Sex-related differences among patients undergoing surgical aortic valve replacement-a propensity score matched study.

OBJECTIVES: We investigated the sex-related difference in characteristics and 2-year outcomes after surgical aortic valve replacement (SAVR) by propensity-score matching (PSM). METHODS: Data from 2 prospective registries, the INSPIRIS RESILIA Durability Registry (INDURE) and IMPACT, were merged, resulting in a total of 933 patients: 735 males and 253 females undergoing first-time SAVR. The PSM was performed to assess the impact of sex on the SAVR outcomes, yielding 433 males and 243 females with comparable baseline characteristics. RESULTS: Females had a lower body mass index (median 27.1 vs 28.0 kg/m2; P = 0.008), fewer bicuspid valves (52% vs 59%; P = 0.036), higher EuroSCORE II (mean 2.3 vs 1.8%; P < 0.001) and Society of Thoracic Surgeons score (mean 1.6 vs 0.9%; P < 0.001), were more often in New York Heart Association functional class III/IV (47% vs 30%; P < 0.001) and angina Canadian Cardiovascular Society III/IV (8.2% vs 4.4%; P < 0.001), but had a lower rate of myocardial infarction (1.9% vs 5.2%; P = 0.028) compared to males. These differences vanished after PSM, except for the EuroSCORE II and Society of Thoracic Surgeons scores, which were still significantly higher in females. Furthermore, females required smaller valves (median diameter 23.0 vs 25.0 mm, P < 0.001). There were no differences in the length of hospital stay (median 8 days) or intensive care unit stay (median 24 vs 25 hours) between the 2 sexes. At 2 years, post-SAVR outcomes were comparable between males and females, even after PSM. CONCLUSIONS: Despite females presenting with a significantly higher surgical risk profile, 2-year outcomes following SAVR were comparable between males and females.

Thoracic sarcopenia measured by Hounsfield unit average calculation predicts morbidity and mortality in coronary artery bypass grafting.

OBJECTIVES: The aim of the study was to investigate the potential prognostic role of preoperative measurement of erector spinae myosteatosis with Hounsfield unit average calculation as a marker for sarcopenia and frailty in patients undergoing coronary bypass surgery. METHODS: Preoperative computer tomography-derived measurements of 479 consecutive patients undergoing coronary bypass surgery between January 2017 and December 2019 were retrospectively performed. The erector spinae muscle at the level of the 12th vertebra was manually outlined bilaterally on the axial computer tomography slices and Hounsfield unit average calculation was performed. The lower quartile of muscle density values was defined as myosteatotic and thus sarcopenic. Sarcopenic (n = 121) versus non-sarcopenic patients (n = 358) were compared regarding postoperative morbidity and short- and long-term mortality. Results were adjusted for age, body mass index, atrial fibrillation and hypertension using inverse probability weighting. RESULTS: Sarcopenia was associated with higher 30-day mortality (4.1% vs 0.8%; P = 0.012), mid-term mortality after 1 year (9.3% vs 3.1%; P = 0.047) and 2 years (10.8% vs 4.2%; P = 0.047). Long-term mortality (5 years) was 20.8% for sarcopenic and 13.0% for non-sarcopenic patients but was not found to be significantly different (P = 0.089). Sarcopenia was associated with higher rates of reintubation (7.5% vs 1.1%; P < 0.001), sternal wound infections (7.5% vs 2.8%; P = 0.039) and acute kidney injury requiring haemodialysis (2.5% vs 0.4%; P = 0.021). CONCLUSIONS: In patients undergoing coronary bypass surgery, sarcopenia was associated with increased short-term mortality, mid-term mortality and morbidity. The measurement of erector spinae myosteatosis could be an easy and useful parameter in preoperative risk assessment.

Large Bouncing Mass in the Right Atrium: Metastasis of Malignant Melanoma.

This paper presents a rare case of malignant melanoma metastasizing to the heart, highlighting the diagnostic journey, therapeutic considerations, and clinical implications. Enhanced awareness of atypical metastases aids early recognition and treatment strategies for improved patient care. Comprehensive understanding of cardiac involvement in melanoma contributes to better outcomes and clinical decision making. (Level of Difficulty: Beginner.).

Manufacturing flexible vascular models for cardiovascular surgery planning and endovascular procedure simulations: An approach to segmentation and post-processing with open-source software and end-user 3D printers.

306Three-dimensional (3D)-printed vascular models for cardiovascular surgery planning and endovascular procedure simulations often lack realistic biological tissues mimicking material properties, including flexibility or transparency, or both. Transparent silicone or silicone-like vascular models were not available for end-user 3D printers and had to be fabricated using complex and cost-intensive workarounds. This limitation has now been overcome by novel liquid resins with biological tissue properties. These new materials enable simple and low-cost fabrication of transparent and flexible vascular models using end-user stereolithography 3D printers and are promising technological advances toward more realistic patient-specific, radiation-free procedure simulations and planning in cardiovascular surgery and interventional radiology. This paper presents our patient-specific manufacturing process of fabricating transparent and flexible vascular models using freely available open-source software for segmentation and 3D post-processing, aiming to facilitate the integration of 3D printing into clinical care.

Impact of concomitant replacement of the ascending aorta in patients undergoing aortic valve replacement on operative morbidity and mortality.

OBJECTIVES: The aim of this study was to evaluate the impact of concomitant ascending aortic replacement on operative morbidity and mortality in patients undergoing aortic valve replacement (AVR). METHODS: We retrospectively analysed our institutional database for all patients undergoing elective isolated AVR and AVR with concomitant replacement of the ascending aorta between January 2009 and May 2020. Patients undergoing surgery for infective endocarditis or requiring hypothermic circulatory arrest were excluded. A 3:1 propensity matching was performed for 688 patients to compare isolated AVR (120 patients) with AVR + ascending aortic replacement (40 patients). RESULTS: There were significant differences in median cardiopulmonary bypass (CPB) time [92.5 (75-114) vs 118.5 (104-131) min; P < 0.001], median aortic cross-clamp time [65.0 (51.5-78.5) vs 84.5 (77-94) min; P < 0.001] and median intensive care unit stay [1 (1-3) vs 2 (1-6) days; P < 0.01]. There was no significant difference in the use of intraoperative and postoperative blood products, re-exploration for bleeding, postoperative atrial fibrillation, acute renal failure, incidence of stroke, perioperative myocardial infarction and 30-day mortality. CONCLUSIONS: Concomitant replacement of the ascending aorta significantly prolongs CPB and aortic clamp times but does not increase operative morbidity and mortality. Therefore, replacement of a dilated ascending aorta appears to be the most durable and safest treatment option in patients undergoing AVR with an aneurysmatic ascending aorta.

Impact of pre-existing comorbidities on outcomes of patients undergoing surgical aortic valve replacement - rationale and design of the international IMPACT registry.

BACKGROUND: Degenerative aortic valve disease accounts for 10-20% of all cardiac surgical procedures. The impact of pre-existing comorbidities on the outcome of patients undergoing surgical aortic valve replacement (SAVR) needs further research. METHODS: The IMPACT registry is a non-interventional, prospective, open-label, multicenter, international registry with a follow-up of 5 years to assess the impact of pre-existing comorbidities of patients undergoing SAVR with the INSPIRIS RESILIA aortic valve on outcomes. IMPACT will be conducted across 25 sites in Austria, Germany, The Netherlands and Switzerland and intends to enroll approximately 500 patients. Patients will be included if they are at least 18 years of age and are scheduled to undergo SAVR with the INSPIRIS RESILIA Aortic Valve with or without concomitant ascending aortic root replacement and/or coronary bypass surgery. The primary objective is to determine all-cause mortality at 1, 3, and 5 years post SAVR. Secondary objectives include cardiac-related and valve-related mortality and structural valve deterioration including hemodynamics and durability, valve performance and further clinical outcomes in the overall study population and in specific patient subgroups characterized by the presence of chronic kidney disease, hypertension, metabolic syndrome and/or chronic inflammation. DISCUSSION: IMPACT is a prospective, multicenter European registry, which will provide much-needed data on the impact of pre-existing comorbidities on patient outcomes and prosthetic valve performance, and in particular the performance of the INSPIRIS RESILIA, in a real-world setting. The findings of this study may help to support and expand appropriate patient selection for treatment with bioprostheses. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04053088 .

Multicentre experience with the frozen elephant trunk technique to treat penetrating aortic ulcers involving the aortic arch.

OBJECTIVES: Our goal was to evaluate the use of the frozen elephant trunk (FET) technique for the treatment of penetrating aortic ulcers involving the aortic arch. METHODS: Between January 2008 and January 2020, a total of 34 patients had the FET technique at 3 aortic centres. The indication for the FET technique was unsuitability for thoracic endovascular aortic repair due to the lack of a sufficient proximal landing zone even after supra-aortic rerouting (subclavian transposition, double transposition), ectasia of the ascending aorta/aortic arch (>40 mm) and/or a shaggy proximal thoracic aorta. RESULTS: Additional cardiac procedures were performed in 14 patients (41%), and the beating heart technique was used in 7 patients (21%). Perioperative mortality was 18% (n = 6); 3 of these patients had a major stroke (9%). No case of spinal cord ischaemia was observed, and 2 patients (6%) developed a non-disabling stroke. After a median follow-up of 7 (first quartile: 1; third quartile 29) months, 2 patients (6%) died (1 of malignant disease and 1 of an unclear cause); 10 additional aortic interventions in all aortic segments (29%; endovascular: n = 8 [24%] and conventional surgical: n = 2 [6%]) were performed in 8 patients. CONCLUSIONS: The FET technique is a good treatment option for patients with penetrating aortic ulcers involving the aortic arch unsuitable for thoracic endovascular aortic repair. However, the high obliterative atherosclerotic load in these patients is accompanied by an un-neglectable risk of perioperative neurological injury. Concomitant cardiac surgical procedures are frequently needed. Patients commonly require secondary aortic procedures in all aortic segments, emphasizing the need for thorough primary conceptual planning and stringent follow-up.

Distal Stent Graft-Induced New Entries After the Frozen Elephant Trunk Procedure.

BACKGROUND: This study sought to evaluate the incidence of and identify risk factors for distal stent graft-induced new entries (dSINEs) after the frozen elephant trunk (FET) procedure. METHODS: Patient characteristics and radiographic and follow-up data on 126 patients treated for aortic dissections with the Thoraflex (Vascutek Ltd, Inchinnan, United Kingdom) FET device in 2 centers between November 2013 and December 2018 were evaluated. Stress-strain behavior and load-displacement curves of the Thoraflex and the E-Vita Open (Jotec Inc, Hechingen, Germany) FET prosthesis were evaluated by applying axial load to the most distal ring of the prostheses. RESULTS: dSINEs were diagnosed in 16 patients (13%). There was no difference in the underlying disease, aortic features, or FET stent graft dimension between patients with and without dSINEs. No predictors for dSINE occurrence in patients treated with the Thoraflex device were identified. The risk for dSINE development was 14% (95% confidence interval [CI], 0% to 22%), 16% (95% CI, 0% to 24%), and 25% (95% CI, 0% to 45%) after 12, 24, and 36 months, respectively. When prostheses were loaded axially to 2-mm maximal displacement, the Thoraflex prosthesis exhibited strongly nonlinear behavior with maximal stiffness for minimal displacements, whereas the E-Vita prosthesis showed nearly constant stiffness. In addition, the Thoraflex prosthesis showed an increase in stiffness when confined. CONCLUSIONS: dSINEs may develop at any time after the FET procedure, and the risk for dSINE development is high. No clinical or patient-specific risk factors were identified in this study. The design of the Thoraflex graft with a stiff distal ring may be a potential reason for the occurrence of dSINEs.

Perceval Sutureless Valve Dysfunction Caused by Valvular Thrombosis.

Until now, to our knowledge no case of bioprosthetic valvular thrombosis after implantation of the sutureless Sorin Perceval valve has been reported. Although sutureless aortic valve replacement has become a powerful tool in our daily practice, recent guidelines from the European Society of Cardiology, the European Association for Cardio-Thoracic Surgery, the American College of Cardiology, and the American Heart Association do not give specific recommendations on postoperative anticoagulation therapy. We report the first case of valve dysfunction resulting from thrombosis 12 months after implantation with a possible link to postoperative cortisole therapy.

Re-sternotomy as an unwelcome side-effect of unknown effervescent tablet intake?

Four hours after surgery for aortic valve stenosis and tricuspid valve regurgitation, an unknown foreign body was present on the routine chest X-ray. We performed re-sternotomy in order to retrieve this foreign body. The foreign body was easy to move on fluoroscopy but we could not extract it. We concluded that the foreign body was in a subdiaphragmatic location. As a consequence, we performed gastroscopy. A white, frothy mass (similar to an undissolved effervescent tablet) within an ulcerated lesion was seen and partially extracted.