Michael Phillip Robich

Background: Patients with severe aortic stenosis with very low resting aortic valve mean gradient (MG) are underrepresented in transcatheter aortic valve replacement (TAVR) studies. We investigated the association of resting aortic valve MG with post‐TAVR outcomes in a large nationwide cohort. Methods: We included patients from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry with a self‐expanding Evolut TAVR (until December 2022) and eligible for 1‐year follow‐up without prior balloon aortic valvuloplasty, TAVR, or surgical aortic valve replacement. Results: Among 80 429 patients (mean age, 80.7±7.9; women, 53.9%; high/extreme surgery risk, 51.2%) stratified into 6 echocardiographic resting aortic valve MG groups (10–P P P <0.001). Conclusions: Baseline aortic valve MG is an important predictor of 1‐year all‐cause mortality in patients with severe aortic stenosis undergoing TAVR. Most patients undergoing TAVR had considerably improved quality‐of‐life assessments regardless of resting MG. Additional studies should elucidate mechanisms associated with MG–mortality risk and whether improved patient selection can further improve outcomes.

Background and Objective: The most common valvular heart disease in the US is moderate to severe mitral regurgitation (MR). Function MR or secondary MR comprises many of these cases. Moderate and severe secondary MR are independently associated with increased all-cause mortality and rehospitalization for heart failure. Both ischemic and nonischemic cardiomyopathy can cause secondary MR via similar pathophysiology that leads to inadequate valve leaflets coaptation. The management of secondary MR is complex. The optimal treatment strategy for secondary MR remains controversial, reflected in the vast array of treatment options and the complexity of therapeutic decision-making. Several surgical mitral valve repair techniques have been described in the literature. Many of these aims to facilitate adequate valve leaflet coaptation. In this review, the pathophysiology of MR is described with a focus on evaluating and managing secondary MR. Methods: A literature review was performed using PubMed and Google Scholar. Clinical trials, meta-analyses, randomized controlled trials, reviews, and systematic reviews were considered from January 1, 1995 through December 31, 2022. Articles published in languages other than English with limited text availability were excluded. Key Content and Findings: Optimal therapeutic approach in severe secondary MR is complex and several patient factor should be considered. We provide a framework for the surgical management of secondary MR based on echocardiographic parameters, the presence of ischemia, and myocardial viability. Conclusions: Further study is needed to guide the selection of patients most likely to benefit from mitral valve repair or replacement in the setting of secondary MR.

Objectives: Risk assessment models for cardiac surgery do not distinguish between degrees of liver dysfunction. We have previously shown that preoperative liver stiffness is associated with hospital length of stay following cardiac surgery. The authors hypothesized that a liver stiffness measurement (LSM) ≥ 9.5 kPa would rule out a short hospital length of stay (LOS < 6 days) following isolated coronary artery bypass grafting (CABG) surgery. Methods: A prospective observational study of one hundred sixty-four adult patients undergoing non-emergent isolated CABG surgery at a single university hospital center. Preoperative liver stiffness measured by ultrasound elastography was obtained for each participant. Multivariate logistic regression models were used to assess the adjusted relationship between LSM and a short hospital stay. Results: We performed multivariate logistic regression models using short hospital LOS (p = 0.03). The ROC curve and resulting AUC of 0.76 (95% CI: 0.68–0.83) suggest the final multivariate model provides good discriminatory performance when predicting early discharge. Conclusions: A preoperative LSM ≥ 9.5 kPa ruled out a short length of stay in nearly 80% of patients when compared to patients with a LSM < 9.5 kPa. Preoperative liver stiffness may be a useful metric to incorporate into preoperative risk stratification.

Gastrointestinal complications after cardiac surgery are relatively rare entities but carry a high mortality. We identified over 70 articles written since 2010 using the PubMed database. We included 40 in our review. The most common complications include paralytic ileus, gastrointestinal bleeding, and bowel ischemia. Patients who undergo cardiac procedures are at risk for poor perfusion of the gastrointestinal tract and, thus, at risk for resulting complications. Risk factors for these complications include peri-operative use of vasopressors, prolonged operative time, and the time of cardiopulmonary bypass. Presentation of gastrointestinal complications tends to differ as patients after open heart surgery can remain intubated, and exams can be limited. Early recognition and aggressive therapy are paramount. We aim to provide a review that will help the reader get familiar with the most common gastrointestinal complications that can negatively affect outcomes after cardiac surgery.

Background: Hypertrophic cardiomyopathy (HCM) is commonly associated with mitral valve pathology. A large majority of patients with HCM have elongated anterior and posterior mitral leaflets. There remains debate regarding the necessity and role of concomitant mitral valve surgery at the time of septal myectomy. We aimed to describe the characteristics and share our surgical experiences with this specific group of patients.Methods: This retrospective single‐center study investigates adult patients with HCM, with or without elongated mitral valve leaflets (MVLs), who underwent elective septal myectomy with or without concomitant mitral valve intervention, between January 1, 2016, and June 30, 2020. Clinical data were obtained from institutional medical records as well as the Society of Thoracic Surgeons data registry. The clinical characteristics and in‐hospital surgical outcomes were compared between patients with an elongated MVL and those without.Results: In total, 379 patients underwent septal myectomy, and 22 patients with intrinsic mitral valve disease were excluded. In addition, 23 patients were excluded due to missing data. Of the remaining 334 patients, 131 (39.2%) had elongated MVL and concomitant MVL plication. Patients with elongated MVL had higher rates of preoperative mitral valve systolic anterior motion (SAM) (94.7% vs. 86.7%, p = 0.019) and higher preoperative provoked left ventricular outflow tract gradient (LVOTG) (134.5 mmHg versus 125.3 mmHg, p = 0.046). Post septal myectomy and mitral valve plication, they had lower rates of postoperative residual mitral regurgitation (3.8% vs. 12.8%, p = 0.006), comparable rates of residual SAM (28.2% vs. 31.5%, p = 0.524), postoperative provoked LVOTG (15.4 mmHg vs. 14.0 mmHg, p = 0.317), 30‐day major adverse cardiopulmonary events (2.3% vs. 3.9%, p = 0.409), and mortality (0% vs. 1.0%, p = 0.255).Conclusions: Elongated MVLs contribute more significantly to dynamic LVOT obstruction, as evidenced during provocative testing. Concomitant mitral valve intervention during septal myectomy can be performed safely and may provide an effective strategy to resolve SAM and stress‐induced LVOTG.

Background. The Perceval S is a sutureless, bovine pericardial aortic prosthesis on a nitinol stent, which has limited data on outcomes, as well as cost, from the United States. Methods. We performed a retrospective review of Perceval S implantation at a single center between 2015 and 2018. After exclusion criteria, we compared 234 patients who underwent sutureless aortic valve (SLV) implantation with 370 patients who underwent standard sutured aortic valves (SAVR). Hospital cost data were reviewed, and risk adjustment, done by propensity score and inverse probability weighting, was used to compare outcomes. Results. Compared to those undergoing SAVR, the SLV group was older and had a higher proportion of multicomponent operations, higher preoperative white blood cell count, higher rate of previous percutaneous coronary interventions, more comorbid conditions (diabetes, renal insufficiency, and dialysis), and more three-vessel coronary disease. For isolated AVR, partial upper hemisternotomy was more frequent in SLV. The mean cardiopulmonary bypass and cross-clamp times for isolated SLV were significantly lower than SAVR. After adjustment, the cohort was balanced. Operative differences for SLV were lower cross-clamp and pump time, larger valve size, more minimally invasive approaches, and shorter operating room times. There were no differences in other postoperative complications (postoperative atrial fibrillation, stroke, renal failure, prolonged ventilation, and in-hospital mortality; for all). Mean and median hospital costs were higher in the SLV group, largely due to the cost of the implant. Conclusion. Sutureless tissue aortic valves can be used safely with lower cardiopulmonary bypass and clamp times than sutured prostheses and facilitate use of minimally invasive approaches. This valve may be advantageous in older, higher risk patients requiring more complex operations.

Introduction. Recent national guidelines recommending mitral valve replacement (MVR) for severe secondary mitral regurgitation have resulted in an increased utilization of mitral bioprosthesis. There is a paucity of data on how longitudinal clinical outcomes vary by prosthesis type. We examined long-term survival and risk of reoperation between patients having bovine vs. porcine MVR. Study Design. A retrospective analysis of MVR or MVR + coronary artery bypass graft (CABG) from 2001 to 2017 among seven hospitals reporting to a prospectively maintained clinical registry was conducted. The analytic cohort included 1,284 patients undergoing MVR (801 bovine and 483 porcine). Baseline comorbidities were balanced using 1 : 1 propensity score matching with 432 patients in each group. The primary end point was all-cause mortality. Secondary end points included in-hospital morbidity, 30-day mortality, length of stay, and risk of reoperation. Results. In the overall cohort, patients receiving porcine valves were more likely to have diabetes (19% bovine vs. 29% porcine; ), COPD (20% bovine vs. 27% porcine; ), dialysis or creatinine >2 mg/dL (4% bovine vs. 7% porcine; ), and coronary artery disease (65% bovine vs. 77% porcine; ). There was no difference in stroke, acute kidney injury, mediastinitis, pneumonia, length of stay, in-hospital morbidity, or 30-day mortality. In the overall cohort, there was a difference in long-term survival (porcine HR 1.17 (95% CI: 1.00–1.37; )) . However, there was no difference in reoperation (porcine HR 0.56 (95% CI: 0.23–1.32; )) . In the propensity-matched cohort, patients were matched on all baseline characteristics. There was no difference in postoperative complications or in-hospital morbidity and 30-day mortality. After 1 : 1 propensity score matching, there was no difference in long-term survival (porcine HR 0.97 (95% CI: 0.81–1.17; )) or risk of reoperation (porcine HR 0.54 (95% CI: 0.20–1.47; )) . Conclusions. In this multicenter analysis of patients undergoing bioprosthetic MVR, there was no difference in perioperative complications and risk of reoperation of long-term survival after matching.