtcvs.2020.04.064DOI Listing
May 2020

Distal repair after frozen elephant trunk: open or endovascular?

Ann Cardiothorac Surg 2020 May;9(3):226-227

Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.21037/acs-2020-fet-26DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7298251PMC
May 2020

State-of-the art bicuspid aortic valve repair in 2020.

Prog Cardiovasc Dis 2020 Jul - Aug;63(4):457-464. Epub 2020 May 5.

Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany. Electronic address:

Patients with a bicuspid aortic valve (BAV) frequently require surgical intervention for aortic regurgitation (AR) and/or aneurysm. Valve-preserving surgery and repair of regurgitant BAVs have evolved into an increasingly used alternative to replacement. Anatomic predictors of possible repair failures have been identified and solutions developed. Using current techniques most non-calcified BAVs can be preserved or repaired. Excellent repair durability and freedom from valve-related complications can be achieved if all pathologic components of aortic valve and root including annular dilatation are corrected. Anatomic variations must be addressed using tailored approaches.
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http://dx.doi.org/10.1016/j.pcad.2020.04.010DOI Listing
October 2020

Intermediate-term outcomes of aortic valve replacement using a bioprosthesis with a novel tissue.

J Thorac Cardiovasc Surg 2020 Feb 21. Epub 2020 Feb 21.

Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Objectives: The COMMENCE trial was conducted to evaluate the safety and effectiveness of an aortic bioprosthesis with novel RESILIA tissue (Edwards Lifesciences, Irvine, Calif). Reports of early noncalcific valve failure resulting from thrombosis or leaflet tears in other valves warrant careful evaluation of early valve performance.

Methods: Patients underwent clinically indicated surgical aortic valve replacement with the Edwards Pericardial Aortic Bioprosthesis, Model 11000A (Edwards Lifesciences) in a prospective, multinational, multicenter (n = 27), single-arm, Food and Drug Administration Investigational Device Exemption trial. Events were adjudicated by an independent clinical events committee; echocardiograms were analyzed by an independent core laboratory.

Results: Between January 2013 and March 2016, 689 patients received the study valve. Mean age was 67.0 ± 11.6 years. Mean Society of Thoracic Surgeons predicted risk of mortality was 2.0% ± 1.8%. Follow-up duration was 3.7 ± 1.2 years, with a total of 2533 patient years of follow-up and a median follow-up of 4 years. Early all-cause mortality was 1.2%, thromboembolism 2.3%, all bleeding 1.0%, and major paravalvular leak 0.1%. One- and 4-year actuarial freedom from all-cause mortality was 97.7% (95% confidence interval, 96.5%-98.8%) and 91.9% (95% confidence interval, 89.7%-94.1%), respectively. At 4 years, New York Heart Association functional class improved compared with baseline in 63.0%, effective orifice area was 1.5 ± 0.5 cm, and mean gradient was 11.0 ± 5.6 mm Hg. Freedom from moderate or greater transvalvular insufficiency was 99.7%. There were no events of structural valve deterioration.

Conclusions: Safety and hemodynamic performance of this aortic bioprosthesis with RESILIA tissue at 4 years are favorable. This novel tissue does not appear to result in unexpected early thrombosis events or noncalcific structural valve deterioration.
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http://dx.doi.org/10.1016/j.jtcvs.2020.01.095DOI Listing
February 2020

Letter by Stetson et al Regarding Article, "Episode Payments for Transcatheter and Surgical Aortic Valve Replacement".

Circ Cardiovasc Qual Outcomes 2020 04 14;13(4):e006493. Epub 2020 Apr 14.

Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA (J.E.B.).

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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.006493DOI Listing
April 2020

Fate of the Preserved Sinuses of Valsalva After Emergency Repair for Acute Type A Aortic Dissection.

Ann Thorac Surg 2020 11 7;110(5):1476-1483. Epub 2020 Mar 7.

Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut. Electronic address:

Background: Patients with acute type A aortic dissection (ATAAD) present with heterogeneous involvement of the aortic root complex. Despite this variation, the aortic root can usually be preserved the majority of the time by Teflon (WL Gore, Newark, DE) inlay patch reconstruction of the dissected sinuses of Valsalva (SOV). In this study, we report the long term anatomic, functional, and clinical outcomes associated with the preserved SOV after surgery for ATAAD.

Methods: From 2002-2017, of 776 emergency ATAAD operations at a single institution, 558 (71.9%) underwent valve resuspension with SOV preservation. Echocardiography reports were reviewed to obtain postoperative SOV dimensions. Cumulative incidence of SOV dilation ≥ 4 5mm was calculated using the Fine-Gray method with death as a competing risk. Repeated-measures linear mixed effects model was used to determine risk factors for SOV growth over time.

Results: During the follow-up period, 62 of 558 (11.1%) patients developed SOV diameter ≥ 45 mm. Cumulative incidence of SOV dilation ≥ 45 mm at 1, 5, and 10 years was 5.5%, 12.4%, and 18.9% respectively. In a multivariable Cox regression model, preoperative SOV diameter ≥ 45 mm was associated with a hazard ratio of 14.11 (95% confidence interval 7.03-31.62) for postoperative SOV dilation ≥ 45 mm. In a repeated-measures linear mixed effects model, preoperative and discharge SOV diameter were significant predictors of SOV dilation. Postoperative time course was also identified as significant indicating growth over time.

Conclusions: The preserved sinuses of Valsalva after surgery for ATAAD may be prone to progressive dilatation over time. Closer echocardiographic surveillance may be warranted in these patients.
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http://dx.doi.org/10.1016/j.athoracsur.2020.01.083DOI Listing
November 2020

2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Report of the American College of Cardiology Solution Set Oversight Committee.

J Am Coll Cardiol 2020 05 14;75(17):2236-2270. Epub 2020 Feb 14.

Mitral regurgitation (MR) is a complex valve lesion that can pose significant management challenges. This expert consensus decision pathway emphasizes that recognition of MR should prompt an assessment of its etiology, mechanism, and severity, as well as consideration of the indications for treatment. The document is a focused update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation, with some sections updated and others added in light of the publication of new trial data related to secondary MR, among other developments. A structured approach to evaluation based on clinical findings, accurate echocardiographic imaging, and, when necessary, adjunctive testing can help clarify decision making. Treatment goals include timely intervention by an experienced multidisciplinary heart team to prevent left ventricular dysfunction, heart failure, reduced quality of life, and premature death.
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http://dx.doi.org/10.1016/j.jacc.2020.02.005DOI Listing
May 2020

Thoracic Endovascular Aneurysm Repair Trends and Outcomes in Over 27,000 Medicare Patients for Descending Thoracic Aneurysms.

Ann Thorac Surg 2020 06 6;109(6):1757-1764. Epub 2020 Feb 6.

Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Background: Since United States Food and Drug Administration approval in 2005, thoracic endovascular aneurysm repair (TEVAR) has replaced open surgery to become the preferred treatment for descending thoracic aneurysms (DTAs). This study investigated TEVAR trends during the previous 15 years regarding patient and hospital characteristics and their effect on survival.

Methods: Between 2000 and 2014, 27,079 Medicare patients underwent TEVAR for DTA. We analyzed TEVAR trends during this period and stratified hospitals based on the number of cases completed during the previous 5 years: low (0-19 cases), medium (20-99 cases), and high (≥100 cases) volume. Trends over time were calculated using Poisson regression to determine the average annual percentage changes (aAPC). Survival was calculated using a multivariate Cox regression and adjusted logistic regression with a restricted cubic spline.

Results: TEVAR volume significantly increased from 81 cases in 2000 to 3478 cases in 2014 (aAPC, 16.2%; P < .001). During the study period, the proportion of cases performed at medium-volume centers increased (aAPC, 5.2%; P < .001). Thirty-day mortality after TEVAR increased in the recent period (2013-2014) to 8.8% as compared with 6.6% in the early years (2004-2006) of TEVAR (P < .001), and a significant contribution was due to increased patient comorbidity score (aAPC, 1.6%; P < .001). Lastly, TEVAR center volume was significantly associated with 30-day survival when fewer than 33 cases were done in the prior 5 years.

Conclusions: From 2000 to 2014, TEVAR volume accelerated, and centers are gaining more experience. TEVAR patients have become more acute, and mortality has increased over this period. Patient selection and procedural experience are critical to improving outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2019.12.054DOI Listing
June 2020

Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.

J Vasc Surg 2020 03 27;71(3):723-747. Epub 2020 Jan 27.

Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.

This Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) document illustrates and defines the overall nomenclature associated with type B aortic dissection. The contents describe a new classification system for practical use and reporting that includes the aortic arch. Chronicity of aortic dissection is also defined along with nomenclature in patients with prior aortic repair and other aortic pathologic processes, such as intramural hematoma and penetrating atherosclerotic ulcer. Complicated vs uncomplicated dissections are clearly defined with a new high-risk grouping that will undoubtedly grow in reporting and controversy. Follow-up criteria are also discussed with nomenclature for false lumen status in addition to measurement criteria and definitions of aortic remodeling. Overall, the document provides a facile framework of language that will allow more granular discussions and reporting of aortic dissection in the future.
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http://dx.doi.org/10.1016/j.jvs.2019.11.013DOI Listing
March 2020