Travis O. Abicht

Mortality While Waiting for Aortic Valve Replacement

BACKGROUND Severe symptomatic aortic stenosis (AS) is associated with high mortality without intervention. The impact of waiting time for aortic valve replacement (AVR), either surgically or transcatheter, has not been reported. METHODS From January 2008 to December 2012, we identified 1,005 patients with severe symptomatic AS. AVR was recommended for 823 patients (82%). Of these 823 patients, 721 (87.6%) underwent AVR. We modeled overall survival (OS) since AVR recommendation or intervention date using Cox and multistate models. RESULTS Overall, the median (first, third quartiles) waiting time until operation was 2.9 (1.3, 5.1) weeks. Mortality at these times was lower (p<0.001) in the AVR group (1.2%, 0.3%, 1.7%, respectively) than in the group that did not receive AVR (6.9%, 2.9%, 9.8%, respectively). Thirty-day mortality after AVR was 3.9% (3.2% surgical AVR [SAVR] and 7.0% transcatheter AVR [TAVR]). In patients receiving AVR, waiting time was not associated with increased mortality. Mortality while waiting for AVR was 3.7% and 11.6% at 1 and 6 months, respectively. Mortality while waiting for TAVR was higher than that for SAVR (1-, 6-, and 12-month mortality of 3.7%, 8.0%, and 9.6%, respectively, in SAVR group and 3.8%, 23.3%, and 27.5%, respectively, in TAVR group; p<0.001). CONCLUSIONS Some patients do not receive AVR in a timely fashion, and prolonged waiting time for AVR is associated with mortality greater than the AVR operative mortality. Although waiting time was not associated with poor operative outcomes after AVR, many patients may die while waiting for AVR. Patients should receive AVR on a semiurgent, not elective, basis.

Complex HeartMate II Infection Treated with Pump Exchange to HeartWare HVAD

Left ventricular assist device (LVAD) infections continue to present a serious challenge in both the destination therapy and the bridge to transplant patient populations. As devices are supporting patients longer due to increased durability, infections can evolve and worsen over time. Complex infections, resistant to standard pharmacologic management, require a more aggressive approach to treatment. A series of patients supported by HeartMate II (HMII) LVADs, treated for multidrug resistant complex driveline infections, failed antibiotic therapy and then underwent device exchange. In each case, the HMII device was exchanged for a HeartWare HVAD as we felt its small size and flexible driveline were advantageous properties when dealing with patients with a complex driveline or pump infection.

Echocardiographic markers of left ventricular unloading using a centrifugal-flow rotary pump

Echocardiographic markers of left ventricular unloading using a centrifugal-flow rotary pump Andrew J. Sauer, MD, Karen Meehan, ACNS-BC, Robert Gordon, MD, Travis Abicht, MD, Jonathan D. Rich, MD, Allen S. Anderson, MD, Clyde Yancy, MD, and Edwin C. McGee Jr, MD University Feinberg School of Medici Review Board. Once all baseline echocardiographic recorded, the speed was decreased every revolutions per minute (rpm) until the spee 2,200 to 2,400 rpm, which is the init determined by the speed that allowed f

Paravalvular regurgitation after conventional aortic and mitral valve replacement: A benchmark for alternative approaches.

OBJECTIVE Paravalvular regurgitation is a known complication after transcatheter and sutureless aortic valve replacement. Paravalvular regurgitation also may develop in patients undergoing percutaneous mitral valve replacement. There are few studies on contemporary surgical valve replacement for comparison. We sought to determine the contemporary occurrence of paravalvular regurgitation after conventional surgical valve replacement. METHODS We performed a single-center retrospective database review involving 1774 patients who underwent valve replacement surgery from April 2004 to December 2012: aortic in 1244, mitral in 386, and combined aortic and mitral in 144. Follow-up echocardiography was performed in 73% of patients. Patients with endocarditis were analyzed separately from noninfectious paravalvular leaks. Statistical comparisons were performed to determine differences in paravalvular regurgitation incidence and survival. RESULTS During follow-up, 1+ or greater (mild or more) paravalvular regurgitation occurred in 2.2% of aortic cases and 2.9% of mitral cases. There was 2+ or greater (moderate or more) paravalvular regurgitation in 0.9% of aortic and 2.2% of mitral cases (P = .10). After excluding endocarditis, late noninfectious regurgitation 2+ or greater was detected in 0.5% of aortic and 0.4% of mitral cases (P = .93); there were no reoperations or percutaneous closures for noninfectious paravalvular regurgitation. CONCLUSIONS In an academic medical center, the overall rate of paravalvular regurgitation is low, and late clinically significant noninfectious paravalvular regurgitation is rare. The benchmark for paravalvular regurgitation after conventional valve replacement is high and should be considered when evaluating patients for transcatheter or sutureless valve replacement.

Update on Antibiotic Prophylaxis for Genitourinary Procedures in Patients with Artificial Joint Replacement and Artificial Heart Valves

Infection of artificial joint replacements and heart valves is an uncommon but serious complication encountered anytime after the implantation of these prostheses. It is known that bacteremia can lead to infection of a prosthetic device. However, there is no strong evidence to correlate urologic procedures with the development of periprosthetic joint infection or prosthetic valve endocarditis. Therefore, antibiotic prophylaxis for the prevention of endocarditis is not recommended in patients undergoing urologic procedures. However, guidelines regarding prophylaxis to prevent infection of an artificial joint in the setting of a genitourinary procedure are more varied.

Overcoming reporting challenges: How to display, summarize, and model late reintervention outcomes, follow-up, and vital status information after surgery for atrial fibrillation

BACKGROUND Postsurgical late reinterventions for atrial fibrillation (AF) include cardioversions (CV) or catheter ablations (CA). Commonly used methods for reporting and modeling the frequency and timing of CA or CV have well-known shortcomings. OBJECTIVE The purpose of this study was to present intuitive and robust methods to visualize, summarize, and model late reinterventions type/timing and vital status simultaneously. METHODS We present (1) the SMART plot (Summary of Mortality And Outcomes Reported Over Time); (2) the reintervention mean cumulative function (MCF); and (3) the proportional means model and the proportional rates model. We illustrate these methods in 3 groups: patients age ≤60 years, 60-75 years (reference), and >75 years who underwent surgical AF ablation. RESULTS Patients age >75 years had a significantly lower MCF of CVs (hazard ratio [HR] 0.50, P <.001). MCF for CAs was not significantly lower for patients age >75 years (HR 0.57, P = .13). For combined reinterventions (CV or CA), the age group >75 years had a significantly lower MCF (HR 0.51, P <.001). There were no significant differences in late CV or CA reintervention patterns for patients age ≤60 years. CONCLUSION The methods presented provide a comprehensive framework for displaying, summarizing, and modeling repeated late reinterventions after surgical AF ablation. Other areas of application are described, further emphasizing the potential for immediate use.

A simple approach to mitral valve repair: Posterior leaflet height adjustment using a partial fold of the free edge

OBJECTIVES Multiple techniques have been used to repair degenerative mitral valve prolapse with leaflet elongation, without creating systolic anterior motion. We describe a simple, reproducible, measured technique to guide repair. METHODS From January 2010 to July 2012, 171 patients underwent mitral valve repair; 128 (75%) with Carpentier type II prolapse. For 48 patients (37.5%), the resected posterior leaflet free edge was partially folded to restore the normal 2:1 ratio of the A2 and P2. All patients underwent complete ring annuloplasty sized to the height of A2. RESULTS The preoperative A2/P2 ratio was 1.5 ± 0.5. After repair, the A2/P2 ratio was 1.9 ± 0.3 and 2.0 ± 0.3 in the no fold and partial fold groups, respectively (P = .57). The ring sizes were larger in the partial fold group (P < .001) because the A2 height was larger (P = .001). No obstructive systolic anterior motion was present. Of the 171 patients, 91.4% had grade 4+ preoperative mitral regurgitation, with no 3 or 4+ mitral regurgitation during follow-up. At the last follow-up visit, grade 2+ mitral regurgitation was observed in 5% of the patients. No 30-day mortalities or reoperations occurred. CONCLUSIONS Partial fold of the posterior leaflet free edge is a simple technique to restore the normal 2:1 ratio of A2/P2 with a ring size determined by the A2 height. Using just the A2 height, mitral surgeons can reproducibly repair the posterior leaflet prolapse, choose the appropriate ring size, and avoid more complex leaflet reconstruction or judgment of the neochord length.

Invasive fungal infection after heart transplantation: A 7-year, single-center experience

Invasive fungal infections (IFIs) are an infrequent but major complication of heart transplantation (HT). We sought to describe the epidemiology at our institution.