Biological composite valve grafts (CVGs) are being performed more frequently, which increases the need for interventions treating bioprosthetic valve failure. The feasibility of valve-in-valve ...procedures in this population is uncertain. This study aimed to assess changes in aortic root geometry and coronary height following CVG implantation to better understand future interventions.
We retrospectively identified 64 patients following bioprosthetic CVG replacement with pre- and postoperative computed tomography angiography. Root assessment was conducted as in preprocedural transcatheter aortic valve evaluation using a virtual valve simulation.
In 64 patients (age, 67.6 ± 9.3 years; 76.6% men) the preoperative coronary height was 14.3 ± 6.8 mm for the left coronary artery (LCA) and 17.9 ± 5.9 mm for the right coronary artery (RCA), which significantly decreased after CVG implantation, with 8.7 ± 4.4 mm for the LCA and 11.3 ± 4.4 mm for the RCA (P < .001). The virtual valve-to-coronary distances measured 4.0 ± 1.3 mm (LCA) and 4.6 ± 1.4 mm (RCA). Overall, 59.4% (n = 38) of patients with bio-CVGs would have been at risk for coronary obstruction, 29.7% (n = 19) for LCA, 10.9% (n = 7) for RCA, and 18.8% (n = 12) for combined LCA and RCA.
Coronary height significantly decreased following CVG implantation. The majority of patients after bio-CVG were at a potential risk for coronary obstruction in future valve-in-valve procedures. Further studies are needed to identify the best possible technique for coronary reimplantation and other measures to diminish the risk for future coronary obstruction in this population.
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Access site complications of postcardiotomy extracorporeal life support Schaefer, Anne-Kristin; Distelmaier, Klaus; Riebandt, Julia ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
11/2022, Letnik:
164, Številka:
5
Journal Article
Recenzirano
Odprti dostop
To assess the influence of primary arterial access in patients receiving peripheral postcardiotomy extracorporeal life support on associated complications and outcome.
Of 573 consecutive patients ...requiring PC-ECLS between 2000 and 2019 at a single center, 436 were included in a retrospective analysis and grouped according to primary arterial extracorporeal life support access site. Survival and rate of access-site–related complications with special emphasis on fatal/disabling stroke were compared.
The axillary artery was cannulated in 250 patients (57.3%), whereas the femoral artery was used as primary arterial access in 186 patients (42.6%). There was no significant difference in 30-day (axillary: 62%; femoral: 64.7%; P = .561) and 1-year survival (axillary: 42.5%; femoral: 44.8%; P = .657). Cerebral computed tomography-confirmed stroke with a modified ranking scale ≥4 was significantly more frequent in the axillary group (axillary: n = 28, 11.2%; femoral: n = 4, 2.2%; P = .0003). Stroke localization was right hemispheric (n = 20; 62.5%); left hemispheric (n = 5; 15.6%), bilateral (n = 5; 15.6%), or infratentorial (n = 2; 6.25%). Although no difference in major cannulation site bleeding was observed, cannulation site change for bleeding was more frequent in the axillary group (axillary: n = 13; 5.2%; femoral: n = 2; 1.1%; P = .03). Clinically apparent limb ischemia was significantly more frequent in the femoral group (axillary: n = 12, 4.8%; femoral: n = 31, 16.7%; P < .0001).
Although survival did not differ, surgeons should be aware of access–site-specific complications when choosing peripheral PC-ECLS access. Although lower rates of limb ischemia and the advantage of antegrade flow seem beneficial for axillary cannulation, the high incidence of right hemispheric strokes in axillary artery cannulation should be considered.
The graphical abstract shows from top to bottom the aim of the present study (section 1), the definition of the study cohort and end points (section 2), as well as the main results and conclusion of the study (sections 3and4). Although no difference in survival between patients with femoral (fem) and axillary (ax) arterial extracorporeal life support (ECLS) cannulation was observed, the rate of stroke and cannulation site change for bleeding was significantly higher in the axillary group, whereas the incidence of limb ischemia and cannulation site wound healing disorders was significantly higher in the femoral group. The distribution of stroke localization in 32 patients with stroke with a modified ranking scale (MRS) score ≥4 is shown. PC-ECLS, Postcardiotomy extracorporeal life support. Display omitted
Objective: Conventional mock circulatory loops (MCLs) cannot replicate realistic hemodynamic conditions without inducing blood trauma. This constrains in-vitro hemocompatibility examinations of blood ...pumps to static test loops that do not mimic clinical scenarios. This study aimed at developing an atraumatic MCL based on a hardware-in-the-loop concept (H-MCL) for realistic hemocompatibility assessment. Methods: The H-MCL was designed for 450 <inline-formula><tex-math notation="LaTeX">\pm</tex-math></inline-formula> 50 ml of blood with the polycarbonate reservoirs, the silicone/polyvinyl-chloride tubing, and the blood pump under investigation as the sole blood-contacting components. To account for inherent coupling effects a decoupling pressure control was derived by feedback linearization, whereas the level control was addressed by an optimization task to overcome periodic loss of controllability. The HeartMate 3 was showcased to evaluate the H-MCL's accuracy at typical hemodynamic conditions. To verify the atraumatic properties of the H-MCL, hemolysis (bovine blood, n = 6) was evaluated using the H-MCL in both inactive (static) and active (minor pulsatility) mode, and compared to results achieved in conventional loops. Results: Typical hemodynamic scenarios were replicated with marginal coupling effects and root mean square error (RMSE) below 1.74 <inline-formula><tex-math notation="LaTeX">\pm</tex-math></inline-formula> 1.37 mmHg while the fluid level remained within <inline-formula><tex-math notation="LaTeX">\pm</tex-math></inline-formula>4% of its target value. The normalized indices of hemolysis (NIH) for the inactive H-MCL showed no significant differences to conventional loops (<inline-formula><tex-math notation="LaTeX">\Delta</tex-math></inline-formula>NIH = −1.6 mg/100 L). Further, no significant difference was evident between the active and inactive mode in the H-MCL (<inline-formula><tex-math notation="LaTeX">\Delta</tex-math></inline-formula>NIH = +0.3 mg/100 L). Conclusion and significance: Collectively, these findings indicated the H-MCL's potential for in-vitro hemocompatibility assessment of blood pumps within realistic hemodynamic conditions, eliminating inherent setup-related risks for blood trauma.
The antiplatelet treatment strategy providing optimal balance between thrombotic and bleeding risks in patients undergoing coronary artery bypass grafting (CABG) is unclear. We prospectively compared ...the efficacy of ticagrelor and aspirin after CABG.
We randomly assigned in double-blind fashion patients scheduled for CABG to either ticagrelor 90 mg twice daily or 100 mg aspirin (1:1) once daily. The primary outcome was the composite of cardiovascular death, myocardial infarction (MI), repeat revascularization, and stroke 12 months after CABG. The main safety endpoint was based on the Bleeding Academic Research Consortium classification, defined as BARC ≥4 for periprocedural and hospital stay-related bleedings and BARC ≥3 for post-discharge bleedings. The study was prematurely halted after recruitment of 1859 out of 3850 planned patients. Twelve months after CABG, the primary endpoint occurred in 86 out of 931 patients (9.7%) in the ticagrelor group and in 73 out of 928 patients (8.2%) in the aspirin group hazard ratio 1.19; 95% confidence interval (CI) 0.87-1.62; P = 0.28. All-cause mortality (ticagrelor 2.5% vs. aspirin 2.6%, hazard ratio 0.96, CI 0.53-1.72; P = 0.89), cardiovascular death (ticagrelor 1.2% vs. aspirin 1.4%, hazard ratio 0.85, CI 0.38-1.89; P = 0.68), MI (ticagrelor 2.1% vs. aspirin 3.4%, hazard ratio 0.63, CI 0.36-1.12, P = 0.12), and stroke (ticagrelor 3.1% vs. 2.6%, hazard ratio 1.21, CI 0.70-2.08; P = 0.49), showed no significant difference between the ticagrelor and aspirin group. The main safety endpoint was also not significantly different (ticagrelor 3.7% vs. aspirin 3.2%, hazard ratio 1.17, CI 0.71-1.92; P = 0.53).
In this prematurely terminated and thus underpowered randomized trial of ticagrelor vs. aspirin in patients after CABG no significant differences in major cardiovascular events or major bleeding could be demonstrated.
NCT01755520.
Abstract
OBJECTIVES
Our aim was to investigate associations between blood stream infection ≥1 positive blood culture (BC) and outcomes in recipients of a left ventricular assist device (LVAD).
...METHODS
We retrospectively analysed all adult recipients of a continuous-flow LVAD between 2006 and 2016 at the Division of Cardiac Surgery, Medical University of Vienna (n = 257; devices: Medtronic HeartWare® HVAD®, Abbott HeartMate II®, Abbott HeartMate 3™). The primary outcome was all-cause mortality during follow-up. Secondary outcomes included the risk of stroke and pump thrombus during follow-up as well as the probability of heart transplantation (HTx). Risk factors for the development of ≥1 positive BC were evaluated additionally.
RESULTS
The incidence of ≥1 positive BC during the first year of LVAD support was 32.1% 95% confidence interval (CI) 26.4–37.9. Multivariable Cox proportional cause-specific hazards regression analysis showed that a positive BC was associated with significantly increased all-cause mortality hazard ratio (HR) 5.51, 95% CI 3.57–8.51; P < 0.001. Moreover, a positive BC was associated with a significantly increased risk of stroke (HR 2.41, 95% CI 1.24–4.68; P = 0.010). There was no association with the risk of pump thrombus or the probability of HTx. Independent risk factors for a positive BC included preoperative albumin and extracorporeal membrane oxygenation/intra-aortic balloon pump support.
CONCLUSIONS
Blood stream infection is common and associated with a significantly increased risk of all-cause mortality and stroke at any given time during LVAD support. Effective strategies of prevention and treatment are necessary.
Objective Superior aortic valve hemodynamic performance can accelerate left ventricular mass regression and enhance survival and functional status after surgical aortic valve replacement. This can be ...achieved by rapid deployment aortic valve replacement using a subannular balloon-expandable stent frame, which functionally widens and reshapes the left ventricular outflow tract, to ensure a larger effective orifice area compared with conventional surgical valves. We report the intermediate-term follow-up data from a large series of patients enrolled in the Surgical Treatment of Aortic Stenosis With a Next Generation Surgical Aortic Valve (TRITON) trial. Methods In a prospective, multicenter (6 European hospitals), single-arm study, 287 patients with aortic stenosis underwent rapid deployment aortic valve replacement using a stented trileaflet bovine pericardial bioprosthesis. Core laboratory echocardiography was performed at baseline, discharge, and 3 months, 1 year, and 3 years after rapid deployment aortic valve replacement. Results The mean patient age was 75.7 ± 6.7 years (range, 45-93; 49.1% women). The mean aortic valve gradient significantly decreased from discharge to 3 years of follow-up. The mean effective orifice area remained stable from discharge to 3 years. At 1 year, the left ventricular mass index had decreased by 14% ( P < .0001) and at 3 years by 16% ( P < .0001) compared with at discharge. The prevalence of severe patient-prosthesis mismatch was 3% at discharge and remained stable during the follow-up period. Conclusions In a large series of elderly patients with symptomatic severe aortic stenosis, rapid deployment aortic valve replacement using a subannular balloon-expandable stent frame demonstrated excellent hemodynamic performance and significant left ventricular mass regression. With continued follow-up, future studies will establish whether these favorable structural changes correlate with improvement in long-term survival and functional status.
Abstract
Background
GDF-15 (growth/differentiation factor 15) is induced by myocardial stretch, volume overload, inflammation, and oxidative stress. Its expression is tightly linked with ...cardiovascular events as well as the risk for major bleeding and all-cause mortality. The present study aimed to elucidate the prognostic potential of GDF-15 in patients after cardiac surgery.
Methods
A total of 504 patients undergoing elective cardiac valve and/or coronary artery bypass graft surgery were prospectively enrolled. GDF-15 levels were measured prior to surgery to evaluate the impact on bleeding events, thromboembolic events, and mortality.
Results
Preoperative GDF-15 was associated with the primary endpoint of intra- and postoperative red blood cell transfusion (for bleeding risk factors adjusted adj OR odds ratio per 1-SD standard deviation of 1.62 95% confidence interval CI: 1.31–2.00;
p
< 0.001). Higher concentrations of GDF-15 were observed in patients reaching the secondary endpoint of major or clinically relevant minor bleeding (for bleeding risk factors adj. OR per 1-SD of 1.70 95% CI: 1.05–2.75;
p
= 0.030) during the first postoperative year, but not for thromboembolic events. GDF-15 was a predictor for cardiovascular mortality (for comorbidities adj. HR hazard ratio per 1-SD of 1.67 95% CI: 1.23–2.27;
p
= 0.001) and all-cause mortality (for comorbidities adj. HR per 1-SD of 1.55 95% CI: 1.19–2.01;
p
= 0.001). A combined risk model of GDF-15 and EuroSCORE II outperformed the EuroSCORE II alone for long-term survival (C-index: 0.75 95% CI: 0.70–0.80,
p
= 0.046; net reclassification improvement: 33.6%,
p
< 0.001).
Conclusion
Preoperative GDF-15 concentration is an independent predictor for intra- and postoperative major bleeding, major bleeding during the first year, and for long-term cardiovascular or all-cause mortality after cardiac surgery.
Fibroblasts are the prevalent cell type and main source for extracellular matrix (ECM) in connective tissue. Depending on their origin, fibroblasts play a central role in non-pathological tissue ...remodeling and disease like fibrosis. This study examined the effect of established culture conditions of primary human fibroblasts, from different origins on the myofibroblast-like phenotype formation. We isolated primary human fibroblasts from aortic adventitia, lung, juvenile- and adult skin and investigated the expression levels of CD90, alpha smooth muscle actin (αSMA) and procollagen I under different concentrations of fetal calf serum (FCS) and ascorbic acid (AA) in culture media by immunoblot and immunofluorescence assays. Furthermore, we determined the viability using XTT and migration/wound healing in scratch assays. Collagen 1 secretion was quantified by specific ELISA. Primary human fibroblasts show in part a myofibroblast-like phenotype even without addition of FCS. Supplemented AA reduces migration of cultured fibroblasts with no or low concentrations of FCS. Furthermore, AA and higher concentrations of FCS in culture media lead to higher levels of collagen 1 secretion instead of procollagen I accumulation. This study provides evidence for a partial switch of primary human fibroblasts of different origin to a myofibroblast-like phenotype under common culture conditions.
Abstract
Background
The choice of aortic valve replacement needs to be decided in an interdisciplinary approach and together with the patients and their families regarding the need for re-operation ...and risks accompanying anticoagulation. We report long-term outcomes after different AVR options.
Methods
A chart review of patients aged < 18 years at time of surgery, who had undergone AVR from May 1985 until April 2020 was conducted. Contraindications for Ross procedure, which is performed since 1991 at the center were reviewed in the observed non-Ross AVR cohort. The study endpoints were compared between the mechanical AVR and the biological AVR cohort.
Results
From May 1985 to April 2020 fifty-five patients received sixty AVRs: 33 mechanical AVRs and 27 biological AVRs. In over half of the fifty-three AVRs performed after 1991 (58.5%; 31/53) a contraindication for Ross procedure was present. Early mortality was 5% (3/60). All early deaths occurred in patients aged < 1 year at time of surgery. Two late deaths occurred and survival was 94.5% ± 3.1% at 10 years and 86.4% ± 6.2% at 30 years. Freedom from aortic valve re-operation was higher (
p
< 0.001) in the mechanical AVR than in the biological AVR cohort with 95.2% ± 4.6% and 33.6% ± 13.4% freedom from re-operation at 10 years respectively.
Conclusions
Re-operation was less frequent in the mechanical AVR cohort than in the biological AVR cohort. For mechanical AVR, the risk for thromboembolic and bleeding events was considerable with a composite linearized event rate per valve-year of 3.2%.
Abstract
OBJECTIVES
Postoperative atrial fibrillation (POAF) represents a common complication after cardiac surgery that is associated with unfavourable clinical outcome. Identifying patients at risk ...for POAF is crucial but challenging. This study aimed to investigate the prognostic potential of speckle-tracking echocardiography on POAF and fatal adverse events from a long-term perspective.
METHODS
A total of 124 patients undergoing elective cardiac surgery were prospectively enrolled and underwent preoperative speckle-tracking echocardiography. Patients were followed prospectively for the occurrence of POAF within the entire hospitalization and reaching the secondary end points cardiovascular and all-cause mortality.
RESULTS
Within the study population 43.5% (n = 53) of enrolled individuals developed POAF. After a median follow-up of 3.9 years, 25 (20.2%) patients died. We observed that patients presenting with POAF had lower global peak atrial longitudinal strain (PALS) values compared to the non-POAF arm {POAF: 14.8% 95% confidence interval (CI): 10.9–17.8 vs non-POAF: 19.4% 95% CI: 14.8–23.5, P < 0.001}. Moreover, global PALS was a strong and independent predictor for POAF adjusted odds ratio per 1 standard deviation: 0.37 (95% CI: 0.22–0.65), P < 0.001 and independently associated with mortality adjusted hazard ratio per 1 standard deviation: 0.63 (95% CI: 0.40–0.99), P = 0.048. Classification and Regression Tree analysis revealed a cut-off value of <17% global PALS as high risk for both POAF and mortality.
CONCLUSIONS
Global PALS is associated with the development of POAF following surgery in an unselected patient population undergoing CABG and/or valve surgery. Since patients with global PALS <17% face a poor long-term prognosis, routine assessment of global PALS needs to be considered in terms of proper secondary prevention in the era of personalized medicine.
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