An Analysis of Early Results after Valve Replacement in Isolated Aortic Valve Stenosis by Using Sutureless vs. Stented Bioprostheses: A Single-Center Middle-Income Country Experience.

Background and Objectives: There is a lack of data about the survival of patients after the implantation of sutureless relative to stented bioprostheses in middle-income settings. The objective of this study was to compare the survival of people with isolated severe aortic stenosis after the implantation of sutureless and stented bioprostheses in a tertiary referral center in Serbia. Materials and Methods: This retrospective cohort study included all people treated for isolated severe aortic stenosis with sutureless and stented bioprostheses from 1 January 2018 to 1 July 2021 at the Institute for Cardiovascular Diseases "Dedinje". Demographic, clinical, perioperative and postoperative data were extracted from the medical records. The follow-up lasted for a median of 2 years. Results: The study sample comprised a total of 238 people with a stented (conventional) bioprosthesis and 101 people with a sutureless bioprosthesis (Perceval). Over the follow-up, 13.9% of people who received the conventional and 10.9% of people who received the Perceval valve died (p = 0.400). No difference in the overall survival was observed (p = 0.797). The multivariate Cox proportional hazard model suggested that being older, having a higher preoperative EuroScore II, having a stroke over the follow-up period and having valve-related complications were independently associated with all-cause mortality over a median of 2 years after the bioprosthesis implantation. Conclusions: This research conducted in a middle-income country supports previous findings in high-income countries regarding the survival of people with sutureless and stented valves. Survival after bioprosthesis implantation should be monitored long-term to ensure optimum postoperative outcomes.

Influence of Three Different Surgical Techniques on Microscopic Damage of Saphenous Vein Grafts-A Randomized Study.

Background and Objectives: The saphenous vein is one of the most common used grafts (SVG) for surgical revascularization. The mechanism of the SVGs occlusion is still unknown. Surgical preparation techniques have an important role in the early and late graft occlusion. Our study analyzed the influence of the three different surgical techniques on the histological and immunohistochemical characteristics of the vein grafts. Methods: Between June 2019 and December 2020, 83 patients who underwent surgical revascularization were prospectively randomly assigned to one of the three groups, according to saphenous vein graft harvesting (conventional (CVH), no-touch (NT) and endoscopic (EVH)) technique. The vein graft samples were sent on the histological (hematoxylin-eosin staining) and immunohistochemical (CD31, Factor VIII, Caveolin and eNOS) examinations. Results: The CVH, NT, and EVH groups included 27 patients (mean age 67.66 ± 5.6), 31 patients (mean age 66.5 ± 7.4) and 25 patients (mean age 66 ± 5.5), respectively. Hematoxylin-eosin staining revealed a lower grade of microstructural vein damage in the NT group (2, IQR 1-2) in comparison with CVH and EVH (3, IQR 2-4), (4, IQR 2-4) respectively (p < 0.001). Immunohistochemical examination revealed a high grade of staining in the NT group compared to the CVH and EVH group (CD 31 antibody p = 0.02, FVIII, p < 0.001, Caveolin, p = 0.001, and eNOS, p = 0.003). Conclusion: The best preservation of the structural vein integrity was in the NT group, while the lowest rate of leg wound complication was in the EVH group. These facts increase the interest in developing and implementing the endoscopic no-touch technique.

Predictors of Early Deterioration of Renal Function in Patients Older Than 70 Years Undergoing Valvular Surgery.

BACKGROUND: Cardiac surgery-associated acute kidney injury (CSA-AKI) is the most common clinically important complication in adult patients undergoing open-heart surgery, with an incidence between 8.9% and 39%. Studies have shown that even a slight increase in serum creatinine levels after cardiac surgery significantly affects the mortality and morbidity of these patients. AIM: This study sought to determine the predictors and incidence of acute kidney injury (AKI) in patients older than 70 years undergoing elective valvular surgery. METHODS: Prospective study included 156 patients scheduled for elective cardiac surgery requiring cardiopulmonary bypass (CPB) at Dedinje Cardiovascular Institute between January and September 2019. Isolated valvular surgery was performed in 87 patients, while the remaining 69 patients underwent combined coronary and valvular surgery. The development and stage of CSA-AKI were diagnosed, according to Kidney Disease Improving Global Outcome (KDIGO) criteria. Predictors and incidence of CSA-AKI development were assessed using univariate binary logistic regression analysis. RESULTS: The incidence of CSA-AKI was 17.3%. CSA-AKI stage 1 was diagnosed in 25 patients  (16.02%). CSA-AKI stage 2 was noted in one patient (0.64%), as well as stage 3 (0.64%). In six patients (3.85%), renal replacement therapy (RRT) was required. Using univariate binary logistic analysis, the following parameters were identified as predictors for CSA-AKI development: duration of cardiopulmonary bypass (OR 1.01; CI 95% (1.01-1.02); P = .002), duration of aortic clamping (OR 1.02; CI 95% (1.01-1.03); P = .002), lactate levels during the intensive care unit (ICU) stay (OR 1.33; CI 95% (1.04-1.70); P = .026), duration of mechanical ventilation (MV) (OR 1.03; CI 95% (1.1-1.07); P = .014), the use of inotropic drugs (adrenaline, dobutamine) (OR 0.38: CI 95% (0.16-0.9); P = .026; and OR 0.23; CI 95% (0.1-0.56); P = .0019, respectively), and the use of diuretics (OR 0.24; CI95% (0.06-095); P = .041). Using Mann-Whitney U test for independent samples show that the group of patients who developed CSA-AKI had significantly longer duration of hospitalization (Z = -2.751); P = .006), prolonged ICU stay (Z = -4.160; P < .001), and need for prolonged mechanical ventilation (Z = -4.411; P < .001). CONCLUSION: Independent predictors for AKI development after valvular surgery in patients older than 70 years are prolonged mechanical ventilation and increased lactate values, while the use of diuretics after surgery reduces the incidence of AKI. Also, the development of CSA-AKI is associated with prolonged ICU stay and a longer duration of hospitalization.

Novel autologous, high concentrated fibrin as advanced hemostatic agent for coronary surgery.

BACKGROUND: Variability in transfusion outcomes and excessive postoperative bleeding represents a significant problem in cardiac surgery. The effort to reduce bleeding complications and transfusion outcomes is desirable. Our study investigated the feasibility of reducing bleeding complications and transfusion requirements by applying perioperatively prepared autologous bio-regenerative fibrin sealant. METHODS: A prospective, case-control study enrolled 74 patients undergoing coronary artery bypass grafting by a single surgeon. Patients in the control group (N = 43), received traditional methods of hemostasis, while patients in the experimental group (N = 31) were treated additionally with autologous bio-regenerative fibrin. RESULTS: Patients were well-matched with regard to basic demographic, laboratory and procedural data. Allogeneic blood transfusion requirement in control group was 39.5 % (17 of 43 patients), compared to 6.5 % (2 of 31 patients) in treated group (p < 0,001). The lower infection rate in the experimental group was also noted. No safety issues were identified during the preparation and application process. CONCLUSION: Autologous bio-regenerative fibrin can be safely prepared, with no time consuming, and was demonstrated to be a useful tool to decrease allogeneic blood transfusion requirements following elective coronary artery bypass grafting surgery. A prospective randomized trial is needed to confirm these findings.

Modification of an Old Technique to Correct Kinking of Tubular Graft Interposed to Reconstruct Ascending Aorta.

Cardiac surgeons are occasionally faced with ascending aorta graft kinking following ascending aorta replacement. Although it may be difficult to precisely assess the correct length of the graft during aortic clamping, while performing proximal and distal graft anastomoses on an empty heart, the major reason for graft kinking is its excessive length. Haemolytic anaemia, graft thrombosis or even heart failure have been reported as a consequence of unrecognised and uncorrected kinking of the ascending aortic graft. This paper describes a modification and improvement of an old aortic graft non-clamping technique to solve the problem of kinked tubular graft without resuming cardiopulmonary bypass.

The role of ministernotomy in aortic valve surgery-A prospective randomized study.

BACKGROUND AND AIMS: The purpose of this prospective randomized study was to compare the early and midterm outcomes of aortic valve replacement (AVR) through upper ministernotomy with conventional AVR through median sternotomy. METHODS: One hundred patients undergoing elective AVR were randomized into two groups: the M group (upper ministernotomy group, n = 50) and the C group (conventional sternotomy group, n = 50). The operative data, major adverse outcomes, and postoperative variables were compared between the two groups of patients. A cross-sectional follow-up was performed 24.9 ± 5.8 months after surgery. RESULTS: The aortic cross-clamp time and cardiopulmonary bypass time were significantly longer in the M group. Similar incidences of major cardiac, neurologic and renal complications were recorded in both groups. Two patients (4%) in the C group developed wound infections. The length of ICU stay was similar in both groups. The patients in the M group had a shorter hospital stay compared with the patients in the C group (7.6 ± 2 days vs 9.3 ± 4.8 days; P = 0.022). Follow-up revealed that the time period needed to reach full recovery was significantly shorter in the ministernotomy group (1.7 ± 1.2 months vs 2.8 ± 1.6 months; P = 0.001). Morbidity and mortality data did not differ between the two groups. CONCLUSIONS: There was no difference in the major outcomes between the patients who underwent upper ministernotomy and those who underwent full sternotomy. The benefits of the minimally invasive approach were the shorter hospital stay and significantly faster recovery of patients after discharge from the hospital.

Challenging surgery of giant right coronary aneurysm associated with coronary sinus fistula.

Coronary artery fistula is a rare congenital or acquired anomaly. It involves an abnormal connection between the coronary artery and the cardiac chambers or the large thoracic vessels. In some cases, the feeding coronary artery can become extremely dilated. The treatment includes a transcatheter or a surgical intervention depending on the complexity of the anomaly. We present the surgical treatment of the coronary artery to coronary sinus fistula, which includes the complete exclusion of the giant right coronary artery and followed by triple bypass surgery.

Consecutive Observational Study to Validate EuroSCORE II Performances on a Single-Center, Contemporary Cardiac Surgical Cohort.

OBJECTIVE: To compare and validate the original EuroSCORE risk stratification models with the renewed EuroSCORE II model in a contemporary cardiac surgical practice. DESIGN: A consecutive observational study to validate EuroSCORE II performances, conducted as retrospective analysis of prospectively collected data. SETTING: A tertiary university institute for cardiovascular diseases. PARTICIPANTS: Adult patients undergoing cardiac surgery between January and December 2012. METHODS: One thousand eight hundred sixty-four consecutive patients were scored preoperatively using additive and logistic EuroSCORE as well as EuroSCORE II. The discriminative power of the EuroSCORE models was tested by calculating the area under the receiver operating characteristic curve (AUC). The calibration of the models was assessed by Hosmer-Lemeshow statistics and with observed-to-expected mortality ratio. MEASUREMENTS AND MAIN RESULTS: The in-hospital overall mortality was 3.65%, with predicted mortalities according to additive EuroSCORE, logistic EuroSCORE, and EuroSCORE II of 5.14%, 6.60%, and 3.51%, respectively. The observed-to-expected (O/E) mortality ratio confirmed good calibration for the entire cohort only for EuroSCORE II (1.05, 95% confidence interval 0.81 - 1.29). Hosmer-Lemeshow test confirmed overall good calibration only for additive EuroSCORE (p = 0.129). The EuroSCORE II confirmed very good discriminatory power for a prolonged intensive care unit (ICU) stay of>2 days and>5 days (AUCs>0.75). Acceptable discriminatory power was confirmed for a prolonged postoperative stay of>7 days and>12 days (AUCs>0.70). CONCLUSION: EuroSCORE II confirmed very good discriminatory capacity, good calibration ability (O/E mortality ratio), and good capability to predict prolonged ICU and postoperative stays in a contemporary patient cohort undergoing cardiac surgery.

Mid-term patency of the inverted left internal thoracic artery conduit.

In order to expand the revascularization of the left anterior descending coronary artery, we have applied the inverted left internal thoracic artery (left internal thoracic artery [LITA] transected near its origin, thus supplied by retrograde flow from superior epigastric and musculophrenic arteries) in carefully selected cases (four patients). The 64-slice multidetector row computed tomographic scans performed postoperatively (range, 6 to 40 days), as well as the scans performed in the follow-up period (range, 18 to 35 months) showed preserved inverted LITA conduits with thrombolysis in myocardial infarction (TIMI) 3 flow in all patients.

Surgical treatment of a left ventricular pseudoaneurysm with an extracellular matrix patch.

Left ventricle pseudoaneurysm is a rare and life-threatening complication of myocardial infarction that is formed as a result of left ventricle free wall rupture contained by the overlying pericardium. Urgent surgical repair is crucial, and in most reports, left ventricle was reconstructed with a Dacron or bovine pericardial patch. We present a case of a 66-year-old female with left ventricle pseudoaneurysm which was successfully repaired with an extracellular matrix patch. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01669-3.

Fatal hyperacute left main thrombosis after aortic root surgery.

Acute aortic root thrombosis is a potentially lethal condition due to the possibility of thrombosis into the ascending aorta branches, resulting in various clinical manifestations. A 29-year-old male patient was admitted to our center with hyperacute left main thrombosis after elective Bentall procedure. Due to massive left ventricular infarction, the patient was supported by extracorporeal membrane oxygenation, but without success to recovery. The patient's blood analyses revealed a high level of the Factor VIII. In conclusion, Factor VIII levels in the blood are elevated by genetic abnormalities, infectious diseases such as severe acute respiratory syndrome-coronavirus 2 infection, and vascular inflammation. This pathological condition may be a reason for hyperacute thrombosis.

Case Report: Giant cholesterol granuloma in the anterior mediastinum.

Cholesterol granuloma is a rare entity, which can develop in many regions of the body, accounting at most 1% of all mediastinal tumors. Etiology of this granuloma is still not clearly understood. The gold standard choice of treatment for cholesterol granuloma is total surgical resection. Symptomatic mediastinum granuloma can be easily diagnosed, but if mass effect is not evident then diagnosis of this tumor is really challenging. We present a rare case of huge cholesterol granuloma in the anterior mediastinum of the patient who underwent on elective coronary artery graft bypass surgery.

Early outcomes of aortic valve replacement with Perceval PLUS sutureless valve: results of the prospective multicentric MANTRA study.

BACKGROUND: The aim of this study is to report the preliminary real-word clinical and hemodynamic performance from the MANTRA study in patients undergoing aortic valve replacement with Perceval PLUS sutureless valve. METHODS: MANTRA is an ongoing "umbrella" prospective, multi-center, international post-market study to collect real-life safety and performance data on Corcym devices (Corcym S.r.l, Saluggia, Italy). Clinical and echocardiographic outcomes were collected preoperatively, at discharge and at each follow up. KCCQ-12 and EQ-5D-5L quality of life questionnaires were collected preoperatively and at 30-days. RESULTS: A total of 328 patients underwent aortic valve replacement with Perceval PLUS in 29 International institutions. Patients were enrolled from July 2021 to October 2023 and enrollment is still ongoing. Mean age was 71.9 ± 6.4 years, mean EuroSCORE II was 2.9 ± 3.9. Minimally invasive approach was performed in 44.2% (145/328) of patients; concomitant procedures were done in 40.8% (134/328) of cases. Thirty-day mortality was 1.8% (6/328) and no re-interventions were reported. Pacemaker implant was required in 4.0% (13/328) of the patients. The assessment of the functional status demonstrated marked and stable improvement in NYHA class in most patients at 30-day follow-up, with significant increase of KCCQ-12 summary score (from 58.8 ± 23.0 to 71.8 ± 22.1, p < 0.0001) and EQ-5D-5L VAS score (from 64.5 ± 20.4 to 72.6 ± 17.5, p < 0.0001). Mean pressure gradient decreased from 46.2 ± 17.3 mmHg to 10.1 ± 4.7 mmHg at 30-day follow-up. Low or no incidence of moderate-to-severe paravalvular or central leak was reported. CONCLUSIONS: Preliminary results demonstrate good clinical outcomes and significant improvement of Quality of Life at 30-days, excellent early hemodynamic performance within patient implanted with Perceval PLUS. TRIAL REGISTRATION: The MANTRA study has been registered in ClinicalTrials.gov (NCT05002543, Initial release 26 July 2021).

First-in-Human µCAB™ Coronary Revascularization Surgery.

Less invasive coronary artery bypass grafting surgery is underused despite more than 25 years of interest from surgeons and growing patient demands for less pain and rapid full recovery. New approaches may offer surgeons additional options to provide enhanced clinical results through reliable subxiphoid bilateral internal thoracic artery harvesting and the creation of durable anastomoses through very small thoracotomy incisions. This first-in-human case report describes 2 patients who received surgical coronary revascularization using the µCAB™ technology and techniques. The encouraging early results indicate that the µCAB™ approach may offer a new ergonomic, affordable method for coronary revascularization with less surgical trauma.

Surgical Reconstruction of the Anomalous Left Coronary Artery From the Pulmonary Artery.

The anomalous left coronary artery from the pulmonary artery is a rare congenital disease. Early surgical reconstruction is mandatory to prevent adverse cardiac events. Direct coronary button transfer, vein graft interposition, ligation, and coronary artery bypass construction are the most commonly used techniques. This case report presents a modified technique of Dacron graft interposition and reimplantation anomalous left coronary artery from the pulmonary artery on the ascending aorta.

Same-Day Carotid Artery Stenting and Coronary Artery Bypass Surgery.

BACKGROUND: The optimal treatment strategy for patients with severe carotid artery disease undergoing coronary artery bypass grafting is still problematic. The important question is whether it is necessary to treat significant carotid disease in patients who have undergone coronary artery bypass grafting. This study analyzed short- and midterm results after same-day carotid artery stenting and coronary artery bypass grafting. METHODS: From 2013 to 2020, a total of 69 patients were enrolled in the study. Same-day carotid artery stenting and coronary artery bypass grafting were performed in all patients. The study's primary end points were the evaluation rate of stroke, myocardial infarction, and death within short- and midterm periods after the procedures. RESULTS: The 30-day mortality was 0%. The occurrences of perioperative adverse events, namely stroke, myocardial infarction, and transient ischemic attack, were 1 (1.4%), 1 (1.4%), and 4 (5.8%), respectively. Mean (IQR) follow-up time was 28 (IQR, 17-43) months. Six (8.8%) patients died during this period. Fatal stroke was registered in 2 cases, and 1 patient experienced a disabling stroke with a fatal outcome. The other 3 patients died because of chronic renal disease, a traffic accident, and for an unknown reason, respectively. Midterm survival in the group was 91.2%. CONCLUSION: The study showed that same-day carotid artery stenting and coronary artery bypass grafting for concomitant carotid and coronary disease treatment could be a promising and feasible therapeutic strategy.

Mitochondrial molecular basis of sevoflurane and propofol cardioprotection in patients undergoing aortic valve replacement with cardiopulmonary bypass.

BACKGROUND/AIMS: Study elucidates and compares the mitochondrial bioenergetic-related molecular basis of sevoflurane and propofol cardioprotection during aortic valve replacement surgery due to aortic valve stenosis. METHODS: Twenty-two patients were prospectively randomized in two groups regarding the anesthetic regime: sevoflurane and propofol. Hemodynamic parameters, biomarkers of cardiac injury and brain natriuretic peptide (BNP) were measured preoperatively and postoperatively. In tissue samples, taken from the interventricular septum, key mitochondrial molecules were determined by Western blot, real time PCR, as well as confocal microscopy and immunohisto- and immunocyto-chemical analysis. RESULTS: The protein levels of cytochrome c oxidase and ATP synthase were higher in sevoflurane than in propofol group. Nevertheless, cytochrome c protein content was higher in propofol than sevoflurane receiving patients. Propofol group also showed higher protein level of connexin 43 (Cx43) than sevoflurane group. Besides, immunogold analysis showed its mitochondrial localization. The mRNA level of mtDNA and uncoupling protein (UCP2) were higher in propofol than sevoflurane patients, as well. On the other hand, there were no significant differences between groups in hemodynamic assessment, intensive care unit length of stay, troponin I and BNP level. CONCLUSIONS: Our data indicate that sevoflurane and propofol lead to cardiac protection via different mitochondrially related molecular mechanisms. It appears that sevoflurane acts regulating cytochrome c oxidase and ATP synthase, while the effects of propofol occur through regulation of cytochrome c, Cx43, mtDNA transcription and UCP2.

Successful surgical aortic valve replacement in a patient with progeria.

The progeroid syndrome includes a group of rare, severe genetic disorders clinically characterized by premature physical ageing. Severe aortic stenosis has been described in progeria patients, but no previous surgical aortic valve replacement was reported. We describe a successful surgical aortic valve replacement combined with coronary artery bypass grafting in a progeria patient with severe aortic stenosis and a small aortic annulus.

On-line risk prediction models for acute type A aortic dissection surgery: validation of the German Registry of Acute Aortic Dissection Type A score and the European System for Cardiac Operative Risk Evaluation II.

OBJECTIVES: The German Registry of Acute Aortic Dissection Type A (GERAADA) on-line score calculator to predict 30-day mortality in patients undergoing surgery for acute type A aortic dissection (ATAAD) was recently launched. Using the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), it is also possible to predict operative mortality for the same type of surgery. The goal of our study was to validate the prediction accuracy of these 2 on-line risk prediction models. METHODS: Prospectively collected data for EuroSCORE II risk factors as well as all data for GERAADA scoring were extracted from an institutional database for 147 patients who underwent surgery for ATAAD between April 2018 and April 2021. The discriminative power was assessed using area under the receiver operating characteristic curve. The calibration of the models was tested by the Hosmer-Lemeshow statistics and by using the observed-to-expected (O/E) mortality ratio with the 95% confidence interval. RESULTS: The observed operative mortality was 14.3%. The mean predicted mortality rates for the GERAADA score and the EuroSCORE II were 15.6% and 10.6%, respectively. The EuroSCORE II discriminative power (area under the curve = 0.799) significantly outperformed the discriminatory power of the GERAADA score (area under the curve = 0.550). The Hosmer-Lemeshow statistics confirmed good calibration for both models (P-values of 0.49 and 0.29 for the GERAADA score and the EuroSCORE II, respectively). The O/E mortality ratio certified good calibration for both scores [GERAADA score (O/E ratio of 0.93, 95% confidence interval: 0.53-1.33); EuroSCORE II (O/E ratio of 1.35, 95% confidence interval: 0.77-1.93)]. CONCLUSIONS: The EuroSCORE II has better discriminative power for predicting operative mortality in ATAAD surgery than the GERAADA score. Both scores confirmed good calibration ability.