Transatlantic analysis of patient profiles and mid-term survival after isolated coronary artery bypass grafting: a head-to-head comparison between the European DuraGraft Registry and the US STS Registry.

Introduction: Although cardiovascular surgery societies in Europe and the USA constantly strive for the exchange of knowledge and best practices in coronary artery bypass grafting (CABG), the available evidence on whether such efforts result in similar patient outcomes is limited. Therefore, in the present analysis, we sought to compare patient profiles and overall survival outcomes for up to 3 years between large European and US patient cohorts who underwent isolated CABG. Methods: Patients from the European DuraGraft Registry (n = 2,522) who underwent isolated CABG at 45 sites in eight different European countries between 2016 and 2019 were compared to randomly selected patients from the US STS database who were operated during the same period (n = 294,725). Free conduits (venous and arterial grafts) from the DuraGraft Registry patients were intraoperatively stored in DuraGraft, an endothelial damage inhibitor, before anastomosis, whereas grafts from the STS Registry patients in standard-of-care solutions (e.g., saline). Propensity score matching (PSM) models were used to account for differences in patient baseline and surgical characteristics, using a primary PSM with 35 variables (2,400 patients matched) and a secondary PSM with 25 variables (2,522 patients matched, sensitivity analysis). The overall survival for up to 3 years after CABG was assessed as the primary endpoint. Results: The comparison of patient profiles showed significant differences between the European and US cohorts. The European patients had more left main disease, underwent more off-pump CABG, and received more arterial grafts together with more complete arterial grafting procedures. In contrast, the US patients received more distal anastomoses with more saphenous vein grafts (SVGs) that were mainly harvested endoscopically. Such differences, however, were well balanced after PSM for the mortality comparison. Mortality comparison at 30 days, 12 months, and 24 months between the European and US patients was 2.38% vs. 1.96%, 4.32% vs. 4.79%, and 5.38% vs. 6.96%, respectively. At 36 months, the mortality was significantly lower in the European patients than that of their US counterparts (7.37% vs. 9.65%; p-value = 0.016). The estimated hazard ratio (HR) was 1.29 (95% CI 1.05-1.59). Conclusion: This large-scale transatlantic comparative analysis shows that there are some significant differences in patient profiles between large cohorts of European and US patients. These differences were adjusted by using PSM for the mortality analysis. No significant difference in mortality was detected between groups through 2 years, but survival was significantly better in the European DuraGraft Registry patients at 3 years post-CABG.

Outcomes after surgical revascularization in diabetic patients.

OBJECTIVES: Patients with diabetes mellitus (DM) undergoing coronary artery bypass grafting (CABG) have been repeatedly demonstrated to have worse clinical outcomes compared to patients without DM. The objective of this study was to evaluate the impact of DM on 1-year clinical outcomes after isolated CABG. METHODS: The European DuraGraft registry included 1130 patients (44.6%) with and 1402 (55.4%) patients without DM undergoing isolated CABG. Intra-operatively, all free venous and arterial grafts were treated with an endothelial damage inhibitor. Primary end point in this analysis was the incidence of a major adverse cardiac event (MACE), a composite of all-cause death, repeat revascularization or myocardial infarction at 1 year post-CABG. To balance between differences in baseline characteristics (n = 1072 patients in each group), propensity score matching was used. Multivariable Cox proportional hazards regression was performed to identify independent predictors of MACE. RESULTS: Diabetic patients had a higher cardiovascular risk profile and EuroSCORE II with overall more comorbidities. Patients were comparable in regard to surgical techniques and completeness of revascularization. At 1 year, diabetics had a higher MACE rate {7.9% vs 5.5%, hazard ratio (HR) 1.43 [95% confidence interval (CI) 1.05-1.95], P = 0.02}, driven by increased rates of death [5.6% vs 3.5%, HR 1.61 (95% CI 1.10-2.36), P = 0.01] and myocardial infarction [2.8% vs 1.4%, HR 1.99 (95% CI 1.12-3.53) P = 0.02]. Following propensity matching, no statistically significant difference was found for MACE [7.1% vs 5.7%, HR 1.23 (95% CI 0.87-1.74) P = 0.23] or its components. Age, critical operative state, extracardiac arteriopathy, ejection fraction ≤50% and left main disease but not DM were identified as independent predictors for MACE. CONCLUSIONS: In this study, 1-year outcomes in diabetics undergoing isolated CABG were comparable to patients without DM.

Infectious complications following major heart surgery from the day of the surgery to hospital discharge.

BACKGROUND: At some point in their lives, many people will require major heart surgery (MHS). Patients are generally older adults with various risk factors for infection. However, the incidence of infection after MHS is poorly known, as reported infection data are frequently biased due to different factors like the surgical procedure, postoperative timing, and infectious syndromes or etiologic agents, among others. In addition, most patient data are retrospectively obtained. PURPOSE AND METHODS: Data were prospectively collected regarding the incidence of all nosocomial infections produced from the time of surgery to hospital discharge in a cohort of 800 adults consecutively undergoing a MHS procedure. RESULTS: During postoperative hospitalization, 124 of the 800 participants developed one or more infections (15.5%): during their ICU stay in 68 patients (54.8%), during their stay on the general ward post ICU in 50 (40.3%), and during their stay in both wards in 6 (4.8%). The most common infections were pneumonia (related or not to mechanical ventilation), surgical site and bloodstream. As etiological agents, 193 pathogens were isolated: mostly Gram-negative bacilli (54.4%), followed by Gram-positive bacteria (30%), viruses (4.6%) and fungi (1.5%). In our cohort, all-cause mortality was recorded in 33 participants (4.1%) and 9 infection-related deaths (1.1%) were produced. Among subjects who developed infections, overall mortality was 13.7% and in those who did not, this was only 2.3%. CONCLUSION: Infection following MHS remains frequent and severe. Our data suggest that hospital-acquired infection studies should consider episodes of infection in all populations during their entire hospital stay and not only those related to specific clinical syndromes or acquired while the patient is in intensive care.

Validation of the TRI-SCORE in patients undergoing surgery for isolated tricuspid regurgitation.

INTRODUCTION: Estimation of peri-procedural risk in patients with tricuspid regurgitation (TR) undergoing isolated tricuspid valve surgery (ITVS) is of paramount importance. The TRI-SCORE is a new surgical risk scale specifically developed for this purpose, which ranged from 0 to 12 points and included eight parameters: right-sided heart failure signs, daily dose of furosemide ≥125 mg, glomerular filtration rate <30 mL/min, elevated bilirubin (with a value of 2 points), age ≥70 years, New York Heart Association Class III-IV, left ventricular ejection fraction <60% and moderate/severe right ventricular dysfunction (with a value of 1 point). The objective of the study was to evaluate the performance of the TRI-SCORE in an independent cohort of patients undergoing ITVS. METHODS: A retrospective observational study was performed in four centres, including consecutive adult patients undergoing ITVS for TR between 2005 and 2022. The TRI-SCORE and the traditional risk scores used in cardiac surgery (Logistic EuroScore (Log-ES) and EuroScore-II (ES-II)) were applied for each patient, and discrimination and calibration of the three scores were evaluated in the entire cohort. RESULTS: A total of 252 patients were included. The mean age was 61.5±11.2 years, 164 (65.1%) patients were female, and TR mechanism was functional in 160 (63.5%) patients. The observed in-hospital mortality was 10.3%. The estimated mortality by the Log-ES, ES-II and TRI-SCORE was 8.7±7.3%, 4.7±5.3% and 11.0±16.6%, respectively. Patients with a TRI-SCORE ≤4 and >4 had an in-hospital mortality of 1.3% and 25.0%, p=0.001, respectively. The discriminatory capacity of the TRI-SCORE had a C-statistic of 0.87 (0.81-0.92), which was significantly higher than both the Log-ES (0.65 (0.54-0.75)) and ES-II (0.67 (0.58-0.79)), p=0.001 (for both comparisons). CONCLUSION: This external validation of the TRI-SCORE demonstrated good performance to predict in-hospital mortality in patients undergoing ITVS, which was significantly better than the Log-ES and ES-II, which underestimated the observed mortality. These results support the widespread use of this score as a clinical tool.

Clinical outcomes and quality of life after contemporary isolated coronary bypass grafting: a prospective cohort study.

OBJECTIVES: The objective of the European Multicenter Registry to Assess Outcomes in coronary artery bypass grafting (CABG) patients (DuraGraft Registry) was to determine clinical outcomes and quality of life (QoL) after contemporary CABG that included isolated CABG and combined CABG/valve procedures, using an endothelial damage inhibitor (DuraGraft) intraoperatively for conduit preservation. Here, we report outcomes in the patient cohort undergoing isolated CABG. METHODS: The primary outcome was the composite of all-cause death, myocardial infarction (MI), or repeat revascularization (RR) [major adverse cardiac events (MACE)] at 1 year. Secondary outcomes included the composite of all-cause death, MI, RR, or stroke [major adverse cardiac and cerebrovascular events (MACCE)], and QoL. QoL was assessed with the EuroQol-5 Dimension questionnaire. Independent risk factors for MACE at 1 year were determined using Cox regression analysis. RESULTS: A total of 2532 patients (mean age, 67.4±9.2 years; 82.5% male) underwent isolated CABG. The median EuroScore II was 1.4 [interquartile range (IQR), 0.9-2.3]. MACE and MACCE rates at 1 year were 6.6% and 7.8%, respectively. The rates of all-cause death, MI, RR, and stroke were 4.4, 2.0, 2.2, and 1.9%, respectively. The 30-day mortality rate was 2.3%. Age, extracardiac arteriopathy, left ventricular ejection fraction less than 50%, critical operative state, and left main disease were independent risk factors for MACE. QoL index values improved from 0.84 [IQR, 0.72-0.92] at baseline to 0.92 [IQR, 0.82-1.00] at 1 year ( P <0.0001). CONCLUSION: Contemporary European patients undergoing isolated CABG have a low 1-year clinical event rate and an improved QoL.

Clinical event rate in patients with and without left main disease undergoing isolated coronary artery bypass grafting: results from the European DuraGraft Registry.

OBJECTIVES: Left main coronary artery disease (LMCAD) is considered an independent risk factor for clinical events after coronary artery bypass grafting (CABG). We have conducted a subgroup analysis of the multicentre European DuraGraft Registry to investigate clinical event rates at 1 year in patients with and without LMCAD undergoing isolated CABG in contemporary practice. METHODS: Patients undergoing isolated CABG were selected. The primary end point was the incidence of a major adverse cardiac event (MACE) defined as the composite of death, myocardial infarction (MI) or repeat revascularization (RR) at 1 year. The secondary end point was major adverse cardiac and cerebrovascular events (MACCE) defined as MACE plus stroke. Propensity score matching was performed to balance for differences in baseline characteristics. RESULTS: LMCAD was present in 1033 (41.2%) and absent in 1477 (58.8%) patients. At 1 year, the MACE rate was higher for LMCAD patients (8.2% vs 5.1%, P = 0.002) driven by higher rates of death (5.4% vs 3.4%, P = 0.016), MI (3.0% vs 1.3%, P = 0.002) and numerically higher rates of RR (2.8% vs 1.8%, P = 0.13). The incidence of MACCE was 8.8% vs 6.6%, P = 0.043, with a stroke rate of 1.0% and 2.4%, P = 0.011, for the LMCAD and non-LMCAD groups, respectively. After propensity score matching, the MACE rate was 8.0% vs 5.2%, P = 0.015. The incidence of death was 5.1% vs 3.7%, P = 0.10, MI 3.0% vs 1.4%, P = 0.020, and RR was 2.7% vs 1.6%, P = 0.090, for the LMCAD and non-LMCAD groups, respectively. Less strokes occurred in LMCAD patients (1.0% vs 2.4%, P = 0.017). The MACCE rate was not different, 8.5% vs 6.7%, P = 0.12. CONCLUSIONS: In this large registry, LMCAD was demonstrated to be an independent risk factor for MACE after isolated CABG. Conversely, the risk of stroke was lower in LMCAD patients. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02922088.

Atrial myxoma surgery and P-wave remodeling.

INTRODUCTION: Data regarding atrial electrocardiographic parameters in patients with atrial myxomas are scarce. METHODS: We aimed to study atrial electrocardiographic features in patients with atrial myxomas, before and after surgery. We also analyze the incidence of atrial fibrillation during follow-up and its correlation with different P-wave indexes. In total 32 patients in sinus rhythm that underwent atrial myxoma surgery were included. RESULTS: Mean age was 55.0 ± 12.6 years and 18 (56.3%) were women. Ten patients had left atrial enlargement (31.3%). Only one myxoma was located in the right atrium. At baseline seven cases of partial interatrial block (IAB) were detected (21.9%), two in the absence of left atrial enlargement. There were significant differences in atrial electrocardiographic indexes before and after surgery, including P-wave duration (108.9 ± 17.9 ms vs. 93.0 ± 12.4 ms; p < .001), partial IAB (21.9% vs. 3.1%; p = .012) and duration of P-wave terminal force in lead V1 negativity (-0.6 ± 0.3 vs. -0.5 ± 0.3 mm; p = .034). At a mean follow-up of 10.0 ± 5.5 years, 10 patients (31.3%) had experienced at least one episode of atrial fibrillation. Post-operative P-wave duration was associated with atrial fibrillation occurrence during follow-up (Hazard ratio: 0.90, 95% confidence interval: 0.83-0.98; p = .020). CONCLUSIONS: Abnormalities in atrial electrocardiographic indexes are common in atrial myxomas and frequently improve after surgery. Post-operative P-wave duration is associated with atrial fibrillation occurrence during follow-up.

Should Advanced Friedreich's Ataxia Be a Contraindication for Heart Transplantation? A Case Report of a Successful Procedure in a 58-Year-Old Patient.

The information on heart transplantation (HT) in patients with Friedreich's Ataxia (FA) is scarce, and the few published case reports are limited to young patients with mild neurological manifestations. We present the case of a 58-year-old patient with advanced FA (Scale for the Assessment and Rating of Ataxia [SARA] score 30/40), wheelchair-bound for the last 16 years and had urinary incontinence, dysarthria, and neurosensorial deafness. The patient was admitted for a refractory arrhythmic storm and had previous hypertrophic cardiomyopathy that evolved to dilated cardiomyopathy with severely reduced left ventricular ejection fraction and recurrent ventricular arrhythmias. A multidisciplinary team discussed the HT option. The patient was aware of the risks and benefits and considered worthy of the intervention, so he was listed for HT. After a successful surgical intervention, the patient had a long postoperative stay in ICU. He required a high dose of vasopressors, underwent hemofiltration for one month, suffered critical illness myopathy, had several respiratory infections and delayed tracheal extubation. Two and a half months after HT and almost five months at the hospital, the patient was successfully discharged. FA patients with severe heart conditions should be carefully evaluated by a multidisciplinary team to decide the candidacy for HT.

Disseminated lomentosporiosis in a heart transplant recipient: Case report and review of the literature.

BACKGROUND: Lomentospora prolificans (formerly S prolificans) is a saprophyte fungi that causes opportunistic infections in solid organ transplant (SOT) recipients. Resulting disseminated infections are difficult to treat and have a high mortality. Indications for antifungal prophylaxis after heart transplantation (HT) include CMV disease, reoperation, renal replacement therapy, extracorporeal membrane oxygenation (ECMO), and high environmental exposure to Aspergillus spores. However, the risk of breakthrough infections, such as Lomentosporiosis, remains a cause of concern. METHODS: We report the clinical findings, microbiology, treatment and outcome of a disseminated Lomentosporiosis in a heart transplant recipient with ECMO and antifungal prophylaxis. RESULTS: A 25-year-old male with complex grown-up congenital heart disease (GUCHD) was admitted for HT. He presented severe post-surgical complications including acute kidney injury and right heart and respiratory failure requiring venoarterial-ECMO, continuous renal replacement therapy (CCRT) and later on (+14) a ventricular assist device (VAD). Ganciclovir, cotrimoxazole, and antifungal prophylaxis with anidulafungin at standard doses had been started on day + 3 post HT. The patient presented seizures (+4), pancytopenia with mild neutropenia (days + 6 to + 11), influenza B (+7), and bacteremic Pseudomonas aeruginosa ventilator associated pneumonia (VAP) (+10). On days + 14 to + 16 Lomentospora prolificans was recovered from blood cultures, broncho aspirate, catheter tip, and skin biopsy. Despite treatment with L-AMB, voriconazole and terbinafine the patients died on day 17 after HT. Necropsy revealed disseminated infection with fungal invasion in central nervous system, heart, lung, cutaneous, and subcutaneous tissue. Broth microdilution tests demonstrated resistance to all antifungals. CONCLUSIONS: Lomentosporiosis is a rare complication that may emerge as a breakthrough invasive fungal infection in heart transplant recipients on ECMO despite antifungal prophylaxis.

Troponin elevation is very common in patients with infective endocarditis and is associated with a poor outcome.

INTRODUCTION: We sought to study the prevalence of cardiac troponin T (TnT) elevation in patients with infective endocarditis (IE) and its association with in-hospital outcomes. METHODS AND RESULTS: Retrospective single-center study. From 2008 to 2018, 528 patients were diagnosed with IE and 250 (47.3%) had at least a TnT determination during hospital admission, 103 with conventional TnT assay and 147 with high-sensitive assay. Elevated TnT levels were found in 210 patients (84.0%). Compared with patients with normal TnT levels, patients with TnT elevation presented higher in-hospital mortality (5 [12.5%] vs. 77 [36.7%], p < 0.001) and more frequent complications: heart failure (9 [22.5%] vs. 106 [50.5%], p < 0.001), cardiac abscesses (4 [10.0%] vs 58 [27.6%], p = 0.03), conduction disorders (0 vs. 26 [12,4%]; p = 0.04), and involvement of the central nervous system (1 [2.5%] vs. 38 [18.1%];p = 0.02). Patients with elevated TnT had more frequent indication for surgery (24 [60.0%] vs. 179 [85.2%], p < 0.001) and were operated on more frequently (16 [40.0%] vs 123 [58.6%], p = 0.03). TnT elevation was an independent predictor of in-hospital mortality (OR 3.31; 95% CI 1.02-10.72, p = 0.05). Adding TnT data to conventional clinical models improved the predictive capability of in-hospital mortality (R2: 0.407 vs. 0.388, χ2: 85.03 vs. 80.40, p < 0.001), resulting in a net reclassification improvement of 0.29 (95% CI: 0.13-0.46, p < 0.01). CONCLUSIONS: TnT elevation is very common in patients with IE and is associated with increased in-hospital mortality and complications, thus routine monitoring should be recommended.

Mitral valve repair in infective endocarditis is not inferior to valve replacement: results from a Spanish nationwide prospective registry.

INTRODUCTION: Infective endocarditis (IE) still carries high morbidity and mortality and frequently requires surgery. The benefit of mitral valve repair (MVr) in the setting of IE is yet to be proven. The goal of this study was to assess the results of MVr in patients with IE after a minimum follow-up of 1 year. METHODS: This study is based on a Spanish nationwide prospective registry that included patients operated on for native mitral valve IE. The collaborating Institutions pooled their pre-, peri-, and postoperative data into the database of the GAMES group [Grupo de Apoyo al Manejo de la EndocarditiS (Group for support and management of infective endocarditis)]. RESULTS: Data from 27 hospitals were recorded and 3524 cases of active IE identified between 2008 and 2016. There were 1513 cases of mitral IE, of which 898 involved native valves. Of these, 437 patients underwent surgical treatment, and 369 completed the 1-year follow-up. The valve was repaired in 68 cases (18.4%). Preoperative groups were comparable (EuroSCORE MVr 7.7 vs MVR 8.0; p = ns). Mortality in the repair group was inferior to that in the replacement group (16.2% vs 27.2%, p = 0.058). At 1 year, mortality remained higher in the replacement group: 3.7% vs 2.9%. Relapse of the infection was slightly more frequent in the repair group (7.1% vs 3.7%; p = ns), although this did not lead to higher rates of reintervention (MVr/MVR: 2.9% vs 4.9%). CONCLUSION: MVr is an attractive option for specific patients with IE and does not seem to negatively impact on relapses.

Do lower respiratory tract samples contribute to the assessment of carriage of Staphylococcus aureus in patients undergoing mechanical ventilation after major heart surgery?

Colonization by Staphylococcus aureus is regularly assessed in patients undergoing major heart surgery (MHS). Despite pre-surgical decontamination attempts, a significant proportion of MHS patients remain colonized by S. aureus at the time of surgery. Nasal sampling can be improved by sampling extra-nasal areas. We evaluated whether processing lower respiratory tract (LRT) secretions enhanced the detection of S. aureus after MHS. Following a standard protocol, nasal swabs and LRT aspirates were obtained from all of the study patients at the time of surgery or in the immediate postoperative period. One swab was used for culture in the microbiology laboratory, and a second swab was used for the Xpert SA Nasal Complete assay. According to our definition of colonization (culture positive and/or PCR positive), 31 of 115 patients (26.9%) were colonized at the time of surgery. Among these, LRT samples only were positive in three patients (2.6% of the whole population and 9.7% of the carriers). The remaining 28 were either positive in the nasal sample or positive in both samples. The yield of the detection of colonization by S. aureus by including also LRT samples in patients undergoing MHS is limited and must be balanced with laboratory workload and demands on laboratory personnel. Trial registration: Clinical trials.gov NCT02640001.

Infections in patients after Berlin Heart® EXCOR assist device implantation.

OBJECTIVES: Berlin Heart® EXCOR devices (BHED) are ventricular assist devices (VAD) used mainly as a bridge to heart transplantation (HT) in pediatric population. The aim of our study is to report the infections diagnosed in adult patients undergoing a BHED implantation. METHODS: Adult patients receiving a BHED between Jul 2009 and Oct 2017 at our institution were included. Infections were classified according to the International Society of Heart and Lung Transplantation definitions in VAD-Specific (VAD-S), VAD-Related (VAD-R) and non-VAD (N-VAD). RESULTS: Fifteen patients underwent BHED implantation, which was maintained for a mean of 92 (19-195) days. Infection occurred in 13 patients who developed 36 infectious episodes: 5 VAD-S (5 cannula infections); 8 VAD-R (5 bloodstream infections and 3 mediastinitis) and 24 N-VAD (7 urinary tract infections, 6 Cytomegalovirus diseases and others). Overall, 27 (75%) were bacterial, 7 (19.4%) were viral and there was one (2.7%) fungal infection. Eleven patients underwent HT and all of them developed at least one infection after it. In 3 cases, all VAD-R or VAD-S infections were caused by the same etiology as before HT. Their median time of appearance was on day +6 (3-11) after BHED removal and HT. Overall mortality was 6/15 (40%). None of the deaths were related to VAD Infection. CONCLUSIONS: Infection complicated BHED implantation in 86.7% of the patients. Overall, 13.9% were specific of BHED and 22.2% were related. However, infections did not preclude HT in any case and carried no attributable mortality.

Prognostic implications of a negative echocardiography in patients with infective endocarditis.

BACKGROUND: Echocardiography plays an important role in infective endocarditis (IE) diagnosis according with the modified Duke criteria. We evaluated the implications of a positive echocardiography in the prognosis of a cohort of patients with IE. METHODS: Prospective multicentre study in 31 Spanish centres. From January 2008 to September 2016, 3467 patients were included (2765 definite IE, 702 possible IE). The main outcome was in-hospital mortality. Echocardiography diagnosis was based on modified Duke criteria for the diagnosis of IE. RESULTS: Median age was 69 years (interquartile range: 57-77 years). Comorbidity was high (mean Charlson index 4.7 ±â€¯2.8). Transoesophageal echocardiography was performed in 2680 (77.3%). The overall inhospital mortality rate was 26.7%. Univariate analysis showed that, in patients with definite IE, inhospital mortality was similar in patients with positive and negative echocardiography (27.7% vs. 24.6%, respectively, p = 0.121). In possible IE these figures were 27.5% vs. 16.7%, respectively, p < 0.001. Complications (cardiac and extracardiac [embolic, immunological, and septic shock]) were more frequent with positive than with negative echocardiography, regardless of clinical suspicion (definite IE 35.5% vs. 16.8%, respectively, p < 0.001; possible IE 20.8% vs. 7.6%, respectively, p < 0.001). Positive echocardiography was a predictor of inhospital death by logistic regression modelling, after adjusting for confounders, definite IE (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.02-1.76, p = 0.036), possible IE (OR 1.59, 95% CI 1.02-2.45, p = 0.036). CONCLUSIONS: A positive echocardiography in patients with IE is associated with increased inhospital mortality, in addition to other clinical factors and comorbidities.

Use of the Perceval Sutureless Valve in Active Prosthetic Aortic Valve Endocarditis.

BACKGROUND: Surgical treatment of active prosthetic aortic valve endocarditis presents a challenge for cardiac surgeons because of tissue friability and destruction caused by infection. Sutureless prostheses, such as the Perceval S (LivaNova, Saluggia, Italy), have emerged as an option among the different surgical approaches for these complicated cases. METHODS: This study presents data from 9 patients who underwent aortic valve re-replacement with the Perceval S because of active prosthetic aortic valve endocarditis between January 2014 and August 2016. Hemodynamic performance (mean transprosthetic gradient and type of aortic regurgitation) was assessed intraoperatively after weaning from cardiopulmonary bypass, at discharge, and to 6 months postoperatively. RESULTS: After weaning from cardiopulmonary bypass, cases 1 and 3 through 6 had no or trivial aortic regurgitation, cases 7 and 8 presented with trivial to mild regurgitation, case 9 showed mild intraprosthetic regurgitation, and case 2 had mild periprosthetic regurgitation. Cases 4 and 7 died of septic shock and multiorgan failure in the perioperative period. In the remaining patients, severity of aortic regurgitation maintained practically invariable at discharge compared with intraoperative results. These 7 patients did well at 6-month follow-up, with good clinical and hemodynamic performance of the Perceval S prosthesis. The median of mean transprosthetic gradient was 11 mm Hg (interquartile range: 10 to 12 mm Hg). Only patient 2 showed mild periprosthetic regurgitation; patient 9 showed mild intraprosthetic insufficiency, and the remaining patients had no or trivial regurgitation. CONCLUSIONS: The sutureless Perceval S valve is a reasonable alternative for surgical treatment of prosthetic aortic valve endocarditis.

Prognostic factors of infective endocarditis in patients on hemodialysis: A case series from a National Multicenter Registry.

BACKGROUND: Infective endocarditis (IE) is a severe complication associated with high mortality. OBJECTIVES: To examine the clinical characteristics of IE in hemodialysis (HD) patients and to determine prognostic factors related to HD. METHODS: From January 2008 to April 2015, 2488 consecutive patients with definite IE were included. Clinical characteristics of IE patients on HD were compared with those of IE patients who were not on HD. RESULTS: A total of 126 patients (63% male, median age: 66years; IQR: 54-74years) with IE (5.1%) were on HD. Fifty-two patients died during hospitalization (41%) and 17 additional patients (14%) died during the first year. The rate of patients who underwent surgery during hospitalization was lower in HD patients (38 patients, 30%) than in non-HD patients (1177 patients, 50%; p<0.001). Age >70years (OR: 4.1, 95% CI: 1.7-10), heart failure (OR: 3.3, 95% CI: 1.4-7-6), central nervous system (CNS) vascular events (OR: 6.7, 95% CI: 2.1-22) and septic shock (OR: 4.1, 95% CI: 1.4-12.1) were independently associated with fatal outcome in HD patients. Of the 38 patients who underwent surgery, 15 (39.5%) died during hospitalization. CONCLUSIONS: HD patients with IE present a high mortality. Advanced age and complications, such as heart failure, CNS stroke or septic shock, are associated with mortality.

Two-Year Follow Up After Surgical Versus Percutaneous Paravalvular Leak Closure: A Non-Randomized Analysis.

BACKGROUND: Percutaneous closure of paravalvular leak (PVL) has emerged as an alternative treatment. Predictors of survival and procedural success are unknown. OBJECTIVES: To review our experience in the treatment of PVL and evaluate efficacy, mortality, predictors of success, and outcomes. METHODS: Retrospective review of percutaneous PVL procedures between years 2008 and 2014. Survival and results were compared with a control cohort of surgical patients. RESULTS: Percutaneous closure was attempted in 51 patients. The surgical group had 36 patients. Defects were perimitral in 67 patients (77%). Mean follow-up (FU) was 784.5 days. After propensity score analysis in-hospital mortality was higher in the surgical group (30.6% vs. 9.8%, OR 6, P 0.01). Clinical improvement was higher in the percutaneous group (71.4% vs. 36.4%, P 0.002). Multivariate analysis showed normal creatinine (OR 15, P < 0.001) as independent predictor of clinical improvement. For the composite end-point of all-cause mortality or readmission, older age (OR 10.7, P 0.001), renal failure, (OR 18, P < 0.01), poor functional class and the absence of clinical improvement (OR 3.9, P < 0.001) were related with a higher risk. There were no differences in survival free from the composite end-point according to the treatment received (surgical or percutaneous). CONCLUSION: Percutaneous PVL closure has a reasonable rate of success and low complication rates, and results compare favorably with surgical treatment. Older patients and those with poor functional class or renal failure (RF) showed a worse prognosis even after a successful closure. © 2016 Wiley Periodicals, Inc.