Impact of nondiameter aortic indices on surgical eligibility: Results from the Treatment in Thoracic Aortic Aneurysm: Surgery Versus Surveillance (TITAN: SvS) randomized controlled trial.

OBJECTIVES: Traditional criterion for intervention on an asymptomatic ascending aortic aneurysm has been a maximal aortic diameter of 5.5 cm or more. The 2022 American College of Cardiology/American Heart Association aortic guidelines adopted cross-sectional aortic area/height ratio, aortic size index, and aortic height index as alternate parameters for surgical intervention. The objective of this study was to evaluate the impact of using these newer indices on patient eligibility for surgical intervention in a prospective, multicenter cohort with moderate-sized ascending aortic aneurysms between 5.0 and 5.4 cm. METHODS: Patients enrolled from 2018 to 2023 in the randomization or registry arms of the multicenter trial, Treatment In Thoracic Aortic aNeurysm: Surgery versus Surveillance, were included in the study. Clinical data were captured prospectively in an online database. Imaging data were derived from a core computed laboratory. RESULTS: Among the 329 included patients, 20% were female. Mean age was 65.0 ± 11.6 years, and mean maximal aortic diameter was 50.8 ± 3.9 mm. In the one-third of all patients (n = 109) who met any 1 of the 3 criteria (ie, aortic size index ≥3.08 cm/m2, aortic height index ≥3.21 cm/m, or cross-sectional aortic area/height ≥ 10 cm2/m), their mean maximal aortic diameter was 52.5 ± 0.52 mm. Alternate criteria were most commonly met in women compared with men: 20% versus 2% for aortic size index (P < .001), 39% versus 5% for aortic height index (P < .001), and 39% versus 21% for cross-sectional aortic area/height (P = .002), respectively. CONCLUSIONS: One-third of patients in Treatment In Thoracic Aortic aNeurysm: Surgery versus Surveillance would meet criteria for surgical intervention based on novel parameters versus the classic definition of diameter 5.5 cm or more. Surgical thresholds for aortic size index, aortic height index, or cross-sectional aortic area/height ratio are more likely to be met in female patients compared with male patients.

Utilization of Shock Team and Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in the Management of Cardiogenic Shock in Northern Ontario.

Background: Despite advancements in critical care and coronary revascularization, cardiogenic shock (CS) outcomes remain poor. Implementing a shock team and use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have been associated with improved CS outcomes, but its feasibility in remote and rural areas remains unknown. Methods: This retrospective study included patients with CS who required mechanical circulatory support (MCS) at Health Sciences North, Sudbury, Ontario. The analysis aimed to accomplish 2 objectives: first, to review the outcomes associated with use of Impella (Abiomed, Danvers, MA) and, second, to assess the feasibility of establishing a shock team to facilitate the local implementation of VA-ECMO. The primary endpoint was in-hospital mortality. Results: The outcomes of 15 patients with CS who received Impella between 2015 and 2021 were reviewed. Their average age was 65 years (standard deviation [SD]: 13), and 8 patients (53%) were female. CS was ischemic in 12 patients (80%). Transfemoral Impella CP (cardiac power) was the most frequently used (93%). Thirteen patients (87%) died during the index hospital stay post-Impella because of progressive circulatory failure. The shock team was established following consultations with several Canadian MCS centres, leading to the development of a protocol to guide use of MCS. There have been 4 cases in which percutaneous VA-ECMO using Cardiohelp (Getinge/Maquet, Wayne, NJ) has been used; 3 (75%) survived beyond the index hospitalization. Conclusions: This analysis demonstrated the feasibility of implementing a shock team in remote Northern Ontario, enabling the use of VA-ECMO with success in a centre with a sizeable rural catchment area. This initiative helps address the gap in cardiac care outcomes between rural and urban areas in Ontario.

Introduction: En dépit des avancées des soins aux patients en phase critique et de la revascularisation coronarienne, les résultats du choc cardiogénique (CC) semblent mauvais. La mise en place d'une équipe de choc et l'utilisation de l'oxygénation extracorporelle (ECMO, de l'anglais extracorporeal membrane oxygenation) par voie veino-artérielle (VA) (VA-ECMO) ont été associées à de meilleurs résultats du CC, mais on ignore sa faisabilité dans les régions éloignées et rurales. Méthodes: La présente étude rétrospective portait sur des patients en CC qui ont eu besoin d'une assistance circulatoire mécanique (ACM) à Horizon Santé-Nord, à Sudbury, en Ontario. L'analyse visait 2 objectifs : le premier objectif était de passer en revue les résultats associés à l'utilisation de Impella (Abiomed, Danvers, MA) et, le deuxième était d'évaluer la faisabilité de la mise en place d'une équipe de choc pour faciliter la mise en œuvre locale de la VA-ECMO. Le principal critère d'évaluation était la mortalité intrahospitalière. Résultats: Nous avons passé en revue les résultats cliniques de 15 patients ayant subi un CC qui avaient reçu une Impella entre 2015 et 2021. L'âge moyen était de 65 ans (écart type [ET] : 13), et 8 patients (53 %) étaient des femmes. Le CC était d'origine ischémique chez 12 patients (80 %). L'Impella CP (cardiac power, soit la pompe cardiaque) par voie transfémorale était la plus fréquemment utilisée (93 %). Treize patients (87 %) sont morts durant le séjour de référence à l'hôpital après l'utilisation de l'Impella en raison d'insuffisance circulatoire progressive. La mise en place de l'équipe de choc à la suite des consultations dans plusieurs centres canadiens d'ACM a mené à l'élaboration d'un protocole d'utilisation de l'ACM. Il y a eu 4 cas chez lesquels la VA-ECMO par voie percutanée à l'aide de Cardiohelp (Getinge/Maquet, Wayne, New Jersey, É.-U.) a été utilisée ; 3 (75 %) ont survécu après l'hospitalisation de référence. Conclusions: Cette analyse a démontré la faisabilité de la mise en place d'une équipe de choc dans les régions éloignées du nord de l'Ontario, qui a permis d'utiliser efficacement la VA-ECMO dans un centre d'une circonscription hospitalière rurale non négligeable. Cette initiative aide à remédier à l'écart des résultats en soins cardiaques entre les régions rurales et urbaines de l'Ontario.

The Canadian Cardiovascular Society Classification of Acute Atherothrombotic Myocardial Infarction Based on Stages of Tissue Injury Severity: An Expert Consensus Statement.

Myocardial infarction (MI) remains a leading cause of morbidity and mortality. In atherothrombotic MI (ST-elevation MI and type 1 non-ST-elevation MI), coronary artery occlusion leads to ischemia. Subsequent cardiomyocyte necrosis evolves over time as a wavefront within the territory at risk. The spectrum of ischemia and reperfusion injury is wide: it can be minimal in aborted MI or myocardial necrosis can be large and complicated by microvascular obstruction and reperfusion hemorrhage. Established risk scores and infarct classifications help with patient management but do not consider tissue injury characteristics. This document outlines the Canadian Cardiovascular Society classification of acute MI. It is an expert consensus formed on the basis of decades of data on atherothrombotic MI with reperfusion therapy. Four stages of progressively worsening myocardial tissue injury are identified: (1) aborted MI (no/minimal myocardial necrosis); (2) MI with significant cardiomyocyte necrosis, but without microvascular injury; (3) cardiomyocyte necrosis and microvascular dysfunction leading to microvascular obstruction (ie, "no-reflow"); and (4) cardiomyocyte and microvascular necrosis leading to reperfusion hemorrhage. Each stage reflects progression of tissue pathology of myocardial ischemia and reperfusion injury from the previous stage. Clinical studies have shown worse remodeling and increase in adverse clinical outcomes with progressive injury. Notably, microvascular injury is of particular importance, with the most severe form (hemorrhagic MI) leading to infarct expansion and risk of mechanical complications. This classification has the potential to stratify risk in MI patients and lay the groundwork for development of new, injury stage-specific and tissue pathology-based therapies for MI.

Simultaneous venous-arterial Doppler during preload augmentation: illustrating the Doppler Starling curve.

Providing intravenous (IV) fluids to a patient with signs or symptoms of hypoperfusion is common. However, evaluating the IV fluid 'dose-response' curve of the heart is elusive. Two patients were studied in the emergency department with a wireless, wearable Doppler ultrasound system. Change in the common carotid arterial and internal jugular Doppler spectrograms were simultaneously obtained as surrogates of left ventricular stroke volume (SV) and central venous pressure (CVP), respectively. Both patients initially had low CVP jugular venous Doppler spectrograms. With preload augmentation, only one patient had arterial Doppler measures indicative of significant SV augmentation (i.e., 'fluid responsive'). The other patient manifested diminishing arterial response, suggesting depressed SV (i.e., 'fluid unresponsive') with evidence of ventricular asynchrony. In this short communication, we describe how a wireless, wearable Doppler ultrasound simultaneously tracks surrogates of cardiac preload and output within a 'Doppler Starling curve' framework; implications for IV fluid dosing are discussed.

Detecting the Change in Total Circulatory Flow with a Wireless, Wearable Doppler Ultrasound Patch: A Pilot Study.

Measuring fluid responsiveness is important in the management of critically ill patients, with a 10-15% change in cardiac output typically being used to indicate "fluid responsiveness." Ideally, these changes would be measured noninvasively and peripherally. The aim of this study was to determine how the common carotid artery (CCA) maximum velocity changes with total circulatory flow when confounding factors are mitigated and determine a value for CCA maximum velocity corresponding to a 10% change in total circulatory flow. DESIGN: Prospective observational pilot study. SETTING: Patients undergoing elective, on-pump coronary artery bypass grafting (CABG) surgery. PATIENTS: Fourteen patients were referred for elective coronary artery bypass grafting surgery. INTERVENTIONS: Cardiopulmonary bypass (CPB) pump flow changes during surgery, as chosen by the perfusionist. MEASUREMENTS: A hands-free, wearable Doppler patch was used for CCA velocity measurements with the aim of preventing user errors in ultrasound measurements. Maximum CCA velocity was determined from the spectrogram acquired by the Doppler patch. CPB flow rates were recorded as displayed on the CPB console, and further measured from the peristaltic pulsation frequency visible on the recorded Doppler spectrograms. MAIN RESULTS: Changes in CCA maximum velocity tracked well with changes in CPB flow. On average, a 13.6% change in CCA maximum velocity was found to correspond to a 10% change in CPB flow rate. CONCLUSIONS: Changes in CCA velocity may be a useful surrogate for determining fluid responsiveness when user error can be mitigated.

Continuous Venous-Arterial Doppler Ultrasound During a Preload Challenge.

A preload challenge (PC) is a clinical maneuver that, first, increases the cardiac filling (i.e., preload) and, second, calculates the change in cardiac output. Fundamentally, a PC is a bedside approach for testing the Frank-Starling-Sarnoff (i.e., "cardiac function") curve. Normally, this curve has a steep slope such that a small change in the cardiac preload generates a large change in the stroke volume (SV) or cardiac output. However, in various disease states, the slope of this relationship flattens such that increasing the volume into the heart leads to little rise in the SV. In this pathological scenario, additional cardiac preload (e.g., intravenous fluid) is unlikely to be physiologically effective and could lead to harm if organ congestion evolves. Therefore, inferring both the cardiac preload and output is clinically useful as it may guide intravenous (IV) fluid resuscitation. Accordingly, the goal of this protocol is to describe a method for contemporaneously tracking the surrogates of cardiac preload and output using a novel, wireless, wearable ultrasound during a well-validated preload challenge.

The Safety of Early Discharge Following Transcatheter Aortic Valve Implantation Among Patients in Northern Ontario and Rural Areas Utilizing the Vancouver 3M TAVI Study Clinical Pathway.

Background: Early hospital ( < 48 hours) discharge following transcatheter aortic valve implantation (TAVI) is an increasingly adopted practice; however, data on the safety of such an approach among patients residing in North Ontario, including remote and medically underserved areas, are lacking. Methods: This retrospective study included patients who underwent TAVI in Sudbury, Ontario. The safety of early discharge after implementation of the Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway was assessed. The primary endpoint was 30-day mortality. Resource utilization before vs after 3M clinical pathway implementation was also compared. Results: A total of 291 patients who underwent TAVI between 2012 and 2021 were included in the study. One in-hospital death (0.6%) occurred after the 3M clinical pathway implementation, with no mortality observed beyond hospital discharge. Eleven patients (6.7%) required rehospitalization within 30 days. The need for mechanical ventilation and surgical vascular cut-down declined from 100% and 97%, respectively, at baseline, to 6% and 2%. The number of patients receiving TAVI on a given procedural day increased from 2 to 3 patients. The median post-TAVI hospital length of stay decreased from 5 days (2-6 days) to 1 day (1-3 days) after 3M clinical pathway implementation. Conclusions: Following TAVI, early discharge of selected patients residing in Northern Ontario, including rural areas, using the Vancouver 3M clinical pathway was associated with favourable outcomes, short length of stay, and more-efficient resource utilization. These data can help improve healthcare efficiency and bridge variations in TAVI funding and accessibility in underserved locations.

Contexte: Il est de plus en plus admis d'accorder un congé rapide de l'hôpital (< 48 heures) après une implantation valvulaire aortique par cathéter (IVAC); toutefois, on ne dispose pas de données sur l'innocuité de cette pratique pour les patients du nord de l'Ontario, y compris ceux qui résident en régions éloignées moins bien desservies par les services médicaux. Méthodologie: Cette étude rétrospective a porté sur des patients ayant subi une IVAC à Sudbury (Ontario). L'innocuité d'un congé rapide après l'implantation selon le parcours de soins Vancouver 3M (multidisciplinaire, multimodal, mais minimaliste) a été évaluée. Le principal paramètre d'évaluation était la mortalité à 30 jours. Une comparaison de l'utilisation des ressources avant et après la mise en œuvre du parcours de soins 3M a également été effectuée. Résultats: Au total, 291 patients ayant subi une IVAC entre 2012 et 2021 ont été inclus dans l'étude. Un décès à l'hôpital (0,6 %) est survenu après la mise en œuvre du parcours de soins 3M, et aucune mortalité n'a été relevée après le congé de l'hôpital. Onze patients (6,7 %) ont dû être réhospitalisés dans les 30 jours suivants. Le recours à la ventilation mécanique et à la dénudation vasculaire a chuté, passant de 100 % et 97 % au départ, respectivement, à 6 % et 2 %. Le nombre de patients par jour d'intervention subissant une IVAC est passé de deux à trois patients. À la suite de la mise en œuvre du parcours de soins 3M, la durée médiane du séjour à l'hôpital après une IVAC est passée de cinq jours (deux à six jours) à un jour (un à trois jours). Conclusions: Après une IVAC, le congé rapide de patients sélectionnés habitant dans le nord de l'Ontario, y compris ceux habitant en région rurale, selon le parcours de soins Vancouver 3M a été associé à des résultats de santé favorables, à une durée courte d'hospitalisation et à une utilisation plus efficace des ressources. Ces données peuvent contribuer à améliorer l'efficacité des soins de santé et à combler des écarts liés aux variations du financement et de l'accessibilité des IVAC dans les régions moins bien desservies.

A Wireless Wearable Doppler Ultrasound Detects Changing Stroke Volume: Proof-of-Principle Comparison with Trans-Esophageal Echocardiography during Coronary Bypass Surgery.

BACKGROUND: A novel, wireless, ultrasound biosensor that adheres to the neck and measures real-time Doppler of the carotid artery may be a useful functional hemodynamic monitor. A unique experimental set-up during elective coronary artery bypass surgery is described as a means to compare the wearable Doppler to trans-esophageal echocardiography (TEE). METHODS: A total of two representative patients were studied at baseline and during Trendelenburg position. Carotid Doppler spectra from the wearable ultrasound and TEE were synchronously captured. Areas under the receiver operator curve (AUROC) were performed to assess the accuracy of changing common carotid artery velocity time integral (ccVTI∆) at detecting a clinically significant change in stroke volume (SV∆). RESULTS: Synchronously measuring and comparing Doppler spectra from the wearable ultrasound and TEE is feasible during Trendelenburg positioning. In two representative cardiac surgical patients, the ccVTI∆ accurately detected a clinically significant SV∆ with AUROCs of 0.89, 0.91, and 0.95 when single-beat, 3-consecutive beat and 10-consecutive beat averages were assessed, respectively. CONCLUSION: In this proof-of-principle research communication, a wearable Doppler ultrasound system is successfully compared to TEE. Preliminary data suggests that the diagnostic accuracy of carotid Doppler ultrasonography at detecting clinically significant SV∆ is enhanced by averaging more cardiac cycles.

Evolving Surgical Techniques and Improving Outcomes for Aortic Arch Surgery in Canada.

BACKGROUND: To explore evolving surgical techniques and outcomes for aortic arch surgery. METHODS: A total of 2435 consecutive patients underwent aortic arch repair with hypothermic circulatory arrest between 2008 and 2018 in 12 institutions across Canada. Trends in patient characteristics, surgical techniques, and in-hospital outcomes, including major morbidity or mortality, were examined. RESULTS: From 2008 to 2018, the age of patients (62.3 ± 13.2 years) and the proportion of women (30.2%) undergoing arch surgery did not change significantly. Aortic diameters at operation decreased (2008: 58 ± 13 mm; 2018: 53 ± 11 mm; P < 0.01). Surgeons performed more valve-sparing root replacements (2008: 0%; 2018: 15%; P < 0.001) and fewer Bentall procedures (2008: 27%; 2018: 20%; P < 0.01). Total arch replacement rates were similar (P = 0.18); however, elephant trunk (2008: 9.5%; 2018: 19%; P < 0.001) and frozen elephant trunk (2008: 3.1%; 2018: 15%; P < 0.001) repair rates have increased. Over time, higher nadir temperatures (2008: 18 [17-21]°C; 2018: 25 [23-28]°C; P < 0.001), and more frequent antegrade cerebral perfusion (2008: 61%; 2018: 83%; P < 0.001) were used. For elective cases, in-hospital mortality rates declined (2008: 6.8%; 2018: 1.2%; P = < 0.01), as did major morbidity or mortality (2008: 24%; 2018: 13%; P < 0.001) and transfusion rates (2008: 61%; 2018: 41%; P < 0.001), but stroke rates remained constant (2008: 6.8%; 2018: 5.3%; P = 0.12). Outcomes remained the same over time for urgent or emergent cases. CONCLUSIONS: Outcomes have improved over the past decade in Canada for elective aortic arch surgery, in the context of operating on smaller aortas, and more frequent use of moderate hypothermia and antegrade cerebral perfusion. Further research is needed to improve stroke rates and outcomes in the emergency setting.

INTRODUCTION: Examiner l'évolution des techniques chirurgicales et les résultats de l'intervention chirurgicale de l'arc aortique. MÉTHODES: Un total de 2 435 patients consécutifs ont subi une réparation de l'arc aortique en arrêt circulatoire en hypothermie entre 2008 et 2018 dans 12 établissements du Canada. Nous avons examiné les tendances en ce qui concerne les caractéristiques des patients, les techniques chirurgicales et les résultats cliniques intrahospitaliers, y compris les principales causes de morbidité ou de mortalité. RÉSULTATS: De 2008 à 2018, l'âge des patients (62,3 ± 13,2 ans) et la proportion de femmes (30,2 %) subissant l'intervention chirurgicale de l'arc n'a pas montré de changement significatif. Les diamètres aortiques à l'opération ont diminué (2008 : 58 ± 13 mm; 2018 : 53 ± 11 mm; P < 0,01). Les chirurgiens ont réalisé un plus grand nombre de remplacements de la racine aortique sans remplacement de la valve (2008 : 0 %; 2018 : 15 %; P < 0,001) et un moins grand nombre d'opérations de Bentall (2008 : 27 %; 2018 : 20 %; P < 0,01). Les taux totaux de remplacements de l'arc étaient similaires (P = 0,18). Toutefois, les taux de réparation avec la technique de la trompe d'éléphant; (2008 : 9,5 %; 2018 : 19 %; P < 0,001) et de la trompe d'éléphant congelée (2008 : 3,1 %; 2018 : 15 %; P < 0,001) ont augmenté. Avec le temps, des nadirs supérieurs de température (2008 : 18 [17-21]°C; 2018 : 25 [23-28]°C; P < 0,001) et des perfusions cérébrales antérogrades plus fréquentes (2008 : 61 %; 2018 : 83 %; P < 0,001) ont été utilisés. Pour les cas non urgents, les taux de mortalité intrahospitalière (2008 : 6,8 %; 2018 : 1,2 %; P = < 0,01) et les taux de morbidité grave et de mortalité (2008 : 24 %; 2018 : 13 %; P < 0,001) et de transfusion (2008 : 61 %; 2018 : 41 %; P < 0,001) ont décru, mais les taux d'accidents vasculaires cérébraux (2008 : 6,8 %; 2018 : 5,3 %; P = 0,12) sont demeurés constants. Les résultats cliniques sont demeurés identiques au fil du temps pour les cas urgents ou les nouveaux cas. CONCLUSIONS: Au Canada, les résultats de l'intervention chirurgicale non urgente de l'arc aortique se sont améliorés au cours de la dernière décennie dans le contexte de l'opération d'aortes plus petites et de l'utilisation plus fréquente de l'hypothermie modérée et de la perfusion cérébrale antérograde. D'autres recherches sont nécessaires pour améliorer les taux d'accidents vasculaires cérébraux et les résultats cliniques dans le cadre d'interventions urgentes.

The Gap in Prescribing Stroke Prevention Therapies in Postoperative Atrial Fibrillation After Isolated Coronary Artery Bypass Grafting Surgery.

BACKGROUND: Postoperative atrial fibrillation (POAF) commonly occurs after coronary artery bypass graft (CABG) surgery. Patients with POAF are at higher risk of stroke and mortality. The use of oral anticoagulation (OAC) in POAF remains inconsistent, and the care gap is unknown. OBJECTIVE: We sought to evaluate rate of adherence and factors associated with OAC use in POAF patients after isolated CABG. METHODS: In this study, all patients who had an isolated CABG between April 1, 2019 and March 30, 2020, at Health Sciences North, Sudbury retrospectively were evaluated. We identified all patients who developed POAF and captured the use of OAC. Multivariable logistic regression models were used to identify predictors of OAC prescription. RESULTS: In total, 339 CABG patients between April 1, 2019 and March 30, 2020, were identified; 86 patients developed POAF. No patients had major perioperative bleeding. All POAF patients had an indication for OAC therapies based on CHADS 65 score. However, only 17 (19.8%) patients with POAF had OAC prescription at the time of hospital discharge.  Baseline characteristics were similar between those with or without OAC. In multivariable analysis, the use of dual antiplatelet therapy was associated with a decreased use of OAC therapy in POAF (OR 0.037 (95% CI 0.005, 0.29), P = .002). Moreover, in comparison to surgeon A, surgeon B was associated with a decreased use of OAC therapy, whereas surgeon C was associated with an increased use of OAC therapy in POAF (OR 0.15 (95% CI 0.03, 0.83), P = .03 and OR 6.49 (95% CI 1.21, 34.82), P = .03, respectively). None of the CHADS 65 elements, including age, hypertension, stroke, diabetes mellitus or congestive heart failure, correlated with the use of OAC. KEY FINDINGS: Eighty percent of patients who developed POAF after isolated CABG failed to receive stroke prevention therapies. The use of dual antiplatelet therapy and individual surgeons' preference were associated with the use of OAC therapy among POAF. CONCLUSIONS: This data set suggests that approximately only 1 in 5 patients with POAF after isolated CABG got prescribed OAC.

Stem cell therapy for heart failure: Medical breakthrough, or dead end?

Heart failure continues to be one of the leading causes of morbidity and mortality worldwide. Myocardial infarction is the primary causative agent of chronic heart failure resulting in cardiomyocyte necrosis and the subsequent formation of fibrotic scar tissue. Current pharmacological and non-pharmacological therapies focus on managing symptoms of heart failure yet remain unable to reverse the underlying pathology. Heart transplantation usually cannot be relied on, as there is a major discrepancy between the availability of donors and recipients. As a result, heart failure carries a poor prognosis and high mortality rate. As the heart lacks significant endogenous regeneration potential, novel therapeutic approaches have incorporated the use of stem cells as a vehicle to treat heart failure as they possess the ability to self-renew and differentiate into multiple cell lineages and tissues. This review will discuss past, present, and future clinical trials, factors that influence stem cell therapy outcomes as well as ethical and safety considerations. Preclinical and clinical studies have shown a wide spectrum of outcomes when applying stem cells to improve cardiac function. This may reflect the infancy of clinical trials and the limited knowledge on the optimal cell type, dosing, route of administration, patient parameters and other important variables that contribute to successful stem cell therapy. Nonetheless, the field of stem cell therapeutics continues to advance at an unprecedented pace. We remain cautiously optimistic that stem cells will play a role in heart failure management in years to come.

Does adding an aortic root replacement or sinus repair during arch repair increase postoperative mortality? Evidence from the Canadian Thoracic Aortic Collaborative.

OBJECTIVES: The aim of this study was to examine the effect of the addition of an aortic root replacement or sinus repair on mortality and morbidity during aortic arch repair. METHODS: A total of 2472 patients underwent proximal or total aortic arch repair with hypothermic circulatory arrest between 2002 and 2018 at 12 centres. Multivariable logistic regressions (MV) and propensity score (PS) with inverse probability of treatment weighting (IPTW) analyses were performed. RESULTS: A total of 1099 (44.5%) patients had additional aortic root replacement (n = 934) or sinus repair (n = 165). Those with aortic root interventions were younger (61 ± 13 vs 64 ± 13 years, P < 0.001) and had less females (23% vs 35%, P < 0.001), less dissection (31% vs 36%, P = 0.004), less urgent cases (35% vs 39%, P = 0.047), more connective tissue disease (7% vs 3%, P < 0.001) and less total arch replacements (14% vs 22%, P < 0.001). On adjusted analyses, the addition of aortic root procedure was associated with increased mortality [MV: odds ratio (OR) 1.41, 95% confidence interval (CI) 1.03-1.92; PS-IPTW: risk increased by 3.7%, 95% CI 1.2-6.3%, P = 0.004]. Reoperation for bleeding was also increased with the addition of aortic root intervention (MV: OR 1.48, 95% 1.10-1.99; PS-IPTW: risk increased by 3.2%, 95% CI 0.8-5.6%, P = 0.009). The risks of stroke and dialysis-dependent renal failure were similar. When looking only at non-elective cases, the increased risk of mortality was more pronounced (MV: OR 1.60, 95% CI 1.11-2.32, P = 0.013; PS-IPTW: risk increased by 6.8%, 95 CI 1.7-11.8%, P = 0.008, and a number need to harm of 15 patients to cause 1 additional death). CONCLUSIONS: The addition of aortic root replacement or sinus repair during proximal or total aortic arch repair seems to increase postoperative mortality only in non-elective cases.

The impact of age on patients undergoing aortic arch surgery: Evidence from a multicenter national registry.

OBJECTIVE: Elderly patients are typically offered aortic surgery at similar diameter thresholds as younger patients, despite limited data quantifying their operative risk. We aim to report the incremental risk experienced by elderly patients undergoing aortic arch surgery. METHODS: In total, 2520 patients underwent aortic arch surgery between 2002 and 2018 in 10 centers. Patients were divided into 3 groups: <65 years (n = 1325), 65 to 74 years (n = 737), and ≥75 years (n = 458). Outcomes of interest were in-hospital mortality, stroke, and the modified Society of Thoracic Surgeons composite for mortality or major morbidity (STS-COMP). Multivariable modeling was performed to determine the association of age with these outcomes. RESULTS: As age increased, there was an increasing rate of comorbidities, including diabetes (P < .001), renal failure (P < .001), and previous stroke (P = .01). Rates of acute aortic syndrome (P = .50) and total arch repair were similar (P = .59) between groups. Older patients had greater mortality (<65: 6.1% vs 65-74: 9.0% vs ≥75: 14%, P < .001), stroke (6.3% vs 7.7% vs 11%, P = .01) and STS-COMP (25% vs 32% vs 38%, P < .001). After multivariable risk-adjustment, a step-wise increase in complications was observed in the older age groups relative to the youngest in terms of in-hospital mortality (65-74: odds ratio [OR] 1.57, P = .04; ≥75: OR, 2.94, P = .001) and STS-COMP (65-74: OR, 1.57, P < .001; ≥75: OR, 1.96, P < .001). CONCLUSIONS: Older patients experienced elevated rates of mortality and morbidity following aortic arch surgery. These results support a more measured approach when evaluating elderly patients. Further research is needed on age-dependent natural history of thoracic aneurysms and size thresholds for intervention.

Influenza Vaccination Blunts the Inflammatory Response in Patients Undergoing Cardiopulmonary Bypass.

BACKGROUND: Coronary artery bypass grafting with cardiopulmonary bypass (CPB) induces an inflammatory reaction that is associated with postoperative complications. Influenza vaccination has been shown to decrease cardiovascular morbidity in patients with cardiovascular disease, possibly via its anti-inflammatory properties. We hypothesize that influenza vaccination would attenuate the inflammatory reaction after CPB. METHODS: Thirty patients undergoing coronary artery bypass grafting were blindly randomized to receive the influenza vaccine (group I, n = 15) or a placebo (group II, n = 15) preoperatively. Serum samples of proinflammatory mediators (interleukin-6, interleukin-8, tumor necrosis factor, C-reactive protein) as well as the anti-inflammatory interleukin-10 were collected at different time points perioperatively. Assessment of myocardial dysfunction was investigated by measuring hemodynamic data, echocardiographic data, and troponin levels. Other clinical outcomes were collected prospectively. RESULTS: Proinflammatory cytokine levels were significantly reduced in the treatment group vs the placebo group (interleukin-6 [157.4 pg/dL vs 256 pg/dL, P = .043], interleukin-8 [65.03 pg/dL vs 118.56 pg/dL, P = .025], and tumor necrosis factor [12.05 pg/dL vs 20.8 pg/dL, P = .003]). These differences were observed at the end of CPB and persisted for 2 days postoperatively. Interestingly, the level of the anti-inflammatory marker interleukin-10 was significantly higher in group I (83.3 pg/dL vs 15.15 pg/dL, P = .008). Evidence of improved myocardial protection was observed in group I, as reflected by troponin measurements postoperatively (6020.2 pg/dL vs 12,098.01 pg/dL, P = .052). CONCLUSIONS: Influenza vaccination attenuates the inflammatory response to CPB as reflected by a reduction in the level of troponin and proinflammatory mediators and an increase in the anti-inflammatory cytokine interleukin-10.

Rare case of iatrogenic aortic valve leaflet tear following a diagnostic coronary angiogram.

We report a rare case of a 44-year-old male who underwent a diagnostic coronary angiogram following a non-ST elevation myocardial infarction complicated by an aortic valve leaflet tear requiring surgical intervention. Routine transthoracic echocardiogram demonstrated a mobile echogenic structure prolapsing into the left ventricular outflow tract. An intraoperative transesophageal echocardiogram confirmed that the structure originated from the ventricular side of left coronary cusp, causing malcoaptation between left and right coronary cusps, and subsequent moderate to severe aortic regurgitation.

Sex-Related Differences in Patients Undergoing Thoracic Aortic Surgery.

BACKGROUND: Contemporary outcomes after surgical management of thoracic aortic disease have improved; however, the impact of sex-related differences is poorly understood. METHODS: A total of 1653 patients (498 [30.1%] female) underwent thoracic aortic surgery with hypothermic circulatory arrest between 2002 and 2017 in 10 institutions of the Canadian Thoracic Aortic Collaborative. Outcomes of interest were in-hospital death, stroke, and a modified Society of Thoracic Surgeons-defined composite for mortality or major morbidity (stroke, renal failure, deep sternal wound infection, reoperation, prolonged ventilation). Multivariable logistic regression was used to determine independent predictors of these outcomes. RESULTS: Women were older (mean±SD, 66±13 years versus 61±13 years; P<0.001), with more hypertension and renal failure, but had less coronary disease, less previous cardiac surgery, and higher ejection fraction than men. Rates of aortic dissection were similar between women and men. Rates of hemiarch, and total arch repair were similar between the sexes; however, women underwent less aortic root reconstruction including aortic root replacement, Ross, or valve-sparing root operations (29% versus 45%; P<0.001). Men experienced longer cross-clamp and cardiopulmonary bypass times, but similar durations of circulatory arrest, methods of cerebral perfusion, and nadir temperatures. Women experienced a higher rate of mortality (11% versus 7.4%; P=0.02), stroke (8.8% versus 5.5%; P=0.01), and Society of Thoracic Surgeons-defined composite end point for mortality or major morbidity (31% versus 27%; P=0.04). On multivariable analyses, female sex was an independent predictor of mortality (odds ratio, 1.81; P<0.001), stroke (odds ratio, 1.90; P<0.001), and Society of Thoracic Surgeons-defined composite end point for mortality or major morbidity (odds ratio, 1.40; P<0.001). CONCLUSIONS: Women experience worse outcomes after thoracic aortic surgery with hypothermic circulatory arrest. Further investigation is required to better delineate which measures may reduce sex-related outcome differences after complex aortic surgery.

An Unusual Case of Cardiac Tamponade Secondary to an Elevated Right Hemidiaphragm.

Diaphragmatic eventration in old age is a rare phenomenon. Typically, it is thought to originate as a result of failure of development of the muscles of the diaphragm. Less commonly, it can occur secondary to acquired conditions resulting from spinal cord or phrenic nerve injury and is only detected incidentally when the patient presents with dyspnea, chest infection, or cardiac compression symptoms. Herein, we report a case of right diaphragmatic paralysis in a 58-year-old man with a presentation of marked elevation of the right hemidiaphragm and ascites causing a picture compatible with cardiac tamponade.

Non-transfemoral access sites for transcatheter aortic valve replacement.

Transfemoral access is currently the standard and preferred access site for transcatheter aortic valve replacement (TAVR), though novel approaches are emerging to expand treatment options for the increasing numbers of patients with a contraindication for the traditional route. Previous publications have provided comparisons between two TAVR access sites, primarily transfemoral versus one of the novel approaches, while others have compared three or four novel approaches. The aim of this report is to provide a comprehensive summary of publications that analyse and compare the six non-transfemoral access sites currently described in the literature. These include the transapical, transaortic, axillary/subclavian, brachiocephalic, transcarotid, and transcaval approaches. Though there remains little consensus as to the superiority or non-inferiority of TAVR approaches, and there has yet to be randomized clinical trials to support published findings, with careful patient and procedural selection, outcomes for novel approaches have been reported to be comparable to standard transfemoral access when performed by skilled physicians. As such, choice of procedure is primarily based on registry data and the judgement of surgical teams as to which approach is best in each individual case. As TAVR continues to be an increasingly widespread treatment, search for the optimal access site will grow, and focus should be placed on the importance of educating surgeons as to all possible approaches so they may review and chose the most appropriate technique for a given patient.