Publications by authors named "Vinay Badhwar"

231 Publications

Utilization and outcomes of transesophageal echocardiography in 1.3 million CABG procedures.

J Am Coll Cardiol 2021 Apr 28. Epub 2021 Apr 28.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida.

Background: Utilization of intraoperative transesophageal echocardiography (TEE) at time of isolated coronary artery bypass grafting (CABG), impact on clinical decision making and associated outcomes are not well understood.

Objective: To determine the association of TEE with post-CABG mortality and changes to the operative plan.

Methods: We performed a retrospective cohort study of planned isolated CABG patients from the Society of Thoracic Surgeons Adult Cardiac Surgery Database between January 1, 2011 and June 30, 2019. The exposure variable of interest was use of intraoperative TEE during CABG, compared to no TEE. The primary outcome was operative mortality. We also assessed the association of TEE with unplanned valve surgery.

Results: Of 1,255,860 planned isolated CABG procedures across 1218 centers, 676,803 (53.9%) had intra-operative TEE. The proportion of patients receiving intra-operative TEE increased over time from 39.9% in 2011 to 62.1% in 2019 (Ptrend<0.0001). CABG patients undergoing intra-operative TEE had lower odds of mortality (adjusted OR 0.95, 95% CI 0.91-0.99, P=0.025), with heterogeneity across STS risk groups (Pinteraction 0.015). TEE was associated with increased odds of unplanned valve procedure in lieu of planned isolated CABG (adjusted OR 4.98, 95% CI 3.98-6.22, P<0.0001) CONCLUSION: Intra-operative TEE usage during planned isolated CABG is associated with lower operative mortality, particularly in higher risk patients, as well as greater odds of unplanned valve procedure. Our findings support usage of TEE to improve outcomes for isolated CABG for high risk patients.
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http://dx.doi.org/10.1016/j.jacc.2021.04.064DOI Listing
April 2021

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

Circulation 2021 May 5. Epub 2021 May 5.

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

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

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

J Am Coll Cardiol 2021 Apr 27. Epub 2021 Apr 27.

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

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

Conclusion: This study indicates 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
April 2021

Multi-institutional Analysis of 100 Consecutive Patients with COVID-19 and Severe Pulmonary Compromise Treated with Extracorporeal Membrane Oxygenation: Outcomes and Trends Over Time.

ASAIO J 2021 05;67(5):496-502

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.

The role of extracorporeal membrane oxygenation (ECMO) in the management of severely ill patients with coronavirus disease 2019 (COVID-19) continues to evolve. The purpose of this study is to review a multi-institutional clinical experience in 100 consecutive patients, at 20 hospitals, with confirmed COVID-19 supported with ECMO. This analysis includes our first 100 patients with complete data who had confirmed COVID-19 and were supported with ECMO. The first patient in the cohort was placed on ECMO on March 17, 2020. Differences by the mortality group were assessed using χ2 tests for categorical variables and Kruskal-Wallis rank-sum tests and Welch's analysis of variance for continuous variables. The median time on ECMO was 12.0 days (IQR = 8-22 days). All 100 patients have since been separated from ECMO: 50 patients survived and 50 patients died. The rate of survival with veno-venous ECMO was 49 of 96 patients (51%), whereas that with veno-arterial ECMO was 1 of 4 patients (25%). Of 50 survivors, 49 have been discharged from the hospital and 1 remains hospitalized at the ECMO-providing hospital. Survivors were generally younger, with a lower median age (47 versus 56.5 years, p = 0.014). In the 50 surviving patients, adjunctive therapies while on ECMO included intravenous steroids (26), anti-interleukin-6 receptor blockers (26), convalescent plasma (22), remdesivir (21), hydroxychloroquine (20), and prostaglandin (15). Extracorporeal membrane oxygenation may facilitate salvage and survival of selected critically ill patients with COVID-19. Survivors tend to be younger. Substantial variation exists in the drug treatment of COVID-19, but ECMO offers a reasonable rescue strategy.
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http://dx.doi.org/10.1097/MAT.0000000000001434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078020PMC
May 2021

Quadricuspid Aortic Valve Repair Facilitated by Geometric Ring Annuloplasty.

Innovations (Phila) 2021 Apr 20:15569845211003095. Epub 2021 Apr 20.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA.

Quadricuspid aortic valve (QAV) is a rare congenital anomaly often associated with aortic insufficiency. The exact anatomy of QAV is variable, and most cases have undergone aortic valve replacement. With the recognition that aortic valve repair achieves superior patient outcomes as compared to replacement, a systematic approach to autologous reconstruction of QAV is needed. This article reports 2 cases having successful repair utilizing geometric aortic annuloplasty rings, and describes a proposed scheme for repairing most QAV defects, based on relative leaflet and commissural characteristics. Using either tri-leaflet or bicuspid ring annuloplasty, the normal sub-commissural triangles can be remodeled into a 120° or 180° configuration, respectively, and then the leaflets can be sutured and plicated to fit annular geometry. With this approach, most quadricuspid valves potentially could undergo autologous reconstruction.
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http://dx.doi.org/10.1177/15569845211003095DOI Listing
April 2021

Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations.

Ann Thorac Surg 2021 Apr 9. Epub 2021 Apr 9.

Duke University, Durham, North Carolina.

Background: The STS Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting surgery (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations +/- CABG procedures.

Methods: Using July 2011 to June 2019 STS Adult Cardiac Surgery Database (ACSD) data, risk models for AVR+MVRR (n=31,968) and AVR+MVRR+CABG (n=12,650) were developed with the following endpoints: operative mortality, major morbidity (any one or more of the following: cardiac reoperation; deep sternal wound infection/mediastinitis; stroke; prolonged ventilation; and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 - June 2017, n=35,109) and validation (July 2017 - June 2019, n=9,509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration.

Results: C-statistics for the overall population of multiple valve +/- CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample.

Conclusions: New STS-ACSD risk models have been developed for multiple valve +/- CABG operations, and these models will be used in subsequent STS performance metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.089DOI Listing
April 2021

Barriers to atrial fibrillation ablation during mitral valve surgery.

J Thorac Cardiovasc Surg 2021 Mar 17. Epub 2021 Mar 17.

Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.

Background: Nearly 40% of patients with atrial fibrillation (AF) undergoing mitral valve surgery do not receive concomitant ablation despite societal guidelines. We assessed barriers to implementation of this evidence-based practice through a survey of cardiac surgeons in 2 statewide quality collaboratives.

Methods: Adult cardiac surgeons across 2 statewide collaboratives were surveyed on their knowledge and practice regarding AF ablation. Questions concerning experience, clinical practice, case scenarios, and barriers to implementation were included.

Results: Among 66 respondents (66 of 135; 48.9%), the majority reported "very comfortable/frequently use" cryoablation (53 of 66; 80.3%) and radiofrequency (55 of 66; 83.3%). Only 12.1% (8/66) were not aware of the recommendations. Approximately one-half of the respondents reported learning AF ablation in fellowship (50.0%; 33 of 66) or attending courses (47.0%; 31 of 66). Responses to clinical scenarios demonstrated wide variability in practice patterns. One-half of the respondents reported no barriers; others cited increased cross-clamp time, excessive patient risk, and arrhythmia incidence as obstacles. Desired interventions included cardiology/electrophysiology support, protocols, pacemaker rate information, and education in the form of site visits, videos and proctors.

Conclusions: Knowledge of evidence-based recommendations and practice patterns vary widely. These data identify several barriers to implementation of concomitant AF ablation and suggest specific interventions (mentorship/support, protocols, research, and education) to overcome these barriers.
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http://dx.doi.org/10.1016/j.jtcvs.2021.03.039DOI Listing
March 2021

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

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

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

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

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

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

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

STS Adult Cardiac Surgery Database: 2021 Update on Outcomes, Quality, and Research.

Ann Thorac Surg 2021 Mar 29. Epub 2021 Mar 29.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It has been the foundation for quality measurement and improvement activities in cardiac surgery, facilitated the generation of accurate risk adjusted performance benchmarks and serves as a platform for novel research. Recent enhancements have added to the database's functionality, ease of use, and value to multiple stakeholders. This report is the sixth in a series of annual reports that provide updated volumes, outcomes, database-related developments, quality improvement initiatives, and research summaries using the Adult Cardiac Surgery Database in the past year.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.043DOI Listing
March 2021

A 34-Year-Old Male Intravenous Drug User with a Third Episode of Tricuspid Valve Endocarditis Treated with Repeat Valve Surgery.

Am J Case Rep 2021 Mar 29;22:e927385. Epub 2021 Mar 29.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, Morgantown, WV, USA.

BACKGROUND Intravenous drug use is an epidemic in the United States. One of the complications of intravenous drug use can be infective endocarditis. The treatment for this disease is a combination of intravenous antibiotics, cardiac surgery consultation, and multidisciplinary psychiatric care. Despite surgical intervention, recurrence of disease is common. In the setting of recurrent infective endocarditis in the setting of intravenous drug use, the ethics of redo cardiac surgery has not been well-established. CASE REPORT A 34-year-old man with history of intravenous drug use presented on 3 separate occasions with infective endocarditis resulting in 3 tricuspid valve surgeries within fewer than 7 months. He said he had not injected drugs since before his first operation, he was considered to have a strong social support system, and he completed his postoperative antibiotic regimens each time. However, prior to his last operation, the patient had a urine drug screen positive for opiates without recorded prescribed opioids. Pathology reports from the 3 intraoperative specimens showed different pathogens each time. An extensive interprofessional discussion ensued. CONCLUSIONS Infective endocarditis in the setting of intravenous drug use and its treatments continue to be a point of ethical and medical discussion for all professionals involved with the care of these patients. This case could be used as an example of individualized decision-making, with rigorous ethical and medical discussion factoring into each decision for cardiac surgery. The ongoing treatment for patients with recurrent endocarditis in the setting of intravenous drug use requires more research and guidelines to help medical professionals better care for this patient population.
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http://dx.doi.org/10.12659/AJCR.927385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021270PMC
March 2021

Incremental effect of complications on mortality and hospital costs in adult ECMO patients.

Perfusion 2021 Mar 26:2676591211005697. Epub 2021 Mar 26.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA.

Introduction: Extracorporeal membrane oxygenation (ECMO) is a resource-intense modality whose usage is expanding rapidly. It is a costly endeavor and best conducted in a multidisciplinary setting. There is a growing impetus to mitigate the mortality and costs associated with ECMO. We sought to examine the impact of complications on mortality and hospital costs in patients on ECMO.

Methods: Using the NIS database, we performed multivariable logistic regression to assess the influence of complications on the primary outcome, in-hospital mortality. Similarly, we performed multivariable survey linear regression analysis to evaluate the effect of the complications on hospital costs.

Results: Of the 12,637 patients supported using ECMO between 2004 and 2013, 9836 (78%) developed at least one complication. The three most common complications were acute kidney injury (32.8%), bloodstream infection (31.8%), and bleeding (27.8%). An ECMO hospitalization with no complications was associated with median costs of $53,470, a single complication with costs of $97,560, two complications with costs of $139,035, and three complication with costs of $162,284. A single complication was associated with a 165% increase in odds of mortality. Two or three complications resulted in 375% or 627% higher odds of mortality, respectively. Having one, two, or three complications was associated with 24%, 38%, or 38% increase in median costs respectively (Figure 1). Complications associated with the highest median costs were central line-associated bloodstream infection $217,751; liver failure $176,201; bloodstream infection $169,529.

Conclusion: In-hospital mortality and costs increase with each incremental complication in patients on ECMO. Accurate prediction and mitigation of complications is likely to improve outcomes and cost.
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http://dx.doi.org/10.1177/02676591211005697DOI Listing
March 2021

Retrospective serosurveillance for anti-SARS-CoV-2 immunoglobulin during a time of low prevalence: A cautionary tale.

J Infect 2021 Mar 17. Epub 2021 Mar 17.

Respiratory Sciences, University of Leicester, LE1 9HN, United Kingdom.

We performed a retrospective screening of 428 serum samples for anti-SARS-CoV-2  immunoglobulin during a period of low prevalence. Employing two different serological tests yielded discrepant results for 10 samples; highlighting an increased risk of potential  false positive results and the need for further confirmatory testing before publication of data.
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http://dx.doi.org/10.1016/j.jinf.2021.03.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968146PMC
March 2021

Leaflet Dimensions as a Guide to Remodeling Annuloplasty During Aortic Valve Repair.

Innovations (Phila) 2021 Mar 18:1556984521997422. Epub 2021 Mar 18.

5631 Department of Cardiovascular and Thoracic Surgery, West Virginia University Heart and Vascular Institute, Morgantown, WV, USA.

Objective: In chronic aortic insufficiency (AI), the method and degree of annular downsizing required to achieve durable coaptation in aortic valve repair (AVr) remains poorly defined. This study evaluated the relationship between leaflet size and annular diameter to predict adequate annular sizing in remodeling AVr.

Methods: Under regulatory supervision, 74 patients with chronic tri-leaflet AI underwent AVr using ring annuloplasty and leaflet reconstruction. Fifty-four (73%) had ascending aortic ( = 25) and/or root ( = 29) aneurysms, and aortic grafts were sized 5 to 7 mm larger than the rings. Intraoperatively, leaflet free-edge length (FEL) was measured with special ball sizers positioned in the coronary sinus, and "normal" annular diameter was predicted from the validated formula: Required "normal" diameter = FEL/1.5. "Normal" annular diameters predicted from FEL were compared with pathologic diameters measured intraoperatively with Hegar dilators, and both were correlated with gender, age, and BSA.

Results: Average age was 62.1 ± 13.3 years (mean ± SD), 73% (54/74) were male, and 96% (71/74) had moderate-to-severe AI. All patients had annular dilatation, with a pathologic diameter 26.6 ± 2.3 mm before repair, and a predicted "normal" diameter of 21.7 ± 1.7 mm ( < 0.001). Both predicted and pathologic annular diameters were larger in men ( < 0.001), but no relationship existed with age. BSA correlated with both predicted and pathologic diameters, although variability was large.

Conclusions: Based on a simple validated method to predict "normal" annular diameter, all patients with chronic AI have some degree of annular dilatation. This finding implies that most AVr should include annuloplasty, with adequate and precise annular reduction based on leaflet size.
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http://dx.doi.org/10.1177/1556984521997422DOI Listing
March 2021

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroconversion in hematology-oncology patients.

J Med Virol 2021 Feb 17. Epub 2021 Feb 17.

Department of Clinical Microbiology, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, UK.

Since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in China at the end of 2019, the virus has spread rapidly across the globe leading to millions of infections and subsequent deaths. Although the virus infects those exposed indiscriminately, there are groups in society at an increased risk of severe infection, leading to increased morbidity. Patients suffering from hematological cancers, particularly leukemia, lymphoma, and myeloma, may be one such group and previous studies have suggested that they may be at a three to four times greater risk of severe COVID-19 after SARS-CoV-2 infection, leading to admissions to ICU, mechanical ventilation, and death compared to those without such malignancies. Serological testing for IgG seroconversion has been extensively studied in the immunocompetent, but fewer publications have characterized this process in large series of immunocompromised patients. This study described 20 patients with hematological cancers who tested positive for SARS-CoV-2 via PCR with 12 of the patients receiving further serological testing. We found that of the 12 patients screened for SARS-CoV-2 IgG antibodies, only 2 (16.6%) were able to generate an immune response to the infection. Yet despite this low seroconversion rate in this cohort, none of these patients died or became particularly unwell with COVID-19 or its related complications.
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http://dx.doi.org/10.1002/jmv.26886DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014444PMC
February 2021

Commentary: Striking the right chord.

J Thorac Cardiovasc Surg 2021 Jan 10. Epub 2021 Jan 10.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.01.002DOI Listing
January 2021

Robotic Surgery for Pediatric and Congenital Cardiac Disease.

Ann Thorac Surg 2021 Feb 1. Epub 2021 Feb 1.

University of Florida Department of Surgery Division of Thoracic and Cardiovascular Surgery 1600 SW Archer Rd Gainesville, FL 32608; Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV.

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http://dx.doi.org/10.1016/j.athoracsur.2020.11.062DOI Listing
February 2021

Anesthetic Choice for Atrial Fibrillation Ablation: A National Anesthesia Clinical Outcomes Registry Analysis.

J Cardiothorac Vasc Anesth 2021 Jan 5. Epub 2021 Jan 5.

Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology, West Virginia University, Morgantown, WV. Electronic address:

Objective: The authors evaluated the type of anesthesia administered in atrial fibrillation ablation, hypothesizing that monitored anesthesia care is used less frequently than general anesthesia.

Design: A retrospective study.

Setting: National Anesthesia Clinical Outcomes Registry data, which are multi-institutional from across the United States.

Participants: Adult patients who underwent elective atrial fibrillation ablation between 2013 and 2018.

Interventions: None.

Measurements And Main Results: National Anesthesia Clinical Outcomes Registry data were evaluated, and covariates were selected a priori within multivariate models to assess for predictors of anesthetic type. A total of 54,321 patients underwent atrial fibrillation ablation; 3,251 (6.0%) received monitored anesthesia care. Patients who received monitored anesthesia care were more likely to be >80 years old (12.4% v 4.9%; p < 0.0001), female (36.1% v 34.3%; p < 0.0001), have American Society of Anesthesiologists physical status >III (17.28% v 10.48%; p < 0.0001), and reside in urban areas (62.23% v 53.37%; p < 0.0001). They received care in the Northeast (17.6% v 10.1%; p < 0.0001) at low-volume centers (median 224 v 284 procedures; p < 0.0001). Multivariate analysis revealed that each five-year increase in age, being female, and having an American Society of Anesthesiologists physical status >III resulted in a 7% (p < 0.0001), 9% (p = 0.032), and 200% (p < 0.0001) increased odds of receiving monitored anesthesia care, respectively. Requiring additional ablation of atria or of a second arrhythmia and residing outside the Northeast resulted in a decreased odds of monitored anesthesia care (adjusted odds ratio 0.24 [p=0.002] and < 0.5 [p < 0.03], respectively). For each 50 cases performed annually at a center, the odds decreased by 5% (p = 0.005).

Conclusions: General anesthesia is the most common type of anesthesia administered for atrial fibrillation ablation. The type of anesthesia administered, however, varies with patient, procedural, and hospital characteristics.
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http://dx.doi.org/10.1053/j.jvca.2020.12.046DOI Listing
January 2021

Utilization of Thromboelastogram and Inflammatory Markers in the Management of Hypercoagulable State in Patients with COVID-19 Requiring ECMO Support.

Case Rep Crit Care 2021 15;2021:8824531. Epub 2021 Jan 15.

Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA.

The role of extracorporeal membrane oxygenation (ECMO) in the management of critically ill patients with COVID-19 is evolving. Extracorporeal support independently confers an increased predilection for thrombosis, which can be exacerbated by COVID-19-associated coagulopathy. We present the successful management of a hypercoagulable state in two patients who required venovenous ECMO for the treatment of COVID-19. This included monitoring inflammatory markers (D-dimer and fibrinogen), performing a series of therapeutic plasma exchange procedures, and administering high-intensity anticoagulation therapy and thromboelastography- (TEG-) guided antiplatelet therapy. TPE was performed to achieve goal D-dimer less than 3000 ng/mL D-dimer units ( ≤ 232 ng/mL D-dimer units) and goal fibrinogen less than 600 mg/dL ( = 200-400 mg/dL). These therapies resulted in improved TEG parameters and normalized inflammatory markers. Patients were decannulated after 37 days and 21 days, respectively. Post-ECMO duplex ultrasound of the upper and lower extremities and cannulation sites revealed a nonsignificant deep venous thrombosis at the site of femoral cannulation in patient 2 and no deep venous thrombosis in patient 1. The results of this case report show successful management of a hypercoagulable state among COVID-19 patients requiring ECMO support by utilization of inflammatory markers and TEG.
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http://dx.doi.org/10.1155/2021/8824531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814409PMC
January 2021

The Society of Thoracic Surgeons Intermacs 2020 Annual Report.

Ann Thorac Surg 2021 03 16;111(3):778-792. Epub 2021 Jan 16.

Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan. Electronic address:

The Society of Thoracic Surgeons (STS)-Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) 2020 Annual Report reviews outcomes on 25,551 patients undergoing primary isolated continuous-flow left ventricular assist device (LVAD) implantation between 2010 and 2019. In 2019, 3198 primary LVADs were implanted, which is the highest annual volume in Intermacs history. Compared with the previous era (2010-2014), patients who received an LVAD in the most recent era (2015-2019) were more likely to be African American (26.8% vs 22.9%, P < .0001) and more likely to be bridged to durable LVAD with temporary mechanical support devices (36.8% vs 26.0%, P < .0001). In 2019, 50% of patients were INTERMACS Profile 1 or 2 before durable LVAD, and 73% received an LVAD as destination therapy. Magnetic levitation technology has become the predominant design, accounting for 77% of devices in 2019. The 1- and 2-year survival in the most recent era has improved compared with 2010 to 2014 (82.3% and 73.1% vs 80.5% and 69.1%, respectively; P < .0001). Major bleeding and infection continue to be the leading adverse events. Incident stroke has declined in the current era to 12.7% at 1 year. STS-Intermacs research publications are highlighted, and the new quality initiatives are introduced.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.038DOI Listing
March 2021

Aortic Annular Enlargement in the Elderly: Short and Long-Term Outcomes in the United States.

Ann Thorac Surg 2021 Jan 6. Epub 2021 Jan 6.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA. Electronic address:

Background: Patient prosthesis mismatch (PPM) is associated with significant long-term morbidity and mortality after aortic valve replacement, but the role and outcomes of annular enlargement (AE) remains poorly defined. We hypothesized that increasing rates of AE may lead to improved outcomes for patients at risk for severe PPM.

Methods: Patients over age 65 undergoing surgical aortic valve replacement (SAVR) with or without coronary artery bypass grafting from 2008-2016 in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD) with matching Center for Medicare Services data were included (n=189,268). Univariate, multivariate, and time-to-event analysis was used to evaluate the association between AE and early and late outcomes. Patients were stratified by projected degree of PPM based on calculated effective orifice area index (EOAi).

Results: A total of 5,412 (2.9%) patients underwent AE. STS predicted mortality was similar between AE and non-AE groups (2.97% vs 2.99%, p=0.052). Patients undergoing AE had higher risk-adjusted rates of 30-day complications and death (5.4% vs 3.4%, p<0.0001), but no differences in long-term rates of stroke, heart failure re-hospitalizations or aortic valve reoperation. Survival analysis demonstrated a higher risk of mortality with AE during the first 3 years after which the survival curves cross, favoring AE.

Conclusions: These data suggest annular enlargement during SAVR is associated with increased short-term risk in a Medicare population. Survival curves crossed after three years, which may portend a benefit in select patients. However, annular enlargement is still only done in the minority of patients who are at risk for PPM.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.023DOI Listing
January 2021

Robotic aortic valve replacement.

J Thorac Cardiovasc Surg 2021 May 16;161(5):1753-1759. Epub 2020 Nov 16.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.078DOI Listing
May 2021

Transcatheter Mitral Valve Repair Following Ring Annuloplasty: Technical Challenges and the Role of Invasive Hemodynamics.

JACC Cardiovasc Interv 2020 12 11;13(23):e207-e209. Epub 2020 Nov 11.

Department of Cardiovascular Disease, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1016/j.jcin.2020.09.046DOI Listing
December 2020

Comparing SARS-CoV-2 and influenza A(H1N1)pdm09-infected patients requiring ECMO - A single-centre, retrospective observational cohort experience.

J Infect 2021 04 9;82(4):84-123. Epub 2020 Nov 9.

Clinical Microbiology, University Hospitals of Leicester, Leicester, UK; Respiratory Sciences, University of Leicester, Leicester, UK. Electronic address:

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http://dx.doi.org/10.1016/j.jinf.2020.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649630PMC
April 2021

Commentary: Cox maze with septal myectomy.

J Thorac Cardiovasc Surg 2021 03 14;161(3):1007-1008. Epub 2020 Sep 14.

Division of Cardiology, West Virginia University, Morgantown, WVa.

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http://dx.doi.org/10.1016/j.jtcvs.2020.09.035DOI Listing
March 2021

Vascular Complications Increase Hospital Charges and Mortality in Adult Patients on Extracorporeal Membrane Oxygenation in the United States.

Semin Thorac Cardiovasc Surg 2020 Sep 23. Epub 2020 Sep 23.

Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.

Patients on extracorporeal membrane oxygenation (ECMO) who suffer vascular complications frequently accrue additional procedures and costs. We sought to evaluate the effect of ECMO-related vascular complications on hospital charges and in-hospital mortality. Adult discharges involving ECMO from 2004 to 2013 in the National Inpatient Sample were examined. There were 12,636 patients in the cohort. Vascular complications, focusing on arterial complications were identified using ICD-9-CM diagnosis and procedure codes. A multivariable survey linear regression model using median hospital charges was used to model the effect of vascular complications on charges. We used multivariable survey logistic regression to evaluate the effect of vascular complications on in-hospital mortality. Of the 12,636 patients examined, 6467 (51.2%) had ECMO-related vascular complications. Median charges in patients with vascular complications were $ 477,363 (interquartile range: 258,660-875,823) and were $ 282,298 (interquartile range: 130,030-578,027) without vascular complications. On multivariable analysis, patients with vascular complications had 24% higher median charges than patients without vascular complications (Ratio: 1.24; 95% confidence interval [CI]: 1.16-1.33; P < 0.0001) and 34% higher odds of experiencing in-hospital mortality than patients without vascular complications (adjusted odds ratio: 1.34; 95% CI:1.08-1.66; P = 0.009). Vascular complications occur in over half of ECMO patients and are associated with an increased risk of high hospital charges and in-hospital mortality. These findings support the need for identification and modification of risk factors for ECMO-related vascular complications. Furthermore, the standardization of protocols using evidence-based measures to mitigate vascular complications may improve overall ECMO outcomes.
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http://dx.doi.org/10.1053/j.semtcvs.2020.09.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985037PMC
September 2020

Usefulness of Semisupervised Machine-Learning-Based Phenogrouping to Improve Risk Assessment for Patients Undergoing Transcatheter Aortic Valve Implantation.

Am J Cardiol 2020 12 15;136:122-130. Epub 2020 Sep 15.

West Virginia University Heart & Vascular Institute, Morgantown, West Virginia. Electronic address:

Semisupervised machine-learning methods are able to learn from fewer labeled patient data. We illustrate the potential use of a semisupervised automated machine-learning (AutoML) pipeline for phenotyping patients who underwent transcatheter aortic valve implantation and identifying patient groups with similar clinical outcome. Using the Transcatheter Valve Therapy registry data, we divided 344 patients into 2 sequential cohorts (cohort 1, n = 211, cohort 2, n = 143). We investigated patient similarity analysis to identify unique phenogroups of patients in the first cohort. We subsequently applied the semisupervised AutoML to the second cohort for developing automatic phenogroup labels. The patient similarity network identified 5 patient phenogroups with substantial variations in clinical comorbidities and in-hospital and 30-day outcomes. Cumulative assessment of patients from both cohorts revealed lowest rates of procedural complications in Group 1. In comparison, Group 5 was associated with higher rates of in-hospital cardiovascular mortality (odds ratio [OR] 35, 95% confidence interval [CI] 4 to 309, p = 0.001), in-hospital all-cause mortality (OR 9, 95% CI 2 to 33, p = 0.002), 30-day cardiovascular mortality (OR 18, 95% CI 3 to 94, p <0.001), and 30-day all-cause mortality (OR 3, 95% CI 1.2 to 9, p = 0.02) . For 30-day cardiovascular mortality, using phenogroup data in conjunction with the Society of Thoracic Surgeon score improved the overall prediction of mortality versus using the Society of Thoracic Surgeon scores alone (AUC 0.96 vs AUC 0.8, p = 0.02). In conclusion, we illustrate that semisupervised AutoML platforms identifies unique patient phenogroups who have similar clinical characteristics and overall risk of adverse events post-transcatheter aortic valve implantation.
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http://dx.doi.org/10.1016/j.amjcard.2020.08.048DOI Listing
December 2020

Less-Invasive Aortic Valve Replacement: Trends and Outcomes From The Society of Thoracic Surgeons Database.

Ann Thorac Surg 2021 04 22;111(4):1216-1223. Epub 2020 Aug 22.

Division of Cardiac Surgery, NYU Langone Health, New York, New York.

Background: This study compares outcomes of conventional and less-invasive (LI) approaches for aortic valve replacement (AVR) using The Society of Thoracic Surgeons database.

Methods: Between 2011 and 2017, we identified 122,474 patients undergoing isolated primary AVR. Patients were categorized into 3 groups: (1) full sternotomy (FS) (n = 98,549; 78%), (2) partial sternotomy (PS) (n = 17,306; 15%), and (3) right thoracotomy (RT) (n = 6619; 7%).

Results: The rate of LI-AVR increased from 17% in 2011 to 23% in 2016 (P < .001). Femoral cannulation was used in 1.5% of FS, 5.4% of PS, and 71% of RT patients (P < .001). Full sternotomy patients were older and had higher rates of preoperative renal failure, atrial fibrillation, and stroke, and had a higher NYHA function class, lower ejection fraction, and higher STS risk score. Total operative, cardiopulmonary bypass, and cross-clamp time were longest in RT-AVR patients and shortest in those who had FS-AVR. Overall, unadjusted operative mortality was 1.9% (1.05% among low-risk patients) and was not different among the 3 groups (1.97% FS, 1.77% PS, and 1.90% RT; P = .4). The rate of postoperative stroke was 1.2% and was not different among the 3 groups (1.2% FS, 1.3% PS, and 1.1% RT; P = .3). After risk adjustment, these differences remained nonsignificant. After risk adjustment, prolonged ventilation and atrial fibrillation were less common in PS-AVR patients. The adjusted risk for blood transfusion was lower in RT-AVR patients, as was the incidence of renal failure. Femoral cannulation was not associated with increased risk for stroke or mortality after LI-AVR.

Conclusions: Less-invasive AVR is associated with an operative mortality and postoperative stroke rate similar to that of FS. Less-invasive AVRs should serve as a benchmark for comparison between transcatheter aortic valve replacement and surgical AVR in low-risk patients.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.039DOI Listing
April 2021

Contemporary Surgical and Transcatheter Management of Mitral Annular Calcification.

Ann Thorac Surg 2021 02 14;111(2):390-397. Epub 2020 Aug 14.

Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, Georgia. Electronic address:

Background: The presence of mitral annular calcification (MAC) in patients with mitral valve (MV) stenosis or regurgitation is a difficult scenario for surgeons and the heart team. Patients with MAC most often have a significant number of comorbidities that exclude them as surgical candidates. This review highlights the various contemporary techniques available to manage MAC during treatment of the MV.

Methods: This study is a focused review of the anatomy, pathology, and management of MAC. The review describes the surgical and transcatheter techniques with outcomes, where available.

Results: The incidence of MAC is between 5% and 42% in patients with severe MV disease. The pathophysiology underlying MAC is not yet clear, but it most likely is related to processes of inflammation and atherosclerosis. Surgical techniques can be grouped into those in which the MAC is completely resected en bloc and those in which the MAC is incompletely resected or left in situ. Transcatheter therapies are feasible in some patients, but they have been limited by the anatomic constraints of MAC; most importantly left ventricular outflow tract obstruction and paravalvular regurgitation.

Conclusions: Surgeons as part of the heart team now have a range of techniques to manage MAC in those patients with severe MV disease. Transcatheter therapies may increase the options for patients whose surgical risk is too high.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.148DOI Listing
February 2021