Arash Salemi

National trends in utilization and in-hospital outcomes of mechanical versus bioprosthetic aortic valve replacements.

OBJECTIVE Substantial controversy surrounds the choice between a mechanical versus bioprosthetic prosthesis for aortic valve replacement (AVR), based on age. This study aims to investigate national trends and in-hospital outcomes of the 2 prosthesis choices. METHODS All patients aged >18 years in the National Inpatient Sample who received an AVR between 1998 and 2011 were considered. Valve-type use was examined by patient, procedural, and hospital characteristics, after which we matched patients based on their propensity score for receiving a bioprosthetic valve and compared their in-hospital outcomes. RESULTS Bioprosthetic valves comprised 53.3% of 767,375 implanted valves, an increase in use from 37.7% in the period 1998 to 2001 to 63.6% in the period 2007 to 2011. The median age was 74 years for patients receiving bioprosthetic valves, and 67 years for those receiving mechanical valves. Use of bioprosthetic valves increased across all age groups, most markedly in patients age 55 to 64 years. Compared with patients receiving mechanical valves, these patients had a higher incidence of renal disease (8.0% vs 4.2%), coronary artery disease (58.5% vs 50.5%), concomitant coronary artery bypass grafting (46.7% vs 41.9%), and having surgery in a high-volume (>250 cases per year) center (31.3% vs 18.5%). Patients receiving bioprosthetic valves had a higher occurrence of in-hospital complications (55.9% vs 48.6%), but lower in-hospital mortality (4.4% vs 4.9%) than patients receiving mechanical valves. This difference was confirmed in propensity-matched analyses (complications: 52.7% vs 51.5%; mortality: 4.3% vs 5.2%). CONCLUSIONS Use of bioprosthetic valves in AVR increased dramatically from 1998 to 2011, particularly in patients age 55 to 64 years. Prosthesis selection varied significantly by facility, with low-volume facilities favoring mechanical valves. Aortic valve replacement with a bioprosthetic valve, compared with a mechanical valve, was associated with lower in-hospital mortality.

Intravenous leiomyomatosis with intracardiac extension: a single-institution experience

OBJECTIVE The aim of this study was to outline the surgical management and outcomes for patients diagnosed with intravenous leiomyomatosis with intracardiac extension at a single institution. STUDY DESIGN This was a retrospective review of patients diagnosed with intravenous leiomyomatosis with intracardiac extension between 2002-2008. RESULTS Four patients were identified. The surgical approach in 3 (75%) patients was a single-stage operation. Four (100%) patients presented with cardiac symptoms: 3 (75%) with syncope and 1 (25%) with an abnormal electrocardiogram. Mean age at presentation was 48 years (range, 42-58 years). Complete resection of tumor was obtained in 1 (25%) patient and 3 (75%) patients experienced incomplete resection. Mean follow-up, including surveillance imaging, was 25.5 months (range, 8-57 months) and all 4 patients (100%) are currently free of recurrence. CONCLUSION Surgical excision remains an effective therapy for treating patients with benign metastasizing leiomyomatosis. Incomplete surgical resection may result in favorable response.

Costs and In-Hospital Outcomes of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Commercial Cases Using a Propensity Score Matched Model

The aim of this study was to compare in-hospital cost and outcomes between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). TAVI is an effective treatment option in patients with symptomatic aortic stenosis who are at high risk for traditional SAVR. Several studies using trial data or outside United States registry data have addressed TAVI cost issues, although there is a paucity of cost data involving commercial cases in the United States. Using Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Nationwide Inpatient Sample files, a propensity score-matched analysis of all commercial TAVI and SAVR cases performed in 2011 was conducted. Overall hospital cost and length of stay, as well as procedural complications, were compared between the 2 matched cohorts: 595 TAVI patients were matched to 1,785 SAVR patients in a 1:3 ratio. There was no difference in mean (

A Population-Based Analysis of Robotic-Assisted Mitral Valve Repair

181,912 vs

Outcomes of Patients Implanted With a Left Ventricular Assist Device at Nontransplant Mechanical Circulatory Support Centers

196,298) or median (

Science for surgeons: Understanding pump thrombogenesis in continuous-flow left ventricular assist devices

152,993 vs

Minithoracotomy for mitral valve repair improves inpatient and postdischarge economic savings

155,974) hospital cost between TAVI and SAVR (p = 0.60). The TAVI group had significantly shorter lengths of hospital stay than the SAVR group (mean 9.76 vs 12.01 days, p <0.001). There was no difference in postprocedural in-hospital death or stroke, but TAVI patients were more likely to have bleeding complications, to have vascular complications, and to require pacemakers. In conclusion, when analyzing in-hospital cost of commercial TAVI and SAVR cases using the Nationwide Inpatient Sample data set, TAVI is an economically satisfactory alternative to SAVR and results in an approximately 2-day shorter length of stay during the index hospitalization.

An Assay to Monitor Bivalirudin Levels on Cardiopulmonary Bypass

BACKGROUND Robotic-assisted mitral valve repair is becoming more frequently performed in cardiac surgery. However, little is known about its utilization and safety at a national level. METHODS Patients undergoing mitral valve repair in the United States from 2008 to 2012 were identified in the National Inpatient Sample. Inhospital mortality, complications, length of stay, and cost for patients undergoing robotic-assisted mitral valve repair were compared with patients undergoing nonrobotic procedures. RESULTS We identified 50,408 isolated mitral valve repair surgeries, of which 3,145 were done with robotic assistance. In a propensity score matched analysis of 631 pairs of patients, we found no difference between patients undergoing robotic-assisted and nonrobotic-assisted mitral valve repair with respect to inhospital mortality, complications, or composite outcomes in unadjusted or multivariable analyses. Robotic-assisted mitral valve repair surgery was associated with a shorter median length of stay (4 versus 6 days, p < 0.001), and there was no difference in median total costs between the two procedures. CONCLUSIONS In our analysis of a large national database with its inherent limitations, robotic-assisted mitral valve repair was found to be safe, with an acceptable morbidity and mortality profile.

Prognostic Importance of Diastolic Dysfunction in Relation to Post Procedural Aortic Insufficiency in Patients Undergoing Transcatheter Aortic Valve Replacement

The goal of this study was to assess outcomes of patients who underwent implantation of left ventricular assist devices (LVADs) at nontransplantation mechanical circulatory support centers. As the availability of LVADs for advanced heart failure has expanded to nontransplantation mechanical circulatory support centers, concerns have been expressed about maintaining good outcomes. Demographics and outcomes were evaluated in 276 patients with advanced heart failure who underwent implantation of LVADs as bridge to transplantation or destination therapy at 27 open-heart centers. Baseline characteristics, operative mortality, length of stay, readmission rate, adverse events, quality of life, and survival were analyzed. The overall 30-day mortality was 3% (8 of 276), and survival rates at 6, 12, and 24 months, respectively, were 92±2%, 88±3%, and 84±4% for the bridge-to-transplantation group and 81±3%, 70±5%, and 63±6% for the destination therapy group, comparable with results published by the national Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). The median length of stay for all patients was 21 days. Bleeding was the most frequent adverse event. Stroke occurred in 4% (bridge to transplantation) and 6% (destination therapy) of patients. Quality-of-life measures and 6-minute walk distances showed sustained improvements throughout support. In conclusion, outcomes with LVAD support at open-heart centers are acceptable and comparable with results from the INTERMACS registry. With appropriate teams, training, center commitment, and certification, LVAD therapy is being disseminated in a responsible way to open-heart centers.

Right anterior thoracotomy aortic valve replacement is associated with less cost than sternotomy-based approaches: a multi-institution analysis of 'real world' data.

Left ventricular assist devices (LVADs) have emerged as a mainstay, lifesaving treatment option for patients with refractory heart failure, with 1and 2-year actuarial survival rates of 80% and 70%, respectively, for the current generation of Food and Drug Administration-approved continuous-flow devices. Despite this progress, continuousflow LVADs are not without their shortcomings. One issue in particular continues to vex these devices and is increasingly garnering attention in the literature: Device thrombosis and its attendant thromboembolic complications. After a recent article exposed an unexpected uptick in the incidence of pump thrombosis with 1 of the 2 approved durable continuous-flow pumps, a flurry of studies quickly ensued that sought to better delineate the problem of LVAD thrombogenesis. Much of this effort focuses on developing patient-level and/or device-specific predictors of thrombus formation as clotting is not inevitable with current devices. The results of such clinical endeavors will no doubt bevital to improving outcomes; however, what is often lost in these analyses is an understanding of the thrombus itself. Simple questions like, ‘‘What exactly is a thrombus?’’ are often taken for granted, yet, overcoming the multifactorial scourge of LVAD thrombosis demands that we understand the answers to these fundamental questions. We therefore present a contemporary review of the basic science of thrombogenesis in the setting of LVAD support and begin by outlining how clots typically form in devices, incorporating new insights into established clotting cascades. Then, we invoke a Virchow’s triad of sorts to explain the 3 fundamental determinants of pump thrombogenesis: (1) titanium’s bioreactive surface acts as a nidus for