Role of Prophylactic N-Acetylcysteine Supplementation on Postoperative Outcomes in Patients Undergoing Elective Double-Valve Replacement (Aortic and Mitral Valve).

AIMS AND OBJECTIVES: The incidence of postoperative liver dysfunction is high in patients undergoing double-valve replacement - mitral and aortic valve replacement (DVR). This study aims to evaluate N-acetylcysteine's free radical scavenging property (NAC) to prevent postoperative liver dysfunction in these patients, thus affecting overall clinical outcomes. METHODS: A single-center, prospective, randomized, double-blinded interventional study of 60 patients divided into two groups of 30 each. Group N received prophylactic intravenous NAC, and Group C received volume-matched 5% dextrose. Data comprised demographics, liver function tests (LFT), renal function tests (RFT), vasoactive-inotropic scores (VIS) score, and C-reactive protein (CRP) at various time intervals. Postoperative parameters such as ventilation duration, length of stay in ICU (LOS-ICU), length of hospital stay (LOHS), atrial fibrillation (AF), acute kidney injury (AKI) requiring hemodialysis, and mortality were noted. Statistical analysis was performed with the Student's t-test and Chi-square test (SPSS 22 software). RESULTS: All postoperative LFT parameters (total bilirubin, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), and alkaline phosphatase (ALP)) were significantly lower (P < 0.05) at 24, 48, and 72 hours in Group N compared to Group C. RFT and VIS scores were lower in Group N; however, were not statistically significant except for Serum Creatinine at 48 hours (P = 0.0478). Ventilation duration (P = 0.0465) and LOS-ICU (P = 0.0431) were significantly lower in Group N. Other outcomes like AF, LOHS, and mortality were lower in Group N but were not statistically significant. CONCLUSION: Our study showed that prophylactic administration of NAC in patients undergoing DVR is associated with a reduction in the incidence of postoperative liver dysfunction with a positive impact on postoperative outcomes.

Homograft implant for prosthetic aortic endocarditis with paravalvular abscess in a patient with persistent left superior vena cava.

We present a case report detailing the surgical intervention in a patient with prosthetic aortic valve endocarditis complicated by a paravalvular abscess extending to the mitral-aortic fibrosa. Urgent surgery was required due to severe detachment of the prosthetic aortic valve, marking her third cardiac surgical procedure. Notably, preoperative imaging revealed the presence of a persistent left superior vena cava, a rare vascular anomaly requiring specialized cannulation techniques. The surgical approach involved removal of the infected tissue and prosthetic valve, followed by replacement with a cryopreserved aortic homograft, chosen for its anatomical adaptability.

Betablockers and clinical outcome after surgical aortic valve replacement: a report from the SWEDEHEART registry.

OBJECTIVES: Previous reports suggest that betablockers appear non-beneficial after surgical aortic valve replacement (SAVR). This study aims to clarify the associations between betablockers and long-term outcome after SAVR. METHODS: All patients with isolated SAVR due to aortic stenosis in Sweden between 2006 and 2020, alive at 6 months after surgery, were included. Patients were identified in the SWEDEHEART registry, and records were merged with data from 3 other mandatory national registries. Association between dispensed betablockers and major adverse cardiovascular events (MACE) (all-cause mortality, myocardial infarction and stroke) was analyzed using Cox proportional hazards models, with time-updated data on medication and adjusted for age, sex and comorbidities at baseline. RESULTS: In total, 11 849 patients were included [median follow-up 5.4 years (range 0-13.5)]. Betablockers were prescribed to 79.7% of patients at baseline, decreasing to 62.2% after 5 years. Continuing treatment was associated with higher risk of MACE [adjusted hazard ratio 1.14 (95% confidence interval, CI 1.05-1.23)]. The association was consistent over subgroups based on age, sex and comorbidities except atrial fibrillation [hazard ratio (HR) 1.05 (95% CI 0.93-1.19)]. A sensitivity analysis including time-updated data on comorbidites attenuated the difference between the groups [HR 1.04 (95% CI 0.95-1.14, P = 0.33)]. CONCLUSIONS: Treatment with betablockers did not appear to be associated with inferior long-term outcome after SAVR, when adjusting for new concomitant diseases. Thus, it is likely that it is the underlying cardiac diseases that are associated with MACE rather than betablocker treatment.

CO2 delivery techniques in mini-sternotomy surgery and neurological events: a multicentric study.

BACKGROUND: The impact of air bubbles into the cerebral circulation after open heart surgery has been a topic of discussion since the introduction of the heart-lung machine. The aim of the study was to evaluate whether the use of a dedicated commercial sponge diffuser is better than a custom-made narrow section cannula or the absence of CO2 in preventing neurological events after aortic valve replacement via J mini-sternotomy. METHODS: Three cohorts of J-shaped mini-sternotomy performed at three different centers were prospectively compared: CO2 supplied via sponge diffuser, CO2 supplied via cannula, and no CO2 supply. Propensity matching was used to obtain comparable groups. The primary endpoints were postoperative stroke, transitory ischemic attack, convulsions, and dizziness. Secondary endpoints were 30-day mortality, duration of mechanical ventilation, and intensive care unit length of stay. RESULTS: 275 patients were enrolled in the study. After propensity matching, the sponge diffuser cohort had a significantly lower duration of mechanical ventilation (P < 0.001) and 30-day mortality (P = 0.05) when compared to the cannula cohort and the no-CO2 cohort, a lower incidence of all neurological events (P = 0.03) and dizziness (P = 0.05) when compare to the no-CO2 cohort, and a lower intensive care unit length of stay when compared to the cannula cohort (P = 0.001). CONCLUSIONS: The sponge diffuser used to deliver the CO2 into the surgical field during aortic valve replacement via J mini-sternotomy has been demonstrated to guarantee better neurological outcomes compared to a custom-made narrow section cannula or the absence of CO2.

Immediate results of transcatheter aortic valve implantation.

OBJECTIVE: Aim: To assess, analyze and present early postoperative results of transcatheter aortic valve implantation in patients with aortic stenosis. PATIENTS AND METHODS: Materials and Methods: During the period from 2017 to 2023, we examined in total 77 patients with severe aortic stenosis and high risk of surgery who were eligible for the TAVI procedure at the "Heart Institute Ministry of Health of Ukraine". RESULTS: Results: Before implantation, the mean and maximum aortic valve gradients were 53.7±19.1 mm Hg and 90.1±28.8 mm Hg, respectively. The mean and maximum aortic valve gradients after implantation were 9.67±3.18 and 18.7±6.41, respectively (p<0.001). The calculated left ventricular ejection fraction was 57.5±8.22% before surgery and 58.8±7.91% after surgery (p=0.412). After the procedure, moderate (2) degree of paravalvular aortic regurgitation was observed in 2 patients and light degree - in 21 patients. Before surgery, mitral regurgitation of 2-3 degrees was observed in 15 patients, and only in two patients after TAVI The survival rate of our patients was 96.4% after 180 days of supervision. In-hospital and 30-day mortality was 1.8%, while 180-day mortality was 3.6%. No deterioration was observed in patients with moderate aortic regurgitation during echocardiographic studies performed at 1, 3 and 6 months after TAVI. CONCLUSION: Conclusions: TAVI is rapidly emerging as a life-saving alternative for patients who are inoperable or at high risk of surgery due to comorbidities. The selection of patients for TAVI is important to optimize procedural and long-term outcomes. It is important for cardiologists in our country to refer patients with severe aortic stenosis after diagnosis to centers that perform TAVI.

Unicuspid aortic valve repair in a neonate.

The patient had a unicuspid aortic valve with severe aortic stenosis and a mildly dilated and hypertrophied left ventricle with moderately impaired systolic function. Herein we demonstrate the technique of severely dysplastic unicuspid aortic valve repair in the neonatal period.

Association Between Body Mass Index and Risk of Aortic Stenosis in Women in the Swedish Medical Birth Registry.

BACKGROUND: Overweight and obesity are increasing globally with aging, as are life expectancy and aging-associated disorders, including calcific aortic stenosis (AS). Studies investigating the correlation between high body mass index (BMI) and AS are contradictory and inconclusive. This study examines a potential association between BMI and AS in women. METHODS AND RESULTS: By linking the Swedish Medical Birth Register and the Swedish National Patient Register, we included women aged 18 to 55 years with a first childbirth from 1981 to 2020. Diagnosis of AS and comorbidities were defined according to the International Classification of Diseases (ICD) codes. The women were divided into groups on the basis of BMI. Cox proportional hazards regression models were used to investigate the difference in the risk of being diagnosed with AS, with reference BMI 20 to <22.5 kg/m2. Among the 1 722 625 included women, the mean age was 28 years, and mean BMI was 24 kg/m2, with 21% being overweight (BMI 25 to <30 kg/m2) and 8.5% obese (BMI ≥30 kg/m2). During median follow-up of 19.5 years, 2488 women (0.14%) were diagnosed with AS. The age-adjusted risk of being diagnosed with AS increased with higher BMI to 2.82 (95% CI, 2.44-3.25) times higher in women with BMI 30 to <35 kg/m2, and to 3.72 (95% CI, 2.95-4.70) times higher in those with BMI ≥35 kg/m2. Similar results were found after excluding AS of rheumatic pathogenesis. CONCLUSIONS: An increase in BMI from its upper normal range was consistently and independently associated with the risk of developing AS in women.

Aortic Homografts in Surgical Management of Prosthetic Valve Endocarditis: A Case Series from Greece.

BACKGROUND Infective endocarditis (IE) is a severe, life-threatening, and relatively common complication after valve replacement operations, with incidence rates varying between 1.8% and 5.8%, with an in-hospital mortality rate of up to 20%. Common microorganisms are (listed by decreasing incidence) Streptococci, Staphylococcus aureus, Enterococci, bacteria of the HACEK group, and fungi. Treatment of IE is complex, typically involving prolonged courses of antibiotics. However, in cases of aortic prosthetic valve endocarditis, root abscess formation with involvement of the aorto-mitral skeleton is not uncommon and complex surgical intervention is required. One of the notable advancements in surgical management is the use of homografts for aortic root endocarditis. CASE REPORT We report the first case series of 8 patients successfully operated on for prosthetic valve endocarditis with extensive aortic root abscess formation in Greece at Onassis Cardiac Surgery Center with the use of aortic homograft. All cases were redo surgeries and had good outcomes. Interestingly, one of the cases had extensive aortic root involvement with abscess formation extending to the aorto-mitral fibrous skeleton, requiring aortic root replacement with homograft, aorto-mitral skeleton reconstruction with bovine pericardium and mitral valve replacement with a mechanical prosthesis. Two other patients required concomitant coronary bypass grafting of the right coronary artery with reversed saphenous vein grafts. CONCLUSIONS Aortic root replacement with aortic homograft is the preferred choice for prosthetic valve endocarditis with aortic root abscess formation. Despite the technical complexity needed for implantation, this option offers a second chance for survival in patients with this challenging condition.

[Minimally Invasive Aortic Valve Replacement for Aortic Valve Infective Endocarditis Complicated by Septic Arthritis of the Sternoclavicular Joint:Report of a Case].

A 54-year-old man with a history of atopic dermatitis was admitted to our hospital for persistent fever and multiple arthralgias unresponsive to antibiotics. On the second day of hospitalization, Staphylococcus aureus was detected in the blood culture, and debridement for presumed pyogenic arthritis was performed on the patient's bilateral wrists and right ankle joints. Echocardiography showed evidence of infective endocarditis of the aortic valve. The patient's fever persisted after drainage of multiple joint abscesses, and blood cultures remained positive. A right sternoclavicular joint abscess that had been noted on computed tomography (CT) at the time of admission had not decreased in size on repeat CT performed 10 days post-admission. After additional drainage of the sternoclavicular joint abscess on the 15th day, the patient's fever subsided, and blood culture was negative. On the 29th day, an aortic valve replacement was performed via a right anterior thoracotomy to prevent sternal osteomyelitis. The postoperative course was uneventful, and the patient was discharged on the 35th day after valve surgery. One year after the surgery, he continues to take antibiotics, and recurrence of infection has not been observed.

Aortic root replacement for bicuspid aortic valve dysfunction does not impair survival rates.

BACKGROUND: Patients with a bicuspid aortic valve carry an increased risk for developing an ascending aortic aneurysm due to intrinsic aortic wall alterations. A lower threshold for aortic surgery may therefore be considered in these patients, especially in those who require aortic valve surgery. This study aimed to compare the outcomes of an isolated aortic valve replacement with that of an aortic root replacement in bicuspid aortic valve patients with an indication for aortic valve surgery. METHODS: Patients were included in retrospect from a tertiary academic hospital. Included patients received an elective aortic valve (AVR) or a composite valve-graft conduit (both mechanical and biological) between 2006 and 2021 without any concomitant procedure. Mortality data were retrieved from a national database and comparisons, including survival analyses, were performed between both groups. RESULTS: A total of 132 isolated AVR and 149 aortic root replacements were included. Patients who received an isolated AVR were significantly older than the aortic root replacement group (62.9 vs. 57.7 year respectively, p < 0.001). Survival analyses showed a comparable long-term mortality between both groups (8.1% vs. 9.1%, p = 0.321). CONCLUSION: This study shows that performing an aortic root replacement with a composite valve-graft conduit in bicuspid aortic valve patients does not impair the survival outcomes. In the light of preventing potential future aortic complications within this patient group with a congenitally and structurally weakened aortic wall, a more aggressive approach towards the treatment of BAV aortopathy might be considered.

Multiomics identification of ALDH9A1 as a crucial immunoregulatory molecule involved in calcific aortic valve disease.

Mitochondrial dysfunction and immune cell infiltration play crucial yet incompletely understood roles in the pathogenesis of calcific aortic valve disease (CAVD). This study aimed to identify immune-related mitochondrial genes critical to the pathological process of CAVD using multiomics approaches. The CIBERSORT algorithm was employed to evaluate immune cell infiltration characteristics in CAVD patients. An integrative analysis combining weighted gene coexpression network analysis (WGCNA), machine learning, and summary data-based Mendelian randomization (SMR) was performed to identify key mitochondrial genes implicated in CAVD. Spearman's rank correlation analysis was also performed to assess the relationships between key mitochondrial genes and infiltrating immune cells. Compared with those in normal aortic valve tissue, an increased proportion of M0 macrophages and resting memory CD4 T cells, along with a decreased proportion of plasma cells and activated dendritic cells, were observed in CAVD patients. Additionally, eight key mitochondrial genes associated with CAVD, including PDK4, LDHB, SLC25A36, ALDH9A1, ECHDC2, AUH, ALDH2, and BNIP3, were identified through the integration of WGCNA and machine learning methods. Subsequent SMR analysis, incorporating multiomics data, such as expression quantitative trait loci (eQTLs) and methylation quantitative trait loci (mQTLs), revealed a significant causal relationship between ALDH9A1 expression and a reduced risk of CAVD. Moreover, ALDH9A1 expression was inversely correlated with M0 macrophages and positively correlated with M2 macrophages. These findings suggest that increased ALDH9A1 expression is significantly associated with a reduced risk of CAVD and that it may exert its protective effects by modulating mitochondrial function and immune cell infiltration. Specifically, ALDH9A1 may contribute to the shift from M0 macrophages to anti-inflammatory M2 macrophages, potentially mitigating the pathological progression of CAVD. In conclusion, ALDH9A1 represents a promising molecular target for the diagnosis and treatment of CAVD. However, further validation through in vivo and n vitro studies is necessary to confirm its role in CAVD pathogenesis and therapeutic potential.

Coronary orifice rotation for symmetric bicuspidization of a paediatric unicuspid aortic valve.

Bicuspidization is a valid option for unicuspid aortic valve repair, in which creating symmetrical commissural orientation is essential for improved outcomes. However, the right coronary orifice often interferes with symmetrical attachment of the neocommissure. In a paediatric patient without aortic root dilation, we rotated the right coronary orifice clockwise by cutting out a triangular piece of the non-coronary sinus wall and augmenting it between the left and right coronary sinuses. A neocommissure with patching was sewn to the left side of the right coronary orifice, and the symmetrical bicuspidized configuration was adjusted in a standardized fashion according to the cusp effective height measurement.

Type a aortic dissection after aortic wrapping performed 26 years ago: a case report.

BACKGROUND: Aortic wrapping (AW) has been performed as a less invasive alternative to aortoplasty. However, AW can also cause long-term aortic complications. In this report, we present a rare case of a dissecting aortic aneurysm between the proximal side of the wrap and the sinotubular junction after AW. CASE PRESENTATION: A female patient had undergone urgent aortic valve replacement with a 19-mm mechanical valve to treat infective endocarditis and AW to treat an enlarged ascending aorta 26 years prior. At the age of 71 years, the patient was diagnosed with a dissecting aortic aneurysm between the proximal side of the wrap and the sinotubular junction. We performed graft replacement of the ascending aorta, including complete resection of the wrap. The patient was discharged on postoperative day 10, and there have been no cardiovascular events during her ongoing follow up. CONCLUSIONS: AW in younger patients can lead to late aortic complications. Careful consideration should be paid when performing AW in young patients, and patients who have previously undergone AW require strict life-long follow-up.

Unmet needs and knowledge gaps in aortic stenosis: A position paper from the Heart Valve Council of the French Society of Cardiology.

Nowadays, valvular heart disease remains a significant challenge among cardiovascular diseases, affecting millions of people worldwide and exerting substantial pressure on healthcare systems. Within the spectrum of valvular heart disease, aortic stenosis is the most common valvular lesion in developed countries. Despite notable advances in understanding its pathophysiological processes, improved cardiovascular imaging techniques and expanding therapeutic options in recent years, there are still unmet needs and knowledge gaps regarding aortic stenosis pathophysiology, severity assessment, management and decision-making strategy. This review, prepared on behalf of the Heart Valve Council of the French Society of Cardiology, describes these gaps and future research perspectives to improve the outcome of patients with aortic stenosis.

The combination of Florida sleeve and Ozaki procedures for aortic root repair.

It is generally accepted that the definitive treatment for irreparable aortic root disease is aortic root replacement with a valved conduit - the Bentall procedure. However, we try to follow a reparative strategy for all aortic root pathology whenever possible. Our "root-sparing" philosophy is achieved by restoration of physiological aortic root dimensions by the Florida sleeve technique and aortic cusp substitution by neocuspidization. The combination of both strategies allows for full reconstruction of the root, instead of its replacement. Our modification is called FLOZ, from "FLorida + OZaki".

Efficacy of a sutureless aortic valve-reoperative alternative to a composite graft replacement.

Findings in the present case underscore the potential of sutureless aortic valve utilization in patients with prior prosthetic root replacement, thereby obviating the need for high-risk procedures such as replacing a prosthetic root or reimplanting a coronary artery. A 75-year-old male who had undergone a Bio-Bentall operation with a bioprosthetic Trifecta valve for aortic regurgitation and annuloaortic ectasia eight years prior presented with symptoms of heart failure, notably dyspnoea, attributed to prosthetic valve dysfunction. Although a transcatheter aortic valve implant is often recommended, it was deemed unsuitable in this case due to a history of type B aortic dissection. Aortic valve replacement utilizing a sutureless Perceval valve with a Trifecta cuff as the valve ring was successfully performed through a repeat median sternotomy, which enabled aortic valve replacement via a higher than usual aortotomy with minimal adhesion dissection. Despite the inherent risks associated with a reoperation post-Bentall surgery, the duration of the procedure was notably short, with only 85 minutes required for cardiopulmonary bypass and 51 minutes for aortic clamping, resulting in an overall operating time of 198 minutes, thus highlighting the minimally invasive and safe nature of this approach.

Genetics of Calcific Aortic Stenosis: A Systematic Review.

Background: Calcific aortic stenosis is the most prevalent valvular abnormality in the Western world. Factors commonly associated with calcific aortic stenosis include advanced age, male sex, hypertension, diabetes and impaired renal function. This review synthesises the existing literature on genetic associations with calcific aortic stenosis. Methods: A systematic search was conducted in the PubMed, Ovid and Cochrane libraries from inception to 21 July 2024 to identify human studies investigating the genetic factors involved in calcific aortic stenosis. From an initial pool of 1392 articles, 78 were selected for full-text review and 31 were included in the final qualitative synthesis. The risk of bias in these studies was assessed using the Newcastle Ottawa Scale. Results: Multiple genes have been associated with calcific aortic stenosis. These genes are involved in different biological pathways, including the lipid metabolism pathway (PLA, LDL, APO, PCSK9, Lp-PLA2, PONS1), the inflammatory pathway (IL-6, IL-10), the calcification pathway (PALMD, TEX41) and the endocrine pathway (PTH, VIT D, RUNX2, CACNA1C, ALPL). Additional genes such as NOTCH1, NAV1 and FADS1/2 influence different pathways. Mechanistically, these genes may promote a pro-inflammatory and pro-calcific environment in the aortic valve itself, leading to increased osteoblastic activity and subsequent calcific degeneration of the valve. Conclusions: Numerous genetic associations contribute to calcific aortic stenosis. Recognition of these associations can enhance risk stratification for individuals and their first-degree relatives, facilitate family screening, and importantly, pave the way for targeted therapeutic interventions focusing on the identified genetic factors. Understanding these genetic factors can also lead to gene therapy to prevent calcific aortic stenosis in the future.

Minimally invasive valve-sparing aortic root replacement via an upper mini-sternotomy in a young adult with Marfan syndrome.

We describe an upper mini-sternotomy for valve-sparing aortic root replacement in a teenager.

The known and unknown of post-pump chorea: a case report on robust steroid responsiveness implicating occult neuroinflammation.

Post-pump chorea (PPC) is characterized by the development of choreiform movements following cardiopulmonary bypass (CPB) surgery. PPC occurs almost exclusively in children, and its pathophysiology remains unclear. Here we present an adult case of PPC after bovine aortic valve replacement (AVR) which exhibited dramatic and reproducible response to steroid, suggesting the presence of occult neuroinflammation. This observation suggests a novel underlying mechanism in certain subgroups of PPC, which is likely a heterogeneous condition to start with. Further research into the pathomechanisms of PPC could offer insights into managing this otherwise symptomatic control-only condition.