New insights and novel perspectives in bileaflet mechanical heart valve prostheses thromboresistance.

BACKGROUND: Although well-known for their thromboresistance, bileaflet mechanical heart valves (BMHV) require lifelong anti-thrombotic therapy. This must be associated with a certain level of thrombogenicity. Since both thromboresistance and thrombogenicity are explained by the blood-artificial surface or liquid-solid interactions, the aim of the present study was to explore BMHV thromboresistance from new perspectives. The wettability of BMHV pyrolytic carbon (PyC) occluders was investigated in under-liquid conditions. The submerged BMHV wettability clarifies the mechanisms involved in the thromboresistance. METHODS: The PyC occluders of a SJM Regent™ BMHV were previously laser irradiated, to create a surface hierarchical nano-texture, featuring three nano-configurations. Additionally, four PyC occluders of standard BMHV (Carbomedics, SJM Regent™, Bicarbon™, On-X®), were investigated. All occluders were evaluated in under-liquid configuration, with silicon oil used as the working droplet, while water, simulating blood, was used as the surrounding liquid. The under-liquid droplet-substrate wetting interactions were analyzed using contact angle goniometry. RESULTS: All the standard occluders showed very low contact angle, reflecting a pronounced affinity for non-polar molecules. No receding of the contact line could be observed for the untreated occluders. The smallest static contact angle of around 61° could be observed for On-X® valve (the only valve made of full PyC). The laser-treated occluders strongly repelled oil in underwater conditions. A drastic change in their wetting behaviour was observed depending on the surrounding fluid, displaying a hydrophobic behaviour in the presence of air (as the surrounding medium), and showing instead a hydrophilic nature, when surrounded by water. CONCLUSIONS: BMHV "fear" water and blood. The intrinsic affinity of BMHV for nonpolar fluids can be translated into a tendency to repel polar fluids, such as water and blood. The blood-artificial surface interaction in BMHV is minimized. The contact between blood and BMHV surface is drastically reduced by polar-nonpolar Van der Waals forces. The "hydro/bloodphobia" of BMHV is intrinsically related to their chemical composition and their surface energy, thus their material: PyC indeed. Pertaining to thromboresistance, the surface roughness does not play a significant role. Instead, the thromboresistance of BMHV lies in molecular interactions. BMHV wettability can be tuned by altering the surface interface, by means of nanotechnology.

A qualitative study of the experiences and perceptions of older patients and relatives prior to cardiac surgery.

BACKGROUND: Shared decision-making plays an important role in ensuring value-based healthcare in cardiac surgery. However, the personal situations of patients in cardiac care have not been widely explored, and thus, little is known about the decision-making experiences of patients and their relatives before surgery. OBJECTIVE: To explore the perceptions of patients indicated for cardiac surgery and their relatives during the decision-making process, as well as their experiences of a conversation aimed at achieving shared decision-making in the treatment trajectory. METHODS: The data were collected through semi-structured in-depth interviews with patients aged ≥70 years who were indicated for cardiac surgery and their relatives until theme saturation. Both inductive and deductive analysis were conducted based on the principles of reflexive thematic analysis. RESULTS: Interviews with 16 patients and 10 relatives provided in-depth insights into the experiences of patients and their relatives in terms of a shared decision-making process prior to surgery. Overall, 15 subthemes were identified, and these were divided into three themes. In general, the patients' experiences and perceptions were influenced by their (1) general daily functioning. The relatives were more concerned about (2) social expectations and (3) existential uncertainty. CONCLUSIONS: Patients eligible for cardiac surgery and their families have unique experiences and perceptions during the process of shared decision-making. The subthemes emerging from this study, such as the overestimation of potential medical outcomes by patients and their relatives, who experience fear about the current health situation of their loved one, require careful attention from healthcare professionals during decision-making conversations.

Proactive Decision Support for Glaucoma Treatment: Predicting Surgical Interventions with Clinically Available Data.

A longitudinal ophthalmic dataset was used to investigate multi-modal machine learning (ML) models incorporating patient demographics and history, clinical measurements, optical coherence tomography (OCT), and visual field (VF) testing in predicting glaucoma surgical interventions. The cohort included 369 patients who underwent glaucoma surgery and 592 patients who did not undergo surgery. The data types used for prediction included patient demographics, history of systemic conditions, medication history, ophthalmic measurements, 24-2 VF results, and thickness measurements from OCT imaging. The ML models were trained to predict surgical interventions and evaluated on independent data collected at a separate study site. The models were evaluated based on their ability to predict surgeries at varying lengths of time prior to surgical intervention. The highest performing predictions achieved an AUC of 0.93, 0.92, and 0.93 in predicting surgical intervention at 1 year, 2 years, and 3 years, respectively. The models were also able to achieve high sensitivity (0.89, 0.77, 0.86 at 1, 2, and 3 years, respectively) and specificity (0.85, 0.90, and 0.91 at 1, 2, and 3 years, respectively) at an 0.80 level of precision. The multi-modal models trained on a combination of data types predicted surgical interventions with high accuracy up to three years prior to surgery and could provide an important tool to predict the need for glaucoma intervention.

Roles and competencies of nurses and physicians in shared decision-making in cardiac surgery: A scoping review.

AIM: Identification and synthesis of research data related to the roles and competencies of physicians and nurses that are prerequisites for careful shared decision-making with patients potentially undergoing cardiac surgery. DESIGN: A scoping review was conducted in accordance with the Joanna Briggs Institute's methodology for scoping reviews and the PRISMA Extension for Scoping Reviews. METHODS: PubMed, EMBASE and CINAHL were searched from inception dates up to March 2022, to identify primary studies published in a peer-reviewed journal. Study selection, assessment of the methodological quality and data extracting of the included studies were done by at least two independent researchers. To describe the findings of the studies, an emergent synthesis approach was used to visualize a descriptive representation of professional roles and competencies in shared decision-making, in an overview. RESULTS: The systematic search revealed 10,055 potential papers, 8873 articles were screened on title and abstract and 76 full texts were retrieved. Eight articles were included for final evaluation. For nurses and physicians, 26 different skills were identified in the literature to practice shared decision-making in cardiac surgery. The skills that emerged were divided into five professional roles: moderator; health educator; data collector; psychological supporter and translator. CONCLUSIONS: This review specifies the professional roles and required competencies related to shared decision-making in cardiac surgery. Further research is needed to compare our findings with other clinical areas and from there to arrive at a professional division of roles between the different clinical disciplines involved. IMPACT: The visualization of generic shared decision-making competencies and roles should establish the professional division of positions between various clinical physician and nurse disciplines in order to create a treatment plan based on evidence, values, preferences and the patient's personal situation. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Multicentre experience with valve-sparing aortic root replacement by means of combined remodelling and external aortic ring annuloplasty in patients with Marfan syndrome.

OBJECTIVES: The most recent valve-sparing root replacement technique combines the advantages of the reimplantation (David) and remodelling (Yacoub) techniques. The aortic root is reconstructed according to the remodelling technique, the aortic valve is repaired according to the principle of effective height, and an external ring provides annular support. The purpose of this study was to evaluate operative and mid-term outcomes using this technique in patients with Marfan syndrome. METHODS: Adult patients with Marfan syndrome who had an indication for aortic root surgery according to European Society of Cardiology guidelines and were operated on using this new root replacement technique were retrospectively evaluated. Follow-up was obtained from standard outpatient visits and included echocardiography. RESULTS: The study group comprised 22 patients (mean age 36 years, 68% males). Mean follow-up was 7.5 years. There were no mortalities. Two patients required aortic valve replacement because of aortic regurgitation. In both patients, the aortic root was severely dilated (≥65 mm) preoperatively, with grade III aortic valve regurgitation and aortic valve cusps that were very fragile. Aortic regurgitation was grade ≤I on follow-up in 18 of the remaining 20 patients. CONCLUSIONS: Valve-sparing root replacement using remodelling combined with aortic-ring annuloplasty is safe in patients with Marfan syndrome. The mid-term outcome is promising in patients undergoing elective valve-sparing root replacement at recommended root diameters. However, in patients with extremely dilated aortic roots and already severe aortic regurgitation, the technique should be used cautiously as aortic cusps are fragile and might not be suitable for durable repair. CLINICAL REGISTRATION NUMBER: UMCG Research registry #11208.

Feasibility of preoperative and postoperative physical rehabilitation for cardiac surgery patients - a longitudinal cohort study.

BACKGROUND: This study aimed to determine the feasibility of a preoperative and postoperative (in- and outpatient) physical rehabilitation program, the Heart-ROCQ-pilot program. METHODS: This cohort study included patients undergoing cardiac surgery (including coronary artery bypass graft surgery, valve surgery, aortic surgery, or combinations of these surgeries) and participated in the Heart-ROCQ-pilot program. Feasibility involved compliance and characteristics of bicycle and strength training sessions in the three rehabilitation phases. RESULTS: Of the eligible patients, 56% (n = 74) participated in the program (41% of exclusions were due to various health reasons). On average across the rehabilitation phases, the compliance rates of bicycle and strength training were 88% and 83%, respectively. Workload to heart rate (W/HR) ratio and total absolute volume load for bicycle and strength training, respectively, improved in each rehabilitation phase (P < 0.05). The W/HR-ratio was higher during the last postoperative session compared to the first preoperative session (0.48 to 0.63 W/beat, P < 0.001) and similar to the last preoperative session (0.65 to 0.64 W/beat, P < 0.497). During less than 1% of the bicycle sessions, patients reported discomfort scores of 5 to 6 (scale 0-10, with higher scores indicating a higher level). CONCLUSIONS: The Heart-ROCQ-pilot program was feasible for patients awaiting cardiac surgery. Patients were very compliant and were able to safely increase the training load before surgery and regained this improvement within eight weeks after surgery.

Long-Term Performance of Epicardial versus Transvenous Left Ventricular Leads for Cardiac Resynchronization Therapy.

Aims: to study the technical performance of epicardial left ventricular (LV) leads placed via video assisted thoracic surgery (VATS), compared to transvenously placed leads for cardiac resynchronization therapy (CRT). Methods: From 2001 until 2013, a total of 644 lead placement procedures were performed for CRT. In the case of unsuccessful transvenous LV lead placement, the patient received an epicardial LV lead. Study groups consist of 578 patients with a transvenous LV lead and 66 with an epicardial LV lead. The primary endpoint was LV-lead failure necessitating a replacement or deactivation. The secondary endpoint was energy consumption. Results: The mean follow up was 5.9 years (epicardial: 5.5 ± 3.1, transvenous: 5.9 ± 3.5). Transvenous leads failed significantly more frequently than epicardial leads with a total of 66 (11%) in the transvenous leads group vs. 2 (3%) in the epicardial lead group (p = 0.037). Lead energy consumption was not significantly different between groups. Conclusions: Epicardial lead placement is feasible, safe and shows excellent long-term performance compared to transvenous leads. Epicardial lead placement should be considered when primary transvenous lead placement fails or as a primary lead placement strategy in challenging cases.

Tricuspid Valve Repair Can Restore the Prognosis of Patients with Hypoplastic Left Heart Syndrome and Tricuspid Valve Regurgitation: A Meta-analysis.

To date, evidence supporting the efficacy of tricuspid valve (TV) repair in interrupting the progression of systemic right ventricular (RV) adverse remodeling in hypoplastic left heart syndrome (HLHS) is conflicting. We conducted a systematic review and meta-analysis of scientific literature to assess the impact of TV repair in effectively modifying the prognosis of patients with HLHS. We conducted a systematic review of PubMed, Web of Science, and Scopus databases. A random-effect meta-analysis was performed and transplant-free survival, freedom from TV regurgitation, and TV reoperation data were reconstructed using the published Kaplan-Meier curves. Nine studies were included, comprising 203 HLHS patients undergoing TV repair and 323 HLHS controls. The estimated transplant-free survival at 1, 5, and 10 years of follow-up was 75.5% [95% confidence interval (CI) = 67.6-84.3%], 63.6% [95% CI = 54.6-73.9%], and 61.9% [95% CI = 52.7-72.6%], respectively. Transplant-free survival was comparable to HLHS peers without TV regurgitation (p = 0.59). Five-year freedom from recurrence of TV regurgitation and freedom from TV reoperation was 57% [95% CI = 46.7-69.7%] and 63.6% [95% CI = 54.5-74.3%], respectively. Younger age and TV repair at the time of Norwood operation increased the risk of TV regurgitation recurrence and the need for TV reoperation. Our meta-analysis supports the efficacy of TV repair in favorably modifying the prognosis of patients with HLHS and TV regurgitation, reestablishing a medium-term transplant-free survival which is comparable to HLHS peers. However, durability of surgery and long-term fate of TV and RV performance are still unclear.

Correlations between the alpha-Gal antigen, antibody response and calcification of cardiac valve bioprostheses: experimental evidence obtained using an alpha-Gal knockout mouse animal model.

Introduction: Preformed antibodies against αGal in the human and the presence of αGal antigens on the tissue constituting the commercial bioprosthetic heart valves (BHVs, mainly bovine or porcine pericardium), lead to opsonization of the implanted BHV, leading to deterioration and calcification. Murine subcutaneous implantation of BHVs leaflets has been widely used for testing the efficacy of anti-calcification treatments. Unfortunately, commercial BHVs leaflets implanted into a murine model will not be able to elicit an αGal immune response because such antigen is expressed in the recipient and therefore immunologically tolerated. Methods: This study evaluates the calcium deposition on commercial BHV using a new humanized murine αGal knockout (KO) animal model. Furtherly, the anti-calcification efficacy of a polyphenol-based treatment was deeply investigated. By using CRISPR/Cas9 approach an αGal KO mouse was created and adopted for the evaluation of the calcific propensity of original and polyphenols treated BHV by subcutaneous implantation. The calcium quantification was carried out by plasma analysis; the immune response evaluation was performed by histology and immunological assays. Anti-αGal antibodies level in KO mice increases at least double after 2 months of implantation of original commercial BHV compared to WT mice, conversely, the polyphenols-based treatment seems to effectively mask the antigen to the KO mice's immune system. Results: Commercial leaflets explanted after 1 month from KO mice showed a four-time increased calcium deposition than what was observed on that explanted from WT. Polyphenol treatment prevents calcium deposition by over 99% in both KO and WT animals. The implantation of commercial BHV leaflets significantly stimulates the KO mouse immune system resulting in massive production of anti-Gal antibodies and the exacerbation of the αGal-related calcific effect if compared with the WT mouse. Discussion: The polyphenol-based treatment applied in this investigation showed an unexpected ability to inhibit the recognition of BHV xenoantigens by circulating antibodies almost completely preventing calcific depositions compared to the untreated counterpart.

Muscle strength trajectories and their association with postoperative health-related quality of life in patients undergoing coronary artery bypass grafting surgery: a prospective cohort study.

BACKGROUND: Patients with sarcopenia have a higher risk of poor recovery after coronary artery bypass grafting (CABG). Little is known about the impact of changes in muscle strength (the primary indicator for sarcopenia) on health-related quality of life (HR-QoL). This study aimed to (1) identify subgroups with different muscle strength trajectories, (2) identify differences in preoperative risk factors among trajectory group membership, and (3) explore their prognostic value on postoperative HR-QoL in patients undergoing CABG. METHODS: In this prospective observational study 131 patients undergoing elective CABG completed grip strength tests and HR-QoL questionnaires. Latent Class Growth Mixture Modelling (LCGMM) was used to identify clinically relevant trajectories (> 5% of study population) for weight-normalised grip strength, measured at admission, 3 days, and 6 months after surgery. Differences between trajectory group membership at baseline were evaluated. The impact of trajectory group membership on postoperative HR-QoL was evaluated with multiple linear regression models. RESULTS: Due to low numbers (n = 15), female patients were excluded from LCGMM and subsequent statistical analyses. In males (n = 116), we identified two main weight-normalised grip strength trajectories: a "stable average" trajectory with a slight decline immediately post-surgery and recovery to preoperative levels (n = 85) and a "high" trajectory with a considerable immediate decline after surgery but followed towards a higher level of recovery compared to preoperative level (n = 27). The "stable average" patients were older (68 vs. 57 years; P = 0.003), had more diabetes (27% vs. 4%; P = 0.01) and had a higher BMI (27.8 vs. 24.8; P = 0.005) compared to the "high" group. After correction for age, diabetes, and baseline HR-QoL, group trajectory membership was not associated with postoperative HR-QoL, yet an increase in individual change scores of weight-normalised grip strength was associated with a better postoperative HR-QoL. We also identified one small trajectory group (n = 4, ≤ 5%). CONCLUSIONS: This study showed two relevant weight-normalised grip strength trajectories in male patients undergoing CABG, varying in important preoperative risk factors. While change scores of grip strength per weight did predict postoperative HR-QoL, the trajectory subgroups could not predict postoperative HR-QoL. Future research should focus on female patients, reacting potentially different on CABG and/or rehabilitation treatment. Trial registration NCT03774342, 12-12-2018.

Decellularized cryopreserved human pericardium: a validation study towards tissue bank practice.

Pericardial patches are currently used as reconstructive material in cardiac surgery for surgical treatment of cardiac septal defects. Autologous pericardial patches, either treated with glutaraldehyde or not, can be used as an alternative to synthetic materials or xenograft in congenital septal defects repair. The availability of an allogenic decellularized pericardium could reduce complication during and after surgery and could be a valid alternative. Decellularization of allogenic tissues aims at reducing the immunogenic reaction that might trigger inflammation and tissue calcification over time. The ideal graft for congenital heart disease repair should be biocompatible, mechanically resistant, non-immunogenic, and should have the ability to growth with the patients. The aim of the present study is the evaluation of the efficacy of a new decellularization protocol of homologous pericardium, even after cryopreservation. The technique has proven to be suitable as a tissue bank procedure and highly successful in the removal of cells and nucleic acids content, but also in the preservation of collagen and biomechanical properties of the human pericardium.

Clinical monitoring of activated clotting time during cardiothoracic surgery: comparing the Hemochron® Response and Hemochron® Signature Elite.

INTRODUCTION: The Activated Clotting Time (ACT) is commonly used to manage anticoagulation during cardiac surgery. The aim of this study was to compare the older manually operated Hemochron® Response and the automated Hemochron® Signature Elite. METHODS: In this observational study the clinically relevant differences of both devices were investigated simultaneously, using duplicate measurements, in 29 patients who underwent a Coronary Artery Bypass Grafting (CABG) or Aortic Valve Replacement (AVR) in order to determine reliability, bias, and to detect which method has the lowest variation. Blood samples were obtained from the arterial line prior to surgery, after administration of 300 IU/kg heparin, 5 minutes after initiation of cardiopulmonary bypass and successively every 30 minutes, and after protamine administration. RESULTS: A total of 202 measurements were performed. Of these 10 measurements were out of range in the Response and 9 in the Elite. About 27 single unstable magnet errors were seen in the Response versus no measurement errors in the Elite. No statistically significant differences between the Response (p = 0.22, Wilcoxon rank) and Elite (p = 0.064) duplicates were observed. The Response values were consistently higher during heparinization than the Elite measurements (p = 0.002, repeated measurements) with an average positive bias of around 56 seconds during heparinization (Bland-Altman). Overall, the coefficient of variation (CoV) increased during heparinization. CONCLUSION: The Elite was more reliable, but the variation was higher for the Elite than the Response. The observed positive bias in the Response compared to the Elite could affect heparin administration during surgery making the two systems not interchangeable.

Mitral Valve Coaptation Reserve Index: A Model to Localize Individual Resistance to Mitral Regurgitation Caused by Annular Dilation.

OBJECTIVES: The objective of this study was to develop a mathematical model for mitral annular dilatation simulation and determine its effects on the individualized mitral valve (MV) coaptation reserve index (CRI). DESIGN: A retrospective analysis of intraoperative transesophageal 3-dimensionalechocardiographic MV datasets was performed. A mathematical model was created to assess the mitral CRI for each leaflet segment (A1-P1, A2-P2, A3-P3). Mitral CRI was defined as the ratio between the coaptation reserve (measured coaptation length along the closure line) and an individualized correction factor. Indexing was chosen to correct for MV sphericity and area of largest valve opening. Mathematical models were created to simulate progressive mitral annular dilatation and to predict the effect on the individual mitral CRI. SETTING: At a single-center academic hospital. PARTICIPANTS: Twenty-five patients with normally functioning MVs undergoing cardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Direct measurement of leaflet coaptation along the closure line showed the lowest amount of coaptation (reserve) near the commissures (A1-P1 0.21 ± 0.05 cm and A3-P3 0.22 ± 0.06 cm), and the highest amount of coaptation (reserve) at region A2 to P2 0.25 ± 0.06 cm. After indexing, the A2-to-P2 region was the area with the lowest CRI in the majority of patients, and also the area with the least resistance to mitral regurgitation (MR) occurrence after simulation of progressive annular dilation. CONCLUSIONS: Quantification and indexing of mitral coaptation reserve along the closure line are feasible. Indexing and mathematical simulation of progressive annular dilatation consistently showed that indexed coaptation reserve was lowest in the A2-to-P2 region. These results may explain why this area is prone to lose coaptation and is often affected in MR.

Smoking and progressive retinal nerve fibre layer thinning in glaucoma.

BACKGROUND/AIMS: To investigate the relationship between smoking and smoking intensity, and the rate of retinal nerve fibre layer (RNFL) thinning in patients with primary open angle glaucoma (POAG). METHODS: In this longitudinal study, patients with POAG who had at least 3 years of follow-up with a minimum of 5 visits of optical coherence tomography (OCT) were enrolled. The smoking intensity was calculated as the pack-year at the baseline OCT. Univariable and multivariable linear mixed models were used to determine the effect of each parameter on the rates of RNFL thinning over time. Non-linear least-squares estimation with piecewise regression model was used to investigate the cut-off point for the relationship between circumpapillary RNFL thinning and smoking intensity. RESULTS: A total of 466 eyes of 314 patients were included over the mean (95% CI) follow-up of 6.6 (6.4 to 6.7) years. Of the 314 patients, 121 (39%) had reported any history of smoking. Greater smoking intensity was associated with faster RNFL thinning (-0.06 (95% CI -0.11 to 0.00) µm/year per 10 pack-year higher; p=0.031) after adjusted for confounding factors. RNFL thinning became significantly faster when smoking intensity was >8 pack-year. CONCLUSIONS: Smoking intensity is associated with faster rates of RNFL thinning. Evaluation of smoking intensity might add information to the assessment of risk of glaucoma progression. Future studies are required to explore if withdrawing smoking as a modifiable risk factor can decrease progression in patients with glaucoma.

Ventricular morphology of single-ventricle hearts has a significant impact on outcomes after Fontan palliation: a meta-analysis.

OBJECTIVES: A conclusive interpretation of the role of ventricular dominance in outcomes after Fontan palliation has not been formulated yet. We conducted a systematic review and meta-analysis of scientific literature to give an insight into the impact of ventricular morphology in single-ventricle palliation, focusing on its influence on survival, morbidities, ventricular performance and functional capacity. METHODS: A systematic review of PubMed, Web of Science and Scopus databases was performed. A random-effect meta-analysis was conducted, and survival data were reconstructed using the published Kaplan-Meier survival curves. RESULTS: Twenty-seven studies were selected, for a total of 4529 left-dominant versus 4844 right-dominant patients. Estimated survival at 1, 5, 10, 20 and 30 years of follow-up was 0.99 [95% confidence interval (CI) = 0.98-0.99], 0.95 [95% CI = 0.94-0.96], 0.92 [95% CI = 0.91-0.93], 0.86 [95% CI = 0.84-0.88] and 0.68 [95% CI = 0.65-0.83] for left-dominant patients and 0.94 [95% CI = 0.93-0.95], 0.89 [95% CI = 0.88-0.9], 0.85 [95% CI = 0.83-0.87], 0.69 [95% CI = 0.63-0.75] and 0.59 [95% CI = 0.5-0.69] for right-dominant patients, respectively. Survival was statistically lower for right-dominant patients (P < 0.001), with an hazard ratio for the mortality of 2.38 (2.03-2.80); also, they displayed significantly longer hospital stay, worse ventricular function, larger ventricular volumes and a higher incidence of moderate or severe atrioventricular valve regurgitation when compared to left-dominant patients. CONCLUSIONS: According to our meta-analysis, the morphology of the dominant ventricle has a significant impact on outcomes after Fontan palliation. Right-dominant patients experience an inferior long-term survival when the anatomical right ventricle is included in the systemic circulation.

Staged single-port thoracoscopic R2 sympathicotomy as a reproducible, safe and effective treatment option for debilitating severe facial blushing.

OBJECTIVES: Our goal was to investigate the safety, feasibility, success rate, complication rate and side effects of staged single-port thoracoscopic R2 sympathicotomy in the treatment of severe facial blushing. Facial blushing is considered a benign condition; however, severe facial blushing can have a major impact on quality of life. When nonsurgical options such as medication and psychological treatments offer no or insufficient relief, surgical treatment with thoracoscopic sympathicotomy should be considered. METHODS: All patients who underwent a staged thoracoscopic sympathicotomy at level R2 for severe facial blushing between January 2016 and September 2021 were included. Clinical and surgical data were prospectively collected and analysed. RESULTS: A total of 16 patients with low operative risk (American Society of Anesthesiologists class 1) were treated. No major perioperative complications were encountered. One patient experienced postoperative unilateral Horner's syndrome that resolved completely after 1 week. Two patients experienced compensatory hyperhidrosis. The success rate was 100%. One patient experienced a slight recurrence of blushing symptoms after 3 years that did not interfere with their quality of life. All patients were satisfied with the results and had no regrets of having undergone the procedure. CONCLUSIONS: Staged single-port thoracoscopic R2 sympathicotomy is a reproducible, safe and highly effective surgical treatment option with low compensatory hyperhidrosis rates and the potential to significantly improve quality of life in carefully selected patients suffering from severe facial blushing. We would like to increase awareness among healthcare professionals for debilitating facial blushing and suggest timely referral for surgical treatment.

Comparison of Machine Learning Models Including Preoperative, Intraoperative, and Postoperative Data and Mortality After Cardiac Surgery.

Importance: A variety of perioperative risk factors are associated with postoperative mortality risk. However, the relative contribution of routinely collected intraoperative clinical parameters to short-term and long-term mortality remains understudied. Objective: To examine the performance of multiple machine learning models with data from different perioperative periods to predict 30-day, 1-year, and 5-year mortality and investigate factors that contribute to these predictions. Design, Setting, and Participants: In this prognostic study using prospectively collected data, risk prediction models were developed for short-term and long-term mortality after cardiac surgery. Included participants were adult patients undergoing a first-time valve operation, coronary artery bypass grafting, or a combination of both between 1997 and 2017 in a single center, the University Medical Centre Groningen in the Netherlands. Mortality data were obtained in November 2017. Data analysis took place between February 2020 and August 2021. Exposure: Cardiac surgery. Main Outcomes and Measures: Postoperative mortality rates at 30 days, 1 year, and 5 years were the primary outcomes. The area under the receiver operating characteristic curve (AUROC) was used to assess discrimination. The contribution of all preoperative, intraoperative hemodynamic and temperature, and postoperative factors to mortality was investigated using Shapley additive explanations (SHAP) values. Results: Data from 9415 patients who underwent cardiac surgery (median [IQR] age, 68 [60-74] years; 2554 [27.1%] women) were included. Overall mortality rates at 30 days, 1 year, and 5 years were 268 patients (2.8%), 420 patients (4.5%), and 612 patients (6.5%), respectively. Models including preoperative, intraoperative, and postoperative data achieved AUROC values of 0.82 (95% CI, 0.78-0.86), 0.81 (95% CI, 0.77-0.85), and 0.80 (95% CI, 0.75-0.84) for 30-day, 1-year, and 5-year mortality, respectively. Models including only postoperative data performed similarly (30 days: 0.78 [95% CI, 0.73-0.82]; 1 year: 0.79 [95% CI, 0.74-0.83]; 5 years: 0.77 [95% CI, 0.73-0.82]). However, models based on all perioperative data provided less clinically usable predictions, with lower detection rates; for example, postoperative models identified a high-risk group with a 2.8-fold increase in risk for 5-year mortality (4.1 [95% CI, 3.3-5.1]) vs an increase of 11.3 (95% CI, 6.8-18.7) for the high-risk group identified by the full perioperative model. Postoperative markers associated with metabolic dysfunction and decreased kidney function were the main factors contributing to mortality risk. Conclusions and Relevance: This study found that the addition of continuous intraoperative hemodynamic and temperature data to postoperative data was not associated with improved machine learning-based identification of patients at increased risk of short-term and long-term mortality after cardiac operations.

Pulmonary Artery Banding for Dilated Cardiomyopathy in Children: Returning to the Bench from Bedside.

Current treatment paradigms for end-stage dilated cardiomyopathy (DCM) in children include heart transplantation and mechanical support devices. However, waitlist mortality, shortage of smaller donors, time-limited durability of grafts, and thrombo-hemorrhagic events affect long-term outcomes. Moreover, both these options are noncurative and cannot preserve the native heart function. Pulmonary artery banding (PAB) has been reinvented as a possible "regenerative surgery" to retrain the decompensated left ventricle in children with DCM. The rationale is to promote positive ventricular-ventricular interactions that result in recovery of left ventricular function in one out of two children, allowing transplantation delisting. Although promising, global experience with this technique is still limited, and several surgical centers are reluctant to adopt PAB since its exact biological bases remain unknown. In the present review, we summarize the clinical, functional, and molecular known and supposed working mechanisms of PAB in children with DCM. From its proven efficacy in the clinical setting, we described the macroscopic geometrical and functional changes in biventricular performance promoted by PAB. We finally speculated on the possible underlying molecular pathways recruited by PAB. An evidence-based explanation of the working mechanisms of PAB is still awaited to support wider adoption of this surgical option for pediatric heart failure.

Treatment of resistant Raynaud's phenomenon with single-port thoracoscopic sympathicotomy: One-year follow-up.

OBJECTIVE: Follow-up of patients with treatment-resistant Raynaud's phenomenon (RP) one-year after single-port thoracoscopic sympathicotomy (SPTS). METHODS: Eight patients (six males, two females, median age of 45 years) with treatment-resistant RP underwent left-sided SPTS at the third rib (R3), unilaterally. Questionnaires were taken, and number and duration of RP attacks were reported over a 2-week period. Perfusion was assessed with a cooling and recovery procedure at baseline and one year after SPTS. Furthermore, laser speckle contrast analysis, pulse wave velocity, heart rate variability and nailfold capillary microscopy were performed. RESULTS: One year after SPTS the duration of the attacks of was reduced with 1.9 h in the left hand versus 0.3 h in the right hand. Furthermore, three aspects of the questionnaire showed a significant improvement (role limitations due to physical health (p = 0.017), pain (p = 0.027) and physical functioning (p = 0.025)). The total area under the curve of the total cooling and recovery procedure of the left hand was larger one year after surgery (101 (75-140) at baseline versus 118 (95-190) one year post-operatively, p = 0.012), implying a better perfusion in the fingers. This was mainly due to the improvement during the recovery phase (21 (1-41) at baseline versus 38 (24-43) one year post-operatively, p = 0.028). CONCLUSION: One year after unilateral R3 SPTS the benefit with regard to the majority of outcome variables persisted, though some effects seem to attenuate. Long-term effects and long-term follow-up results will be investigated in an on-going study. CLINICAL TRIAL REGISTRATION NUMBER: NCT02680509.

Pulmonary valve preservation during tetralogy of Fallot repair: midterm functional outcomes and risk factors for pulmonary regurgitation.

OBJECTIVES: Many centres have recently adopted pulmonary valve (PV) preservation (PVP) during tetralogy of Fallot (ToF) repair. We sought to identify the midterm functional outcomes and risk factors for pulmonary regurgitation after this procedure. METHODS: All patients undergoing PVP during transatrial-transpulmonary repair for ToF with PV stenosis at our institution between January 2007 and December 2020 were reviewed. RESULTS: Overall, 73 patients were included. At the index surgery, the body surface area was 0.31 ± 0.04 m2, the age was 4.9 ± 2.9 months and the preoperative PV z-score was -3.02 ± 1.11. At a mean follow-up of 5.3 ± 2.7 years, the fractional area change of the right ventricle (RV) was 47.1 ± 5.2%, and the tricuspid annular plane systolic excursion z-score was -3.31 ± 1.89%. The 5-year freedom from moderate/severe PV regurgitation was 61.3% [95% confidence interval (CI): 48, 73%]. There was a significant correlation between RV function and moderate/severe PR at follow-up (R2: 0.08; P = 0.03). A comparison with a group of patients undergoing a transannular patch procedure (N = 33) showed superior outcomes for patients with PVP. The preoperative PV z-score and the degree of PR at discharge were risk factors for the early development of moderate/severe PR at follow-up [hazard ratio (HR): 0.64; 95% CI: 0.48, 0.86, P = 0.01 and HR: 2.31; 95% CI: 1.00, 5.36, P = 0.04, respectively]. A preoperative PV annulus z-score ≤ -2.85 was found to be predictive for moderate/severe PR at 5 years after PVP (HR: 2.56; 95% CI: 1.31, 5.01, P = 0.002). CONCLUSIONS: A pulmonary valve preservation strategy during tetralogy of Fallot repair should always be attempted. However, a preoperative PV annulus z-score < -2.85 and moderate/severe regurgitation upon discharge are risk factors for midterm pulmonary regurgitation.