Publications by authors named "Shinya Unai"

62 Publications

Radical pericardiectomy for pericardial diseases.

Multimed Man Cardiothorac Surg 2021 Oct 25;2021. Epub 2021 Oct 25.

Heart Vascular & Thoracic Institute, Cleveland Clinic, OH, USA.

Pericarditis is the most common form of pericardial disease. Its exact incidence remains unknown, probably because many cases resolve without diagnosis. Indications for pericardiectomy from the standpoint of the cardiac surgeon are based mainly on the physiopathology of 2 different entities that can overlap: inflammatory or relapsing pericarditis and constrictive pericarditis. Surgical indications are not always straightforward. Patients with inflammatory or relapsing pericarditis may undergo radical pericardiectomy because they experience severe symptoms despite maximal medical treatment or have sequelae from the medical treatment. Pericardiectomy is the standard treatment in patients with chronic constrictive pericarditis and persistent symptoms who are in New York Heart Association functional class III or IV and a class I recommendation in the European Society of Cardiology/European Association of Cardio-Vascular Surgery guidelines. The goal of surgery is always complete removal of any site of inflammation through a radical pericardiectomy.
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http://dx.doi.org/10.1510/mmcts.2021.069DOI Listing
October 2021

Cardiac Operations after Transcatheter Aortic Valve Replacement.

Ann Thorac Surg 2021 Nov 17. Epub 2021 Nov 17.

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

Background: Transcatheter aortic valve replacement (TAVR) is now frequently performed for severe aortic stenosis. Data regarding cardiac operations after TAVR are limited, however. Therefore, we investigated patient characteristics, operative timing and indications, and outcomes of these operations in a single-center experience.

Methods: From 1/2012-7/2020, 59 patients (median age 70) underwent cardiac operations after TAVR, 38 (64%) of the latter performed outside our center. Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) was calculated at time of prior TAVRs and at applicable index cardiac operations.

Results: From 2012-2018, there were fewer than 10 operations after TAVR, but 18 in 2019. Interval between prior TAVR and cardiac surgery decreased exponentially from 7 to less than 1 year over the experience. In applicable cases (n=19; 32%), median STS-PROM was 5.5% (15-85th percentiles, 3.1%-25%); 40 (68%) were complex operations with no calculable STS-PROM. The TAVR valve was explanted in 46 (78%); 5 were isolated surgical AVRs. TAVR valve stenosis/regurgitation (n=34; 58%) was the leading indication, followed by paravalvular leak (14; 24%) and endocarditis (n=10/17%). When the TAVR valve was not explanted, mitral regurgitation was the leading indication for operation. Operative mortality was 5 (8.5%), postoperative stroke 2 (3.4%), and postoperative dialysis 6 (10%).

Conclusions: Cardiac operations after TAVR are increasing and interval between TAVR and operation decreasing. Most cardiac operations are complex, high-risk reoperations and isolated AVR rare. These findings should be considered when TAVR is selected for low-intermediate risk patients, particularly with multiple cardiac pathologies not addressed by TAVR.
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http://dx.doi.org/10.1016/j.athoracsur.2021.10.022DOI Listing
November 2021

Derivation and Validation of Risk Prediction Model for 30-Day Readmissions Following Transcatheter Mitral Valve Repair.

Curr Probl Cardiol 2021 Nov 5:101033. Epub 2021 Nov 5.

Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH.

Introduction: Transcatheter mitral valve repair (TMVr) has shown to reduce heart failure (HF) rehospitalization and all cause mortality. However, the 30-day all-cause readmission remains high (∼15%) after TMVr. Therefore, we sought to develop and validate a 30-day readmission risk calculator for TMVr.

Methods: Nationwide Readmission Database from January 2014 to December 2017 was utilized. A linear calculator was developed to determine the probability for 30-day readmission. Internal calibration with bootstrapped calculations were conducted to assess model accuracy. The root mean square error and mean absolute error were calculated to determine model performance.

Results: Of 8,339 patients who underwent TMVr, 1,246 (14.2%) were readmitted within 30 days. The final 30-day readmission risk prediction tool included the following variables: Heart failure, Atrial Fibrillation, Anemia, length of stay ≥4 days, Acute kidney injury (AKI), and Non-Home discharge, Non-Elective admission and Bleeding/Transfusion. The c-statistic of the prediction model was 0.63. The validation c-statistic for readmission risk tool was 0.628. On internal calibration, our tool was extremely accurate in predicting readmissions up to 20%.

Conclusion: A simple and easy to use risk prediction tool identifies TMVr patients at increased risk of 30-day readmissions. The tool can guide in optimal discharge planning and reduce resource utilization.
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http://dx.doi.org/10.1016/j.cpcardiol.2021.101033DOI Listing
November 2021

When echocardiography fails, intravascular ultrasound as an alternative for adequate graft patency in hybrid elephant trunk surgery.

Ann Card Anaesth 2021 Oct-Dec;24(4):495-497

Anesthesiology Institute, Cleveland Clinic; Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA.

Aortic pathology is a common cardiovascular disease in the US. Transesophageal Echocardiogram is an invaluable imaging modality in the management of aortic pathology in perioperative setting. Intravascular ultrasound can assess coronary obstruction during coronary interventions and can be used in endovascular aneurysm repair. A 54-year-old male underwent Hybrid Elephant Trunk Surgery, for complex open aorta repair. There was functional confirmation graft patency via the femoral arterial line tracing, there was surgical confirmation via visual and physical inspection of graft, but there was lacking anatomical confirmation. Epiaortic ultrasound reassured the graft patency at level of the arch. However, transesophageal echocardiogram was not reassuring for adequate anatomical confirmation of patency. Intravascular ultrasound was used for anatomical confirmation of graft patency and position. This technology provides real time graft patency and is a great tool in open aorta reconstruction surgery.
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http://dx.doi.org/10.4103/aca.ACA_131_20DOI Listing
November 2021

Mitral annular calcification and valvular dysfunction: multimodality imaging evaluation, grading, and management.

Eur Heart J Cardiovasc Imaging 2021 Sep 9. Epub 2021 Sep 9.

Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA.

Mitral annular calcification (MAC) refers to calcium deposition in the fibrous skeleton of the mitral valve. It has many cardiovascular associations, including mitral valve dysfunction, elevated cardiovascular risk, arrhythmias, and endocarditis. Echocardiography conventionally is the first-line imaging modality for anatomic assessment, and evaluation of mitral valve function. Cardiac computed tomography (CT) has demonstrated importance as an imaging modality for the evaluation and planning of related procedures. It also holds promise in quantitative grading of MAC. Currently, there is no universally accepted definition or classification system of MAC severity. We review the multimodality imaging evaluation of MAC and associated valvular dysfunction and propose a novel classification system based on qualitative and quantitative measurements derived from echocardiography and cardiac CT.
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http://dx.doi.org/10.1093/ehjci/jeab185DOI Listing
September 2021

Commentary: Rooting for the Best Root Prosthesis.

Semin Thorac Cardiovasc Surg 2021 Sep 23. Epub 2021 Sep 23.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1053/j.semtcvs.2021.09.010DOI Listing
September 2021

Impact of Frailty and Mitral Valve Surgery on Outcomes of Severe Mitral Stenosis Due to Mitral Annular Calcification.

Am J Cardiol 2021 12 20;160:83-90. Epub 2021 Oct 20.

Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute. Electronic address:

We sought to evaluate the outcomes of patients with severe mitral stenosis (MS) resulting from mitral annular calcification and assessed the prognostic impact of co-morbidities and frailty in guiding management. Among 6,915 patients with calcific MS who underwent echocardiography between January 2011 and March 2020, a total of 283 patients with severe calcific MS were retrospectively enrolled. We calculated the Charlson co-morbidity index (CCI). Frailty was scored from 0 to 3 points, with 1 point each assigned for reduced hemoglobin, reduced albumin, and inactivity. The primary end point was all-cause death. The mean age was 72 ± 11 years. The mean mitral valve (MV) area was 1.1 ± 0.4 cm, and the mean transmitral gradient was 12 ± 4 mm Hg. Although 33% of the patients underwent MV intervention, 67% were conservatively managed. During a median follow-up of 360 days, 35% died. Patients who underwent MV intervention had an improved prognosis compared with those who were treated conservatively, even after propensity score matching. On multivariate Cox regression analysis, higher CCI (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.04 to 1.38, p = 0.011) and frailty score (HR 1.58, 95% CI 1.12 to 2.23, p = 0.01) were predictors of all-cause mortality, and MV intervention (HR 0.45, 95% CI 0.25 to 0.83, p = 0.011) and angiotensin converting enzyme inhibitor/angiotensin receptor blocker use (HR 0.39, 95% CI 0.20 to 0.79, p = 0.009) were associated with an improved prognosis. In conclusion, patients with severe calcific MS were often frail with multiple co-morbidities and were often managed conservatively. Higher CCI and worse frailty were associated with worse prognosis, regardless of the treatment strategy. MV intervention for select patients was associated with improved prognosis.
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http://dx.doi.org/10.1016/j.amjcard.2021.08.036DOI Listing
December 2021

Clinical and Echocardiographic Characteristics of Bartonella Infective Endocarditis: An 8-Year Single-Centre Experience in the United States.

Heart Lung Circ 2021 Aug 26. Epub 2021 Aug 26.

Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: Infective endocarditis due to Bartonella species is rare. The clinical and echocardiographic characteristics are not well defined. We aimed to investigate the clinical and echocardiographic findings of Bartonella endocarditis in the contemporary era.

Methods: The infective endocarditis (IE) registry and echocardiographic database at our institution were retrospectively analysed to evaluate the clinical and echocardiographic features of Bartonella endocarditis.

Results: Between January 2008 and December 2015, there were 11 patients with Bartonella IE (0.84% among a total of 1,308 cases of definite IE): median age 54 (30-69) years, all male, 9 Caucasian, 10 had a history of cat exposure, 10 had a pre-existing valvulopathy including 6 patients with a prosthetic valve with prosthesis age range between 3 to 5 years and 1 patient with implantable cardioverter defibrillator (ICD). Bartonella henselae was responsible for all the cases. Echocardiographic evidence of IE was found in 6 of 11 patients on transthoracic echocardiography (TTE), and 6 of 8 on transoesophageal echocardiography (TEE). Bartonella IE was associated with significant valvular destruction and dysfunction on echocardiography. Nine (9) patients were managed surgically with excellent outcomes, including two patients who failed initial medical therapy. Two (2) patients who were managed medically had progression of valvular dysfunction. At a median follow-up of 6 months, there were no deaths attributable to IE or other cardiovascular causes.

Conclusion: In a contemporary single-centre cohort in the United States, Bartonella IE remains rare, but should be considered when pathogen could not be identified in patients with suspected IE, especially those with prosthetic valves or bicuspid aortic valve (BAV). The vast majority of patients with Bartonella IE were managed surgically with excellent outcomes.
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http://dx.doi.org/10.1016/j.hlc.2021.07.021DOI Listing
August 2021

Contemporary review in the multi-modality imaging evaluation and management of tricuspid regurgitation.

Cardiovasc Diagn Ther 2021 Jun;11(3):804-817

Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.

The tricuspid valve has gained interest recently because of the poor outcomes with current treatments and advances in percutaneous valve interventions. A sound understanding of the anatomy and pathologies of the tricuspid valve is critical in its evaluation and management of tricuspid regurgitation (TR). A multi-modality imaging approach with transthoracic echocardiography, transesophageal echocardiography, computed tomography, magnetic resonance imaging all have their individual and collective roles in the evaluation of TR and guidance of surgical and percutaneous procedures. This combined with clinical factors will contribute to defining timing, indications, modality selection and risk stratification for tricuspid valve interventions, which currently remains controversial.
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http://dx.doi.org/10.21037/cdt.2020.01.06DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8261753PMC
June 2021

A case series of cardiac amyloidosis patients supported by continuous-flow left ventricular assist device.

ESC Heart Fail 2021 10 16;8(5):4353-4356. Epub 2021 Jul 16.

Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.

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http://dx.doi.org/10.1002/ehf2.13422DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497221PMC
October 2021

Transcatheter Mitral Valve Repair and Mitral Valve Surgery Following Acute Myocardial Infarction (Insights From a Nationwide Cohort Study).

Am J Cardiol 2021 08 8;152:174-177. Epub 2021 Jun 8.

Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

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http://dx.doi.org/10.1016/j.amjcard.2021.04.026DOI Listing
August 2021

Evolution of Recipient Characteristics Over 3 Decades and Impact on Survival After Lung Transplantation.

Transplantation 2021 Dec;105(12):e387-e394

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.

Background: Lung transplantation (LTx) is a definitive treatment for end-stage lung disease. Herein, we reviewed our center experience over 3 decades to examine the evolution of recipient characteristics and contemporary predictors of survival for LTx.

Methods: We retrospectively reviewed the data of LTx procedures performed at our institution from January 1990 to January 2019 (n = 1819). The cohort is divided into 3 eras; I: 1990-1998 (n = 152), II: 1999-2008 (n = 521), and III: 2009-2018 (n = 1146). Univariate and multivariate analyses of survival in era III were performed.

Results: Pulmonary fibrosis has become the leading indication for LTx (13% in era I, 57% in era III). Median recipient age increased (era I: 46 y-era III: 61 y) as well as intraoperative mechanical circulatory support (era I: 0%-era III: 6%). Higher lung allocation score was associated with primary graft dysfunction (P < 0.0001), postoperative extracorporeal mechanical support (P < 0.0001), and in-hospital mortality (P = 0.002). In era III, hypoalbuminemia, thrombocytopenia, and high primary graft dysfunction grade were multivariate predictors of early mortality. The 5-y survival in eras II (55%) and III (55%) were superior to era I (40%, P < 0.001). Risk factors for late mortality in era III included recipient age, chronic allograft dysfunction, renal dysfunction, high model for end-stage liver disease score, and single LTx.

Conclusions: In this longitudinal single-center study, recipient characteristics have evolved to include sicker patients with greater complexity of procedures and risk for postoperative complications but without significant impact on hospital mortality or long-term survival. With advancing surgical techniques and perioperative management, there is room for further progress in the field.
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http://dx.doi.org/10.1097/TP.0000000000003756DOI Listing
December 2021

Invasive Aortic Valve Endocarditis: Clinical and Tissue Findings From a Prospective Investigation.

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

Department of Thoracic and Cardiovascular Surgery Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Advanced aortic valve infective endocarditis (IE) with progression and destruction beyond the valve cusps-invasive IE-is incompletely characterized. This study aimed to characterize further the invasive disease extent, location, and stage and correlate macroscopic operative findings with microscopic disease patterns and progression.

Methods: A total of 43 patients with invasive aortic valve IE were prospectively enrolled from August 2017 to July 2018. Of these patients, 23 (53%) had prosthetic valve IE, 2 (5%) had allograft IE, and 18 (42%) had native aortic valve IE. Surgical findings and intraoperative photography were analyzed for invasion location, extent, and stage. Surgical samples were formalin fixed and analyzed histologically. The time course of disease and management were evaluated.

Results: Pathogens included Staphylococcus aureus in 17 patients (40%). Invasion predominantly affected the non-left coronary commissure (76%) and was circumferential in 15 patients (35%) (14 had prosthetic valves). Extraaortic cellulitis was present in 29 patients (67%), abscess in 13 (30%), abscess cavity in 29 (67%), and pseudoaneurysm in 8 (19%); 7 (16%) had fistulas. Histopathologic examination revealed acute inflammation, abscess formation, and lysis of connective tissue but not of myocardium or elastic tissue. Median time from onset of symptoms to antibiotics was 5 days, invasion confirmation 15 days, and surgery 37 days. Patients with S aureus had a 21-day shorter time course than patients non-S aureus. New or worsening heart block developed in 8 patients.

Conclusions: Advanced invasive aortic valve IE demonstrates consistent gross patterns and stages correlating with histopathologic findings. Invasion results from a confluence of factors, including pathogen, time, and host immune response, and primarily affects the fibrous skeleton of the heart and expands to low-pressure regions.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.072DOI Listing
April 2021

Multimodality Imaging-Guided Evaluation and Management of Prosthetic Aortic Valve Endocarditis Complicated by a Giant Peri-Aortic Abscess.

Circ Cardiovasc Imaging 2021 04 2;14(4):e011944. Epub 2021 Apr 2.

Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine (S.L.P., R.R., W.J., V.K., B.X.), Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, OH.

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http://dx.doi.org/10.1161/CIRCIMAGING.120.011944DOI Listing
April 2021

Role of Cardiac CT in Infective Endocarditis: Current Evidence, Opportunities, and Challenges.

Radiol Cardiothorac Imaging 2021 Feb 18;3(1):e200378. Epub 2021 Feb 18.

Section of Cardiovascular Imaging, Imaging Institute (M.B.S., T.K.M.W., P.C., M.A.B.), Section of Cardiovascular Imaging, Heart and Vascular Institute (T.K.M.W., P.C., M.A.B.), and Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute (S.U., G.B.P.), Cleveland Clinic, 9500 Euclid Ave, J1-4, Cleveland, OH 44915; Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands (A.R.W., R.P.J.B.); Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (A.R.W.); and Department of Cardiology, Haga Hospital, The Hague, the Netherlands (A.R.W.).

Infective endocarditis (IE) can present with variable clinical and imaging findings and is associated with high morbidity and mortality. Substantial improvement of CT technology, most notably improved temporal and spatial resolution, has resulted in increased use of this modality in the evaluation of IE. The aim of this article is to review the potential role of cardiac CT in evaluating IE. Supplemental material is available for this article. © RSNA, 2021.
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http://dx.doi.org/10.1148/ryct.2021200378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977690PMC
February 2021

Evolution of Alternative-access Transcatheter Aortic Valve Replacement.

Ann Thorac Surg 2021 Dec 27;112(6):1877-1885. Epub 2021 Feb 27.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Transfemoral access is the most common approach for transcatheter aortic valve replacement (TAVR). However, a subset of patients require alternative access. This study describes the evolution and outcomes of alternative-access TAVR at Cleveland Clinic.

Methods: From January 2006 to January 2019, 2446 patients underwent TAVR, 414 (17%) through alternative access (247 transapical, 95 transaortic, 56 transaxillary, 2 transcarotid, 10 transiliac, 4 transcaval). Patients undergoing alternative-access TAVR had high preoperative risk. Propensity-matched comparisons were targeted at comparing transfemoral versus transaxillary approaches since 2012.

Results: Over time, the favored alternative-access approach shifted from transapical and transaortic to transaxillary. Pacemaker requirement was similar for alternative-access and transfemoral approaches. Compared with transfemoral access, major vascular injuries were higher in the alternative-access group (12 [2.9%] vs 27 [1.3%], P = .02), but minor vascular injuries were lower (13 [3.1%] vs 198 [9.8%], P < .0001). Non-risk-adjusted 5-year survival was lower in the alternative-access group (45% vs 59%). Compared with intrathoracic approaches (transapical and transaortic), transaxillary access was associated with fewer blood transfusions (12 [21%] vs 176 [51%], P < .0001), less prolonged ventilation (1 [1.8%] vs 38 [11%], P = .03), and shorter length of stay (median, 5 vs 7.5 days, P < .0001). Survival and major morbidity were similar in matched comparisons of the transfemoral and transaxillary approaches. No brachial plexus injuries occurred with transaxillary access.

Conclusions: The transaxillary approach has emerged as our preferred alternative-access strategy for TAVR. It is associated with superior operative outcomes compared with transthoracic approaches, and results are comparable with those of the transfemoral approach.
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http://dx.doi.org/10.1016/j.athoracsur.2021.02.018DOI Listing
December 2021

Comparing outcomes of general anesthesia and monitored anesthesia care during transcatheter aortic valve replacement: The Cleveland Clinic Foundation experience.

Catheter Cardiovasc Interv 2021 09 29;98(3):E436-E443. Epub 2021 Jan 29.

Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Background: Monitored anesthesia care (MAC) has become more widely used during transcatheter aortic valve replacement (TAVR) to avoid the complications of general anesthesia (GA).

Methods: We included consecutive patients who underwent transfemoral-TAVR at our institution between January 2012 and April 2017. We compared outcomes with GA versus MAC.

Results: Of 998 patients, MAC was used in 43.9%. MAC was associated with shorter procedural time (96.9 ± 30.9 vs. 135 ± 64.6 mins; p < .001), fluoroscopy time (20.4 ± 8.9 vs. 29 ± 18.7 mins; p < .001), lower contrast volume (45.5 ± 27 vs. 60.4 ± 43 cc; p < .001), and decreased radiation exposure (12,869 ± 8,099 vs. 20,630 ± 16,276 cGy-cm ; p < .001). Patients who underwent MAC had a briefer median (IQR) intensive care unit stay [23.3 (21-24) vs. 23.4 (20.8-26) hrs; p < .001], and hospital stay [2 (2, 3) vs. 3 (2-6) days; p < .001], and were more frequently discharged to home (93.4% vs. 82.9%; p < .001). MAC was associated with lower mortality at 30 days (0.5% vs. 2.9%; log-rank p = .012; adjHR 0.22, 95% CI 0.06-0.82; p = .024), but not at 1 year (11.7% vs. 14.6%; log-rank p = .157) or 3 years (36.8% vs. 38.4%; log-rank p = 0.433). There were no differences in major adverse cardiac and cerebrovascular events (MACCE) at either 30 days (4.6% vs. 9.3%; log-rank p = .14) or 1 year (21.1% vs. 21.5%; log-rank p = .653). Similar findings were seen among patients who received newer-generation SAPIEN-3 valves.

Conclusion: Utilizing MAC and omitting intraprocedural transesophageal echocardiography during TAVR seems to be more efficient without compromising safety. Better TAVR outcomes can be achieved with newer generation valves without needing GA.
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http://dx.doi.org/10.1002/ccd.29496DOI Listing
September 2021

Symptomatic Left Ventricular Outflow Tract Obstruction Caused by Mitral Annular Calcification.

CASE (Phila) 2020 Dec 3;4(6):490-493. Epub 2020 Sep 3.

Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1016/j.case.2020.07.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7756159PMC
December 2020

Severe Mobile Mitral Annular Calcification Mimicking Vegetation.

Circ Cardiovasc Imaging 2020 11 11;13(11):e010541. Epub 2020 Nov 11.

Department of Cardiovascular Medicine (P.T.H., B.X., R.A.G., R.L.M.), Cleveland Clinic, OH.

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http://dx.doi.org/10.1161/CIRCIMAGING.120.010541DOI Listing
November 2020

Performance and Durability of Cryopreserved Allograft Aortic Valve Replacements.

Ann Thorac Surg 2021 06 25;111(6):1893-1900. Epub 2020 Sep 25.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: The value of allografts for aortic root replacement is controversial, with recent concern about limited durability. Currently, we prefer allografts for invasive infective endocarditis. Purposes of this study were to assess allograft performance and durability in our cumulative experience with aortic allografts.

Methods: From January 1987 to January 2017, 2042 adults received 2110 aortic allograft root replacements at our institution: 986 (47%) for infective endocarditis (669 [68%] for prosthetic valve endocarditis) and 1124 (53%) for other indications. Mean recipient age was 54 ± 15 years, and mean allograft donor age was 35 ± 13 years. Follow-up was 85% complete and comprised 17,253 patient-years of data. Longitudinal allograft performance was extracted from 6339 available echocardiographic studies. Durability was assessed by explant for allograft structural failure.

Results: Allograft mean gradient at hospital discharge was 6 mm Hg and 9, 13, and 15 mm Hg at 5, 10, and 15 years post-implant, respectively. Severe aortic regurgitation was 0% at hospital discharge, but 14%, 25%, and 35% at 5, 10, and 15 years, respectively. A total of 405 allografts were explanted for structural failure, actuarially 2%, 14%, 34%, and 51% at 5, 10, 15, and 20 years, respectively. Risk factors for structural failure were younger recipient age, larger body surface area, hypertension, and thoracic aorta disease; donor factors were older age and larger allograft size. Implant for infective endocarditis was not associated with accelerated structural failure.

Conclusions: This study affirms allografts' long-term acceptable hemodynamic performance and durability. Concern about structural failure should not limit allograft use. Recipient hypertension, allograft size, and donor age are modifiable risk factors.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.033DOI Listing
June 2021

Complementary Diagnostic and Prognostic Contributions of Cardiac Computed Tomography for Infective Endocarditis Surgery.

Circ Cardiovasc Imaging 2020 09 9;13(9):e011126. Epub 2020 Sep 9.

Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute (T.K.M.W., N.C., B.X., P.C., R.A.G., B.P.G., S.D.F., Z.B.P., M.A.B.), Cleveland Clinic, OH.

Background: Cardiac computed tomography (CT) is emerging as an adjunctive modality to echocardiography in the evaluation of infective endocarditis (IE) and surgical planning. CT studies in IE have, however, focused on its diagnostic rather than prognostic utility, the latter of which is important in high-risk diseases like IE. We evaluated the associations between cardiac CT and transesophageal echocardiography (TEE) findings and adverse outcomes after IE surgery.

Methods: Of 833 consecutive patients with surgically proven IE during May 1, 2014 to May 1, 2019, at Cleveland Clinic, 155 underwent both preoperative ECG-gated contrast-enhanced CT and TEE. Multivariable analyses were performed to identify CT and TEE biomarkers that predict adverse outcomes after IE surgery, adjusting for EuroSCORE II (European System for Cardiac operative Risk Evaluation II).

Results: CT and TEE were positive for IE in 123 (75.0%) and 124 (75.6%) of patients, respectively. Thirty-day mortality occurred in 3 (1.9%) patients and composite mortality or morbidities in 72 (46.5%). Pseudoaneurysm or abscess detected on TEE was the only imaging biomarker to show independent association with composite mortality or morbidities in-hospital, with odds ratio (95% CI) of 3.66 (1.76-7.59), =0.001. There were 17 late deaths, and both pseudoaneurysm or abscess detected on CT and fistula detected on CT were the only independent predictors of total mortality during follow-up, with hazards ratios (95% CI) of 3.82 (1.25-11.7), <0.001 and 9.84 (1.89-51.0), =0.007, respectively.

Conclusions: We identified cardiac CT and TEE features that predicted separate adverse outcomes after IE surgery. Imaging biomarkers can play important roles incremental to conventional clinical factors for risk stratification in patients undergoing IE surgery.
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http://dx.doi.org/10.1161/CIRCIMAGING.120.011126DOI Listing
September 2020

Natural History of Pleural Complications After Lung Transplantation.

Ann Thorac Surg 2021 02 24;111(2):407-415. Epub 2020 Aug 24.

Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Transplant Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address:

Background: Despite advances in lung transplantation, 5-year survival remains at 56%. Although the focus has been on chronic lung allograft dysfunction and infection, pleural complications in some may contribute to adverse outcomes. Therefore, we determined (1) the prevalence of, and risk factors for, pleural complications after lung transplantation and (2) their association with allograft function and mortality.

Methods: From 2006 to 2017, 1039 adults underwent primary lung transplantation at Cleveland Clinic in Cleveland, Ohio. Multivariable analyses were performed in the multiphase mixed longitudinal and hazard function domains to identify risk factors associated with allograft function and survival.

Results: A total of 468 patients (45%) had pleural complications, including pleural effusion in 271 (26%), pneumothorax in 152 (15%), hemothorax in 128 (12%), empyema in 47 (5%), and chylothorax in 9 (1%). Risk factors for pleural complications within the first 3 months included higher recipient-to-donor weight ratio, lower recipient albumin, and recipient-to-donor race mismatch; risk factors extending beyond 3 months included older age, hypertension, smoking history, lower lung allocation score, and donor death from anoxia. Cardiopulmonary bypass and previous thoracic interventions were not risk factors in patients with pleural effusions who were treated with thoracentesis only, and forced expiratory volume in 1 second improved after drainage; however, repeat percutaneous or surgical interventions did not impart a similar benefit. Pleural complications were associated with worse survival.

Conclusions: Pleural complications are common after lung transplantation and are associated with worse allograft function and survival. These complications are likely secondary to other underlying clinical problems. Malnourishment and size mismatch are modifiable risk factors.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.052DOI Listing
February 2021

Cardiac papillary fibroelastoma originating from the coumadin ridge and review of literature.

BMJ Case Rep 2020 Aug 26;13(8). Epub 2020 Aug 26.

Cardiovascular Medicine, Fairview Hospital, Cleveland, Ohio, USA.

Papillary fibroelastomas represent the second most common benign cardiac tumour, secondary only to cardiac myxoma. A majority of patients are asymptomatic on presentation. The most common clinical manifestations include stroke, transient ischaemic attack, myocardial infarction and angina. Echocardiography remains the primary imaging modality for identification of these tumours. The majority of papillary fibroelastomas arise from the valves. Simple surgical excision is the mainstay of treatment, carrying an excellent prognosis. We present an unusual case of cardiac papillary fibroelastoma originating from the coumadin ridge (CR) in a 70-year-old woman. The patient exhibited increasing paroxysms of her atrial fibrillation and was pursuing a MAZE procedure. Preoperatively, a transesophageal echocardiogram revealed a 0.7×1 cm intracardiac mass that had echocardiographic appearance of a fibroelastoma. Surgical resection and MAZE procedures were performed. The gross specimen and histopathology findings were consistent with papillary fibroelastoma. This case reports the seventh documented case of fibroelastoma originating from the CR.
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http://dx.doi.org/10.1136/bcr-2020-235361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451947PMC
August 2020

Early Outcomes of Transconal Repair of Transseptal Anomalous Left Coronary Artery From Right Sinus.

Ann Thorac Surg 2021 08 19;112(2):595-602. Epub 2020 Aug 19.

Division of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: Anomalous aortic origin of the left coronary artery (AAOCLA) with an extended transseptal course behind the right ventricular outflow tract (RVOT) is a rare variant that poses challenges not addressed by current surgical techniques. We utilized a novel transconal approach in 7 consecutive patients.

Methods: A retrospective review was made of a prospectively collected database for consecutive patients undergoing transconal unroofing of transseptal AAOLCA. Surgical repair entails transection of the RVOT, unroofing the septal course of the AAOLCA, followed by RVOT extension with a rectangular strip of autologous pericardium. Preoperative characteristics, operative details, and postoperative course were abstracted.

Results: All 7 patients identified were symptomatic. Median age was 48 years (range, 12 to 62). The AAOLCA with transseptal course was confirmed by computed tomography angiography. Three patients had provocative testing demonstrating anterolateral ischemia. Four patients underwent cardiac catheterization with intravascular ultrasound and indexed fractional flow reserve, confirming flow-limiting lesion. Importantly, 3 patients had negative provocative noninvasive testing for ischemia. Median postoperative hospital length of stay was 6 days (range, 4 to 12). No mortality or major complications occurred during a median follow-up of 0.75 years. Postoperative evaluation demonstrated anatomically patent unroofed AAOLCA with improved indexed fractional flow reserve compared with preoperative (0.59 ± 0.16 vs 0.90 ± 0.03, P = .05).

Conclusions: Complete unroofing of AAOLCA with transseptal course repaired with posterior extension of RVOT is an effective technique with excellent early outcome. Multimodality provocative testing is critical to evaluate these lesions as individual studies may be misleading. Intravascular ultrasound with indexed fractional flow reserve is clinically useful to confirm the hemodynamic significance of specific lesions.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.149DOI Listing
August 2021

Impact of thoracic aortic aneurysm on outcomes of transcatheter aortic valve replacement: A nationwide cohort analysis.

Catheter Cardiovasc Interv 2021 02 13;97(3):549-553. Epub 2020 Aug 13.

Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.

Background: The use of transcatheter aortic valve replacement (TAVR) has expanded to patient populations of varying surgical risk in light of recent clinical trials, yet its role in patients with aortic stenosis and coexisting thoracic aortic aneurysm (TAA) is not well-delineated. We aimed to evaluate whether risk factors and in-hospital outcomes vary between TAVR patients with and without an unruptured TAA.

Methods: The Nationwide Readmissions Database was queried for patients hospitalized between January 2012 and December 2017 who underwent TAVR with and without an unruptured TAA. In-hospital outcomes were compared between cohorts after adjusting for sex, comorbidities, and TAVR approach, and in a subgroup analysis that excluded those with bicuspid aortic valves.

Results: Among 171,011 TAVR patients, 1,677 (1%) presented with TAA. Patients with TAA were younger (median age 80 vs. 82 years, p < .001) and more likely to have bicuspid aortic valves (9.3% vs. 0.9%, p < .001). Among patients with aneurysm, 2.6% died, 2.2% developed stroke, 1% developed aortic dissection, and 1.4% experienced cardiac tamponade while hospitalized. After adjusting for age, sex, bicuspid aortic valve, and all comorbidities, TAA was associated with significantly higher risk of post-TAVR aortic dissection (OR = 2.117, 95% CI [1.304-3.435], p = .002) and cardiac tamponade (OR = 1.682, 95% CI [1.1-2.572], p = .02).

Conclusions: While the overall incidence of post-TAVR complications is low, patients with an unruptured TAA should be carefully considered by the Heart Team in weighing the additional risks of aortic dissection and cardiac tamponade after TAVR with those associated with surgery.
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http://dx.doi.org/10.1002/ccd.29195DOI Listing
February 2021

Contemporary Outcomes of Pulmonary Valve Endocarditis: A 16-Year Single Centre Experience.

Heart Lung Circ 2020 Dec 11;29(12):1799-1807. Epub 2020 Jun 11.

Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Background: Limited data exist regarding the clinical characteristics and contemporary outcomes of patients with pulmonary valve (PoV) infective endocarditis (IE).

Methods: This is a retrospective cohort study of patients with a confirmed diagnosis of IE affecting the PoV at our centre between January 2002 and October 2018. Electronic medical records were reviewed to gather the clinical and echocardiographic variables. The population was subdivided according to risk factor profiles: group 1: miscellaneous risk factors; group 2: patients with congenital heart disease (CHD); and group 3: patients who inject drugs (PWID). The primary outcome was all-cause mortality.

Results: Out of 2,124 cases of IE during the study period, 24 (1.1%) patients had PoV IE. The majority of cases of PoV IE occurred in patients with prosthetic valves (54.2%). Coagulase-negative Staphylococci species were the most common micro-organisms. Seventy-five per cent (75%) of the patients required surgical management. The median follow-up was 2.8 years (interquartile range: 0.2-5.3 years). Patients with miscellaneous risk factors were older (p<0.01), and had higher rates of hypertension (p=0.01) and hyperlipidaemia (p=0.04). There was a statistically significant difference in survival between the groups (p=0.03), mainly driven by better outcomes of patients with CHD, compared to those with miscellaneous risk factors.

Conclusions: In a contemporary 16-year series, a high proportion of patients with PoV IE required surgical management. Patients with PoV IE and CHD had better survival, compared to patients with miscellaneous risk factors at a median follow-up of 2.8 years.
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http://dx.doi.org/10.1016/j.hlc.2020.04.015DOI Listing
December 2020

Surgical infective endocarditis and concurrent splenic abscess requiring splenectomy: a case series and review of the literature.

Diagn Microbiol Infect Dis 2020 Aug 17;97(4):115082. Epub 2020 May 17.

Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Splenic abscess is an uncommon but serious complication of infective endocarditis (IE). The timing of surgical management of splenic abscess can be challenging when valve surgery is required. The American Heart Association (AHA) and the European Society of Cardiology (ESC) currently recommends splenectomy before valve replacement due to fear of reinfection of the heart valve; however, published data to support this recommendation are limited. In this series, we report outcomes for 5 patients with IE and splenic abscess who underwent valve replacement first, followed by splenectomy at a median of 19 days (range: 10-77 days) after valve surgery, with no recurrent infection of the new valve. Our experience and review of the available literature provide reassurance for splenectomy after valve surgery for IE.
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http://dx.doi.org/10.1016/j.diagmicrobio.2020.115082DOI Listing
August 2020
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