Development and validation of a prediction model for early mortality after transcatheter aortic valve implantation (TAVI) based on the Netherlands Heart Registration (NHR): The TAVI-NHR risk model.

BACKGROUND: The currently available mortality prediction models (MPM) have suboptimal performance when predicting early mortality (30-days) following transcatheter aortic valve implantation (TAVI) on various external populations. We developed and validated a new TAVI-MPM based on a large number of predictors with recent data from a national heart registry. METHODS: We included all TAVI-patients treated in the Netherlands between 2013 and 2018, from the Netherlands Heart Registration. We used logistic-regression analysis based on the Akaike Information Criterion for variable selection. We multiply imputed missing values, but excluded variables with >30% missing values. For internal validation, we used ten-fold cross-validation. For temporal (prospective) validation, we used the 2018-data set for testing. We assessed discrimination by the c-statistic, predicted probability accuracy by the Brier score, and calibration by calibration graphs, and calibration-intercept and calibration slope. We compared our new model to the updated ACC-TAVI and IRRMA MPMs on our population. RESULTS: We included 9144 TAVI-patients. The observed early mortality was 4.0%. The final MPM had 10 variables, including: critical-preoperative state, procedure-acuteness, body surface area, serum creatinine, and diabetes-mellitus status. The median c-statistic was 0.69 (interquartile range [IQR] 0.646-0.75). The median Brier score was 0.038 (IQR 0.038-0.040). No signs of miscalibration were observed. The c-statistic's temporal-validation was 0.71 (95% confidence intervals 0.64-0.78). Our model outperformed the updated currently available MPMs ACC-TAVI and IRRMA (p value < 0.05). CONCLUSION: The new TAVI-model used additional variables and showed fair discrimination and good calibration. It outperformed the updated currently available TAVI-models on our population. The model's good calibration benefits preprocedural risk-assessment and patient counseling.

Investigating the physiology of normothermic ex vivo heart perfusion in an isolated slaughterhouse porcine model used for device testing and training.

BACKGROUND: The PhysioHeart™ is a mature acute platform, based isolated slaughterhouse hearts and able to validate cardiac devices and techniques in working mode. Despite perfusion, myocardial edema and time-dependent function degradation are reported. Therefore, monitoring several variables is necessary to identify which of these should be controlled to preserve the heart function. This study presents biochemical, electrophysiological and hemodynamic changes in the PhysioHeart™ to understand the pitfalls of ex vivo slaughterhouse heart hemoperfusion. METHODS: Seven porcine hearts were harvested, arrested and revived using the PhysioHeart™. Cardiac output, SaO2, glucose and pH were maintained at physiological levels. Blood analyses were performed hourly and unipolar epicardial electrograms (UEG), pressures and flows were recorded to assess the physiological performance. RESULTS: Normal cardiac performance was attained in terms of mean cardiac output (5.1 ± 1.7 l/min) and pressures but deteriorated over time. Across the experiments, homeostasis was maintained for 171.4 ± 54 min, osmolarity and blood electrolytes increased significantly between 10 and 80%, heart weight increased by 144 ± 41 g, free fatty acids (- 60%), glucose and lactate diminished, ammonia increased by 273 ± 76% and myocardial necrosis and UEG alterations appeared and aggravated. Progressively deteriorating electrophysiological and hemodynamic functions can be explained by reperfusion injury, waste product intoxication (i.e. hyperammonemia), lack of essential nutrients, ion imbalances and cardiac necrosis as a consequence of hepatological and nephrological plasma clearance absence. CONCLUSIONS: The PhysioHeart™ is an acute model, suitable for cardiac device and therapy assessment, which can precede conventional animal studies. However, observations indicate that ex vivo slaughterhouse hearts resemble cardiac physiology of deteriorating hearts in a multi-organ failure situation and signalize the need for plasma clearance during perfusion to attenuate time-dependent function degradation. The presented study therefore provides an in-dept understanding of the sources and reasons causing the cardiac function loss, as a first step for future effort to prolong cardiac perfusion in the PhysioHeart™. These findings could be also of potential interest for other cardiac platforms.

Aortic valve stenosis and aortic diameters determine the extent of increased wall shear stress in bicuspid aortic valve disease.

BACKGROUND: Use of 4-dimensional flow magnetic resonance imaging (4D-flow MRI) derived wall shear stress (WSS) heat maps enables identification of regions in the ascending aorta with increased WSS. These regions are subject to dysregulation of the extracellular matrix and elastic fiber degeneration, which is associated with aortic dilatation and dissection. PURPOSE: To evaluate the effect of the presence of aortic valve stenosis and the aortic diameter on the peak WSS and surface area of increased WSS in the ascending aorta. STUDY TYPE: Prospective. SUBJECTS: In all, 48 bicuspid aortic valve (BAV) patients (38.1 ± 12.4 years) and 25 age- and gender-matched healthy individuals. FIELD STRENGTH/SEQUENCE: Time-resolved 3D phase contrast MRI with three-directional velocity encoding at 3.0T. ASSESSMENT: Peak systolic velocity, WSS, and aortic diameters were assessed in the ascending aorta and 3D heat maps were used to identify regions with elevated WSS. STATISTICAL TESTS: Comparisons between groups were performed by t-tests. Correlations were investigated by univariate and multivariate regression analysis. RESULTS: Elevated WSS was present in 15 ± 11% (range; 1-35%) of the surface area of the ascending aorta of BAV patients with aortic valve stenosis (AS) (n = 10) and in 6 ± 8% (range; 0-31%) of the ascending aorta of BAV patients without AS (P = 0.005). The mid-ascending aortic diameter negatively correlated with the peak ascending aortic WSS (R = -0.413, P = 0.004) and the surface area of elevated WSS (R = -0.419, P = 0.003). Multivariate linear regression analysis yielded that the height of peak WSS and the amount of elevated WSS depended individually on the presence of aortic valve stenosis and the diameter of the ascending aorta. DATA CONCLUSION: The extent of increased WSS in the ascending aorta of BAV patients depends on the presence of aortic valve stenosis and aortic dilatation and is most pronounced in the presence of AS and a nondilated ascending aorta. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2018;48:522-530.

Four-dimensional flow MRI of stented versus stentless aortic valve bioprostheses.

OBJECTIVES: To evaluate aortic velocity, wall shear stress (WSS) and viscous energy loss (EL) of stented and stentless bioprostheses using 4D flow MRI 1 year after surgical aortic valve replacement. METHODS: For this cross-sectional study 28 patients with stented (n = 14) or stentless (n = 14) bioprosthesis underwent non-contrast-enhanced 4D-flow MRI at 1.5 T. Analyses included a comparison of velocity, WSS and EL in the ascending aorta during peak systole for both spatially averaged values and a comparison of local differences using per-voxel analysis. RESULTS: No significant differences were found in peak and mean velocity (stented vs. stentless: 2.45 m/s vs. 2.11 m/s; p = 0.09 and 0.60 m/s vs. 0.62 m/s; p = 0.89), WSS (0.60 Pa vs. 0.59 Pa; p = 0.55) and EL (10.17 mW vs. 7.82 mW; p = 0.10). Per-voxel analysis revealed significantly higher central lumen velocity, and lower outer lumen velocity, WSS and EL for stentless versus stented prostheses. CONCLUSION: One year after aortic valve implantation with stented and stentless bioprostheses, velocity, WSS and EL were comparable when assessed for averaged values in the ascending aorta. However, the flow profile described with local analysis for stentless prosthesis is potentially favourable with a significantly higher central velocity profile and lower values for outer lumen velocity, WSS and EL. KEY POINTS: • Stentless bioprostheses can be implanted instead of stented aortic valve bioprostheses. • Haemodynamic performance of valve prosthesis can be assessed using 4D flow MRI. • Averaged ascending aorta PSV, WSS and EL are comparable 1 year post-implantation. • Centreline velocity is highest, WSS and EL is lowest for stentless prosthesis.

Totally thoracoscopic ablation for atrial fibrillation: a systematic safety analysis.

Aims: Thoracoscopic surgical ablation has evolved into a successful strategy for symptomatic atrial fibrillation (AF) refractory to other therapy. More widespread referral is limited by the lack of information on potential complications. Our aim was to systematically evaluate 30-day complications of totally thoracoscopic surgical ablation. Methods and results: We retrospectively studied consecutive patients undergoing totally thoracoscopic surgical ablation at a referral centre in the Netherlands (2007-2016). Patients received pulmonary vein isolation, with additional lesion lines as needed, and left atrial appendage exclusion. The primary outcomes were freedom from any complications and freedom from irreversible complications at 30-days. Secondary outcomes included intra- and post-operative complications according to severity. Included were 558 patients with median age 62 years (interquartile range 56-68 years), 70% male and 53% with a previous failed catheter ablation. The cohort consisted of 43% paroxysmal AF, 47% persistent AF, and 10% long-standing persistent AF. Freedom from any 30-day complication was 88.2%, and from complications with life-long affecting consequences 97.5%. The intra-operative complication rate was 2.3% with no strokes or death observed. The median hospital length of stay was 4 days. The percentage of patients with major and minor complications at 30-days was 3.2% and 8.1%, respectively, with one patient dying of an ischaemic stroke. The only patient groups with excess complications were women aged ≥70 years and patients with a history of congestive heart failure. Conclusions: Totally thoracoscopic ablation is associated with a low complication rate in a referral centre and may be a useful alternative to other rhythm control strategies.

A randomized trial of remote ischemic preconditioning and control treatment for cardioprotection in sevoflurane-anesthetized CABG patients.

BACKGROUND: Remote ischemic preconditioning (RIPC) efficacy is debated. Possibly, because propofol, which has a RIPC-inhibiting action, is used in most RIPC trials. It has been suggested that clinical efficacy is, however, present with volatile anesthesia in the absence of propofol, although this is based on one phase 1 trial only. Therefore, in the present study we further explore the relation between RIPC and cardioprotection with perioperative anesthesia restricted to sevoflurane and fentanyl, in CABG patients without concomitant procedures. METHODS: In a single-center study, we aimed to randomize 46 patients to either RIPC (3x5 min inflation of a blood pressure cuff around the arm) or control treatment (deflated cuff around the arm). Blood samples were obtained before and after RIPC to evaluate potential RIPC-induced mediators (Interleukin (IL)-6, IL-10, Tumor Necrosis Factor-α, Macrophage Inhibitory Factor). An atrial tissue sample was obtained at cannulation of the appendix of the right atrium for determination of mitochondrial bound hexokinase II (mtHKII) and other survival proteins (Akt and AMP-activated protein kinase α). In blood samples taken before and 6, 12 and 24 h after surgery cardiac troponin T (cTnT) and C-reactive protein (CRP) were determined. Surgery was strictly performed under sevoflurane anesthesia (no propofol). RESULTS: We actually randomized 16 patients to control treatment and 13 patients to RIPC. The mean 24 h area under the curve (AUC) cTnT was 11.44 (standard deviation 4.66) in the control group and 10.90 (standard deviation 4.73) in the RIPC group (mean difference 0.54, 95% CI -3.06 to 4.13; p = 0.76). The mean 24 h AUC CRP was 1319 (standard deviation 92) in the control group and 1273 (standard deviation 141) in the RIPC group (mean difference 46.2, 95% CI -288 to 380; p = 0.78). RIPC was without effect on survival proteins in atrial tissue samples obtained before surgery (mitochondrial hexokinase, Akt and AMPK) and inflammatory mediators obtained before and immediately after RIPC (IL-6, IL-10, TNF-α, macrophage migration inhibitory factor). CONCLUSION: Many factors can interfere with the outcome of RIPC. Trying to correct for this led to strict inclusion criteria, which, in combination with a decreased institutional frequency of CABG without concomitant procedures and a change in institutional anesthetic regimen away from volatile anesthetics towards total intravenous anesthesia, caused slow inclusion and halting of this trial after 3 years, before target inclusion could be reached. Therefore this study is underpowered to prove its primary goal that RIPC reduced AUC cTnT by < 25%. Nevertheless, we have shown that the effect of RIPC on 24 h AUC cTnT, in cardiac surgery with anesthesia during surgery restricted to sevoflurane/fentanyl (no propofol), was between a decrease of 27% and an increase of 36%. These findings are not in line with previous studies in this field. TRIAL REGISTRATION: The Netherlands Trial Register: NTR2915 ; Registered 25 Mei 2011.

Assessment of Cardiac Device Position on Supine Chest Radiograph in the ICU: Introduction and Applicability of the Aortic Valve Location Ratio.

OBJECTIVES: The use of intracardiac assist devices is expanding, and correct position of these devices is required for optimal functioning. The aortic valve is an important landmark for positioning of those devices. It would be of great value if the device position could be easily monitored on plain supine chest radiograph in the ICU. We introduce a ratio-based tool for determination of the aortic valve location on plain supine chest radiograph images, which can be used to evaluate intracardiac device position. DESIGN: Retrospective observational study. SETTING: Large academic medical center. PATIENTS: Patients admitted to the ICU and supported by an intracardiac assist device. INTERVENTIONS: We developed a ratio to determine the aortic valve location on supine chest radiograph images. This ratio is used to assess the position of a cardiac assist device and is compared with echocardiographic findings. MEASUREMENTS AND MAIN RESULTS: Supine anterior-posterior chest radiographs of patients with an aortic valve prosthesis (n = 473) were analyzed to determine the location of the aortic valve. We calculated several ratios with the potential to determine the position of the aortic valve. The aortic valve location ratio, defined as the distance between the carina and the aortic valve, divided by the thoracic width, was found to be the best performing ratio. The aortic valve location ratio determines the location of the aortic valve caudal to the carina, at a distance of 0.25 ± 0.05 times the thoracic width for male patients and 0.28 ± 0.05 times the thoracic width for female patients. The aortic valve location ratio was validated using CT images of patients with angina pectoris without known valvular disease (n = 95). There was a good correlation between cardiac device position (Impella) assessed with the aortic valve location ratio and with echocardiography (n = 53). CONCLUSIONS: The aortic valve location ratio enables accurate and reproducible localization of the aortic valve on supine chest radiograph. This tool is easily applicable and can be used for assessment of cardiac device position in patients on the ICU.

Effect of helium pre- or postconditioning on signal transduction kinases in patients undergoing coronary artery bypass graft surgery.

BACKGROUND: The noble gas helium induces pre- and postconditioning in animals and humans. Volatile anesthetics induce cardioprotection in humans undergoing coronary artery bypass graft (CABG) surgery. We hypothesized that helium induces pre- and postconditioning in CABG-patients, affecting signaling molecules protein kinase C-epsilon (PKC-ε), p38 mitogen activated protein kinase (p38 MAPK), extracellular signal-regulated kinase 1/2 (ERK-1/2) and heat shock protein 27 (HSP-27) within cardiac tissue, and reducing postoperative troponin levels. METHODS: After ethical approval and informed consent, 125 elective patients undergoing CABG surgery were randomised into this prospective, placebo controlled, investigator blinded, parallel arm single-centre study. Helium preconditioning (3 × 5 min of 70 % helium and 30 % oxygen) was applied before aortic cross clamping; postconditioning (15 min of helium) was applied before release of the aortic cross clamp. Signaling molecules were measured in right atrial appendix specimens. Troponin-T was measured at 4, 12, 24 and 48 h postoperatively. RESULTS: Baseline characteristics of all groups were similar. Helium preconditioning did not significantly alter the primary outcome (molecular levels of kinases PKC-ε and HSP-27, ratio of activated p38 MAPK or ERK ½). Postoperative troponin T was 11 arbitrary units [5, 31; area-under-the-curve (interquartile range)] for controls, and no statistically significant changes were observed after helium preconditioning [He-pre: 11 (6, 18)], helium postconditioning [He-post: 11 (8, 15)], helium pre- and postconditioning [He-PP: 14 (6, 20)] and after sevoflurane preconditioning [APC: 12 (8, 24), p = 0.13]. No adverse effects related to study treatment were observed in this study. CONCLUSIONS: No effect was observed of helium preconditioning, postconditioning or the combination thereof on activation of p38 MAPK, ERK 1/2 or levels of HSP27 and PKC-ε in the human heart. Helium pre- and postconditioning did not affect postoperative troponin release in patients undergoing CABG surgery. Clinical trial number Dutch trial register ( http://www.trialregister.nl/ ) number NTR1226.

Baseline MDCT findings after prosthetic heart valve implantation provide important complementary information to echocardiography for follow-up purposes.

OBJECTIVES: Recent studies have proposed additional multidetector-row CT (MDCT) for prosthetic heart valve (PHV) dysfunction. References to discriminate physiological from pathological conditions early after implantation are lacking. We present baseline MDCT findings of PHVs 6 weeks post implantation. METHODS: Patients were prospectively enrolled and TTE was performed according to clinical guidelines. 256-MDCT images were systematically assessed for leaflet excursions, image quality, valve-related artefacts, and pathological and additional findings. RESULTS: Forty-six patients were included comprising 33 mechanical and 16 biological PHVs. Overall, MDCT image quality was good and relevant regions remained reliably assessable despite mild-moderate PHV-artefacts. MDCT detected three unexpected valve-related pathology cases: (1) prominent subprosthetic tissue, (2) pseudoaneurysm and (3) extensive pseudoaneurysms and valve dehiscence. The latter patient required valve surgery to be redone. TTE only showed trace periprosthetic regurgitation, and no abnormalities in the other cases. Additional findings were: tilted aortic PHV position (n = 3), pericardial haematoma (n = 3) and pericardial effusion (n = 3). Periaortic induration was present in 33/40 (83 %) aortic valve patients. CONCLUSIONS: MDCT allowed evaluation of relevant PHV regions in all valves, revealed baseline postsurgical findings and, despite normal TTE findings, detected three cases of unexpected, clinically relevant pathology. KEY POINTS: • Postoperative MDCT presents baseline morphology relevant for prosthetic valve follow-up. • 83 % of patients show periaortic induration 6 weeks after aortic valve replacement. • MDCT detected three cases of clinically relevant pathology not found with TTE. • Valve dehiscence detection by MDCT required redo valve surgery in one patient. • MDCT is a suitable and complementary imaging tool for follow-up purposes.

When Not to Go SOLO? Contraindications Based on Implant Experience.

BACKGROUND AND AIM OF THE STUDY: Because of the design and specific implantation technique of the stentless Freedom SOLO bioprosthesis, patient selection is crucial. The aim of the study was to discuss the contraindications to this prosthesis based on the authors' implant experience. METHODS: Between April 2005 and February 2015, one surgeon at the authors' center performed 292 aortic valve replacements using a bioprosthesis, with the initial intention of implanting a SOLO valve in every patient. A search was conducted for all of these patients and data collected on whether a SOLO valve was used, or not. RESULTS: A SOLO valve was implanted in 238 patients (82%), and a stented bioprosthesis in 54 (18%). The predominant reasons not to implant a SOLO valve were asymmetric commissures (26%) and a large aortic annulus (24%). Only one patient had structural valve deterioration, and none of the patients had to undergo reoperation because of aortic valve insufficiency or paravalvular leakage. CONCLUSIONS: Asymmetric commissures, large aortic annulus (>27 mm), calcified aortic sinuses, dilated sinotubular junction, aberrant location of coronary ostia and whenever the stent of a stented bioprosthesis is useful, were contraindications to implant a SOLO valve. When these contraindications were taken into account, a very good durability could be achieved with the SOLO valve during mid-term follow up.

Diagnosing poststernotomy mediastinitis in the ED.

PURPOSE: Poststernotomy mediastinitis (PSM), the severe chest wall and mediastinal infection that may arise at any time after a sternotomy, causes significant morbidity and mortality globally. Late recognition and diagnosis are the major contributors to a poor outcome. This review focuses on recent advances in diagnosing PSM (particularly after cardiovascular surgery) at the earliest opportunity--in the emergency department. RECENT FINDINGS: Morbidity and mortality of PSM, especially when associated with numerous other complications, remain unaltered high. Careful history taking and clinical examination remain the mainstays of a preliminary diagnosis. No specific signs are indicative of PSM alone. Procalcitonin as a biomarker and neutrophil volume distribution width obtained during a complete blood count with differential, assessed in the clinical context, offer interesting prospects of obtaining a speedy and accurate diagnosis. Adjunctive diagnostic imaging modalities such as contrast-enhanced computed tomography can differentiate PSM from postcardiac injury syndrome and other causes of vague chest pain some time after sternotomy with increasing accuracy. CONCLUSION: The speed and accuracy of diagnosing PSM have improved with recent advances in imaging and laboratory methodologies. In the symptomatic patient with a closed sternotomy wound or scar, with either fever (>38°C) or sternal instability, together with well-described signs on contrast-enhanced computed tomography, in whom other life-threatening causes of chest pain have been excluded, the diagnosis of PSM can be made without awaiting the outcome of microbiological confirmation. Nevertheless, there still remain significant research opportunities for clinicians and scientists to improve the early diagnostic accuracy of PSM.

Ex vivo proof-of-concept of end-to-end scaffold-enhanced laser-assisted vascular anastomosis of porcine arteries.

OBJECTIVE: The low welding strength of laser-assisted vascular anastomosis (LAVA) has hampered the clinical application of LAVA as an alternative to suture anastomosis. To improve welding strength, LAVA in combination with solder and polymeric scaffolds (ssLAVA) has been optimized in vitro. Currently, ssLAVA requires proof-of-concept in a physiologically representative ex vivo model before advancing to in vivo studies. This study therefore investigated the feasibility of ex vivo ssLAVA in medium-sized porcine arteries. METHODS: Scaffolds composed of poly(ε-caprolactone) (PCL) or poly(lactic-co-glycolic acid) (PLGA) were impregnated with semisolid solder and placed over coapted aortic segments. ssLAVA was performed with a 670-nm diode laser. In the first substudy, the optimum number of laser spots was determined by bursting pressure analysis. The second substudy investigated the resilience of the welds in a Langendorf-type pulsatile pressure setup, monitoring the number of failed vessels. The type of failure (cohesive vs adhesive) was confirmed by electron microscopy, and thermal damage was assessed histologically. The third substudy compared breaking strength of aortic repairs made with PLGA and semisolid genipin solder (ssLAVR) to repairs made with BioGlue. RESULTS: ssLAVA with 11 lasing spots and PLGA scaffold yielded the highest bursting pressure (923 ± 56 mm Hg vs 703 ± 96 mm Hg with PCL ssLAVA; P = .0002) and exhibited the fewest failures (20% vs 70% for PCL ssLAVA; P = .0218). The two failed PLGA ssLAVA arteries leaked at 19 and 22 hours, whereas the seven failed PCL ssLAVA arteries burst between 12 and 23 hours. PLGA anastomoses broke adhesively, whereas PCL welds failed cohesively. Both modalities exhibited full-thickness thermal damage. Repairs with PLGA scaffold yielded higher breaking strength than BioGlue repairs (323 ± 28 N/cm(2) vs 25 ± 4 N/cm(2), respectively; P = .0003). CONCLUSIONS: PLGA ssLAVA yields greater anastomotic strength and fewer anastomotic failures than PCL ssLAVA. Aortic repairs with BioGlue were inferior to those produced with PLGA ssLAVR. The results demonstrate the feasibility of ssLAVA/R as an alternative method to suture anastomosis or tissue sealant. Further studies should focus on reducing thermal damage.

Cathether-based interventional strategies for cor triatriatum in the adult - feasibility study through a hybrid approach.

BACKGROUND: Cor triatriatum is a rare congenital cardiac abnormality, consisting of an obstructing membrane between the pulmonary veins and the mitral valve in varying patterns. The entitiy can mimick the pathophysiology of mitral stenosis, necessitating surgical resection. Occasionally, percutaneous balloon dilatation of the membrane has been successfully performed. CASE PRESENTATION: We report two cases with cor triatriatum where intraoperative balloon dilatation of the membrane was attempted followed by surgical resection, to explore the feasibility of cathether-based interventional strategies for cor triatriatum. CONCLUSIONS: Various anatomical variations exist of cor triatriatum, depending on the drainage of the pulmonary veins and the drainage of the proximal chamber in the right or left atrium. Only isolated forms of cor triatriatum where all pulmonary veins ultimately drain into the left atrium can be recommended for percutaneous strategies. In addition, several anatomical characteristics should be considered to predict technical success of cathether-based interventional strategies, such as the location of the membrane, the degree of pulmonary vein stenosis, the extent of calcification, and the presence of other (congenital) cardiovascular abnormalities. Furthermore, long-term efficacy of these strategies remains to be confirmed. As such, surgical treatment of cor triatriatum remains the mainstay of treatment in adult patients, especially when other cardiovascular anomalies are present which require surgical correction.

Functional decline of older patients 1 year after cardiothoracic surgery followed by intensive care admission: a prospective longitudinal cohort study.

BACKGROUND: there is a growing demand for cardiothoracic surgery in patients' aged ≥65 years. OBJECTIVE: : to explore which variables were independently associated with functional decline 12 months after cardiothoracic surgery followed by intensive care admission. DESIGN: prospective cohort study. SETTING: cardiothoracic unit of a university teaching hospital. SUBJECTS: a total of 356 elderly patients undergoing cardiothoracic surgery followed by intensive care unit admission. METHODS: functioning was assessed at hospital admission and 3 and 12 months after hospital discharge with the modified Katz activities of daily living (ADL) index. Data collection included demographics, surgical procedure, diagnosis, comorbidities, pre-morbid geriatric conditions and intensive care unit length of stay. Functional decline was defined as a one-point loss on the modified Katz ADL index score at 1 year compared with baseline functioning at hospital admission. Logistic regression analysis was performed to study the association between independent variables and functional decline. RESULTS: the 1-year mortality rate was 8.7% of which 4.8% was in-hospital mortality. The youngest group consisted of 295 patients (64% men; 72 ± 4 years), there were 61 octogenarians (56% men; 82 ± 2 years). One year after hospital discharge, younger patients demonstrated less functional decline (45 versus 56%, P < 0.001). Cognitive impairment, higher age, female gender, alcohol use, type of cardiac procedure and serum creatinine were independently associated with functional decline 1 year after discharge. CONCLUSIONS: the survival rates after cardiothoracic surgery were good, the rates of functional decline were substantial. These results suggest that studies on geriatric rehabilitation before and after surgery might be needed to overcome the decline in functioning.

Current status of surgical treatment for aortic valve stenosis.

In this review, we discuss the current surgical treatment for aortic valve stenosis. Surgical strategy for treatment of aortic valve stenosis is based on the risk profile of the patient. We reviewed the existing literature and present the current state of the art of these various approaches, taking into account clinical outcomes, quality of life, costs, and learning curve.

Elderly patients benefit from minimally invasive mitral valve surgery: perioperative risk management matters.

OBJECTIVES: The goal was to assess the single-centre results of minimally invasive mitral valve surgery (MIMVS) in the elderly population. METHODS: All patients referred for minimally invasive valve surgery underwent a standardized preoperative screening. We performed a retrospective analysis of 131 consecutive elderly patients (≥75 years) who underwent endoscopic MIMVS through a right mini-thoracotomy. Survival and postoperative course were assessed in 2 groups: a repair group and a replacement group. RESULTS: Eighty-five patients underwent mitral valve repair, and 46 had mitral valve replacement. The mean age was 79 ± 2.9 years, and the median follow-up duration was 3.8 years. The cardiopulmonary bypass time (128.7 min vs 155.9 min, P = 0.012) and the cross-clamp time (84.9 min vs 124.1 min, P = 0.005) were significantly longer in the replacement group. Except for more reinterventions for bleeding in the replacement group (10.9% vs 0%, P = 0.005), there were no significant differences in the postoperative course between the 2 groups. Low mortality rates at the midterm follow-up were observed in both groups, and no differences were observed between the 4-and the 12-month follow-up. Survival rates after 1 year and 5 years were 97.6% and 88.6%, respectively, with no significant differences between the 2 groups. CONCLUSIONS: MIMVS is an excellent treatment option in vulnerable elderly patients with excellent short- and long-term results. Although other studies suggest that repair could be superior to replacement even in older patients, our experience suggests that replacement is equivalent to repair in terms of mortality and major adverse cardiac and cerebrovascular events. Experience and standardized preoperative screening are mandatory to achieve optimal results.

Balancing Scaffold Degradation and Neo-Tissue Formation in In Situ Tissue Engineered Vascular Grafts.

An essential aspect of cardiovascular in situ tissue engineering (TE) is to ensure balance between scaffold degradation and neo-tissue formation. We evaluated the rate of degradation and neo-tissue formation of three electrospun supramolecular bisurea-based biodegradable scaffolds that differ in their soft-block backbone compositions only. Scaffolds were implanted as interposition grafts in the abdominal aorta in rats, and evaluated at different time points (t = 1, 6, 12, 24, and 40 weeks) on function, tissue formation, strength, and scaffold degradation. The fully carbonate-based biomaterial showed minor degradation after 40 weeks in vivo, whereas the other two ester-containing biomaterials showed (near) complete degradation within 6-12 weeks. Local dilatation was only observed in these faster degrading scaffolds. All materials showed to some extent mineralization, at early as well as late time points. Histological evaluation showed equal and non-native-like neo-tissue formation after total degradation. The fully carbonate-based scaffolds lagged in neo-tissue formation, presumably as its degradation was (far from) complete at 40 weeks. A significant difference in vessel wall contrast enhancement was observed by magnetic resonance imaging between grafts with total compared with minimal-degraded scaffolds.

The incidence, risk factors, and outcome of transfusion-related acute lung injury in a cohort of cardiac surgery patients: a prospective nested case-control study.

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-related morbidity and mortality. Both antibodies and bioactive lipids that have accumulated during storage of blood have been implicated in TRALI pathogenesis. In a single-center, nested, case-control study, patients were prospectively observed for onset of TRALI according to the consensus definition. Of 668 patients, 16 patients (2.4%) developed TRALI. Patient-related risk factors for onset of TRALI were age and time on the cardiopulmonary bypass. Transfusion-related risk factors were total amount of blood products (odds ratio [OR] = 1.2; 95% confidence interval [CI], 1.03-1.44), number of red blood cells stored more than 14 days (OR = 1.6; 95% CI, 1.04-2.37), total amount of plasma (OR = 1.2; 95% CI, 1.03-1.44), presence of antibodies in donor plasma (OR = 8.8; 95% CI, 1.8-44), and total amount of transfused bioactive lipids (OR = 1.0; 95% CI, 1.00-1.07). When adjusted for patient risk factors, only the presence of antibodies in the associated blood products remained a risk factor for TRALI (OR = 14.2; 95% CI, 1.5-132). In-hospital mortality of TRALI was 13% compared with 0% and 3% in transfused and nontransfused patients, respectively (P < .05). In conclusion, the incidence of TRALI is high in cardiac surgery patients and associated with adverse outcome. Our results suggest that cardiac surgery patients may benefit from exclusion of blood products containing HLA/HNA antibodies.

Simulation of changes in myocardial tissue properties during left ventricular assistance with a rotary blood pump.

We considered a mathematical model to investigate changes in geometric and hemodynamic indices of left ventricular function in response to changes in myofiber contractility and myocardial tissue stiffness during rotary blood pump support. Left ventricular assistance with a rotary blood pump was simulated based on a previously published biventricular model of the assisted heart and circulation. The ventricles in this model were based on the one-fiber model that relates ventricular function to myofiber contractility and myocardial tissue stiffness. The simulations showed that indices of ventricular geometry, left ventricular shortening fraction, and ejection fraction had the same response to variations in myofiber contractility and myocardial tissue stiffness. Hemodynamic measures showed an inverse relation compared with geometric measures. Particularly, pulse pressure and arterial dP/dtmax increased when myofiber contractility increased, whereas increasing myocardial tissue stiffness decreased these measures. Similarly, the lowest pump speed at which the aortic valve remained closed increased when myofiber contractility increased and decreased when myocardial tissue stiffness increased. Therefore, simultaneous monitoring of hemodynamic parameters and ventricular geometry indirectly reflects the status of the myocardial tissue. The appropriateness of this strategy will be evaluated in the future, based on in vivo studies.

Peri-operative care in adults with congenital heart disease: room for improvement in after care.

BACKGROUND: Patient satisfaction with care has received little attention within the field of congenital heart disease. Our objective was to examine patient satisfaction with the care received when undergoing open-heart surgery in order to identify the best and worst aspects of peri-operative care. Moreover, we examined whether having contact with a specialised nurse in addition to usual care is associated with higher patient satisfaction levels. METHODS: Patient satisfaction was measured by the Satisfaction with Hospital Care Questionnaire, evaluating nine aspects of care by answering individual items and giving overall grades. A top 10 of the best and worst items was selected. Linear regression analyses were used to examine the relationship between having contact with a specialised nurse and patient satisfaction (9 grades), independent of patient characteristics--sex, age, educational level, and health status. RESULTS: Data were available for 75 patients. Grades ranged from 6.74 for "discharge and after care" to 8.18 for "medical care". In all, 21% of patients were dissatisfied with the clarity of the information about lifestyle adjustments given by the surgeon. However, patients who had contact with a specialised nurse were more satisfied with the provided information (B-coefficient is 0.497, p-value is 0.038), independent of patient characteristics. CONCLUSIONS: Patients were satisfied with the received care, although there is room for improvement, especially in discharge and after care and the clarity of the information provided by the surgeon. This gap in care can be compensated for by specialised nurses, as patients who were counselled by a specialised nurse were more satisfied with the provided information.