Surgical Ablation of Atrial Fibrillation in High-Risk Patients: Success versus Risk.

BACKGROUND: Surgical atrial ablation is evaluated by surgeons in relation to the estimated surgical risk. We analyze whether high-risk patients (HRPs) experience risk escalation by ablation procedures. METHODS: The CASE-Atrial Fibrillation (AF) registry is a prospective, multicenter, all-comers registry of atrial ablation in cardiac surgery. We analyzed the 1-year outcome regarding survival and rhythm endpoints of 1,000 consecutive patients according to the operative risk classification (EuroSCORE II ≤ 2 vs. >2). RESULTS: Higher NYHA (New York Heart Association) score, ischemic heart failure, status poststroke, renal insufficiency, chronic obstructive pulmonary disease, and diabetes mellitus were strongly represented in HRPs. HRPs exhibit more left ventricular ejection fraction < 40% (19.2 vs. 8.8%; p < 0.001) but identical left atrial diameter and left ventricular end-diastolic diameter compared with low-risk patients (LRPs). CHA2DS-Vasc-score (2.4 ± 1 vs. 3.6 ± 1.5; p < 0.001), sternotomies, combination surgeries, coronary artery bypass graft, and mitral valve procedures were increased in HRPs. LRPs underwent stand-alone ablations as well. Ablation energy did not differ. Left atrial appendage closure was performed in up to 86.1% (mainly cut-and-sew procedures). Mortality corresponded to the original risk class without an escalation that may be related to ablation, stroke rate, or myocardial infarction. A total of 60.6% of HRPs versus 75.1% of LRPs were discharged in sinus rhythm. Long-term EHRA (European Heart Rhythm Association) score symptoms were lower in HRPs. Repeated rhythm therapies were rare. Additional antiarrhythmics received a minority without group dependency. A total of 1.6 versus 4.1% of HRPs (p = 0.042) underwent long-term stroke; excess mortality was not observed. Anticoagulation remained common in HRPs. CONCLUSION: Surgical risk and long-term mortality are determined by the underlying disease. In HRPs, freedom from AF and symptom relief can be achieved. Preoperative risk scores should not lead to withholding an ablation procedure.

New Perspectives for Prosthetic Valve Endocarditis: Impact of Molecular Imaging by FISHseq Diagnostics.

BACKGROUND: The microbial etiology of prosthetic valve infective endocarditis (PVE) can be difficult to identify. Our aim was to investigate the benefit of molecular imaging technique fluorescence in situ hybridization (FISH) combined with 16S rRNA-gene polymerase chain reaction (PCR) and sequencing (FISHseq) for the analysis of infected prosthetic heart valves. METHODS: We retrospectively evaluated the diagnostic outcome of 113 prosthetic valves from 105 patients with suspected PVE, treated in 2003-2013 in the Department of Cardiac Surgery, Charité University Medicine Berlin. Each prosthetic valve underwent cultural diagnostics and was routinely examined by FISH combined with 16S rRNA gene PCR and sequencing. We compared classical microbiological culture outcomes (blood and valve cultures) with FISHseq results and evaluated the diagnostic impact of the molecular imaging technique. RESULTS: Conventional microbiological diagnostic alone turned out to be insufficient, as 67% of preoperative blood cultures were noninformative (negative, inconclusive, or not obtained) and 67% of valve cultures remained negative. FISHseq improved the conventional cultural diagnostic methods in PVE in 30% of the cases and increased diagnostic accuracy. Of the valve culture-negative PVE cases, FISHseq succeeded in identifying the causative pathogen in 35%. CONCLUSIONS: FISHseq improves PVE diagnostics, complementing conventional cultural methods. In addition to species identification, FISH provides information about the severity of PVE and state of the pathogens (eg, stage of biofilm formation, activity, and localization on and within the prosthetic material). As a molecular imaging technique, FISHseq enables the unambiguous discrimination of skin flora as contaminant or infectious agent.

Functional reserve and contractile phenotype of atrial myocardium from patients with atrial remodeling without and with atrial fibrillation.

Atrial contractility and functional reserve in atrial remodeling (AR) without (AR/-AF) or with atrial fibrillation (AR/+AF) are not well characterized. In this study, functional measurements were performed in right atrial muscle strips (n = 71) obtained from patients (N = 22) undergoing routine cardiac surgery with either no AR [left atrial (LA) diameter < 40 mm and no history of AF (hAF)], AR/-AF (LA diameter ≥ 40 mm, no hAF), or AR/+AF (hAF and LA diameter ≥ 40 mm or LAEF < 45%). AR/-AF and AR/+AF were associated with a prolongation of half-time-to-peak (HTTP, P < 0.001) and time-to-peak (TTP) contraction (P < 0.01) when compared with no AR. This effect was seen at baseline and during ß-adrenergic stimulation with isoproterenol (Iso). Early relaxation assessed by half-relaxation time (HRT) was prolonged in AR/-AF (P = 0.03) but not in AR/+AF when compared with no AR at baseline, but this delay in relaxation in AR/-AF was attenuated with Iso. Late relaxation (τ) did not differ between AR/-AF and no AR but was consistently shorter in AR/+AF than no AR before (P = 0.04) and during Iso (P = 0.01), indicating accelerated late relaxation in AR/+AF. Relative force increase during Iso was higher (P = 0.01) and more dispersed (P = 0.047) in patients with AR/+AF. Relative adrenergic response was unaltered in the myocardium of patients with AR/-AF and AR/+AF. In conclusion, AR/-AF and AR/+AF are associated with changes in myocardial inotropic reserve and contractility. The changes are particularly pronounced in patients with AR/+AF, suggesting that the progression from AR/-AF to AR/+AF is associated with progressive alterations in atrial function that may contribute to arrhythmogenesis.NEW & NOTEWORTHY Mechanical alterations in atrial remodeling without (AR/-AF) and with atrial fibrillation (AR/+AF) have not been studied in detail in human atrial tissue preparations. To our knowledge, this is the first study to compare the mechanical phenotype and inotropic reserve in human atrial myocardial preparations from patients with no atrial remodeling, AR/-AF, and AR/+AF. We identify specific patterns of contractile dysfunction and heterogeneity for both, AR/-AF and AR/+AF, indicating the progression of atrial disease.

Rothia aeria and Rothia dentocariosa as biofilm builders in infective endocarditis.

BACKGROUND: Rothia sp. are Gram-positive bacteria in the class of Actinobacteria that are part of the physiological oral flora. In rare cases, Rothia aeria and Rothia dentocariosa can cause infective endocarditis (IE). The biofilm potential of Rothia in endocarditis is unknown. METHODS: Specimen from two cases of Rothia endocarditis were obtained during cardiac surgery. One of the patients suffered mitral valve IE from Rothia aeria. In the other case, IE of a prosthetic pulmonary valve was caused by Rothia dentocariosa. Fluorescence in situ hybridization (FISH) was used for visualization of microorganisms within heart valve tissues in combination with PCR and sequencing (FISHseq). RESULTS: The two heart valve specimens featured mature biofilms of bacteria that were identified by FISHseq as Rothia aeria and Rothia dentocariosa, respectively. FISH showed in situ biofilms of both microorganisms that feature distinct phenotypes for the first time ex vivo. Both of our reported cases were treated successfully by heart valve surgery and antibiotic therapy using beta-lactam antibiotics. CONCLUSION: The biofilm potential of Rothia sp. must be taken into account. The awareness of Rothia aeria and Rothia dentocariosa as rare but relevant pathogens for infective endocarditis must be raised. Use of biofilm-effective antibiotics in Rothia IE should be discussed.

Randomized trial of ticagrelor vs. aspirin in patients after coronary artery bypass grafting: the TiCAB trial.

AIMS: 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. METHODS AND RESULTS: 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). CONCLUSION: 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. CLINICALTRIALS.GOV IDENTIFIER: NCT01755520.

Is the Freedom SOLO Stentless Bioprosthesis a Useful Tool for Patients with Aortic Endocarditis and Aortic Annular Destruction?

BACKGROUND: The Freedom SOLO (FS) stentless bovine-pericardial prosthesis with a supra-annular implantation technique can be a viable option for patients with endocarditic annular destruction. We assessed early- and long-term outcomes following the use of this prosthesis in extensive aortic valve endocarditis. METHODS: From 2006 to 2016, 59 patients with extensive aortic endocarditis underwent aortic valve replacement (AVR) with FS (cumulative follow-up 263 patients-years) in three European centers; all patients presented annular tissue infection, while 54.3% of patients had annular abscess. RESULTS: Mean age was 66 ± 11 years and mean EuroSCORE I was 30.3% (standard deviation: 24.1%). In our series, 30.5% of patients had prosthetic valve endocarditis. Early mortality was 15.2% (nine patients). Estimated overall survival at 5 and 10 years was 68.9% (95% confidence interval [CI]: 62.8-75.0%) and 59.1% (95% CI: 66.8-81.2%), respectively. At 10-year survival, freedom from valve-related death was 83.7% (95% CI: 80.9-86.5%). No structural valve deterioration was reported in this series. Five patients (8.5%) had recurrent endocarditis during follow-up and two of them underwent reoperation. Survival freedom from reoperation and endocarditis at 10-year follow-up was 88.0% (CI: 80.4-95.6%) and 86.7% (CI: 80.5-92.9%), respectively. CONCLUSION: FS stentless bioprosthesis is a valuable and simple option to achieve AVR in patients with extensive aortic annulus endocarditis. Although in this group of complex patients, early mortality remains considerably high, late survival outcomes are comparable to the more technically demanding homografts and conventional stentless bioprostheses, with low rates of endocarditis recurrence.

Risks and Challenges of Surgery for Aortic Prosthetic Valve Endocarditis.

BACKGROUND: Prosthetic valve endocarditis is the most severe form of infective endocarditis. This study assessed the risks and challenges of surgery for aortic prosthetic valve endocarditis. METHODS: In total, 116 consecutive patients (98 males, age 65.2±12.7years), who underwent redo-surgery for active aortic prosthetic valve endocarditis between 2000 and 2014, were reviewed. Cox regression analysis was used to identify factors for aortic root destructions as well as for morbidity and mortality. Median follow-up was 3.8 years (0-13.9 years). RESULTS: Aortic root destructions (42 limited and 29 multiple lesions) were associated with early prosthetic valve endocarditis and delayed diagnosis (≥14 d), but not with mortality. There were 16 (13.8%) early (≤30 d) and 32 (27.6%) late (>30 days) deaths. Survival at 1, 5, and 10 years was 72±4.3%, 56±5.4%, and 46±6.4%, respectively. The cumulative incidence of death, reinfection, and reoperation was 19.0% at 30days and 36.2% at 1year. Delayed diagnosis, concomitant procedures, and EuroSCORE II >20% were predictors for early mortality and need for mechanical circulatory support, age >70years, and critical preoperative state were predictors for late mortality. In their absence, survival at 10 years was 70±8.4%. Reinfections and reoperations occurred more frequently if ≥1 risk factor for endocarditis and aortic root destructions were present. At 10 years, freedom from reinfection and reoperation was 89±4.2% and 91±4.0%. CONCLUSIONS: The risks of death, reinfection, and reoperation are significant within the first year after surgery for aortic prosthetic valve endocarditis. Early diagnosis and aortic root destructions are the most important challenges, but advanced age, critical preoperative state, and the need for mechanical circulatory support determine long-term survival.

Mid-regional pro-adrenomedullin (MR-proADM) and mid-regional pro-atrial natriuretic peptide (MR-proANP) in severe aortic valve stenosis: association with outcome after transcatheter aortic valve implantation (TAVI).

BACKGROUND: This study aimed to assess the association of mid-regional (MR) pro-adrenomedullin (MR-proADM) and MR-pro-A-type natriuretic peptide (MR-proANP) in comparison to N-terminal pro-natriuretic peptide (NT-proBNP) with outcome in patients with aortic stenosis (AS) treated with transcatheter aortic valve implantation (TAVI). METHODS: One hundred consecutive TAVI patients were included in this prospective study. Association of preinterventional levels of MR-proADM, MR-proANP, NT-proBNP, C-reactive protein (CrP), and high-sensitive cardiac Troponin T (hsTN) with 30-day and 1-year outcome was analyzed. RESULTS: There was no association with 30-day outcome, but all markers were associated with 1-year cardiovascular events and all-cause mortality. The combined biomarker analysis further improved risk prediction. CONCLUSIONS: In TAVI patients MR-proADM, MR-proANP, and NT-proBNP are promising predictors of adverse events within 1 year. Integration of these biomarkers into decision pathways may help to identify patients at higher risk.

The Ross Procedure in Adults: Long-Term Results of Homografts and Stentless Xenografts for Pulmonary Valve Replacement.

Background The Ross procedure is an established method to treat aortic valve disease, offering excellent hemodynamic characteristics, growth potential, low risk of thromboembolism and no need for anticoagulation. Limitation of homograft quality and availability led to the use of different stentless xenografts. Long-term outcome and implications are yet to be addressed. Methods Forty five adult patients (mean age 38.8 ± 9.6 years) with aortic valve stenosis and/or insufficiency, who underwent the Ross procedure between 1995 and 2002 were identified for long-term evaluation. Patients younger than 18 years, with previous heart surgery and endocarditis were excluded. Stentless xenografts were used in 22 cases (Group X) and homografts in 23 cases (Group H). After review of the patients' history, morbidity and mortality were analyzed and risk stratification was performed. Results Between groups, baseline characteristics and operative data did not differ significantly. Total follow-up was 621.0 patient-years and 98.8% complete. Overall freedom from reoperation at 15 years was 68.4 ± 10.6% in group X and 85. ± 7.9% in group H (p = 0.09), respectively. Freedom from aortic valve reoperation at 15 years was comparable (83.9 ± 8.5% in group X and 85.3 ± 7.9% in group H, p = 0.61), whereas freedom from pulmonary valve reoperation at 15 years was significantly lower in group X (78.9 ± 9.4% versus 100%, p = 0.02). Long-term survival at 15 years was 79.7 ± 9.3% in group X and 94.4 ± 5.4% in group H (p = 0.07), respectively. Conclusions Stentless xenografts used as pulmonary valve substitute in the Ross procedure led to lower freedom from pulmonary valve reoperation compared with homografts. Additionally, there was a trend to inferior long-term survival with xenografts. Therefore, homografts should remain the preferred option for pulmonary valve replacement in the Ross procedure.

Long-Term Outcome of the Sorin Freedom SOLO Stentless Aortic Valve.

BACKGROUND AND AIM OF THE STUDY: The Sorin Freedom SOLO valve is a third-generation stentless aortic valve which shows beneficial hemodynamic performance compared to stented bioprostheses. Long-term results regarding hemodynamics, the durability of the valve, and patient outcome are scarce, and their acquisition was the aim of this single-center study. METHODS: Between 2005 and 2006, a total of 68 consecutive patients (30 males, 38 females; mean age at surgery 76.1 ± 6.3 years) underwent aortic valve replacement with a Sorin Freedom SOLO prosthesis. Indications were aortic stenosis (n = 50), aortic regurgitation (n = 1) and mixed lesions (n = 17). Associated procedures were performed in 31 patients (45.6%), most of which were coronary artery bypass grafting (68.8 %). The follow up was performed by telephone interviews, and clinical and echocardiographic examinations. Morbidity, mortality and echocardiographic data were analyzed. RESULTS: The total follow up was 501.1 patient-years, with a mean follow up of 7.4 ± 3.4 years (maximum 11.2 years). The follow up was 100% complete. Hospital mortality was 4.4% (n = 3). Actuarial survival at five and 10 years was 76.5 ± 5.1% and 41.5 ± 6.5%, respectively. Reinterventions were performed in eight patients; these included three reoperations due to endocarditis, four transcatheter aortic valve implantations, and one reoperation due to structural valve deterioration (SVD). The overall freedom from valve reintervention due to SVD at five and 10 years was 97.8 ± 2.2% and 82.9 ± 7.5%, respectively. After eight years, echocardiography demonstrated peak and mean transvalvular gradients of 18 ± 11 and 10 ± 7 mmHg, respectively. The overall effective and indexed aortic valve orifice areas were 1.73 ± 0.58 cm2 and 0.92 ± 0.33 cm2/m2, respectively. CONCLUSIONS: At long-term follow up the Sorin Freedom SOLO bioprosthesis was associated with favourable hemodynamic results and survival. Freedom from SVD was not superior to that occurring with stented bioprostheses.

High central venous saturation after cardiac surgery is associated with increased organ failure and long-term mortality: an observational cross-sectional study.

INTRODUCTION: Central venous saturation (ScvO2) monitoring has been suggested to address the issue of adequate cardiocirculatory function in the context of cardiac surgery. The aim of this study was to determine the impact of low (L) (<60%), normal (N) (60%-80%), and high (H) (>80%) ScvO2 measured on intensive care unit (ICU) admission after cardiac surgery. METHODS: We conducted a retrospective, cross-sectional, observational study at three ICUs of a university hospital department for anaesthesiology and intensive care. Electronic patient records of all adults who underwent cardiac surgery between 2006 and 2013 and available admission measurements of ScvO2 were examined. Patients were allocated to one of three groups according to first ScvO2 measurement after ICU admission: group L (<60%), group N (60%-80%), and group H (>80%). Primary end-points were in-hospital and 3-year follow-up survival. RESULTS: Data from 4,447 patients were included in analysis. Low and high initial measurements of ScvO2 were associated with increased in-hospital mortality (L: 5.6%; N: 3.3%; H: 6.8%), 3-year follow-up mortality (L: 21.6%; N: 19.3%; H: 25.8%), incidence of post-operative haemodialysis (L: 11.5%; N: 7.8%; H: 15.3%), and prolonged hospital length of stay (L: 13 days, 9-22; N: 12 days, 9-19; H: 14 days, 9-21). After adjustment for possible confounding variables, an initial ScvO2 above 80% was associated with adjusted hazard ratios of 2.79 (95% confidence interval (CI) 1.565-4.964, P <0.001) for in-hospital survival and 1.31 (95% CI 1.033-1.672, P = 0.026) for 3-year follow-up survival. CONCLUSIONS: Patients with high ScvO2 were particularly affected by unfavourable outcomes. Advanced haemodynamic monitoring may help to identify patients with high ScvO2 who developed extraction dysfunction and to establish treatment algorithms to improve patient outcome in these patients.

The St. Jude Toronto stentless bioprosthesis: up to 20 years follow-up in younger patients.

BACKGROUND: A retrospective long-term evaluation of the St. Jude Toronto stentless bioprosthesis in patients aged 60 years or younger. METHODS: From 1994 to 1997, 50 patients underwent aortic valve replacement with the prosthesis. Patients mean age at surgery was 54.5±6.3 years. Follow-up data were acquired by patient file research and telephone interviews. Morbidity and mortality were evaluated with time-to-event analyses using the Kaplan-Meier-method. The log-rank test was used to determine influencing factors for long-term survival and reoperation. RESULTS: Mean follow-up was 13.5±6.3 years with a total follow-up of 661.8 patient-years and a maximum of 20.0 years. Follow-up was 97.8% complete. Associated procedures were performed in 12 patients (24%), including coronary artery bypass grafting, mitral valve replacement and replacement of the ascending aorta. Freedom from reoperation at 10 and 15 years was 76.0±6.7% and 44.1±8.9%, respectively. Reoperations (n=26) started 4.4 years after implantation and were necessary due to: valve degeneration with regurgitation in 79.2% and stenosis in 12.5%, endocarditis in 4.2% and sinus valsalva aneurysm in 4.2% of the cases. The log-rank test revealed that only body-mass-index>25 lowered freedom-from-reoperation, while renal dysfunction, diabetes mellitus and arterial hypertension were not. Overall long-term survival at 10 and 20 years was 82.3±5.7% and 49.9±8.9%, respectively. CONCLUSION: In younger patients the Toronto-bioprosthesis provided reliable long-term survival despite limited durability.

Determinants for increased resource utilization after surgery for prosthetic valve endocarditis.

UNLABELLED: Mechanical circulatory support (11 intra-aortic balloon pump; two right ventricular assist device; one left ventricular assist device) was required in 14 patients (9.4%). At 30 days, mortality was 12.8% (n=17) and morbidity 78.5% (117 patients experienced at least one complication). At one, five and 10 years, the overall survival was 78.4 +/- 3.5%, 76.7 +/- 3.6% and 74.9 +/- 3.8%, respectively. The duration of postoperative MV was 8 +/- 20.7 days, while ICU and hospital stays were 11 +/- 20.8 and 37 +/- 30.2 days, respectively. The following predictors for increased resource utilization were identified: preoperative ventilatory support, mechanical circulatory support, recent myocardial infarction, and urgency for MV >3 days; preoperative ventilator support and mechanical circulatory support for ICU >7 days; and urgency and age for HS >42 days. CONCLUSION: A critical preoperative state and perioperative mechanical circulatory were strongly predictive of increased resource utilization. Hence, if resource utilization is to be reduced, an early operation seems more appropriate than to postpone surgery until an uncertain or unattainable re-normalization of organ dysfunction becomes evident. BACKGROUND AND AIM OF THE STUDY: Surgery for prosthetic valve endocarditis (PVE) is associated with significant morbidity and mortality. As treatment also demands substantial healthcare resources, a search was made for determinants of increased resource utilization. METHODS: Between 2000 and 2010, a total of 149 consecutive patients (107 males, 42 females; mean age 63.5 +/- 13.8 years) underwent re-do surgery for PVE at the authors' institution; 92 patients (61.7%) had aortic valve replacement, 42 (28.2%) had mitral valve replacement, and 15 (10.1%) had double valve replacement. Multivariate binary regression analysis was used to identify predictors of increased resource utilization, defined as mechanical ventilation (MV) >3 days, intensive care unit (ICU) stay >7 days, and hospital stay (HS) >42 days. RESULTS: Preoperatively, 14 patients (9.4%) presented with shock and 17 (11.4%) with acute renal failure. Ventilatory and pharmacological circulatory support was required in 17 (11.4%) and 19 (12.8%) patients, respectively. The logistic EuroSCORE was >20% in 121 patients (81.2%). Staphylococci were the most common infecting microorganisms (41 patients; 27.5%), while 53 cases (35.6%) were culture-negative. The operative, cardiopulmonary bypass and aortic cross-clamp times were 259 + 88.3 min, 149 +/- 62.4 min, and 112 +/- 44.3 min, respectively.

Long-term Doppler hemodynamics and effective orifice areas of Edwards SAPIEN and medtronic CoreValve prostheses after TAVI.

BACKGROUND: Although initial hemodynamics of percutaneously implanted aortic bioprostheses compare favorably to surgically implanted valves, the durability of the flow characteristics remains unknown. As biological prostheses are at potential risk for early degeneration, the aim of our study was to compare Doppler hemodynamics and effective orifice area (EOA) directly after and at least 1 year after valve implantation. METHODS: In this monocentric, prospective study, we determined peak velocity, peak and mean systolic gradients, and EOA by echocardiography in 75 patients (Edwards SAPIEN, n = 20; CoreValve, n = 55) 1 week (median 7 ± 25 days) and 1 year (median 378 ± 157 days, maximum 1034 days) after transcatheter aortic valve implantation (TAVI). RESULTS: After 12 months, Doppler performance of the aortic valve prostheses remained unchanged. The peak instantaneous velocity was 1.9 ± 0.4 m/s directly after TAVI versus 1.8 ± 0.5 m/s (P = ns) at follow-up, with a mean gradient of 8.5 ± 3.7 mmHg and 8.1 ± 4.2 (P = ns), respectively. Interestingly, the degree of mitral regurgitation (MR) decreased significantly (P = 0.007) over time, and the severity of aortic regurgitation (AR) remained unchanged during follow-up (P = ns). CONCLUSION: For at least 1 year after TAVI, the excellent Doppler hemodynamics and EOA are preserved in transcatheter aortic valve prostheses, and the severity of MR decreased significantly. In addition, we found no evidence of early valve deterioration or progression of AR.

Epicardial and Endocardial Surgical Ablation of Atrial Fibrillation: Outcomes from CASE-AF Registry.

OBJECTIVES: The German CArdioSurgEry Atrial Fibrillation Registry is a prospective, multicentric registry analyzing outcomes of patients undergoing surgical ablation for atrial fibrillation as concomitant or stand-alone procedures. This data sub-analysis of the German CArdioSurgEry Atrial Fibrillation Registry aims to describe the in-hospital and one-year outcomes after concomitant surgical ablation, based on two different ablation approaches, epicardial and endocardial surgical ablation. MATERIALS AND METHODS: Between January 2017 and April 2020 seventeen German cardiosurgical units enrolled 763 consecutive patients after concomitant surgical ablation. In the epicardial group, 413 patients (54.1%), 95.6% underwent radiofrequency ablation. In the endocardial group, 350 patients (45.9%), 97.7% underwent cryoablation. 61.5% of patients in the epicardial- and 49.4% of patients in the endocardial group presenting with paroxysmal atrial fibrillation. Pre-, intra-, and post-operative data were gathered. RESULTS: Upon discharge, 32.3% (n = 109) of patients after epicardial- and 24.0% (n = 72) of patients after endocardial surgical ablation showed recurrence of AF. The in-hospital mortality rate was low, 2.2% (n = 9) in the epi- and 2.9% (n = 10) in the endocardial group. The overall one-year procedural success rate was 58.4% in the epi- and 62.2% in the endocardial group, with significant symptom improvement in both groups. The one-year mortality rate was 7.7% (n = 30) in epi- and 5.0% (n = 17) in the endocardial group. CONCLUSIONS: Concomitant surgical ablation is safe and effective with significant improvement in patient symptoms and freedom from atrial fibrillation. Adequate cardiac rhythm monitoring should be prioritized for higher-quality data acquisition.

Surgical-transcatheter approach for endocarditis of a calcified aortic homograft.

Repeat aortic valve replacement (AVR) after freestanding homograft root replacement with reimplantation of the coronary arteries is challenging and risky, especially in patients with major homograft wall calcifications. Although new transcatheter techniques for AVR may offer an alternative in structurally degenerated homografts, they are not suitable to treat endocarditis. Here, the case is reported of successful treatment of bacterial endocarditis within a totally calcified homograft after aortic root replacement by combining conventional surgery and transcatheter techniques.

Influence of timing of Levosimendan administration on outcomes in cardiac surgery.

Purpose: Though a subgroup analysis has shown improved survival for patients suffering severely reduced ventricular function undergoing coronary artery bypass grafting, RCTs were not able to demonstrate overall beneficial effects of perioperative Levosimendan in cardiac surgery. This might be due to Levosimendan's pharmacokinetics reaching a steady-state concentration only 4-8 h after administration. Thus, this study now analysed the influence of timing of Levosimendan administration on perioperative outcome in cardiac surgery patients preoperatively presenting with severely reduced ventricular function and therefore considered at high-risk for intra- or postoperative low cardiac output syndrome. We hypothesized that prolonged preoperative Levosimendan administration ("preconditioning") would reduce mortality. Methods: All adult patients undergoing cardiac surgery between 2006 and 2018 perioperatively receiving Levosimendan were included in this retrospective, observational cohort study (n = 498). Patients were stratified into 3 groups: Levosimendan started on the day prior to surgery ("preop"), Levosimendan started on the day of surgery ("intraop") or post ICU admission ("postop"). After propensity score matching (PSM) was performed, outcomes defined according to proposed standard definitions for perioperative outcome research were compared between groups. Results: After PSM, there were no significant differences in patients' characteristics, comorbidities and type/priority of surgery between groups. Compared to intraop or postop Levosimendan treatment, preop treated patients had significantly lower in-hospital-mortality (preop vs. intraop. vs. postop = 16,7% vs. 33,3% vs. 42,3%), duration of mechanical ventilation and rate of continuous renal replacement therapy. Conclusions: Prolonged preoperative treatment with Levosimendan of cardiac surgery patients preoperatively presenting with severely reduced left ventricular function might be beneficial in terms of postoperative outcome. Our results are in line with recent experts' recommendations concerning the prolonged perioperative use of Levosimendan. We strongly recommend that future randomized trials include this "preconditioning" treatment as an experimental arm.

Surgical ablation of long-standing persistent atrial fibrillation: 1-year outcomes from the CArdioSurgEry Atrial Fibrillation (CASE-AF) registry.

OBJECTIVES: The CArdioSurgEry Atrial Fibrillation (CASE-AF) registry is a prospective, multicentre study for collecting and analysing real-world data of surgical atrial fibrillation (AF) treatment. This study aimed to evaluate outcomes of surgery for long-standing persistent AF at 1 year. METHODS: In total, 17 centres consecutively include all eligible patients with continuous AF lasting for ≥1 year. Exclusion criteria are missing informed consent or age <18 years. For patient-reported outcomes measures, the European Heart Rhythm Association score was used. No presence of AF (based on ECG findings including Holter ECG and/or implanted devices), no re-ablation, no further cardioversion and no rehospitalization due to AF after a 3-month blanking period defined no AF recurrence at 1 year. RESULTS: From January 2017 to January 2020, a total of 1115 patients were enrolled in CASE-AF. Of them, 202 patients (mean age 69.7 ± 7.8 years, 27.2% female) underwent surgical ablation of long-standing persistent AF (study cohort), mostly accompanied by left atrial appendage closure (n = 180 [89%], resection n = 75 [42%]) and predominantly performed as concomitant (n = 174 [86%]) and left atrial only procedure (n = 144 [71%]). Early mortality (30 days) was 2.0% and morbidity was low. At follow-up (median 14.4 months, interquartile range, 12.7-17.6 months, 100% complete), 106 patients (56%) had no AF recurrence and 93% of them were asymptomatic. AF recurrence was accompanied by AF-related rehospitalization (n = 12, P = 0.003), direct current shock cardioversion (n = 23, P < 0.001), AF ablation (n = 7, P = 0.003) and stroke (n = 3, P = 0.059). Multivariable analysis identified cryoablation, predominantly performed endocardially including additional left atrial (74%) and biatrial (42%) lesions, as a significant factor for freedom from AF recurrence (odds ratio 2.7, 95% confidence interval 1.07-6.79, P = 0.035). CONCLUSIONS: According to CASE-AF, surgical ablation of long-standing persistent AF is most effective when concomitantly performed using endocardial cryoablation. Ongoing follow-up allows further elucidation of efficacious treatment strategies.