Publications by authors named "Michael A Acker"

172 Publications

The Surgeon's Role in Cardiogenic Shock.

Curr Heart Fail Rep 2021 Aug 6;18(4):240-251. Epub 2021 May 6.

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

Purpose Of Review: Cardiogenic shock represents a very challenging patient population due to the undifferentiated pathologies presenting as cardiogenic shock, difficult decision-making, prognostication, and ever-expanding support options. The role of cardiac surgeons on this team is evolving.

Recent Findings: The implementation of a shock team is associated with improved outcomes in patients with cardiogenic shock. Early deployment of mechanical circulatory support devices may allow an opportunity to rescue these patients. Cardiothoracic surgeons are a critical component of the shock team who can deploy timely mechanical support and surgical intervention in selected patients for optimal outcomes.
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http://dx.doi.org/10.1007/s11897-021-00514-1DOI Listing
August 2021

Clinical and echocardiographic results of AVR in the failing ventricle: do AS and AR differ?

Ann Thorac Surg 2021 Feb 22. Epub 2021 Feb 22.

The University of Pennsylvania, Philadelphia, PA, United States.

Background: We hypothesized that long-term clinical and echocardiographic recovery of the impaired ventricle from pressure (AS) and volume (AR) overload would be different following aortic valve replacement (AVR).

Methods: We compared the results of AVR in patients with a pre-operative ejection fraction (EF) of 0.35 or less due to AS, AR or mixed disease. We constructed a mixed-effects model of EF and left ventricular end diastolic diameter (LVEDD) to understand ventricular recovery over the short (in-hospital), intermediate (3-6 month) and longer (>24 months) terms. We sought to identify factors associated with clinical and echocardiographic recovery using multivariable analysis.

Results: Between July 2011 and 2017, 136 patients with pre-operative EF of 0.35 or less and severe AS (83), severe AR (18) or mixed AS and AR (35) underwent AVR. There were 2 early deaths in the AS group (1.5%). Survival at 1, 2 and 5 years did not differ between groups. Baseline EF did not differ between the groups but improved with markedly different trajectory and time course in AS, AR and mixed groups over time. LVEDD regressed in all patient cohorts, following a different pattern for AS and AR. Baseline EF and LVEDD predicted long term fate of the LV but did not determine survival. We identify factors associated with long term survival.

Conclusions: The pattern of LV recovery appears to be early in AS and delayed in AR. Baseline clinical factors, rather than echocardiographic status of the LV, appear to determine late survival.
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http://dx.doi.org/10.1016/j.athoracsur.2021.02.016DOI Listing
February 2021

Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation.

J Am Coll Cardiol 2021 02;77(6):713-724

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

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

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

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

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

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

Correlating oxygen delivery on cardiopulmonary bypass with Society of Thoracic Surgeons outcomes following cardiac surgery.

J Thorac Cardiovasc Surg 2020 Dec 19. Epub 2020 Dec 19.

Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.

Background: The relationship between low oxygen delivery (DO) on cardiopulmonary bypass and morbidity and mortality following cardiac surgery remains unexamined.

Methods: We reviewed patients undergoing Society of Thoracic Surgeons index procedures from March 2019 to July 2020, coincident with implementation of a new electronic perfusion record that provides for continuous recording of DO and flow parameters. Continuous perfusion variables were analyzed using area-over-the-curve (AOC) calculations below predefined thresholds (DO <280 mL O/min/m, cardiac index <2.2 L/min, hemoglobin < baseline, and mean arterial pressure <65 mm Hg) to quantify depth and duration of potentially harmful exposures. Multivariable logistic regression adjusted by Society of Thoracic Surgeons predicted-risk scores were used to assess for relationship of perfusion variables with the primary composite outcome of any Society of Thoracic Surgeons index procedure, as well as individual Society of Thoracic Surgeons secondary outcomes (eg, mortality, renal failure, prolonged ventilation >24 hours, stroke, sternal wound infection, and reoperation).

Results: Eight hundred thirty-four patients were included; 42.7% (356) underwent isolated coronary artery bypass grafting (CABG), whereas 57.3% underwent nonisolated CABG (eg, valvular or combined CABG/valvular operations). DO <280-AOC trended toward association with the primary outcome across all cases (P = .07), and was significantly associated for all nonisolated CABG cases (P = .02)-more strongly than for cardiac index <2.2-AOC (P = .04), hemoglobin <7-AOC (P = .51), or mean arterial pressure <65-AOC (P = .11). Considering all procedures, DO <280-AOC was independently associated prolonged ventilation >24 hours (P = .04), an effect again most pronounced in nonisolated-CABG cases (P = .002), as well as acute kidney injury <72 hours (P = .04). Patients with glomerular filtration rate <65 mL/min and baseline hemoglobin <12.5 g/dL appeared especially vulnerable.

Conclusions: Low DO on bypass may be associated with morbidity/mortality following cardiac surgery, particularly in patients undergoing nonisolated CABG. These results underscore the importance of goal-directed perfusion strategies.
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http://dx.doi.org/10.1016/j.jtcvs.2020.12.008DOI Listing
December 2020

Low Microcirculatory Perfused Vessel Density and High Heterogeneity are Associated With Increased Intensity and Duration of Lactic Acidosis After Cardiac Surgery with Cardiopulmonary Bypass.

Shock 2021 08;56(2):245-254

Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: Lactic acidosis after cardiac surgery with cardiopulmonary bypass is common and associated with an increase in postoperative morbidity and mortality. A number of potential causes for an elevated lactate after cardiopulmonary bypass include cellular hypoxia, impaired tissue perfusion, ischemic-reperfusion injury, aerobic glycolysis, catecholamine infusions, and systemic inflammatory response after exposure to the artificial cardiopulmonary bypass circuit. Our goal was to examine the relationship between early abnormalities in microcirculatory convective blood flow and diffusive capacity and lactate kinetics during early resuscitation in the intensive care unit. We hypothesized that patients with impaired microcirculation after cardiac surgery would have a more severe postoperative hyperlactatemia, represented by the lactate time-integral of an arterial blood lactate concentration greater than 2.0 mmol/L.

Methods: We measured sublingual microcirculation using incident darkfield video microscopy in 50 subjects on intensive care unit admission after cardiac surgery. Serial measurements of systemic hemodynamics, blood gas, lactate, and catecholamine infusions were recorded each hour for the first 6 h after surgery. Lactate area under the curve (AUC) was calculated over the first 6 h. The lactate AUC was compared between subjects with normal and low perfused vessel density (PVD < 18 mm/mm2), high microcirculatory heterogeneity index (MHI > 0.4), and low vessel-by-vessel microvascular flow index (MFIv < 2.6).

Results: Thirteen (26%) patients had a low postoperative PVD, 20 patients (40%) had a high MHI, and 26 (52%) patients had a low MFIv. Patients with low perfused vessel density had higher lactate AUC compared with subjects with a normal PVD (22.3 [9.4-31.0] vs. 2.6 [0-8.8]; P < 0.0001). Patients with high microcirculatory heterogeneity had a higher lactate AUC compared with those with a normal MHI (2.5 [0.1-8.2] vs. 13.1 [3.7-31.1]; P < 0.001). We did not find a difference in lactate AUC when comparing high and low MFIv.

Conclusion: Low perfused vessel density and high microcirculatory heterogeneity are associated with an increased intensity and duration of lactic acidosis after cardiac surgery with cardiopulmonary bypass.
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http://dx.doi.org/10.1097/SHK.0000000000001713DOI Listing
August 2021

Coronary Artery Bypass Grafting in Cardiogenic Shock: Decision-Making, Management Options, and Outcomes.

J Cardiothorac Vasc Anesth 2021 Jul 17;35(7):2144-2154. Epub 2020 Sep 17.

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

Coronary artery bypass grafting is a highly efficacious mode of myocardial revascularization that reduces mortality from ischemic heart disease. The patient presenting after acute myocardial infarction in cardiogenic shock presents a unique challenge. Early revascularization is proven to reduce mortality, but many questions remain, including the optimal mode and extent of revascularization, the role of mechanical circulatory support, and which patients are candidates for surgical intervention. Unprecedented attention to the outcomes of cardiac surgery means decisions about the management of the acute myocardial infarction in cardiogenic shock patients are influenced by risk aversion. The authors here review this topic to arm the reader with a comprehensive understanding of the literature to better guide surgical decision-making and perioperative management.
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http://dx.doi.org/10.1053/j.jvca.2020.09.108DOI Listing
July 2021

The effect of transfusion of blood products on ventricular assist device support outcomes.

ESC Heart Fail 2020 12 14;7(6):3573-3581. Epub 2020 Oct 14.

Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Aims: Perioperative blood transfusions are common among patients undergoing left ventricular assist device (LVAD) implantation. The association between blood product transfusion at the time of LVAD implantation and mortality has not been described.

Methods And Results: This was a retrospective cohort study of all patients who underwent continuous flow LVAD implantation at a single, large, tertiary care, academic centre, from 2008 to 2014. We assessed used of packed red blood cells (pRBCs), platelets, and fresh frozen plasma (FFP). Outcomes of interest included all-cause mortality and acute right ventricular (RV) failure. Standard regression techniques were used to examine the association between blood product exposure and outcomes of interest. A total of 170 patients were included in this study (mean age: 56.5 ± 15.5 years, 79.4% men). Over a median follow-up period of 11.2 months, for every unit of pRBC transfused, the hazard for mortality increased by 4% [hazard ratio (HR) 1.04; 95% CI 1.02-1.07] and odds for acute RV failure increased by 10% (odds ratio 1.10; 95% CI 1.05-1.16). This association persisted for other blood products including platelets (HR for mortality per unit 1.20; 95% CI 1.08-1.32) and FFP (HR for mortality per unit 1.08; 95% CI 1.04-1.12). The most significant predictor of perioperative blood product exposure was a lower pre-implant haemoglobin.

Conclusions: Perioperative blood transfusions among patients undergoing LVAD implantation were associated with a higher risk for all-cause mortality and acute RV failure. Of all blood products, FFP use was associated with worst outcomes. Future studies are needed to evaluate whether pre-implant interventions, such as intravenous iron supplementation, will improve the outcomes of LVAD candidates by decreasing need for transfusions.
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http://dx.doi.org/10.1002/ehf2.12780DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754735PMC
December 2020

Toward a Standard Practice to Quantify von Willebrand Factor Degradation During Left Ventricular Assist Device Support.

Ann Thorac Surg 2021 10 20;112(4):1257-1264. Epub 2020 Nov 20.

Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: Continuous-flow left ventricular assist devices (LVADs) cause degradation of von Willebrand factor (VWF) multimers and bleeding. Multiple techniques exist to characterize VWF deficiency. However, a standard methodology has not been established in LVAD patients. Toward this goal, we evaluated 4 methods to quantify VWF multimers.

Methods: We collected paired blood samples from patients (n = 48) before and after 1 week of LVAD support. After 652 ± 59 days of support, patients were classified as bleeders (≥1 bleeding episode) or nonbleeders. VWF multimers were resolved with electrophoresis and immunoblotting, the gold-standard to evaluate VWF multimers. We evaluated 4 quantification methods.

Results: Each method demonstrated significant VWF degradation during LVAD support vs a paired, pre-LVAD sample (method 1, VWF length: 48 of 48 patients, -10% ± 1%, P < .0001; method 2, VWF density: 40 of 48, -34% (interquartile range, -46% to -8%), P < .0001; method 3, pre-LVAD to LVAD ratio: 46 of 48, 17 ± 5: 10 ± 1, P < .0001; method 4, LVAD/pre-LVAD index: 46 of 48, 57% (interquartile range, 50% to 73%), P < .0001). Bleeding occurred in 27 of 48 patients. Method 1 demonstrated significantly fewer VWF multimers in bleeders compared with nonbleeders (-11% ± 1% vs -8% ± 1%; P = .01). Other methods did not demonstrate this potentially important clinical relationship.

Conclusions: A standardized methodology is needed to quantify VWF multimer degradation with mechanical circulatory support devices. Novel method 1 successfully quantified the patient-specific change in VWF multimer length during LVAD support and demonstrated a difference in VWF multimers between bleeders and nonbleeders. Adoption of consensus methodology will assist to standardize patient-specific bleeding risk, inform anticoagulation and antiplatelet therapy, and evaluate LVAD hemocompatibility.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.039DOI Listing
October 2021

Oral anticoagulant use in patients with atrial fibrillation and mitral valve repair.

Am Heart J 2021 02 24;232:1-9. Epub 2020 Oct 24.

Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, PA; Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA.

Background: Patients with atrial fibrillation (AF) who have undergone mitral valve repair are at risk for thromboembolic strokes. Prior to 2019, only vitamin K antagonists were recommended for patients with AF who had undergone mitral valve repair despite the introduction of direct oral anticoagulants (DOAC) in 2010.

Objective: To characterize the use of anticoagulants in patients with AF who underwent surgical mitral valve repair (sMVR) or transcatheter mitral valve repair (tMVR).

Methods: We performed a retrospective cohort analysis of patients with AF undergoing sMVR or tMVR between 04/2014 and 12/2018 using Optum's de-identified Clinformatics® Data Mart Database. We identified anticoagulants prescribed within 90 days of discharge from hospitalization.

Results: Overall, 1997 patients with AF underwent valve repair: 1560 underwent sMVR, and 437 underwent tMVR. The mean CHADS-VASc score among all patients was 4.1 (SD 1.9). The overall use of anticoagulation was unchanged between 2014 (72.2%) and 2018 (70.0%) (P = .49). Among patients who underwent sMVR or tMVR between April 2014 and December 2018, the use of VKA therapy decreased from 62.9% to 32.1% (P < .01 for trend) and the use of DOACs increased from 12.4% to 37.3% (P < .01 for trend).

Conclusions: Among patients with AF who underwent sMVR or tMVR between 2014 and 2018, roughly 30% of patients were not treated with any anticoagulant within 90 days of discharge, despite an elevated stroke risk in the cohort. The rate of DOAC use increased steadily over the study period but did not significantly increase the rate of overall anticoagulant use in this high-risk cohort.
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http://dx.doi.org/10.1016/j.ahj.2020.10.056DOI Listing
February 2021

Relationship of intraoperative perfusion parameters to the need for immediate extracorporeal support following heart transplantation.

Perfusion 2021 Oct 17;36(7):704-709. Epub 2020 Sep 17.

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

Purpose: We sought to assess the relationship of intraoperative perfusion parameters while on cardiopulmonary bypass, including oxygen delivery (DO), to the need for ECMO following orthotopic heart transplantation (OHT).

Methods: We included all adult (>18 years old) OHTs performed at our institution since implementation of an electronic perfusion record (March 2019-February 2020). Multi-organ transplants were excluded. The primary outcome was the need for immediate venoarterial ECMO in the OR following OHT. Univariable statistics were computed across demographic, clinical, operative, and perfusion variables, including oxygen delivery (DO) measured each minute.

Results: Fifty-three OHT were included with a median age of 54 years (interquartile range, 45-61). The primary outcome occurred in eight patients (15.1%). A significantly greater proportion of patients requiring ECMO had ischemic cardiomyopathy (50.0% (4/8) vs. 15.6% (7/45), p = 0.02) and had preoperative ventricular assist devices (37.5% (3/8) vs. 8.9% (4/45), p = 0.03). Median bypass times were longer in the ECMO group (217 vs. 147 minutes, p = 0.001). Phenylephrine doses were nonsignificantly higher in ECMO patients (4.1 vs. 1.9 mg, p = 0.10). No significant differences were observed in single-point median DO (275 vs. 294 mL O/min/m BSA, p = 0.17) and nadir DO (226 vs. 222, p = 0.94), but increasing time and depth of DO2 below a threshold of 300 mL O/min/m BSA (i.e. area over the DO curve (AOC) but below threshold) was significantly associated with the need for postoperative ECMO (p = 0.04).

Conclusion: This is the first study to examine the relationship of perfusion parameters, including oxygen delivery, to outcomes following heart transplantation. We note that DO < 300-AOC was significantly associated with the need for postoperative ECMO following heart transplant. Further study will clarify whether potential DO differences in patients who require post-OHT ECMO reflect vasoplegia, or a more causative relationship which might be leveraged to improve outcomes.
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http://dx.doi.org/10.1177/0267659120958153DOI Listing
October 2021

Intraoperative post-annuloplasty three-dimensional valve analysis does not predict recurrent ischemic mitral regurgitation.

J Cardiothorac Surg 2020 Jul 2;15(1):161. Epub 2020 Jul 2.

Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA.

Background: High ischemic mitral regurgitation (IMR) recurrence rates continue to plague IMR repair with undersized ring annuloplasty. We have previously shown that pre-repair three-dimensional echocardiography (3DE) analysis is highly predictive of IMR recurrence. The objective of this study was to determine the quantitative change in 3DE annular and leaflet tethering parameters immediately after repair and to determine if intraoperative post-repair 3DE parameters would be able to predict IMR recurrence 6 months after repair.

Methods: Intraoperative pre- and post-repair transesophageal real-time 3DE was performed in 35 patients undergoing undersized ring annuloplasty for IMR. An advanced modeling algorhythm was used to assess 3D annular geometry and regional leaflet tethering. IMR recurrence (≥ grade 2) was assessed with transthoracic echocardiography 6 months after repair.

Results: Annuloplasty significantly reduced septolateral diameter, commissural width, annular area, and tethering volume and significantly increased all segmental tethering angles (except A2). Intraoperative post-repair annular geometry and leaflet tethering did not differ significantly between patients with recurrent IMR (n = 9) and patients with non-recurrent IMR (n = 26). No intraoperative post-repair predictors of IMR recurrence could be identified.

Conclusions: Undersized ring annuloplasty changes mitral geometry acutely, exacerbates leaflet tethering, and generally fixes IMR acutely, but it does not always fix the delicate underlying chronic problem of continued left ventricular dilatation and remodeling. This may explain why pre-repair 3D valve geometry (which reflects chronic left ventricular remodeling) is highly predictive of recurrent IMR, whereas immediate post-repair 3D valve geometry (which does not completely reflect chronic left ventricular remodeling anymore) is not.
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http://dx.doi.org/10.1186/s13019-020-01138-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333337PMC
July 2020

Severe Impairment of Microcirculatory Perfused Vessel Density Is Associated With Postoperative Lactate and Acute Organ Injury After Cardiac Surgery.

J Cardiothorac Vasc Anesth 2021 Jan 14;35(1):106-115. Epub 2020 May 14.

Department of Emergency Medicine, Center for Resuscitation Science, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.

Objective: Resuscitation after cardiac surgery needs to address multiple pathophysiological processes that are associated with significant morbidity and mortality. Functional microcirculatory derangements despite normal systemic hemodynamics have been previously described but must be tied to clinical outcomes. The authors hypothesized that microcirculatory dysfunction after cardiac surgery would include impaired capillary blood flow and impaired diffusive capacity and that subjects with the lowest quartile of perfused vessel density would have an increased postoperative lactate level and acute organ injury scores.

Design: Prospective, observational study.

Setting: A single, tertiary university cardiovascular surgical intensive care unit.

Participants: 25 adults undergoing elective cardiac surgery requiring cardiopulmonary bypass.

Intervention: Sublingual microcirculation was imaged using incident dark field microscopy before and 2 to 4 hours after surgery in the intensive care unit.

Measurements And Main Results: Compared with baseline measurements, postoperative vessel-by-vessel microvascular flow index (2.9 [2.8-2.9] v 2.5 [2.4-2.7], p < 0.0001) and perfused vessel density were significantly impaired (20.7 [19.3-22.9] v 16.3 [12.8-17.9], p < 0.0001). The lowest quartile of perfused vessel density (<12.8 mm/mm) was associated with a significantly increased postoperative lactate level (6.0 ± 2.9 v 1.8 ± 1.2, p < 0.05), peak lactate level (7.6 ± 2.8 v 2.8 ± 1.5, p = 0.03), and sequential organ failure assessment (SOFA) score at 24 and 48 hours.

Conclusion: In patients undergoing cardiac surgery, there was a significant decrease in postoperative microcirculatory convective blood flow and diffusive capacity during early postoperative resuscitation. Severely impaired perfused vessel density, represented by the lowest quartile of distribution, is significantly related to hyperlactatemia and early organ injury.
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http://dx.doi.org/10.1053/j.jvca.2020.04.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666105PMC
January 2021

Multiorgan procurement is associated with a survival benefit after heart transplantation.

Clin Transplant 2020 08 25;34(8):e13901. Epub 2020 May 25.

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

We assessed the impact of donor multiorgan procurement on survival following orthotopic heart transplantation (OHT). From the UNOS STAR database, we included all adult (≥18 Y) heart transplants (OHT) performed since 2000 and used donor IDs to determine how many other organs were procured from the same donor as the recipient's heart allograft (regardless of recipient). The Kaplan-Meier survival functions and risk-adjusted Cox proportional hazards regression models were computed to assess the association of multiorgan procurement with post-heart transplantation mortality. We included 40 336 OHT patients. Including the heart, the median number of donor organs procured was 3 (IQR, 3-4). Heart donors underwent liver procurement in 89.7%; kidney(s) in 98.1% (single 95%, bilateral 5%); lung(s) in 38.0% (single 28%, bilateral 72%); pancreas in 10.4%; and intestine in 1.6%. Following risk adjustment across 16 recipient- and donor-specific variables, an increasing number of organs procured were independently associated with reduced post-OHT mortality (HR 0.98, 95% CI 0.96-0.99, P = .025). Though no significant associations were found examining specific organ types, double lung procurement trended toward a protective effect (HR 0.96, 0.92-1.01, P = .086), with counts of non-lung organs procured still bordering on significance (HR 0.97, 95% CI 0.95-1.00, P = .067). These results likely reflect improved multiorgan donor quality.
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http://dx.doi.org/10.1111/ctr.13901DOI Listing
August 2020

Transcatheter mitral valve repair for functional mitral regurgitation: Evaluating the evidence.

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

Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Md.

Objectives: Two trials (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation Trial and Percutaneous Repair with the MitraClip Device for Severe Functional/Secondary Mitral Regurgitation Trial) were published in 2018 evaluating the effectiveness and safety of transcatheter repair for patients with heart failure with significant functional mitral regurgitation, which yielded different results. This article reviews the strength of the evidence, differences in trial designs, ethical and implementation implications, and delineates future research needs to help guide the appropriate dissemination of transcatheter repair for functional patients with mitral regurgitation.

Methods: The National Heart, Lung, and Blood Institute convened a workshop of interdisciplinary experts to address these objectives.

Results: Transcatheter repair of functional mitral regurgitation can provide significant benefits in terms of heart failure hospitalizations, survival, and quality of life when appropriate heart failure candidates with moderate to severe or severe mitral regurgitation while on optimal guideline-directed medical therapy can be identified. Key ingredients for success are preoperative evaluation and management and postoperative care by an interdisciplinary heart team.

Conclusions: Given the discordance observed between trials, ongoing innovation in patient management, and potential expansion of indications for use, the evidence base must be expanded to optimize appropriate implementation of this complex therapy. This will require more complete capture of outcome data in real-world settings for all eligible candidates whether or not they receive this therapy. Inevitably, the indications for use of this therapy will expand, as will the devices and therapeutic approaches for this population, necessitating the study of comparative effectiveness through randomized trials or observational studies. Moreover, given the substantial variations in care delivery, conducting implementation research to delineate characteristics of the optimal care model would be of benefit.
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http://dx.doi.org/10.1016/j.jtcvs.2020.02.132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935447PMC
March 2020

Update to an early investigation of outcomes with the new 2018 donor heart allocation system in the United States.

J Heart Lung Transplant 2020 07 5;39(7):725-726. Epub 2020 Mar 5.

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

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http://dx.doi.org/10.1016/j.healun.2020.02.018DOI Listing
July 2020

Clinical and procedural characteristics predicting need for chronotropic support and permanent pacing post-heart transplantation.

Heart Rhythm 2020 07 27;17(7):1132-1138. Epub 2020 Feb 27.

Cardiac Electrophysiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: Postoperative bradycardia can complicate orthotopic heart transplantation (OHT). Previous studies suggested donor age and surgical technique as possible risk factors. However, risk factors in the era of bicaval anastomosis have not been elucidated.

Objective: We sought to examine the association between donor/recipient characteristics with need for chronotropic support and permanent pacemaker (PPM) implantation in patients with OHT.

Methods: All patients treated with OHT between January 2003 and January 2018 at the Hospital of the University of Pennsylvania were retrospectively evaluated until June 2018. Chronotropic support was given upon postoperative inability to increase the heart rate to patient's demands and included disproportionate bradycardia and junctional rhythm.

Results: A total of 820 patients (mean age 51.3 ± 12.6 years; 607, 74% men) underwent 826 OHT procedures (787 patients, 95.3% bicaval anastomosis). Patients who were exposed to amiodarone (odds ratio [OR] 2.30; 95% confidence interval [CI] 1.58-3.34; P < .001) and have older donor (OR 1.02; 95% CI 1.01-1.04; P = .001) were more likely to develop need for chronotropic support. In multivariable analysis, recipient age (OR 1.03; 95% CI 1.00-1.06; P = .04) and biatrial anastomosis (OR 6.12; 95% CI 2.48-15.09) were significantly associated with PPM implantation within 6 months of OHT. No association was found between pre-OHT amiodarone use and PPM implantation. No risk factors assessed were associated with PPM implantation 6 months post-OHT.

Conclusion: Surgical technique and donor age were the main risk factors for the need for chronotropic support post-OHT, whereas surgical technique and recipient age were risk factors for early PPM implantation.
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http://dx.doi.org/10.1016/j.hrthm.2020.02.021DOI Listing
July 2020

Trends in MitraClip, mitral valve repair, and mitral valve replacement from 2000 to 2016.

J Thorac Cardiovasc Surg 2021 08 22;162(2):551-562.e4. Epub 2020 Jan 22.

Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.

Objective: The dissemination of mitral valve repair as the first-line treatment and the introduction of MitraClip for patients who have a prohibitive risk for surgery have changed the landscape of mitral valve intervention. The aim of this study is to provide current and generalizable data regarding the trend of mitral valve interventions and outcomes from 2000 to 2016.

Methods: Patients ≥18 years of age who underwent mitral-valve interventions were identified using the National Inpatient Sample database. National estimates were generated by means of discharge weights; comorbid conditions were identified using Elixhauser methods. All trends were analyzed with JoinPoint software.

Results: A total of 656,030 mitral valve interventions (298,102 mitral valve replacement, 349,053 mitral valve repair, and 8875 MitraClip) were assessed. No changes in rate of procedures (per 100,000 people in the United States) were observed over this period (annual percent change, -0.4; 95% confidence limit, -1.1 to 0.3; P = .3). From 2000 to 2010, the number of replacements decreased by 5.6% per year (P < .001), whereas repair increased by 8.4% per year from 2000 to 2006 (P < .001). MitraClip procedures increased by 84.4% annually from 2013 to 2016 (P < .001). The burden of comorbidities increased throughout the study for all groups, with the greatest score for MitraClip recipients. Overall, length of stay has decreased for all interventions, most significantly for MitraClip. In-hospital mortality decreased from 8.5% to 3.7% for all interventions, with MitraClip having the most substantial decrease from 3.6% to 1.5%.

Conclusions: Over a 17-year period, mitral-valve interventions were associated with improved outcomes despite being applied to an increasingly sicker population.
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http://dx.doi.org/10.1016/j.jtcvs.2019.12.097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957952PMC
August 2021

Association of overlapping cardiac surgery with short-term patient outcomes.

J Thorac Cardiovasc Surg 2021 07 9;162(1):155-164.e2. Epub 2020 Jan 9.

Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa. Electronic address:

Objective: This study seeks to assess the safety of overlap in cardiac surgery.

Methods: Coarsened exact matching was used to assess the impact of overlap on outcomes among cardiac surgical interventions (n = 4463) over 2 years (2014-2016). Overlap was categorized as any, beginning, or end overlap. Study subjects were matched 1:1 on 11 variables, including Charlson comorbidity score, surgical costs, body mass index, length of postoperative hospitalization, and race, among others. Serious unanticipated events were studied, including readmission, unplanned return to the operating room, and mortality.

Results: A total of 984 patients had any overlap and were matched to similar patients without overlap (n = 1501). For beginning/end overlap, separate matched groups were created (n = 462, n = 329 patients, respectively). Among matched patients, any overlap did not predict unanticipated return to surgery at 30 or 90 days. Any overlap did not predict increased readmission, reoperation, or emergency department visits at 30 or 90 days. Overlap did not predict higher rates of death over follow-up. Beginning/end overlap had results similar to any overlap.

Conclusions: Nonconcurrent, overlapping surgery is not associated with an increase in adverse outcomes in a large, matched cardiac surgery population.
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http://dx.doi.org/10.1016/j.jtcvs.2019.11.136DOI Listing
July 2021

Causes, Risk Factors, and Costs of 30-Day Readmissions After Mitral Valve Repair and Replacement.

Ann Thorac Surg 2019 12 31;108(6):1729-1737. Epub 2019 Aug 31.

Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: Postsurgical readmissions are an increasingly scrutinized marker of health care quality. We sought to estimate the risk factors and costs associated with readmissions after mitral valve (MV) surgery in a large, nationally representative cohort.

Methods: Adult patients undergoing MV repair or replacement were queried from the National Readmissions Database from 2010 to 2014. Data were collected on the prevalence and indications for readmission within 30 days as well as the hospital-, procedure, and patient-level risk factors as determined by multivariable logistic regression.

Results: Among 76,342 patients undergoing MV surgery, the rate of 30-day readmission was 17.0%. Those undergoing replacement procedures had significantly higher readmission rates (20.7% vs 13.1%; P < .001) compared with repair. Significant independent predictors of readmission after both MV repair and replacement included length of stay ≥8 days, chronic lung disease, chronic renal disease, and low hospital procedural volume for MV surgery. Readmissions to nonindex hospitals accounted for 26.6% of all readmissions. The most common indications for readmission were heart failure (21.4%), arrhythmia (17.0%) and respiratory diagnoses (15.0%), and infections (10.2%). The mean cost per readmission was $15,397, and among readmitted patients, the cost of readmission accounted for 17.8% of the total cost of the episode of care.

Conclusions: Nearly 1 in 5 patients undergoing MV surgery are readmitted within 30 days. Treatment at a low-volume center was strongly associated with readmission, and much of the readmission burden falls on nonindex hospitals. Further characterization of readmissions may improve the quality of care associated with MV surgery.
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http://dx.doi.org/10.1016/j.athoracsur.2019.07.033DOI Listing
December 2019

Cost-effectiveness of coronary artery bypass grafting plus mitral valve repair versus coronary artery bypass grafting alone for moderate ischemic mitral regurgitation.

J Thorac Cardiovasc Surg 2020 06 2;159(6):2230-2240.e15. Epub 2019 Jul 2.

International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.

Objective: The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival.

Methods: We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty.

Results: In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; -0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [-3866 to 56,826]) and quality-adjusted life years showed no difference (-0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year.

Conclusions: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.
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http://dx.doi.org/10.1016/j.jtcvs.2019.06.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6960356PMC
June 2020

Operative Outcomes of Concomitant Minimally Invasive Mitral and Tricuspid Valve Surgery.

Innovations (Phila) 2019 Oct 24;14(5):412-418. Epub 2019 Jul 24.

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

Objective: The aim of this study was to evaluate whether the addition of concomitant tricuspid valve surgery (TVS) negatively impacted operative outcomes of minimally invasive mitral valve surgery (MIMVS).

Methods: Patients undergoing MIMVS via a port-access right minithoracotomy between 2002 and 2014 at a single institution were reviewed. Patients were primarily stratified by those undergoing isolated MIMVS versus MIMVS+TVS. Propensity-matched cohorts were generated. Operative outcomes were compared between the propensity-matched cohorts and included operative mortality, complications, and length of hospital stay.

Results: A total of 1,158 patients underwent MIMVS via port-access right minithoracotomy. The majority of cases were elective (93%; = 1,071) and 148 (13%) underwent concomitant MIMVS + TVS. Patients undergoing MIMVS + TVS were at higher risk at baseline. After propensity-matching, there were 119 isolated MIMVS and 119 MIMVS + TVS patients that were well matched with respect to all baseline variables. Cardiopulmonary bypass (148 ± 54 minutes versus 175 ± 54 minutes, < 0.001) and aortic occlusion times (105 ± 36 minutes versus 128 ± 40 minutes, < 0.001) were longer in the MIMVS + TVS group. Operative mortality was comparable (3% isolated MIMVS versus 4% for MIMVS + TVS; = 0.73). Permanent pacemakers were required less frequently in the isolated MIMVS group (1% versus 6%; = 0.03). All other complication rates were similar. Median length of hospital stay (7 versus 8 days; = 0.13) and discharge-to-home rates (89% versus 94%; = 0.15) were comparable.

Conclusions: Despite longer operative times, minimally invasive TVS performed concomitantly with MIMVS has similar operative outcomes with the exception of a higher pacemaker rate when compared with isolated MIMVS.
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http://dx.doi.org/10.1177/1556984519864939DOI Listing
October 2019

Intramyocardial Injection of Mesenchymal Precursor Cells and Successful Temporary Weaning From Left Ventricular Assist Device Support in Patients With Advanced Heart Failure: A Randomized Clinical Trial.

JAMA 2019 03;321(12):1176-1186

Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina.

Importance: Left ventricular assist device (LVAD) therapy improves myocardial function, but few patients recover sufficiently for explant, which has focused attention on stem cells to augment cardiac recovery.

Objective: To assess efficacy and adverse effects of intramyocardial injections of mesenchymal precursor cells (MPCs) during LVAD implant.

Design, Setting, And Participants: A randomized phase 2 clinical trial involving patients with advanced heart failure, undergoing LVAD implant, at 19 North American centers (July 2015-August 2017). The 1-year follow-up ended August 2018.

Interventions: Intramyocardial injections of 150 million allogeneic MPCs or cryoprotective medium as a sham treatment in a 2:1 ratio (n = 106 vs n = 53).

Main Outcomes And Measures: The primary efficacy end point was the proportion of successful temporary weans (of 3 planned assessments) from LVAD support within 6 months of randomization. This end point was assessed using a Bayesian analysis with a predefined threshold of a posterior probability of 80% to indicate success. The 1-year primary safety end point was the incidence of intervention-related adverse events (myocarditis, myocardial rupture, neoplasm, hypersensitivity reactions, and immune sensitization). Secondary end points included readmissions and adverse events at 6 months and 1-year survival.

Results: Of 159 patients (mean age, 56 years; 11.3% women), 155 (97.5%) completed 1-year of follow-up. The posterior probability that MPCs increased the likelihood of successful weaning was 69%; below the predefined threshold for success. The mean proportion of successful temporary weaning from LVAD support over 6 months was 61% in the MPC group and 58% in the control group (rate ratio [RR], 1.08; 95% CI, 0.83-1.41; P = .55). No patient experienced a primary safety end point. Of 10 prespecified secondary end points reported, 9 did not reach statistical significance. One-year mortality was not significantly different between the MPC group and the control group (14.2% vs 15.1%; hazard ratio [HR], 0.89; 95%, CI, 0.38-2.11; P = .80). The rate of serious adverse events was not significantly different between groups (70.9 vs 78.7 per 100 patient-months; difference, -7.89; 95% CI, -39.95 to 24.17; P = .63) nor was the rate of readmissions (0.68 vs 0.75 per 100 patient-months; difference, -0.07; 95% CI, -0.41 to 0.27; P = .68).

Conclusions And Relevance: Among patients with advanced heart failure, intramyocardial injections of mesenchymal precursor cells, compared with injections of a cryoprotective medium as sham treatment, did not improve successful temporary weaning from left ventricular assist device support at 6 months. The findings do not support the use of intramyocardial mesenchymal stem cells to promote cardiac recovery as measured by temporary weaning from device support.

Trial Registration: clinicaltrials.gov Identifier: NCT02362646.
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http://dx.doi.org/10.1001/jama.2019.2341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439694PMC
March 2019

Transplant Volume Is Associated With Graft Acceptance Threshold and Center Resource Availability.

J Card Fail 2020 Jun 18;26(6):522-526. Epub 2019 Mar 18.

Division of Cardiovascular Surgery, Department of Surgery. Electronic address:

Background: Heart transplant volume varies significantly among centers. We hypothesized that centers where the transplant team routinely accepts organs previously declined by other centers and where operating room availability is unrestricted have higher transplant volumes.

Methods And Results: We used the potential transplant recipient sequence number in the United Network for Organ Sharing database as a surrogate for graft acceptance threshold and the number of transplantations occurring on weekends and 8 major holidays as a marker of center resource availability. Centers were classified as low-, medium-, or high-volume if the average annual number of transplants were, respectively, <10, 10-30, or >30 over a 10-year period. From July 12, 2006, to December 31, 2015, 19,054 transplants were performed by 142 centers. There were 59 low-volume centers, 69 medium-volume centers, and 14 high-volume centers with median potential transplant recipient sequence numbers for transplanted candidates of 7 (interquartile range 3-11), 7 (5-10), and 15 (7-40), respectively (P = .002). The median proportion of off-hours transplantations performed by medium-volume centers was 28% (25%-31%) compared with 32% (29%-33%) by high-volume centers (P = .009). Five-year survival was equivalent among all centers (P = .053).

Conclusions: Transplants for candidates with high sequence numbers and unrestricted operating room availability are associated with increased center volume without sacrificing post-transplantation survival.
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http://dx.doi.org/10.1016/j.cardfail.2019.03.009DOI Listing
June 2020

A Novel Toroidal-Flow Left Ventricular Assist Device Minimizes Blood Trauma: Implications of Improved Ventricular Assist Device Hemocompatibility.

Ann Thorac Surg 2019 06 23;107(6):1761-1767. Epub 2018 Dec 23.

Windmill Cardiovascular Systems, Inc, Austin, Texas; Division of Cardiovascular Medicine, Department of Medicine, University of Texas Health Center, McGovern Medical School, Houston, Texas.

Background: Continuous-flow left ventricular assist devices (LVADs) cause blood trauma that includes von Willebrand factor degradation, platelet activation, and subclinical hemolysis. Blood trauma contributes to bleeding, thrombosis, and stroke, which cause significant morbidity and mortality. The TORVAD (Windmill Cardiovascular Systems, Inc, Austin, TX) is a first-of-its kind, toroidal-flow LVAD designed to minimize blood trauma. We tested the hypothesis that the TORVAD causes less blood trauma than the HeartMate II (Abbott Laboratories, Pleasanton, CA) LVAD.

Methods: Whole human blood was circulated for 6 hours in ex vivo circulatory loops with a HeartMate II (n = 8; 10,000 rpm, 70 ± 6 mm Hg, 4.0 ± 0.1 L/min) or TORVAD (n = 6; 144 rpm, 72 ± 0.0 mm Hg, 4.3 ± 0.0 L/min). von Willebrand factor degradation was quantified with electrophoresis and immunoblotting. Platelet activation was quantified by cluster of differentiation (CD) 41/61 enzyme-linked immunosorbent assay (ELISA). Hemolysis was quantified by plasma free hemoglobin ELISA.

Results: The TORVAD caused significantly less degradation of high-molecular-weight von Willebrand factor multimers (-10% ± 1% vs -21% ± 1%, p < 0.0001), accumulation of low-molecular-weight von Willebrand factor multimers (22% ± 2% vs 45% ± 2%, p < 0.0001), and accumulation of von Willebrand factor degradation fragments (7% ± 1% vs 25% ± 6%, p < 0.05) than the HeartMate II. The TORVAD did not activate platelets, whereas the HeartMate II caused significant platelet activation (CD 41/61: 645 ± 20 ng/mL vs 1,581 ± 150 ng/mL, p < 0.001; normal human CD 41/61, 593 ng/mL; range, 400 to 800 ng/mL). Similarly, the TORVAD caused minimal hemolysis, whereas the HeartMate II caused significant hemolysis (plasma free hemoglobin: 11 ± 2 vs 109 ± 10 mg/dL, p < 0.0001; normal human plasma free hemoglobin <4 mg/dL).

Conclusions: The TORVAD design, with markedly lower shear stress and pulsatile flow, caused significantly less blood trauma than the HeartMate II. LVADs with reduced blood trauma are likely to improve clinical outcomes and expand LVAD therapy into patients with less advanced heart failure.
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http://dx.doi.org/10.1016/j.athoracsur.2018.11.053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6709877PMC
June 2019

Left Ventricular Assist Devices.

Circulation 2018 12;138(24):2841-2851

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

Ventricular assist device has rapidly emerged as a durable and safe therapy for end-stage heart failure patients with >22 000 implantations to date. Though originally conceived for bridge-to-transplant indication, significant advancements in medical management as well as technology with arrivals of newer generation devices have improved patient outcomes, leading to increasing use as destination therapy. Despite such improvement, however, the burden of adverse events remains significant and defines the most pressing issue in the current state of ventricular assist device therapy. Eventual use of ventricular assist device technology as a comparable alternative to heart transplantation will ultimately rely on our ability to mitigate these risks. Therefore, this review article provides the narrative surrounding the rapid integration of this technology into the heart failure paradigm, specifically in the context of the most recent data on its outcomes and adverse event profiles. It describes ongoing investigations and general trends that may have significant implications for future improvements in device-related outcomes, as the field continues to grow as the epitome of synergy between advancements in engineering and clinical medicine.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.118.035566DOI Listing
December 2018

Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery: New analytical approaches and end points.

J Thorac Cardiovasc Surg 2019 01 27;157(1):234-243.e9. Epub 2018 Jul 27.

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

Objective: To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation during mitral valve surgery (MVS).

Methods: Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P < .001) by 72-hour Holter monitoring, without evident difference between lesion sets (for which the trial was underpowered).

Results: Estimated freedom from AF/AFL/AT on any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95-5.65; P = .07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57-1.43; P = .6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P < .02).

Conclusions: Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.
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http://dx.doi.org/10.1016/j.jtcvs.2018.06.093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486838PMC
January 2019

Redo mitral valve surgery following prior mitral valve repair.

J Card Surg 2018 Dec 12;33(12):772-777. Epub 2018 Dec 12.

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

Background: The optimal treatment strategy following a failed mitral valve repair remains unclear. This study evaluated early and long-term outcomes of redo mitral valve repair (MVr) and replacement (MVR) after prior mitral valve repair.

Methods: Patients undergoing redo mitral valve surgery after prior mitral valve repair at a single institution between 2002 and 2014 were reviewed. Primary outcomes included operative mortality (30-day or in-hospital mortality) and long-term freedom from mitral valve reoperation and death. Secondary outcomes included postoperative complications.

Results: 305 patients underwent redo MVr (n = 48) or MVR (n = 257) after prior mitral valve repair. Concomitant procedures included tricuspid valve repair or replacement (23%), aortic valve replacement (6%), and coronary artery bypass grafting (4%), with no differences between cohorts. 18% were performed via right mini-thoracotomy (24% MVr vs 18% MVR, P = 0.31). Unadjusted and risk-adjusted operative mortality were lower with MVr (0% vs 8%, P = 0.04). Rates of postoperative complications were similar except for blood product transfusion (35% MVr vs 59% MVR, P = 0.003) and prolonged mechanical ventilation (8% MVr vs 29% MVR, P = 0.003). Long-term freedom from mortality was comparable: 96% MVr versus 86% MVR at 1 year and 78% MVr versus 68% MVR at 5 years (P = 0.29).

Conclusions: When technically feasible, mitral valve re-repair can be safely performed with outcomes comparable to MVR.
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http://dx.doi.org/10.1111/jocs.13944DOI Listing
December 2018

Cognition and Cerebral Infarction in Older Adults After Surgical Aortic Valve Replacement.

Ann Thorac Surg 2019 03 10;107(3):787-794. Epub 2018 Nov 10.

Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas; Department of Cardiovascular Surgery, University of Texas Southwestern, Dallas, Texas; Department of Radiology, University of Texas Southwestern, Dallas, Texas.

Background: Aortic valve replacement (AVR) for calcific aortic stenosis is associated with high rates of perioperative stroke and silent cerebral infarcts on diffusion-weighted magnetic resonance imaging (MRI), but cognitive outcomes in elderly AVR patients compared with individuals with cardiac disease who do not undergo surgery are uncertain.

Methods: One hundred ninety AVR patients (mean age 76 ± 6 years) and 198 non-surgical participants with cardiovascular disease (mean age 74 ± 6 years) completed comprehensive cognitive testing at baseline (preoperatively) and 4 to 6 weeks and 1 year postoperatively. Surgical participants also completed perioperative stroke evaluations, including postoperative brain MRI. Mixed model analyses and reliable change scores examined cognitive outcomes. Stroke outcomes were evaluated in participants with and without postoperative cognitive dysfunction.

Results: From reliable change scores, only 12.4% of the surgical group demonstrated postoperative cognitive dysfunction at 4 to 6 weeks and 7.5% at 1 year. Although the surgical group had statistically significantly lower scores in working memory/inhibition 4 to 6 weeks after surgery, the groups did not differ at 1 year. In surgical participants, postoperative cognitive dysfunction was associated with a greater number (p < 0.01) and larger total volume (p < 0.01) of acute cerebral infarcts on MRI.

Conclusions: In high-risk, aged participants undergoing surgical AVR for aortic stenosis, postoperative cognitive dysfunction was surprisingly limited and was resolved by 1 year in most. Postoperative cognitive dysfunction at 4 to 6 weeks was associated with more and larger acute cerebral infarcts.
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http://dx.doi.org/10.1016/j.athoracsur.2018.09.057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382522PMC
March 2019

Clinical Outcomes of Mitral Valve Reoperations in the United States: An Analysis of The Society of Thoracic Surgeons National Database.

Ann Thorac Surg 2019 03 23;107(3):754-759. Epub 2018 Oct 23.

Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland.

Background: This study evaluated outcomes of reoperative mitral valve surgery (MVS) in the United States.

Methods: Adults undergoing isolated MVS with prior open-heart operation in The Society of Thoracic Surgeons (STS) National Database between July 2011 and September 2016 were included. Urgent or emergent operations as well as all indications and causes for MVS were included. Primary outcomes were operative mortality and morbidity. Multivariable models were used for risk-adjustment, incorporating variables from the STS Valve Risk Model as well as type of prior operation and reoperative approach.

Results: A total of 17,195 patients underwent isolated reoperative MVS at 962 centers. The STS predicted risk of mortality was 8.0%, with 20% having an STS predicted risk of mortality greater than 10%. Prior cardiac operations included previous MVS (61%), coronary artery bypass (39%), aortic valve surgery (18%), and tricuspid valve surgery (6%). Operative mortality for the overall study cohort was 6.6%, and postoperative stroke occurred in 2.4%. Observed-to-expected mortality for the overall cohort was 0.82. The strongest independent predictors of operative mortality included salvage operation, preoperative dialysis dependence, congestive heart failure, recent myocardial infarction, and active endocarditis. Prior aortic valve replacement was associated with increased mortality risk, whereas prior MVS reduced mortality risk. Surgical approach did not affect mortality. For patients with prior MVS undergoing elective, non-endocarditis operations, the operative mortality was 3.4%.

Conclusions: Despite a high-risk patient profile, surgical outcomes of reoperative MVS were acceptable, particularly in patients with prior MVS and without endocarditis undergoing elective operations.
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http://dx.doi.org/10.1016/j.athoracsur.2018.08.083DOI Listing
March 2019
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