Publications by authors named "Thoralf M Sundt"

391 Publications

International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes.

Radiol Cardiothorac Imaging 2021 Aug 22;3(4):e200496. Epub 2021 Jul 22.

St Paul's Hospital, University of British Columbia, Vancouver, Canada.

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes. ©  2021 Jointly between the RSNA, the European Association for Cardio-Thoracic Surgery, The Society of Thoracic Surgeons, and the American Association for Thoracic Surgery. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. All rights reserved. Bicuspid Aortic Valve, Aortopathy, Nomenclature, Classification.
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http://dx.doi.org/10.1148/ryct.2021200496DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424700PMC
August 2021

Are Significant Differences Significant?

Authors:
Thoralf M Sundt

Ann Thorac Surg 2021 Aug 10. Epub 2021 Aug 10.

Division of Cardiac Surgery, Massachusetts General Hospital, 55 Fruit Street, Cox 652, Boston, MA 2114. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2021.07.022DOI Listing
August 2021

The role of diffuse correlation spectroscopy and frequency-domain near-infrared spectroscopy in monitoring cerebral hemodynamics during hypothermic circulatory arrests.

JTCVS Tech 2021 Jun 29;7:161-177. Epub 2021 Jan 29.

Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.

Objectives: Real-time noninvasive monitoring of cerebral blood flow (CBF) during surgery is key to reducing mortality rates associated with adult cardiac surgeries requiring hypothermic circulatory arrest (HCA). We explored a method to monitor cerebral blood flow during different brain protection techniques using diffuse correlation spectroscopy (DCS), a noninvasive optical technique which, combined with frequency-domain near-infrared spectroscopy (FDNIRS), also provides a measure of oxygen metabolism.

Methods: We used DCS in combination with FDNIRS to simultaneously measure hemoglobin oxygen saturation (SO), an index of cerebral blood flow (CBF), and an index of cerebral metabolic rate of oxygen (CMRO) in 12 patients undergoing cardiac surgery with HCA.

Results: Our measurements revealed that a negligible amount of blood is delivered to the cerebral cortex during HCA with retrograde cerebral perfusion, indistinguishable from HCA-only cases (median CBF drops of 93% and 95%, respectively) with consequent similar decreases in SO (mean decrease of 0.6 ± 0.1% and 0.9 ± 0.2% per minute, respectively); CBF and SO are mostly maintained with antegrade cerebral perfusion; the relationship of CMRO to temperature is given by CMRO = 0.052e.

Conclusions: FDNIRS-DCS is able to detect changes in CBF, SO, and CMRO with intervention and can become a valuable tool for optimizing cerebral protection during HCA.
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http://dx.doi.org/10.1016/j.xjtc.2021.01.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8311503PMC
June 2021

International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes.

J Thorac Cardiovasc Surg 2021 Sep 22;162(3):e383-e414. Epub 2021 Jul 22.

St Paul's Hospital, University of British Columbia, Vancouver, Canada.

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.
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http://dx.doi.org/10.1016/j.jtcvs.2021.06.019DOI Listing
September 2021

Summary: International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional, and research purposes.

J Thorac Cardiovasc Surg 2021 09 22;162(3):781-797. Epub 2021 Jul 22.

St Paul's Hospital, University of British Columbia, Vancouver, Canada; aeCedars Sinai Heart Institute, Los Angeles, Calif; afDivision of Cardiology, Columbia University Irving Medical Center/NY Presbyterian Hospital, New York, NY.

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.
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http://dx.doi.org/10.1016/j.jtcvs.2021.05.008DOI Listing
September 2021

Summary: International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes.

Ann Thorac Surg 2021 09 22;112(3):1005-1022. Epub 2021 Jul 22.

St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.
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http://dx.doi.org/10.1016/j.athoracsur.2021.05.001DOI Listing
September 2021

International Consensus Statement on Nomenclature and Classification of the Congenital Bicuspid Aortic Valve and Its Aortopathy, for Clinical, Surgical, Interventional and Research Purposes.

Ann Thorac Surg 2021 09 22;112(3):e203-e235. Epub 2021 Jul 22.

St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.119DOI Listing
September 2021

International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes.

Eur J Cardiothorac Surg 2021 Sep;60(3):448-476

St Paul's Hospital, University of British Columbia, Vancouver, Canada.

This International Consensus Classification and Nomenclature for the congenital bicuspid aortic valve condition recognizes 3 types of bicuspid valves: 1. The fused type (right-left cusp fusion, right-non-coronary cusp fusion and left-non-coronary cusp fusion phenotypes); 2. The 2-sinus type (latero-lateral and antero-posterior phenotypes); and 3. The partial-fusion (forme fruste) type. The presence of raphe and the symmetry of the fused type phenotypes are critical aspects to describe. The International Consensus also recognizes 3 types of bicuspid valve-associated aortopathy: 1. The ascending phenotype; 2. The root phenotype; and 3. Extended phenotypes.
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http://dx.doi.org/10.1093/ejcts/ezab038DOI Listing
September 2021

Summary: international consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes.

Eur J Cardiothorac Surg 2021 Sep;60(3):481-496

St Paul's Hospital, University of British Columbia, Vancouver, Canada.

This International evidence-based nomenclature and classification consensus on the congenital bicuspid aortic valve and its aortopathy recognizes 3 types of bicuspid aortic valve: 1. Fused type, with 3 phenotypes: right-left cusp fusion, right-non cusp fusion and left-non cusp fusion; 2. 2-sinus type with 2 phenotypes: Latero-lateral and antero-posterior; and 3. Partial-fusion or forme fruste. This consensus recognizes 3 bicuspid-aortopathy types: 1. Ascending phenotype; root phenotype; and 3. extended phenotypes.
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http://dx.doi.org/10.1093/ejcts/ezab039DOI Listing
September 2021

Outcomes of Lung Transplantation from HCV Viremic Donors.

Ann Thorac Surg 2021 May 29. Epub 2021 May 29.

Department of Cardiothoracic Surgery, Methodist Hospital, San Antonio, TX.

Background: Direct-acting antiviral (DAA) therapy for hepatitis C (HCV) has encouraged lung transplantation with HCV+ donors. Early trials have been promising(1, 2), however nationwide data has not been previously examined.

Methods: The United Network for Organ Sharing registry was queried for adult patients receiving lung transplants from 2016-2019. We excluded multiorgan transplants, incomplete data, and loss to follow-up. Nucleic acid testing (NAT) determined HCV status. Propensity matching was performed for comparison of outcomes.

Results: HCV NAT+ lungs were transplanted in 189 patients, compared to 9511 recipients of NAT- lungs. HCV NAT+ donors were younger (mean: 33 vs 35 years, p=0.017) with higher rates of PaO2/FiO2 >300 (83.6% vs 76.5%, p=0.029). Recipients of NAT+ lungs had lower lung allocation scores (mean: 39.3 vs 42.4; p=0.009). Distance traveled was significantly further for HCV viremic donor lungs (mean: 416 vs 206 miles, p<0.001). Kaplan Meier survival analysis demonstrated no difference in survival (p=0.56). There were no differences in airway dehiscence (p-0.629), acute rejection (p>0.999) or reintubation (p=0.304). At mean follow-up of 395 days, 63 recipients of NAT+ lungs (40.0%) seroconverted, 14 with viremia. 1-year mortality rates among seroconverted patients was 6.0% and did not differ significantly from 14.0% in non-seroconverted patients or 13.2% in recipients of HCV-negative lungs.

Conclusions: Short-term outcomes of lung transplantation from HCV viremic donors are promising, with no difference in early complications or survival. The effects of seroconversion and long-term outcomes including chronic rejection and infection need to be further explored.
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http://dx.doi.org/10.1016/j.athoracsur.2021.05.010DOI Listing
May 2021

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

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

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

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

Mitral Surgery After Transcatheter Edge-to-Edge Repair: Society of Thoracic Surgeons Database Analysis.

J Am Coll Cardiol 2021 07 1;78(1):1-9. Epub 2021 May 1.

Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Transcatheter edge-to-edge (TEER) mitral repair may be complicated by residual or recurrent mitral regurgitation. An increasing need for surgical reintervention has been reported, but operative outcomes are ill defined.

Objectives: This study evaluated national outcomes of mitral surgery after TEER.

Methods: The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify 524 adults who underwent mitral surgery after TEER between July 2014 and June 2020. Emergencies (5.0%; n = 26), previous mitral surgery (5.3%; n = 28), or open implantation of transcatheter prostheses (1.5%; n = 8) were excluded. The primary outcome was 30-day or in-hospital mortality.

Results: In the study cohort of 463 patients, the median age was 76 years (interquartile range [IQR]: 67 to 81 years), median left ventricular ejection fraction was 57% (IQR: 48% to 62%), and 177 (38.2%) patients had degenerative disease. Major concomitant cardiac surgery was performed in 137 (29.4%) patients: in patients undergoing isolated mitral surgery, the median STS-predicted mortality was 6.5% (IQR: 3.9% to 10.5%), the observed mortality was 10.2% (n = 23 of 225), and the ratio of observed to expected mortality was 1.2 (95% confidence interval [CI]: 0.8 to 1.9). Predictors of mortality included urgent surgery (odds ratio [OR]: 2.4; 95% CI: 1.3 to 4.6), nondegenerative/unknown etiology (OR: 2.2; 95% CI: 1.1 to 4.5), creatinine of >2.0 mg/dl (OR: 3.8; 95% CI: 1.9 to 7.9) and age of >80 years (OR: 2.1; 95% CI: 1.1 to 4.4). In a volume outcomes analysis in an expanded cohort of 591 patients at 227 hospitals, operative mortality was 2.6% (n = 2 of 76) in 4 centers that performed >10 cases versus 12.4% (n = 64 of 515) in centers performing fewer (p = 0.01). The surgical repair rate after failed TEER was 4.8% (n = 22) and was 6.8% (n = 12) in degenerative disease.

Conclusions: This study indicates that mitral repair is infrequently achieved after failed TEER, which may have implications for treatment choice in lower-risk and younger patients with degenerative disease. These findings should inform patient consent for TEER, clinical trial design, and clinical performance measures.
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http://dx.doi.org/10.1016/j.jacc.2021.04.062DOI Listing
July 2021

Association between hospital cardiovascular procedural volumes and transcatheter mitral valve repair outcomes.

Cardiovasc Revasc Med 2021 Apr 21. Epub 2021 Apr 21.

Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. Electronic address:

Background: Cardiovascular procedural volumes can serve as metrics of hospital infrastructure and quality, and are the basis for thresholds for initiating transcatheter mitral valve repair (TMVr) programs. Whether hospital volumes of TMVr, surgical mitral valve replacement or repair (SMVRr), and percutaneous coronary intervention (PCI) are indicators of TMVr quality of care is not known.

Methods: We used the 2017 Nationwide Readmissions Database to identify hospitals that performed at least 5 TMVr procedures. Hospitals were divided into quartiles of TMVr volume. Associations of hospital TMVr, SMVRr, and PCI volumes, as well as SMVRr and PCI outcomes with TMVr outcomes were examined. Outcomes studied were risk-standardized in-hospital mortality rate (RSMR) and 30-day readmission rate (RSRR).

Results: The study included 3404 TMVr procedures performed across 150 hospitals in the US. The median hospital TMVr volume was 17 (IQR 10, 28). The mean hospital-level RSMR and RSRR for TMVr were 3.0% (95% CI 2.5%, 3.4%) and 14.8% (95% CI 14.5%, 15.0%), respectively. There was no significant association between hospital TMVr volume (as quartiles or as a continuous variable) and TMVr RSMR or RSRR (P > 0.05). Similarly, there was weak or no correlation between hospital SMVRr and PCI volumes and outcomes with TMVr RSMR or RSRR (Pearson correlation coefficients, r = -0.199 to 0.269).

Conclusion: In this study, we found no relationship between hospital TMVr, SMVRr, and PCI volume and TMVr outcomes. Further studies are needed to determine more appropriate structure and process measures to assess the performance of established and new TMVr centers.
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http://dx.doi.org/10.1016/j.carrev.2021.04.017DOI Listing
April 2021

Commentary: The three Cs of a successful heart center intensive care unit: Cooperation, coordination, and communication.

J Thorac Cardiovasc Surg 2021 Mar 30. Epub 2021 Mar 30.

Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.085DOI Listing
March 2021

Commentary: Lesson from 0.9538° S, 90.9656° W: Survival of the adaptable.

Authors:
Thoralf M Sundt

J Thorac Cardiovasc Surg 2021 Mar 2. Epub 2021 Mar 2.

Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.02.089DOI Listing
March 2021

Outcomes of open and endovascular repair of Kommerell diverticulum.

Eur J Cardiothorac Surg 2021 07;60(2):305-311

Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Objectives: Kommerell diverticulum (KD) is a rare congenital vascular anomaly often associated with an aberrant subclavian artery (ASCA). Definitive indications for intervention remain unclear. We present open and endovascular (EV) operative outcomes in a large contemporary series and propose a management algorithm.

Methods: Between 2004 and 2020, 224 patients presented with ASCA and associated KD to our institution. Of the 43 (19.2%) patients who underwent operative repair, 31 (72.1%) had open surgical (OS) repair via thoracotomy and 12 (27.9%) had EV repair. Univariable and bivariable statistical analyses were conducted stratified by approach. The median follow-up time was 5.4 years (IQR, 2.9-9.7).

Results: Patients in EV group were older (68 years vs 47 years, P < 0.001) and had larger aneurysms (base diameter 3.2 cm vs 21.5 cm, P = 0.007). All patients with dysphagia lusoria were treated with open surgery (n = 20). Asymptomatic patients with incidentally detected KD (50% vs 16.1%), those with chest or back pain (50% vs 19.4%) and patients who presented with an aortic emergency (25% vs 6.5%) were more likely to be treated endovascularly (P = 0.001). Carotid-to-subclavian bypass was used in 38 (88.4%) patients. There were no operative mortalities. In-hospital mortality was similar between groups (3.2% vs 16.7%, P = 0.121). Mid-term mortality was higher in the EV group [4 (33.8%) vs 0, P < 0.001]. There were 2 (15.4%) postoperative strokes in the EV group. There were no statistically significant differences in other postoperative complications or hospital length of stay between groups.

Conclusions: KD can be managed using open or EV approaches with low morbidity and mortality. Treatment strategy should depend on clinical presentation and patient factors.
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http://dx.doi.org/10.1093/ejcts/ezab072DOI Listing
July 2021

Trends in the use of hepatitis C viremic donor hearts.

J Thorac Cardiovasc Surg 2020 Sep 16. Epub 2020 Sep 16.

Department of Surgery, Massachusetts General Hospital, Boston, Mass; Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass. Electronic address:

Objective: To examine trends in utilization of hearts from hepatitis C virus (HCV) viremic donors for transplantation, a strategy to expand organ availability.

Methods: The United Network for Organ Sharing (UNOS) registry was queried for adult patients undergoing heart transplantation between 2015 and 2019. We excluded multiorgan transplants, incomplete data, and loss to follow-up. Nucleic acid testing (NAT) defined HCV status.

Results: Between 2015 and 2019, a total of 11,393 adults underwent heart transplantation: 326 from HCV NAT donors and 11,067 from NAT donors. The use of NAT hearts increased from 1 in 2015 to 137 in 2018 against a static number of NAT organs. The use of NAT hearts varied significantly across regions and individual centers. More than 75% of NAT hearts were transplanted in the Northeast region, leading to further travel (mean, 299 miles vs 173 miles for NAT transplantations; P < .001), with longer ischemic times (mean: 3.52 hours vs 3.10 hours; P < .001). More than one-half of NAT transplantations were performed by 5 individual centers, and a single institution accounted for >20% of all transplantations from viremic donors. Survival in the 2 groups did not differ by Kaplan-Meier analysis (P = .240), and multivariable regression showed no differences in acute rejection (P = .455) or 30-day mortality (P = .490). Of the 326 recipients of NAT hearts, 38 seroconverted and 14 became viremic within 1 year. Survival was 100% in the viremic patients and 97.4% in seroconverted patients at 1 year.

Conclusions: Heart transplantation from HCV viremic donors continues to increase but varies significantly across UNOS regions and individual centers. Short-term outcomes are comparable, but effects of seroconversion and long-term outcomes remain unclear.
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http://dx.doi.org/10.1016/j.jtcvs.2020.09.044DOI Listing
September 2020

Non-Vitamin K Antagonist Oral Anticoagulant vs Warfarin for Post Cardiac Surgery Atrial Fibrillation.

Ann Thorac Surg 2021 Jan 10. Epub 2021 Jan 10.

Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Background: Treatment guidelines for nonvalvular atrial fibrillation (AF) recommend use of non-vitamin K antagonist oral anticoagulants (NOACs) over warfarin, yet clinical trials excluded individuals with post cardiac surgery AF. We sought to compare outcomes with NOACs vs warfarin for new onset post cardiac surgery AF.

Methods: We examined 26,522 patients from The Society of Thoracic Surgeons' database with post cardiac surgery AF who were discharged on oral anticoagulation from July 2017-December 2018. Three primary outcomes were evaluated: 30-day mortality, major bleeding complications, and stroke/transient ischemic attack. Secondary outcomes included postoperative length of stay, 30-day myocardial infarction, venous thromboembolism, and pericardial effusion/tamponade.

Results: A total of 9769 (36.8%) participants were prescribed NOACs and 16,753 (63.2%) warfarin. In multivariable analysis, there was no association between type of anticoagulant and 30-day major bleeding complications (odds ratio [OR] 0.76, 95% confidence interval [CI] 0.49-1.18), stroke/transient ischemic attack (OR 0.94, 95% CI 0.53-1.67) or mortality (OR 1.08, 95% CI 0.80-1.45). After stratification by renal function or isolated coronary bypass vs valve surgery, there remained no difference in the primary outcomes. Additionally, there was no difference in 30-day myocardial infarction (OR 1.17, 95% CI 0.62-2.22), venous thromboembolism (OR 0.91, 95% CI 0.47-1.78), or pericardial effusion/tamponade (OR 1.09, 95% CI 0.80-1.47) between the 2 groups. NOAC therapy was associated with a half-day reduction in postoperative length of stay (β -0.47, 95% CI -0.62 to -0.33).

Conclusions: NOACs are associated with a reduction in postoperative length of stay, without excess bleeding or other short-term complications, compared with warfarin. These findings support the broader use of NOACs as a safe alternative to warfarin in patients with post cardiac surgery AF at elevated stroke risk and acceptable bleeding risk.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.031DOI Listing
January 2021

Factors Related to Survival in Low-Glomerular Filtration Rate Cohorts Undergoing Lung Transplant.

Ann Thorac Surg 2021 Jan 7. Epub 2021 Jan 7.

Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: Historically, a glomerular filtration rate (GFR) of less than 50 mL/min per 1.73 m has been considered a contraindication to lung transplantation. Combined or sequential lung-kidney transplantation is an option for those with a GFR less than 30 mL/min per 1.73 m. Patients with a GFR of 30 to 50 mL/min per 1.73 m are provided with no options for transplantation. This study explores factors associated with improved survival in patients who undergo isolated lung transplantation with a GFR of 30 to 50 mL/min per 1.73 m.

Methods: The United Network for Organ Sharing database was queried for adult patients undergoing primary isolated lung transplantation between January 2007 and March 2018. Regression models were used to identify factors associated with improved survival in lung recipients with a preoperative GFR of 30 to 50 mL/min per 1.73 m. The propensity score method was used to match highly performing patients (outpatient recipients aged less than 60 years) with a GFR of 30 to 50 mL/min per 1.73 m with patients who had a GFR greater than 50 mL/min per 1.73 m. Kaplan-Meier, Cox, and logistic regression analyses compared outcomes in matched populations.

Results: A total of 21,282 lung transplantations were performed during the study period. Compared with patients with a GFR greater than 50 mL/min per 1.73 m, survival was significantly worse for patients with a GFR of 30 to 50 mL/min per 1.73 m. Multivariate analysis of patients with a GFR of 30 to 50 mL/min per 1.73 m demonstrated outpatient status and age less than 60 years to be predictive of superior survival. After propensity matching, survival of this highly performing subset with a GFR of 30 to 50 mL/min per 1.73 m was no different from that of patients with a normal GFR.

Conclusions: Outpatient recipients aged less than 60 years represent an optimal subset of patients with a GFR of 30 to 50 mL/min per 1.73 m. Lung transplant listing should not be declined based only on a GFR less than 50 mL/min per 1.73 m.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.021DOI Listing
January 2021

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

J Am Coll Cardiol 2021 02 17;77(4):450-500. Epub 2020 Dec 17.

Aim: This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

Methods: A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline.

Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.
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http://dx.doi.org/10.1016/j.jacc.2020.11.035DOI Listing
February 2021

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

Circulation 2021 Feb 17;143(5):e35-e71. Epub 2020 Dec 17.

Aim: This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

Methods: A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.
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http://dx.doi.org/10.1161/CIR.0000000000000932DOI Listing
February 2021

Joint preoperative transthoracic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality.

Interact Cardiovasc Thorac Surg 2021 01;32(1):9-19

Department of Anesthesiology, Boston University School of Medicine, Boston, MA, USA.

Objectives: Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P.

Methods: Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics.

Results: In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11-1.55) vs 1.02 (0.89-1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96-2.14) vs 1.27 (0.80-2.02)].

Conclusions: In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy.
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http://dx.doi.org/10.1093/icvts/ivaa230DOI Listing
January 2021

In the Realm of Nature There Is Nothing Purposeless, Trivial, or Unnecessary.

Authors:
Thoralf M Sundt

Ann Thorac Surg 2021 10 9;112(4):1227. Epub 2020 Dec 9.

Division of Cardiac Surgery, Massachusetts General Hospital, 55 Fruit St, Cox 652, Boston, MA 2114. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2020.10.052DOI Listing
October 2021

Revascularization for Isolated Proximal Left Anterior Descending Artery Disease.

Ann Thorac Surg 2021 08 2;112(2):555-562. Epub 2020 Nov 2.

Department of Anesthesiology, Columbia-Presbyterian Irving Medical Center, New York, New York.

Background: Most studies of patients with isolated proximal left anterior descending (PLAD) coronary artery disease do not include all 3 procedural options: percutaneous coronary intervention (PCI), conventional coronary artery bypass graft (CABG) surgery, or minimally invasive CABG.

Methods: New York's cardiac registries were used to identify patients who underwent revascularization for isolated PLAD disease between January 1, 2010, and November 30, 2016, in New York State. After exclusions, 14,327 patients, of whom 13,115 received PCI, 1001 of whom underwent CABG surgery, and 211 of whom underwent minimally invasive CABG were monitored through the end of 2017 to compare outcomes. Registry data were matched to vital statistics data to obtain deaths occurring after discharge and matched to claims data to obtain subsequent admissions for myocardial infarction and stroke.

Results: There were no significant differences in mortality or in mortality/myocardial infarction/stroke after 7 years (with median follow-up times in excess of 4 years) among the 3 procedures after adjusting for differences in patient risk factors. However, conventional CABG surgery was associated with a lower subsequent revascularization rate than PCI (adjusted hazard ratio, 0.45; 95% confidence interval, 0.35-0.58) and minimally invasive CABG surgery (adjusted hazard ratio, 0.46; 95% confidence interval, 0.32-0.66).

Conclusions: Among patients with isolated PLAD disease undergoing any of 3 revascularization options (PCI, conventional CABG surgery, or minimally invasive CABG surgery), conventional CABG surgery was associated with lower subsequent revascularization rates, but there were no differences in mortality or mortality/myocardial infarction/stroke rates.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.049DOI Listing
August 2021

Association of Anesthesiologist Handovers With Short-term Outcomes for Patients Undergoing Cardiac Surgery.

Anesth Analg 2020 12;131(6):1883-1889

Department of Anesthesiology, Columbia-Presbyterian Medical Center, New York, New York.

Background: Complete handover of anesthesia care to a second anesthesiologist has been demonstrated to be associated with worse short-term adverse outcomes among cardiac surgery patients, but little information from multi-institutional studies is available.

Methods: New York's cardiac surgery registry was used to identify patients who underwent cardiac surgery in New York between 2010 and 2016 with and without complete handovers of anesthesia care. A retrospective observational study with inverse probability treatment weighting (IPTW) based on the propensity score was used to adjust for differences in preoperative patient characteristics while comparing differences in the primary outcome (in-hospital/30 day mortality), major complications in the index admission or within 30 days of the index surgery, readmissions within 30 days, and length of stay.

Results: A total of 8.5% of the 103,102 cardiac surgery procedures involved complete handovers. After adjustment, there was a difference between patients with and without handovers in the primary outcome (2.86% vs 2.48%, adjusted risk ratio [ARR] = 1.15 [1.01-1.31]). There was no difference in readmissions within 30 days (13.7% vs 14.4%, ARR = 0.95 [0.90-1.00]), and the differences in complications and length of stay were not clinically meaningful (adjusted differences of <10%).

Conclusions: Cardiac surgery patients in New York who had complete anesthesia handovers experienced higher short-term mortality rates, but there were no meaningful differences in other outcomes. Unnecessary handovers should be carefully monitored.
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http://dx.doi.org/10.1213/ANE.0000000000005221DOI Listing
December 2020
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