PET-scan in diagnosis of non-bacterial thrombotic endocarditis: a case report.

BACKGROUND: Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis or Libman-Sacks endocarditis, is a rare non-infectious condition affecting mostly the left-sided heart valves of patients who, most often, suffer from malignancies and connective tissue disorders. Herein, we present a case of a male patient with marantic endocarditis due to occult lung adenocarcinoma. CASE PRESENTATION: The patient fulfilled the modified Duke's criteria of possible bacterial endocarditis of the aortic valve; however, multiple blood cultures and serological tests were negative. In addition, the patient's clinical course was constantly deteriorating. Thus, a fluorodeoxyglucose-positron emission tomography (FDG-PET) scan was conducted. This examination revealed multiple positive thoracic lymph node groups, as well as a positive lung lesion. The patient underwent aortic valve replacement and lymph biopsies during the operation established the diagnosis of solid/micropapillary lung adenocarcinoma and consequently of the non-bacterial thrombotic endocarditis. CONCLUSIONS: Advanced imaging techniques may be needed to diagnose NBTE and should be kept in mind when the Duke criteria are not definite. Clinical suspicion is key to implement these premises. However, the exact role of the PET-scan has yet to be specified.

Tracheal resection in patients post-COVID-19 is associated with high reintervention rate and early restenosis.

Objectives: A remarkable increase in the number of patients presenting with tracheal complications after prolonged endotracheal intubation and mechanical ventilation for the management of the severe COVID-19-associated respiratory failure has been observed. In this study, we assessed the postoperative outcomes of tracheal resection in patients with COVID-19. Methods: We conducted a retrospective study in which all patients with a history of prolonged invasive mechanical ventilation due to COVID-19 infection, who were treated with tracheal resection and reconstruction, were included. The primary objective was in-hospital mortality and postoperative reintervention rate. The secondary objective was the time to tracheal restenosis. Results: During the 16-month study period, 11 patients with COVID-19 with tracheal complications underwent tracheal resection with end-to-end anastomosis. Mean patient age was 51.5 ± 9 years, and the majority were male (9 patients). Eight patients were referred for management of postintubation tracheal stenosis, and 3 patients were referred for tracheoesophageal fistula. Eight patients had a history of tracheostomy during the COVID-19 infection hospitalization. There was 1 in-hospital death (9.1%) due to septicemia in the intensive care unit approximately 2 months after the operation. Postoperatively, 32 reinterventions were required for tracheal restenosis due to granulation tissue formation. The risk for reintervention was higher during the first 3 months after the index operation. Four patients developed tracheal restenosis (36.4%), and 2 of them required endotracheal stent placement during the follow-up period. Conclusions: Tracheal resection and reconstruction after COVID-19 infection are associated with a high reintervention rate postoperatively. Such patients require close follow-up in expert interventional pulmonology units, and physicians should be on high alert for the early diagnosis and optimal management of tracheal restenosis.

Individual Patient Data Meta-Analysis of 10-Year Follow-Up after Endovascular and Open Repair for Ruptured Abdominal AorticAneurysms.

BACKGROUND: Endovascular aortic repair (EVAR) has conferred an early survival advantage compared to an open surgical repair (OSR) in patients with ruptured abdominal aortic aneurysms (rAAA). However, the long-term survival benefit after EVAR was not displayed among randomized controlled trials (RCTs), whereas many non-RCTs have provided conflicting results. We conducted a time-to-event individual patient data (IPD) meta-analysis on long-term rAAA data. METHODS: All studies comparing mortality after EVAR versus OSR for rAAA were included. We used restricted mean survival times (RMSTs) as a measure of life expectancy for EVAR and OSR. RESULTS: A total of 21 studies, including 12,187 patients (4952 EVAR and 7235 OSR) were finally deemed eligible. A secondary IPD analysis included 725 (372 EVAR and 353 OSR) patients only from the 3 RCTs (Immediate Management of the Patient With Rupture : Open Versus Endovascular Repair, Endovasculaire ou Chirurgie dans les Anévrysmes aorto-iliaques Rompus and Amsterdam Acute Aneurysm Trial trials). Among all studies, the median survival was 4.20 (95% confidence interval [CI]: 3.70-4.58) years for EVAR and 1.91 (95% CI: 1.57-2.39) years for OSR. Although EVAR presented with increased hazard risk from 4 to 7 years, which peaked at 6 years after the operation, the RMST difference was 0.54 (95% CI: 0.35-0.73; P < 0.001) years gained with EVAR at the end of the 10-year follow-up. IPD meta-analysis of RCTs did not demonstrate significant differences. CONCLUSIONS: At 10-years follow-up, EVAR was associated with a 6.5 month increase in life expectancy when compared to OSR after analyzing all eligible studies. Evidence from our study suggests that a strict follow-up program would be desirable, especially for patients with long-life expectancy.

Ascending Aorta Dissection Before 5.5 cm Diameter; "It Wasn't Raining When Noah Built the Ark".

INTRODUCTION: The aim of this study was to compare mean maximum ascending aortic diameter at the time of acute aortic dissection with the current surgical threshold for elective ascending aortic operations on non-syndromic thoracic aortic aneurysms. MATERIAL AND METHODS: All consecutive non-syndromic adult patients admitted for acute type A aortic dissection in a single tertiary centre were prospectively enrolled from April 2020 to March 2021. The primary endpoint was the difference between mean maximum aortic diameter at the time of dissection and the 5.5 cm threshold for elective repair. Secondary endpoints included 30-day/in-hospital mortality, aortic length and comparison with normal controls, length/height ratio index, "actual" preoperative Euroscore II and "predicted" Euroscore II if electively operated. RESULTS: Among 31 patients ageing 67.3±12.03 years on average, mean maximum aortic diameter at the time of dissection was 5.13±0.66 cm, significantly lower than the guidelines-derived surgical threshold of 5.5 cm (p=0.004). Mean aortic length was 11±1.47 cm, also significantly longer compared normal controls reported in the literature (p<0.001). The 30-day/in-hospital mortality was 35.5%. Mean length/height ratio index was 6.18±0.76 cm/m. Finally, mean "actual" preoperative Euroscore II was 10.43±4.07 which was significantly higher than the 1.47±0.57 "predicted" Euroscore II (p<0.05). CONCLUSIONS: The maximum aortic diameter at the time of acute type A aortic dissection of non-syndromic cases was significantly lower than the current recommendation for elective repair. Lowering of the current diameter-based surgical threshold of 5.5 cm may be profitable in terms of prevention, but further investigations should be undertaken. Length-based thresholds could also add to timely aortic dissection prevention.

Echocardiographic Changes in Cardiac Function After Thoracic Endovascular Aortic Repair: A Systematic Review and Meta-Analysis.

BACKGROUND: Evidence suggests thoracic stent grafts increase the aortic stiffness postimplantation. Our objective was to examine the effect of thoracic aortic stenting on heart function, as demonstrated with echocardiography. METHODS: We considered nonrandomized studies examining echocardiographic parameters (left ventricle ejection fraction (LVEF), left ventricle end-diastolic (LVED) and end-systolic diameter (LVESD), posterior wall thickness (LVPWT), interventricular septal thickness (IVST), mass, and mass index) pre and poststent graft implantation in patients with thoracic aortic diseases (aneurysm, dissection, and blunt injury). MEDLINE and CENTRAL were searched (up to March 2021) for eligible studies. The National Institutes of Health Quality Assessment Tool was used for risk of bias assessment. Echocardiographic data pre and postimplantation were compared using the pooled standardized mean difference (SMD) and 95% confidence interval (CI). RESULTS: Four studies were included in the meta-analysis. Three of the studies were judged to be "good" quality and one "fair". Nonsignificant differences pre and postimplantation were found for ejection fraction (SMD = -0.53, 95% CI = -1.8 to 0.728, P = 0.406), IVST (SMD = -0.79, 95%, CI = -3.25 to 1.66, P = 0.52), EDD (SMD = -0.10, 95% CI = -0.48 to 0.28, P = 0.60), ESD (SMD = -0.66, 95% CI = -2.35 to 1.02, P = 0.44), and PWT (SMD = -2.20, 95% CI = -5.89 to 1.47, P = 0.24). A trend toward an increase in mass postimplantation was found (SMD = 0.28, 95%, CI = -0.03 to 0.60, P = 0.08), but there was no significant difference in mass index (SMD = 0, 95%, CI = -0.195 to 0.195, P = 1). CONCLUSIONS: Thoracic aortic stenting does not appear to significantly impact cardiac physiology as indicated by echocardiographic parameters.

Converting the Fontan Circulation: Challenges and Evolution.

The Fontan operation, the final palliative step after a series of complex operations in patients with univentricular hearts, has undergone multiple modifications throughout the last decades, with the goal of finding the method which combines the optimal hemodynamic effects of the Fontan circulation with minimal long term side effects. An understanding of the operative evolution and subsequent side effects, as well as the management thereof seems imperative. Since its inception by Francis Fontan the, now obsolete, initial atriopulmonary connection has passed through several milestones into having now reached the era of total cavopulmonary connection. However, recently published results bring to light the new option of biventricular conversion which comes to challenge the management of Fontan patients as we know it. Currently, there is no consensus as to whether to continue with palliation in this challenging group of patients or proceed with heart transplantation. In this collective review, we provide a historic overview of the Fontan evolution as well as future insights, discussing the perspectives of options for patients with failing Fontan, including the latest addition of biventricular correction.

Chronic Thoracic Aortic Dissection: How to Treat, When to Intervene.

Thoracic aortic dissection (AD) is associated with increased morbidity and mortality. Acute aortic syndrome is the first presentation of the disease in most cases. While acute AD management follows concrete guidelines because of its urgent and life-threatening nature, chronic AD is usually overlooked, although it concerns a wide spectrum of patients surviving an acute event. Acute AD survivors ultimately enter a chronic aortic disease course. Patients with chronic thoracic AD (CTAD) require lifelong surveillance and a proportion of them may present with symptoms and late complications demanding further surgical or endovascular treatment. However, the available data concerning the management of CTAD is sparse in the literature. The management of patients with CTAD is challenging as far as determining the best medical therapy and deciding on intervention are concerned. Until recently, there were no guidelines or recommendations for imaging surveillance in patients with chronic AD. The diagnostic methods for imaging aortic diseases have been improved, while the data on new endovascular and surgical approaches has increased significantly. In this review, we summarize the current evidence in the diagnosis and management of CTAD and the latest recommendations for the surgical/endovascular aortic repair of CTAD.

Frozen elephant trunk for blunt aortic arch injury.

Total arch replacement with the frozen elephant trunk technique is expanding its indications to treat a wide range of aortic arch and descending aortic conditions. Although blunt thoracic aortic injury commonly occurs at the aortic isthmus or descending thoracic aorta, we encountered a 36-year-old male patient with Grade III blunt aortic injury located in the mid-arch. An endovascular approach was not feasible and thus the patient underwent total arch replacement using the frozen elephant trunk technique.

E-Vita OPEN NEO Hybrid Stent Graft: A New Frontier for Total Arch Replacement.

BACKGROUND: The ever-changing landscape of aortic arch surgery necessitates a constant update on the available devices and technologies for the contemporary management of complex aortic diseases. The E-Vita OPEN NEO hybrid stent graft system offers a unique approach for aortic arch replacement with the frozen elephant trunk technique. In contrast to its predecessors and other commercially available devices, it fits to each individual patient's needs by allowing for more proximal graft anastomosis. We sought to present our initial experience with the novel E-Vita OPEN NEO hybrid stent graft system focusing on its description, optimal graft selection, operative technique, and results in a clinical setting. METHODS: We prospectively collected data on all patients in whom the E-Vita OPEN NEO device was used between October 2020 and May 2021. The primary outcome was perioperative or with 30-day mortality. Secondary outcomes were the incidence of neurologic complications (stroke and spinal cord ischemia) and endoleak on a postoperative computed tomography angiography. RESULTS: During the study period, six patients received the novel hybrid stent device. The mean patient age was 59.3 ± 13.3 years and 83% were male. Two patients were operated on an emergent setting due to acute Stanford type A aortic dissection and there were two reoperations in patients with a history of previous repaired type A dissection. There was no perioperative or 30-day mortality and none of the patients exhibited adverse neurologic events. Two patients required completion thoracic endovascular repair due to type Ib endoleak. One patient died after a prolonged stay in the intensive care unit due to pneumonia and multiorgan failure. CONCLUSIONS: This novel device adapts to each patient's characteristics and offers a curative option for acute and chronic aortic arch and descending aortic conditions such as aneurysmal disease and aortic dissection. In addition, it offers an excellent landing station for potential endovascular therapies and allows for complete aortic remodeling.

Surgical Treatment of Pulmonary Embolism and Chronic Thromboembolic Pulmonary Hypertension.

Venous thromboembolism clinically presents as deep venous thrombosis or acute pulmonary embolism and is globally recognized as the third most frequent acute cardiovascular syndrome after myocardial infarction and stroke. Although pulmonary embolism does not typically cause severe pulmonary hypertension in the acute setting, thrombus organization and fibrosis can lead to stenosis or obliteration of pulmonary arteries in a minority of patients, which in turn result in severe pulmonary hypertension and right heart failure. This disease is labeled chronic thromboembolic pulmonary hypertension and can occur after a single episode or multiple ones of pulmonary embolism. The cornerstone of pulmonary embolism treatment is medical therapy, whereas systemic thrombolytic therapy has to be considered for patients with hemodynamic instability. Given the current acceptable short-term surgical mortality, the potential of first-line surgical embolectomy as an alternative to medical thrombolysis has gained momentum as far as pulmonary embolism treatment is concerned. In contrast to pulmonary embolism, bilateral complete pulmonary endarterectomy under short deep hypothermic circulatory arrest intervals is the treatment of choice against chronic thromboembolic pulmonary hypertension, given patients' operability. Pulmonary endarterectomy is suggested in every operable patient when the operation is offered by an experienced multidisciplinary team, including at least one experienced surgeon. Surgical embolectomy should also be limited to large institutions since it also requires an experienced heart team. This review concerns a thorough discussion regarding surgical treatment of pulmonary embolism and chronic thromboembolic pulmonary hypertension. Eligibility criteria, operation-related complications and postoperative outcomes are discussed in detail.

Implantable cardioverter defibrillators in left ventricular assist device patients: Α systematic review and meta-analysis.

Implantable cardioverter-defibrillators (ICDs) remain the standard of care in advanced heart failure with reduced ejection fraction patients for the prevention of sudden cardiac death. However, current guidelines remain conflicting with respect to the use of ICDs in patients supported with a continuous flow left ventricular assist device (CF-LVAD). The current review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies comparing the use of ICD in patients with CF-LVADs were included. The 2 primary outcomes studied were all-cause mortality, and a successful bridge to heart transplantation. We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs). We also compared baseline characteristics between US and European studies, for CF-LVAD patients with an ICD. Among all studies, the use of an ICD was not associated with all-cause mortality in patients with CF-LVADs (OR: 0.85, 95% CIs: 0.64-1.12, p = 0.24). The presence of an ICD was associated with a trend towards increased likelihood of successful bridge to heart transplantation (OR: 1.12, 95% CI: 1.0-1.3, p = 0.06). A subgroup analysis of studies published by European centers revealed a significant decrease in pooled mortality (OR: 0.58, 95% CI: 0.4-0.83, p = 0.003) with the use of ICD, contrary to an increase in pooled mortality among studies published by US centers (OR: 1.2, 95% CI 1.02-1.33, p = 0.025). Moreover, we identified significant differences in baseline characteristics such as bridge to transplantation rate, Interagency Registry for Mechanically Assisted Circulatory Support profiles, and use of an intra-aortic balloon pump or extracorporeal membrane oxygenation preoperatively, between the US and European populations. While this meta-analysis did not show an overall survival benefit with the use of an ICD in CF-LVAD patients, it revealed significant differences in the derived benefit, in distinct patient populations. This might reflect differences in baseline patient characteristics and warrants further investigation.

Wearable cardioverter defibrillator: bridging for implantable defibrillators in left ventricular assist device patients.

There is currently conflicting data available regarding the use of implantable cardioverter-defibrillators (ICD) in left ventricular assist device (LVAD) patients. While the benefit of an ICD in heart failure patients is well demonstrated, such benefit has failed to reach the LVAD population. In lack of randomized control trial data on the topic of ICD use in LVAD recipients, major societal guidelines are in disagreement when comes to the topic of routine implantation of a permanent defibrillator in prospective ventricular assist device patients. Alternative permanent defibrillator strategies have been suggested for the LVAD population such as subcutaneous implantable cardioverter defibrillators (S-ICDs) but eligibility of patients for such practice remains disappointing. Although most of the heart failure patients undergoing LVAD implantation already bear an ICD, clinicians are left with the decision of de novo implanting an ICD in an important number of patients. Wearable cardioverter defibrillators could prove beneficial in LVAD recipients by utilizing them as a bridge to decision towards the implantation of a permanent defibrillator.

Elective replacement of the ascending aorta: is the 5.5-cm threshold appropriate? The insidious, small aorta.

OBJECTIVES: As thoracic aortic aneurysm disease continues to cause significant morbidity and mortality in the general population, the cardiovascular community continues the search for the golden threshold of elective surgical replacement of the ascending aorta. METHODS: Thoracic aortic aneurysm is a common disease, classified within the 20 most common causes of death in patients over 65 years old. Once aortic complications like dissection or rupture occur, they can prove fatal. Prophylactic surgical replacement of the ascending aorta remains the mainstay of treatment to prevent these complications. Current American and European guidelines agree that the threshold for the diameter for elective replacement of the ascending aorta in non-syndromic, asymptomatic aneurysmal disease is 5.5 cm. Overall, aortic dissection is related to poor prognosis, thus making early intervention paramount. RESULTS: There is a critical size above which the risk of dissection or rupture becomes extremely high. However, a significant post-dissection increase in diameter is reported, thus rendering the predissection aortic diameter well below the current threshold for elective surgical replacement of the ascending aorta. Moreover, it is widely reported that the majority of acute aortic dissections would not meet the criteria for prophylactic surgery prior to dissection. Additionally, elective surgical ascending aortic replacement in the current era shows a significantly improved risk-benefit ratio, which justifies a more aggressive approach in the management of aortic aneurysmal disease. CONCLUSIONS: As a result, there is a lot of discussion in the literature about the requirement of a leftward shifting of the surgical threshold for elective aortic replacement.