Hyperlactatemia and poor outcome After postcardiotomy veno-arterial extracorporeal membrane oxygenation: An individual patient data meta-Analysis.

INTRODUCTION: Postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) is associated with significant mortality. Identification of patients at very high risk for death is elusive and the decision to initiate V-A-ECMO is based on clinical judgment. The prognostic impact of pre-V-A-ECMO arterial lactate level in these critically ill patients has been herein evaluated. METHODS: A systematic review was conducted to identify studies on postcardiotomy VA-ECMO for the present individual patient data meta-analysis. RESULTS: Overall, 1269 patients selected from 10 studies were included in this analysis. Arterial lactate level at V-A-ECMO initiation was increased in patients who died during the index hospitalization compared to those who survived (9.3 vs 6.6 mmol/L, p < 0.0001). Accordingly, in hospital mortality increased along quintiles of pre-V-A-ECMO arterial lactate level (quintiles: 1, 54.9%; 2, 54.9%; 3, 67.3%; 4, 74.2%; 5, 82.2%, p < 0.0001). The best cut-off for arterial lactate was 6.8 mmol/L (in-hospital mortality, 76.7% vs. 55.7%, p < 0.0001). Multivariable multilevel mixed-effect logistic regression model including arterial lactate level significantly increased the area under the receiver operating characteristics curve (0.731, 95% CI 0.702-0.760 vs 0.679, 95% CI 0.648-0.711, DeLong test p < 0.0001). Classification and regression tree analysis showed the in-hospital mortality was 85.2% in patients aged more than 70 years with pre-V-A-ECMO arterial lactate level ≥6.8 mmol/L. CONCLUSIONS: Among patients requiring postcardiotomy V-A-ECMO, hyperlactatemia was associated with a marked increase of in-hospital mortality. Arterial lactate may be useful in guiding the decision-making process and the timing of initiation of postcardiotomy V-A-ECMO.

Tricuspid Valve Surgery in Patients Receiving Left Ventricular Assist Devices.

BACKGROUND: Tricuspid regurgitation (TR) is common and related to poor prognosis in patients after left ventricular assist device (LVAD) implantation. The concomitant tricuspid valve surgery (TVS) at the time of LVAD implantation on short and long-term outcomes are controversial in current evidence. METHODS: This is a single-center, observational, retrospective study. We enrolled patients with moderate-to-severe TR who received LVAD implantations from 2009 to 2020. Postoperative right ventricular failure (RVF), right ventricular assist device (RVAD) use, hospital mortality, new-onset renal replacement therapy (RRT), and acute kidney injury (AKI) were evaluated retrospectively. RESULTS: Sixty-eight patients were included, 36 with and 32 without concomitant TVS. Baseline characteristics did not differ between the two groups. Patients receiving TVS had significantly increased incidences of postoperative RVF (52.8 vs. 25.0%, p = 0.019), RVAD implantation (41.7 vs. 18.8%, p = 0.041), and new-onset RRT (22.2 vs. 0%, p = 0.004). No difference in the incidence of AKI and hospital mortality was detected. Besides, these associations remained consistent in patients who underwent LVAD implantation via median sternotomy. During a median follow-up of 2.76 years, Kaplan-Meier analysis and competing-risk analysis showed that TVS was not associated with better overall survival in patients after LVAD implantation compared with the no-TVS group. CONCLUSION: Our study suggests that concomitant TVS failed to show benefits in patients receiving LVAD implantation. Even worse, concomitant TVS is associated with significantly increased incidences of RVF, RVAD use, and new-onset of RRT. Considering the small sample size and short follow-up, these findings warrant further study.

Gender and the Outcome of Postcardiotomy Veno-arterial Extracorporeal Membrane Oxygenation.

OBJECTIVE: There is a paucity of sex-specific data on patients' postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO). The present study sought to assess this issue in a multicenter study. DESIGN: Retrospective, propensity score-matched analysis of an international registry. SETTING: Multicenter study, tertiary university hospitals. PARTICIPANTS: Data on adult patients undergoing postcardiotomy VA-ECMO. MEASUREMENTS AND MAIN RESULTS: Between January 2010 and March 2018, patients treated with postcardiotomy VA-ECMO at 17 cardiac surgery centers were analyzed. Index procedures considered were coronary artery bypass graft surgery, isolated valve surgery, their combination, and proximal aortic root surgery. Hospital and five-year mortality constituted the endpoints of interest. Propensity score matching was adopted with logistic regression. A total of 358 patients (mean age: 63.3 ± 12.3 years; 29.6% female) were identified. Among 94 propensity score-matched pairs, women had a higher hospital mortality (70.5% v 56.4%, p = 0.049) compared with men. Logistic regression analysis showed that women (odds ratio [OR], 1.87; 95% confidence interval [CI] 1.10-3.16), age (OR, 1.06; 95%CI 1.04-1.08) and pre-ECMO arterial lactate (OR, 1.09; 95%CI 1.04-1.16) were independent predictors of hospital mortality. No differences between female and male patients were observed for other outcomes. Among propensity score-matched pairs, one-, three-, and five-year mortality were 60.6%, 65.0%, and 65.0% among men, and 71.3%, 71.3%, and 74.0% among women, respectively (p = 0.110, adjusted hazard ratio, 1.27; 95%CI 0.96-1.66). CONCLUSIONS: In postcardiotomy VA-ECMO, female patients demonstrated higher hospital mortality than men. Morbidity and late mortality were similar between the two groups.

Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation With and Without Intra-Aortic Balloon Pump.

OBJECTIVES: To compare the outcomes of patients with postcardiotomy shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) only compared with VA-ECMO and intra-aortic balloon pump (IABP). DESIGN: A retrospective multicenter registry study. SETTING: At 19 cardiac surgery units. PARTICIPANTS: A total of 615 adult patients who required VA-ECMO from 2010 to 2018. The patients were divided into 2 groups depending on whether they received VA-ECMO only (ECMO only group) or VA-ECMO plus IABP (ECMO-IABP group). MEASUREMENTS AND MAIN RESULTS: The overall series mean age was 63 ± 13 years, and 33% were female. The ECMO-only group included 499 patients, and 116 patients were in the ECMO-IABP group. Urgent and/or emergent procedures were more common in the ECMO-only group. Central cannulation was performed in 47% (n = 54) in the ECMO-IABP group compared to 27% (n = 132) in the ECMO-only group. In the ECMO-IABP group, 58% (n = 67) were successfully weaned from ECMO, compared to 46% (n = 231) in the ECMO-only group (p = 0.026). However, in-hospital mortality was 63% in the ECMO-IABP group compared to 65% in the ECMO-only group (p = 0.66). Among 114 propensity score-matched pairs, ECMO-IABP group had comparable weaning rates (57% v 53%, p = 0.51) and in-hospital mortality (64% v 58%, p = 0.78). CONCLUSIONS: This multicenter study showed that adjunctive IABP did not translate into better outcomes in patients treated with VA-ECMO for postcardiotomy shock.

Population pharmacokinetic evaluation of cefuroxime in perioperative antibiotic prophylaxis during and after cardiopulmonary bypass.

AIMS: The purpose of this study was to explore pharmacokinetic and pharmacodynamic aspects of a contemporary dosing scheme of cefuroxime as perioperative prophylaxis in cardiac surgery using cardiopulmonary bypass (CPB). METHODS: Cefuroxime plasma concentrations were measured in 23 patients. A 1.5-g dose of cefuroxime was administered at start of surgery and CPB, followed by 3 additional doses every 6 hours postoperative. Drug levels were used to build a population pharmacokinetic model. Target attainment for Staphylococcus aureus (2-8 mg/L) and Escherichia coli (8-32 mg/L) were evaluated and dosing strategies for optimization were investigated. RESULTS: A dosing scheme of 1.5 g cefuroxime preoperatively with a repetition at start of CPB achieves plasma unbound concentrations of 8 mg/L in almost all patients during surgery. The second administration is critical to provide this level of coverage. Simulations indicate that higher unbound concentrations up to 32 mg/L are reached by a continuous infusion rate of 1 g/h after a bolus of 1 g. In the postoperative phase, most patients do not reach unbound concentrations above 2 mg/L. To improve target attainment up to 8 mg/L, the continuous application of cefuroxime with infusion rates of 0.125-0.25 g/h is simulated and shown to be an alternative to bolus dosing. CONCLUSION: Dosing recommendations for cefuroxime as perioperative antibiotic prophylaxis in cardiac surgery are sufficient to reach plasma unbound concentration to cover S. aureus during the operation. Target attainment is not achieved in the postoperative period. Continuous infusion of cefuroxime may optimize target attainment.

Outcome of Repeat Venoarterial Extracorporeal Membrane Oxygenation in Postcardiotomy Cardiogenic Shock.

OBJECTIVE: Data on patients requiring a second run of venoarterial extracorporeal membrane oxygenation (VA-ECMO) support in patients affected by postcardiotomy cardiogenic shock (PCS) are very limited. The authors aimed to investigate the effect of a second run of VA-ECMO on PCS patient survival. DESIGN: Retrospective analysis of an international registry. SETTING: Multicenter study, tertiary university hospitals. PARTICIPANTS: Data on adult PCS patients receiving a second run of VA-ECMO. MEASUREMENTS AND MAIN RESULTS: A total of 674 patients with a mean age of 62.9 ± 12.7 years were analyzed, and 21 (3.1%) patients had a second run of VA-ECMO. None of them required more than two VA-ECMO runs. The median duration of VA-ECMO therapy was 135 hours (interquartile range [IQR] 61-226) in patients who did not require a VA-ECMO rerun. In the rerun VA-ECMO group the median overall duration of VA-ECMO therapy was 183 hours (IQR 107-344), and the median duration of the first run was 114 hours (IQR 66-169). Nine (42.9%) of the patients who required a second run of VA-ECMO died during VA-ECMO therapy, whereas five (23.8%) survived to hospital discharge. No differences between patients treated with single or second VA-ECMO runs were observed in terms of hospital mortality and late survival. In patients requiring a second VA-ECMO run, the actuarial survival estimates at three and 12 months after VA-ECMO weaning were 23.8% ± 9.3% and 19.6% ± 6.4%, respectively. CONCLUSIONS: Repeat VA-ECMO therapy is a valid treatment strategy for PCS patients. Early and late survivals are similar between patients who have undergone a single or second run of VA-ECMO.

Six-Month Survival After Extracorporeal Membrane Oxygenation for Severe COVID-19.

OBJECTIVES: The authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO). DESIGN: Multicenter retrospective, observational study. SETTING: Ten tertiary referral university and community hospitals. PARTICIPANTS: Patients with confirmed severe COVID-19-related ARDS. INTERVENTIONS: Venovenous or venoarterial ECMO. MEASUREMENTS AND MAIN RESULTS: One hundred thirty-two patients (mean age 51.1 ± 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19-related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 ± 4.4, mean pH was 7.23 ± 0.09, and mean PaO2/fraction of inspired oxygen ratio was 77 ± 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 ± 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality. CONCLUSIONS: The present findings suggested that about half of adult patients with severe COVID-19-related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities. CLINICAL TRIAL REGISTRATION: identifier, NCT04383678.

Duration of Venoarterial Extracorporeal Membrane Oxygenation and Mortality in Postcardiotomy Cardiogenic Shock.

OBJECTIVE: The optimal duration of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients affected by postcardiotomy cardiogenic shock (PCS) remains controversial. The present study was conducted to investigate the effect of VA-ECMO duration on hospital outcomes. DESIGN: Retrospective analysis of an international registry. SETTING: Multicenter study including 19 tertiary university hospitals. PARTICIPANTS: Between January 2010 and March 2018, data on PCS patients receiving VA-ECMO were retrieved from the multicenter PC-ECMO registry. INTERVENTIONS: Patients were stratified according to the following different durations of VA-ECMO therapy: ≤three days, four-to-seven days, eight-to-ten days, and >ten days. MEASUREMENTS AND MAIN RESULTS: A total of 725 patients, with a mean age of 62.9 ± 12.9 years, were included. The mean duration of VA-ECMO was 7.1 ± 6.3 days (range 0-39 d), and 39.4% of patients were supported for ≤three days, 29.1% for four-seven days, 15.3% for eight-ten days, and finally 20.7% for >ten days. A total of 391 (53.9%) patients were weaned from VA-ECMO successfully; however, 134 (34.3%) of those patients died before discharge. Multivariate logistic regression showed that prolonged duration of VA-ECMO therapy (four-seven days: adjusted rate 53.6%, odds ratio [OR] 0.28, 95% confidence interval [CI] 0.18-0.44; eight-ten days: adjusted rate 61.3%, OR 0.51, 95% CI 0.29-0.87; and >ten days: adjusted rate 59.3%, OR 0.49, 95% CI 0.31-0.81) was associated with lower risk of mortality compared with VA-ECMO lasting ≤three days (adjusted rate 78.3%). Patients requiring VA-ECMO therapy for eight-ten days (OR 1.96, 95% CI 1.15-3.33) and >10 days (OR 1.85, 95% CI 1.14-3.02) had significantly greater mortality compared with those on VA-ECMO for 4 to 7 days. CONCLUSIONS: PCS patients weaned from VA-ECMO after four-seven days of support had significantly less mortality compared with those with shorter or longer mechanical support.

Neurologic Injury in Patients Treated With Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock.

OBJECTIVE: To investigate the frequency, predictors, and outcomes of neurologic injury in adults treated with postcardiotomy extracorporeal membrane oxygenation (PC-ECMO). DESIGN: A retrospective multicenter registry study. SETTING: Twenty-one European institutions where cardiac surgery is performed. PARTICIPANTS: A total of 781 adult patients who required PC-ECMO during 2010 to 2018 were divided into patients with neurologic injury (NI) and patients without neurologic injury (NNI). MEASUREMENTS AND MAIN RESULTS: Baseline and operative data, in-hospital outcomes, and long-term survival were compared between the NI and the NNI groups. Predictors of neurologic injury were identified. A subgroup analysis according to the type of neurologic injury was performed. Overall, NI occurred in 19% of patients in the overall series, but the proportion of patients with NI ranged from 0% to 65% among the centers. Ischemic stroke occurred in 84 patients and hemorrhagic stroke in 47 patients. Emergency procedure was the sole independent predictor of NI. In-hospital mortality was higher in the NI group than in the NNI group (79% v 61%, p < 0.001). The one-year survival was lower in the NI group (17%) compared with the NNI group (37%). Long-term survival did not differ between patients with ischemic stroke and those with hemorrhagic stroke. CONCLUSION: Neurologic injury during PC-ECMO is common and associated with a dismal prognosis. There is considerable interinstitutional variation in the proportion of neurologic injury in PC-ECMO-treated adults. Well-known risk factors for stroke are not associated with neurologic injury in this setting.

Long-term follow-up of patients supported with the HeartWare left ventricular assist system.

The aim of the present study is to report our long-term experience with the HeartWare Ventricular Assist System (HVAD). Between July 2009 and February 2018, a total of 103 patients (mean age 50.0 ± 14.4, range 28-74 years; 22 females) received HVAD implantation in a single center institution. A total of 26 (25.4%) patients were in cardiogenic shock preoperatively and received extracorporeal life support (ECLS) prior to HVAD implantation. The aim of left ventricular assist device (LVAD) implantation was bridge to transplantation (BT) in 59 (57.3%), destination therapy (DT) in 28 (27.2%), and bridge to decision in 16 (15.5%). There were 211.1 total patient years of support. Mean survival was 2.05 ± 2.14 years. Kaplan-Meier analysis showed an overall survival rate of 69.7%, 56.7%, 46.0%, and 25.0% at 1, 2, 4, and 8 years, respectively. A total of 23 patients (22.3%) died during the hospital stay. Of them 65.2% (15 patients) were preoperatively in cardiogenic shock (INTERMACS 1). Sub-analysis of the BT patients showed a mean survival of 2.45 ± 2.29 years with a survival rate of 85.1%, 75.1%, 67.2%, and 44.8% at 1, 2, 4, and 8 years, respectively. Among them, 20 patients received heart transplantation on follow-up. Mean survival of DT patients was 2.18 ± 1.91 years with a survival rate of 67.9%, 49.0%, and 25.1% at 1, 2, and 4 years, respectively. At latest follow-up in September 2018, 26 patients (25.24%) were still on LVAD. A total of five patients completed 6 years on LVAD, of them two were supported over 8 years. The most common adverse event reported was gastrointestinal bleeding requiring rehospitalization (0.161 EPPY). A total of 19 patients reported disabling stroke. Pump thrombosis was diagnosed in six patients (5.8%) (0.02 EPPY), of them four patients underwent pump exchange. To the best of our knowledge, this is the longest experience with HVAD reported so far. Patients supported with an HVAD show a satisfactory long-term survival. Further multicenter evaluations are needed to confirm these single-center results.

Aortic valve replacement in a patient with extra-anatomic aortic and subclavian bypasses. / Zamena aortal'nogo klapana u patsienta s ékstraanatomicheskimi aortal'nymi i podkliuchichnymi shuntami.

The patient was 62-year-old male who successfully underwent an anatomic repair of aortic coarctation at the age of 15 and an extra-anatomic ascending aorta- to-descending aorta bypass (graft size 20 mm) and an extra-anatomic ascending aorta to the left subclavian artery bypass (graft size 10 mm) at the age of 49. As he grew older he started presenting clinical symptoms of aortic stenosis. The echocardiogram showed a bicuspid aortic valve with severe stenosis and a mean gradient of 65 mm Hg. Despite the high surgical risk, we decided to perform an open valve replacement with installing the CPB prior to re-sternotomy with a simultaneous cannulation of the axillary and femoral arteries by reason of interrupted descending aorta. The postoperative course was uneventful.

Pulmonary Bleeding During Right Ventricular Support After Left Ventricular Assist Device Implantation.

OBJECTIVES: Right heart failure still occurs in up to 20% of patients after implantation of a left ventricular assist device (LVAD). One treatment option for these patients is the implantation of a temporary right ventricular assist device (RVAD). Experimental data suggest that non-pulsatile perfusion of the lungs is associated with an increased rate of pulmonary hemorrhage. The aim of this study was to determine the incidence of pulmonary bleeding complications in these patients. DESIGN: Observational study. SETTING: Single center, university hospital. PARTICIPANTS: This study included patients undergoing LVAD implantation for end-stage heart failure and subsequent implantation of a temporary right ventricular support system. INTERVENTIONS: In this study, 25 patients who underwent LVAD and additional temporary RVAD implantation were screened for pulmonary bleeding complications. MEASUREMENTS AND MAIN RESULTS: The mean Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level at the time of LVAD implantation was 2.84. All patients experienced severe right ventricular failure (tricuspid annular plane systolic excursion [TAPSE], 10.16±26.3 mm) and severe pulmonary hypertension (right atrial [RA] pressure, 56.21±15.58 mmHg). Average duration of right ventricular support was 11.12±7.20 days, with right ventricular support being administered to 14 patients for more than 7 days. Seventeen patients were weaned successfully from right ventricular support after a mean support duration of 5 days. Five patients developed pulmonary bleeding complications, diagnosed using computed tomography scan and bronchoscopy. All bleeding occurred after postoperative day 7 and was associated with RVAD flow of more than 4 L/min within 24 hours before bleeding occurred. CONCLUSIONS: The data presented in this study suggested that right ventricular support for more than 7 days and a blood flow greater than 4 L/min were associated with pulmonary bleeding complications. This should be taken into consideration when temporary right ventricular support after LVAD implantation is planned.

Can Perioperative Right Ventricular Support Prevent Postoperative Right Heart Failure in Patients With Biventricular Dysfunction Undergoing Left Ventricular Assist Device Implantation?

OBJECTIVES: Depending on the pre-existing condition of the right ventricle (RV), left ventricular assist device (LVAD) implantation may have a detrimental effect on RV function, subsequently leading to right heart failure. This study details the authors' experience with perioperative mechanical RV support in patients with biventricular impairment but primarily scheduled for isolated LVAD implantation. DESIGN: Retrospective study. SETTING: Two center study, university hospital. PARTICIPANTS: This study included LVAD recipients with preoperative biventricular impairment who received an additional right ventricular assist device (RVAD) after a failed weaning attempt from cardiopulmonary bypass due to acute RV failure. INTERVENTIONS: Outcomes of 25 patients who underwent LVAD and unplanned temporary RVAD implantation were analyzed. MEASUREMENTS AND MAIN RESULTS: All patients experienced significant preoperative RV impairment (tricuspid annular plane systolic excursion: 10.2±26.3 mm; right atrium pressure: 17.9±10.4 mmHg) and pulmonary hypertension (pulmonary artery pressure: 54.8±25.7 mmHg). In 15 patients, additional tricuspid valve annuloplasty was performed. Mean duration of temporary RVAD support was 11.1±7.2 days. In 23 patients (92%), the RVAD was removed successfully. None of the patients developed RV failure after RVAD removal. Hospital survival and the 1-year survival rate of the study group were 68% and 56%, respectively. CONCLUSIONS: The results of perioperative RVAD support in LVAD recipients with biventricular dysfunction are encouraging. Temporary RVAD support allows an already compromised RV to become attuned to the hemodynamic conditions after LVAD implantation. This strategy provides patients with preoperative impaired RV function a high likelihood to permanently undergo LVAD support only.

Is Implantation of a Left Ventricular Assist Device in Patients With Critical or Impending Cardiogenic Shock an Absolute Contraindication? Looking Back at Our Past Experience Trying to Identify Contraindicative Risk Factors.

Poor survival has been demonstrated after ventricular assist device (VAD) implantation for Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 and 2 patients compared with more stable levels. However, risk factors within this high-risk cohort have not been determined so far. The aim of the present study was to identify risk factors associated with this very high mortality rate. Between February 1993 and January 2013, 298 patients underwent VAD implantation in our institution. One hundred nine patients were in INTERMACS level 1 and 49 patients were in INTERMACS level 2 and were therefore defined as hemodynamically critical (overall 158 patients). Assist devices implanted were: HVAD HeartWare n = 18; Incor n = 11; VentrAssist n = 2; DeBakey n = 22; and pulsatile systems n = 105. After cumulative support duration of 815.35 months, Kaplan-Meier analysis revealed a survival of 63.9, 48.8, and 40.3% at 1, 6, and 12 months, respectively. Cox regression analyses identified age > 50 (P = 0.001, odds ratio [OR] 2.48), white blood cell count > 13.000/µL (P = 0.01, OR 2.06), preoperative renal replacement therapy (P = 0.001, OR 2.63), and postcardiotomy failure (P < 0.001, OR 2.79) as independent predictors of mortality. Of note, last generation VADs were not associated with significantly better 6-month survival (P = 0.59). Patients without the aforementioned risk factors could yield a survival of 79.2% at 6 months. This single-center experience shows that VAD implantation in hemodynamically unstable patients generally results in poor early outcome, even in third-generation pumps. However, avoiding the aforementioned risk factors could result in improved outcome.

Minimally invasive mitral valve repair.

PURPOSE OF REVIEW: Meanwhile mitral valve insufficiency is probably the second most common heart valve disease represented in cardiac surgery. Due to low perioperative morbidity and mortality, nowadays mitral valve repair can even be considered in asymptomatic patients. The enhancements of minimally invasive surgical techniques led to a decrease in surgical trauma and accelerated postoperative recovery, resulting in increased acceptance of these operating techniques. Therefore, the present review focuses on the different surgical access ways to the mitral valve and their significance for mitral valve repair. RECENT FINDINGS: The emergence of transcatheter approaches to mitral valve repair has focused attention on outcomes after surgical mitral valve repair. Results from the EVEREST II trial demonstrated worse short-term major adverse event rates for surgical repair. Recently, several studies were published analyzing contemporary outcomes, morbidity, mortality, and quality of life after conventional and minimally invasive surgical mitral valve repair to establish benchmarks for future therapeutic comparisons. SUMMARY: Today mitral valve repair is the gold standard for treatment of significant mitral valve regurgitation with low perioperative morbidity and mortality and excellent long-term results. It can be performed through minimally invasive surgical techniques without compromising long-term durability of repair results, but with a decrease in surgical trauma and accelerated postoperative recovery. Currently, endovascular therapy for mitral regurgitation (e.g., the MitraClip procedure) should be limited to patients who otherwise would not be eligible for surgery.

Economic aspects of long-term left ventricular assist device treatment for chronic heart failure.

AIMS: Technological advances and the current shortage of donor organs have contributed to an increase in the number of left ventricular assist device (LVAD) implantations in patients with end-stage heart failure. Demographic change and medical progress might raise the number of these patients, resulting in a further increase in the number of LVAD implantations. The aim of this study was to evaluate the long-term costs of LVAD therapy and identify diagnoses resulting in expensive stays. METHODS AND RESULTS: In this retrospective analysis of prospectively collected data, all patients after implantation of a second- or third-generation LVAD by 31 March 2022 were included. In addition to demographic and survival data, revenues and case mix points were determined for each patient. Of the 163 patients included, 75.5% were male. The mean age at LVAD implantation was 52 ± 14 years. The mean survival was 1458 ± 127 days. During follow-up, the total inpatient treatment time per patient was 70 ± 87 days. The average duration of outpatient treatment was 55.1%, based on the total duration of support. The average revenue per patient for the implant stay was $193 192.35 ± $111 801.29, for inpatient readmissions $52 068.96 ± $116 630.00, and for outpatient care $53 195.94 ± $62 363.53. CONCLUSIONS: LVAD implantation in patients with end-stage heart failure leads to improved survival but a significant increase in treatment costs. Further multi-centre studies are necessary in order to be able to assess the effects of long-term LVAD treatment on the healthcare system.

Calcium channel blockers and clinical outcomes in patients with continuous-flow left ventricular assist devices.

AIMS: Current guidelines suggest calcium channel blockers (CCBs) as the second or third option for blood pressure management in patients with left ventricular assist device (LVAD). However, the clinical outcomes of patients with LVAD who receive CCBs remain unclear. Our study aims to analyse the association of CCBs with clinical outcomes in patients after LVAD implantation. METHODS AND RESULTS: This is a retrospective analysis based on the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) from 2006 to 2017, and adult patients who were alive with LVAD and CCB treatment information at 6 months after implantation were included. Among 10 717 patients, 1369 received CCBs 6 months after implantation, and there was an increasing trend of CCB use after LVAD. Patients receiving CCB therapy at 6 months had a similar 5 year survival rate to those not receiving CCB [49.6%, 95% confidence interval (CI): 47.5-51.7% vs. 51.1%, 95% CI: 45.3-56.7%]. In both Cox and competing risk regressions after adjusting for confounding factors, CCB treatment at 6 months after implantation was not associated with long-term mortality [hazard ratio (HR): 1.03, 95% CI: 0.91-1.17, P = 0.624 and subdistribution HR (SHR): 1.07, 95% CI: 0.95-1.22, P = 0.260]. Consistently, in time-varying models, CCB treatment was not linked to long-term mortality (HR: 0.97, 95% CI: 0.87-1.09, P = 0.682 and SHR: 1.05, 95% CI: 0.94-1.18, P = 0.359). This null association remained in subgroup analysis according to device strategy and propensity-matching analyses. Neurological dysfunction, stroke, bleeding, rehospitalization, and renal dysfunction were more likely to occur among those with CCB when compared with those without CCB treatment. CONCLUSIONS: In patients with LVAD, CCB therapy fails to show benefits in long-term survival and is associated with increased incidences of neurological dysfunction, bleeding, renal dysfunction, and rehospitalization.

Inter-institutional analysis of the outcome after postcardiotomy veno-arterial extracorporeal membrane oxygenation.

INTRODUCTION: Patients requiring postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) have a high risk of early mortality. In this analysis, we evaluated whether any interinstitutional difference exists in the results of postcardiotomy V-A-ECMO. METHODS: Studies on postcardiotomy V-A-ECMO were identified through a systematic review for individual patient data (IPD) meta-analysis. Analysis of interinstitutional results was performed using direct standardization, estimation of observed/expected in-hospital mortality ratio and propensity score matching. RESULTS: Systematic review of the literature yielded 31 studies. Data from 10 studies on 1269 patients treated at 25 hospitals were available for the present analysis. In-hospital mortality was 66.7%. The relative risk of in-hospital mortality was significantly higher in six hospitals. Observed versus expected in-hospital mortality ratio showed that four hospitals were outliers with significantly increased mortality rates, and one hospital had significantly lower in-hospital mortality rate. Participating hospitals were classified as underperforming and overperforming hospitals if their observed/expected in-hospital mortality was higher or lower than 1.0, respectively. Among 395 propensity score matched pairs, the overperforming hospitals had significantly lower in-hospital mortality (60.3% vs 71.4%, p = 0.001) than underperforming hospitals. Low annual volume of postcardiotomy V-A-ECMO tended to be predictive of poor outcome only when adjusted for patients' risk profile. CONCLUSIONS: In-hospital mortality after postcardiotomy V-A-ECMO differed significantly between participating hospitals. These findings suggest that in many centers there is room for improvement of the results of postcardiotomy V-A-ECMO.

External validation of the REMEMBER score.

Background: The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary artery bypass grafting (CABG) is associated with high in-hospital mortality rates. The pRedicting mortality in patients undergoing venoarterial Extracorporeal MEMBrane oxygenation after coronary artEry bypass gRafting (REMEMBER) score has been created to predict in-hospital mortality in this subgroup of patients. The aim of this study is to externally validate the REMEMBER score. Methods: All CABG patients who received VA-ECMO during or after the operation at our center between 01/2012 and 12/2021 were included in the analysis. Discrimination was assessed using concordance statistics, visualized by ROC curve analysis. Calibration-in-the-large and Calibration slope were tested separately. Results: A total of 107 patients (male: n = 78, 72.9%) were included in this study. The in-hospital mortality rate in our cohort was 45.8% compared with 55% in the original study. The REMEMBER score median predicted mortality rate was 52% (76.9-36%). However, the REMEMBER score showed low discriminative ability [AUC: 0.623 (p = 0.0244; 95% CI = 0.524-0.715)] and inaccurate calibration (intercept = 0.25074; p = 0.0195; slope = 0.39504; p = 0.0303), indicating poor performance. Conclusions: The REMEMBER score did not predict in-hospital mortality and was therefore not applicable in our cohort of patients. Additional external validation studies in a multicenter setting are therefore advisable.

To hit a home run as a heterotopic heart recipient-living with two hearts for over three decades: a case report.

Heterotopic heart transplantation (HHT) is an alternative to the orthotopic technique in selected patients with terminal heart failure. We report the case of the longest survival after HHT, with an uneventful follow-up for over three decades after transplantation. At the age of 25 years, endomyocardial fibrosis following myocarditis rendered the patient's native heart unable to maintain the body's needs. An allograft provided a second chance at life. The HHT technique was favoured due to severe pulmonary hypertension. The patient had an uneventful follow-up since then. The scarcity of donors and the revolutionary advances in the mechanical circulatory device field restricted the utilization of the HHT technique, but it has the potential to provide an excellent prognosis with a good quality of life.