Perioperative neuromonitoring during thoracoabdominal aortic aneurysm open repair: a systematic review.

OBJECTIVES: While open surgical repair remains the gold standard for thoracoabdominal aortic aneurysm (TAAA) treatment, there is still no consensus regarding perioperative neuromonitoring technique for prevention of spinal cord ischaemia. METHODS: In this systematic review, we aimed to explore the effects and practices of neuromonitoring during the open TAAA repair. A systematic literature search in PubMed, Embase via Ovid, Cochrane library and ClinicalTrialsGov until December 2022 was performed. RESULTS: A total of 535 studies were identified from the literature search, of which 27 studies including a total of 3130 patients met the eligibility criteria. Most studies (21 out of 27, 78%) investigated the feasibility of motor-evoked potentials (MEP), while 15 analysed somatosensory-evoked potentials (SSEP) and 2 studies analysed near-infrared spectroscopy during open TAAA repair. CONCLUSIONS: Current literature suggest that rates of postoperative spinal cord ischaemia can be kept at low levels after open TAAA repair with the adequate precautions and perioperative manoeuvres. Neuromonitoring with MEP provides the surgeon objective criteria to direct selective intercostal reconstruction or other protective anaesthetic and surgical manoeuvres. Simultaneous monitoring of MEP and SSEP is a reliable method that can rapidly detect important findings and direct adequate protective manoeuvres during open TAAA repair.

Factors associated with long-term outcomes in adult congenital heart disease patients with infective endocarditis: a 16-year tertiary single-centre experience.

OBJECTIVES: Studies concerning factors associated with long-term outcomes in adult congenital heart disease (ACHD) patients after infective endocarditis (IE) are scarce, while IE-related mortality in these patients remains a burden. We evaluated the factors associated with long-term survival in ACHD patients admitted for IE. METHODS: We performed a retrospective single-centre study of all ACHD patients admitted for IE to a tertiary cardiothoracic centre between 1999 and 2015. Underlying ACHD, detailed echocardiographic and clinical data, surgical treatment and long-term follow-up were analysed. RESULTS: We identified 151 ACHD patients admitted due to 176 episodes IE with 30-day, 6-month and 1-, 5- and 10-year survival of 95.4%, 92.7%, 92.7%, 84.7% and 75.6%, respectively. In a multivariable analysis, adjusted estimated probability of death was consistently higher after an IE episode among patients with complex as compared to simple/moderate ACHD: 10.6% vs 2.4% at 30 days, 15.0% vs 3.4% at 6 months and 1 year, 30.4% vs 7.8% at 5 years and 44.9% vs 13.1% at 10 years. Risk of death was higher among patients with prosthetic valve in comparison with those without (risk ratios 1.73-1.92). Surgical treatment was required in 76 (43.2%) episodes with 30-day mortality of 3.9%. Risk of death appeared to be lower than in the conservatively treated subgroup (risk ratios 0.71-0.78). CONCLUSIONS: We demonstrated satisfactory long-term survival in ACHD patients who were treated for IE in a tertiary cardiothoracic centre. Early mortality tended to be lower in the surgically treated subgroup. Factors negatively associated with long-term survival were complex ACHD and presence of prosthetic valve.

Comparing mid-term outcomes of Cox-Maze procedure and pulmonary vein isolation for atrial fibrillation after concomitant mitral valve surgery: A systematic review.

BACKGROUND: Although concomitant pulmonary vein isolation (PVI) is used more frequently than the Cox-Maze procedure, which is currently the gold standard treatment for atrial fibrillation (AF), data on the comparative effectiveness of the two procedures after concomitant mitral valve (MV) surgery are still limited. OBJECTIVE: We conducted a systematic review to identify randomized controlled trials (RCTs) and observational studies comparing the mid-term mortality and recurrence of AF after concomitant Cox-Maze and PVI in patients with AF undergoing MV surgery based on 12-month follow-up. METHODS: Medline, EMBASE databases, and the Cochrane Library were searched from 1987 up to March 2022 for studies comparing concomitant Cox-Maze and PVI. Additionally, a meta-analysis of RCTs was performed to compare the mid-term clinical outcomes between these two surgical ablation techniques. RESULTS: Three RCTs and three observational studies meeting the inclusion criteria were included in this systematic review with 790 patients in total (532 concomitant Cox-Maze and 258 PVI during MV surgery). Most studies reported that the concomitant Cox-Maze procedure was associated with higher freedom from AF at 12-month follow-up than PVI. Regarding AF recurrence, estimates pooled across the three RCTs indicated large heterogeneity and high uncertainty. In the largest and highest quality RCT, 12-month AF recurrence was higher in the PVI arm (risk ratio = 1.58, 95% CI: 0.91-2.73). In two out of three higher-quality observational studies, 12-month AF recurrence was higher in PVI than in the Cox-Maze arm (estimated adjusted probabilities 11% vs. 8% and 35% vs. 17%, respectively). RCTs demonstrated comparable 12-month mortality between concomitant Cox-Maze and PVI, while observational studies demonstrated the survival benefit of Cox-Maze. CONCLUSIONS: Concomitant Cox-Maze in AF patients undergoing MV surgery is associated with better mid-term freedom from AF when compared to PVI with comparable mid-term survival. Large observational studies suggest that there might be a mid-term survival benefit among patients after concomitant Cox-Maze. Further large RCTs with longer standardized follow-up are required to clarify the benefits of concomitant Cox-Maze in AF patients during MV surgery.

Fiftieth anniversary of the first heart transplantation in Switzerland in the context of the worldwide history of heart transplantation.

On 3 December 1967, Christiaan Barnard performed the first heart transplantation in the world at Groote Schuur Hospital in Cape Town, South Africa. In the succeeding months, heart transplantations in the USA, Asia and Europe followed. On 14 April 1969, Åke Senning successfully accomplished the first heart transplantation in Switzerland at the former Cantonal Hospital in Zurich. In the summer of 1969, he undertook a second heart transplantation. Although the surgical procedure went well technically, both patients died within weeks to months after transplantation. Causes of death were infection in the first and rejection in the second patient. Senning’s colleagues around the world had similar experiences. Survival after heart transplantation was unacceptably low. The heart transplant community recognised the lack of knowledge about immunological processes and appropriate immunosuppressive regimens as underlying reason for the early deaths. Most transplant centres decided to refrain from heart transplantation until sufficient immunological insight became available. After the introduction of the new immunosuppressive drug ciclosporin into the clinic and the availability of tools to monitor rejection in the early 1980s, heart transplant programmes were restarted all over the world. The legal recognition of brain death allowed procurement of donor hearts without exposure to warm ischaemia, and the principle of cold storage enabled prolongation of ischaemia time and acceptance of donors in distant hospitals, resulting in enlargement of the donor pool. In Switzerland, Marko Turina resumed heart transplantation in 1985 at Senning’s former workplace in Zurich. The number of heart transplants in Switzerland and in the world grew rapidly because the outcome markedly improved. Particularly over the long-term, survival in Zurich surpassed the outcome worldwide. Zurich created internationally recognised milestones such as transplantation of patients with grown-up congenital heart disease, the implementation of the bicaval instead of the right atrial anastomosis during the transplant procedure and the dual transplantation of one heart. Since the middle of the 1990s, however, the number of heart transplants has plateaued, mainly because of donor shortage. The current era is characterised by efforts to increase the number of donors. The utilisation of marginal donors, the change from informed to presumed consent for organ donation and donation after cardiocirculatory-determined death have been proposed to augment the donor pool.

Incidence and pathophysiology of atrioventricular block following mitral valve replacement and ring annuloplasty.

BACKGROUND: In this retrospective study we evaluate the causative mechanisms underlying postoperative atrioventricular block (AVB) following mitral valve replacement and mitral valve annuloplasty. METHODS: Between January 1990 and December 2003, 391 patients underwent mitral valve replacement or ring annuloplasty and quadrangular resection. Exclusion criteria were preoperative AV block, two or three valvular procedures, reoperations and procedures combined with coronary artery bypass grafting. The presence of the postoperative AVB was compared with preoperative and intraoperative variables. On 55 post-mortem specimens the relationship between the AV node, AV node artery and mitral valve annulus was investigated. RESULTS: The mean age was 59+/-14 years and 44% of patients were female. Postoperatively AVB occurred in 92 (23.5%) patients. AVB III was found in 17 (4%) patents, in whom a pacemaker was implanted within median interval of 4 days. Second degree AVB occurred and first degree AVB in five (1.3%) and in 70 (18%) patients respectively. In dry dissected human hearts in 23% of investigated cases the AV node artery was discovered to run close to the annulus of the mitral valve. CONCLUSIONS: Data collected in this study showed that, sotalol and amiodarone as well as a prolonged cross-clamp time may slightly influence the 23% incidence of postoperative AVB. The morphological investigation showed that the AV node artery runs in close proximity to the annulus in 23% of cases. We speculate that damage of the AV node artery may play a role in development of AVB.