Background/Aim: In patients with bicuspid aortic valves, guidelines call for regular follow-up to monitor disease progression and guide timely intervention. We aimed to evaluate how closely these recommendations are followed at a tertiary care center. Methods: This was retrospective cohort study at a tertiary care center. Among 48,504 patients who received echocardiograms between 2013-2018, 245 patients were identified to have bicuspid aortic valve. Bivariate analyses compared patient and echocardiographic characteristics between patients who did and did not receive follow-up by a cardiovascular specialist. Results: The mean age of the cohort was 55.2  15.6 years and 30.2% were female. During a median follow-up of 3.5  2.2 years, 72.7% of patients had at least one visit with a cardiovascular specialist after diagnosis of bicuspid aortic valve by echocardiogram. Patients followed by specialists had a higher proportion of follow-up surveillance by echocardiogram (78.7% vs. 34.3%, p< .0001), or by CT or MRI (41.0% vs. 3.0%, p < .0001), and were more likely to undergo valve or aortic surgery compared with patients not followed by specialists. Patients with moderate to severe valvular or aortic pathology (aortic stenosis/regurgitation, dilated ascending aorta) were not more likely to be followed by a cardiovascular specialist or receive follow-up echocardiograms. Conclusions: Follow-up care for patients with bicuspid aortic valve was highly variable, and surveillance imaging was performed sparsely despite guidelines. There is an urgent need for surveillance and clinical follow-up mechanisms to monitor this patient population with increased risk of progressive valvulopathy and aortopathy.

Michael Shang

and 9 more

Background: Thoracic aortic aneurysm is a significant risk factor for aortic dissection and rupture. Guidelines recommend referral of patients to a cardiovascular specialist for periodic surveillance imaging with surgical intervention determined primarily by aneurysm size. We investigated the association between socioeconomic status and surveillance practices in patients with ascending aortic aneurysms. Methods: We retrospectively reviewed records of 465 consecutive patients diagnosed between 2013-2016 with ascending aortic aneurysm ≥4cm on computed tomography scans. Primary outcomes were clinical follow-up with a cardiovascular specialist and aortic surveillance imaging within 2 years following index scan. We stratified patients into quartiles using the area deprivation index (ADI), a validated percentile measure of 17 variables characterizing socioeconomic status at the census block group level. Competing risks analysis was used to determine interquartile differences in risk of death prior to follow up with a cardiovascular specialist. Results: Lower socioeconomic status was associated with significantly lower rates of surveillance imaging and referral to a cardiovascular specialist. On competing risks regression, the ADI quartile with lowest socioeconomic status had lower hazard of follow-up with a cardiologist or cardiac surgeon prior to death (HR 0.46 [0.34, 0.62], p<0.001). Though there were no differences in aneurysm size at time of surgical repair, patients in the lowest socioeconomic quartile were more frequently symptomatic at surgery than other quartiles (92% vs 23-38%, p<0.001). Conclusion: Patients with lower socioeconomic status receive less timely follow-up imaging and specialist referral for thoracic aortic aneurysms, resulting in surgical intervention only when alarming symptoms are already present.

Michael Shang

and 5 more

Background: Bicuspid aortic valve is the most common congenital heart defect and predisposes patients to developing aortic stenosis more frequently and at a younger age than the general population. However, the influence of bicuspid aortic valve on the rate of progression of aortic stenosis remains unclear. Methods: In 236 patients (177 tricuspid aortic valve, 59 bicuspid aortic valve) matched by initial severity of mild or moderate aortic stenosis, we retrospectively analyzed baseline echocardiogram at diagnosis with latest available follow-up echocardiogram. Baseline comorbidities, annualized progression rate of hemodynamic parameters, and hazard of aortic valve replacement were compared between valve phenotypes. Results: Median echocardiographic follow-up was 2.6 (IQR 1.6-4.2) years. Patients with tricuspid aortic stenosis were significantly older with more frequent comorbid hypertension and congestive heart failure. Median annualized progression rate of mean gradient was 2.3 (IQR 0.6-5.0) mmHg/year vs. 1.5 (IQR 0.5-4.1) mmHg/year (p=0.5), and that of peak velocity was 0.14 (IQR 0-0.31) m/s/year vs. 0.10 (IQR 0.04-0.26) m/s/year (p=0.7) for tricuspid vs. bicuspid aortic valve, respectively. On multivariate analyses, bicuspid aortic valve was not significantly associated with more rapid progression of aortic stenosis. In a stepwise Cox proportional hazards model adjusted for baseline mean gradient, bicuspid aortic valve was associated with increased hazard of aortic valve replacement (HR: 1.7, 95% CI [1.0, 3.0], p=0.049). Conclusion: Bicuspid aortic valve may not significantly predispose patients to more rapid progression of mild or moderate aortic stenosis. Guidelines for echocardiographic surveillance of aortic stenosis need not be influenced by valve phenotype.

Clancy Mullan

and 1 more

How much troponin leak is too much before CABG?Clancy W. Mullan, MD and Arnar Geirsson, MDDivision of Cardiac SurgeryDepartment of SurgeryYale School of Medicine330 Cedar Street, BB204New Haven, CT 06511Acute myocardial infarction (MI) is a well-recognized risk factor for worse outcomes after coronary artery bypass grafting (CABG), and the proportion of patients undergoing CABG after MI appears to be increasing over time(1). With nearly a third of patients undergoing CABG having presented with MI, the question has been asked repeatedly of whether the degree of troponin leak correlates to post-operative outcomes, with conflicting results through the years(2, 3). In this edition of theJournal of Cardiac Surgery , Dr. Hess and colleagues present a compelling argument against the use of the degree of troponinemia in predicting major outcomes of surgical revascularization after non-ST elevation MI (NSTEMI). Principally, the authors demonstrate that neither troponin I leak above median nor increasing troponinemia independently predict mortality or major adverse cardiac or cerebrovascular events (MACCE). Secondarily, they find that multivariable adjustment obviates the association of peak troponin level with prolonged ventilation, prolonged intensive care unit stay, and prolonged hospital stay.With these data, the reader must ask: does there exist a residual argument for delaying surgical revascularization? A key observation in the present study is that nearly the entire cohort underwent urgent, rather than emergent or elective, revascularization. In the context of this relatively large cohort, this suggests a degree of stability to the “average” NSTEMI patient. Furthermore, given that the time from peak troponin to revascularization did not differ between the low- and high-risk cohorts and that time from peak troponin to surgery was not associated with post-operative mortality or MACCE, the data reported argue that patients can afford to wait for optimization prior to proceeding to surgery, certainly a controversial topic with a notable lack of society-level guidance that the authors appropriately address in their discussion. While the 2014 American Heart Association/American College of Cardiology guidelines for management of patients with NSTEMI provides some guidance on timing of surgical revascularization in relation to P2Y12 antiplatelet agent administration, no recommendations are provided on when to proceed with CABG otherwise. The authors findings seemingly fit directly on the middle of the debate’s metaphorical fence; however, interpretation of this is challenging given a lack of information such as time from presentation to peak troponin level, from presentation to coronary catheterization, or from catheterization to surgery.What should, then, dictate when to take a patient with NSTEMI to the operating room? There is no straightforward answer to this question, but, generally, these patients should proceed to surgery soon enough to prevent progression from a non-transmural to a transmural injury but late enough to avoids the bleeding risk of potent P2Y12 inhibitor loads (4, 5). While emergent revascularization is likely not warranted in the absence of arrythmias or evidence of continued ischemia, urgent revascularization within 24 hours should be encouraged barring prohibitive bleeding risk from an antiplatelet agent load. Interestingly, the authors did not find intra-aortic balloon pump (IABP) placement to be associated with post-operative mortality hazard, suggesting that IABPs were not especially targeted to unstable patients in their population. However, pre-operative inotrope requirement was associated with increased post-operative mortality, supporting an argument that NSTEMI patients, like their STEMI counterparts, with cardiogenic shock represent a particularly vulnerable population that should be revascularized with greater urgency. Where coronary anatomy demands surgical revascularization and cardiac surgical resources are not available, medical optimization followed by prompt referral to a surgical center is key.The tenacity with which the authors undertook the principal analyses of the manuscript should be commended. Hess et al. present a thorough and convincing argument that a patient’s risk from NSTEMI is likely fixed and dictated by the overall clinical picture rather than dependent on the degree of troponinemia and that the peak troponin level should not dictate clinical decisions.References1. Alkhouli M, Alqahtani F, Kalra A et al. Trends in characteristics and outcomes of hospital inpatients undergoing coronary revascularization in the united states, 2003-2016. JAMA Network Open 2020;3(2):e1921326-e1921326.2. Beller JP, Hawkins RB, Mehaffey JH et al. Does preoperative troponin level impact outcomes after coronary artery bypass grafting? The Annals of thoracic surgery 2018;106(1):46-51.3. Thielmann M, Massoudy P, Neuhäuser M et al. Prognostic value of preoperative cardiac troponin i in patients undergoing emergency coronary artery bypass surgery with non-st-elevation or st-elevation acute coronary syndromes. Circulation 2006;114(1 Suppl):I448-453.4. Amsterdam EA, Wenger NK, Brindis RG et al. 2014 aha/acc guideline for the management of patients with non-st-elevation acute coronary syndromes: A report of the american college of cardiology/american heart association task force on practice guidelines. Circulation 2014;130(25):e344-426.5. Hillis LD, Smith PK, Anderson JL et al. 2011 accf/aha guideline for coronary artery bypass graft surgery. Journal of the American College of Cardiology 2011;58(24):e123-e210.

Sameh Yousef

and 12 more

Background. Query a single institution computed tomography (CT) database to assess the prevalence of aortic arch anomalies in general adult population and their potential association with thoracic aortopathies. Methods. CT chest scan reports of patients aged 50-85 years old performed for any indication at a single health system between 2013 and 2016 were included in the analysis. Characteristics of patients with and without aortic arch anomalies were compared by t-test and Fisher exact tests. Logistic regression analysis was performed to assess for independent risk factors of thoracic aortic aneurysm. Results. Of 21,336 CT scans, 603 (2.8%) described arch anomalies. Bovine arch (n=354, 58.7%) was the most common diagnosis. Patients with arch anomalies were more likely to be female (p<0.001), non-Caucasian(p<0.001), and hypertensive (p<0.001). Prevalence of thoracic aortic aneurysm in arch anomalies group was 10.8% (n=65) compared to 4.1% (n=844) in the non-arch anomaly cohort (p<0.001). The highest prevalence of thoracic aneurysm was associated with right-sided arch combined with aberrant left subclavian configuration (33%), followed by bovine arch (13%), and aberrant right subclavian artery (8.2%). On binary logistic regression, arch anomaly (OR=2.85 [2.16-3.75]), aortic valve pathology (OR 2.93 [2.31-3.73]), male sex (OR 2.38 [2.01-2.80]), and hypertension (OR 1.47 [1.25-1.73]) were significantly associated with increased risk of thoracic aneurysm disease. Conclusions. Reported prevalence of aortic arch anomalies by CT imaging in the older adult population is ~3%, with high association of thoracic aortic aneurysm (OR=2.85) incidence in this subgroup. This may warrant a more tailored surveillance strategy for aneurysm disease in this subpopulation.

Sameh Yousef

and 9 more

Objective: To assess the impact of surgeon experience on the outcomes of degenerative mitral valve disease. Methods: We reviewed all patients who had surgery for degenerative mitral valve disease between 2011-2016. Experienced surgeon was defined as performing  25 mitral valve operations/year. Patient characteristics and outcomes were compared. Multivariable analysis was performed to identify factors associated with MR recurrence. Survival analysis for mortality was done using Kaplan Meier curve and Cox proportional Hazard method. Results: There were 575 patients treated by 9 surgeons for severe mitral regurgitation caused by degenerative mitral valve disease between 2011-2016. Three experienced surgeons performed 77.2% of the operations. Patients treated by less experienced surgeons had worse comorbidity profile and were more likely to have an urgent or emergent operation (P=0.001). Experienced surgeons were more likely to attempt repair (P=0.024), to succeed in repair (94.7% vs 87%, P=0.001), had shorter cross-clamp times (P=0.001), and achieved higher repair rate (81.3% vs 69.7%, P=0.005). Experienced surgeons were more likely to use neochordae (P=0.001) and less likely to use chordae transfer (P=0.001). Surgeon experience was not associated with recurrence (moderate or higher MR) within the first two years after surgery but was an independent risk factor for mortality (HR= 2.64, P=0.002). Conclusions: Techniques of degenerative mitral valve surgery differ with surgeon experience, with higher rates of repair and better outcomes associated with more experienced surgeons.

Gabe Weininger

and 7 more

Background: Complex cardiac operations may have better outcomes when performed by mid-career surgeons compared with surgeons in early or late stages of their career. However, it is unknown how cardiac case complexities are distributed among surgeons of different experience levels. Methods: We performed a cross-sectional study using New York (NY) and California (CA) statewide surgeon-level coronary artery bypass grafting (CABG) outcome data, including 336 cardiac surgeons who performed 43,604 CABGs. Surgeon-level data including observed mortality rate (OMR) and expected mortality rates (EMR) was collected from 2014-2016 in NY and 2015-2016 in CA. Surgeons’ number of years-in-practice was determined by searching for each surgeon’s training history on online registries. Loess and linear regression models were then used to characterize the relationship between surgeon EMR and surgeon years-in-practice. Results: The median number of surgeon years-in-practice was 20 (interquartile range [IQR] 11-28) with median case volume 103 (IQR 42,171). The median surgeon observed to expected mortality (O:E) ratio was 0.87 (IQR 0.19-1.4). Linear regression relating EMR to years in practice showed that EMR was similar across years in practice. Linear regression relating surgeon isolated CABG O:E ratio to years in practice also showed similar outcomes across years in practice. Conclusion: There is a relatively equal distribution of high and low risk CABG cases among surgeons of differing experience levels. This equal distribution of high and low risk cases does not reflect a triaging of more complex cases to more experienced cardiac surgeons, which prior research shows may optimize patient outcomes.

Cornell Brooks

and 7 more

Background: We analyzed center-level outcome correlations between valve surgery and coronary artery bypass graft (CABG) in New York (NY) State and how volume-outcome effect differ between case types. Methods: We used the 2014-2016 NY cardiac surgery outcomes report. Center-level observedto-expected (O/E) ratio for operative mortality provided risk-adjusted operative outcomes for isolated CABG and valve operations. Correlation coefficient characterized the concordance in center-level outcomes in CABG and valve. Discordant outcomes were defined as having O/E ratio >2 in one operation type with O/E ratio ≤1 in another. Linearized slope of volume-outcome effect in case types offered insights into centers with discordant performances between procedures. Results: Among 37 NY centers, annual center volumes were 220±120 cases for CABG and 190±178 cases for valve operations. Modest center-level correlation between CABG and valve O/E ratio was shown (R2 = 0.31). Two centers had discordant performance between valve and CABG (O/E ≤1 for CABG while O/E > 2 for valve procedures). No centers had CABG O/E ratio > 2 while valve O/E ratio ≤1. Linearized slope describing volume-outcome effects showed stronger effect in valve operations compared to CABG: O/E ratio declined 0.1 units per 100 CABG volume increase, while O/E ratio declined 0.33 units per 100 valve volume increase. Conclusions: In NY hospitals, favorable valve outcomes may indicate good CABG outcomes but good CABG outcomes may not ensure valve outcomes. Outcome variation in valve operation could be related to stronger volume-outcome effect in valve operations relative to CABG. Valve operations may benefit from regionalization.

Alina Hasan

and 2 more

Sameh Yousef

and 7 more