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Mitral Leaflet Shortening as an Ancillary Procedure in Obstructive Hypertrophic Cardiomyopathy

Swistel, Daniel G; Massera, Daniele; Stepanovic, Alexandra; Adlestein, Elizabeth; Reuter, Maria; Wu, Woon; Scheinerman, Joshua A; Nampi, Robert; Paone, Darien; Kim, Bette; Sherrid, Mark V
BACKGROUND:Mitral leaflet elongation is common in hypertrophic cardiomyopathy (HCM), contributes to obstructive physiology, and presents a challenge to dual surgical goals of abolition of outflow gradients and mitral regurgitation. Anterior leaflet shortening, performed as an ancillary surgical procedure during myectomy, is controversial. METHODS:This was a retrospective study of all patients undergoing myectomy from 1/2010 to 3/2020 analyzing survival and echocardiographic results. We compared outcomes of patients treated with myectomy and concomitant mitral leaflet shortening with patients treated with myectomy alone. Over this time technique for mitral shortening evolved from anterior leaflet plication to residual leaflet excision (ReLex). RESULTS:Myectomy was performed on 416 patients age 57.5±13.6 years, 204 (49%) female. Average follow up was 5.4±2.8 years. Survival follow-up was complete in 415. Myectomy without valve replacement was performed in 332 patients, of whom 192 had mitral valve shortening (58%). Mitral leaflet plication was performed in 73, ReLex in 151 and both in 32. Hospital mortality for patients undergoing myectomy was 0.7%. At 8 years, cumulative survival was 95% for both myectomy plus leaflet shortening and myectomy alone groups, with no difference in survival between the two. There was no difference in survival between anterior leaflet plication and ReLex groups. Echocardiography 2.5 years after surgery showed a decrease in resting and provoked gradients, mitral regurgitation and left atrial volume and no difference in key variables between ancillary leaflet shortening and myectomy alone patients. CONCLUSIONS:These results affirm that mitral shortening may be an appropriate surgical judgment for selected patients.
PMID: 38518836
ISSN: 1552-6259
CID: 5640912

Routine Extubation in the Operating Room After Isolated Coronary Artery Bypass

James, Les; Smith, Deane E; Galloway, Aubrey C; Paone, Darien; Allison, Michael; Shrivastava, Shashwat; Vaynblat, Mikhail; Swistel, Daniel G; Loulmet, Didier F; Grossi, Eugene A; Williams, Mathew R; Zias, Elias
BACKGROUND:The benefits of fast-track extubation in the intensive care unit (ICU) after cardiac surgery are well established. Although extubation in the operating room (OR) is safe in carefully selected patients, widespread use of this strategy in cardiac surgery remains unproven. This study was designed to evaluate perioperative outcomes with OR vs ICU extubation in patients undergoing nonemergency, isolated coronary artery bypass grafting (CABG). METHODS:The Society of Thoracic Surgeons (STS) data for all single-center patients who underwent nonemergency isolated CABG over a 6-year interval were analyzed. Perioperative morbidity and mortality with ICU vs OR extubation were compared. RESULTS:Between January 1, 2017 and December 31, 2022, 1397 patients underwent nonemergency, isolated CABG; 891 (63.8%) of these patients were extubated in the ICU, and 506 (36.2%) were extubated in the OR. Propensity matching resulted in 414 pairs. In the propensity-matched cohort, there were no differences between the 2 groups in incidence of reintubation, reoperation for bleeding, total operative time, stroke or transient ischemic attack, renal failure, or 30-day mortality. OR-extubated patients had shorter ICU hours (14 hours vs 20 hours; P < .0001), shorter postoperative hospital length of stay (3 days vs 5 days; P < .0001), a greater likelihood of being discharged directly to home (97.3% vs 89.9%; P < .0001), and a lower 30-day readmission rate (1.7% vs 4.1%; P = .04). CONCLUSIONS:Routine extubation in the OR is a feasible and safe strategy for a broad spectrum of patients after nonemergency CABG, with no increase in perioperative morbidity or mortality. Wider adoption of routine OR extubation for nonemergency CABG is indicated.
PMID: 37806334
ISSN: 1552-6259
CID: 5605312

Apical Aneurysms and Mid-Left Ventricular Obstruction in Hypertrophic Cardiomyopathy

Sherrid, Mark V; Bernard, Samuel; Tripathi, Nidhi; Patel, Yash; Modi, Vivek; Axel, Leon; Talebi, Soheila; Ghoshhajra, Brian B; Sanborn, Danita Y; Saric, Muhamed; Adlestein, Elizabeth; Alvarez, Isabel Castro; Xia, Yuhe; Swistel, Daniel G; Massera, Daniele; Fifer, Michael A; Kim, Bette
BACKGROUND:Apical left ventricular (LV) aneurysms in hypertrophic cardiomyopathy (HCM) are associated with adverse outcomes. The reported frequency of mid-LV obstruction has varied from 36% to 90%. OBJECTIVES/OBJECTIVE:The authors sought to ascertain the frequency of mid-LV obstruction in HCM apical aneurysms. METHODS:The authors analyzed echocardiographic and cardiac magnetic resonance examinations of patients with aneurysms from 3 dedicated programs and compared them with 63 normal controls and 47 controls with apical-mid HCM who did not have aneurysms (22 with increased LV systolic velocities). RESULTS:]; P = 0.004). Complete emptying occurs circumferentially around central PMs that contribute to obstruction. Late gadolinium enhancement was always brightest and the most transmural apical of, or at the level of, complete emptying. CONCLUSIONS:The great majority (95%) of patients in the continuum of apical aneurysms have associated mid-LV obstruction. Further research to investigate obstruction as a contributing cause to apical aneurysms is warranted.
PMID: 36681586
ISSN: 1876-7591
CID: 5419392

Histopathology of the Mitral Valve Residual Leaflet in Obstructive Hypertrophic Cardiomyopathy

Troy, Aaron L; Narula, Navneet; Massera, Daniele; Adlestein, Elizabeth; Alvarez, Isabel Castro; Janssen, Paul M L; Moreira, Andre L; Olivotto, Iacopo; Stepanovic, Alexandra; Thomas, Kristen; Zeck, Briana; Chiriboga, Luis; Swistel, Daniel G; Sherrid, Mark V
BACKGROUND:Mitral valve (MV) elongation is a primary hypertrophic cardiomyopathy (HCM) phenotype and contributes to obstruction. The residual MV leaflet that protrudes past the coaptation point is especially susceptible to flow-drag and systolic anterior motion. Histopathological features of MVs in obstructive hypertrophic cardiomyopathy (OHCM), and of residual leaflets specifically, are unknown. OBJECTIVES/OBJECTIVE:The purpose of this study was to characterize gross, structural, and cellular histopathologic features of MV residual leaflets in OHCM. On a cellular-level, we assessed for developmental dysregulation of epicardium-derived cell (EPDC) differentiation, adaptive endocardial-to-mesenchymal transition and valvular interstitial cell proliferation, and genetically-driven persistence of cardiomyocytes in the valve. METHODS:Structural and immunohistochemical staining were performed on 22 residual leaflets excised as ancillary procedures during myectomy, and compared with 11 control leaflets from deceased patients with normal hearts. Structural components were assessed with hematoxylin and eosin, trichrome, and elastic stains. We stained for EPDCs, EPDC paracrine signaling, valvular interstitial cells, endocardial-to-mesenchymal transition, and cardiomyocytes. RESULTS:= 0.08). No markers of primary cellular processes were identified. CONCLUSIONS:MV residual leaflets in HCM were characterized by histologic findings that were likely secondary to chronic hemodynamic stress and may further increase susceptibility to systolic anterior motion.
PMCID:10306242
PMID: 37383048
ISSN: 2772-963x
CID: 5540432

Low-Dose vs Standard Warfarin After Mechanical Mitral Valve Replacement: A Randomized Trial

Chu, Michael W A; Ruel, Marc; Graeve, Allen; Gerdisch, Marc W; Damiano, Ralph J; Smith, Robert L; Keeling, William Brent; Wait, Michael A; Hagberg, Robert C; Quinn, Reed D; Sethi, Gulshan K; Floridia, Rosario; Barreiro, Christopher J; Pruitt, Andrew L; Accola, Kevin D; Dagenais, Francois; Markowitz, Alan H; Ye, Jian; Sekela, Michael E; Tsuda, Ryan Y; Duncan, David A; Swistel, Daniel G; Harville, Lacy E; DeRose, Joseph J; Lehr, Eric J; Alexander, John H; Puskas, John D
BACKGROUND:Current guidelines recommend a target international normalized ratio (INR) range of 2.5 to 3.5 in patients with a mechanical mitral prosthesis. The Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT) Mitral randomized controlled noninferiority trial assessed safety and efficacy of warfarin at doses lower than currently recommended in patients with an On-X (Artivion, Inc) mechanical mitral valve. METHODS:After On-X mechanical mitral valve replacement, followed by at least 3 months of standard anticoagulation, 401 patients at 44 North American centers were randomized to low-dose warfarin (target INR, 2.0-2.5) or standard-dose warfarin (target INR, 2.5-3.5). All patients were prescribed aspirin, 81 mg daily, and encouraged to use home INR testing. The primary end point was the sum of the linearized rates of thromboembolism, valve thrombosis, and bleeding events. The design was based on an expected 7.3% event rate and 1.5% noninferiority margin. RESULTS:Mean patient follow-up was 4.1 years. Mean INR was 2.47 and 2.92 (P <.001) in the low-dose and standard-dose warfarin groups, respectively. Primary end point rates were 11.9% per patient-year in the low-dose group and 12.0% per patient-year in the standard-dose group (difference, -0.07%; 95% CI, -3.40% to 3.26%). The CI >1.5%, thus noninferiority was not achieved. Rates (percentage per patient-year) of the individual components of the primary end point were 2.3% vs 2.5% for thromboembolism, 0.5% vs 0.5% for valve thrombosis, and 9.13% vs 9.04% for bleeding. CONCLUSIONS:Compared with standard-dose warfarin, low-dose warfarin did not achieve noninferiority for the composite primary end point. (PROACT Clinicaltrials.gov number, NCT00291525).
PMID: 36610532
ISSN: 1552-6259
CID: 5426292

Ventricular Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy (Analysis Spanning 60 Years Of Practice): AJC Expert Panel

Maron, Barry J; Dearani, Joseph A; Smedira, Nicholas G; Schaff, Hartzell V; Wang, Shuiyun; Rastegar, Hassan; Ralph-Edwards, Anthony; Ferrazzi, Paolo; Swistel, Daniel; Shemin, Richard J; Quintana, Eduard; Bannon, Paul G; Shekar, Prem S; Desai, Milind; Roberts, William C; Lever, Harry M; Adler, Arnon; Rakowski, Harry; Spirito, Paolo; Nishimura, Rick A; Ommen, Steve R; Sherrid, Mark V; Rowin, Ethan J; Maron, Martin S
Surgical myectomy remains the time-honored primary treatment for hypertrophic cardiomyopathy patients with drug refractory limiting symptoms due to LV outflow obstruction. Based on >50 years experience, surgery reliably reverses disabling heart failure by permanently abolishing mechanical outflow impedance and mitral regurgitation, with normalization of LV pressures and preserved systolic function. A consortium of 10 international currently active myectomy centers report about 11,000 operations, increasing significantly in number over the most recent 15 years. Performed in experienced multidisciplinary institutions, perioperative mortality for myectomy has declined to 0.6%, becoming one of the safest currently performed open-heart procedures. Extended myectomy relieves symptoms in >90% of patients by ≥ 1 NYHA functional class, returning most to normal daily activity, and also with a long-term survival benefit; concomitant Cox-Maze procedure can reduce the number of atrial fibrillation episodes. Surgery, preferably performed in high volume clinical environments, continues to flourish as a guideline-based and preferred high benefit: low treatment risk option for adults and children with drug refractory disabling symptoms from obstruction, despite prior challenges: higher operative mortality/skepticism in 1960s/1970s; dual-chamber pacing in 1990s, alcohol ablation in 2000s, and now introduction of strong negative inotropic drugs potentially useful for symptom management.
PMID: 35965115
ISSN: 1879-1913
CID: 5299672

Surgical Septal Myectomy and Alcohol Ablation: Not Equivalent in Efficacy or Survival [Comment]

Sherrid, Mark V; Massera, Daniele; Swistel, Daniel G
PMID: 35483752
ISSN: 1558-3597
CID: 5213622

Mitral annular calcification in hypertrophic cardiomyopathy

Massera, Daniele; Xia, Yuhe; Li, Boyangzi; Riedy, Katherine; Swistel, Daniel G; Sherrid, Mark V
BACKGROUND:Changes in mitral valve anatomy contribute to left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM). Mitral annular calcification (MAC) is common among patients with HCM but its implications are currently unknown. METHODS:We tested the hypothesis that echocardiographic MAC would be associated with anterior displacement of the mitral valve and LVOTO in a cohort of 304 patients with HCM aged ≥ 60 years (mean [SD] age 71.6 [7.7] years, 52% women). RESULTS:MAC was present in 141 (46%) patients. The mean (SD) MAC offset distance was 9.8 (4.8) mm. A higher proportion of those with MAC compared to those without MAC had SAM (84.2 vs. 63.8%, p < 0.001) and LVOTO (80.9 vs. 57.9%, p < 0.001). In patients with MAC, the septal-mitral valve distance was shorter compared to those without (19.4 [4.0] vs 21.5 [4.9] mm, p < 0.001). The mitral valve position ratio was greater in those with MAC compared to those without (1.00 [0.79, 1.22] vs. 0.86 [0.67, 1.05], p < 0.001) denoting greater anterior displacement, especially in those with MAC and LVOTO. After multivariable adjustment, MAC offset distance was associated with LVOTO (OR 1.16 [95% CI 1.07, 1.28] per mm, p = 0.001). Over a median follow-up of 2.7 years, 42 (29.8%) patients with MAC underwent surgery to relieve LVOTO, with no deaths. CONCLUSION/CONCLUSIONS:This study adds MAC to the known geometrical alterations of the mitral valve that predispose to LVOTO and suggests that surgical relief of LVOTO in the presence of MAC is safe when performed by an experienced surgeon.
PMID: 34848211
ISSN: 1874-1754
CID: 5065612

Low-Dose Versus Standard Warfarin After Mechanical Mitral Valve Replacement: A Randomized Controlled Trial

Chu, Michael W A; Ruel, Marc; Graeve, Allen; Gerdisch, Marc W; Damiano, Ralph J; Smith, Robert L; Keeling, William Brent; Wait, Michael A; Hagberg, Robert C; Quinn, Reed D; Sethi, Gulshan K; Floridia, Rosario; Barreiro, Christopher J; Pruitt, Andrew L; Accola, Kevin D; Dagenais, Francois; Markowitz, Alan H; Ye, Jian; Sekela, Michael E; Tsuda, Ryan Y; Duncan, David A; Swistel, Daniel G; Harville, Lacy E; DeRose, Joseph J; Lehr, Eric J; Puskas, John D
BACKGROUND:Current guidelines recommend a target international normalized ratio (INR) range of 2.5 to 3.5 in patients with a mechanical mitral prosthesis. The Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT) Mitral randomized controlled trial assessed the safety and efficacy of warfarin at doses lower than currently recommended, in patients with an On-X mechanical mitral valve. METHODS:After On-X mechanical mitral valve replacement followed by at least 3 months of standard anticoagulation, 401 patients at 44 North American centers were randomized to low-dose warfarin (target INR 2.0 to 2.5) or standard-dose warfarin (target INR 2.5 to 3.5). All patients were prescribed aspirin 81 mg daily and encouraged to use home INR testing. The primary endpoint was the sum of the linearized rates of thromboembolism, valve thrombosis, and bleeding events. Secondary endpoints included death, valve-related events, New York Heart Association classification, and valve hemodynamics. RESULTS:Mean patient follow-up was 4.1 years. Mean INR was 2.47 and 2.92 (P <.001) in the low-dose and standard-dose warfarin groups, respectively. Primary endpoint rates were 11.9%/patient-year in the low-dose group and 12.0%/patient-year in the standard-dose group (P = .97). The -0.07% difference (95% confidence interval: -0.07, -0.06) was noninferior (<1.5% margin). Individual rates (expressed as %/patient-year) of thromboembolism (2.3% vs 2.5%), valve thrombosis (0.5% vs 0.5%), and major bleeding (4.9% vs 4.3%) were also similar and noninferior. CONCLUSIONS:Low-dose warfarin was noninferior to standard-dose warfarin in patients with an On-X mechanical mitral prosthesis, following >3 postoperative months of standard anticoagulation therapy. (PROACT Clinicaltrials.gov number, NCT00291525).
PMID: 35101419
ISSN: 1552-6259
CID: 5153402

Syndrome of Reversible Cardiogenic Shock and Left Ventricular Ballooning in Obstructive Hypertrophic Cardiomyopathy

Sherrid, Mark V; Swistel, Daniel G; Olivotto, Iacopo; Pieroni, Maurizio; Wever-Pinzon, Omar; Riedy, Katherine; Bach, Richard G; Husaini, Mustafa; Cresci, Sharon; Reyentovich, Alex; Massera, Daniele; Maron, Martin S; Maron, Barry J; Kim, Bette
Background Cardiogenic shock from most causes has unfavorable prognosis. Hypertrophic cardiomyopathy (HCM) can uncommonly present with apical ballooning and shock in association with sudden development of severe and unrelenting left ventricular (LV) outflow obstruction. Typical HCM phenotypic features of mild septal thickening, outflow gradients, and distinctive mitral abnormalities differentiate these patients from others with Takotsubo syndrome, who have normal mitral valves and no outflow obstruction. Methods and Results We analyzed 8 patients from our 4 HCM centers with obstructive HCM and abrupt presentation of cardiogenic shock with LV ballooning, and 6 cases reported in literature. Of 14 patients, 10 (71%) were women, aged 66±9 years, presenting with acute symptoms: LV ballooning; depressed ejection fraction (25±5%); refractory systemic hypotension; marked LV outflow tract obstruction (peak gradient, 94±28 mm Hg); and elevated troponin, but absence of atherosclerotic coronary disease. Shock was managed with intravenous administration of phenylephrine (n=6), norepinephrine (n=6), β-blocker (n=7), and vasopressin (n=1). Mechanical circulatory support was required in 8, including intra-aortic balloon pump (n=4), venoarterial extracorporeal membrane oxygenation (n=3), and Impella and Tandem Heart in 1 each. In refractory shock, urgent relief of obstruction by myectomy was performed in 5, and alcohol ablation in 1. All patients survived their critical illness, with full recovery of systolic function. Conclusions When cardiogenic shock and LV ballooning occur in obstructive HCM, they are marked by distinctive anatomic and physiologic features. Relief of obstruction with targeted pharmacotherapy, mechanical circulatory support, and myectomy, when necessary for refractory shock, may lead to survival and normalization of systolic function.
PMID: 34634917
ISSN: 2047-9980
CID: 5061922