Hemodynamics and Diastolic Function after Native Aortic Valve Preserving vs. Replacing Surgery.

BACKGROUND: Alterations in left ventricular (LV) diastolic function following native tissue-preserving aortic valve (AV) procedures have not been systematically investigated. Furthermore, no comparisons have been made between these changes and those observed after prosthetic AV replacement. METHODS: From October 2017 to August 2020, 74 patients aged <65 years were referred to our institution for elective AV surgery. Preoperative and postoperative (i.e., discharge, 3-month and 1-year follow-up) transthoracic echocardiography was analyzed. RESULTS: Native tissue-preserving surgery was performed in 55 patients (AV repair: n = 42, Ross procedure: n = 13). The remaining 19 patients underwent prosthetic AV replacement. Preoperatively and at discharge, transvalvular hemodynamics and LV diastolic function were comparable in both groups. At 1-year follow-up, native valve (NV) patients showed significantly lower mean transvalvular gradient (7 ± 5 vs. 9 ± 3 mmHg, p = 0.046) and peak velocity (1.74 ± 0.51 vs. 2.26 ± 0.96 m/s, p = 0.004), and significantly better septal e' (9.1 ± 2.7 vs. 7.7 ± 2.5 cm/s, p = 0.043) and lateral e' (14.7 ± 3.1 vs. 11.7 ± 3.7 cm/s, p = 0.001). From preoperatively to 1-year postoperatively, septal and lateral e' and E/e' improved markedly after NV preservation (septal e': +0.7 cm/s, p = 0.075; lateral e': +2.3 cm/s, p < 0.001; E/e': -1.5, p = 0.001) but not after AV replacement (septal e': +0.2 cm/s, p = 0.809; lateral e': +0.8 cm/s, p = 0.574; E/e': -1.2, p = 0.347). Significant negative linear correlations between postoperative transvalvular gradients and absolute changes in lateral e' and E/e' were detected during follow-up. CONCLUSION: Preservation of native tissue in AV surgery results in superior transvalvular hemodynamics compared with prosthetic AV replacement. This may induce faster LV reverse remodeling and may explain more pronounced improvement in LV diastolic function.

Outcomes of extracorporeal membrane oxygenation and cardiopulmonary bypass in children after drowning-related resuscitation.

Drowning is one of the leading causes of accidental deaths in children worldwide. However, the use of long-term extracorporeal life support (ECLS) in this setting is not widely established, and rewarming is often achieved by short-term cardiopulmonary bypass (CPB) treatment. Thus, we sought to add our experience with this means of support as a bridge-to-recovery or to-decision. This retrospective single-center study analyzes the outcome of 11 children (median 23 months, minimum-maximum 3 months-6.5 years) who experienced drowning and subsequent cardiopulmonary resuscitation (CPR) between 2005 and 2016 and who were supported by veno-arterial extracorporeal membrane oxygenation (ECMO), CPB, or first CPB then ECMO. All but one incident took place in sweet water. Submersion time ranged between 10 and 50 minutes (median 23 minutes), water temperature between 2°C and 28°C (median 14°C), and body core temperature upon arrival in the emergency department between 20°C and 34°C (median 25°C). Nine patients underwent ongoing CPR from the scene until ECMO or CPB initiation in the operating room. The duration of ECMO or CPB before successful weaning/therapy withdrawal ranged between 2 and 322 hours (median 19 hours). A total of four patients (36%) survived neurologically mildly or not affected after 4 years of follow-up. The data indicate that survival is likely related to a shorter submersion time and lower water temperature. Resuscitation of pediatric patients after drowning has a poor outcome. However, ECMO or CPB might promote recovery in selected cases or serve as a bridge-to-decision tool.

A novel technique to quantify aortic valve annulus deformation: A pilot study.

OBJECTIVES: We evaluated the potential of cardiac magnetic resonance (CMR)-derived strain to assess aortic valve (AV) annulus deformation during the cardiac cycle in regurgitant and well-functioning AVs. METHODS: Four patients with severe aortic regurgitation and seven healthy controls underwent CMR. Assessment of longitudinal strain was performed by hypothesizing the AV annulus would be the left ventricle in long-axis orientation. Longitudinal strain of the segments belonging to the muscular and fibrous AV annulus was weighted and averaged to obtain regional values (RLS). RESULTS: Comparison of RLS between regurgitant and well-functioning AVs showed a considerably different deformation of the muscular AV annulus (i.e., median RLS: 4.18 % [patients] vs. -10.41 % [controls], p = .024). The fibrous AV annulus demonstrated comparable deformational changes in both groups. CONCLUSION: CMR-derived strain allows for quantification of AV annulus deformation during the cardiac cycle and shows an altered RLS in the muscular AV annulus in patients with severe aortic regurgitation.

External fixation of an internal aortic annuloplasty device: advancing the technique.

We present a modified technique of Hemispherical Aortic Annuloplasty Reconstructive Technology (HAART) 200 annuloplasty ring implantation in bicuspid aortic valve morphology by external fixation of the looping sutures to avoid common complications associated with the original implantation technique. Preliminary results are promising and should be confirmed in subsequent multicentre studies.

Different approach, similar outcomes: the impact of surgical access routes in minimally invasive cardiac surgery on enhanced recovery after surgery.

Objectives: Enhanced recovery after surgery (ERAS) is a growing phenomenon in all surgical disciplines and aims to achieve a faster functional recovery after major operations. Minimally invasive cardiac surgery (MICS) therefore integrates well into core ERAS values. Surgical access routes in MICS include right anterolateral mini-thoracotomy (MT) as well as partial upper mini-sternotomy (PS). We seek to compare outcomes in these two cohorts, both of which were enrolled in an ERAS scheme. Methods: 358 consecutive patients underwent MICS and perioperative ERAS at our institution between 01/2021 and 03/2023. Patients age >80 years, with BMI > 35 kg/m², LVEF ≤ 35%, endocarditis or stroke with residuum were excluded. Retrospective cohort analysis and statistical testing was performed on the remaining 291 patients. The primary endpoint was successful ERAS, secondary endpoints were the occurrence of major bleeding, ERAS-associated complications (reintubation, return to ICU) as well as access-related complications (wound infection, pleural and pericardial effusions). Results: 170 (59%) patients received MT for mitral and/or tricuspid valve surgery (n = 162), closure of atrial septal defect (n = 4) or resection of left atrial tumor (n = 4). The remaining 121 (41%) patients had PS for aortic valve repair/replacement (n = 83) or aortic root/ascending surgery (n = 22) or both (n = 16). MT patients' median age was 63 years (IQR 56-71) and 65% were male, PS patients' median age was 63 years (IQR 51-69) and 74% were male. 251 (MT 88%, PS 83%, p = 0.73) patients passed through the ERAS program successfully. There were three instances of reintubation (2 MT, 1 PS), and three instances of readmission to ICU (2 MT, 1 PS). Bleeding requiring reexploration occurred six times (3 MT, 3 PS). There was one death (PS), one stroke (MT), and one myocardial infarction requiring revascularization (MT). There were no significant differences in any of the post-operative outcomes recorded, except for the incidence of pericardial effusions (MT 0%, PS 3%, p = 0.03). Conclusions: Despite different surgical access routes and underlying pathologies, results in both the MT and the PS cohort were generally comparable for the recorded outcomes. ERAS remains safe and feasible in these patient groups.

Predictors of post-pericardiotomy syndrome after native valve-sparing aortic valve surgery.

BACKGROUND: We aimed to determine the rate and impact of post-pericardiotomy syndrome after native valve-sparing aortic valve surgery and the perioperative factors associated with its occurrence. METHODS: All consecutive patients who underwent native valve-sparing aortic valve surgery (i.e., repair ± ascending aorta replacement, valve-sparing root replacement, Ross procedure ± ascending aorta replacement) at our institution between January 2021 and August 2023 served as our study population. Post-pericardiotomy syndrome was diagnosed if patients showed at least two of the following diagnostic criteria: evidence of (I) new/worsening pericardial effusion, or (II) new/worsening pleural effusions, (III) pleuritic chest pain, (IV) fever or (V) elevated inflammatory markers without alternative causes. A logistic regression model was calculated. RESULTS: During the study period, 91 patients underwent native valve-sparing aortic valve surgery. A total of 21 patients (23%) developed post-pericardiotomy syndrome early after surgery (PPS group). The remaining 70 patients (77%) showed no signs of post-pericardiotomy syndrome (non-PPS group). Multivariate logistic regression revealed blood type O (OR: 3.15, 95% CI: 1.06-9.41, p = 0.040), valve-sparing root replacement (OR: 3.12, 95% CI: 1.01-9.59, p = 0.048) and peak C-reactive protein >15 mg/dl within 48 hours postoperatively (OR: 4.27, 95% CI: 1.05-17.29, p = 0.042) as independent risk factors. 73% (8/11) of patients displaying all three risk factors, 60% (9/15) of patients with blood type O and valve-sparing root replacement, 52% (11/21) of patients with blood type O and early postoperative peak C-reactive protein >15 mg/dl and 45% (13/29) of patients with early postoperative peak C-reactive protein >15 mg/dl and valve-sparing root replacement developed post-pericardiotomy syndrome. CONCLUSION: In summary, blood type O, valve-sparing root replacement and peak C-reactive protein >15 mg/dl within 48 hours postoperatively are significantly associated with post-pericardiotomy syndrome after native valve-sparing aortic valve surgery. Particularly, the presence of all three risk factors is linked to a particularly high risk of post-pericardiotomy syndrome.

Feasibility of deescalating postoperative care in enhanced recovery after cardiac surgery.

Introduction: Enhanced Recovery After Surgery (ERAS) prioritizes faster functional recovery after major surgery. An important aspect of postoperative ERAS is decreasing morbidity and immobility, which can result from prolonged critical care. Using current clinical data, our aim was to analyze whether a six-hour monitoring period after Minimally Invasive Cardiac Surgery (MICS) might be sufficient to recognize major postoperative complications in a future Fast Track pathway. Additionally, we sought to investigate whether it could be possible to deescalate the setting of postoperative monitoring. Methods: 358 patients received MICS and were deemed suitable for an ERAS protocol between 01/2021 and 03/2023 at our institution. Of these, 297 patients could be successfully extubated on-table, were transferred to IMC or ICU in stable condition and therefore served as study cohort. Outcomes of interest were incidence and timing of Major Adverse Cardiac Events (MACE; death, myocardial infarction requiring revascularization, stroke), bleeding requiring reexploration and Fast Track-associated complications (reintubation and readmission to ICU). Results: Patients' median age was 63 years (IQR 55-70) and 65% were male. 189 (64%) patients received anterolateral mini-thoracotomy, primarily for mitral and/or tricuspid valve surgery (n = 177). 108 (36%) patients had partial upper sternotomy, primarily for aortic valve repair/replacement (n = 79) and aortic surgery (n = 17). 90% of patients were normotensive without need for vasopressors within 6 h postoperatively, 82% of patients were transferred to the general ward on postoperative day 1 (POD). Two (0.7%) MACE events occurred, as well as 4 (1.3%) postoperative bleeding events requiring reexploration. Of these complications, only one event occurred before transfer to the ward - all others took place on or after POD 1. There was one instance of reintubation and two of readmission to ICU. Conclusions: If MICS patients can be successfully extubated on-table and are hemodynamically stable, major postoperative complications were rare in our single-center experience and primarily occurred after transfer to the ward. Therefore, in well selected MICS patients with uncomplicated intraoperative course, monitoring for six hours, possibly outside of an ICU, followed by transfer to the ward appears to be a feasible theoretical concept without negative impact on patient safety.

Physical and Mental Recovery after Aortic Valve Surgery in Non-Elderly Patients: Native Valve-Preserving Surgery vs. Prosthetic Valve Replacement.

Background: Exercise capacity and patient-reported outcomes are increasingly considered crucial following aortic valve (AV) surgery in non-elderly adults. We aimed to prospectively evaluate the effect of native valve preservation compared with prosthetic valve replacement. Methods: From October 2017 to August 2020, 100 consecutive non-elderly patients undergoing surgery for severe AV disease were included. Exercise capacity and patient-reported outcomes were evaluated upon admission, and 3 months and 1 year postoperatively. Results: In total, 72 patients underwent native valve-preserving procedures (AV repair or Ross procedure, NV group), and 28 patients, prosthetic valve replacement (PV group). Native valve preservation was associated with an increased risk of reoperation (weighted hazard ratio: 10.57 (95% CI: 1.24-90.01), p = 0.031). The estimated average treatment effect on six-minute walking distance in NV patients at 1 year was positive, but not significant (35.64 m; 95% CI: -17.03-88.30, adj. p = 0.554). The postoperative physical and mental quality of life was comparable in both groups. Peak oxygen consumption and work rate were better at all assessment time points in NV patients. Marked longitudinal improvements in walking distance (NV, +47 m (adj. p < 0.001); PV, +25 m (adj. p = 0.004)) and physical (NV, +7 points (adj. p = 0.023); PV, +10 points (adj. p = 0.005)) and mental quality of life (NV, +7 points (adj. p < 0.001); PV, +5 points (adj. p = 0.058)) from the preoperative period to the 1-year follow-up were observed. At 1 year, there was a tendency of more NV patients reaching reference values of walking distance. Conclusions: Despite the increased risk of reoperation, physical and mental performance markedly improved after native valve-preserving surgery and was comparable to that after prosthetic aortic valve replacement.

Proteomic Analysis in Valvular Cardiomyopathy: Aortic Regurgitation vs. Aortic Stenosis.

Left ventricular (LV) reverse remodeling after aortic valve (AV) surgery is less predictable in chronic aortic regurgitation (AR) than in aortic stenosis (AS). We aimed to disclose specific LV myocardial protein signatures possibly contributing to differential disease progression. Global protein profiling of LV myocardial samples excised from the subaortic interventricular septum in patients with isolated AR or AS undergoing AV surgery was performed using liquid chromatography-electrospray ionization-tandem mass spectrometry. Based on label-free quantitation protein intensities, a logistic regression model was calculated and adjusted for age, sex and protein concentration. Web-based functional enrichment analyses of phenotype-associated proteins were performed utilizing g:Profiler and STRING. Data are available via ProteomeXchange with identifier PXD039662. Lysates from 38 patients, including 25 AR and 13 AS samples, were analyzed. AR patients presented with significantly larger LV diameters and volumes (end-diastolic diameter: 61 (12) vs. 48 (13) mm, p < 0.001; end-diastolic volume: 180.0 (74.6) vs. 92.3 (78.4), p = 0.001). A total of 171 proteins were associated with patient phenotype: 117 were positively associated with AR and the enrichment of intracellular compartment proteins (i.e., assigned to carbohydrate and nucleotide metabolism, protein biosynthesis and the proteasome) was detected. Additionally, 54 were positively associated with AS and the enrichment of extracellular compartment proteins (i.e., assigned to the immune and hematopoietic system) was observed. In summary, functional enrichment analysis revealed specific AR- and AS-associated signatures of LV myocardial proteins.

Correlation of Myocardial Native T1 and Left Ventricular Reverse Remodeling after Valvular Surgery.

Myocardial native T1 is a known cardiovascular magnetic resonance (CMR) imaging biomarker to quantify diffuse myocardial fibrosis in valvular cardiomyopathy. We hypothesized that diffuse myocardial fibrosis assessed by preoperative T1 mapping might correlate with LV reverse remodeling after valvular surgery. A prospective monocentric cohort study was conducted including 79 consecutive patients with valvular cardiomyopathy referred for surgical treatment of severe aortic or severe functional mitral regurgitation. Native T1 values were assessed by CMR before surgery. LV geometry parameters (i.e., LVEDV, LVESV) were obtained by 2D transthoracic echocardiography before and six months after surgery. Postoperative change of LV geometry parameters was calculated as delta (∆) variable (i.e., six months value minus baseline value). Mean native T1 was 1047 ± 39 ms, mean ∆LVEDV was -33 ± 42 mL, and mean ∆LVESV was -15 ± 27 mL. Native T1 values correlated with ∆LVEDV (Pearson r = 0.29; p = 0.009) and ∆LVESV (Pearson r = 0.29; p = 0.015). Native T1 values < 1073 ms were identified as independent predictor of postoperative reduction of LVEDV (HR 3.0; 95%-CI: 1.1-8.0; p = 0.03) and LVESV (HR 2.9; 95%-CI: 1.1-7.4; p = 0.03). Diffuse myocardial fibrosis assessed by myocardial native T1 correlates with LV reverse remodeling at six months after valvular surgery. T1 mapping may be a valuable tool to predict LV reverse remodeling in valvular heart disease.

Rare Presentation of Sinus of Valsalva Aneurysm Treated by Aortic Valve Reimplantation Technique.

Sinus of Valsalva aneurysm is a rare cardiac abnormality which can be acquired or of congenital origin. A spontaneous rupture into the right atrium is possible and, if not adequately treated, may result in a progressive heart failure due to the left-to-right intracardiac shunt. If ruptured sinus of Valsalva aneurysm is diagnosed, surgical repair is indicated, and different surgical techniques have been reported. If concomitant aortic regurgitation is present, aortic valve replacement is usually performed. Herein, we describe an uncommon clinical presentation of a ruptured sinus of Valsalva aneurysm which has been corrected by aortic valve reimplantation.

Aortic Valve Repair in Annular Dilatation: External vs Internal Suture Annuloplasty.

BACKGROUND: Annuloplasty is essential in aortic valve repair. The most appropriate technique is highly controversial, however. We aimed to evaluate changes in postoperative annulus diameter on serial echocardiography after external and internal suture annuloplasty. METHODS: We retrospectively reviewed serial transthoracic echocardiography of consecutive patients from our institutional aortic valve repair registry who had received suture annuloplasty. Midsystolic annulus diameter was measured on parasternal long-axis view preoperatively, at discharge, 3-6 months, and at 1, 2 and 3 years postoperatively. Primary endpoint was the prevalence of annulus redilatation. Secondary endpoints were the correlation between annulus redilatation and (1) external vs internal technique and (2) reoccurrence of aortic insufficiency ≥2. RESULTS: A total of 70 patients (mean ± SD age: 43 ± 13 years, 91% male) underwent aortic valve repair including external (n = 27) or internal (n = 43) suture annuloplasty between February 2016 and November 2019. Mean follow-up was 17 ± 11 (range: 3-50) months. Mean preoperative annulus diameter of 29.7 ± 2.8 (23.8-37.8) mm was significantly reduced to 22.7 ± 2.9 (16.7-31.7) mm, P < .001 at discharge and increased to 23.8 ± 2.3 (20.9-27.0) mm, P = .037 during follow-up. The mild increase in postoperative annulus diameter did not correlate with the reoccurrence of aortic insufficiency ≥2. Preoperative annulus was significantly larger in the external group (external: 30.6 ± 3.2 mm; internal: 29.1 ± 2.5 mm; P = .032). However, we found no significant difference in postoperative annulus increase rate between both techniques. CONCLUSIONS: Although mild, a significant continuous increase of annulus diameter after suture annuloplasty was seen, which did not correlate with the reoccurrence of aortic insufficiency ≥2 at mid-term follow-up. Annulus redilatation was comparable between external and internal technique.

Right aortic arch forming a true vascular ring: a clinical review.

OBJECTIVES: This review aims at presenting and summarizing the current state of literature on the presentation and surgical management of a right-sided aortic arch with a left-sided ligamentum forming a complete vascular ring around the oesophagus and trachea. METHODS: A systematic database search for appropriate literature was conducted on PubMed/MEDLINE. Articles were considered relevant when providing details on the presentation, diagnosis and surgical treatment of this specific congenital arch anomaly in human beings. RESULTS: Affected patients present with respiratory and/or oesophageal difficulties due to tracheoesophageal compression. Conservative treatment might be reasonable in asymptomatic or mildly symptomatic cases; however, once moderate-to-severe symptoms develop, surgical intervention is definitely indicated. Surgery is commonly performed through a left thoracotomy or median sternotomy and includes the division of the left ductal ligamentum; if a Kommerell's diverticulum is present that is >1.5 times the diameter of the subclavian artery, then concomitant resection of the large diverticulum and translocation of the aberrant left subclavian artery is also conducted. Postoperative morbidity and mortality are low and are rather related to concomitant intracardiac and extracardiac anomalies than to the procedure itself. In a majority of patients, full resolution of symptoms is seen within months to years from the surgery. Nevertheless, there is also a subset of patients who remain with some tracheobronchial narrowing, sometimes even requiring reintervention during follow-up due to persisting or recurring symptoms. CONCLUSIONS: Overall, the surgical management of a right aortic arch forming a true vascular ring in infancy, childhood and adulthood seems relatively safe and effective in providing symptomatic relief despite some persistent tracheobronchial and/or oesophageal narrowing in some cases.

Predicting clinical outcome by indexed mitral valve tenting in functional mitral valve regurgitation.

OBJECTIVES: Mitral valve (MV) tenting parameters are indicators of left ventricular remodelling severity and may predict outcome in functional mitral regurgitation (FMR). We hypothesised that indexing of MV tenting area to body surface area (BSA), to mitral annulus diameter or gender-adjusted analysis of tenting parameters may improve their prognostic value. METHODS: We identified retrospectively 240 patients with consecutive FMR (mean age 68±10 years; men=135) from our institutional database who underwent isolated MV annuloplasty during a period of 7 years (2010-2016). Using preoperative two-dimensional transthoracic echocardiographic images, MV tenting parameters including tenting area, tenting height and annulus diameter were systematically assessed. Follow-up protocol consisted of chart review and structured clinical questionnaire. Primary study endpoint was the composite of death and adverse cardiac events (ie, MV reoperation, cardiac resynchronisation therapy implantation, ventricular assist device implantation or heart transplantation). RESULTS: BSA-indexed MV tenting area was identified as independent predictor of primary study endpoint (HR 1.9; 95% CI 1.1 to 3.5; p=0.02). After cut-off point analysis, BSA-indexed MV tenting area >1.35 cm2/m2 was significantly associated with primary study outcome (HR 2.3; 95% CI 1.3 to 4.0; p=0.003). Annulus-indexed MV tenting area showed only a tendency towards primary study endpoint prediction (HR 2.8; 95% CI 0.6 to 12.6; p=0.17). Between female and male patients, BSA-indexed MV tenting area was similar (1.42±0.4 cm2/m2 vs 1.45±0.4cm2/cm2; p=0.6) and gender was not associated with primary study outcome (HR 0.8; 95% CI 0.5 to 1.4; p=0.5). CONCLUSION: In our FMR cohort, BSA-indexed MV tenting area showed the strongest association with negative outcomes following isolated MV annuloplasty. Patients with BSA-indexed MV tenting area >1.35cm2/m2 could potentially benefit from additional surgical maneuvers addressing left ventricular remodelling.

Focus on a rare clinical entity: unicuspid aortic valve disease.

INTRODUCTION: While the understanding of the pathophysiology and clinical implication of bicuspid aortic valves evolves rapidly, the natural history of unicuspid aortic valves is still poorly understood. Hence, a universally accepted diagnostic work-up process and therapy recommendations for UAV still have to be established. AREAS COVERED: This article aims to give an overview on the most recent literature addressing the pathophysiology, the diagnostic tools and appropriate surgical therapy options of unicuspid aortic valve. Due to the rare prevalence, the understanding of pathophysiology is still missing. Further, symptomatic aortic valve disease are seen much earlier life stage in this cohorts. Thus, it highlights the several surgical treatment options with pro and contra especially for the young adult cohorts. EXPERT OPINION: Large scale prospective observational studies using standardized diagnostic criteria are needed to reveal the clinical course. Further appropriate treatment strategies of unicuspid aortic valve patients is demanded.

Rare Presentation of Sinus of Valsalva Aneurysm Treated by Aortic Valve Reimplantation Technique

Abstract Sinus of Valsalva aneurysm is a rare cardiac abnormality which can be acquired or of congenital origin. A spontaneous rupture into the right atrium is possible and, if not adequately treated, may result in a progressive heart failure due to the left-to-right intracardiac shunt. If ruptured sinus of Valsalva aneurysm is diagnosed, surgical repair is indicated, and different surgical techniques have been reported. If concomitant aortic regurgitation is present, aortic valve replacement is usually performed. Herein, we describe an uncommon clinical presentation of a ruptured sinus of Valsalva aneurysm which has been corrected by aortic valve reimplantation.