Bicuspid Aortic Valve dilemma: TAVI or SAVR? Insights from the NOTION-2 trial.

The Nordic Aortic Valve Intervention-2 (NOTION-2) trial is the first randomized controlled trial to compare transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) in low-risk patients, specifically focusing on relatively younger patients and those with bicuspid valves. It randomized 370 patients (mean age 71 years) to assess outcomes at 1 year. Results indicated a higher composite primary endpoint rate for TAVI (10.2%) compared to SAVR (7.1%) in the overall cohort, with even more pronounced differences in patients with bicuspid valves (14.3% for TAVI vs. 3.9% for SAVR). The risk of death or disabling stroke at 1 year was also three times higher with TAVI.

Gender disparities in cardiothoracic surgery: a comparative study in India.

Background: This study aimed to examine the prevalence of gender bias in the field of cardiothoracic vascular surgery in India and compared women surgeons and trainees in India and abroad. Methods: This was a comparative, cross-sectional analytical study using an online questionnaire. The survey included questions about demographics, career choice, training, academic and leadership opportunities, and the impact of choosing cardiothoracic-vascular surgery as a career on personal life. Results: A total of 203 practicing surgeons and trainees participated in the study and included 121 (59.6%) men and 82 (40.3%) women. Out of the 82 women, 48 (58.5%) were from India, and 34 (41.5%) were from other countries. Satisfaction with the specialty was similar among men and women (105 (86.7%) vs. 68 (82.9%), p = 0.44 respectively). Majority (n = 30, 62.5%) of the female surgeons in India reported being discriminated against, as well as receiving favored treatment 11 (22.9%). Compared to men, women surgeons in India were more frequently advised against pursuing a career in cardiothoracic and vascular surgery (p < 0.001) and were more frequently subjected to gender-related references (p < 0.001). In addition, they had fewer presentation opportunities (p = 0.016) at national or regional meetings during their training compared to men. Additionally, 50% (24) of the women in India reported being single, in contrast to 7% (6) of men, and only 15 (31.3%) women reported having a child, compared to 57 (66.3%) of the men. Conclusion: The study revealed significant gender disparities within the field of cardiothoracic vascular surgery in India and highlights the urgent need to address gender disparities and bias in cardiothoracic vascular surgery.

Technologies for retrospective radiation dosimetry.

Radiation dosimetry is an important task for assessing the biological damages created in human being due to ionising radiation exposure. Ionising radiation being invisible and beyond the perception of human natural sensors, the dosimetry equipments/systems are the utmost requirement for its measurement. Retrospective measurement of radiation doses is a challenging task as conventional radiation dosemeters are not available at the exposure site. The material/s in close proximity of exposed individual or individuals' biological samples may be used as retrospective radiation sensor for dosimetry purpose. Environment materials such as sand, bricks, ceramics, sand stones, quartz, feldspar, glasses and electronic chips have been utilised using TL (Thermoluminescence) techniques for retrospective gamma dose (min 10 cGy) measurement. Electron Spin Resonance techniques have been employed to human biological samples such as tooth enamel, bones, nails, hair, etc. and reported for dosimetry for ~20 cGy min dose measurement. Some commercial glasses have been found sensitive enough to measure the minimum gamma doses of the order of 100 cGy using TL techniques. For internal retrospective dosimetry, the radioactivity contamination assessment in food items, water, other edible product and ambient air are the prerequisites. The radioactivity concentration vis-à-vis their consumption rate may help in controlling the internal contamination and estimation of dose absorption in human body. Defence Laboratory, Jodhpur has been working extensively on the dosimetry techniques for external dose measurement using environmental material and developed portable contamination monitoring systems for food and water radioactivity measurement in the range of 50 Bq kg-1 to 1000 kBq kg-1 in 60 s measurement time. The recent research and development in the methodologies, equipments and systems undertaken towards capacity building and self-reliance in retrospective radiation dosimetry is reported in this paper.

Pre-operative anaemia-does it influence post-operative outcomes after isolated coronary artery bypass grafting?

Introduction: Preoperative anaemia is prevalent in a number of patients undergoing coronary artery bypass grafting. Studies provide conflicting results due to several reasons including variation in the threshold of haematocrit used to define anaemia. We aimed to assess the independent effect of preoperative anaemia on outcomes in patients undergoing off pump coronary artery bypass grafting (OPCAB). Methods: In this retrospective study, patients with a hemoglobin level less than 11g/dl (haematocrit <33%) were considered to have moderate-to-severe anaemia as per the recommendations of the World Health Organization. Association between haematocrit <33% and mortality as well as adverse post-operative outcomes was assessed. Multivariable logistic regression (MLR) was carried out to assess the independent effect of haematocrit<33% on 30-day mortality and other outcomes. Results: The study included 4957 consecutive patients undergoing isolated OPCAB surgery between 2015 and 2020. Out of 4957, 635 (12.8%) had haematocrit <33% and 4322 (81.2%) had haematocrit ≥33%. Patients with haematocrit < 33% had a 30-day mortality of 13 (2%) compared to 38 (0.9%) in patients without anaemia and had a greater requirement for blood transfusion (p<0.0001). It was also associated with an increased incidence of renal failure (p<0.0001), tracheostomy (p=.0.012) and risk of re-intubation (p=0.006). On multiple linear regression (MLR), haematocrit < 33% was not an independent predictor of 30-day mortality odds ratio (OR) 1.47, 95% confidence interval (CI) 0.745-2.917; p=0.26. It was however an important independent risk factor for blood transfusion (OR 1.80, 95% CI 1.29-2.50, p<0.001) and renal failure (OR 3.06, 95% CI 1.338-7.012, p=0.008). The receiver operating characteristic (ROC)-area under the curve (AUC) was 0.63 suggesting moderate discriminatory value of haematocrit < 33% for 30-day mortality. Conclusion: Haematocrit < 33% is an important risk factor for adverse outcomes following isolated, primary, elective OPCAB. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-024-01746-1.

Impact of distension pressure on saphenous vein endothelial injury in coronary artery bypass grafting.

Introduction: Long saphenous vein grafts (LSVGs) are pivotal conduits in coronary artery bypass grafting (CABG), yet concerns persist regarding early failure and long-term patency. Endothelial damage, a potent initiator of graft failure, necessitates exploration of factors contributing to endothelial injury during LSVG preparation. Methods: A prospective, single-center study was conducted, assessing the impact of unregulated distension pressure on LSVG endothelium during CABG. Histological and CD31 (cluster of differentiation 31) immunohistochemical analyses were performed on 21 paired vein samples, categorized into non-distended (group A) and distended (group B) groups. Pressure recordings were obtained using different syringe sizes during vein distension. Results: Histological examination revealed a significantly higher percentage of endothelial cell loss in distended veins (31.95% ± 31.31) compared to non-distended veins (11.67% ± 28.65) (p = 0.034). CD31 immunohistochemistry corroborated greater endothelial cell loss in distended veins (p = 0.001). The pressure recordings with a 20-cc syringe, as opposed to using a 10-cc syringe, were considerably lower (44.5 mmHg vs. 92.75 mmHg) emphasizing the inverse relationship between syringe size and pressure generated. In our study, pre-existing endothelial injury was observed in one-third of diabetic patients (36%), with all instances of such injury exclusively identified in individuals with diabetes. Conclusion: Unregulated distension pressure during LSVG preparation is associated with greater endothelial damage, as evidenced by histological and immunohistochemical analyses. The inverse relationship between syringe size and pressure underscores the importance of controlled distension.

DEDICATE trial: the devil lies in the definition of "low risk".

Transcatheter aortic-valve replacement (TAVR) has evolved from a treatment strategy for high-risk patients to an option for low-risk individuals, prompting the need for rigorous comparisons with surgical aortic-valve replacement (SAVR). The German-Austrian Prospective Randomized Trial of Transcatheter Aortic Valve Implantation Versus Conventional Surgical Aortic Valve Replacement in Low and Intermediate Risk Patients (DEDICATE) trial compares low- and intermediate-risk patient undergoing SAVR and TAVR. This review outlines the trial design, key findings, strengths, and weaknesses of the study and also highlights the urgent need for standardized definitions of low-risk patients in future trials to ensure accurate comparisons and robust conclusions.

Adoption of Technology by Healthcare Personnel: An Institutional Survey.

BACKGROUND: In the current era, technology has a significant influence on healthcare outcomes. Despite that, there are significant barriers and concerns toward the adoption of digital laboratory reporting systems among healthcare professionals in India. The aim of the study was to understand the overall attitude, barriers, and motivators toward the adoption of technology by healthcare personnel. METHODS: The study was conducted through a single-center and prospective questionnaire survey among physicians and surgeons of various specialities, with 107 participants. The electronic laboratory system at the institution, called "AADI," could be accessed across any computer terminal and through a web-based application that could be downloaded on any mobile device. RESULTS: The results of the study revealed that 98 out of 107 (91.59%) healthcare professionals used the digital platform regularly to access laboratory results, while only 9 (8.4%) did not use it. The mean satisfaction score of the users was 4.62 ± 0.51. The study showed that most users found the digital system to be more secure and reliable, which led to significant time savings compared to the paper-based system. The study also found that age was a determinant of usage, with younger healthcare professionals using the application more frequently. CONCLUSION: Overall, the study suggests that digital laboratory reporting systems have significant benefits, and further efforts are needed to increase adoption in healthcare establishments in India.

Performance Drift in Machine Learning Models for Cardiac Surgery Risk Prediction: Retrospective Analysis.

Background: The Society of Thoracic Surgeons and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II risk scores are the most commonly used risk prediction models for in-hospital mortality after adult cardiac surgery. However, they are prone to miscalibration over time and poor generalization across data sets; thus, their use remains controversial. Despite increased interest, a gap in understanding the effect of data set drift on the performance of machine learning (ML) over time remains a barrier to its wider use in clinical practice. Data set drift occurs when an ML system underperforms because of a mismatch between the data it was developed from and the data on which it is deployed. Objective: In this study, we analyzed the extent of performance drift using models built on a large UK cardiac surgery database. The objectives were to (1) rank and assess the extent of performance drift in cardiac surgery risk ML models over time and (2) investigate any potential influence of data set drift and variable importance drift on performance drift. Methods: We conducted a retrospective analysis of prospectively, routinely gathered data on adult patients undergoing cardiac surgery in the United Kingdom between 2012 and 2019. We temporally split the data 70:30 into a training and validation set and a holdout set. Five novel ML mortality prediction models were developed and assessed, along with EuroSCORE II, for relationships between and within variable importance drift, performance drift, and actual data set drift. Performance was assessed using a consensus metric. Results: A total of 227,087 adults underwent cardiac surgery during the study period, with a mortality rate of 2.76% (n=6258). There was strong evidence of a decrease in overall performance across all models (P<.0001). Extreme gradient boosting (clinical effectiveness metric [CEM] 0.728, 95% CI 0.728-0.729) and random forest (CEM 0.727, 95% CI 0.727-0.728) were the overall best-performing models, both temporally and nontemporally. EuroSCORE II performed the worst across all comparisons. Sharp changes in variable importance and data set drift from October to December 2017, from June to July 2018, and from December 2018 to February 2019 mirrored the effects of performance decrease across models. Conclusions: All models show a decrease in at least 3 of the 5 individual metrics. CEM and variable importance drift detection demonstrate the limitation of logistic regression methods used for cardiac surgery risk prediction and the effects of data set drift. Future work will be required to determine the interplay between ML models and whether ensemble models could improve on their respective performance advantages.

Risk factors and outcomes for surgical repair of obstructed total anomalous pulmonary venous connection.

Background: Surgical repair of obstructed total anomalous pulmonary venous connection (TAPVC) is a high-risk surgical cohort. This study aimed to assess surgical risk factors and outcomes in infants with TAPVC treated at a single centre. Methods: This was a prospective single-centre, observational study that included consecutive patients presenting with obstructed TAPVC. Patients with obstructed supra-cardiac, cardiac, and infra-cardiac TAPVC were included in the study. In-hospital mortality was the primary outcome. Multivariable logistic regression was carried out to identify risk factors for in-hospital mortality. Results: Of the 41 patients, 31 (75.6%) were males. Ages were distributed as follows: 20 (48.8%) between 1 and 3 months, 11 (26.88%) between >3 months, and 10 (24.4%) neonates. The in-hospital mortality was 19.5% (n=8). Of the remaining 33 patients, there were no deaths during the follow-up. Short-term follow-up was achieved for 100% of cases (up to 6 months post-operatively). The mean duration of follow-up was 43.6± 3.6 months. One (3%) early and 2 (6%) late pulmonary vein obstructions were observed during follow-up. Age less than 30 days and pre-operative ventilation were associated with significantly increased risk of in-hospital mortality. Conclusions: Despite logistical challenges, reasonable surgical outcomes are attainable in obstructed TAPVC cases. Age less than 30 days and need for pre-operative ventilation were independent predictors of in-hospital mortality, while pulmonary venous obstruction in the post-operative period contributed to re-interventions.

Posterior reversible encephalopathy syndrome: a rare cause of seizures following non-transplant cardiac surgery.

Posterior reversible encephalopathy syndrome (PRES) is rarely reported as a cause for seizures following cardiac surgery. PRES in non-transplant cardiac surgery may reflect under-diagnosis and under-reporting. While the condition is reversible, a delay in diagnosis can lead to irreversible brain injury. We describe a case of PRES that occurred after aortic valve replacement with concomitant coronary artery bypass grafting.

From NOTIONs to nuances: TAVR and SAVR in low-risk patients.

The NOTION trial, in this 10-year follow-up report, comprehensively compares transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in low-risk patients. The study reveals similar outcomes in terms of mortality, stroke, and myocardial infarction. TAVR demonstrates advantages such as improved effective orifice area and transprosthetic gradients, along with reduced rates of new-onset atrial fibrillation. However, it is associated with higher rates of permanent pacemaker implantation and paravalvular leaks. Concerns exist regarding the generalizability of findings and unblinding during outcome assessments.

Feasibility and Safety of Concomitant Laparoscopic Cholecystectomy With Open-Heart Surgery: A Systematic Review and Our Early Clinical Experience.

Significant valvular or coronary artery disease may co-exist in patients presenting with symptomatic cholelithiasis. Isolated laparoscopic cholecystectomy in these cases is often associated with cardiac complications. Addressing the cardiac condition first may result in flaring up of cholecystitis during postoperative recovery and is associated with adverse outcomes. Open-heart surgery followed by laparoscopic cholecystectomy during a single operative setting is an option in these situations. The aim of our study is to review the published articles for this strategy and to share our initial experience with two such patients. PubMed, OVID Medline, and Cochrane library database were used, and we searched these databases using Medical Subject Headings (MeSH) terms and keywords from the inception date until August 1, 2023, and did not restrict our search to any language, study type, sample size, or publication date. All the publications reporting concomitant laparoscopic cholecystectomy and open-heart surgery were identified and a systematic review was carried out. Our first case underwent coronary artery bypass grafting and laparoscopic cholecystectomy. The second patient underwent a double valve replacement and laparoscopic cholecystectomy. Both the patients made an uneventful recovery, and are alive and doing well. Concomitant open-heart surgery and laparoscopic cholecystectomy in certain situations may be necessary and can be performed safely.

Impact of explanted valve type on aortic valve reoperations: nationwide UK experience.

OBJECTIVES: This nationwide retrospective cohort study assessed the impact of the explanted valve type on reoperative outcomes in aortic valve surgery within the UK over a 23-year period. METHODS: Data were sourced from the National Institute for Cardiovascular Outcomes Research (NICOR) database. All patients undergoing first-time isolated reoperative aortic valve replacement between 1996 and 2019 in the UK were included. Concomitant procedures, homograft implantation or aortic root enlargement were excluded. Propensity score matching was utilized to compare outcomes and risk factors for in-hospital mortality was evaluated through multivariable logistic regression. Final model selection was conducted using Akaike Information Criterion through bootstrapping. The primary end point was in-hospital mortality, and secondary end points included postoperative morbidities. RESULTS: Out of 2371 patients, 24.9% had mechanical and 75% had bioprosthetic valves implanted during the primary procedure. Propensity matched groups of 324 patients each, were compared. In-hospital mortality for mechanical and bioprosthetic valve explants was 7.1% and 5.9%, respectively (P = 0.632). On multivariable logistic regression analysis, valve type was not a risk factor for mortality [odds ratio (OR) 0.62, 95% confidence interval (CI) 0.37-1.05; P = 0.1]. Age (OR 1.03, 95% CI 1.01-1.05; P < 0.05), left ventricular ejection fraction (OR 1.62, 95% CI 1.08-2.42; P < 0.05), creatinine ≥ 200 mg/dl (OR 2.21, 95% CI 1.17-4.04; P < 0.05) and endocarditis (OR 2.66, 95% CI 1.71-4.14; P < 0.05) emerged as risk factors for mortality. CONCLUSIONS: The type of valve initially implanted (mechanical or bioprosthetic) did not determine mortality. Instead, age, left ventricular ejection fraction, renal impairment and endocarditis were significant risk factors for in-hospital mortality.

Complex management of pulmonary embolism in APLA syndrome: a case study of ECMO and bivalirudin utilization.

We report a case of a 22-year-old female with antiphospholipid antibody (APLA) syndrome who presented with severe dyspnea. Diagnostic imaging confirmed pulmonary embolism (PE), and treatment comprised unfractionated heparin and apixaban. APLA syndrome was diagnosed based on clinical, serological, and radiological findings. During evaluation, the patient developed cardiogenic shock necessitating catheter-directed thrombolysis, followed by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) due to deteriorating condition and suspected heparin-induced thrombocytopenia (HIT). Surgical embolectomy with bivalirudin use followed, and a hybrid veno-arterial-venous (VAV) ECMO setup was implemented. Postoperatively, the patient improved, transitioning to veno-venous (VV) ECMO and eventually ECMO withdrawal. ECMO is a valuable tool for managing complex cardiorespiratory cases like PE. In the context of HIT and APLA syndrome, prompt anticoagulant transition is vital, and bivalirudin is an effective heparin alternative. Our study highlights the challenges involved in managing patients needing ECMO support with immunothrombotic conditions like HIT and APLA syndrome.

EVOLUT Low-Risk Trial data: "We see what we want to see!"

In the 4-year update of the EVOLUT Low-Risk Trial (NCT02701283), the authors highlight a non-significant improvement in the primary endpoint and a statistically significant, yet clinically irrelevant, enhancement in hemodynamics with transcatheter aortic valve replacement (TAVR) compared to surgical aortic valve replacement (SAVR). Overlooking the concurrent surgical procedures in SAVR patients, mortality rates remain similar at 4 years. Unaddressed is the substantial increase in permanent pacemaker implantations with TAVR and the fate of patients with paravalvular leaks.

Trend in mitral valve prostheses of choice and early outcomes in the United Kingdom.

OBJECTIVE: Despite the superiority of mitral valve repair, surgical mitral valve replacement (SMVR) remains an important intervention for patients with valve stenosis, infective endocarditis and complex mitral valve degeneration. There has been an increasing popularity in the worldwide use of biological valves due to the avoidance of long-term anti-coagulation and recent advancements in transcatheter techniques. We aim to evaluate the trend, early clinical outcomes and the choice of prostheses use in isolated SMVR over a 23 years period in the United Kingdom. METHODS: All patients (n = 13,147) who underwent elective or urgent isolated SMVR from March 1996 to April 2019 were identified from the National Adult Cardiac Surgery Audit database. Trends in clinical outcomes, predicted/observed mortality of patients and the utilization of biological prostheses across 5 different age groups: <50, 50-59, 60-69, 70-79 and ≥80 years old were investigated. Early clinical outcomes associated with the use of mechanical and biological mitral valve prostheses in patients between the age of 60-70 years old were analysed. RESULTS: The number of isolated SMVR performed has remained stable with approximately 600 cases annually since 2010. The in-hospital/30-day mortality rate has decreased from 7.41% (1996) to 3.92% (2018), despite the EuroScore II increasing from 1.42% in 1996 to 2.43% in 2018. Biological prostheses usage increased across all age group, and particularly in the 60-69 and 70-79 group, from 17.86% and 53.85% in 1996 to 48.85% and 82.38% in 2018, respectively. The use of mechanical prostheses was reduced in patients between the age of 50-59 from 100% in 1996 to 80.65% in 2018. There were no differences in short term outcomes among patients aged 60-70 years who received either a biological or mechanical prostheses. CONCLUSION: There has been a significant reduction in surgical mitral valve replacement early in-hospital mortality, despite an observed increase in the risk profile of patients over 23 years. A shifting trend in valve replacement choices was observed with a rise in the use of biological prostheses, particularly within the 60-69 and 70-79 age group. Early in hospital outcomes for patients aged 60-70 were not determined by the implanted valve type.

Cardiovascular diseases and the heart-gut cross talk.

The purpose of this narrative review is to provide a comprehensive overview of current research on heart-gut cross talk and its implications for cardiovascular disease. To uncover relevant preclinical and clinical research examining heart-gut cross talk, a thorough literature search was undertaken utilising electronic databases. The chosen publications were critically examined, and major findings were synthesised to offer a thorough perspective on the subject. We want to synthesise the most recent study findings, explain the underlying mechanisms, and provide potential treatment techniques. By exploring bidirectional connection between the heart and the gut, we shed light on novel future options for the prevention and treatment of cardiovascular diseases. The heart-gut cross talk is an exciting field of study with implications for cardiovascular disease. Understanding the complex connection between the heart and the gastrointestinal tract may lead to the development of novel therapeutic targets and therapies for the prevention and management of cardiovascular diseases. Future research should concentrate on identifying the specific processes driving this crosstalk as well as assessing the efficacy of therapies targeting the gut microbiota and the gut-brain axis in improving cardiovascular outcomes.

Experimental Investigation of X-Ray Radiation Shielding and Radiological Properties for Various Natural Composites.

BACKGROUND: Shielding from radiation and plan dose verification is vital during the potential applications in industrial and medical applications. A number of natural composites have been investigated for protecting against high-energy X-ray shielding. OBJECTIVE: The aim is to learn about how natural composites behave under various X-ray energies at STP. MATERIAL AND METHODS: The radiological parameters of wood samples were determined using computed tomography imaging, specifically relative electron density (RED), Hounsfield units (HUs), and mass density (MD). Percentage attenuation was measured using a semiflux ionization chamber incorporated with a brass build-up cap and an ionization chamber placed at the beam Isocenter for a different type of natural composite. Measurements are being carried out on a Linear accelerator at an SSD of 110 cm with different collimator sizes. RESULTS: Measured values of  HUs, RED, and MD were -232 ± 40, 0.738 ± 0.039, 0.768 ± 0.024 g/cc,-368 ± 41, 0.662 ± 0.047, 0.632 ± 0.024 g/cc, -334 ± 44, 0.639 ± 0.042, 0.666 ± 0.026 g/cc, -370±61, 0.604±0.059, 0.63± 0.036 g/cc, -433±39, 0.543±0.038, 0.608 ± 0.035 g/cc, -382±54, 0.5±0.052, 0.618 ± 0.0316 g/cc, -292±68, 0.680±0.066, 0.708 ± 0.039 g/cc, -298±27, 0.680±0.0229, 0.702± 0.131 g/cc, for Acacia Nilotica, Mangifera Indica, Azadirachta Indica, Tectona Grandis L, Ficus Religiosa, Tecomella Undulata, Sesamum Indicum, Pinus respectively. CONCLUSION: Measurements show that attenuation is affected by the energy of incident photons, collimator opening, and the type of density of the wood. Various radiological parameters were determined for wood samples that can be utilized to create inhomogeneous phantoms in dosimetry. The largest attenuation is found in Acacia Nilotica and Sesamum Indicum, while the lowest attenuation is found in Ficus religiosa.