Publications by authors named "Vinay Badhwar"

284 Publications

Comparing Consumer-Directed Hospital Rankings with STS Adult Cardiac Surgery Database Outcomes.

Ann Thorac Surg 2022 Aug 3. Epub 2022 Aug 3.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University, Durham, NC, USA.

Background: Public interest in stratifying hospital performance has led to the proliferation of commercial, consumer-oriented hospital rankings. In cardiac surgery, little is known about how these rankings correlate with clinical registry quality ratings.

Methods: The STS Adult Cardiac Surgery Database (ACSD) was queried for isolated coronary artery bypass grafting (CABG) or CABG+valve patients at hospitals among the top 100 US News & World Report (USNWR) Cardiology & Heart Surgery rankings from 2016-2020. Hospitals were grouped into deciles by risk-adjusted observed/expected (O/E) ratios for morbidity/mortality using the STS 2018 risk models. Agreement between STS ACSD and USNWR ranked deciles was calculated using Bowker's symmetry test. The association between each center's annual change in STS O/E ratio and change in USNWR ranking was modeled in repeated measures regression analysis.

Results: Inclusion criteria were met by 524,393 patients from 149 hospitals that ranked in USNWR top 100 at least once during the study period. There was no agreement between USNWR ranking and STS major morbidity/mortality O/E ratio (p>0.50 for all years). Analysis of patients undergoing surgery at the 65 hospitals that were consistently ranked in the top 100 during the study period demonstrated no association between annual change in hospital ranking and change in O/E ratio (p all >0.3).

Conclusions: There was no agreement between annual USNWR hospital ranking and corresponding risk-adjusted STS morbidity/mortality. Further, annual changes in USNWR rankings could not be accounted for using clinical outcomes. These findings suggest that factors unrelated to key surgical outcomes may be driving consumer-directed rankings.
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http://dx.doi.org/10.1016/j.athoracsur.2022.06.050DOI Listing
August 2022

Mortality and cost of post-cardiotomy extracorporeal support in the United States.

Perfusion 2022 Aug 5:2676591221117355. Epub 2022 Aug 5.

Department of Cardiovascular and Thoracic Surgery, 536580West Virginia University, Morgantown, WV, USA.

Background: Extracorporeal membrane oxygenation (ECMO) has been used increasingly for cardiopulmonary rescue. Despite recent advances however, post-cardiotomy shock (PCS)-ECMO survival remains comparatively poor. We sought to evaluate outcomes and define factors that predict in-hospital mortality.

Methods: We used the Nationwide Inpatient Sample (NIS) to evaluate adult hospitalizations with a primary procedure code for coronary artery bypass grafting (CABG), and/or valve procedures performed between 2013 and 2018, which also required post cardiotomy ECMO support. Patient-related factors and hospital costs were evaluated to identify those associated with in-hospital mortality.

Results: There were 1,247,835 admissions for cardiac surgical procedures during the study period. Post-cardiotomy shock-ECMO support was provided in 4475 (0.3%) within the study cohort. A total of 2000 (44.7%) hospitalizations involved isolated valvular procedures, 1700 (38.0%) isolated CABG, and 775 (17.3%) involved a combination of both. Overall, in-hospital mortality was 42.1% ( = 1880). Factors significantly associated with in-hospital mortality included patients with multiple comorbidities (> 7) and those undergoing combination of valve and CABG procedures. Only 26.6% of those who survived to discharge, were discharged home independently.

Conclusion: Survival to independent home discharge is rare following PCS-ECMO. Its high mortality is associated with multiple comorbidities and combination of CABG and valve surgery.
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http://dx.doi.org/10.1177/02676591221117355DOI Listing
August 2022

Early trends in ECMO mortality during the first quarters of 2019 and 2020: Could we have predicted the onset of the pandemic?

Perfusion 2022 Jul 15:2676591221114959. Epub 2022 Jul 15.

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

Objective: To compare mortality trends in patients requiring Extracorporeal Membrane Oxygenation (ECMO) support between the first quarters of 2019 and 2020 and determine whether these trends might have predicted the severe acute respiratory syndrome coronavirus-2 (SARS)-Cov-2 pandemic in the United States.

Methods: We analyzed 5% Medicare claims data at aggregate, state, hospital, and encounter levels using MS-DRG (Medicare Severity-Diagnosis Related Group) codes for ECMO, combining state-level data with national census data. Necessity and sufficiency relations associated with change in mortality between the 2 years were modeled using qualitative comparative analysis (QCA). Multilevel, generalized linear modeling was used to evaluate mortality trends.

Results: Based on state-level data, there was a 3.36% increase in mortality between 2019 and 2020. Necessity and sufficiency evaluation of aggregate data at state and institutional levels did not identify any association or combinations of risk factors associated with this increase in mortality. However, multilevel and generalized linear models using disaggregated patient-level data to evaluate institution mortality and patient death, identified statistically significant differences between the first ( = .019) and second ( = .02) months of the 2 years, the first and second quarters ( < .001 and = .042, respectively), and the first 6 months ( < .001) of 2019 and 2020.

Conclusion: Mortality in ECMO patients increased significantly during the first quarter of 2020 and may have served as an early warning of the SARS-Cov-2 pandemic. Granular data shared in real-time may be used to better predict public health threats.
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http://dx.doi.org/10.1177/02676591221114959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9289645PMC
July 2022

Impact of Hospital Volume on Outcomes of Septal Myectomy for Hypertrophic Cardiomyopathy.

Ann Thorac Surg 2022 Jun 30. Epub 2022 Jun 30.

Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Left ventricular outflow tract obstruction is common among symptomatic patients with hypertrophic cardiomyopathy, yet septal reduction by surgical myectomy (septal myectomy [SM]) is performed infrequently in many centers. This study examined the possible relationship between institutional case volume and early outcomes of SM.

Methods: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for patients with hypertrophic cardiomyopathy who underwent SM from January 2012 to December 2019. The study defined center case volume categories as <1, 1 to 4.99, 5 to 9.99, and ≥10 cases performed on average per year.

Results: The study population included 5935 patients at 481 centers with 933 surgeons. The range of average center volume was <1 to 138 cases per year. Overall early mortality was 2.6%, ventricular septal defect (VSD) occurred in 1.9%, and complete heart block occurred in 9.0%. Concomitant mitral valve (MV) repair was performed in 28.7%, and MV replacement was performed in 17.1%. In multivariable analysis, the lowest annual case volume (average <1 case/y) was consistently associated with greater early mortality (odds ratio [OR], 5.4; CI, 3.0-9.9; P < .001), greater risk of VSD (OR, 9.3; CI ,4.2-20.4; P < .001), increased incidence of complete heart block (OR, 2.0; CI, 1.5-2.7; P < .001), and a higher likelihood of MV replacement (OR, 9.4; CI, 7.5-11.8; P < .001).

Conclusions: Volume of SM cases varies widely among institutions reporting to the Society of Thoracic Surgeons Adult Cardiac Surgery Database. There appears to be an important association between surgical experience, as reflected by institutional case volume, and early outcomes, including mortality, as well as the occurrence of VSD, heart block, and MV replacement.
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http://dx.doi.org/10.1016/j.athoracsur.2022.05.062DOI Listing
June 2022

Aortic valve repair for isolated right coronary leaflet prolapse.

JTCVS Tech 2022 Jun 3;13:26-30. Epub 2022 Mar 3.

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

Objectives: Isolated right coronary leaflet prolapse is a common cause of nonaneurysmal aortic insufficiency, but can rarely occur in patients with proximal aortic aneurysms. Standardized techniques for routine autologous repair of this disorder are presented.

Methods: Most aortic valve leaflet prolapse is isolated to the right coronary leaflet, with hypertension and annular dilatation being contributory. Echocardiographically, a posteriorly eccentric aortic insufficiency jet together with "fracture" of the right leaflet tip are diagnostic. Primary repair includes internal geometric ring annuloplasty to downsize and reshape the annulus, together with central plication of the prolapsing leaflet. Thickened, scarred, or retracted noduli are released using an ultrasonic aspirator. The goal is to achieve equivalent coaptation heights of ≥8 mm for all 3 leaflets.

Results: Three videos of 6 cases are provided to illustrate these techniques. In the first, 3 patients are shown with classic isolated right leaflet prolapse. In the second and third videos, alternative pathologies are presented for contrast. Applying the reconstructive approaches of geometric ring annuloplasty, leaflet plication, and ultrasonic nodular release, excellent early and late repair outcomes are obtainable in most patients.

Conclusions: The combination of aortic ring annuloplasty, central leaflet plication, and ultrasonic nodular release allows routine and standardized repair of right coronary leaflet prolapse, either isolated or concomitant with aneurysm surgery.
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http://dx.doi.org/10.1016/j.xjtc.2022.02.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9196763PMC
June 2022

Assessing the Performance of Risk Models with Discrimination and Calibration.

Ann Thorac Surg 2022 Jun 7. Epub 2022 Jun 7.

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

In the final analysis, no clinically relevant risk model is perfect; however, it is a fact that use of all STS risk models as tools to facilitate the evaluation of programmatic performance (including these models for multiple valve operations) is more informative than the simple comparison of unadjusted programmatic data to national aggregate data. For these reasons, surgeons should feel very confident about the discrimination and calibration of the current STS risk models for multiple valve +/- CABG operations.
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http://dx.doi.org/10.1016/j.athoracsur.2022.05.032DOI Listing
June 2022

Changing trends in pseudoretinoblastoma diagnoses: A 10 year review from the United Kingdom.

Eur J Ophthalmol 2022 Apr 28:11206721221093190. Epub 2022 Apr 28.

Retinoblastoma Service, Royal London Hospital, 9744Barts Health NHS Trust, London, UK.

Aim: To study the different types and frequency of pseudoretinoblastoma (pseudoRB) lesions who present to a retinoblastoma centre due to concern that the condition may be retinoblastoma.

Methods: A retrospective chart review of 341 patients presenting sporadically to the Royal London Hospital from January 2009 to December 2018.

Results: 220 patients (65%) were confirmed to have retinoblastoma, while 121 (35%) had pseudoRB. There were 23 differential diagnoses in total. The top 3 differential diagnoses were Coats' disease (34%), Persistent Foetal Vasculature (PFV) (17%) and Combined Hamartoma of Retina and Retinal Pigment Epithelium (CHR-RPE) (13%). PseudoRBs differed with age at presentation. Under the age of 1 (n = 42), the most likely pseudoRB conditions were PFV (36%), Coats' disease (17%) and CHR-RPE (12%). These conditions were also the most common simulating conditions between the ages of 1 and 2 (n = 21), but Coats' disease was the most common in this age group (52%), followed by CHR-RPE (19%) and PFV (14%). Between the ages of 2 and 5 (n = 32), Coats' disease remained the most common (44%) pseudoRB lesion followed by CHR-RPE (13%), or PFV, Retinal Astrocytic Hamartoma (RAH), familial exudative vitreoretinopathy (FEVR) (all 6.3%). Over the age of 5 (n = 26), pseudoRBs were most likely to be Coats' disease (35%), RAH (12%), Uveitis, CHR-RPE, FEVR (all 7.7%).

Conclusion: 35% of suspected retinoblastoma cases are pseudoRB conditions. Overall, Coats' disease is the most common pseudoRB condition, followed by PFV. Hamartomas (CHR-RPE & RAH) are more prevalent in this cohort, reflecting improvements in diagnostic accuracy from referring ophthalmologists.
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http://dx.doi.org/10.1177/11206721221093190DOI Listing
April 2022

Early Outcomes of Patients Undergoing Neoaortic Valve Repair Incorporating Geometric Ring Annuloplasty.

World J Pediatr Congenit Heart Surg 2022 05;13(3):304-309

University of Michigan, Ann Arbor, MI, USA.

Objectives: During congenital heart surgery, the pulmonary valve and root may be placed into the systemic position, yielding a "neoaortic" valve. With the stress of systemic pressure, the pulmonary roots can dilate, creating aneurysms and/or neoaortic insufficiency (neoAI). This report analyzes the early outcomes of patients undergoing neoaortic valve repair incorporating geometric ring annuloplasty.

Methods: Twenty-one patients underwent intended repair at six centers and formed the study cohort. Thirteen had previous Ross procedures, five had arterial switch operations, and three Fontan physiology. Average age was 21.7 ± 12.8 years (mean  ±  SD), 80% were male, and 11 (55%) had symptomatic heart failure. Preoperative neoAI Grade was 3.1  ±  1.1, and annular diameter was 30.7  ±  6.5 mm.

Results: Valve repair was accomplished in 20/21, using geometric annuloplasty rings and leaflet plication (n = 13) and/or nodular release (n = 7). Fourteen had neoaortic aneurysm replacement (13 with root remodeling). Two underwent bicuspid valve repair. Six had pulmonary conduit changes, one insertion of an artificial Nodulus Arantius, and one resection of a subaortic membrane. Ring size averaged 21.9  ±  2.3 mm, and aortic clamp time was 171  ±  54 minutes. No operative mortality or major morbidity occurred, and postoperative hospitalization was 4.3  ±  1.4 days. At discharge, neoAI grade was 0.2  ±  0.4 ( < .0001), and valve mean gradient was ≤20 mm Hg. At average 18.0  ±  9.1 months of follow-up, all patients were asymptomatic with stable valve function.

Conclusions: Neoaortic aneurysms and neoAI are occasionally seen late following Ross, arterial switch, or Fontan procedures. Neoaortic valve repair using geometric ring annuloplasty, leaflet reconstruction, and root remodeling provides a patient-specific approach with favorable early outcomes.
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http://dx.doi.org/10.1177/21501351221079523DOI Listing
May 2022

Cannulate, extubate, ambulate approach for extracorporeal membrane oxygenation for COVID-19.

J Thorac Cardiovasc Surg 2022 Mar 11. Epub 2022 Mar 11.

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

Objective: We compared outcomes in patients with severe COVID-19 versus non-COVID-19-related acute respiratory distress syndrome (ARDS) managed using a dynamic, goal-driven approach to venovenous extracorporeal membrane oxygenation (ECMO).

Methods: We performed a retrospective, single-center analysis of our institutional ECMO registry using data from 2017 to 2021. We used Kaplan-Meier plots, Cox proportional hazard models, and propensity score analyses to evaluate the association of COVID-19 status (COVID-19-related ARDS vs non-COVID-19 ARDS) and survival to decannulation, discharge, tracheostomy, and extubation. We also conducted subgroup analyses to compare outcomes with the use of extracorporeal cytoreductive techniques (CytoSorb [CytoSorbents Corp] and plasmapheresis).

Results: The sample comprised 128 patients, 50 with COVID-19 and 78 with non-COVID-19 ARDS. Advancing age was associated with decreased probability of survival to decannulation (P = .04). Compared with the non-COVID-19 ARDS group, patients with COVID-19 had a greater probability of survival to extubation (P < .01) and comparable survival to discharge (P = .14).

Conclusions: Patients with COVID-19 managed with ECMO had comparable outcomes as patients with non-COVID ARDS. A strategy of early extubation and ambulation might be a safe and effective strategy to improve outcomes and survival, even for patients with severe COVID-19.
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http://dx.doi.org/10.1016/j.jtcvs.2022.02.049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8915439PMC
March 2022

Contemporary left atrial appendage management during adult cardiac surgery.

J Thorac Cardiovasc Surg 2022 Feb 24. Epub 2022 Feb 24.

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

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http://dx.doi.org/10.1016/j.jtcvs.2022.02.029DOI Listing
February 2022

Minimally Invasive Mitral Valve Surgery After Transcatheter Edge-to-Edge Repair.

Innovations (Phila) 2022 Jan-Feb;17(1):42-49

8785University of California San Francisco, CA, USA.

Objective: Up to 28% of patients may need mitral valve (MV) surgery after transcatheter edge-to-edge repair (TEER). This study evaluates the outcomes of minimally invasive MV surgery after TEER. International multicenter registry of minimally invasive MV surgery after TEER between 2013 and 2020. Subgroups were stratified by the number of devices implanted (≤1 vs >1), as well as time interval from TEER to surgery (≤1 year vs >1 year). A total of 56 patients across 13 centers were included with a mean age of 73 ± 11 years, and 50% were female. The median Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) score for MV replacement was 8% (Q1-Q3 = 5% to 11%) and the ratio of observed to expected mortality was 0.9. The etiology of mitral regurgitation (MR) prior to TEER was primary MR in 75% of patients and secondary MR in 25%. There were 30 patients (54%) who had >1 device implanted. The median time between TEER and surgery was 252 days (33 to 636 days). Hemodynamics, including MR severity, MV area, and mean gradient, significantly improved after minimally invasive surgery and sustained to 1-year follow-up. In-hospital and 30-day mortality was 7.1%, and 1-year actuarial survival was 85.6% ± 6%. Minimally invasive MV surgery after TEER may be achieved as predicted by the STS PROM. Most patients underwent MV replacement instead of repair. As TEER is applied more widely, patients should be informed about the potential need for surgical intervention over time after TEER. These discussions will allow better informed consent and post-procedure planning.
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http://dx.doi.org/10.1177/15569845211070568DOI Listing
March 2022

Multi-institutional Analysis of 505 Patients With Coronavirus Disease-2019 Supported With Extracorporeal Membrane Oxygenation: Predictors of Survival.

Ann Thorac Surg 2022 07 18;114(1):61-68. Epub 2022 Feb 18.

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

Background: We reviewed our experience with 505 patients with confirmed coronavirus disease-2019 (COVID-19) supported with extracorporeal membrane oxygenation (ECMO) at 45 hospitals and estimated risk factors for mortality.

Methods: A multi-institutional database was created and used to assess all patients with COVID-19 who were supported with ECMO. A Bayesian mixed-effects logistic regression model was estimated to assess the effect on survival of multiple potential risk factors for mortality, including age at cannulation for ECMO as well as days between diagnosis of COVID-19 and intubation and days between intubation and cannulation for ECMO.

Results: Median time on ECMO was 18 days (interquartile range, 10-29 days). All 505 patients separated from ECMO: 194 patients (38.4%) survived and 311 patients (61.6%) died. Survival with venovenous ECMO was 184 of 466 patients (39.5%), and survival with venoarterial ECMO was 8 of 30 patients (26.7%). Survivors had lower median age (44 vs 51 years, P < .001) and shorter median time interval from diagnosis to intubation (7 vs 11 days, P = .001). Adjusting for several confounding factors, we estimated that an ECMO patient intubated on day 14 after the diagnosis of COVID-19 vs day 4 had a relative odds of survival of 0.65 (95% credible interval, 0.44-0.96; posterior probability of negative effect, 98.5%). Age was also negatively associated with survival: relative to a 38-year-old patient, we estimated that a 57-year-old patient had a relative odds of survival of 0.43 (95% credible interval, 0.30-0.61; posterior probability of negative effect, >99.99%).

Conclusions: ECMO facilitates salvage and survival of select critically ill patients with COVID-19. Survivors tend to be younger and have shorter time from diagnosis to intubation. Survival of patients supported with only venovenous ECMO was 39.5%.
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http://dx.doi.org/10.1016/j.athoracsur.2022.01.043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8855605PMC
July 2022

3D Transesophageal Echocardiography for Guiding Transcatheter Aortic Valve Replacement Without Prior Cardiac Computed Tomography in Patients With Renal Dysfunction.

Cardiovasc Revasc Med 2022 Aug 13;41:63-68. Epub 2022 Jan 13.

Department of Cardiology, West Virginia University School of Medicine, Morgantown, WV 26506, USA. Electronic address:

Background: Pre-procedural chronic kidney disease (CKD) and in-hospital acute kidney injury (AKI) are associated with worse outcomes following transcatheter aortic valve replacement (TAVR). We tested the feasibility of reducing overall AKI by avoiding pre-procedural cardiac CT angiography (CCTA) by using direct 3D-TEE guidance in TAVR patients with known CKD.

Methods: An institutional TAVR database was examined from January 2016 to June 2020 to identify 396 patients in whom CCTA sizing was performed and 54 patients with creatinine (Cr) of >1.6 mg/dL in whom direct 3D-TEE, without prior CCTA, was used for TAVR guidance. Baseline demographics, procedural, echocardiographic, and clinical endpoints were compared as defined by the Valve Academic Research Consortium-2 criteria.

Results: Baseline demographics and risk factors were similar in both groups other than the creatinine level in CCTA vs. TEE groups (1.33 ± 1.1 vs 1.76 ± 0.7 mg/dL, p = 0.005). Procedural contrast volume was significantly lower in the TEE group compared to the CCTA group. No differences were noted in echocardiographic and clinical endpoints for both groups. Despite higher baseline Cr, patents in the TEE group experienced a similar pattern of changes in Cr compared to the CCTA group, with an overall renal improvement noted at the time of discharge for both groups.

Conclusions: In patients with baseline CKD, careful avoidance of large contrast loads associated with CCTA and intra-procedural aortography by using TEE guidance may help reduce AKI following TAVR.
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http://dx.doi.org/10.1016/j.carrev.2021.12.026DOI Listing
August 2022

Commentary: A rose by any other name.

JTCVS Tech 2021 Dec 18;10:80-81. Epub 2021 Oct 18.

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

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http://dx.doi.org/10.1016/j.xjtc.2021.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8691932PMC
December 2021

Commentary: Dogma to diachronicity: Evolving to lesion-specific repair of Barlow valves.

JTCVS Tech 2021 Dec 28;10:64-65. Epub 2021 Sep 28.

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

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http://dx.doi.org/10.1016/j.xjtc.2021.09.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8691818PMC
December 2021

May the Force Be With You.

Ann Thorac Surg 2022 04 29;113(4):1384-1385. Epub 2021 Dec 29.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, 1 Medical Center Dr, Morgantown, WV 26506. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2021.11.060DOI Listing
April 2022

The Patient, Only and Always.

Ann Thorac Surg 2021 Dec 20. Epub 2021 Dec 20.

Department of Cardiovascular and Thoracic Surgery West Virginia University.

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http://dx.doi.org/10.1016/j.athoracsur.2021.11.038DOI Listing
December 2021

Commentary: Morning, afternoon, and evening.

J Thorac Cardiovasc Surg 2021 Dec 9. Epub 2021 Dec 9.

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.12.012DOI Listing
December 2021

Early outcomes of transcatheter mitral valve replacement with the Tendyne system in severe mitral annular calcification.

EuroIntervention 2022 Apr;17(18):1523-1531

Valve Science Center, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA.

Background: Treatment of mitral regurgitation (MR) associated with severe mitral annular calcification (MAC) is challenging due to the high risk of fatal atrioventricular groove disruption and significant paravalvular leak.

Aims: The aim of this study was to evaluate the outcomes of transcatheter mitral valve replacement (TMVR) with the Tendyne valve (Abbott Structural) in patients with MR and MAC.

Methods: Twenty patients (mean age 78 years; 11 women) who were treated with the Tendyne valve, either compassionate use (CU; closed) or as part of The Feasibility Study of Tendyne in MAC (NCT03539458), had reported outcomes in a median follow-up duration of 368 days.

Results: In all patients, a valve was implanted with no procedural mortality and successful hospital discharge. Two embolic events occurred, including one with mesenteric ischaemia and one non-disabling stroke. At 30 days and one year, all-cause mortality occurred in one (5%) and eight patients (40%), respectively. At one year, six patients had been hospitalised for heart failure (30%). There was no prosthetic dysfunction, and MR remained absent in all patients at one year. Clinical improvement, measured by New York Heart Association Functional Class, occurred in 11 of 12 patients who were alive at one year. Among seven survivors with Kansas City Cardiomyopathy Questionnaire (KCCQ) data, mean increase in KCCQ score was 29.9±26.3 at one year with improvement of ≥10 points in five (71.4%) patients.

Conclusions: In patients with MR and severe MAC, TMVR with the Tendyne valve was associated with encouraging acute outcomes, midterm durability, and clinical improvement. Dedicated TMVR therapy may have a future role in these anatomically challenging, high-risk patients.
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http://dx.doi.org/10.4244/EIJ-D-21-00745DOI Listing
April 2022

Optimal circulatory arrest temperature for aortic hemiarch replacement with antegrade brain perfusion.

J Thorac Cardiovasc Surg 2021 Nov 12. Epub 2021 Nov 12.

Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa; University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pa. Electronic address:

Objective: This study sought to identify the optimal temperature for moderate hypothermic circulatory arrest in patients undergoing elective hemiarch replacement with antegrade brain perfusion.

Methods: The Society of Thoracic Surgeons adult cardiac surgery database was queried for elective hemiarch replacements using antegrade brain perfusion for aneurysmal disease (2014-2019). Generalized estimating equations and restricted cubic splines were used to determine the risk-adjusted relationships between temperature as a continuous variable and outcomes.

Results: Elective hemiarch replacement with antegrade brain perfusion occurred in 3898 patients at 374 centers with a median nadir temperature of 24.9 °C (first quartile, third quartile = 22.0 °C, 27.5 °C) and median circulatory arrest time of 19 minutes (first quartile, third quartile = 14.0 minutes, 27.0 minutes). After adjustment for comorbidities, circulatory arrest time, and individual surgeon, patients cooled between 25 and 28 °C had an early survival advantage compared with 24 °C, whereas those cooled between 21 and 23 °C had higher risks of mortality compared with 24 °C. A nadir temperature of 27 °C was associated with the lowest risk-adjusted odds of mortality (odds ratio, 0.62; 95% confidence interval, 0.42-0.91). A nadir temperature of 21 °C had the highest risk of mortality (odds ratio, 1.4; 95% confidence interval, 1.13-1.73). Risk of experiencing a major morbidity was elevated in patients cooled between 21 and 23 °C, with the highest risk occurring in patients cooled to 21 °C (odds ratio, 1.12; 95% confidence interval, 1.01-1.24).

Conclusions: For patients with aneurysmal disease undergoing elective hemiarch with antegrade brain perfusion, circulatory arrest with a nadir temperature of 27 °C confers the greatest early survival benefit and smallest risk of postoperative morbidity.
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http://dx.doi.org/10.1016/j.jtcvs.2021.09.068DOI Listing
November 2021

Strategies for Mechanical Right Ventricular Support During Left Ventricular Assist Device Implant.

Ann Thorac Surg 2022 08 26;114(2):484-491. Epub 2021 Nov 26.

Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Background: Refractory right ventricular failure at the time of left ventricular assist device implantation requires treatment with supplemental mechanical circulatory support. However, the optimal strategy for support remains unknown.

Methods: All patients undergoing first-time durable left ventricular assist device implantation with a contemporary device were selected from The Society of Thoracic Surgeons National Database (2011 to 2019). Patients requiring right ventricular assist device (RVAD) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) were included in the analysis. Patients were stratified by RVAD or VA-ECMO and by timing of placement (intraoperative vs postoperative).

Results: In all, 18 423 left ventricular assist device implants were identified, of which 940 (5.1%) required RVAD (n = 750) or VA-ECMO (n = 190) support. Patients receiving an RVAD more frequently had preoperative inotrope requirement (76% vs 62%, P < .01) and severe tricuspid regurgitation (20% vs 13%, P < .01). The RVAD patients had lower rates of postoperative renal failure (40% vs 51%, P = .02) and limb ischemia (4% vs 13%, P < .01), as well as significantly less operative mortality (41% vs 54%, P < .01). After risk adjustment with propensity score analysis, support with VA-ECMO was associated with a higher risk of mortality (risk ratio 1.46; 95% confidence interval, 1.21 to 1.77; P < .01) compared with patients receiving an RVAD. Importantly, institution of right ventricular support postoperatively was associated with higher mortality (1.43, P < .01) compared with intraoperative initiation.

Conclusions: Patients with severe right ventricular failure in the setting of durable left ventricular assist device implantation may benefit from the use of RVAD over VA-ECMO. Regardless of the type of support, initiation at the index operation was associated with improved outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2021.10.032DOI Listing
August 2022

Association of Volume and Outcomes in 234 556 Patients Undergoing Surgical Aortic Valve Replacement.

Ann Thorac Surg 2021 Nov 14. Epub 2021 Nov 14.

Department of Cardiac Surgery, Ottawa Heart Institute, Ottawa, Ontario, Canada.

Background: The relationship between institutional volume and operative mortality after surgical aortic valve replacement (SAVR) remains unclear.

Methods: From January 2013 to June 2018, 234 556 patients underwent isolated SAVR (n = 144 177) or SAVR with coronary artery bypass grafting (CABG) (n = 90 379) within the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The association between annualized SAVR volume (group 1 [1-25 SAVRs], group 2 [26-50 SAVRs], group 3 [51-100 SAVRs], and group 4 [>100 SAVRs]) and operative mortality and composite major morbidity or mortality was assessed. Random effects models were used to evaluate whether historical (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes.

Results: The annualized median number of SAVRs per site was 35 (interquartile range, 22-59; isolated aortic valve replacement [AVR], 20; AVR with CABG, 13). Among isolated SAVR cases, the mean operative mortality and composite morbidity or mortality were 1.5% and 9.7%, respectively, at the highest-volume sites (group 4), with significantly higher rates among progressively lower-volume groups (P trend < .001). After adjustment, lower-volume centers had increased odds of operative mortality (group 1 vs group 4 [reference]: adjusted odds ratio [AOR] for SAVR, 2.24 [95% CI, 1.91-2.64]; AOR for SAVR with CABG, 1.96 [95% CI, 1.67-2.30]) and major morbidity or mortality (AOR for SAVR, 1.53 [95% CI, 1.39-1.69]; AOR for SAVR with CABG, 1.46 [95% CI, 1.32-1.61]) compared with the highest-volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category, and prior outcomes explained a greater proportion of hospital operative outcomes than did prior volume.

Conclusions: Operative outcomes after SAVR with or without CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive of future outcomes than is prior volume. Given the excellent outcomes observed at many lower-volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.
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http://dx.doi.org/10.1016/j.athoracsur.2021.06.095DOI Listing
November 2021

Robotic-assisted biatrial Cox-maze ablation for atrial fibrillation.

Authors:
Vinay Badhwar

J Thorac Cardiovasc Surg 2021 Oct 5. Epub 2021 Oct 5.

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.2021.09.053DOI Listing
October 2021

2-Year Outcomes of Transcatheter Mitral Valve Replacement in Patients With Severe Symptomatic Mitral Regurgitation.

J Am Coll Cardiol 2021 11;78(19):1847-1859

West Virginia University Heart and Vascular Institute, Morgantown, West Virginia, USA.

Background: Transcatheter mitral valve replacement (TMVR) is feasible for selected patients with severe mitral regurgitation (MR) who are poor candidates for valve surgery. Intermediate-term to long-term TMVR outcomes have not been reported.

Objectives: This study sought to evaluate the safety and effectiveness through 2-year follow-up of TMVR in high-surgical-risk patients with severe MR.

Methods: The first 100 patients enrolled in the Expanded Clinical Study of the Tendyne Mitral Valve System, an open-label, nonrandomized, prospective study of transapical TMVR, were followed for 2 years.

Results: The patients (aged 74.7 ± 8.0 years, 69.0% male) had symptomatic (66.0% New York Heart Association [NYHA] functional class III or IV) grade 3+ or 4+ MR that was secondary or mixed in 89 (89.0%). Prostheses were successfully implanted in 97 (97.0%) patients. At 2 years, all-cause mortality was 39.0%; 17 (43.6%) of 39 deaths occurred during the first 90 days. Heart failure hospitalization (HFH) fell from 1.30 events per year preprocedure to 0.51 per year in the 2 years post-TMVR (P < 0.0001). At 2 years, 93.2% of surviving patients had no MR. No patient had >1+ MR. The improvement in symptoms at 1 year (88.5% NYHA functional class I or II) was sustained to 2 years (81.6% NYHA functional class I or II). Among survivors, the left ventricular ejection fraction was 45.6 ± 9.4% at baseline and 39.8 ± 9.5% at 2 years (P = 0.0012). Estimated right ventricular systolic pressure decreased from 47.6 ± 8.6 mm Hg to 32.5 ± 10.4 mm Hg (P < 0.005).

Conclusions: In this study, the impact of TMVR on severity of MR, reduction in HFH rate, and improvement in symptoms was sustained through 2 years. All-cause mortality and the need for HFH was highest in the first 3 months postprocedure. (Expanded Clinical Study of the Tendyne Mitral Valve System; NCT02321514).
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http://dx.doi.org/10.1016/j.jacc.2021.08.060DOI Listing
November 2021

Vermicomposting of textile mill sludge employing Eisenia fetida: Role of cow dung and tea waste amendments.

Environ Sci Pollut Res Int 2022 Mar 2;29(13):19823-19834. Epub 2021 Nov 2.

M.Tech Environmental Science & Engineering, Guru Nanak Dev Engineering College, Ludhiana, 141006, India.

Vermicomposting of textile mill sludge (TMS) with cow dung (CD) and tea waste (TW) as amendments was done in seven different combinations using Eisenia fetida for 90 days. Results revealed that pH decreased from 7.68-8.63 to 7.09-7.59. TOC content and C/N ratio reductions were in range of 15.71-20.08% and 39.33-50.05%, respectively (P < 0.05). The macronutrients in the form of TN, TP, and TK increased 0.38-0.64, 1.07-2.27, and 0.56-1.98 times respectively after end of bioconversion process (P < 0.05), among increases in ash content and EC. The biomass and cocoon production of E. fetida increased significantly (P < 0.05), while high mortality rate of earthworms was observed in treatments containing 50% or more TMS content. The bacterial population beneficial for degradation of organic matter increased significantly over initial substrates (0th day) (P < 0.05). Increased humification index in end-product indicated better maturity of vermicompost as observed in treatments containing higher proportions of amendments. The addition of amendments favored earthworm activity which significantly decreased the heavy metal concentration (Fe, Cu, Pb, Zn) in the end-product. The study concluded that sustainable utilization of TMS could be achieved for cleaner and enriched vermicompost production by addition of amendments CD and TW in proportions of 50% and above.
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http://dx.doi.org/10.1007/s11356-021-17185-zDOI Listing
March 2022
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