Considering the worsening opioid epidemic, complicated infective endocarditis (IE) secondary to intravenous drug use (IVDU) that fails medical management is increasingly common. We present a 31-year-old patient post tricuspid valve replacement who relapsed with recurrent IE and secondary complications of severe tricuspid stenosis and regurgitation, ventricular septal defect (VSD), pulmonary emboli, right-sided heart failure with severe hepatic congestion, and cardiogenic shock. Despite maximal medical management, the patient remained in septic and cardiogenic shock with a potential disposition to hospice care. Upon consulting cardiothoracic surgery, she underwent a first-stage valvectomy with Extracorporeal Membrane Oxygenation (ECMO) as a bridge to definitive treatment. After clearance of infection, she underwent a second-stage valve replacement, VSD repair, and final ECMO decannulation. Our case alludes to ECMO as a potential bridge for patients with complicated infective endocarditis who fail medical management and are high-risk candidates for immediate definitive surgical management.

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.

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.

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.

AngioVac suction embolectomy is recommended by the manufacturer to be performed with a centrifugal pump due to safety considerations. However, roller head pumps are significantly cheaper to use, and thus may be more readily available during shortages and in resource poor settings. We present the technique of Angiovac suction embolectomy being successfully performed with a roller pump to evacuate a clot-in-transit in the inferior vena cava and right atrium, along with discussion of important safety caveats.

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.

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.

Purpose: Diffuse mega-aorta is challenging. Prior studies have raised concerns regarding the safety of the open two-stage elephant trunk (ET) approach for extensive thoracic aortic aneurysm (TAA), specifically in regard to inter-stage mortality. This study evaluates the safety of the two-stage ET approach for management of extensive TAA. Methods: Between 2003–2018, 152 patients underwent a Stage I ET procedure by a single surgeon (mean age 64.5±14.8). Second stage ET procedure was planned in 60 patients (39.4%) and to-date has been performed in 54 patients (90%). (In the remaining patients, the elephant trunk was prophylactic for the long-term, with no plan for near-term utilization). Results: In-hospital mortality after the Stage I procedure was 3.3% (5/152). In patients planned for Stage II, the median inter-stage interval was 5 weeks (range: 0-14). Of the remaining six patients with planned, but uncompleted Stage II procedures, five patients expired from various causes in the interval period (inter-stage mortality of 8.3%). There were no cases of aortic rupture in the inter-stage interval. Stage II was completed in 58 patients (including 4 unplanned) with 30-day morality of 10.3% (6/58). Seven patients developed strokes after Stage II (12%), and three patients (5.1%) developed paraplegia. Conclusions: The overall mortality, including Stage I, inter-stage interval, and Stage II was 18.6%. This cumulative mortality for the open two-staged ET approach for treatment of extensive TAA is acceptable for aortic disease of this severity. Fear of inter-stage rupture should not preclude the aggressive Two-Stage approach to management of extensive TAA.

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.

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.

Objective: Reports of prevalence and clinical significance of bicuspid aortic valve (BAV) disease are variable. We assessed our institutional echocardiography (ECHO) database to understand the reported prevalence of BAV and its potential association with thoracic aortic aneurysm disease (TAAD). Methods: All ECHOs of adult patients (>18 years) performed at a single institution between calendar year 2013 to 2018 were reviewed. BAV patients were categorized by age group (Young age:18-39 years; Middle age:40-65 years; Old age: >65years) to assess for aortic valvulopathy and TAAD. Logistic regression analysis was performed to understand association of BAV with TAAD. Results: Of 48,503 unique patient ECHOs, 245 (0.51%) described a diagnosis of BAV, with 93(40%) concomitant TAAD. Increased association with endocarditis (p=0.01) and severe aortic insufficiency (p=0.005) was seen in the Young group. Ascending aortic diameter was significantly higher in the Middle compared to the Young group (p<0.001), but similar to Old group. On multivariable regression, BSA(OR=7.31(2.27-23.57)) and age (OR=1.02(1.00-1.04)), but not BAV dysfunction (OR1.07(0.51-2.26)) were associated with TAAD. Conclusions: In this large cross-sectional ECHO study, reported BAV prevalence was 0.51%. We found high association of BAV with concomitant TAAD especially in patients greater than 40 years of age. This suggests that more frequent aortic surveillance may be warranted in the middle and old age BAV subjects.

We report an emergent complex hybrid repair of a type A Intramural Hematoma with a tear of the aortic arch at the site of Kommerell's Diverticulum and an Aberrant Right Subclavian Artery. We identified a type Ia endoleak intraoperatively, which was managed immediately with proximal extension. Performing this operation in the hybrid operating room facilitated optimal surgical management.