Risk Factor Analysis for 30-day Mortality After Surgery for Infective Endocarditis.

BACKGROUND: Infective endocarditis (IE) remains a challenging disease associated with high mortality. Several scores have been suggested to assess surgical risk. None was sufficiently adequate. We therefore analyzed risk factors for 30-day mortality. METHODS: A total of 438 consecutive patients had surgery for IE in our department between 2002 and 2020. Patients were divided into two groups, one consisting of 30-day survivors (362 patients; 82.6%) and one of nonsurvivors (76 patients; 17.4%). Logistic regression analysis on pre- and intraoperative risk factors was performed and the groups were compared by univariable analyses. RESULTS: Patients in mortality group were older (69 [58, 77] vs. 63 [50, 72] years; p < 0.001), EuroSCORE II was higher (24.5 [12.1, 49.0] vs. 8.95 [3.7, 21.2]; p < 0.001) and there were more females. More frequently left ventricular function (below 30%), preoperative acute renal insufficiency, chronic dialysis, insulin-dependent diabetes mellitus, NYHA-class IV (New York Heart Association heart failure class IV), and cardiogenic shock occurred. Patients in the mortality group were often intensive care unit patients (40.8 vs. 22.4%; p < 0.001) or had a preoperative stroke (26.3 vs. 16.0%; p = 0.033). In the nonsurvivor group Staphylococcus aureus was prevalent. Streptococcus viridans was common in the survivor group as was isolated aortic valve endocarditis (32.9 vs. 17.1%; p = 0.006). Prosthetic valve endocarditis (PVE) and abscesses occurred more often in nonsurvivors. In the logistic regression analysis, female gender, chronic dialysis, cardiogenic shock, and NYHA IV and from intraoperative variables PVE, cardiopulmonary bypass time, and mitral valve surgery were the strongest predictors for 30-day mortality. CONCLUSION: This study indeed clearly indicates that significant risk factors for 30-day mortality cannot be changed. Nevertheless, they should be taken into account for preoperative counselling, and they will alert the surgical team for an even more careful management.

Preoperative Imaging Signs of Cerebral Malperfusion in Acute Type A Aortic Dissection: Influence on Outcomes and Prognostic Implications-A 20-Year Experience.

BACKGROUND: Acute type A aortic dissection (ATAAD) continues to be a subject of active research due to its high mortality rates and associated complications. Cerebral malperfusion in ATAAD can have a devastating impact on patients' neurological function and overall quality of life. We aimed to explore the risk profile and prognosis in ATAAD patients presenting with preoperative imaging signs of cerebral malperfusion (PSCM). METHODS: We obtained patient data from our Aortic Dissection Registry, which included 480 consecutive ATAAD cases who underwent surgical repair between 2001 and 2021. Primary endpoint outcomes included the in-hospital and 30-day mortality, postoperative new neurological deficit, mechanical ventilation hours, and intensive care unit (ICU) length of stay. RESULTS: Of the total cohort, 82 patients (17.1%) had PSCM. Both groups had similar distributions in terms of age, sex, and body mass index. The patients in the PSCM group presented with a higher logistic EuroSCORE (47, IQR [31, 64] vs. 24, IQR [15, 39]; p < 0.001) and a higher portion of patients with a previous cardiac surgery (7.3% vs. 2.0%; p = 0.020). Intraoperatively, the bypass, cardioplegia, and aortic cross-clamp times were similar between both groups. However, the patients in the PSCM group received significantly more intraoperative packed red blood cells, fresh frozen plasma, and platelets transfusions (p < 0.05). Following the surgery, the patients who presented with PSCM had markedly longer ventilation hours (108.5 h, IQR [44, 277] vs. 43 h, IQR [16, 158], p < 0.001) and a significantly longer ICU length of stay (7 days, IQR [4, 13] vs. 5 days, IQR [2, 11]; p = 0.013). Additionally, the patients with PSCM had significantly higher rates of postoperative new neurological deficits (35.4% vs. 19.4%; p = 0.002). In the Cox regression analysis, PSCM was associated with significantly poorer long-term survival (hazard ratio (HR) 1.75, 95%CI [1.20-2.53], p = 0.003). Surprisingly, hypertension was shown as a protective factor against long-term mortality (HR: 0.59, 95%CI [0.43-0.82], p = 0.001). CONCLUSION: PSCM in ATAAD patients is linked to worse postoperative outcomes and poorer long-term survival, emphasizing the need for early recognition and tailored management.

Transcatheter Aortic Valve Implantation by Intercostal Access: Initial Experience with a No-Touch Technique.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is now a well-established therapeutic option in an elderly high-risk patient cohort with aortic valve disease. Although most commonly performed via a transfemoral route, alternative approaches for TAVI are constantly being improved. Instead of the classical mini-sternotomy, it is possible to achieve a transaortic access via a right anterior mini-thoracotomy in the second intercostal space. We describe our experience with this sternum- and rib-sparing technique in comparison to the classical transaortic approach. METHODS: Our retrospective study includes 173 patients who were treated in our institution between January 2017 and April 2020 with transaortic TAVI via either upper mini-sternotomy or intercostal thoracotomy. The primary endpoint was 30-day mortality, and secondary endpoints were defined as major postoperative complications that included admission to the intensive care unit and overall hospital stay, according to the Valve Academic Research Consortium 3. RESULTS: Eighty-two patients were treated with TAo-TAVI by upper mini-sternotomy, while 91 patients received the intercostal approach. Both groups were comparable in age (mean age: 82 years) and in the proportion of female patients. The intercostal group had a higher rate of peripheral artery disease (41% vs. 22%, p = 0.008) and coronary artery disease (71% vs. 40%, p < 0.001) with a history of percutaneous coronary intervention or coronary artery bypass grafting, resulting in significantly higher preinterventional risk evaluation (EuroScore II 8% in the intercostal vs. 4% in the TAo group, p = 0.005). Successful device implantation and a reduction of the transvalvular gradient were achieved in all cases with a significantly lower rate of trace to mild paravalvular leakage in the intercostal group (12% vs. 33%, p < 0.001). The intercostal group required significantly fewer blood transfusions (0 vs. 2 units, p = 0.001) and tended to require less reoperation (7% vs. 15%, p = 0.084). Hospital stays (9 vs. 12 d, p = 0.011) were also shorter in the intercostal group. Short- and long-term survival in the follow-up showed comparable results between the two approaches (30-day, 6-month- and 2-year mortality: 7%, 23% and 36% in the intercostal vs. 9%, 26% and 33% in the TAo group) with acute kidney injury (AKI) and reintubation being independent risk factors for mortality. CONCLUSIONS: Transaortic TAVI via an intercostal access offers a safe and effective treatment of aortic valve stenosis.

Aortic Root Replacement Surgery-A Center Experience with Biological Valve Prostheses.

OBJECTIVE: Outcomes after surgical aortic root replacement using different valved conduits are rarely reported. The present study shows the experience of a single center with the use of the partially biological LABCOR (LC) conduit and the fully biological BioIntegral (BI) conduit. Special attention was paid to preoperative endocarditis. METHODS: All 266 patients who underwent aortic root replacement by an LC conduit (n = 193) or a BI conduit (n = 73) between 01/01/2014 and 31/12/2020 were studied retrospectively. Dependency on an extracorporeal life support system preoperatively and congenital heart disease were exclusion criteria. For patients with (n = 67) and without (n = 199) preoperative endocarditis subanalyses were made. RESULTS: Patients treated with a BI conduit were more likely to have diabetes mellitus (21.9 vs. 6.7%, p < 0.001), previous cardiac surgery (86.3 vs. 16.6%; p < 0.001), permanent pacemaker (21.9 vs. 2.1%; p < 0.001), and had a higher EuroSCORE II (14.9 vs. 4.1%; p < 0.001). The BI conduit was used more frequently for prosthetic endocarditis (75.3 vs. 3.6%; <0.001), and the LC conduit was used predominantly for ascending aortic aneurysms (80.3 vs. 41.1%; <0.001) and Stanford type A aortic dissections (24.9 vs. 9.6%; p = 0.006). The LC conduit was used more often for elective (61.7 vs. 47.9%; p = 0.043) and emergency (27.5 vs. 15.1%; p = 0-035) surgeries, and the BI conduit for urgent surgeries (37.0 vs. 10.9%; p < 0.001). Conduit sizes did not differ significantly, with a median of 25 mm in each case. Surgical times were longer in the BI group. In the LC group, coronary artery bypass grafting and proximal or total replacement of the aortic arch were combined more frequently, whereas in the BI group, partial replacement of the aortic arch were combined. In the BI group, ICU length of stay and duration of ventilation were longer, and rates of tracheostomy and atrioventricular block, pacemaker dependence, dialysis, and 30-day mortality were higher. Atrial fibrillation occurred more frequently in the LC group. Follow-up time was longer and rates of stroke and cardiac death were less frequent in the LC group. Postoperative echocardiographic findings at follow-up were not significantly different between conduits. Survival of LC patients was better than that of BI patients. In the subanalysis of patients with preoperative endocarditis, significant differences between the used conduits were found with respect to previous cardiac surgery, EuroSCORE II, aortic valve and prosthesis endocarditis, elective operation, duration of operation, and proximal aortic arch replacement. For patients without preoperative endocarditis, significant differences were observed concerning previous cardiac surgery, pacemaker implantation history, duration of procedure, and bypass time. The Kaplan-Meier curves for the subanalyses showed no significant differences between the used conduits. CONCLUSIONS: Both biological conduits studied here are equally suitable in principle for complete replacement of the aortic root in all aortic root pathologies. The BI conduit is often used in bail-out situations, especially in severe endocarditis, without being able to show a clinical advantage over the LC conduit in this context.

Midterm Follow-up of the Transatrial-to-Left Ventricle Cannulation for Acute Type A Dissection.

BACKGROUND: It is still controversial as to which cannulation strategy for acute type A aortic dissection (AAD) is optimal. Antegrade perfusion to diminish further organ malperfusion and ischemia is preferable. METHODS: We retrospectively analyzed a total of 420 patients who underwent AAD surgery from January 2001 to December 2020. Group A included 229 patients with a transatrial cannulation; group B included 191 patients with all other additionally used cannulation sites. A retrospective analysis was conducted at 30 days and according to clinical outcome and midterm mortality. Risk factors for probability of death were analyzed by multifactorial logistic regression. RESULTS: The calculated risk scores and demographic preoperative variables were comparable except for hyperlipoproteinemia (P = .011) and redo operation in group B (P < .001) and more pericardial tamponade in group A (P = .006). In addition, fewer patients with postoperative new onset of renal failure were observed in group A (P = .039), although new onset of dialysis was not different between the groups (P = .878). Patients in group A were discharged from the hospital significantly earlier (P = .004). Nevertheless, although significantly more total arch surgery was performed in group A, shorter operation times (P < .001) and lower transfusion rates were observed in group A. Patients' follow-up after a median time of 3.6 (0.6-7.6) years showed no difference in 30-day, 1-year, and long-term mortality. Multivariate logistic regression revealed aortic valve stenosis (P = .041), coronary artery bypass graft surgical procedures (P = .014), preoperative cardiopulmonary resuscitation (P < .001), and length of surgery (P = .032) as the strongest risk factors for mortality. CONCLUSIONS: Transatrial cannulation for AAD operation was safe and successfully performed under emergent conditions. Although no benefit in mortality was achieved, clinical benefits of shorter operation times, less transfusion, better kidney preservation, and earlier discharge of the patient were observed.

Mid- and Long-Term Surgical Outcomes Due to Infective Endocarditis in Elderly Patients: A Retrospective Cohort Study.

BACKGROUND: Infective endocarditis (IE) is one of the true remaining dreaded situations in cardiovascular medicine. Current international guidelines do not include specific recommendations for treatment options of infective endocarditis (conventional vs. surgical) based on the patient's age, functional status or comorbidities. Elderly patients have less invasive and often delayed surgeries compared to younger patients due to their shorter long-term survival probabilities. In the setting of IE, this might not be the right treatment, as surgery is the only curative option in up to 50% of all endocarditis patients. The aim of our study was to evaluate the mid- and long-term surgical outcomes due to infective endocarditis of patients aged ≥70 years. METHODS: Between 2002 and 2020, a retrospective study with 137 patients aged 70 years and older and 276 patients aged below 70 years was conducted. Altogether, 413 consecutive patients who received surgery due to infective native or prosthetic valve endocarditis were assigned to either the elderly (E)-Group or the control (C)-Group. Primary endpoints were short- and long-term MACCEs (Major Adverse Cardiac and Cerebrovascular Events) as a composite of death or major adverse events, and secondary endpoints were intraoperative variables and postoperative course. RESULTS: Preoperative risk factors differed significantly. Elderly patients had more arterial hypertension, atrial fibrillation, diabetes, chronic renal insufficiency and coronary heart disease. Fewer of them were in a state of emergency. Time from diagnosis to OR, antibiotic pretreatment, length of surgery and cardiopulmonary bypass time were significantly longer in the E-Group. Furthermore, 44.5% of patients in the E-Group had prosthesis endocarditis as opposed to 29.7% in the C-group. During postoperative follow-up, new onset of hemodialysis, duration of ventilation, delirium, reintubation and tracheotomy rates were significantly higher in the E-Group. There were significant differences in 7- and 30-day mortality. One- year survival was 62% for the E-Group and 79% for the C-Group. Five-year survival was 47% for the E-Group and 67% for the C-Group. CONCLUSIONS: This study demonstrates that surgery for infective endocarditis is a high-risk procedure, especially for elderly people. Nevertheless, as it is more or less the only concept to increase long-term survival, it should be offered generously to all patients who are still able to take care of themselves.

Sex-Specific Risk Factors for Short- and Long-Term Outcomes after Surgery in Patients with Infective Endocarditis.

(1) Background: Surgery for infective endocarditis (IE) is associated with considerable mortality and it is controversial whether the female gender is predictive for a worse outcome. This large single-center study investigated the impact of sex on outcomes after surgery for IE. (2) Methods: 413 patients (25.4% female) were included into this retrospective observational study. Univariate and multivariable analyses identified sex-specific risk factors for 30 day and late mortality. Survival was estimated by the Kaplan-Meier-method. (3) Results: Women presented more often with mitral valve infection (p = 0.039). Men presented more frequently with previous endocarditis (p = 0.045), coronary heart disease (p = 0.033), and aortic valve infection (p = 0.005). Blood transfusion occurred more frequently intraoperatively in women (p < 0.001), but postoperatively in men (p = 0.015) and men had a longer postoperative stay (p = 0.046). Women showed a higher 30 day mortality than men (p = 0.007) and female gender was predictive for 30 day mortality (OR 2.090). Late survival showed no sex-specific difference (p = 0.853), and the female gender was not an independent predictor for late mortality (p = 0.718). Risk factors for early and late mortality showed distinct sex-specific differences such as increased preoperative CRP level in women and culture-negative IE in men.

Severe Pulmonary Bleeding after Assist Device Implantation: Incidence, Risk Factors and Prognostic Impact.

Background: Continuous flow left ventricular assist devices (CF-LVAD) improve survival in patients with advanced heart failure but confer risk of bleeding complications. Whereas pathophysiology and risk factors for many bleeding complications are well investigated, the literature lacks reports about pulmonary bleeding. Therefore, it was the aim of the present study to assess incidence, risk factors, and clinical relevance of pulmonary bleeding episodes after LVAD implantation. Methods: We retrospectively analyzed our institutional database of 125 consecutive patients who underwent LVAD implantation between 2008 and 2017. Demographic and clinical variables related to bleeding were collected. The primary endpoint was incidence of severe pulmonary bleeding (SPB). Results: Nine out of 125 patients suffered from SPB during the postoperative course (7.2%) 11 days after surgery in the median. None of them had a known history of lung disease or bleeding disorder. History of prior myocardial infarction (0% vWD. 42.2%, p = 0.012) and ischemic cardiomyopathy (25.0% vs. 50.0%, p = 0.046) were less frequent in the SBP group. Concomitant aortic valve replacement was more common in the group with SPB (33.3% versus 7.0%, p = 0.034). Surgical (blood loss 9950 vs. 3800 mL, p = 0.012) as well as ear-nose-throat (ENT) bleedings (33% vs. 4.6%, p = 0.015) were observed more frequently in patients with SPB. SPB was associated with a complicated postoperative course with a higher incidence of acute kidney failure (100% versus 36.7%, p = 0.001) and delirium (44.4% versus 14.8%, p = 0.045); a higher need for red blood cell (26 packs versus 7, p < 0.001), fresh frozen plasma (18 units versus 6, p = 0.002), and platelet transfusion (8 pools versus 1, p = 0.001); longer ventilation time (1206 versus 171 h, p = 0.001); longer ICU-stay (58 versus 13 days, p = 0.002); and higher hospital mortality (66.7% vs. 29%, p = 0.029). Conclusion: SPB is a rare but serious complication after LVAD implantation and is significantly associated with higher morbidity and mortality. The pathophysiology and potential risk factors are unknown but may include coagulation disorders and frequent suctioning or empiric bronchoscopy causing airway irritation.

Cardiac Myxomas Resembling Malignant Neoplasia: Incidentally Diagnosed vs. Cerebral Embolized Myxomas.

Background: Cardiac myxomas (CM) are the most common primary cardiac tumors in adults. They are usually benign; however, malignant changes are known to occur but are extremely rare. Embolization is a common complication of cardiac myxomas and can cause neurological deficits before their surgical removal. The current study analyzed the outcomes after operative myxoma excision in patients, with and without cerebral embolic events prior to excision. Methods: All 66 consecutive patients who underwent a surgical excision of CM between 2005 and 2019 at our department were analyzed retrospectively. Patients with (n = 14) and without (n = 52) preoperative strokes caused by cerebral tumor embolization were compared. Results: The mean age was 58.4 ± 12.7 years in the stroke group (SG) and 62.8 ± 11.7 years in the non-stroke group (N-SG) (p = 0.226). Gender (35.7% vs. 61.5% female; p = 0.084) did not differ significantly, and comorbidities were comparable in both groups. The left hemisphere in the territory of the middle cerebral artery was affected by preoperative cerebral infarction most commonly (28.6%). The time from diagnosis to cardiac surgery procedure was 7 (3−24) days in the SG and 23 (5−55) days in the N-SG (p = 0.120). Cardiac myxomas were localized in the left atrium in both groups more frequently (SG: 92.9% vs. N-SG: 78.8%; p = 0.436). In the SG, 57.1% of CM had a non-solid surface, were localized in the left heart, and had a pedunculated attachment away from the fossa ovalis. In the N-SG, 92.3% of CM did not meet all these criteria (p < 0.001). The maximal diameters of CM were comparable (SG: 3.4 ± 1.5 cm vs. N-SG: 3.8 ± 2.1 cm; p = 0.538). The operation times (192.5 (139.3−244.5) min vs. 215.5 (184.5−273.3) min; p = 0.046) and the cross-clamp times (54.5 (33.3−86.5) min vs. 78.5 (55−106.8) min; p = 0.035) were significantly shorter in the SG. Only in the N-SG were reconstructions of the endocardium with bovine pericardium required after resection (51.9% vs 0%; p < 0.001). In the N-SG, CM were explored via the right atrium more often (57.7% vs. 14.3%; p = 0.007). Patients in the N-SG required significantly shorter ICU care after surgery (p = 0.020). Other postoperative courses did not differ significantly. After tumor removal, 1.9% of the N-SG suffered their first stroke and 14.3% of the SG had a cerebral re-infarction (p = 0.111). The 30-day mortality rates were 1.9% in the N-SG and 7.1% in the SG (p = 0.382). In one case in the N-SG, a tumor recurrence was diagnosed. The Kaplan−Meiercurves showed a significantly better long-term prognosis for patients in the N-SG (p = 0.043). Conclusions: After the surgical removal of CM, the outcome is compromised if preoperative cerebral embolization occurs. Surgical treatment is therefore indicated as soon as possible, especially when CM have a non-solid surface, are localized in the left heart, and have a pedunculated attachment away from the fossa ovalis.

Association between Duration of Deep Hypothermic Circulatory Arrest and Surgical Outcome in Patients with Acute Type A Aortic Dissection: A Large Retrospective Cohort Study.

(1) Background: Deep hypothermic circulatory arrest (DHCA) with selective antegrade cerebral perfusion (ACP) is an established cerebral protection technique for the conduction of complex surgical procedures involving the aortic arch. It is controversial whether the duration of DHCA is associated with adverse outcome in patients with acute type A aortic dissection (AAAD). Our goal was to investigate whether DHCA time was associated with surgical outcome in patients undergoing a surgical treatment of AAAD. (2) Methods: A total of 410 patients were divided into two groups based on the DHCA time less than 60 min and equal to or longer than 60 min. (3) Results: Patients with longer DHCA times were significantly younger (p = 0.001). Intraoperatively, complex procedures with aortic arch surgery were more common in patients with longer DHCA times (p < 0.001). Accordingly, cardiopulmonary bypass (p < 0.001), cross-clamping (p < 0.001) and DHCA times (p < 0.001) were significantly longer in this group. Postoperatively, only the duration of mechanical ventilation (p < 0.001) and the rate of tracheotomy were significantly higher in these patients. Thirty-day mortality was satisfactory for both groups (p = 0.746). (4) Conclusions: Our results showed that improvements in perioperative management including ACP allow for the successful performance of surgical treatment of AAAD under DHCA with a duration of even longer than 60 min.

Preoperative Predictors of Adverse Clinical Outcome in Emergent Repair of Acute Type A Aortic Dissection in 15 Year Follow Up.

BACKGROUND: Acute type A aortic dissection (AAAD) has high mortality. Improvements in surgical technique have lowered mortality but postoperative functional status and decreased quality of life due to debilitating deficits remain of concern. Our study aims to identify preoperative conditions predictive of undesirable outcome to help guide perioperative management. METHODS: We performed retrospective analysis of 394 cases of AAAD who underwent repair in our institution between 2001 and 2018. A combined endpoint of parameters was defined as (1) 30-day versus hospital mortality, (2) new neurological deficit, (3) new acute renal insufficiency requiring postoperative renal replacement, and (4) prolonged mechanical ventilation with need for tracheostomy. RESULTS: Total survival/ follow-up time averaged 3.2 years with follow-up completeness of 94%. Endpoint was reached by 52.8%. Those had higher EuroSCORE II (7.5 versus 5.5), higher incidence of coronary artery disease (CAD) (9.2% versus 3.2%), neurological deficit (ND) upon presentation (26.4% versus 11.8%), cardiopulmonary resuscitation (CPR) (14.4% versus 1.6%) and intubation (RF) before surgery (16.9% versus 4.8%). 7-day mortality was 21.6% versus 0%. Hospital mortality 30.8% versus 0%. CONCLUSIONS: This 15-year follow up shows, that unfavorable postoperative clinical outcome is related to ND, CAD, CPR and RF on arrival.

Outcome of Unilateral Pulmonary Edema after Minimal-Invasive Mitral Valve Surgery: 10-Year Follow-Up.

The study was approved by the institutional review board (IRB) at the University Medical Center Campus Kiel, Kiel, Germany (reference number: AZ D 559/18) and registered at the German Clinical Trials Register (reference number: DRKS00022222). OBJECTIVE: Unilateral pulmonary edema (UPE) is a complication after minimally invasive mitral valve surgery (MIMVS). We analyzed the impact of this complication on the short- and long-term outcome over a 10-year period. METHODS: We retrospectively observed 393 MIMVS patients between 01/2009 and 12/2019. The primary endpoint was a radiographically and clinically defined UPE within the first postoperative 24 h, secondary endpoints were 30-day and long-term mortality and the percentage of patients requiring ECLS. Risk factors for UPE incidence were evaluated by logistic regression, and risk factors for mortality in the follow-up period were assessed by Cox regression. RESULTS: Median EuroSCORE II reached 0.98% in the complete MIMVS group. Combined 30-day and in-hospital mortality after MIMVS was 2.0% with a 95, 93 and 77% survival rate after 1, 3 and 10 years. Seventy-two (18.3%) of 393 patients developed a UPE 24 h after surgery. Six patients (8.3%) with UPE required an extracorporeal life-support system. Logistic regression analysis identified a higher creatinine level, a worse LV function, pulmonary hypertension, intraoperative transfusion and a longer aortic clamp time as predictors for UPE. Combined in hospital mortality and 30-day mortality was slightly but not significantly higher in the UPE group (4.2 vs. 1.6%; p = 0.17). Predictors for mortality during follow-up were age ≥ 70 years, impaired RVF, COPD, drainage loss ≥ 800 mL and length of ventilation ≥ 48 h. During a median follow-up of 4.6 years, comparable survival between UPE and non-UPE patients was seen in our analysis after 5 years (89 vs. 88%; p = 0.98). CONCLUSIONS: In-hospital outcome with UPE after MIMVS was not significantly worse compared to non-UPE patients, and no differences were observed in the long-term follow-up. However, prolonged aortic clamp time, worse renal and left ventricular function, pulmonary hypertension and transfusion are associated with UPE.

Minimally Invasive Direct Coronary Artery Bypass in High-Risk Patients with Multivessel Disease.

BACKGROUND: High-risk patients with multivessel disease (MVD) including a complex stenosis of the left anterior descending coronary may not be ideal candidates for guideline compliant therapy by coronary artery bypass grafting (CABG) regarding invasiveness and perioperative complications. However, they may benefit from minimally invasive direct coronary artery bypass (MIDCAB) grafting and hybrid revascularization (HCR). METHODS: A logistic European system for cardiac operative risk evaluation score (logES) >10% defined high risk. In high-risk patients with MVD undergoing MIDCAB or HCR, the incidence of major adverse cardiac and cerebrovascular events (MACCEs) after 30 days and during midterm follow-up was evaluated. RESULTS: Out of 1,250 patients undergoing MIDCAB at our institution between 1998 and 2015, 78 patients (logES: 18.5%; age, 76.7 ± 8.6 years) met the inclusion criteria. During the first 30 days, mortality and rate of MACCE were 9.0%; early mortality was two-fold overestimated by logES. Complete revascularization as scheduled was finally achieved in 64 patients (82.1%). Median follow-up time reached 3.4 (1.2-6.5) years with a median survival time of 4.7 years. Survival after 1, 3, and 5 years was 77, 62, and 48%. CONCLUSION: In high-risk patients with MVD, MIDCAB is associated with acceptable early outcome which is better than predicted by logES. Taking the high-risk profile into consideration, midterm follow-up showed satisfying results, although scheduled HCR was not realized in a relevant proportion. In selected cases of MVD, MIDCAB presents an acceptable alternative for high-risk patients.

Active Infective Native and Prosthetic Valve Endocarditis: Short- and Long-Term Outcomes of Patients after Surgical Treatment.

BACKGROUND: Active infective endocarditis (IE) is a serious disease associated with high mortality. The current study represents our experience over 18 years with surgical treatment for active infective native and prosthetic valve endocarditis (INVE, IPVE). METHOD: Analysis of 413 patients (171 with IPVE vs. 242 with INVE) who underwent cardiac surgery due to IE between 2002 and 2020. RESULTS: Patients with IPVE were significantly older (64.9 ± 13.2 years vs. 58.3 ± 15.5 years; p < 0.001) with higher EuroSCORE II (21.2 (12.7; 41.8) vs. 6.9 (3.0; 17.0); p < 0.001)) and coronary heart disease (50.6% vs. 38.0%; p < 0.011). Preoperative embolization was significantly higher within INVE (35.5% vs. 16.4%; p < 0.001) with high incidence of cerebral embolization (18.6% vs. 7.6%; p = 0.001) and underwent emergency curative surgery than the IPVE group (19.6% vs. 10.6%; p < 0.001). However, patients with IPVE were significantly represented with intracardiac abscess (44.4% vs.15.7%; p < 0.001). Intraoperatively, the duration of surgery was expectedly significantly higher in the IPVE group (356 min vs. 244 min.; p = 0.001) as well as transfusion of blood (4 units (0-27) vs. 2 units (0-14); p < 0.001). Post-operatively, the incidence of bleeding was markedly higher within the IPVE group (700 mL (438; 1163) vs. 500 mL (250; 1075); p = 0.005). IPVE required significantly more permanent pacemakers (17.6% vs. 7.5%: p = 0.002). The 30-day mortality was higher in the IPVE group (24.6% vs. 13.2%; p < 0.003). CONCLUSION: Patients with INVE suffered from a higher incidence of cerebral embolization and neurological deficits than patients with IPVE. Surgical treatment in INVE is performed mostly as an emergency indication. However, patients with IPVE were represented commonly with intracardiac abscess, and had a higher indication of pacemaker implantation. The short- and long-term mortality rate among those patients was still high.

Influence of Age on Postoperative Neurological Outcomes after Surgery of Acute Type A Aortic Dissection.

BACKGROUND: Acute type A aortic dissection (AAAD) is considered a fatal disease which requires an emergent surgical intervention. This study focuses onthe neurological outcome after surgical repair in cases of AAAD in comparison between elderly and young patients. METHODS: a retrospective analysis of 368 consecutive patients who underwent emergency surgery of ascending aorta in moderate hypothermic circulatory arrest (MHCA) (20-24 °C) and antegrade cerebral perfusion after AAAD between 2001 and 2016. Patients were divided into two groups: those aged 75 years and older (68 (18.5%)) and those younger than 75 years (300 (81.5%)). RESULTS: Comparing both groups, average age was 79.0 ± 3.2 vs. 59.2 ± 10.7 years (p < 0.001); female gender represents 58.8% of elderly patients vs. 28.7% in younger patients (p < 0.001). Intraoperatively, cardiopulmonary bypass time (155 min (131; 187) vs. 171 min (137; 220); p = 0.012), cross-clamping time (79 min (60; 105) vs. 93 min (71; 134); p = 0.001] and circulatory arrest time (29 min (22; 40) vs. 33 min (26; 49); p = 0.011) were significantly shorter in elderly than younger group. Postoperatively, there was no significant difference in delirium (11.8% vs. 20.5%; p = 0.0968) or stroke (11.8% vs. 16.1%; p = 0.369). The 30-day mortality was satisfactory for both groups but significantly higher in the elderly group (27.9% vs. 14.3%; p = 0.007). CONCLUSION: The current study concluded that surgical treatment of AAAD in elderly patients can be applied safely without increasing risk of neurological complication. However, minimizing operation time may help limit the occurrence of postoperative neurological complication.

Risk Factors for Mortality in Acute Aortic Dissection Type A: A Centre Experience Over 15 Years.

INTRODUCTION: Acute aortic dissection Type A (AADA) is still associated with a high mortality rate and frequent postoperative complications. This study was designed to evaluate the risk factors for mortality in AADA patients. PATIENTS AND METHODS: This retrospective analysis included 344 consecutive patients who underwent surgery for AADA in moderate hypothermic circulatory arrest (20-24°C nasopharyngeal) between 2001 and 2016. RESULTS: The 30-day mortality rate was 18%. Nonsurvivors were significantly older (65.7 ± 12.0 years vs. 62.0 ± 12.5 years; p = 0.034) with significantly higher Euro-score II [15.4% (6.6; 23.0) vs. 4.63% (2.78; 9.88); p < 0.001)]. Intraoperatively, survivors had statistically shorter cardiopulmonary bypass times [163 (134; 206) vs. 198 min (150; 245); p = 0.001]. However, the hypothermic circulatory arrest time was similar between both groups. Postoperatively, the incidence of acute kidney injury (AKI) (55.9 vs. 15.2%; p < 0.001), stroke (27.9 vs. 12.1%; p = 0.002) and sepsis (18.0 vs. 2.1%; p < 0.001) were significantly higher among nonsurvivors. The multi-variable logistic regression confirmed that older age, previous cardiac surgery, preoperative cardiopulmonary resuscitation (CPR), blood transfusion and postoperative acute kidney injury (AKI) were independent risk factors for mortality. CONCLUSION: Our analysis suggested that the reason for mortality was multifactorial, especially age, previous cardiac surgery, CPR, transfusion, as well as postoperative AKI were considered risk factors for mortality.

Sex-Specific Outcome after Ascending Aortic Surgery in Moderate Hypothermic Circulatory Arrest.

BACKGROUND: Historically, female patients had worse outcome undergoing heart surgery. No recent data exist on gender-specific outcome after moderate hypothermic circulatory arrest (MHCA). The aim of this large retrospective analysis was to investigate gender disparity in patients undergoing elective surgery of ascending aorta in MHCA at 24°C. METHODS: We conducted a retrospective review of 905 (33.3% female) cases of elective heart surgery in MHCA for ascending aortic aneurysm (90.9%) or severely calcified aorta (12.5%) between 2001 and 2015. Furthermore, 299 female and 299 male patients matched by propensity score were compared. Patients with dissection of the aorta were excluded. RESULTS: Women were older (68.4 ± 9.9 vs. 65.8 ± 11.6 years; p = 0.002), had higher logistic EuroSCORE I (18.4 [11.7; 29.2] vs. 12.3% [7.4; 22.6]; p < 0.001), and significantly shorter cardiopulmonary bypass (CPB) time (132 [105; 175] vs. 150 [118; 192] minutes; p < 0.001), while mean MHCA time was longer (15 [13; 19] vs. 14 [12; 17] minutes; p = 0.003). Surgical procedures were less complex in women and they were treated more frequently by isolated supracoronary ascending aorta replacement (61 vs. 54%; p = 0.046). Postoperatively, men showed a higher incidence of neurologic complications (7.0 vs. 3.3%; p = 0.03). The 30-day mortality (women 4.9% vs. men 3.9%; p = 0.48) did not differ significantly, likewise after statistical matching (4.7 vs. 2.3%; p = 0.120). Age, CPB time, and blood transfusion, but not female gender, were risk factors for mortality in multivariable regression analysis. CONCLUSION: This study supports the hypothesis that female gender is not associated with increased short-term mortality or perioperative adverse events in elective aortic surgery in MHCA.

Comparison of outcomes in DeBakey type I versus DeBakey type II aortic dissection: a 17-year single center experience.

BACKGROUND: It is controversial if the type or the size of aortic dissection is associated with the mortality in patients with acute aortic dissection (AAD) type I or type II according to DeBakey. Due to the pronounced aortic pathology in DeBakey type I compared to DeBakey type II, it is to be expected, that the DeBakey type I is associated with a significant higher morbidity and mortality. But we hypothesize that the current advances in surgical techniques, circulatory management, and postoperative care improve the clinical outcome of patients with DeBakey type I and II. The purpose of this study was to evaluate retrospectively the effect of these parameters on surgical outcome in patients with DeBakey type I and type II in a large cohort study. METHODS: From 2001 to 2019, 395 consecutive patients (34.2% female) underwent surgical aortic repair at our institution. Patients were retrospectively classified into 2 groups: patients with type 1 dissection (group 1: n=309, median age of 62.0 years) and patients with type 2 dissection (group 2: n=86, 67.5 years). Survival was estimated by Kaplan-Meier estimator. Risk factors were analyzed by logistic regression analysis. RESULTS: The patients in group 1 suffered significantly more often from coronary heart disease [43 (13.9%) vs. 20 (23.3%), P=0.036]. Otherwise, there were no significant differences between both groups concerning preoperative risk factors. The median surgical duration (279 vs. 263 min, P=0.026) and the circulatory arrest time (35 vs. 27 min, P<0.001) in group 1 were significantly higher. In a significantly higher number of patients in group 1, the aortic arch was completely replaced (18.4% vs. 1.2%, P<0.001) and a simultaneous coronary artery bypass grafting [18 (5.8%) vs. 11 (12.8%), P=0.028] was performed. The rate of re-thoracotomy [62 (20.1%) vs. 9 (10.5%), P=0.040], of postoperative delirium [66 (21.4%) vs. 9 (10.6%), P=0.024], and of tracheotomy [85 (27.5%) vs. 14 (16.3%), P=0.034] were significantly higher in group 1. Thirty-day mortality was 15.7% and did not differ significantly between both groups (P=0.867), as well as the long-term survival rates (P=0.956). CONCLUSIONS: Due to the pronounced aortic pathology in type I compared to type II, it is to be expected, that the type I is associated with a significant higher morbidity and mortality. DeBakey type I was an independent predictor for 30-day mortality in our study, however, based on our 17-year single center experience there was no difference between the long-term survival in both groups.

Is total arch replacement associated with an increased risk after acute type A dissection?

BACKGROUND: The surgical strategy for acute type A aortic dissection (AADA) usually consists of reconstruction of the tear-lesion in the affected part of the ascending aorta. The optimal strategy either to replace the ascending aorta (AAR) or to replace the ascending aorta and the total aortic arch (TAAR) is still under debate. Our study compares the 30-day mortality between AAR and TAAR in AADA surgery. METHODS: In this retrospective observational study, we analysed a total patient cohort of 339 patients who underwent surgery for AADA from January 2001 until December 2016. A propensity score-matched analysis between the AAR- and the TAAR-group with 43 patients for each subgroup was subsequently carried out. A multivariable analysis was performed to identify risk-factors for the 30-d-mortality. The 30-day mortality was defined as the primary end-point and long-term survival was the secondary endpoint. RESULTS: In 292 (86.1%) patients AAR and in 47 (13.9%) patients TAAR was performed for emergent AADA. Patients were older (P=0.049) in the AAR group. The median log Euro-SCORE was 25.5% (12.7; 41.7) for AAR and 19.7% (11.7; 32.2) for the TAAR patient cohort (P=0.12). Operative time, cardiopulmonary bypass- (CPB), cross-clamp- and ischemic time were significantly longer in the TAAR group (P<0.001). The overall 30-day mortality-rate was 17.7% (n=60) but was not significantly different between the two groups (P=0.27). Forty-nine (16.8%) patients died in the AAR and 11 patients (23.4%) in the TAAR group. After propensity-score matching, no difference in mortality was seen between the subgroups as well (P=0.44). Multivariable analysis identified the Euro-SCORE, long operation-time, postoperative dialysis and arrhythmia and administration of red blood cell concentrates as risk factors for 30-day mortality, but not for TAAR versus AAR. CONCLUSIONS: The therapeutic goal in AADA surgery should be the complete restoration of the aorta to avoid further long-term complications and re-operations. Though 30-day mortality and postoperative co-morbidity for AAR are comparable to those in TAAR after treatment of AADA in our analysis, decision-making for the surgical strategy should weigh the operative risk of TAAR against the long-term outcome.

Influence of moderate hypothermic circulatory arrest on outcome in patients undergoing elective replacement of thoracic aorta.

BACKGROUND: The ideal technique of cerebral protection in the surgical operation of the ascending aorta.is currently controversial. The current analysis evaluates the influence of moderate hypothermic circulatory arrest (MHCA) on elective replacement of the ascending aorta. METHODS: The study included 905 consecutive patients between 2001 and 2015, who underwent replacement of ascending aorta in MHCA. Patients were divided according to the postoperative 30-day mortality into survivor und non-survivor group. RESULTS: The average age was 66.5±11.1 in survivors vs. 70.0±10.5 years in non-survivors (P=0.057). The survivor group had a significantly lower Euro-SCORE II than non-survivors [4.0% (2.3, 6.6) vs. 9.5% (4.8, 20.9); P<0.001)]. The incidence of coronary heart disease (38.0% vs. 58.3%; P=0.022) and chronic renal failure (10.0% vs. 33.3%, P<0.001 was significantly higher in non-survivors. Intraoperatively, the cardiopulmonary bypass time [140 min (112, 185) vs. 194 min (164, 271); P<0.001] and cross-clamping time [91 min (64, 124) vs.119 min (94, 157); P<0.001] were significantly longer in non-survivors. However, the MHCA time was similar in both groups with statistical significance (P=0.023). Postoperatively, re-exploration due to bleeding was highly significant in non-survivors (5.4% vs. 33.3%; P<0.001) with a higher incidence of stroke (4.6% vs. 33.3%; P<0.001). The duration of mechanical ventilation was significantly shorter in survivors than in non-survivors [17 h (12, 26) vs. 147 h (49, 337); P<0.001] with a lower incidence of pulmonary infection (6.0% vs.16.7%; P=0.023). The multivariable logistic regression analysis showed age, female gender, aortic aneurysm, additional CABG, total arch replacement and cardiopulmonary bypass time were independent risk factors for 30-day mortality. CONCLUSIONS: The acceptable morbidity and mortality rates show that MHCA can be considered as a safe technique for cerebral protection in surgical replacement of thoracic aorta.