Citations

Abstract Objectives The study aimed to compare long-term outcomes of the David and Yacoub valve-sparing aortic root replacement (VSARR) procedures in a nationwide, low-volume setting. Methods All patients undergoing elective VSARR in Denmark between January 2010 and April 2022 were identified using the Danish registries. The primary end-point was all-cause death. Secondary end-points included stroke, reoperation, a composite of death or reoperation, and long-term echocardiographic outcomes. Analyses were performed in both crude and propensity score-matched (PSM) populations and compared with outcomes from a control group comprised of all elective composite root replacement procedures performed at the contributing centres in the study period. Results A total of 160 patients underwent VSARR (median age; David vs Yacoub; 49.7 [SD 14.1] years vs 51.5 [SD 14.3] years; P = .42) with the David (n = 92, 57.5%; median follow-up 8.2 [SD 3.6] years) or Yacoub (n = 68, 42.5%; median follow-up 7.1 [SD 2.4] years) procedure. Ten-year all-cause death was similar (David 9.3% [95% CI: 2.3-15.2] vs Yacoub 8.8% [95% CI: 3.6-20.6]; log-rank P = .54). Reoperation rates (log-rank P = .12), stroke incidence (P = .41), and the composite end-point of death or reoperation (log-rank P = .63) were comparable, with consistent findings in the PSM cohort. Long-term echocardiographic follow-up demonstrated no difference in recurrent regurgitation, stenosis, or valve-related complications. Compared to elective composite root replacement (CRR) (n = 486), VSARR demonstrated lower rate of all-cause death (P = .027) and stroke (P = .026), while reoperation rate was higher (13.8% vs 4.3%; P < .001). However, the risk of reoperation was comparable between procedures when accounting for competing risk of death (log-rank P = .17). Conclusions Long-term outcomes following elective VSARR using the David and Yacoub procedure were comparable. VSARR was associated with lower risk of all-cause death and stroke compared to elective CRR, supporting the two VSARR procedures as durable options when performed in experienced centres with careful patient selection, even in low-volume settings.

Abstract Objectives The progression of extra-mitral valve (MV) cardiac damage in patients with primary mitral regurgitation (MR) following surgical repair has not been described. We aimed to investigate the evolution of extra-MV cardiac damage after MV repair and to assess its prognostic significance. Methods Patients with severe primary MR undergoing surgical repair at 5 referral centres were included when echocardiographic follow-up assessment was available. Based on echocardiographic parameters at baseline and at a median follow-up of 7 (interquartile range [IQR] 4-11) months after MV repair, patients were hierarchically classified as follows: stage 0: no cardiac damage; stage 1: left ventricular dilatation and/or dysfunction; stage 2: left atrial dilatation and/or atrial fibrillation; stage 3: pulmonary hypertension and/or significant tricuspid regurgitation. The primary outcome was all-cause mortality. Results A total of 764 patients (mean age 62 ± 13 years, 70% men) were included. Compared to baseline, 43% improved at least 1 stage, 49% remained unchanged, and 8% worsened at least 1 stage during follow-up after MV repair. At a median follow-up of 91 months after MV repair, 94 patients (12%) died. By multivariate Cox regression analysis, after adjusting for potential confounders, extra-MV cardiac damage staging at follow-up (HR per-1-stage-increase = 1.571; P = .009) and cardiac damage evolution (improved group, HR = 0.467; P = .034; worsened group, HR = 2.481, P = .037) were independently associated with all-cause mortality and had incremental prognostic value over preprocedural assessment. Conclusions Extra-MV cardiac damage improves significantly after MV repair, and its evolution is independently associated with all-cause mortality, suggesting the importance of comparative echocardiographic assessment following MV repair to improve risk stratification.

Abstract STUDY QUESTION What is the fertility preservation (FP) utilization rate among transgender and gender diverse (TGD) patients at the Transgender and Intersex Specialty Care Clinic (TISCC) within the Mayo Clinic? SUMMARY ANSWER The rate of utilization of FP services by TGD patients at Mayo Clinic’s TISCC was determined to be 6.62%. WHAT IS KNOWN ALREADY TGD patients encounter several barriers when pursuing FP, which may contribute to a lower utilization rate of these services. These barriers include financial constraints and lack of insurance coverage, as well as societal and healthcare provider attitudes; TGD individuals face discrimination or lack of understanding, making it uncomfortable or difficult to discuss FP options. Additionally, there continues to be a lack of inclusive policies and support within healthcare systems that can further impede access to FP services for TGD individuals. STUDY DESIGN, SIZE, DURATION The study was executed in two phases. In the first phase, a retrospective cohort study was completed with TGD patients who provided electronic health record (EHR) research authorization from Mayo Clinic’s TISCC in Rochester, MN between 1 January 2015 and 30 July 2021. Search terms related to FP were used to determine the FP utilization rate among this patient population. In the second phase of the study, two sets of patients, (i) patients who were included in the cohort study in Phase 1, and (ii) members of JASMYN, a community organization specializing in care and wellness coordination for Lesbian, Gay, Bisexual, and Transgender (LGBT) teens and young adults in North Florida. Individuals were invited to participate in a qualitative interview exploring their cumulative healthcare experiences accessing gender-affirming care. Interviews were conducted from January 2023 to June 2023. Interviews examined participants’ perceptions of FP options, motivations for pursuing FP, and barriers to accessing both gender and fertility care. When applicable, participants also discussed their experiences pursuing FP and reflected on their satisfaction with their fertility and family planning decisions. PARTICIPANTS/MATERIALS, SETTING, METHODS In phase 1, a total of N = 1189 patients sought care from Mayo Clinic’s TISCC in Rochester, MN. Out of these patients, N = 589 patients provided research authorization and were included in the retrospective cohort study. The study team assessed whether FP terms were mentioned in each patient’s EHR, and whether patients scheduled and attended appointments with either the Department of Reproductive Endocrinology or the Department of Urology. FP search terms included sperm cryopreservation, sperm extraction, sperm aspiration, testicular tissue cryopreservation, oocyte cryopreservation, embryo cryopreservation, and ovarian tissue cryopreservation. In phase 2, N = 36 participants were interviewed, with N = 25 participants recruited from Mayo Clinic’s TISCC in Rochester, MN, and N = 11 participants recruited from JASMYN in Jacksonville, FL. Participants recruited from the Mayo Clinic participated in a video-call-based interview and those enrolled from JASMYN were interviewed in person. MAIN RESULTS AND THE ROLE OF CHANCE The study team observed a 6.62% utilization rate of FP services among N = 589 patients (median age: 28 years; age range: 8–78 years) included in the retrospective cohort study. N = 39 patients completed FP, with N = 14 receiving these services at other institutions before seeking care with the TISCC at Mayo Clinic. N = 25 patients pursued FP services within the Mayo Clinic. Patients with testes were more likely to complete FP via sperm cryopreservation when compared to the utilization of egg cryopreservation among patients with ovaries. Participants who completed an interview in Phase 2 (median age 27 years; age range: 22–80 years) reflected on their decision on whether to preserve their fertility and what factors influenced these decisions, and how their satisfaction with this decision has changed over their lifespan. The major themes reported here include the desire for biological children, planning gender care around fertility desires, conversations about FP options, physical and psychosocial barriers to pursuing FP, reflections on personal FP decisions, and reflections on having to make decisions about FP at a young age. LIMITATIONS, REASONS FOR CAUTION All participants who completed an interview have done so voluntarily; as such, there is a possibility of selection and recall bias. WIDER IMPLICATIONS OF THE FINDINGS Findings suggest that there is a need for more structured conversations around FP when TGD patients seek medical and surgical gender-affirming care. Accessibility, including financial barriers and limited insurance coverage, continues to limit the utilization of FP services among TGD patients. Increased affordability through insurance coverage may additionally improve FP utilization. STUDY FUNDING/COMPETING INTEREST(S) This project was funded by the Mayo Clinic Department of Obstetrics and Gynecology and the Mayo Clinic Center for Clinical and Translational Science (CCaTS), grant number UL1TR002377. This project was also supported by Clinical and Translational Science Award (CTSA) Grant Number TL1TR002380 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Felicity Enders reports grants from the National Institutes of Health and the Agency for Healthcare Research and Quality paid to her institution; speakers’ fees for lectures or presentations from Mount Sinai, University of Washington, University of Minnesota, University of Rochester, Cincinnati University, the National Institutes of Health, Duke University, Wake Forest University, the Patient Centered Outcomes Research Institute, Johns Hopkins University; travel support from the Association for Clinical and Translational Science and Cold Spring Harbor Laboratory; and an unpaid leadership role on the Board of Directors of the Association for Clinical and Translational Science. All other authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.

Substance use disorders (SUD) remain a significant source of morbidity and mortality in the United States, and access to treatment continues to be inadequate. Primary Care Clinicians (PCCs) are well-positioned to provide long-term SUD care for patients. However, multiple provider-level barriers exist. Collaborative Care Management (CoCM) has proven successful in supporting PCCs in treating psychiatric conditions, such as depression. Our group proposes an addiction-focused modified CoCM that leverages telemedicine and an electronic platform (Senyo) into primary care. This study assesses PCCs’ attitudes toward this proposed model and their likelihood (with support) of prescribing medications for alcohol and opioid use disorder. To achieve this, an anonymized and confidential electronic survey was deployed to all 489 of our institutions’ PCCs. Eighty-five completed the survey (17.4% response); the majority (94%) agreed that digital CoCM for SUD will be helpful for their practice, and 85% expressed agreement that such a model will increase their confidence and likelihood to prescribe anti-craving medications. Additionally, we found that PCCs’ comfort level in addressing SUD with patients is not associated with years in practice, clinician type (attending physicians, resident/fellow physicians, nurse practitioner or physician assistant), or their perception of currently available SUD treatment resources. Future work to evaluate practice changes, including rates of anti-craving medication prescribing and SUD-treatment outcomes after implementation of our digital CoCM will prove useful in determining the effectiveness of this model.

Background Cardiovascular biomarkers such as NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) are used for heart failure risk stratification in patients with acquired heart disease, but there are limited data about its role in patients with congenitally corrected transposition of the great arteries. The current study aims to assess the role of serial NT‐proBNP measurements for risk stratification in adults with congenitally corrected transposition of the great arteries. Methods We studied adults with congenitally corrected transposition of the great arteries with ≥2 NT‐proBNP measurements (2003–2024). Temporal change in NT‐proBNP was calculated as relative change from baseline levels. Results Of 152 patients (age 47±13 years, 45% men), baseline NT‐proBNP was 539 (interquartile range, 193–1549) pg/mL, and relative change from baseline levels of NT‐proBNP was 34% (interquartile range, −11 to 67). Of 152 patients, 45 (30%) had cardiovascular events (heart failure hospitalization [n=29], ventricular assist device [n=5], heart transplantation [n=11], and death [n=10]), yielding a 10‐year incidence of 26%. Higher baseline NT‐proBNP and relative change from baseline levels were associated with cardiovascular events. Serial NT‐proBNP measurements had incremental prognostic value compared with baseline measurement. The correlates of higher NT‐proBNP levels were atrial fibrillation, hypertension, right ventricular dilation and dysfunction, and atrioventricular valve regurgitation. Renin–angiotensin–aldosterone system antagonist was associated with lower NT‐proBNP levels and lower risk of cardiovascular events. Conclusions NT‐proBNP testing is inexpensive, widely available, and noninvasive, making it well suited for longitudinal surveillance in adults with congenital heart disease. Most of the correlates for elevated NT‐proBNP levels were modifiable, providing target for therapeutic interventions.

Introduction: Online self-triage is a newer eHealth modality, and there is a paucity of research on patient adherence to self-triage recommendations. We evaluated patient compliance with online self-triage guidance to seek emergency care and compared to nurse-triage adherence rates. Methods: We reviewed primary care empaneled patients who had either nurse phone triage or an online self-triage encounter that resulted in an emergency care recommendation between January 1, 2023, and November 30, 2024. Patients triaged for mood concerns, abdominal pain, chest pain, constipation, cough, and diarrhea were included. We reviewed whether patients had an emergency department visit within 24 h of their triage encounter. For self-triage encounters, we also examined whether patients called nurse triage within 24 h of their self-triage encounter. Results: There were 689 self-triage and 2,385 nurse triage encounters with an emergency care endpoint. Adherence to the emergency care recommendation was substantially lower after self-triage (22%) than after nurse triage (61%). Patients who underwent nurse triage were significantly more likely to seek emergency care than those who self-triaged (odds ratio of 5.4 [95% CI: 4.5–6.6] p < 0.001). Both male and female patients were less likely to follow emergency care recommendations after self-triage compared to nurse triage ( p < 0.001). There were 258 patients with an emergency care endpoint from self-triage who chose to call nurse triage (median time between encounters of 16 min). Only 78 (30.2%) also received an endpoint recommendation for emergency care, and 73% of those patients sought emergency care within 24 h. Discussion: Patient compliance with online self-triage recommendations to seek emergency care was poor and significantly less than nurse triage. Follow-up calls to nurse triage led to higher compliance. Health systems using online symptom checkers should consider employing mechanisms to follow up on emergency care recommendations. Further research should elucidate factors that contribute to patients’ willingness to follow care recommendations.

BACKGROUND: Transcatheter mitral valve-in-valve replacement is an established therapy for intermediate and high-risk patients with degenerated bioprostheses, but restricted transcatheter valve (THV) expansion within rigid surgical frames and elevated gradients have raised durability concerns. This study aimed to evaluate midterm outcomes of mitral valve-in-valve patients according to THV expansion and sizing strategy. METHODS: Patients who underwent mitral valve-in-valve with balloon-expandable valves at Mayo Clinic Rochester between 2014 and 2023 were retrospectively analyzed. THV expansion (inflow, waist, outflow) was measured from procedural fluoroscopy and indexed to nominal size, with zero indicating expansion to nominal dimensions. Median index values were used as subgroup cutoffs to compare the incidence of the primary composite outcome of all-cause mortality, heart failure readmission, and valve reintervention. RESULTS: The analysis included 80 patients with a median follow-up of 2.5 years. A total of 53 (66%) valves were underexpanded across all 3 sizes, with median inflow, waist, and outflow expansion indices of −10.2, −16.2, and −3.2, respectively. Across all indices, THV expansion closer to nominal size was associated with lower rates of the primary outcome ( P <0.05). Greater expansion correlated with a larger mitral valve area and lower transvalvular mean gradient. Oversized THVs were significantly less expanded and had a higher incidence of the primary composite outcome compared with recommended-size THVs ( P =0.02). CONCLUSIONS: THV underexpansion in degenerated mitral bioprostheses is common and associated with elevated gradients and worse midterm outcomes. Further research is warranted to define THV expansion targets and improve outcomes following mitral valve-in-valve intervention.