Tricuspid Regurgitation and TAVR: Outcomes, Risk Factors and Biomarkers.

Background. The significance of concomitant tricuspid regurgitation (TR) in the context of transcatheter aortic valve replacement (TAVR) remains unclear. This study aimed to analyze the severity of TR before and after TAVR with regard to short- and long-term survival and to analyze the influencing factors. Methods. In our retrospective analysis, TR before and after TAVR was examined and patients were classified into groups accordingly. Special attention was paid to patients with post-interventional changes in TR. Mortality after TAVR was considered the primary endpoint of the analysis and major complications according to the Valve Academic Research Consortium 3 (VARC3) were compared. Moreover, biomarkers and risk factors for worsening or improvement of TR through TAVR were analyzed. Results. Among 775 patients who underwent TAVR in our center between January 2009 and December 2019, 686 patients (89%) featured low- and 89 patients (11%) high-grade TR. High-grade pre-TAVR TR was associated with worse short- (30-day), mid- (2-year) and long-term survival up to 8 years. Even though in nearly half of the patients with high-grade TR the regurgitation improved within seven days after TAVR (n = 42/89), this did not result in a survival benefit for this subgroup. On the other hand, a worsening of low-grade TR was seen in more than 10% of the patients (n = 73/686), which was also associated with a worse prognosis. Predictors of worsening of TR after TAVR were adipositas, impaired right ventricular function and the presence of mild TR. Age, atrial fibrillation, COPD, impaired renal function and elevated cardiac biomarkers were risk factors for mortality after TAVR independent from the grade of TR. Conclusions. Not only pre-interventional, but also post-TAVR high-grade TR is associated with a worse prognosis after TAVR. TAVR can change concomitant tricuspid regurgitation, but improvement does not have any impact on short- and long-term survival. Worsening of TR after TAVR is possible and impairs the prognosis.

Long-term outcome and quality of life following emergency surgery for acute aortic dissection type A: a comparison between young and elderly adults.

Objectives: Innovations in surgical techniques and perioperative management have continuously improved survival rates for acute aortic dissection type A (AADA). The aim of our study was to evaluate long-term outcome and quality of life (QoL) after surgery for AADA in elderly patients compared with younger patients. Methods: We retrospectively evaluated 242 consecutive patients, who underwent surgery for AADA between January 2004 and April 2014. Patients were divided into two groups: those aged 70 years and older (elderly group; n = 78, mean age, 76 ± 4 years) and those younger than 70 years (younger group; n = 164, mean age, 56 ± 10 years). QoL was assessed with the Short Form Health Survey Questionnaire (SF-36) 1 year after surgery. Results: The questionnaire return rate was 91.0%. There were already significant differences noted between the two groups with regard to preoperative risk factors on admission. The clinical presentation with a cardiac tamponade was higher in the elderly group (62.8% vs 47.6%; P = 0.03). Intraoperatively, complex procedures were more common in the younger group (21.3% vs 5.2%; P = 0.001). Accordingly, cardiopulmonary bypass and cross-clamping times were significantly longer in the younger group. The operative mortality was similar in both groups (3.8% vs 1.2%; P = 0.33). In the elderly population, 30-day mortality was higher (21.8% vs 7.9%; P = 0.003). One-year (72% vs 85%), 3-year (68% vs 84%) and 5-year (63% vs 79%) survival rates were satisfactory for the elderly group, but significantly lower compared with the younger group ( P = 0.008). The physical component summary score also was similar between the groups (39.14 ± 11.12 vs 39.12 ± 12.02; P = 0.99). However, the mental component summary score might be slightly higher in the elderly group but not statistically significant (51.61 ± 10.73 vs 48.63 ± 11.25; P = 0.12). Conclusions: Satisfactory long-term outcome and the general perception of well-being encourage surgery in selected elderly patients with AADA.

Iatrogenic Catheter-Induced Acute Aortic Dissection Type A after Coronary Angiography-A Retrospective Consecutive Case Series.

Background Acute aortic dissection type A (AADA) is one of the most life-threatening situations and surgical demanding procedures even today. Usually AADA develops spontaneously, but it can be related also to interventional procedures. Methods We analyzed the data of 14 patients surgically treated in our institution with catheter-induced AADA (ciAADA) during coronary angiography between January 2004 and December 2014. Data were compared with overall AADA patients in this time period (n = 288). Results Nine of the 14 patients were female. Subjects were significantly older compared to the AADA patients (69 ± 11 vs. 62 ± 11; p = 0.021). At admission, ciAADA patients were more often hemodynamically instable and mechanically ventilated. Twelve patients underwent replacement of the ascending aorta and two patients received a modified Bentall operation. Cardiopulmonary bypass time (210 ± 92 vs. 172 ± 51 min) and cross-clamp time (122 ± 63 vs. 92 ± 40 min) were significantly longer due to additional coronary artery bypass grafts in 71.4 versus 3.1% due to myocardial ischemia. Operative mortality (7.1 vs. 2.1%, p = 0.29) and 30-day mortality (50.0 vs. 10.7%, p < 0.001) were higher in the ciAADA group. Conclusion Coronary angiography-induced AADA is a rare but severe complication. Due to additional myocardial ischemia and preoperative hemodynamic instability, patients with ciAADA have adverse outcome compared to overall AADA patients.

Transatrial Cannulation of the Left Ventricle for Acute Type A Aortic Dissection: A 5-Year Experience.

BACKGROUND: Acute type A aortic dissection (AAD) is a life-threatening disorder with a high rate of mortality and complications. All cannulation techniques currently used to establish arterial flow for cardiopulmonary bypass are associated with a considerable risk of organ malperfusion, stroke, or access site trauma. Here, we report the impact of transatrial cannulation of the left ventricle on patient outcome after surgical treatment of AAD. METHODS: Between 2010 and 2013, 46 patients underwent emergency surgery for AAD using transatrial cannulation of the left ventricle. Their outcome was retrospectively compared with that of 73 age- and sex-matched patients operated on for AAD between 2006 and 2010 before introduction of the new technique. RESULTS: No differences concerning preoperative details were found. Arterial flow before 2010 was established after preparation of the femoral artery in 46 patients (63.0%) or by direct cannulation of the ascending aorta in 27 patients (37.0%). Operation times were significantly lower in the transatrial cannulation group (271.2 ± 75.4 versus 308.3 ± 78.2; p = 0.02). Postoperatively, we observed a significantly reduced stroke rate in the group with transatrial cannulation (6.5% versus 26.5%; p = 0.007) and a decreased rate of acute renal failure (20.0% versus 32.4%; p = 0.003). Intraoperative mortality (0% versus 6.8%; p = 0.16), 30-day mortality (8.9% versus 10.3%; p = 1.00), and mortality during follow-up (9.8% versus 34.4%; p = 0.08) did not differ. However, overall mortality was significantly lower in the group after transatrial cannulation (17.7% versus 45.2%; p = 0.003). CONCLUSIONS: In patients undergoing surgery for AAD, transatrial cannulation of the left ventricle proved to be a safe and easy cannulation method that significantly reduced postoperative complications.

Transapical mitral valved stent implantation: computed tomographic evaluation of different prototype designs.

AIMS: The evaluation of in vivo shaping of mitral valved stent prototypes using cardiac computed tomography (CT) was the focus of this study. METHODS AND RESULTS: Twelve pigs received a self-expanding mitral valved stent, composed of an atrial element connected to a tubular ventricular body at a modified angle (45°, 90°, 110°) resulting in three designs. Cardiac CT was performed three weeks after implantation, with focus placed on stent design-related parameters: possible left ventricular outflow tract obstruction and stent shaping. CT was successfully conducted in 11/12 animals showing correct stent position within the mitral annulus and no obstruction of the left ventricular outflow tract in 9/11 animals. Minor radial deformations of the stent body were detected. At the atrioventricular junction, deformations of the stent structure were observed in all cases. Stents with a 45° angle exhibited the greatest deflection (≤56.4°±14.5°). CONCLUSIONS: The effectiveness of cardiac computed tomography in the development process of valved stents to provide essential information and quantitative data about the in vivo stent geometry was demonstrated. The in vivo mechanical deformations of the stent were quantified, identifying critical design areas: a larger preset angle leads to less deflection and improved alignment and hence reduces the mechanical load.

Very large left atrial myxoma: an unusual differential diagnosis of bronchial hyper-reactivity.

Intra- and paracardiac tumors are rare. Clinical symptoms are typically secondary to mechanical effects of the mass. We describe a patient, who was in good general health, presenting with a 6-month history of unspecific symptoms considered consistent with reccurrent lower airway infections by her primary care physician. A chest X-ray suggested left-atrial enlargement and a questionable mass, which eventually was identified as large left-atrial tumor partially obstructing the mitral orifice. The case demonstrates that even a very large left-atrial tumor, causing intermittent partial obstruction of the mitral valve may present with mild unspecific symptoms.

Predictors for long-term outcome and quality of life of patients after cardiac surgery with prolonged intensive care unit stay.

OBJECTIVES: This study investigated factors determining the long-term outcome and quality of life of patients with a prolonged intensive care unit (ICU) stay after cardiac surgery. DESIGN: A retrospective analysis was performed in 230 patients that had undergone cardiac surgery and suffered from a post-operative ICU stay of 7 or more days at our institution. Among 11 pre-, 13 intra-, and 14 post-operative variables, factors influencing 5-year outcome were identified by logistic regression analysis. Quality of life was determined using the Short Form-36 questionnaire. RESULTS: In-hospital mortality was 12%. One hundred and eleven of 187 patients (59%) were alive after 5 years. Non-survivors were older (70 vs. 65 years, p = 0.005) and had a higher additive EuroSCORE (7 vs. 5, p = 0.034). Logistic regression identified pre-operative atrial fibrillation (AF), (28 vs. 10%, p = 0.003) as the strongest predictor for a 5-year outcome, followed by myocardial infarction (62 vs. 41%, p = 0.005), and prolonged mechanical ventilation (8 vs. 5 days, p = 0.036). Survivors did not show an impaired physical component summary SF-36 score (39 vs. 46, p = 0.737) or mental component summary score (55 vs. 55, p = 0.947) compared to an age-matched German Normative Sample. CONCLUSIONS: Pre-operative AF proved to be the most important factor determining the 5-year outcome of patients with a prolonged ICU stay after cardiac surgery. Neither physical nor mental health appeared to be impaired in these patients.

Dynamic and volumetric variables reliably predict fluid responsiveness in a porcine model with pleural effusion.

BACKGROUND: The ability of stroke volume variation (SVV), pulse pressure variation (PPV) and global end-diastolic volume (GEDV) for prediction of fluid responsiveness in presence of pleural effusion is unknown. The aim of the present study was to challenge the ability of SVV, PPV and GEDV to predict fluid responsiveness in a porcine model with pleural effusions. METHODS: Pigs were studied at baseline and after fluid loading with 8 ml kg(-1) 6% hydroxyethyl starch. After withdrawal of 8 ml kg(-1) blood and induction of pleural effusion up to 50 ml kg(-1) on either side, measurements at baseline and after fluid loading were repeated. Cardiac output, stroke volume, central venous pressure (CVP) and pulmonary occlusion pressure (PAOP) were obtained by pulmonary thermodilution, whereas GEDV was determined by transpulmonary thermodilution. SVV and PPV were monitored continuously by pulse contour analysis. RESULTS: Pleural effusion was associated with significant changes in lung compliance, peak airway pressure and stroke volume in both responders and non-responders. At baseline, SVV, PPV and GEDV reliably predicted fluid responsiveness (area under the curve 0.85 (p<0.001), 0.88 (p<0.001), 0.77 (p = 0.007). After induction of pleural effusion the ability of SVV, PPV and GEDV to predict fluid responsiveness was well preserved and also PAOP was predictive. Threshold values for SVV and PPV increased in presence of pleural effusion. CONCLUSIONS: In this porcine model, bilateral pleural effusion did not affect the ability of SVV, PPV and GEDV to predict fluid responsiveness.

A comparison of third-generation semi-invasive arterial waveform analysis with thermodilution in patients undergoing coronary surgery.

Uncalibrated semi-invasive continous monitoring of cardiac index (CI) has recently gained increasing interest. The aim of the present study was to compare the accuracy of CI determination based on arterial waveform analysis with transpulmonary thermodilution. Fifty patients scheduled for elective coronary surgery were studied after induction of anaesthesia and before and after cardiopulmonary bypass (CPB), respectively. Each patient was monitored with a central venous line, the PiCCO system, and the FloTrac/Vigileo-system. Measurements included CI derived by transpulmonary thermodilution and uncalibrated semi-invasive pulse contour analysis. Percentage changes of CI were calculated. There was a moderate, but significant correlation between pulse contour CI and thermodilution CI both before (r(2) = 0.72, P < 0.0001) and after (r(2) = 0.62, P < 0.0001) CPB, with a percentage error of 31% and 25%, respectively. Changes in pulse contour CI showed a significant correlation with changes in thermodilution CI both before (r(2) = 0.52, P < 0.0001) and after (r(2) = 0.67, P < 0.0001) CPB. Our findings demonstrated that uncalibrated semi-invasive monitoring system was able to reliably measure CI compared with transpulmonary thermodilution in patients undergoing elective coronary surgery. Furthermore, the semi-invasive monitoring device was able to track haemodynamic changes and trends.

Variation of left ventricular outflow tract velocity and global end-diastolic volume index reliably predict fluid responsiveness in cardiac surgery patients.

PURPOSE: The ability of the global end-diastolic volume index (GEDVI) and respiratory variations in left ventricular outflow tract velocity (ΔVTI(LVOT)) for prediction of fluid responsiveness is still under debate. The aim of the present study was to challenge the predictive power of GEDVI and ΔVTI(LVOT) compared with pulse pressure variation (PPV) and stroke volume variation (SVV) in a large patient population. MATERIAL AND METHODS: Ninety-two patients were studied before coronary artery surgery. Each patient was monitored with central venous pressure (CVP), the PiCCO system (Pulsion Medical Systems, Munich, Germany), and transesophageal echocardiography. Responders were defined as those who increased their stroke volume index by greater than 15% (ΔSVI(TPTD) >15%) during passive leg raising. RESULTS: Central venous pressure showed no significant correlation with ΔSVI(TPTD) (r = -0.06, P = .58), in contrast to PPV (r = 0.71, P < .0001), SVV (r = 0.61, P < .0001), GEDVI (r = -0.54, P < .0001), and ΔVTI(LVOT) (r = 0.54, P < .0001). The best area under the receiver operating characteristic curve (AUC) predicting ΔSVI(TPTD) greater than 15% was found for PPV (AUC, 0.82; P < .0001) and SVV (AUC, 0.77; P < .0001), followed by ΔVTI(LVOT) (AUC, 0.74; P < .0001) and GEDVI (AUC, 0.71; P = .0006), whereas CVP was not able to predict fluid responsiveness (AUC, 0.58; P = .18). CONCLUSIONS: In contrast to CVP, GEDVI and ΔVTI(LVOT) reliably predicted fluid responsiveness under closed-chest conditions. Pulse pressure variation and SVV showed the highest accuracy.

Uncalibrated pulse power analysis fails to reliably measure cardiac output in patients undergoing coronary artery bypass surgery.

INTRODUCTION: Uncalibrated arterial pulse power analysis has been recently introduced for continuous monitoring of cardiac index (CI). The aim of the present study was to compare the accuracy of arterial pulse power analysis with intermittent transpulmonary thermodilution (TPTD) before and after cardiopulmonary bypass (CPB). METHODS: Forty-two patients scheduled for elective coronary surgery were studied after induction of anaesthesia, before and after CPB respectively. Each patient was monitored with the pulse contour cardiac output (PiCCO) system, a central venous line and the recently introduced LiDCO monitoring system. Haemodynamic variables included measurement of CI derived by transpulmonary thermodilution (CITPTD) or CI derived by pulse power analysis (CIPP), before and after calibration (CIPPnon-cal., CIPPcal.). Percentage changes of CI (ΔCITPTD, ΔCIPPnon-cal./PPcal.) were calculated to analyse directional changes. RESULTS: Before CPB there was no significant correlation between CIPPnon-cal. and CITPTD (r2 = 0.04, P = 0.08) with a percentage error (PE) of 86%. Higher mean arterial pressure (MAP) values were significantly correlated with higher CIPPnon-cal. (r2 = 0.26, P < 0.0001). After CPB, CIPPcal. revealed a significant correlation compared with CITPTD (r2 = 0.77, P < 0.0001) with PE of 28%. Changes in CIPPcal. (ΔCIPPcal.) showed a correlation with changes in CITPTD (ΔCITPTD) only after CPB (r2 = 0.52, P = 0.005). CONCLUSIONS: Uncalibrated pulse power analysis was significantly influenced by MAP and was not able to reliably measure CI compared with TPTD. Calibration improved accuracy, but pulse power analysis was still not consistently interchangeable with TPTD. Only calibrated pulse power analysis was able to reliably track haemodynamic changes and trends.