Background
Limited data evaluated the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with prosthetic valves. This study aimed to compare the outcomes of ECMO support for ...postcardiotomy cardiogenic shock in patients with mechanical versus bioprosthetic valves.
Methods
This retrospective study included patients with ECMO support for postcardiotomy cardiogenic shock after valve replacement. Patients were grouped into bioprosthetic (n = 49) and mechanical valve (n = 22) groups.
Results
There were no differences in ECMO duration, inotropic support, intra-aortic balloon pump (IABP), stroke, duration of ICU, and hospital stay between groups. Postoperative thrombosis occurred in 2 patients with bioprosthetic valves (5.41%) and 2 with mechanical valves (14.29%), p = .30. All patients with thrombosis had central ECMO cannulation, concomitant IABP, and inotropic support during ECMO. All thrombi were related to the mitral valve. Three patients with thrombi had hospital mortality.
Survival at 6, 12, and 36 months for bioprosthetic valve patients was 30.88%, 28.55%, and 25.34% and for mechanical valves was 36.36% for all time intervals (Log-rank p = .93). One patient had bioprosthetic aortic valve endocarditis after 1 year. Three patients with bioprosthetic valves had structural valve degeneration after 1, 2, and 5 years.
Conclusions
Outcomes of ECMO in patients with prosthetic valves are comparable between bioprosthetic and mechanical valves. Thrombosis might occur in both valve types and was associated with high mortality. ECMO could affect the long-term durability of the bioprosthetic valves.
Nickel hypersensitivity is reported in about 10–15% of the general population and manifests mainly with dermatological signs. Chest discomfort, palpitations, signs and symptoms of pericarditis, and ...migraine are symptoms reported in rare cases of nickel hypersensitivity after implantation of a cardiac device made of nickel. We present the case of a patient with a nickel allergy from an Amplatzer device in which the removal of the device produced resolution of the symptoms. doi: 10.1111/jocs.12331 (J Card Surg 2014;29:349–350)
Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became ...challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. We present a series of 10 patients who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization were necessary. Particularly with the COVID-19 restrictions in place, these cases highlight the need for physicians to be aware of the dramatic increase in the incidence of stuck prosthetic valves in patients on chronic warfarin therapy.
We studied the effect of tricuspid valve (TV) surgery combined with surgical ventricular restoration (SVR) on operative outcomes, rehospitalization, recurrent tricuspid regurgitation, and survival of ...patients with ischemic cardiomyopathy. Additionally, surgery was compared to conservative management in patients with mild or moderate tricuspid regurgitation. To the best of our knowledge, the advantage of combining TV surgery with SVR in patients with ischemic cardiomyopathy had not been investigated before.
This retrospective cohort study included 137 SVR patients who were recruited from 2009 to 2020. Patients were divided into two groups - those with no concomitant TV surgery (n=74) and those with concomitant TV repair or replacement (n=63).
Extracorporeal membrane oxygenation use was higher in SVR patients without TV surgery (P=0.015). Re-exploration and blood transfusion were significantly higher in those with TV surgery (P=0.048 and P=0.037, respectively). Hospital mortality occurred in eight (10.81%) patients with no TV surgery vs. five (7.94%) in the TV surgery group (P=0.771). Neither rehospitalization (log-rank P=0.749) nor survival (log-rank P=0.515) differed in patients with mild and moderate tricuspid regurgitation in both groups. Freedom from recurrent tricuspid regurgitation was non-significantly higher in mild and moderate tricuspid regurgitation patients with no TV surgery (P=0.059). Conservative management predicted the recurrence of tricuspid regurgitation.
TV surgery concomitant with SVR could reduce the recurrence of tricuspid regurgitation; however, its effect on the clinical outcomes of rehospitalization and survival was not evident. The same effects were observed in patients with mild and moderate tricuspid regurgitation.
Background
EuroSCORE stratifies surgical risk in cardiac surgery; however, it is not explicitly for tricuspid valve surgery. Therefore, we aimed to apply machine learning (ML) methods to predict ...operative mortality after tricuspid valve surgery and compare the predictive ability of these models to EuroSCORE.
This retrospective analysis included 1161 consecutive patients who underwent tricuspid valve surgery at a single center from 2009 to 2021. The study outcome was operative mortality (
n
=112), defined as mortality occurring within 30 days of surgery or the same hospital admission. Random forest, LASSO, elastic net, and logistic regression were used to identify predictors of operative mortality.
Results
EuroSCORE was significantly higher in patients who had operative mortality 8.52 (4.745–20.035) vs.4.11 (2.29–6.995),
P
<0.001 AUC=0.73. Random forest identified eight variables predicting operative mortality with an accuracy of 92% in the test set (age≥70 years, heart failure, emergency surgery, chronic kidney disease grade IV, diabetes mellitus, tricuspid valve replacement, hypertension, and redo surgery). The classification error rate in the training data was 9%, and in the testing data, it was 4.8%. Logistic regression identified eight variables with an AUC of 0.76. LASSO identified 13 variables with an AUC of 0.78, and elastic net identified 17 variables (AUC=0.795). The AUCs of the elastic net (
P
=0.048) and random forest (
P
<0.001) models were significantly higher than that of EuroSCORE.
Conclusions
ML effectively predicted TV surgery mortality more accurately than the traditional risk-scoring method. Incorporating ML in cardiac surgery risk scoring with comprehensive inclusion of all possible variables is recommended.
Q fever prosthetic valve endocarditis in association with antiphospholipid antibody syndrome (APS) in systemic lupus erythematosus (SLE) has not been previously reported. Here, we report a ...22-year-old Saudi female diagnosed with SLE and APS. She had mitral valve replacement with bio-prosthesis five years earlier for Libman–Sack endocarditis. She presented with two months’ history of fever, cough, palpitations, and progressive shortness of breath. A transthoracic echocardiogram showed a degenerative mitral valve prosthesis with a large mass causing severe obstruction. Open heart surgery revealed multiple masses on the mitral valve. PCR from the resected tissues was positive for Coxiella burnetii DNA. Q fever serology showed phase two IgG 1:2048, phase one IgG 1:512, and IgM 1:1024. The valve was replaced with a bio-prosthesis. She was well at 12 months of follow-up.
Background
The debate about the optimal approach for aortic valve replacement continues. We compared the hospital and long-term outcomes (survival, aortic valve reintervention, heart failure ...readmissions, and stroke) between transcatheter vs. surgical (TAVR vs. SAVR) aortic valve replacement. The study included 789 patients; 293 had isolated SAVR, and 496 had isolated TAVR. Patients with concomitant procedures were excluded. Propensity score matching identified 53 matched pairs.
Results
Patients who had TAVR were significantly older (
P
˂ 0.001) and had significantly higher EuroSCORE II (
P
˂ 0.001), NYHA class (
P
˂ 0.001), and more prevalence of diabetes mellitus (
P
˂ 0.001), hypertension (
P
˂ 0.001), chronic lung disease (
P
= 0.001), recent myocardial infarction (
P
= 0.002), and heart failure (
P
˂ 0.001), stroke (
P
= 0.02), atrial fibrillation (
P
= 0.004), and previous percutaneous coronary interventions (
P
˂ 0.001) than SAVR patients. In the matched cohort, atrial fibrillation occurred more frequently after SAVR (
P
= 0.01), and hospital stay was significantly longer in SAVR patients (
P
˂ 0.001). There were no differences in hospital mortality between groups (
P
˃ 0.99). Survival at 1, 3, and 5 years was 97%, 95%, and 94% for SAVR and 91%, 79%, and 58% for TAVR patients. Survival was lower in TAVR patients before matching (
P
˂ 0.001) and after matching (
P
= 0.045). Freedom from the composite endpoint of stroke, aortic valve reintervention, and heart failure readmission at 1, 3, and 5 years was 98.9%, 96%, and 94% for SAVR and 94%, 86%, and 75% for TAVR. The composite endpoint was significantly higher in the TAVR group than in SVR before matching (
P
˂ 0.001), while there was no difference after matching (
P
= 0.07). There was no significant difference in the change in ejection fraction between groups (
β
: −0.88 (95%
CI
: −2.20–0.43),
P
= 0.19), and the reduction of the aortic valve peak gradient was significantly higher with TAVR (
β
: −7.80 (95%
CI
: −10.70 to −4.91);
P
˂ 0.001).
Conclusions
TAVR could reduce postoperative atrial fibrillation and hospital stay. SAVR could have long-term survival benefits over TAVR with comparable long-term stroke, heart failure readmission, and aortic valve reinterventions between SAVR and TAVR.
There are scarce data comparing different mechanical valves in the aortic position. The objective of this study was to compare the early hemodynamic changes after aortic valve replacement between ...ATS, Bicarbon, and On-X mechanical valves.
We included 99 patients who underwent aortic valve replacement with mechanical valves between 2017 and 2019. Three types of mechanical valves were used, On-X valve (n=45), ATS AP360 (n=32), and Bicarbon (n=22). The mean prosthetic valve gradient was measured postoperatively and after six months.
Preoperative data were comparable between groups, and there were no differences in preoperative echocardiographic data. Pre-discharge echocardiography showed no difference between groups in the ejection fraction (P=0.748), end-systolic (P=0.764) and end-diastolic (P=0.723) diameters, left ventricular mass index (P=0.348), aortic prosthetic mean pressure gradient (P=0.454), and indexed aortic prosthetic orifice area (P=0.576). There was no difference in the postoperative aortic prosthetic mean pressure gradient between groups when stratified by valve size. The changes in the aortic prosthetic mean pressure gradient of the intraoperative period, at pre-discharge, and at six months were comparable between the three prostheses (P=0.08). Multivariable regression analysis revealed that female gender (beta coefficient -0.242, P=0.027), body surface area (beta coefficient 0.334, P<0.001), and aortic prosthetic size (beta coefficient -0.547, P<0.001), but not the prosthesis type, were independent predictors of postoperative aortic prosthetic mean pressure gradient.
The three bileaflet mechanical aortic prostheses (On-X, Bicarbon, and ATS) provide satisfactory early hemodynamics, which are comparable between the three valve types and among different valve sizes.
Background
Del Nido cardioplegia was recently introduced to adult cardiac surgery with encouraging results. The effect of Del Nido cardioplegia in patients with low ejection fraction (EF) has not ...been thoroughly evaluated. The objective of this study was to assess the safety of Del Nido cardioplegia in adult patients with low EF compared to intermittent warm blood cardioplegia.
Results
During 2018 and 2019, 73 adult patients with an EF of ≤ 40% underwent cardiac surgery using Del Nido cardioplegia. The patients were compared to a historical cohort of consecutive patients with low EF who had intermitted warm blood cardioplegia (
n
= 81). Patients who had Del Nido cardioplegia had significantly lower EuroSCORE II (2.73 (1.7–4.1) vs. 4.5 (2.4–7.4),
P
= 0.004). There were no differences in creatinine clearance and preoperative echocardiographic data between the groups. Cardiopulmonary bypass and cross-clamp times were non-significantly lower with Del Nido cardioplegia. There were no differences in stroke and postoperative echocardiographic data between the groups. No hospital mortality was reported in both groups. Peak troponin levels were significantly higher in patients who had Del Nido cardioplegia (0.88 (0.58–1.47) vs. 0.7 (0.44–1.01) ng/dL;
P
= 0.01); however, after multivariable regression analysis, cardiopulmonary bypass time was the only predictor of postoperative troponin level (coefficient 0.005 (95% CI: 0.003–0.008);
P
< 0.001). ICU stay was significantly longer in patients who had Del Nido cardioplegia (4 (3–6) vs. 2(1–4) days,
P
< 0.001), while postoperative hospital stay did not differ between the groups. After multivariable regression, the use of intermittent warm blood cardioplegia was significantly associated with shorter ICU stay (coefficient − 1.80 (95% CI − 3.06 – -0.55);
P
= 0.01).
Conclusions
Prolonged ICU was reported with Del Nido cardioplegia; however, there were no differences in the duration of hospital stay and the clinical outcomes between the groups. Despite the proven efficacy of intermittent warm blood cardioplegia, the use of Del Nido cardioplegia might be safe in patients with low EF.
A 56-year old male with ischemic heart disease and an unremarkable preoperative echocardiogram underwent surgical coronary revascularization. An intraoperative post pump trans-esophageal ...echocardiogram (TOE) performed while the patient was being ventilated at a positive end expiratory pressure (PEEP) of 8 cm H2O demonstrated a right to left interatrial shunt across a patent foramen ovale (PFO). Whereas oxygen saturation was normal, a reduction of the PEEP to 3 cm H2O led to the complete resolution of the shunt with no change in arterial blood gases. Attempts to increase the PEEP level above 3 mmHg resulted in recurrence of the interatrial shunt. The remaining of the TEE was unremarkable. Mechanical ventilation, particularly with PEEP, causes an increase in intrathoracic pressure. The resulting rise in right atrial pressure, mostly during inspiration, may unveil and pop open an unrecognized PFO, thus provoking a right to left shunt across a seemingly intact interatrial septum. This phenomenon increases the risk of paradoxical embolism and can lead to hypoxemia. The immediate management would be to adjust the ventilatory settings to a lower PEEP level. A routine search for a PFO should be performed in ventilated patients who undergo a TEE.
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