Interaction of heparin with human cardiac troponin complex and its influence on the immunodetection of troponins in human blood samples.

OBJECTIVES: Heparin is a highly charged polysaccharide used as an anticoagulant to prevent blood coagulation in patients with presumed myocardial infarction and to prepare heparin plasma samples for laboratory tests. There are conflicting data regarding the effects of heparin on the measurement of cardiac isoforms of troponin I (cTnI) and troponin T (cTnT), which are used for the immunodiagnosis of acute myocardial infarction. In this study, we investigated the influence of heparin on the immunodetection of human cardiac troponins. METHODS: Gel filtration (GF) techniques and sandwich fluoroimmunoassay were performed. The regions of сTnI and cTnT that are affected by heparin were investigated with a panel of anti-cTnI and anti-cTnT monoclonal antibodies, specific to different epitopes. RESULTS: Heparin was shown to bind to the human cardiac full-size ternary troponin complex (ITC-complex) and free cTnT, which increased their apparent molecular weights in GF studies. Heparin did not bind to the low molecular weight ITC-complex and to binary cTnI-troponin С complex. We did not detect any sites on cTnI in the ITC-complex that were specifically affected by heparin. In contrast, cTnT regions limited to approximately 69-99, 119-138 and 145-164 amino acid residues (aar) in the ITC-complex and a region that lies approximately between 236 and 255 aar of free cTnT were prone to heparin influence. CONCLUSIONS: Heparin binds to the ITC-complex via cTnT, interacting with several sites on the N-terminal and/or central parts of the cTnT molecule, which might influence the immunodetection of analytes in human blood.

Extracorporeal membrane oxygenation in obstetric patients: An Israeli nationwide study.

BACKGROUND: The leading causes of maternal mortality include respiratory failure, cardiovascular events, infections, and hemorrhages. The use of extracorporeal membrane oxygenation (ECMO) as rescue therapy in the peripartum period for cardiopulmonary failure is expanding in critical care medicine. METHODS: This retrospective observational study was conducted on a nationwide cohort in Israel. During the 3-year period, between September 1, 2019, and August 31, 2022, all women in the peripartum period who had been supported by ECMO for respiratory or circulatory failure at 10 large Israeli hospitals were identified. Indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and complications were collected. RESULTS: During the 3-year study period, in Israel, there were 540 234 live births, and 28 obstetric patients were supported by ECMO, with an incidence of 5.2 cases per 100 000 or 1 case per 19 000 births (when excluding patients with COVID-19, the incidence will be 2.5 cases per 100 000 births). Of these, 25 were during the postpartum period, of which 16 (64%) were connected in the PPD1, and 3 were during pregnancy. Eighteen patients (64.3%) were supported by V-V ECMO, 9 (32.1%) by V-A ECMO, and one (3.6%) by a VV-A configuration. Hypoxic respiratory failure (ARDS) was the most common indication for ECMO, observed in 21 patients (75%). COVID-19 was the cause of ARDS in 15 (53.7%) patients. The indications for the V-A configuration were cardiomyopathy (3 patients), amniotic fluid embolism (2 patients), sepsis, and pulmonary hypertension. The maternal and fetal survival rates were 89.3% (n = 25) and 100% (n = 28). The average ECMO duration was 17.6 ± 18.6 days and the ICU stay was 29.8 ± 23.8 days. Major bleeding complications requiring surgical intervention were observed in one patient. CONCLUSIONS: The incidence of using ECMO in the peripartum period is low. The maternal and neonatal survival rates in patients treated with ECMO are high. These results show that ECMO remains an important treatment option for obstetric patients with respiratory and/or cardiopulmonary failure.

Early tracheostomy after cardiac surgery improves intermediate- and long-term survival / La traqueotomía temprana después de la cirugía cardíaca mejora la supervivencia intermedia y a largo plazo

Objective: Complicated post-cardiac surgery course, can lead to both prolonged ICU stay and ventilation, and may require a tracheostomy. This study represents the single-center experience with post-cardiac surgery tracheostomy. The aim of this study was to assess the timing of tracheostomy as a risk factor for early, intermediate, and late mortality. The study’s second aim was to assess the incidence of both superficial and deep sternal wound infections. Design: Retrospective study of prospectively collected data. Setting: Tertiary hospital. Patients: Patients were divided into 3 groups, according to the timing of tracheostomy; early (4−10 days); intermediate (11−20 days) and late (≥21 days). Interventions: None. Main variables of interest: The primary outcomes were early, intermediate, and long-term mortality. The secondary outcome was the incidence of sternal wound infection. Results: During the 17-year study period, 12,782 patients underwent cardiac surgery, of whom 407 (3.18%) required postoperative tracheostomy. 147 (36.1%) had early, 195 (47.9%) intermediate, and 65 (16%) had a late tracheostomy. Early, 30-day, and in-hospital mortality was similar for all groups. However, patients, who underwent early- and intermediate tracheostomy, demonstrated statistically significant lower mortality after 1- and 5-year (42.8%; 57.4%; 64.6%; and 55.8%; 68.7%; 75.4%, respectively; P < .001). Cox model demonstrated age [1.025 (1.014–1.036)] and timing of tracheostomy [0.315 (0.159−0.757)] had significant impacts on mortality. Conclusions: This study demonstrates a relationship between the timing of tracheostomy after cardiac surgery and mortality: early tracheostomy (within 4−10 days of mechanical ventilation) is associated with better intermediate- and long-term survival. (AU)

Objetivo: La evolución complicada de un postoperatorio de сirugía cardiaca puede dar lugar tanto a una estancia prolongada en UCI como a ventilación mecánica prolongada y puede requerir de una traqueotomía. Este estudio presenta la experiencia acumulada sobre traqueostomía en el postoperatorio de cirugía cardiaca en un único hospital.El objetivo era evaluar el momento de la realización de la traqueotomía como factor de riesgo de mortalidad temprana, intermedia y tardía. Diseño: Estudio retrospectivo. Ámbito: Hospital terciario. Pacientes: Pacientes fueron divididos en 3 grupos según el momento de la traqueotomía; temprano (4−10 días); intermedio (11−20 días); tardío (≥21 días). Intervenciones: No. Variables de interés principal: Los resultados primarios fueron la mortalidad en cada grupo. Resultados: Durante los 17 años de duración del estudio, de los 12.782 pacientes sometidos a cirugía cardíaca, 407 (3,18%) requirieron traqueotomía postoperatoria. Se practicaron 147 (36,1%) traqueotomías tempranas, 195 (47,9%) intermedias y 65 (16%) tardías. La mortalidad temprana, a los 30 días dentro del marco hospitalario, fue similar en todos los grupos. Sin embargo, las traqueotomía temprana e intermedia demostraron una mortalidad inferior estadísticamente significativa a 1 y 5 años (42,8%; 57,4%; 64,6%; y 55,8%; 68,7%; 75,4%, respectivamente; P < ,001). El modelo de Cox demostró que la edad [1,025 (1,014–1,036)] y el momento [0,315 (0,159–0,757)] impacta significativamente la mortalidad. Conclusiones: La traqueotomía temprana (dentro de los 4−10 días de ventilación mecánica) en el postoperatorio de cirugía cardíaca se asoció con una mejor supervivencia a medio/largo plazo. (AU

Timing of Lung Transplant Referral in Patients with Severe COVID-19 Lung Injury Supported by ECMO.

Severe respiratory failure caused by COVID-19 often requires mechanical ventilation, including extracorporeal membrane oxygenation (ECMO). In rare cases, lung transplantation (LTx) may be considered as a last resort. However, uncertainties remain about patient selection and optimal timing for referral and listing. This retrospective study analyzed patients with severe COVID-19 who were supported by veno-venous ECMO and listed for LTx between July 2020 and June 2022. Out of the 20 patients in the study population, four who underwent LTx were excluded. The clinical characteristics of the remaining 16 patients were compared, including nine who recovered and seven who died while awaiting LTx. The median duration from hospitalization to listing was 85.5 days, and the median duration on the waitlist was 25.5 days. Younger age was significantly associated with a higher likelihood of recovery without LTx after a median of 59 days on ECMO, compared to those who died at a median of 99 days. In patients with severe COVID-19-induced lung damage supported by ECMO, referral to LTx should be delayed for 8-10 weeks after ECMO initiation, particularly for younger patients who have a higher probability of spontaneous recovery and may not require LTx.

Subclinical postoperative atrial fibrillation: a randomized trial.

Background: Postoperative atrial fibrillation (POAF) is the most common complication of cardiac surgery, requiring interventions and prolonging hospital stay. POAF is associated with increased mortality and a higher rate of systemic thrombo-embolism. The rates of recurrent AF, optimal follow-up and management remain unclear. We aimed to evaluate the incidence of recurrent atrial fibrillation (AF) events, during long term follow-up in patients with POAF following cardiac surgery. Methods: Patients with POAF and a CHA2DS2-VASc score of ≥2 were randomized in a 2:1 ratio to either implantation of a loop recorder (ILR) or ECG monitoring using periodic Holters. Participants were followed prospectively for 2 years. The primary end point was the occurrence of AF longer than 5 min. Results: The final cohort comprised of 22 patients, of whom 14 received an ILR. Over a median follow up of 25.7 (IQR of 24.7-44.4) months, 8 patients developed AF, representing a cumulative annualized risk of AF recurrence of 35.7%. There was no difference between ILR (6 participants, 40%) and ECG/Holter (2 participants, 25% p = 0.917). All 8 patients with AF recurrence were treated with oral anticoagulation. There were no cases of mortality, stroke or major bleeding. Two patients underwent ILR explantation due to pain at the implantation site. Conclusions: The rate of recurrent AF in patients with POAF after cardiac surgery and a CHA2DS2-VASc score of ≥2 is approximately 1 in 3 when followed systematically. Further research is need to assess the role of ILRs in this population.

Surgical ablation for atrial fibrillation: impact of Diabetes Mellitus type 2.

BACKGROUND: Diabetes mellitus (DM) type 2 is an independent risk factor for atrial fibrillation (AF). Surgical ablation or "maze procedure" is an option for patients with AF undergoing concomitant or isolated cardiac surgery. The aim of this study was to evaluate the impact of DM type 2 on early and long-term outcomes of patients following surgical AF ablation. METHODS: We performed an observational cohort study in Israel's largest tertiary care center. All data of patients who underwent surgical AF ablation, between 2006 and 2021 were extracted from our departmental database. Patients were divided into Group I (non-diabetic patients) and Group II (DM type 2 patients). We compared the two groups with respect to freedom from recurrent atrial arrhythmia, and mortality rate. RESULTS: The study population included 606 patients. Group I (non-DM patients), consisting of 484 patients, and Group II (DM type 2 patients), comprised 122 patients. Patients with DM were older, had more hypertension and incidence of cerebrovascular accident (CVA)/transient ischemic attack (TIA), higher EuroSCORE (p < .05 for all), and a longer bypass time-130 ± 40 vs. 122 ± 36 min (p = 0.028). The mean follow-up duration was 39.0 ± 22.7 months. Freedom from atrial fibrillation was similar between the non-DM and DM type 2 groups after a 1-year follow-up, 414 (88.2%) vs. 101 (87.1%) (p = 0.511), after a 3-year follow-up, 360 (86.3%) vs. 84 (79.9%) (p = 0.290) and after a 5-year follow-up, 226 (74.1%) vs. 55 (71.5%) (p = 0.622) respectively. Furthermore, 1- and 3-year mortality was similar between non-DM and DM type 2 groups, 2.5% vs. 4.9%, (p = 0.226) and 5.6% vs. 10.5% (p = 0.076) respectively. 5-year mortality was higher in Group II (DM type 2 patients) compared with Group I (non-DM patients), 11.1% vs. 23.4% (p = 0.009). CONCLUSION: Surgical ablation had a high success rate, with freedom from recurrent atrial arrhythmia at 1- 3- and 5- years follow-up in both the DM type 2 and non-DM groups. Furthermore,1- and 3-year mortality after surgical ablation was also similar in both groups. However, 5-year mortality was higher in the DM type 2 group.

Perfusion-Dependent Focal Neurologic Deficits in a Critically Ill Heart Transplant Recipient: A Case of Tacrolimus-Associated Reversible Cerebral Vasospasm Syndrome?

TACROLIMUS, a mainstay of immunosuppression after orthotopic heart transplantation (OHT), is associated with a broad range of side effects. Vasoconstriction caused by tacrolimus has been proposed as a mechanism underlying common side effects such as hypertension and renal injury. Neurologic side effects attributed to tacrolimus include headaches, posterior reversible encephalopathy syndrome (PRES), or reversible cerebral vasospasm syndrome (RCVS). Six case reports have been published describing RCVS in the setting of tacrolimus administration after OHT. The authors report a case of perfusion-dependent focal neurologic deficits attributed to tacrolimus-induced RCVS in an OHT recipient.

Fragmentation of human cardiac troponin T after acute myocardial infarction.

BACKGROUND: Blood measurement of cardiac troponin T (cTnT) is one of the most widespread methods of acute myocardial infarction (MI) diagnosis. cTnT degradation may have a significant influence on the precision of cTnT immunodetection; however, there are no consistent data describing the level and sites of cTnT proteolysis in the blood of MI patients. In this study, we bordered major cTnT fragments and quantified their relative abundance in the blood at different times after MI. METHODS: Serial heparin plasma samples were collected from 37 MI patients 2-37 h following the onset of MI. cTnT and its fragments were studied by western blotting and immunofluorescence analysis using monoclonal antibodies specific to various cTnT epitopes. RESULTS: cTnT was present in the blood of MI patients as 23 proteolytic fragments with an apparent molecular mass of âˆ¼ 8-37 kDa. Two major sites of cTnT degradation were identified: between amino acid residues (aar) 68 and 69 and between aar 189 and 223. Analysis of the abundance of cTnT fragments showed an increase in the fraction of free central fragments in the first few hours after MI, while the fraction of the C-terminal fragments of cTnT remained almost unchanged. CONCLUSION: cTnT progressively degrades after MI and appears in the blood as a mixture of 23 proteolytic fragments. The cTnT region approximately bordered by aar 69-158 is a promising target for antibodies used for measurement of total cTnT.

Early tracheostomy after cardiac surgery improves intermediate- and long-term survival.

OBJECTIVE: Complicated post-cardiac surgery course, can lead to both prolonged ICU stay and ventilation, and may require a tracheostomy. This study represents the single-center experience with post-cardiac surgery tracheostomy. The aim of this study was to assess the timing of tracheostomy as a risk factor for early, intermediate, and late mortality. The study's second aim was to assess the incidence of both superficial and deep sternal wound infections. DESIGN: Retrospective study of prospectively collected data. SETTING: Tertiary hospital. PATIENTS: Patients were divided into 3 groups, according to the timing of tracheostomy; early (4-10 days); intermediate (11-20 days) and late (≥21 days). INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: The primary outcomes were early, intermediate, and long-term mortality. The secondary outcome was the incidence of sternal wound infection. RESULTS: During the 17-year study period, 12,782 patients underwent cardiac surgery, of whom 407 (3.18%) required postoperative tracheostomy. 147 (36.1%) had early, 195 (47.9%) intermediate, and 65 (16%) had a late tracheostomy. Early, 30-day, and in-hospital mortality was similar for all groups. However, patients, who underwent early- and intermediate tracheostomy, demonstrated statistically significant lower mortality after 1- and 5-year (42.8%; 57.4%; 64.6%; and 55.8%; 68.7%; 75.4%, respectively; P < .001). Cox model demonstrated age [1.025 (1.014-1.036)] and timing of tracheostomy [0.315 (0.159-0.757)] had significant impacts on mortality. CONCLUSIONS: This study demonstrates a relationship between the timing of tracheostomy after cardiac surgery and mortality: early tracheostomy (within 4-10 days of mechanical ventilation) is associated with better intermediate- and long-term survival.

Prevalence and clinical implication of thrombocytopenia and heparin-induced thrombocytopenia in patients who are critically ill with COVID-19.

As the COVID-19 pandemic continues to evolve, different clinical manifestations are better understood and studied. These include various haematologic disorders that have been shown to be associated with increased morbidity and mortality. We studied the prevalence of one unusual manifestation, heparin-induced thrombocytopenia (HIT) and its clinical implications in patients who are severely ill with COVID-19 in a single tertiary centre in Israel. The presence of thrombocytopenia, disseminated intravascular coagulation (DIC) and HIT, and their association with clinical course and outcomes were studied. One-hundred and seven patients with COVID-19 were included. Fifty-seven (53.2%) patients developed thrombocytopenia, which was associated with the worst outcomes (ventilation, DIC and increased mortality). Sixteen (28.0%) patients with thrombocytopenia were positive for HIT, all of which were supported by extracorporeal devices. HIT was independently associated with ventilation days, blood product transfusions, longer hospitalisation and mortality.Platelet abnormalities and HIT are common in patients who are critically ill with COVID-19 and are associated with the worst clinical outcomes. The mechanisms underlying HIT in COVID-19 are yet to be studied; HIT may contribute to the dysregulated immunologic response associated with COVID-19 critical illness and may play a significant part in the coagulopathy seen in these patients. As many patients with COVID-19 require aggressive thromboprophylaxis, further understanding of HIT and the implementation of appropriate protocols are important.

Early de-cannulation from extracorporeal membrane oxygenation following ventricular tachycardia radiofrequency ablation.

Objectives: Ventricular tachycardia ablation (VTA) with hemodynamic compromise presents a challenge. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support allows the safe completion of the procedure. There are limited data regarding the safety of weaning off VA-ECMO at the end of the procedure. We report our experience with early VA-ECMO de-cannulation after VTA. Materials and methods: All patients undergoing VA-ECMO-assisted VTA, between January 2013 and December 2020 at a large tertiary center were included. Clinical characteristics, history of arrhythmia, procedural details, and outcomes were collected. Patients weaned from VA-ECMO immediately at the end of the procedure were compared to those that were de-cannulated at a later time. Results: A total of 46 patients (93.5% male, age 62 ± 10 years) were ablated with VA-ECMO support. Most had ischemic cardiomyopathy (65%) and (70%) presented with VT storm. The clinical VT was induced in the majority of patients (76%). A total of 99 VTs were induced of which 76 (77%) were targeted and successfully ablated. Non-inducibility was achieved in 74% of cases and most patients (83%) were de-cannulated at the end of the procedure on the procedure table. Survival at 1 year was higher among early de-cannulated patients (86 vs. 38% [log-rank p-value < 0.001]). At 1-year follow-up, 91.3% of surviving patients were free of appropriate ICD shocks. Conclusion: De-cannulation from VA-ECMO may be done immediately at the conclusion of VTA in most cases. Failure to timely wean off VA-ECMO is a strong predictor of mortality.

Surgical treatment on infective endocarditis: impact of diabetes on mortality.

BACKGROUND: Type 2 diabetes mellitus (DM) is a frequent co-morbidity among patients suffering from infective endocarditis (IE). The aim of the study was to evaluate the impact of type 2 DM on the early-, intermediate- and long-term mortality of patients who underwent surgical treatment of endocarditis. METHODS: We performed an observational cohort study in the large tertiary center in Israel during 14 years. All data of patients who underwent surgical treatment of endocarditis, performed between 2006 and 2020 were extracted from the departmental database. Patients were divided into two groups: Group I (non-diabetic patients), and Group II (diabetic patients). RESULTS: The study population includes 420 patients. Group I (non-diabetic patients), comprise 326 patients, and Group II (diabetic patients), comprise 94 patients. Mean follow-up duration was 39.3 ± 28.1 months. Short-term, 30-day and in-hospital mortality, also intermediate-term mortality (1- and 3-year) was higher in the DM group compared with the non-DM group, but did not reach statistical significance: 11.7% vs. 7.7%. (p = 0.215); 12.8% vs. 8.3% (p = 0.285); 20.2% vs. 13.2% (p = 0.1) and 23.4% vs. 15.6% (p = 0.09) respectively. Long-term, 5-year mortality was significantly higher in the DM group, compared to the non-DM group: 30.9% vs. 16.6% (p = 0.003). Furthermore, predictors for long-term mortality included diabetes (CI 1.056-2.785, p = 0.029), as demonstrated by regression analysis. CONCLUSIONS: Diabetic patients have trend to increasing mortality at the short- and intermediate period post-surgery for IE, but this is not statistically significant. Survival of diabetic patients deteriorates after more than three years follow surgery. Diabetes is an independent predictor for long-term, 5-year mortality after surgical treatment of endocarditis, regardless of the patients age and comorbidities. Trial registration Ethical Committee of Sheba Medical Centre, Israel on 02.12. 2014, Protocol 4257.

Effect of levosimendan infusion prior to left ventricular assist device implantation on right ventricular failure.

OBJECTIVE: Investigate the safety and efficacy of preoperative levosimendan in patients undergoing left ventricular assist device (LVAD) implantation. METHODS: Consecutive patients who received LVADs (HeartMate-2, 3, HVAD) in a single tertiary medical center (2012-2018). INTERMACS profile 1 patients were excluded. The primary outcome was post-LVAD right ventricular failure (RVF) and inhospital mortality rates. The secondary outcomes included other clinical, echocardiographic and hemodynamic parameters at follow-up. RESULTS: Final cohort consisted of 62 patients (40[65%] in the levosimendan group and 22[35%] in the no-levosimendan group). Post-operative RVF rate and inotrope or ventilation support time were similar in the levosimendan and no-levosimendan groups (7.5% vs. 13.6%; P = 0.43, median of 51 vs. 72 h; P = 0.41 and 24 vs. 27 h; P = 0.19, respectively). Length of hospitalization, both total and in the intensive care unit, was not statistically significant (median days of 13 vs. 16; P = 0.34, and 3 vs. 4; P = 0.44, respectively). Post-operative laboratory and echocardiographic parameters and in-hospital complication rate did not differ between the groups, despite worse baseline clinical parameters in the Levosimendan group. There was no significant difference in the in-hospital and long term mortality rate (2.5% vs. 4.5%; P > 0.999 and 10% vs. 27.3% respectively; P = 0.64). CONCLUSIONS: Levosimendan infusion prior to LVAD implantation was safe and associated with comparable results without significant improved post-operative outcomes, including RVF.

Diastolic Plateau - Invasive Hemodynamic Marker of Adverse Outcome Among Left Ventricular Assist Device Patients.

Background: Diastolic plateau is an invasive hemodynamic marker of impaired right ventricular (RV) diastolic filling. The purpose of the current analysis was to evaluate the prognostic importance of this sign in left ventricular assist device (LVAD) patients. Methods: The analysis included all LVAD patients who received continuous-flow LVAD (HeartMate 3) at the Sheba medical center and underwent right heart catheterization (RHC) during follow up post-LVAD surgery. Patients were dichotomized into 2 mutually exclusive groups based on a plateau duration cutoff of 55% of diastole. The primary end point of the current analysis was the composite of death, heart transplantation, or increase in diuretic dosage in a 12-month follow-up period post-RHC. Results: Study cohort included 59 LVAD patients with a mean age of 57 (IQR 54-66) of whom 48 (81%) were males. RHC was performed at 303 ± 36 days after LVAD surgery. Patients with and without diastolic plateau had similar clinical, echocardiographic, and hemodynamic parameters. Kaplan-Meier survival analysis showed that the cumulative probability of event at 1 year was 65 ± 49% vs. 21 ± 42% for primary outcomes among patients with and without diastolic plateau (p Log rank < 0.05 for both). A multivariate model with adjustment for age, INTERMACS score and ischemic cardiomyopathy consistently showed that patients with diastolic plateau were 4 times more likely to meet the study composite end point (HR = 4.35, 95% CI 1.75-10.83, p = 0.002). Conclusion: Diastolic plateau during RHC is a marker of adverse outcome among LVAD patients.

Impact of pre-existing right or left bundle branch block on patients undergoing surgical aortic valve replacement.

OBJECTIVES: Contemporary data on the prognostic impact of pre-existing left or right bundle branch block on clinical outcomes after aortic valve (AV) replacement are limited. The aim of this study was to evaluate the impact of pre-existing bundle branch block on clinical outcomes in patients undergoing AV replacement. METHODS: Data from patients who underwent AV replacement surgery between 2004 and 2020 were obtained from our departmental database. RESULTS: Of the 2704 study patients, 203 (7.5%) had pre-existing bundle branch block and 2501 (92.5%) had normal atrioventricular conduction. The mean age was 68 (13) years, 1697 (63%) were male and 683 (25%) had a unicuspid or bicuspid AV. The in-hospital mortality rate was higher in patients with pre-existing bundle branch block compared to those without on admission (5.9% vs 2.9%, P = 0.032), and more frequent in patients with left compared with right bundle branch block (11.9% vs 4.3%, P = 0.003). New pacemaker implantation was most frequent in those patients with pre-existing left bundle branch block, followed by right and no bundle branch block on admission (28.6% vs 7.5% vs 2.8% respectively, P < 0.001; odds ratio 4.96 95% confidence interval 2.96-8.08, P < 0.001). The 10-year cumulative survival rate was lower in patients with bundle branch block compared with patients with no bundle branch block (76.8% vs 82.8%, log-rank P < 0.001; hazard ratio 0.73, confidence interval 0.54-0.99, P = 0.042). CONCLUSIONS: This study indicates that patients with pre-existing bundle branch block have a higher incidence of pacemaker implantation and all-cause mortality after AV replacement compared with patients without a conduction disturbance.

The impact of diabetes on short-, intermediate- and long-term mortality following left ventricular assist device implantation.

OBJECTIVES: Type 2 diabetes mellitus (DM) is a frequent comorbidity among patients suffering from advanced heart failure necessitating a left ventricular assist device (LVAD) implant. The goal of this study was to evaluate the impact of type 2 DM on early and long-term outcomes of patients following an LVAD implant. METHODS: We performed an observational cohort study in a large tertiary care centre in Israel. All data of patients who underwent a continuous flow LVAD implant between 2006 and 2020 were extracted from our departmental database. Patients were divided into 2 groups: group I (patients without diabetes) and group II (patients with diabetes). We compared short-term (30-day and 3-month) mortality, intermediate-term (1- and 3-year) mortality and long-term (5 year) mortality between the 2 groups. RESULTS: The study population included 154 patients. Group I (patients without diabetes) comprised 88 patients and group II (patients with diabetes) comprised 66 patients. The mean follow-up duration was 38.2 ± 30.3 months. Short- and intermediate-term mortality (30 days, 1 year and 3 years) was higher in the group with DM compared with the group without DM but did not reach any statistically significant difference: 16.1% vs 9.8% (P = 0.312), 24.2% vs 17.3% (P = 0.399) and 30.6% vs 21.9% (P = 0.127) respectively. Long-term 5-year mortality was significantly higher in the group with DM compared to the group without: 38.7% vs 24.4% (P = 0.038). Furthermore, predictors of long-term mortality included diabetes (hazard ratio 2.09, confidence interval 1.34-2.84, P = 0.004), as demonstrated by regression analysis. CONCLUSIONS: Patients with diabetes and those without diabetes have similar 30-day and short- and intermediate-term mortality rates. The mortality risk of diabetic patients begins to increase 3 years after an LVAD implant. Diabetes is an independent predictor of long-term, 5-year mortality after an LVAD implant. CLINICAL TRIAL REGISTRATION: Ethical Committee of Sheba Medical Centre, Israel, on 2 December 2014, Protocol 4257.

Chronic thromboembolic pulmonary hypertension in patients with antiphospholipid syndrome: Risk factors and management.

BACKGROUND: Antiphospholipid syndrome (APS) may cause chronic thromboembolic pulmonary hypertension (CTEPH). Current knowledge regarding prevalence and risk factors for CTEPH among APS patients is limited. We sought to determine clinical features and biomarkers that could identify APS subjects suffering from CTEPH, and describe the prevalence, course and treatment outcomes of patients with APS-CTEPH. METHODS: 504 APS patients were treated in our center during 2008 to 2019. We studied clinical and laboratory features of 69 APS patients, comparing 19 patients diagnosed with CTEPH (APS-CTEPH) and treated accordingly, with 50 consecutive age and gender matched patients with no evidence of pulmonary hypertension (APS-No-CTEPH). RESULTS: CTEPH prevalence was 3.8% in our APS cohort and was linked with the following parameters: primary APS (p < 0.05); prior pulmonary embolism (p < 0.001); recurrent venous thromboembolism (VTE) (p < 0.001); lower platelet counts (p < 0.001); triple anti-phospholipid antibodies positivity (p < 0.001), higher titers of anti-cardiolipin IgG (p < 0.001), anti-B2GPI IgG (p < 0.001), and high Russell viper venom time ratio (RVVT-ratio) (p < 0.05). Additionally, history of catastrophic APS was more prevalent in APS-CTEPH vs APS-No-CTEPH (p < 0.05). Of APS-CTEPH patients, 15/19 underwent pulmonary endarterectomy (PEA): In 12/15 the procedure was elective and resulted in good perioperative and long-term outcomes, while only 1 of 3 patients that underwent urgent PEA survived. CONCLUSIONS: CTEPH is relatively common in APS. Primary APS, prior PE, recurrent VTE, thrombocytopenia and specific anti-phospholipid antibodies predict CTEPH in APS. Active assessment for CTEPH in APS patients should be considered, as PEA was found to be effective and relatively safe, especially if electively performed.

Repair with annuloplasty only of balanced bileaflet mitral valve prolapse with severe regurgitation.

OBJECTIVES: Repair of severe mitral valve and mitral regurgitation (MR) in patients with degenerative bileaflet pathology can be challenging. Initial results with a ring-only repair (ROR) approach have shown promising results, but long-term outcomes in larger series are lacking. We report on outcomes of ROR in severe MR secondary to bileaflet prolapse, including Barlow's disease. METHODS: Eighty patients with degenerative multi-segment bileaflet disease underwent ROR for severe MR with a predominantly central regurgitant jet indicating balanced bileaflet prolapse. The main outcome measure of this study was long-term recurrent MR probability. Secondary outcomes were late mortality, reoperation and in-hospital complications. RESULTS: The mean age was 53 ± 15 years and 54% were males. The mean ejection fraction was 59.2 ± 6.6, 24% and 40% had atrial fibrillation. Barlow's disease was found in 77% of the patients. Minimally invasive surgery was performed in 15 patients (19%). There were no perioperative mortalities or cerebrovascular events in the entire cohort. Post-repair mild outflow tract obstruction (systolic anterior motion) was observed in 4 patients (5%) after ROR. In a mean follow-up of 60 ± 48 months, there was 1 case of death. At follow-up, there was 1 (1%) reoperation due to recurrent MR, and 4 patients who had recurrent moderate or more MR. The 10-year freedom from recurrent MR was 97%. None had severe MR at the latest follow-up. CONCLUSIONS: In patients with severe MR and a central regurgitant jet secondary to balanced multi-segment bileaflet mitral valve prolapse, ROR is a simple and efficient approach providing excellent long-term results without a substantial risk of systolic anterior motion.