Aortic valve performance after remodelling versus reimplantation in a propensity-matched comparison.

OBJECTIVES: Both aortic root remodelling and aortic valve (AV) reimplantation have been used for valve-sparing root replacement in patients with aortic root aneurysm with or without aortic regurgitation. There is no clear evidence to support one technique over the another. This study aimed to compare remodelling with basal ring annuloplasty versus reimplantation on a multicentre level with the use of propensity-score matching. METHODS: This was a retrospective international multicentre study of patients undergoing remodelling or reimplantation between 2010 and 2021. Twenty-three preoperative covariates (including root dimensions and valve characteristics) were used for propensity-score matching. Perioperative outcomes were analysed along with longer-term freedom from AV reoperation/reintervention and other major valve-related events. RESULTS: Throughout the study period, 297 patients underwent remodelling and 281 had reimplantation. Using propensity-score matching, 112 pairs were selected and further compared. We did not find a statistically significant difference in perioperative outcomes between the matched groups. Patients after remodelling had significantly higher reintervention risk than after reimplantation over the median follow-up of 6 years (P = 0.016). The remodelling technique (P = 0.02), need for decalcification (P = 0.03) and degree of immediate postoperative AV regurgitation (P < 0.001) were defined as independent risk factors for later AV reintervention. After exclusion of patients with worse than mild AV regurgitation immediately after repair, both techniques functioned comparably (P = 0.089). CONCLUSIONS: AV reimplantation was associated with better valve function in longer-term postoperatively than remodelling. If optimal immediate repair outcome was achieved, both techniques provided comparable AV function.

Anomalous Arising of Right Coronary Artery from the Pulmonary Artery.

Coronary artery anomalies are seen in less than 1% of the general population and in 1.6% of cardiac catheterization cases. The anomalous origin of the coronary artery from the pulmonary artery is one of four groups of coronary artery origin anomalies. The incidence of anomalous origin of the right coronary artery from the pulmonary artery is 1 in 500,000 and was first described in 1882 by John Brook. This case report reports on a 67-year-old man with a diagnosis of asymptomatic anomalous origin of the right coronary artery from the pulmonary artery. The patient underwent surgery of the aortic valve because of valve stenosis. A concomitant surgical procedure included repositioning of the right coronary artery origin to the aortic root sinus. The patient was discharged on the 12th postoperative day, in good condition. Anomalous origin of the right coronary artery from the pulmonary artery is commonly asymptomatic, and surgery is required only if myocardial ischemia is presented.

Anomalous arising of left coronary artery from the pulmonary artery (ALCAPA).

Computed tomography 3D reconstruction of a patient with Bland-White-Garland syndrome showing a dilated right coronary artery and thin left coronary artery.

A multicentre, propensity score matched analysis comparing a valve-sparing approach to valve replacement in aortic root aneurysm: Insight from the AVIATOR database.

OBJECTIVES: Our goal was to evaluate the outcome of valve-sparing root replacement (VSRR) and to compare the outcomes to those of patients having composite valve-graft conduit aortic root replacement (CVG-ARR) in a cohort of patients with aortic root aneurysm ± valve insufficiency, without valvular stenosis. Although valve-sparing procedures are preferable in young patients, there is a lack of comparative data in comparable patients. METHODS: The VSRR procedures were performed in 2005 patients, and 218 patients underwent a CVG-ARR procedure. Exclusion criteria included aortic dissection, endocarditis and valvular stenosis. Propensity score matching (3:1 ratio) was applied to compare VSRR (reimplantation 33% and remodelling 67%) and CVG-ARR. RESULTS: We matched 218 patients with CVG-ARR to 654 patients with VSRR (median age, 56.0; median follow-up was 4 years in both groups; interquartile range 1-5 years). Early mortality was 1.1% of those who had VSRR versus 2.3% in those who had CVG-ARR. Survival was 95.4% [95% confidence interval (CI) 94-97%] at 5 years in patients who had VSRR versus 85.4% (95% CI 82-92%) in those who had CVG-ARR; P = 0.002. Freedom from reintervention at 5 years was 96.8% (95% CI 95-98%) with VSRR and 95.4% (95% CI 91-99%) with CVG-ARR (P = 0.98). Additionally, there were more thromboembolic, endocarditis and bleeding events in the patients who had CVG-ARR (P = 0.02). CONCLUSIONS: This multicentre study shows excellent results after valve-sparing root replacement in patients with an ascending aortic aneurysm with or without valve insufficiency. Compared to composite valve-graft aortic root replacement, survival is better and valve-related events are fewer. Consequently, valve-sparing procedures should be considered whenever a durable repair is feasible. We advocate a valve-sparing strategy even in more complex cases when performed in experienced centres.

Comparison of bicuspidization and Ross procedure in the treatment of unicuspid aortic valve disease in adults - Insight from the AVIATOR registry.

Background: Unicuspid aortic valve (UAV) is the second most common underlying cause of aortic valve dysfunction in young adults after the bicuspid valve. The valve may be replaced (for example by pulmonary autograft) or repaired using the bicuspidization technique. The aim of our study was to compare short- and mid-term outcomes of Ross procedure with bicuspidization in patients with severe UAV dysfunction. Methods: This was a multi-center retrospective observational cohort study comparing data from two dedicated Ross centers in the Czech Republic with bicuspidization outcomes provided by AVIATOR registry. As for the Ross group, only the patients with UAV were included. Primary endpoint was mid-term freedom from reintervention. Secondary endpoints were mid-term freedom from major adverse events, endocarditis and pacemaker implantation. Results: Throughout the study period, 114 patients underwent the Ross procedure (years 2009-2020) and 126 patients underwent bicuspidization (years 2006-2019). The bicuspidization group was significantly younger and presented with a higher degree of dyspnea, a lower degree of aortic valve stenosis and more often with pure regurgitation. The primary endpoint occurred more frequently in the bicuspidization group than in the Ross group - 77.9 vs. 97.9 % at 5 years and 68.4 vs. 75.2 % at 10 years (p < 0.001). There was no difference in secondary endpoints. Conclusion: Ross procedure might offer a significantly lower mid-term risk of reintervention than bicuspidization in patients with UAV. Both procedures have comparable survival and risk of other short- and mid-term complications postoperatively.

Non-iatrogenic left atrial wall dissection.

Non-iatrogenic left atrial wall dissection is a rare lesion defined as a gap from the mitral valve annulus to the interatrial septum or wall of the left atrium. We report the case of a 57-year-old man with symptoms of acute cardiac and renal failure. Trans-esophageal echocardiography and computed tomography showed significant mitral valve regurgitation and dissection of the posterior wall of the left atrium. On the basis of detailed trans-esophageal echocardiography, the patient underwent mitral valve replacement with closure of the dissection orifice, which appears to be the appropriate therapeutic strategy in cases of spontaneous left atrial wall dissection.

Right aortic arch with an aberrant left subclavian artery and aortic coarctation including a descending aortic aneurysm.

BACKROUND: The right aortic arch and aortic coarctation are rare congenital anomalies with the incidence of 0.1% and 0.03-0.04%. We present a case report of a 51-year-old woman with the right aortic arch with aberrant left subclavian artery and coarctation of the aorta with post-stenotic aneurysm. CASE PRESENTATION: Resection of the coarctation and aneurysm with replacement by tubular prosthesis was performed on partial cardiopulmonary bypass via femoral vessels. CONCLUSION: Partial cardiopulmonary bypass is an applicable method for ensuring the perfusion of the distal part of the body and an aberrant left subclavian artery is not a contraindication of this technique.

Left atrial appendage strain rate is associated with documented thromboembolism in nonvalvular atrial fibrillation.

BACKGROUND: The left atrial appendage (LAA) strain and strain rate have not yet been studied in the prediction of cardiac thromboembolism. Therefore, this study aimed to evaluate the significance of LAA strain and strain rate as assessed by speckle-tracking imaging in relation to documented thromboembolic events. METHODS: A group of 80 patients with a mean age of 65 years who were referred for electrical cardioversion of nonvalvular atrial fibrillation was retrospectively analyzed. Each patient underwent 2D transesophageal echocardiography (TEE). Velocity vector imaging (VVI)-derived LAA strain and strain rate in parallel with other conventional TEE predictors were analyzed in terms of their association with previous embolic stroke and peripheral embolization. RESULTS: By comparing the two groups of patients with (22/80) and without embolic events (58/80), patients with embolic events were older, had higher CHA2DS2-VASc scores, higher incidence of coronary artery disease and LAA thrombi, and worse LAA strain and strain rate. Moreover, patients without embolization more often used anticoagulants than patients with embolic events. After adjusting for the abovementioned embolic risk factors, only the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [double weight], diabetes mellitus, stroke [double weight], vascular disease, age from 65 to 74 years, sex category) score and the LAA strain rate remained as significant predictors of embolic events. CONCLUSION: The results of the study show that the VVI-derived LAA strain rate is a significant predictor of documented ischemic stroke and systemic thromboembolism in patients with nonvalvular atrial fibrillation. Its predictive power is similar to the predictive power of the CHA2DS2-VASc score.

Aortic Valve Repair of a Stenotic Unicuspid Aortic Valve in Young Patients.

BACKGROUND: The unicuspid aortic valve (UAV) is a well-described pediatric congenital abnormality, with incidence of 0.02% in the general population. Bicuspidization has been described as a potential surgical option to repair this defect. METHODS: Seventeen symptomatic young patients with a unicuspid valve combined with either valve insufficiency or valve stenosis underwent aortic valve (AV) bicuspidization procedure by using an equine pericardium. In addition to bicuspidization, 8 patients underwent aortic ring implantation and 5 patients underwent supracoronary replacement of the aorta. RESULTS: Our results show safety of the bicuspidization procedure. No deaths occurred during our average follow-up period of 26 months. Freedom from reoperation for any valve-related reason was 100% during this follow-up period. We observed a statistically significant increase in the AV area from 0.8 ± 0.1 cm2 to 2.8 ± 0.7 cm2 (p < 0.01), a statistically significant decrease in the mean systolic pressure gradient from 36 ± 13.3 mm Hg to 9 ± 4 mm Hg (p < 0.001), a statistically significant decrease in aortic insufficiency grade from 2.1 ± 1.0 to 0.6 ± 0.7 (p < 0.01) before and after bicuspidization, respectively, and a statistically significant decrease in the left ventricular end-diastolic diameter from 49.88 ± 5.11 mm to 40.46 ± 7.20 mm (p < 0.0005) and a statistically significant increase of the left ventricular ejection fraction from 56% ± 8.20% to 64% ± 7.83% at the time of follow-up. CONCLUSIONS: From our study, bicuspidization is an attractive surgical option to repair UAV, particularly in young patients who do not want to be subjected to long-term anticoagulation therapy or who refuse a more traditional surgical approach, such as Ross procedure, for reasons described previously.

Melatonin treatment in the prevention of postoperative delirium in cardiac surgery patients.

INTRODUCTION: Post-cardiac surgery delirium is a severe complication. The circadian rhythm of melatonin secretion has been shown to be altered postoperatively. AIM OF THE STUDY: It was hypothesized that restoring normal sleeping patterns with a substance that is capable of resynchronizing circadian rhythm such as exogenous administration of melatonin may possibly reduce the incidence of postoperative delirium. MATERIAL AND METHODS: This paper represents a prospective clinical observational study. Two consecutive groups of 250 consecutive patients took part in the study. Group A was the control group and group B was the melatonin group. In group B, the patients received prophylactic melatonin treatment. The main objectives were to observe the incidence of delirium, to identify any predictors of delirium, and to compare the two groups based on the delirium incidence. RESULTS: The incidence of delirium was 8.4% in the melatonin group vs. 20.8% in the control group (p = 0.001). Predictors of delirium in the melatonin group were age (p = 0.001) and higher EuroSCORE II value (p = 0.001). In multivariate analysis, age and EuroSCORE II value (p = 0.014) were predictors of postoperative delirium. Comparing the groups, the main predictors of delirium were age (p = 0.001), EuroSCORE II value (p = 0.001), cardio-pulmonary bypass (CPB) time (p = 0.001), aortic cross-clamping (ACC) time (p = 0.008), sufentanil dose (p = 0.001) and mechanical ventilation (p = 0.033). CONCLUSIONS: Administration of melatonin significantly decreases the incidence of postoperative delirium after cardiac surgery. Prophylactic treatment with melatonin should be considered in every patient scheduled for cardiac surgery.

"V" aortoplasty of the proximal descending aorta in the elephant trunk procedure.

Complex pathology of the aorta, especially in patients presenting an aneurysm involving the entire aortic arch and proximal descending aorta has been approached in one or two stages. Surgical management of those with an extremely wide diameter of the proximal descending aorta is not yet well defined. The patient in this case was an asymptomatic 47-year-old female with systemic lupus erythematosus (SLE) associated with aneurysm of the ascending aorta, whose aortic arch and descending aorta had presented only overall weakness (examination by inspection and palpation without histological verification). The imaging identified a giant aorta arising at the level of the sinotubular junction (STJ), ending up immediately below the diaphragm. In the first stage she underwent surgical replacement of the entire ascending aorta, aortic arch and proximal part of the descending aorta by combining the elephant trunk with a new type of aortoplasty. In the second stage an endovascular stent graft was inserted into the elephant trunk in the descending aorta. The patient continues to do well 20 months following the repair. In this manuscript type we describe a novel technique of "V" aortoplasty of the proximal descending aorta in order to facilitate the performing of anastomosis between the Dacron graft and aortic aneurysm.

Surgical management of a hypoplastic distal aortic arch and coarctation of aorta in a patient with Klippel-Feil syndrome, ascending aortic aneurysm and bicuspid aortic valve.

Klippel-Feil syndrome has been associated with cardiovascular malformations, but only 3 cases have been reported to be associated with aortic coarctation and surgical management is not defined. A 51-year old woman with Klippel-Feil syndrome associated with an aneurysm of the ascending aorta, hypoplastic aortic arch and aortic coarctation at the level of the left subclavian artery presented with shortness of breath 2 years after diagnosis. Imaging identified interim development of a 7.2-cm aneurysm at the level of the aortic coarctation. She underwent surgical repair with a Dacron interposition graft under hypothermic circulatory arrest. She continues to do well 18 months following repair.

The occurrence of postoperative atrial fibrillation according to different surgical settings in cardiac surgery patients.

OBJECTIVES: Atrial fibrillation is the most common arrhythmia after cardiac surgery. The pathogenesis of postoperative atrial fibrillation is multifactorial. The aim of the study was to analyse preoperative, intraoperative and postoperative factors and their relationships with the occurrence and duration of atrial fibrillation. METHODS: One hundred and ninety-six patients with coronary heart disease (152 men, age 62.7 ± 10.1 years) underwent surgical revascularization. Extracorporeal circulation was used in 64 patients and minimal extracorporeal circulation was used in 75 patients. Fifty-seven patients underwent surgery without extracorporeal circulation. During the first three postoperative days, subjects were monitored for the duration and incidence of atrial fibrillation, laboratory markers of inflammation (C-reactive protein, leucocytes) and serum potassium. RESULTS: Demographic data and associated cardiovascular diseases in the groups were not statistically different. The overall incidence of atrial fibrillation was 56% (110 patients). The highest incidence of atrial fibrillation was found in the extracorporeal circulation subgroup, with a significantly lower incidence using minimal extracorporeal circulation, and in patients operated on without extracorporeal circulation (75 vs 47 vs 46%, P <0.001). The longest duration of atrial fibrillation was found in patients operated on with extracorporeal circulation compared with minimal extracorporeal circulation, and without extracorporeal circulation (9.7 ± 11.6 vs 4.9 ± 8.3 vs 3.1 ± 5.2, P ≤0.001). The incidence of postoperative atrial fibrillation significantly correlated with elevation of inflammatory markers (C-reactive protein, leucocytes) compared with patients who were free of atrial fibrillation (P ≤0.001, P ≤0.05). The values of serum potassium were not significantly different. The relationship between postoperative atrial fibrillation and echocardiographic parameters was not confirmed. CONCLUSIONS: The use of extracorporeal circulation leads to a higher incidence of postoperative atrial fibrillation compared with the use of minimal extracorporeal circulation or with surgery without extracorporeal circulation, probably due to enhanced systemic inflammatory response.

Diagnostic accuracy of global myocardial deformation indexes in coronary artery disease: a velocity vector imaging study.

The aim of our study was to assess the diagnostic accuracy of a global longitudinal strain and strain rate (GLS, GLSR) and mean radial strain and strain rate (MRS, MRSR) of the left ventricle to predict multivessel disease. In 113 patients, who underwent coronary angiography, left ventricular deformation was analysed by speckle-tracking based velocity vector imaging. In three standard apical views strain and strain rate curves were generated corresponding with two opposite basal, mid, and apical segments. The negative peaks of systolic strain and strain rate from 18 curves were averaged as GLS and GLSR. Similarly, in short axis view 6 negative systolic peaks were averaged and considered as MRS and MRSR. Four subgroups were defined: (1) without significant coronary stenosis, 0-vessel disease (0VD), (2) single-vessel disease (1VD), (3) double-vessel disease (2VD), and (4) triple-vessel disease (3VD). In comparison with patients without significant coronary artery disease, all deformation indexes were significantly decreased in patients with 3VD. The left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) showed lower significance level as deformation parameters. MRSR was the strongest predictor of multivessel disease. Receiver-operating characteristic curves (ROC) showed that MRSR had the highest diagnostic accuracy. Comparing ROC areas, MRSR had significantly higher diagnostic accuracy than LVEF and WMSI. The results of our study show that global deformation indexes have a good diagnostic accuracy in differentiating multivessel disease. MRSR tended to be better in identification of 3VD than traditional indexes of global and regional left ventricular function.

Use of left ventricle assist device in a pregnant woman with acute aortic and coronary dissections.

We report the case of a 31-year-old female in her 32nd week of pregnancy, who experienced an acute type A aortic dissection resulting in severe aortic insufficiency, dissection of the left anterior descending coronary artery, and left ventricular infarct with ejection fraction of 20%. After a successful cesarean section, she underwent a Bentall operation and three-vessel coronary artery bypass grafting. Despite maximal inotropic support, her cardiovascular indices deteriorated postoperatively. On the first postoperative day she was started on mechanical circulatory support with the Levitronix CentriMag left ventricular assist device. Her myocardial function improved and she was successfully weaned from this mechanical support on post-implant day 14. She remains alive and well to date.