Holst, Kimberly A

Abstract Objectives This study examined the indications, frequency, and outcomes of cardiac surgery following transcatheter aortic valve replacement (TAVR) at a single institution. As TAVR volumes increase, understanding the nature and outcomes of subsequent cardiac operations is critical, particularly as the procedure expands to younger, lower-risk populations. Methods We analysed outcomes of 61 patients who underwent cardiac surgery after TAVR at our institution from August 2011 to September 2023, excluding periprocedural complications and staged procedures. Patients were stratified into 2 groups: those requiring surgical aortic valve replacement (SAVR) with or without concomitant procedures (n = 33) and those undergoing non-SAVR cardiac operations (n = 28). Data were collected from a prospectively maintained cardiovascular surgery database and electronic health records. Indications for surgery, operative characteristics, and outcomes were analysed, with survival assessed using Kaplan-Meier estimates. Results The median interval between TAVR and cardiac surgery was 19 months. Indications for SAVR included infective endocarditis (36%), non-structural valve deterioration (36%), structural valve deterioration (12%), and valve thrombosis (6%). Non-SAVR operations primarily addressed mitral valve disease (43%) and coronary artery disease (29%). Operative mortality was 6.6%, with no deaths in the endocarditis subgroup. Postoperative complications included prolonged mechanical ventilation (18%), new-onset renal failure (7%), and stroke (2%). Kaplan-Meier survival estimates were 83% at 1 year and 50% at 5 years. Conclusions Although complex, cardiac operations in patients who have undergone TAVR can be performed with acceptable mortality rates. Structural valve deterioration, paravalvular leak, and endocarditis were the primary indications for SAVR, while mitral valve and coronary artery disease predominated in non-SAVR cases. These findings highlight the importance of considering nonaortic valve pathologies in TAVR planning, particularly as the procedure expands to younger, lower-risk populations.

Objective: To evaluate the reproductive experiences of physicians across gender and specialty. Patients and Methods: Between November and December 2021, we surveyed nontrainee physicians of all genders at a single quaternary institution using a modified version of an existing survey instrument. Experiences with family planning, fertility, pregnancy, and parental leave were assessed. Results: There were 422 completed responses. Respondents reported a higher prevalence of infertility as compared to the general U.S. population (26% versus 19%), with no difference in infertility or obstetrical complications by specialty. Most respondents (75%) reported stigma regarding having children in medicine, and 71% reported delaying childbearing. These trends were strongest in the subanalysis of female respondents. Forty-five percent of respondents reported that their work increased the risk for subfertility, infertility, or pregnancy complications. Surgeons were significantly more likely to report physically demanding work conditions (75% versus 30%, p < 0.001), radiation exposure (39% versus 14%, p < 0.001), and bloodborne pathogen exposure (25% versus 12%, p = 0.03) as occupational reproductive hazards. Only 55% of respondents with a pregnancy history reported ever taking parental leave. Among those who took less than the full amount offered, 63% cited concerns about falling behind educationally or professionally as significantly influencing this decision. Conclusions: These results support previous trends showing delayed childbearing and increased infertility among physicians while shedding new light on stigma associated with childbearing and parental leave. A better understanding of the reproductive experiences of physicians is critical to recruiting and retaining a skilled workforce and fostering career and life satisfaction in this profession.

Congenital heart diseases, including single ventricle circulations, are clinically challenging due to chronic pressure overload and the inability of the myocardium to compensate for lifelong physiological demands. To determine the clinical relevance of autologous umbilical cord blood–derived mononuclear cells (UCB-MNCs) as a therapy to augment cardiac adaptation following surgical management of congenital heart disease, a validated model system of right ventricular pressure overload due to pulmonary artery banding (PAB) in juvenile pigs has been employed. PAB in a juvenile porcine model and intramyocardial delivery of UCB-MNCs was evaluated in three distinct 12-week studies utilizing serial cardiac imaging and end-of-study pathology evaluations. PAB reproducibly induced pressure overload leading to chronic right ventricular remodeling including significant myocardial fibrosis and elevation of heart failure biomarkers. High-dose UCB-MNCs (3 million/kg) delivered into the right ventricular myocardium did not cause any detectable safety issues in the context of arrhythmias or abnormal cardiac physiology. In addition, this high-dose treatment compared with placebo controls demonstrated that UCB-MNCs promoted a significant increase in Ki-67-positive cardiomyocytes coupled with an increase in the number of CD31+ endothelium. Furthermore, the incorporation of BrdU-labeled cells within the myocardium confirmed the biological potency of the high-dose UCB-MNC treatment. Finally, the cell-based treatment augmented the physiological adaptation compared with controls with a trend toward increased right ventricular mass within the 12 weeks of the follow-up period. Despite these adaptations, functional changes as measured by echocardiography and magnetic resonance imaging did not demonstrate differences between cohorts in this surgical model system. Therefore, this randomized, double-blinded, placebo-controlled pre-clinical trial establishes the safety of UCB-MNCs delivered via intramyocardial injections in a dysfunctional right ventricle and validates the induction of cardiac proliferation and angiogenesis as transient paracrine mechanisms that may be important to optimize long-term outcomes for surgically repaired congenital heart diseases.

In pigs, the deep location of the common carotid artery and overlying sternomastoideus muscle in the neck has led to the recommendation for a surgical cutdown for common carotid access, as opposed to minimally invasive techniques for vascular access. We sought to determine if direct percutaneous common carotid artery access in piglets is attainable. Seventeen piglets were anesthetized and intubated. Under two-dimensional and color flow Doppler ultrasound guidance, a 21 gauge needle was utilized to access the right common carotid artery. Following arterial puncture, the Seldinger technique was applied to place a 4 or 5 French introducer. Upon completion of cardiac catheterization with intracoronary stem cell infusion the introducer was removed and manual pressure was applied to prevent hematoma development. Successful access with an introducer was achieved in all 17 piglets. The average weight was 8.5 ± 1.7 kg. One piglet developed a hematoma with hemorrhaging from the catheterization site and was euthanized. This piglet was given bivalirudin for the procedure. After this incident, subsequent piglets were not given anticoagulation and no other complications occurred. Ultrasound guided percutaneous common carotid artery access in piglets is attainable in a safe, reliable, and reproducible manner when performed by microvascular experts.

Successful outcome in the care of patients with congenital heart disease depends on a comprehensive multidisciplinary team. Surgery is offered for almost every heart defect, despite complexity. Early mortality for cardiac surgery in the neonatal period is ≈10% and beyond infancy is <5%, with 90% to 95% of patients surviving with a good quality of life into the adult years. Advances in imaging have facilitated accurate diagnosis and planning of interventions and surgical procedures. Similarly, advances in the perioperative medical management of patients, particularly with intensive care, has also contributed to improving outcomes. Arrhythmias and heart failure are the most common late complications for the majority of defects, and reoperation for valvar problems is common. Lifelong surveillance for monitoring of recurrent or residual structural heart defects, as well as periodic assessment of cardiac function and arrhythmia monitoring, is essential for all patients. The field of congenital heart surgery is poised to incorporate new innovations such as bioengineered cells and scaffolds that will iteratively move toward bioengineered patches, conduits, valves, and even whole organs.