A Single-Centre Experience of the Management of Infective Endocarditis.

BACKGROUND: Treatment for infective endocarditis (IE) is usually medical, with surgery reserved for those failing medical management or developing complications. Currently, 25%-50% of patients undergo surgery for IE with a 70%-80% immediate survival rate. However, there is controversy over the timing of surgery following cerebrovascular events, which occur in 15%-30% of IE patients. This study aimed to investigate whether surgical management is superior to medical management in patients with IE and to determine the optimal timing for surgery following the development of neurological symptoms. METHODS: Data were collected retrospectively between 2012 and 2018 from 436 patients diagnosed with IE and treated at our tertiary teaching hospital. The authors analysed the type of treatment, the timing of surgery, and the outcomes of these including mortality, IE recurrence, and length of hospital stay. RESULTS: A total of 421 patients were included in the analysis. More than two-thirds (69.1%) of patients underwent surgical intervention. The survival rate of patients having surgery for IE was 77.2%, compared to 50.7% in patients who did not undergo surgical intervention. 6.8% of patients presented with neurological symptoms; 73.3% of these patients had surgery within 14 days with a 90.9% survival. CONCLUSION: This study finds surgery to be safe with a seemingly higher survival rate compared to medical management alone, although this may be confounded by patients in the medical group being less likely to have surgery. Surgery in patients presenting with neurological symptoms is safe within 2 weeks from presentation with excellent outcomes.

Surgery for Active Infective Endocarditis on Mitral Valve: Anatomical, Surgical, and Disease Factors as Long-Term Outcome Modifiers.

Background and Objectives: Determinants of long-term outcomes after surgery for native mitral valve endocarditis have not been thoroughly investigated. The aim of this study was to assess anatomical, disease, and surgical risk factors for long-term mortality and need of reintervention, in patients undergoing mitral valve surgery for active endocarditis. Materials and Methods: Patients who underwent surgery for active native mitral valve endocarditis at three academic centres, between 2000 and 2022, were analysed. The primary outcome was long-term survival. The secondary outcome was the freedom from mitral reoperation. Survival curves were constructed with Kaplan-Meier methodology. Multivariable Cox regression was used to identify demographic, anatomical, disease, and surgical factors associated with late mortality and reoperation. Results: 335 consecutive patients with active mitral endocarditis were analysed. Two hundred and one patients (70.5%) had infection confined to the valve cusp whereas 89 (25.6%) had invasive disease extended to the annulus and surrounding tissues. Preoperative neurological events occurred at the diagnosis in 52 cases. Streptococci were the most common causative organisms followed by Staphylococcus aureus, Coagulase-negative Staphylococcus, and Enterococcus. Valve repair was performed in 108 patients (32.2%). Survival at 5 and 10 years was 70.1% and 59.2%, respectively. Staphylococcus emerged as an independent predictor of late mortality, along with age, chronic obstructive pulmonary disease, and previous cardiac surgery. Survival was considerably reduced in patients with S. aureus compared with those without (log rank p < 0.001). The type of surgery (repair vs. replacement) did not emerge as a risk factor for late mortality and reoperation. Seventeen patients underwent mitral reoperation during the follow-up. The 5- and 10-year freedom from reoperation was 94.7% and 91.8%, respectively. Conclusions: Active mitral valve endocarditis remains a life-threatening disease with impaired survival. While lesion characteristics influenced surgical decision-making and intraoperative management, their impact on long-term survival and freedom from reintervention appears to be moderated by other factors such as infecting pathogens and patient comorbidities.

Redo aortic valve replacement versus valve-in-valve trans-catheter aortic valve implantation: a UK propensity-matched analysis.

This study sought to compare the morbidity and mortality of redo aortic valve replacement (redo-AVR) versus valve-in-valve trans-catheter aortic valve implantation (valve-in-valve TAVI) for patients with a failing bioprosthetic valve. A multicenter UK retrospective study of redo-AVR or valve-in-valve TAVI for patients referred for redo aortic valve intervention due to a degenerated aortic bioprosthesis. Propensity score matching was performed for confounding factors. From July 2005 to April 2021, 911 patients underwent redo-AVR and 411 patients underwent valve-in-valve TAVI. There were 125 pairs for analysis after propensity score matching. The mean age was 75.2±8.5 years. In-hospital mortality was 7.2% (n=9) for redo-AVR versus 0 for valve-in-valve TAVI, p=0.002. Surgical patients suffered more post-operative complications, including intra-aortic balloon pump support (p=0.02), early re-operation (p<0.001), arrhythmias (p<0.001), respiratory and neurological complications (p=0.02 and p=0.03) and multi-organ failure (p=0.01). The valve-in-valve TAVI group had a shorter intensive care unit and hospital stay (p<0.001 for both). However, moderate aortic regurgitation at discharge and higher post-procedural gradients were more common after valve-in-valve TAVI (p<0.001 for both). Survival probabilities in patients who were successfully discharged from the hospital were similar after valve-in-valve TAVI and redo-AVR over the 6-year follow-up (log-rank p=0.26). In elderly patients with a degenerated aortic bioprosthesis, valve-in-valve TAVI provides better early outcomes as opposed to redo-AVR, although there was no difference in mid-term survival in patients successfully discharged from the hospital.

Re-sternotomy for aortic valve replacement in octogenarian patients in age of evolving transcatheter therapies.

BACKGROUND: The aim of this study was to analyze perioperative results and long-term survival of re-sternotomy for surgical aortic valve replacement (SAVR) in octogenarians in age of transcatheter therapies. METHODS: This is a retrospective, single-center study (April 2000 to December 2019). Perioperative data were compared for re-sternotomy with isolated SAVR (Isolated redoSAVR) and re-sternotomy with SAVR and concomitant cardiac procedure (Associated redoSAVR). Regression analyses were performed to identify predictors of in-patient mortality. Hazard ratios and Kaplan-Meier survival curves were compared for groups. RESULTS: There were 163 patients (Isolated redoSAVR; 69, Associated redoSAVR; 94). Emergency/salvage cases were excluded. The median age was 83 (81-85) years and the median logEuroSCORE was 19.2 (13.0-26.7)%. The follow-up was 4.2 ± 3.5 years. Inpatient mortality was 4.9% (1.4% vs. 7.4% for Isolated redoSAVR and Associated redoSAVR respectively, p = .08). TIA/stroke rate was 8% (9% vs. 7% for Isolated redoSAVR and Associated redoSAVR, respectively, p = .78). COPD was a predictor of inpatient mortality (odds ratio: 8.86; 95% confidence interval: 1.19-66.11, p = .03). Survival was 88.7%, 86.4%, 70.1%, 49.5%, and 26.3% at 1, 2, 5, 7, and 10 years. There was no survival difference between Isolated redoSAVR and Associated redoSAVR (log rank p = .36, Wilcoxon p = .84). Significant adverse predictors of long-term survival were COPD, postoperative TIA/stroke, and length of stay. Survival was lower than age and gender-matched first-time SAVR and general population of the United Kingdom. CONCLUSION: RedoSAVR in octogenarians is associated with significant morbidity and mortality. Shared decision-making should consider emerging transcatheter therapies as a valuable option in selected patients.

Effect of Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement on All-Cause Mortality in Patients With Aortic Stenosis: A Randomized Clinical Trial.

Importance: Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement and is the treatment of choice for patients at high operative risk. The role of TAVI in patients at lower risk is unclear. Objective: To determine whether TAVI is noninferior to surgery in patients at moderately increased operative risk. Design, Setting, and Participants: In this randomized clinical trial conducted at 34 UK centers, 913 patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk due to age or comorbidity were enrolled between April 2014 and April 2018 and followed up through April 2019. Interventions: TAVI using any valve with a CE mark (indicating conformity of the valve with all legal and safety requirements for sale throughout the European Economic Area) and any access route (n = 458) or surgical aortic valve replacement (surgery; n = 455). Main Outcomes and Measures: The primary outcome was all-cause mortality at 1 year. The primary hypothesis was that TAVI was noninferior to surgery, with a noninferiority margin of 5% for the upper limit of the 1-sided 97.5% CI for the absolute between-group difference in mortality. There were 36 secondary outcomes (30 reported herein), including duration of hospital stay, major bleeding events, vascular complications, conduction disturbance requiring pacemaker implantation, and aortic regurgitation. Results: Among 913 patients randomized (median age, 81 years [IQR, 78 to 84 years]; 424 [46%] were female; median Society of Thoracic Surgeons mortality risk score, 2.6% [IQR, 2.0% to 3.4%]), 912 (99.9%) completed follow-up and were included in the noninferiority analysis. At 1 year, there were 21 deaths (4.6%) in the TAVI group and 30 deaths (6.6%) in the surgery group, with an adjusted absolute risk difference of -2.0% (1-sided 97.5% CI, -∞ to 1.2%; P < .001 for noninferiority). Of 30 prespecified secondary outcomes reported herein, 24 showed no significant difference at 1 year. TAVI was associated with significantly shorter postprocedural hospitalization (median of 3 days [IQR, 2 to 5 days] vs 8 days [IQR, 6 to 13 days] in the surgery group). At 1 year, there were significantly fewer major bleeding events after TAVI compared with surgery (7.2% vs 20.2%, respectively; adjusted hazard ratio [HR], 0.33 [95% CI, 0.24 to 0.45]) but significantly more vascular complications (10.3% vs 2.4%; adjusted HR, 4.42 [95% CI, 2.54 to 7.71]), conduction disturbances requiring pacemaker implantation (14.2% vs 7.3%; adjusted HR, 2.05 [95% CI, 1.43 to 2.94]), and mild (38.3% vs 11.7%) or moderate (2.3% vs 0.6%) aortic regurgitation (adjusted odds ratio for mild, moderate, or severe [no instance of severe reported] aortic regurgitation combined vs none, 4.89 [95% CI, 3.08 to 7.75]). Conclusions and Relevance: Among patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, TAVI was noninferior to surgery with respect to all-cause mortality at 1 year. Trial Registration: isrctn.com Identifier: ISRCTN57819173.

Impact of valve size, predicted effective and indexed effective orifice area after aortic valve replacement.

INTRODUCTION: The impact of manufacturer labeled prosthesis size and predicted effective orifice area (EOA) on long-term survival after aortic valve replacement is not clear although indexed effective orifice area (iEOA) has been associated with worse survival. METHODS: Data was retrospectively collected from Jan 2000-Dec 2019 for prosthesis type, model, and size for isolated aortic valve replacements. Stratified survival was compared between groups and subgroups for labeled valve size, EOA and predicted patient prosthesis mismatch (PPM). RESULTS: A total of 3444 patients were included. Moderate and severe PPM was 15.6% and 1.6%, respectively. Cumulative lifetime hazard was worse for biological valves (mortality: biological 77.7% vs. mechanical 64.8%, p = .001). Moderate prosthetic aortic stenosis (AS), (EOA = 1-1.5 cm2 ) was 12.1% and severe prosthetic AS (EOA ≤ 1 cm2 ) was 0.8%, respectively. Survival was 10.5 ± 0.4 years with moderate to severe prosthetic AS (EOA≤1.5 cm2 ) versus 12.6 ± 0.2 years with mild to no prosthetic AS (EOA>1.5 cm2 ), p = .001. Worse survival in the presence of moderate-severe prosthetic AS was seen with biological valves (9.7 ± 0.4 years vs. 11.2 ± 0.2 years, p = .001 for EOA≤1.5, >1.5 cm2 , respectively). Moderate to severe PPM was associated with worse survival (11.1 ± 0.4 years for iEOA ≤ 0.85 cm2 /m2 vs. 12.5 ± 0.2 years with iEOA > 0.85 cm2 /m2 , p = .001). Moderate to severe PPM predicted worse long term survival (hazard ratio: 3.56; 95% confidence interval: 1.37-9.25; p = .009). CONCLUSION: Predicted prosthetic moderate to severe AS and moderate to severe PPM adversely affect long term survival. Smaller valves are associated with reduced survival.

Type A aortic syndromes in COVID-19 positive patients: Case series from a UK multicentre study.

OBJECTIVE: The coronavirus disease (COVID-19) increases the respiratory complications and carries a higher mortality in the immediate postoperative period. The aim of this study was to analyze the outcomes of patients with type A acute aortic syndromes (AAS) diagnosed with COVID-19 in the perioperative period. METHODS: Retrospective analysis of prospectively collected data between March and August 2020 from 20 participating cardiac surgery centers in the United Kingdom. RESULTS: Among 122 patients who underwent emergency surgical repair for type A AAS at the participating centers, 3 patients (2.5%) tested positive for COVID-19 in the preoperative screeing, and 4 cases turned to be positive in the postoperative period having been operated on an unknown COVID-19 status. Another patient was diagnosed of COVID-19 disease based on radiological features. These eight patients had increased postoperative complications, including respiratory failure, longer ventilation times, and Intensive Therapy Unit (ITU) stay and increased mortality when compared with COVID-19 negative patients. CONCLUSION: COVID-19 disease in the perioperative period of type A AAS poses a challenge. Despite the increasing morbidity and mortality associated with the virus, the prognosis of the aortic disease is poorer and emergency surgery should not be contraindicated based on the COVID-19 diagnosis alone.

Early and Midterm Results of Stent Endarterectomy for Left Anterior Descending Coronary Artery "Full Metal Jacket".

OBJECTIVE: Modern coronary interventional practice can result in coronary vessels that are totally stented. The term "full metal jacket" has been coined to refer to vessels that have an overlapping stent in series along the whole length of the vessel. This poses a serious challenge to surgical revascularization, particularly when a left internal thoracic artery (LITA) to the left anterior descending (LAD) needs to be undertaken. We evaluated the early and midterm results of on-pump coronary artery bypass grafting (CABG) following "stent endarterectomy" for the LAD with LITA to LAD grafting. METHODS: During October 2017 to September 2020, 21 patients presented with multi-vessel disease and a totally occluded LAD with a stent full metal jacket. No distal target for LITA grafting was available, despite a viable myocardial territory. The LAD was endarterectomised, removing the column of totally occluded stents with the medial wall of the vessel, leaving the proximal stent in place to avoid competitive flow. Long length anastomosis was then undertaken with the LITA graft. Postoperatively, patients were followed up clinically and by coronary computed tomography (CT) angiography at 6- and 18-month intervals. All patients were discharged on a combination of aspirin and warfarin for three months and then aspirin and clopidogrel for the rest of the first year and then aspirin alone for life. RESULTS: Patients had a mean age of 58.07 ± 2.06 yr. Sixteen (76.2%) were males, 13 (61.9%) patients were diabetics, 18 (85.7%) were hypertensive, 15 (71.4%) were dyslipidemic, six (28.6%) were obese, 11 (52.4%) were smokers, and five (23.8%) had positive family history of ischemic heart disease (IHD). The number of grafts per patient ranged 3-5, with a mean cross-clamp time of 64.71± 8.84 min. There were no postoperative deaths nor MI clinically, by electrocardiogram (ECG) criteria nor by troponin or CK-MB. In-hospital complications included one (4.8%) patient who required re-exploration for bleeding, one (4.8%) developed a superficial wound, and three (14.3%) developed atrial fibrillation (AF), during their hospital stay. Mean hospital stay was 7.71±1.73 days. All patients completed the 6-month follow up showing patent LITA to LAD with coronary CT angiography. One patient was lost to follow up after six months; five patients are awaiting their 18-month CT angiography, while 15 (71.4%) patients have completed their 18-month CT angiography, and all have a patent LITA to LAD. CONCLUSIONS: Stent endarterectomy for a totally occluded LAD with a full metal jacket and viable myocardial territory is a safe procedure with good early and midterm results. This technique should be considered in these difficult cases presenting for revascularisation when no other option is available.

Surgical vs transfemoral aortic valve replacement in low-risk patients: An updated meta-analysis of trial and registry data.

BACKGROUND: Transfemoral aortic valve replacement (TAVR) has been studied extensively in patients with improving safety and efficacy in high to intermediate-risk patients with aortic stenosis. TAVR has been now approved for patients with low surgical risk. OBJECTIVE: The purpose of this study is to integrate the evidence from randomized controlled trials (RCT) and large registry data comparing TAVR to surgical aortic valve repair (SAVR). METHODS: Seven studies (three RCTs, one post hoc study of a RCT, and three registries) were included. Incidence rate ratios (IRR) of outcomes of interest (overall mortality, 30-day mortality, cardiovascular death, stroke, pacemaker implantation [PPMI], myocardial infarction, moderate-severe paravalvular leak [PVL], and re-intervention) were compared using a random-effects model. RESULTS: The pooled analysis included 24 819 patients (TAVR, 8227 and SAVR, 16 592). 2,952 (11.9%) patients were from RCTs and 21 867 (88.1%) were registry patients. Thirty-day mortality was lower in TAVR (logIRR, -0.43; 95% CI. -0.61 to -0.25; P < .001), whereas the rate of moderate-severe PVL (logIRR, 1.44; 95% CI, 0.58-2.3; P < .001) and PPMI (logIRR, 1.13; 95% CI, 1.02-1.24; P < .001) were higher. There were no significant differences in the rates of overall mortality, reintervention, cardiovascular death, myocardial infarction, or stroke between SAVR and TAVR. CONCLUSIONS: Early mortality is higher in SAVR while rates of PVL and PPMI are substantially higher in TAVR. There is no significant advantage with TAVR for overall survival, cardiovascular death, stroke, MI, and re-intervention rates.

Initial experience with xenograft bioconduit for the treatment of complex prosthetic valve endocarditis.

INTRODUCTION: The treatment of complex prosthetic valve endocarditis (PVE) with aortic root abscess remains a surgical challenge. Several studies support the use of biological tissues to minimize the risk of recurrent infection. We present our initial surgical experience with the use of an aortic xenograft conduit for aortic valve and root replacement. METHODS: Between October 2013 and August 2015, 15 xenograft bioconduits were implanted for complex PVE with abscess (13.3% female). In 6 patients, concomitant procedures were performed: coronary bypass (n=1), mitral valve replacement (n=5) and tricuspid annuloplasty (n=1). The mean age at operation was 60.3±15.5 years. The mean Logistic European system for cardiac operating risk evaluation (EuroSCORE) was 46.6±23.6. The median follow-up time was 607±328 days (range: 172-1074 days). RESULTS: There were two in-hospital deaths (14.3% mortality), two strokes (14.3%) and seven patients required permanent pacemaker insertion for conduction abnormalities (46.7%). The mean length of hospital stay was 26 days. At pre-discharge echocardiography, the conduit mean gradient was 9.3±3.3mmHg and there was either none (n=6), trace (n=6) or mild aortic insufficiency (n=1). There was no incidence of mid-term death, prosthesis-related complications or recurrent endocarditis. CONCLUSIONS: Xenograft bioconduits may be safe and effective for aortic valve and root replacement for complex PVE with aortic root abscess. Although excess early mortality reflects the complexity of the patient population, there was good valve hemodynamics, with no incidence of recurrent endocarditis or prosthesis failure in the mid-term. Our data support the continued use and evaluation of this biological prosthesis in this high-risk patient cohort.

A unique case of "double-orifice aortic valve"-comprehensive assessment by 2-, 3-dimensional, and color Doppler echocardiography.

Transesophageal echocardiography (TEE) is a powerful imaging tool for the comprehensive assessment of valvular structure and function. TEE may be of added benefit when anatomy is difficult to delineate accurately by transthoracic echocardiography. In this article, we present 2-, 3-dimensional, and color Doppler TEE images from a male patient with aortic stenosis. A highly unusual and complex pattern of valvular calcification created a functionally "double-orifice" valve. Such an abnormality may have implications for the accuracy of continuous-wave Doppler echocardiography, which assumes a single orifice valve in native aortic valves.

Early in-vivo hemodynamic comparison of supra-annular aortic bioprostheses: Trifecta versus Perimount Magna Ease.

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare early postoperative hemodynamic gradients after supra-annular implantation of the Trifecta and Perimount Magna Ease aortic bioprostheses. METHODS: Between January 2010 and December 2011, a total of 235 patients (105 males, 130 females; mean age at surgery 73.8 +/- 10.2 years) underwent supra-annular aortic valve replacement (AVR), with or without concomitant procedures. The patients were divided into 2 groups receiving either the Perimount Magna Ease (n = 117) or Trifecta (n = 118). Concomitant procedures were performed in 133 patients (56.6%), and 25 procedures (10.6%) were redos. Patients with postoperative severe left ventricular dysfunction and moderate to severe mitral regurgitation were excluded. Gradients were calculated pre-discharge using transthoracic echocardiography. Effective orifice area calculations were not performed. Data were collected retrospectively from hospital databases and analyzed using SPSS 17. RESULTS: Both groups compared well for 14 variables. Group A had a higher number of redo operations and the patients were younger. Postoperative peak and mean gradients (in mmHg) for the Magna Ease group versus Trifecta group were: 19 mm valves, 33.5 +/- 16 versus 24.7 +/- 10 (p = 0.11) and 17.4 +/- 6.5 versus 12.7 +/- 4.4 (p = 0.05); 21 mm, 27.2 +/- 9.1 versus 21.8 +/- 7.2 (p = 0.001) and 13.8 +/- 4.7 versus 10.7 +/- 3.4 (p = 0.001); 23 mm, 25.6 +/- 7.8 versus 20.1 +/- 7.9 (p = 0.005) and 13 +/- 4 versus 10.1 +/- 4.3 (p = 0.002); 25 mm, 22.3 +/- 7.8 versus 15.6 +/- 5.1 (p = 0.01) and 12.8 +/- 4.1 versus 8 +/- 2.8 (p = 0.02). The overall mortality was 3.4%. The median hospital stay was nine days in both groups (p = 0.13). Mortality (p = 0.5), and incidences of perioperative stroke (p = 0.45), postoperative new-onset atrial fibrillation (p = 0.26) and permanent pacemaker implantation (p = 0.8) were similar in both groups. CONCLUSION: Early postoperative gradients were significantly lower in patients receiving Trifecta valves, although the long-term clinical outcome and durability of the valve will require further evaluation.

The outcomes of triple-valve surgery: eleven years' experience from a single center.

BACKGROUND AND AIM OF THE STUDY: Triple-valve surgery is a challenging and complex procedure with significant risk, even at centers experienced at performing such operations. The study aim was to investigate the early and late outcomes of this surgery, performed at a single center for the past 11 years. METHODS: A total of 45 consecutive patients (19 males, 26 females; mean age 69.42 +/- 12.72 years) underwent triple-valve surgery at the authors' institution between 2000 and 2011. The mean logistic EuroSCORE was 22.46 +/- 12.8%. The most common aortic valve pathology was calcific degeneration (40%), while the mitral valves were mostly rheumatic (31%) or degenerative (26%). The tricuspid valve pathology was functional regurgitation in 64% of patients. The aortic valve procedures were all replacements, while the mitral valves were either repaired (n = 20) or replaced (n = 25). The tricuspid valves were almost exclusively repaired (n = 43). Univariate and multivariate analyses were performed to highlight predictors of mortality. A Kaplan-Meier analysis was also performed. RESULTS: The operative mortality was 8.9% (n = 4). Survival at one, three, and five years was 91%, 85.5% and 66.4%, respectively. Morbidity was not particularly high: the incidence of all postoperative neurological complications was 13%, that of transient renal impairment was 18%, and pacemaker implantation 8.9%. CONCLUSION: The results of triple-valve surgery were considerably improved compared to historical reports. Early mortality was close to that occurring after less complex procedures, while late survival was comparable to that after single-valve surgery. It is believed that the best results are achieved by centers experienced in valve procedures. Compared to older studies, rheumatic disease was not the most frequent requirement for of triple-valve surgery among the present patients.

Central cannulation by Seldinger technique: a reliable method in ascending aorta and aortic arch replacement.

BACKGROUND: Extensive type A aortic dissections that involve peripheral great vessels can complicate the choice of a cannulation site for cardiopulmonary bypass. We started to employ direct cannulation of the true lumen on the concavity of the aortic arch by Seldinger technique and evaluated the efficacy of this access technique as an alternative arterial inflow target in aortic surgery. MATERIAL/METHODS: Twenty-four consecutive patients (mean age: 59±14 years) underwent type A aortic dissection repair using selective antegrade cerebral perfusion. Direct aortic cannulation was used in 14 cases, subclavian access in 6 patients, and femoral entry in 4 patients. Perioperative factors were evaluated to identify the reliability and eventual benefits of direct cannulation method at the aortic arch. RESULTS: There were no operative deaths and cumulative 30-day mortality rate was 25% (6). Permanent neurological deficits were not observed; in 1 patient transient changes occurred (4%). Time to reach circulatory arrest was the shortest in the direct access group, with mean 27±11 (CI: 20.6-33.3) min vs. 43±22 (28.0-78.0) min (p=0.058) and 32±8 (23.6-40.4) min (p=0.34) by femoral cannulation and subclavian entry, respectively. Direct arch cannulation resulted in the best renal function in the first 72 h after surgery and similar characteristics were observed in lactic acid levels. CONCLUSIONS: Ultrasound-guided direct cannulation on the concavity of the aortic arch using a Seldinger technique is a reliable method in dissection repairs. Prompt antegrade perfusion provides not only cerebral but also peripheral organ and tissue protection, which is an advantage in this high-risk group of patients.

Surgical repair and replacement for native mitral valve infective endocarditis.

AIMS: The clinical benefits of mitral valve repair over replacement in the setting of mitral infective endocarditis are not clearly established. METHODS: Data of patients who underwent cardiac surgery for infective endocarditis over a 20-year period (2001-2021) at two cardiac centres were reviewed. Among them, 282 patients underwent native mitral valve surgery and were included in the study. Nearest-neighbour propensity-score matching was performed to account for differences in patients' profile between the repair and replacement subgroups. RESULTS: Mitral valve replacement was performed in 186 patients, while in 96 cases patients underwent mitral valve repair. Propensity match analysis provided 89 well matched pairs. Mean age was 60 ±â€Š15 years; 75% of the patients were male. Mitral valve replacement was more commonly performed in patients with involvement of both mitral leaflets, commissure(s) and mitral annulus. Patients with lesion(s) limited to P2 segment formed the majority of the cases undergoing mitral valve repair. There was no difference in terms of microbiological findings. In-hospital mortality was 7% with no difference between the repair and the replacement cohorts. Survival probabilities at 1, 5 and 10 years were 88%, 72% and 68%, respectively after mitral repair, and 88%, 78% and 63%, respectively after mitral replacement (log-rank P  = 0.94). CONCLUSIONS: Mitral valve repair was more commonly performed in patients with isolated single leaflet involvement and provided good early and 10-year outcomes. Patients with annular disruption, lesion(s) on both leaflets and commissure(s) were successfully served on early and mid-term course by mitral valve replacement.

Elective Thoracic Aortic Aneurysm Surgery: A Tertiary Center Experience.

Background A thoracic aortic aneurysm (TAA) is a diseased expansion of the thoracic aorta. There is morbidity associated with a dilated aorta, as well as significant mortality. Open thoracic surgery is the fundamental management for proximal lesions, offering definitive treatment with excellent results. This study aimed to summarize preoperative data and operative outcomes of patients who underwent TAA repair at our institution. Methods Data were retrospectively collected from 234 patients that underwent elective open thoracic surgery at University Hospital Southampton for TAA disease, between 2015 and 2019. Demographics, clinical factors, surgical details, as well as outcome measures, were gathered. Results There were 166 males and 68 females, with an overall mean age of 66 years. The breakdown of operations comprised 105 aortic roots, 171 ascending aorta, 20 aortic arch, and 12 descending aorta cases. The mean follow-up was 370 days. 30-day mortality was 5.13%. Mortality was associated with female gender, aortic root surgery, and prosthetic valves. Mean aortic diameters at the time of surgery for the non-genetic aortopathy and genetic aortopathy groups were respectively 4.93cm and 4.63cm in the aortic root, 5.56cm and 4.88cm in the ascending aorta, 5.08cm and 3.87cm in the aortic arch, and 6.63cm and 5.50cm in the descending aorta. Conclusion Several factors are associated with complications and morbidity, which should be considered when discussing the risks of intervention with patients. There were no neuroprotective strategies that altered post-operative neurological function. Current practice in our unit fits in with current international guidance.

Right ventricular blood cyst causing outflow tract obstruction in an adult.

Blood cysts are benign intracardiac masses that are well described in infants. We present a rare adult presentation of a blood cyst tethered to the right ventricular wall and the tricuspid valve causing right ventricular outflow obstruction. Multimodality imaging approach was found to be of great importance in the diagnosis and treatment of this patient.

Modes of failure of Trifecta aortic valve prosthesis.

OBJECTIVES: Several concerns have been recently raised regarding the durability of Trifecta prostheses. Different mechanisms of early failure were reported. Our aim was to study in a large population the modes of failure of Trifecta valves. METHODS: We conducted a retrospective analysis of patients who underwent surgical aortic valve replacement with a Trifecta prosthesis during the period 2010-2018. Details regarding the mode of failure and haemodynamic dysfunction were collected for patients who underwent reintervention for structural valve failure. The Kaplan-Meier method was used to calculate survival. Competing risk analysis was performed to calculate the cumulative risk of reintervention for structural valve failure. RESULTS: The overall population comprises 1228 patients (1084 TF model and 144 TFGT model). Forty-four patients-mean patients' age at the time of the first implant 69 (standard deviation: 12) years and 61% female-underwent reintervention for structural valve failure after a median time of 63 [44-74] months. The cumulative incidence of reintervention for structural valve failure was 0.16% (SE 0.11%), 1.77% (SE 0.38%) and 5.11% (SE 0.98%) at 1, 5 and 9 years, respectively. In 24/44 patients (55%), a leaflet tear with dehiscence at the commissure level was found intraoperatively or described by imaging assessment. The cumulative incidence of reintervention for failure due to leaflet(s) tear was 0.16% (SE 0.11%), 1.08% (SE 0.29%) and 3.03% (SE 0.88%) at 1, 5 and 9 years, respectively. CONCLUSIONS: Leaflet(s) tear with dehiscence along the stent post was the main mode of early failure, up to 5 years, after Trifecta valves' implantation.

Early and long-term outcomes of re-sternotomy for aortic valve replacement with patent coronary artery grafts.

OBJECTIVE: The aim was to evaluate early and long-term outcomes of re-sternotomy for aortic valve replacement (AVR) with previous patent coronary artery grafts. METHODS: Data for re-sternotomy for AVRs (group 1 isolated AVR, group 2 AVR with concomitant procedure) were collected (2000-2019). Logistic regression analysis was performed to identify predictors of in-hospital mortality and postoperative composite outcome (in-hospital death, transient ischemic attack/stroke, renal failure requiring new hemofiltration, deep sternal wound infection, re-exploration for bleeding/tamponade and length of stay >30 days). Survival curves were compared using log-rank test Cox proportion hazards model was used for predictors of long-term survival. RESULTS: Total 178 patients were included (groups 1-90 patients, group 2-88 patients). Mean age was 75 ± 4 years and mean log EuroSCORE was 17 ± 12% (15 ± 8% - group 1 vs. 19 ± 14% - group 2, p = 0.06). Mean follow-up was 6.3 ± 4.4 years. Cardiovascular injury occurred in 12%. Left internal mammary artery was most commonly injured. In-hospital mortality was 7.8% (5% - group 1 vs. 10.2% - group 2, p = 0.247). NYHA class III-IV, perioperative intra-aortic balloon pump and cardiovascular injury were independent predictors of in-hospital mortality (hazard ratio: 13.33, 95% confidence interval: 2.04-83.33, p = 0.007). Survival was significantly worse with cardiovascular injury at re-sternotomy up to 5 years (46% vs. 67%, p = 0.025) and postoperative complications (p = 0.023). Survival was significantly lower than age-matched first-time AVR and UK population. CONCLUSIONS: Long-term survival is significantly impaired by cardiovascular injury and perioperative complications of re-sternotomy.

Reconsidered surgical aortic valve replacement after declined transcatheter valve implantation.

BACKGROUND: Outcomes for high surgical risk patients who declined transcatheter aortic valve implantation (TAVI) and then reconsidered for conventional aortic valve replacement (rSAVR) for severe calcific aortic stenosis are not well known. METHODS: This single-centre, case-control study (rSAVR vs Conservative group) retrospectively analysed patients for rSAVR (2009-2019). Multivariable logistic regression was used to identify independent predictors of composite of neurological sequelae/renal failure/deep sternal wound infection/re-exploration and death. Survival was compared using Kaplan-Meier curves and log-rank test. A Cox proportional hazards model was used to determine predictors of survival. RESULTS: TAVI was denied in 519/1095 patients, 114(10.4%) had rSAVR (cases) and 405 (37%) were managed conservatively (controls). Mean age for rSAVR was 80 years (IQR: 73.5-85 years). The commonest reason for declining TAVI was prohibitive high risk due to multiple comorbidities. Among rSAVR, hospital mortality was 2.2% and stroke was 4.4%. Median follow-up was conservative; 14.4 months versus rSAVR; 34.8 months. Five-year survival was conservative; 12.6% versus rSAVR; and 59.5% (overall conservative; 38.0% vs. rSAVR; 60.5%, p < 0.001). rSAVR was protective (hazard ratio [HR]: 0.37, 95% confidence interval [CI]: 0.26, 0.51, p < 0.001) and high comorbidities had high hazard (HR: 1.57, 95% CI: 1.19, 2.07, p = 0.001). rSAVR had fewer hospital readmission episodes (Conservative; 13.6/patient-year vs. rSAVR; 6.9/patient-year, p = 0.002). CONCLUSIONS: rSAVR may be considered in high surgical risk elderly patients who have been declined TAVI in centres with low operative mortality. rSAVR may be superior to conservative management in carefully selected patients.