IMPORTANCE Recent data indicate that women with hypertrophic cardiomyopathy (HCM) are older and more symptomatic at presentation and have worse clinical outcomes than men. However, to our knowledge, there are no large studies of the association of patient sex with outcomes after surgical myectomy. OBJECTIVE To analyze preoperative characteristics and overall survival of women and men undergoing septal myectomy for obstructive HCM. DESIGN, SETTING, AND PARTICIPANTS This retrospective, single-center study included the clinical data of adult patients who underwent septal myectomy from January 1961 through April 2016. Data analysis occurred from December 2017 to December 2018. EXPOSURES Septal myectomy. MAIN OUTCOMES AND MEASURES Survival. RESULTS A total of 2506 adults were included; 1379 patients (55.0%) were men. At the time of surgery, women were older, with median (IQR) age of 59.5 (46.6-68.2) years vs 52.9 (42.9-62.7) years in men (P < .001). Women were more likely to have New York Heart Association class III or IV status at presentation (women, 1023 [90.8%]; men, 1169 [84.8%]; P < .001) and more severe obstructive physiology, as reflected in higher resting left ventricular outflow tract gradients (women, 67.0 [36.0-97.0] mm Hg; men, 50.0 [23.0-81.0] mm Hg; P < .001). Women also had a greater likelihood of having moderate or severe mitral regurgitation (606 [55.2%]) than men (581 [43.1%]; P < .001) and higher right ventricular systolic pressure (women, 36.0 [30.0-46.0] mm Hg; men, 33.0 [28.0-39.0] mm Hg; P < .001). The unadjusted overall survival was lower in women, corresponding to a median 3.9-year shorter survival than men (median [IQR] survival time: women, 18.2 [12.1-27.2] years; men, 22.1 [15.1-32.5] years; P < .001). In a multivariable Cox regression analysis, however, the association between sex and mortality was attenuated and not significant after controlling for other baseline variables (hazard ratio, 0.98 [95% CI, 0.76-1.26]; P = .86). Among the covariates in the model, older age at surgery (adjusted hazard ratio [aHR], 3.09 [95% CI, 2.12-4.52]; P < .001), higher body mass index (aHR, 1.22 [95% CI, 0.90-1.66]; P < .001), greater NYHA class (aHR, 2.31 [95% CI, 1.03-5.15]; P = .04), and presence of diabetes prior to surgery (aHR, 1.57 [95% CI, 1.10-2.24]; P = .01) were each independently associated with increased mortality. Operations performed later in the study period (2013 vs 2004) were associated with decreased mortality (aHR, 0.82 [95% CI, 0.55-1.22]; P = .001). CONCLUSIONS AND RELEVANCE In this large cohort of surgical patients with obstructive HCM, we observed significant differences at clinical presentation between women and men, in that women were older and more symptomatic. However, after adjustment for important baseline prognostic factors, there was no survival difference after septal myectomy by sex. Improved care of women with obstructive HCM should focus on early identification of disease and prompt surgical referral of appropriate patients who do not respond to medical treatment.

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Background. Limited data exist on the management of vascular rings (VR) in adults. We reviewed our experience of surgical treatment of these patients. Methods. All adult patients with VR (n [ 65) who underwent VR repair (mean age, 45 ± 16 years; 33 women [51%]) from January 1972 to January 2018 were retrospectively reviewed. Anatomic variants were right arch with aberrant left subclavian artery (SA) and Kommerell diverticulum (KD) in 22 (34%), left arch with aberrant right SA and KD in 20 (31%), double aortic arch in 12 (18%), right arch with mirror imaging and persistent ligamentum off KD in 7 (11%), and others in 4 (6%). Indications for operation included dysphagia in 43 (63%), respiratory symptoms in 28 (43%), aneurysmal KD in 12 (18%), and dissection/ rupture in 7 (11%). Results. KD was found in 51 patients (78%). The surgical approach included left thoracotomy in 50 (77%), right thoracotomy in 7 (11%), sternotomy in 5 (8%), and hybrid repair in 3 (5%). A 2-stage repair with carotid-SA transposition, followed by transthoracic KD excision, was done in 51% of aberrant SA (n [ 23). There was 1 early death. Morbidity included recurrent laryngeal nerve injury in 5 (8%) and chylothorax in 3 (5%). Symptomatic improvement occurred in 97%. Survival was 96.1%, 85.0%, and 73.4% at 1, 5, and 10 years, respectively. Dysphagia recurred in 9 (14%), which included 7 (11%) with esophageal dysmotility. Conclusions. Repair of VR in adults can be performed safely. Dysphagia is the most common symptom and improves in most after repair. Excision of the KD and aberrant vessel is the preferred approach to prevent acute aortic events or recurrent symptoms. Early operation should be considered with esophageal compression to avoid late dysmotility.

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IMPORTANCEAlthough several studies have reported data on surgical aortic valve durability, variability in study methodologies and definitions as well as inadequate follow-up make the interpretation of data from these studies difficult to interpret.OBJECTIVE To review available data on structural valve deterioration (SVD) of surgical bioprosthetic aortic valves by examining the published literature as well as data reported to the US Food and Drug Administration (FDA).EVIDENCE REVIEW A systematic review using Preferred Reporting Items for Systematic Review and Meta-Analysis reporting guidelines to obtain all available data from preexisting literature on the actuarial freedom from SVD and outcomes of SVD. Data were collected from database inception to November 2016. Additionally, data reported to the FDA were obtained. FINDINGS In total, 167 studies and 12 FDA reports including 101 650 patients and 17 different valve types were analyzed. There were 11 different definitions of SVD used in the studies. Core laboratory data were available for 11 studies. Mean follow-up ranged from less than 1 year to 14 years. Kaplan-Meier estimates were reported for up to 30 years of follow-up, with 0% to 37% of patients remaining at risk at maximum follow-up. Food and Drug Administration-reported data are similarly variable in duration (mean follow-up range, 1.2 to 7 years) and completeness of follow-up, with final follow-up of 0.1% to 95%. CONCLUSIONS AND RELEVANCEThere is considerable variability in reporting SVD of surgical aortic valves, with different definitions and inadequate long-term systematically collected core laboratory data. Rigorously collected long-term data with standardized definitions for surgical valves are needed to provide a benchmark for the durability of rapidly evolving transcatheter valves.