Crestanello, Juan A.

AbstractObjectivesThe aim of this study was to determine the safety of eliminating the pre‐discharge transthoracic echocardiogram (TTE) on 30‐day outcomes in patients undergoing transcatheter aortic valve replacement (TAVR).BackgroundTTE is utilized before, during, and after TAVR. Post‐procedural, pre‐discharge TTE assists in assessment of prosthesis function and detection of clinically significant paravalvular leak (PVL) after TAVR.MethodsPatients who underwent TAVR at Mayo Clinic from July 2018 to July 2019 were included in a prospective institutional registry. Patients undergoing TAVR prior to February 2019 received a pre‐discharge TTE, while those undergoing TAVR after February 2019 did not. Both cohorts were evaluated with TTE at 30 days post‐TAVR.ResultsA total of 330 consecutive patients were included. Of these, 160 patients (age 81.1 ± 7.6) had routine pre‐discharge TTE, while 170 patients (age 78.9 ± 7.5) were dismissed without routine pre‐discharge TTE. Mortality at 30 days was similar between the two groups (0% and 1.2%, respectively). One episode of PVL requiring intervention (0.6%) occurred in the pre‐discharge TTE group and none in the group without pre‐discharge TTE at 30‐day follow‐up. There was a similar incidence of total composite primary and secondary adverse events between the cohort receiving a pre‐discharge TTE and those without (28.1% vs. 25.3%, P = 0.56) at 30 days. The most common event was need for permanent pacemaker or ICD implantation in both groups (13.1% vs. 11.8%, P = 0.71).ConclusionsElimination of the pre‐discharge TTE is safe and associated with comparable 30‐day outcomes to routine pre‐discharge TTE. These findings have implication for TAVR practice cost‐efficiency and health care utilization.

The purpose of this study was to describe procedural outcomes, hemodynamic improvement, regression of left ventricular (LV) mass hypertrophy, and cardiovascular. The primary outcomes were procedural complications, reinterventions, and hemodynamic improvement after coarctation of aorta (COA) repair. The secondary outcomes were improvement in the severity of hypertension, regression of LV mass index, and incidence of cardiovascular events (atrial fibrillation, ventricular tachycardia, heart failure hospitalization, and cardiovascular death) after COA repair. Secondary outcomes were assessed only in patients with isolated COA who had clinical and imaging follow-up at 1 year and 3 years postintervention. Of 172 patients that underwent COA repair (surgical 161; transcatheter 11), there were no procedural deaths, and all patients had residual COA gradient <20 mm Hg. Of 128 patients that met criteria for secondary outcomes assessment, 39 (36%) had a reduction in the intensity of antihypertension therapy, and cardiovascular events occurred in 16 (13%) patients. There was no significant reduction in the overall prevalence of hypertension (stage 1 and stage 2) over time (78% versus 70% versus 73%, P =0.4 at baseline, 1 year and 3 years). Postintervention hypertension (both stage 1 and 2) were independent risk factors for suboptimal left ventricular mass index regression and cardiovascular events. Persistent hypertension was common after repair of native COA in adults and was associated with suboptimal left ventricular mass index regression and cardiovascular events. These results suggest that optimal blood pressure control with medical therapy after COA repair may result in improved clinical outcomes.

Background Pericardiectomy for post-radiation constrictive pericarditis has been reported to generally have unfavorable outcomes. This study sought to evaluate surgical outcomes in a large cohort of patients undergoing pericardiectomy for radiation-associated pericardial constriction. Methods A retrospective analysis of all patients (≥18years) who underwent pericardiectomy for a diagnosis of constrictive pericarditis with a prior history of mediastinal irradiation from June 2002 to June 2019 was conducted. There were 100 patients (mean age 57.2±10.1 years, 49% females) who met the inclusion criteria. Records were reviewed to look at surgical approach, extent of resection, early mortality and late survival. Results The overall operative mortality was 10.1% (n=10). The rate of operative mortality decreased over the study period; however, the test of trend was not statistically significant (P=0.062). Hodgkin’s disease was the most common malignancy (64%) for which mediastinal radiation had been received. Only 27% patients had an isolated pericardiectomy, and concomitant pericardiectomy and valve surgery was performed in 46% patients. Radical resection was performed in 50% patients, whereas 47% patients underwent a subtotal resection. Prolonged ventilation (26%), atrial fibrillation (21%) and pleural effusion (16%) were the most common post-operative complications. The overall 1,5- and 10-years survival was 73.6%, 53.4% and 32.1% respectively. Increasing age (HR 1.044, 95%CI 1.017-1.073) appeared to have a significant negative effect on overall survival in the univariate model. Conclusion Pericardiectomy performed for radiation associated constrictive pericarditis has poor long-term outcomes. The early mortality, though high (~10%), has been showing a decreasing trend in the test of time.

Background The temporal incidence of high‐grade atrioventricular block (HAVB) after transcatheter aortic valve replacement (TAVR) is uncertain. As a result, periprocedural monitoring and pacing strategies remain controversial. This study aimed to describe the temporal incidence of initial episode of HAVB stratified by pre‐ and post‐TAVR conduction and identify predictors of delayed events. Methods and Results Consecutive patients undergoing TAVR at a single center between February 2012 and June 2019 were retrospectively assessed for HAVB within 30 days. Patients with prior aortic valve replacement, permanent pacemaker (PPM), or conversion to surgical replacement were excluded. Multivariable logistic regression was performed to assess predictors of delayed HAVB (initial event >24 hours post‐TAVR). A total of 953 patients were included in this study. HAVB occurred in 153 (16.1%). After exclusion of those with prophylactic PPM placed post‐TAVR, the incidence of delayed HAVB was 33/882 (3.7%). Variables independently associated with delayed HAVB included baseline first‐degree atrioventricular block or right bundle‐branch block, self‐expanding valve, and new left bundle‐branch block. Forty patients had intraprocedural transient HAVB, including 16 who developed HAVB recurrence and 6 who had PPM implantation without recurrence. PPM was placed for HAVB in 130 (13.6%) (self‐expanding valve, 23.7% versus balloon‐expandable valve, 11.9%; P <0.001). Eight (0.8%) patients died by 30 days, including 1 unexplained without PPM present. Conclusions Delayed HAVB occurs with higher frequency in patients with baseline first‐degree atrioventricular block or right bundle‐branch block, new left bundle‐branch block, and self‐expanding valve. These findings provide insight into optimal monitoring and pacing strategies based on periprocedural ECG findings.

Background Transcatheter mitral valve repair (TMVr) is currently offered at selected centers that meet certain operator and institutional requirements. We sought to explore the hypothesis that the availability of TMVr is associated with improved outcomes of MV surgery. Methods and Results We used the Nationwide Readmissions Database to identify patients who underwent MV surgery at centers with or without TMVr capabilities between January 1 and December 31, 2017. The primary end point was in‐hospital mortality. Secondary end points were postoperative complications, resource use, and 30‐day readmissions. A total of 24 477 patients from 595 centers (446 TMVr, 149 non‐TMVr) were included. There were modest but statistically significant differences in the prevalence of comorbidities between the groups. Patients at non‐TMVr centers had higher unadjusted in‐hospital mortality than those at TMVr centers (5.6% versus 3.6%, P <0.001). They also had higher rates of postoperative complications, longer hospitalizations, higher cost, and fewer home discharges but similar 30‐day readmission rates. After propensity matching, mortality remained higher at non‐TMVr centers (5.5% versus 4.0%, P <0.001). Rates of postoperative complications, prolonged hospitalizations, and nonhome discharges also remained higher. Postoperative mortality was consistently higher at non‐TMVr centers in multiple risk‐adjustment analyses incrementally accounting for differences in risk factors, surgical volume, availability of surgical repair, and excluding concomitant procedures. In the most comprehensive model, surgery at non‐TMVr centers was associated with higher odds of death (odds ratio, 1.41; 95% CI, 1.14–1.73; P =0.002). Conclusions Mitral valve surgery at TMVr centers is associated with improved in‐hospital outcomes compared with non‐TMVr centers.

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Detection of immobile leaflets immediately following bioprosthetic valve implantation is a rare but important intraoperative finding. Restriction of leaflet movement can occur in the closed or open position, leading to abnormal prosthesis function. We sought to determine the clinical implications of immobile leaflets seen on intraoperative echocardiography. METHODS Patients with immobile leaflets identified on intra-operative/procedure echocardiography immediately post implantation between 2009-2020 were identified from an institutional database. All echocardiograms were reviewed de-novo to confirm immobile leaflets in the immediate post-implantation period. Identified cases were matched 1:2 to controls for age; sex; prosthesis position, model and size; and implantation approach (surgical vs. transcatheter). Nominal logistic regression and proportional hazards were used to analyze outcomes. RESULTS Thirty patients with immobile leaflets immediately post-bioprosthesis implantation were included. Clinical characteristics are summarized in the Table. Immobile leaflets were documented in procedural reports in only 18 (60%) patients. Moderate stenosis was present intraoperatively in 1 patient, none demonstrated ≥moderate regurgitation, and none resulted in immediate corrective action. In 3 (10%), valve re-intervention was required within 30 days due to symptomatic prosthesis dysfunction. Presence of restricted leaflet motion was associated with higher need for post-operative extracorporeal membrane oxygenation use (odds-ratio 7.3, p = 0.02) and composite end-point of death, valve re-replacement, prosthesis thrombosis, or cardiac hospitalizations (risk ratio 2.1, p = 0.03, Figure). CONCLUSION Immobile leaflet(s) immediately post-bioprosthetic valve implantation is an uncommon, under-reported, and under-treated phenomenon. Even in the absence of significant prosthetic valve dysfunction, it can be associated with worse post-operative course as well as worse outcomes. Baseline characteristics Age 76 (67-84) Sex, male 10 (33%) Surgical approach 25 (83%) Aortic 5 (17%) Mitral 12 (40%) Tricuspid 12 (40%) Pulmonary 1 (3%) Re-intervention within 10 days 3 (10%) Numbers are presented as median (interquartile range) or number (percentage). Abstract Figure. Clinical outcome of stuck leaflets

Background Whether the poor outcomes of isolated tricuspid valve surgery are related to the operation itself or to certain patient characteristics including late referral is unknown. Methods and Results Adult patients who underwent isolated tricuspid valve surgery were identified in the Nationwide Readmissions Database (2016–2017). Patients who had redo tricuspid valve surgery, endocarditis, or congenital heart disease were excluded. Multivariable logistic regression was performed to identify contributors to postoperative mortality. A total of 1513 patients were included (mean age 55.7±16.6 years, 49.6% women). Surrogates of late referral were frequent: 41% of patients were admitted with decompensated heart failure, 44.3% had a nonelective surgery status, 16.8% had advanced liver disease, and 31% had an unplanned hospitalization in the prior 90 days. The operation was performed on day 0 to 1 of the hospitalization in only 50% of patients, and beyond day 10 in 22% of patients. In‐hospital mortality occurred in 8.7% of patients. Median length of stay was 14 days (7–35 days), and median cost was $87 223 ($43 122–$200 872). In multivariable logistic regression analysis, surrogates for late referrals (acute heart failure decompensation, nonelective surgery status, or advanced liver disease) were the strongest predictors of in‐hospital mortality (odds ratio [OR], 4.75; 95% CI, 2.74–8.25 [ P <0.001]). This was also consistent in a second model incorporating unplanned hospitalizations in the 90 days before surgery as a surrogate for late referral (OR, 5.50; 95% CI, 2.28–10.71 [ P <0.001]). Conclusions The poor outcomes of isolated tricuspid valve surgery may be largely explained by the late referral for intervention. Studies are needed to determine the role of early intervention for severe isolated tricuspid regurgitation.