A Minimally Invasive Model of Aortic Stenosis in Swine.

Large animal models of heart failure play an essential role in the development of new therapeutic interventions due to their size and physiological similarities to humans. Efforts have been dedicated to creating a model of pressure-overload induced heart failure, and ascending aortic banding while still supra-coronary and not a perfect mimic of aortic stenosis in humans, closely resembling the human condition. The purpose of this study is to demonstrate a minimally invasive approach to induce left ventricular pressure overload by placing an aortic band, precisely calibrated with percutaneously introduced high-fidelity pressure sensors. This method represents a refinement of the surgical procedure (3Rs), resulting in homogenous trans-stenotic gradients and reduced intragroup variability. Additionally, it enables swift and uneventful animal recovery, leading to minimal mortality rates. Throughout the study, animals were followed for up to 2 months after surgery, employing transthoracic echocardiography and pressure-volume loop analysis. However, longer follow-up periods can be achieved if desired. This large animal model proves valuable for testing new drugs, particularly those targeting hypertrophy and the structural and functional alterations associated with left ventricular pressure overload.

Human-umbilical cord matrix mesenchymal cells improved left ventricular contractility independently of infarct size in swine myocardial infarction with reperfusion.

Background: Human umbilical cord matrix-mesenchymal stromal cells (hUCM-MSC) have demonstrated beneficial effects in experimental acute myocardial infarction (AMI). Reperfusion injury hampers myocardial recovery in a clinical setting and its management is an unmet need. We investigated the efficacy of intracoronary (IC) delivery of xenogeneic hUCM-MSC as reperfusion-adjuvant therapy in a translational model of AMI in swine. Methods: In a placebo-controlled trial, pot-belied pigs were randomly assigned to a sham-control group (vehicle-injection; n = 8), AMI + vehicle (n = 12) or AMI + IC-injection (n = 11) of 5 × 105 hUCM-MSC/Kg, within 30 min of reperfusion. AMI was created percutaneously by balloon occlusion of the mid-LAD. Left-ventricular function was blindly evaluated at 8-weeks by invasive pressure-volume loop analysis (primary endpoint). Mechanistic readouts included histology, strength-length relationship in skinned cardiomyocytes and gene expression analysis by RNA-sequencing. Results: As compared to vehicle, hUCM-MSC enhanced systolic function as shown by higher ejection fraction (65 ± 6% vs. 43 ± 4%; p = 0.0048), cardiac index (4.1 ± 0.4 vs. 3.1 ± 0.2 L/min/m2; p = 0.0378), preload recruitable stroke work (75 ± 13 vs. 36 ± 4 mmHg; p = 0.0256) and end-systolic elastance (2.8 ± 0.7 vs. 2.1 ± 0.4 mmHg*m2/ml; p = 0.0663). Infarct size was non-significantly lower in cell-treated animals (13.7 ± 2.2% vs. 15.9 ± 2.7%; Δ = -2.2%; p = 0.23), as was interstitial fibrosis and cardiomyocyte hypertrophy in the remote myocardium. Sarcomere active tension improved, and genes related to extracellular matrix remodelling (including MMP9, TIMP1 and PAI1), collagen fibril organization and glycosaminoglycan biosynthesis were downregulated in animals treated with hUCM-MSC. Conclusion: Intracoronary transfer of xenogeneic hUCM-MSC shortly after reperfusion improved left-ventricular systolic function, which could not be explained by the observed extent of infarct size reduction alone. Combined contributions of favourable modification of myocardial interstitial fibrosis, matrix remodelling and enhanced cardiomyocyte contractility in the remote myocardium may provide mechanistic insight for the biological effect.

Aortic Valve Surgery in Patients with Infective Endocarditis: Mid-Term Follow-up of Patients Treated With the ST. Jude Medical Trifecta Valve.

BACKGROUND: It is particularly difficult to choose the appropriate prosthesis to treat infective endocarditis. OBJECTIVES: To investigate the outcomes after aortic valve replacement with a stented bioprosthesis (Trifecta) in patients with active or previous infective endocarditis. METHODS: We performed a single-centre, retrospective study including consecutive patients with infective endocarditis who underwent aortic valve replacement between July 2011 and June 2019. Survival and reintervention were assessed as of December 2021. Hospital mortality was defined as death in-hospital or within 30-days of surgery. Kaplan-Meier method was used for time-to-event outcome assessment (all-cause mortality and reoperation). Data are median (minimum and maximum) or absolute (relative) frequencies. RESULTS: We included 51 patients, median age of 69 (40 to 87) years, 78% male. The median follow-up time was 5.4 years and the maximum was 10 years. Most patients (71%) had native valve infective endocarditis and 16% had previous endocarditis. Surgery was urgent in 82%. Hospital mortality occurred in 10 patients (20%). After excluding these patients, 1-, 3-, 6-, and 9-years cumulative survival rates were 93%, 78%, 72%, and 72%, respectively. There were five bioprosthesis-related reoperations: 4 due to endocarditis at 1-year, 3-years, and 5-years on follow-up (n=1, 1 and 2, respectively) and 1 due to non-structural deterioration, 6-years after surgery. CONCLUSIONS: Despite the small sample size, this report supports a satisfactory performance profile of the Trifecta bioprosthesis in the treatment of infective endocarditis.

Basic principles of cardiothoracic surgery training: a position paper by the European Association for Cardiothoracic Surgery Residents Committee.

OBJECTIVES: Across Europe there are significant variations in the fundamental structure and content of cardiothoracic surgery (CTS) training programmes. Previous efforts have been made to introduce a Unified European Training System, which outlined the fundamentals of the ideal programme and supported a paradigm shift from an apprenticeship to a competency-based model. This article's goal was to define key structural, administrative and executive details of such a programme to lay the foundations for the standardization of cardiothoracic surgical training across Europe. METHODS: The European Association for Cardiothoracic Surgery Residents Committee had previously conducted a residents' training survey across Europe in 2020. Training curricula from the twelve most represented countries across Europe were either searched online or obtained from the countries' national trainee representative and reviewed by the committee. Information was collated and placed into one of the following categories to develop the position paper: (i) selection of eligible candidates, (ii) guidance for an outcome-based syllabus, (iii) documentation and evaluation of training progress, (iv) mandatory rotations and training courses, (v) number of independent or assisted cases and (vi) requirements and quality assurance of teachers. RESULTS: An independent professional body should promote an outcome-based syllabus and take responsibility for the training programme's quality assurance. Trainees should be selected on merit by an open and transparent process. Training should be delivered within a defined period and supervised by an appointed training committee to ensure its implementation. This committee should review the trainees progression regularly, provide feedback and offer trainees the opportunity to experience various training environments and trainers. A common electronic portal be used by trainees to record their agreed objectives and to evidence their completion. Trainees should regularly attend specialty-relevant courses and conferences to promote professional and academic development. The end of training is reached when the formal requirements of the training programme are met and the trainee is able to perform at the level expected of a day-1 independent surgeon. CONCLUSIONS: This article defines the key structural, administrative, and executive principles for CTS training. Programmes are encouraged to review and modify their training curricula, if necessary, to ensure the delivery of high-quality, standardized, outcome-orientated CTS training across Europe.

Myocardial oedema: pathophysiological basis and implications for the failing heart.

Myocardial fluid homeostasis relies on a complex interplay between microvascular filtration, interstitial hydration, cardiomyocyte water uptake and lymphatic removal. Dysregulation of one or more of these mechanisms may result in myocardial oedema. Interstitial and intracellular fluid accumulation disrupts myocardial architecture, intercellular communication, and metabolic pathways, decreasing contractility and increasing myocardial stiffness. The widespread use of cardiac magnetic resonance enabled the identification of myocardial oedema as a clinically relevant imaging finding with prognostic implications in several types of heart failure. Furthermore, growing experimental evidence has contributed to a better understanding of the physical and molecular interactions in the microvascular barrier, myocardial interstitium and lymphatics and how they might be disrupted in heart failure. In this review, we summarize current knowledge on the factors controlling myocardial water balance in the healthy and failing heart and pinpoint the new potential therapeutic avenues.

Trophic position, altitudinal distribution, and water dependence as determining factors for mercury concentrations in tropical montane anurans.

Mercury (Hg) is a widespread and toxic contaminant with potential for long-range atmospheric transport. Previous work has shown that temperate and subtropical montane ecosystems have great potential for deposition of this element. However, little information exists regarding Hg dynamics in tropical mountains. In present study, we evaluated the influence of altitudinal distribution, size, trophic position, and degree of water dependence on Hg concentration in amphibians. For this purpose, we determined the mercury concentration in topsoil and amphibian samples collected at 32 points distributed between 327 and 2181 m above sea level in Serra dos Órgãos, a mountainous complex located in southeastern Brazil. We analyzed the concentration of mercury in whole body samples of 200 individuals of 30 amphibian species. Trophic position of the specimens was estimated by nitrogen stable isotope (δ15N) composition in muscle tissues. We observed a positive relationship between elevation and Hg concentration in topsoil samples from rainforest sites. However, in samples from nebular forest and campos de altitude (highland grasslands) sites, the concentration of Hg was considered lower than expected by the trend in rainforest points, indicating that the vegetation structure plays an important role in the deposition of atmospheric mercury. Mercury concentration in amphibians varies according to the functional characteristics of the species and the environment in which the individual is inserted. Elevation, trophic level and water dependence explained at least some degree of variation in Hg concentration in amphibian tissues. Thus, this community-level analysis suggests that mountainous areas in the tropical region, as recorded for temperate and subtropical mountains, act as regional convergence and deposition sites for atmospheric mercury.

A systematic review and meta-analysis of randomized controlled studies comparing off-pump versus on-pump coronary artery bypass grafting in the elderly.

INTRODUCTION: Comparison of short and mid-term outcomes between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) in patients older than 65 throughout a meta-analysis of randomized clinical trials (RCTs). EVIDENCE ACQUISITION: A literature search was conducted using 3 databases. RCTs reporting mortality outcomes of OPCAB versus ONCAB among the elderly were included. Data on myocardial infarction, stroke, re-revascularization, renal failure and composite endpoints after CABG were also collected. Random effects models were used to compute statistical combined measures and 95% confidence intervals (CI). EVIDENCE SYNTHESIS: Five RCTs encompassing 6221 patients were included (3105 OPCAB and 3116 ONCAB). There were no significant differences on mid-term mortality (pooled HR: 1.02, 95%CI: 0.89-1.17, P=0.80) and composite endpoint incidence (pooled HR: 0.98, 95%CI: 0.88-1.09, P=0.72) between OPCAB and ONCAB. At 30-day, there were no differences in mortality, myocardial infarction, stroke and renal complications. The need for early re-revascularization was significantly higher in OPCAB (pooled OR: 3.22, 95%CI: 1.28-8.09, P=0.01), with a higher percentage of incomplete revascularization being reported for OPCAB in trials included in this pooled result (34% in OPCAB vs. 29% in ONCAB, P<0.01). CONCLUSIONS: Data from RCTs in elderly patients showed that OPCAB and ONCAB provide similar mid-term results. OPCAB was associated with a higher risk of early re-revascularization. As CABG on the elderly is still insufficiently explored, further RCTs, specifically designed targeting this population, are needed to establish a better CABG strategy for these patients.

Multiple versus single arterial grafting in the elderly: a meta-analysis of randomized controlled trials and propensity score studies.

INTRODUCTION: The benefit of adding a second arterial conduit is still controversial, mainly in specific subgroups. We conducted a meta-analysis of randomized controlled trials (RCTs) and propensity score (PS) studies comparing survival and early results in elderly patients who underwent coronary artery bypass grafting (CABG) with multiple (MAG) versus single arterial grafting (SAG). EVIDENCE ACQUISITION: MEDLINE, Web of Science and Cochrane Library were used to find relevant literature (1960-April 2020). Survival at a ≥1-year follow-up and early outcomes were evaluated. Outcomes were collected from matched samples or PS adjusted analysis: hazard ratio (HR) along with their variance, frequencies or odds ratios. Random effect models were used to compute combined statistical measures and 95% confidence intervals (CI) through generic inverse variance method (time-to-event) or Mantel-Haenszel method (binary events). EVIDENCE SYNTHESIS: Eleven PS cohorts and 1 RCT comprising >18,800 patients older than 70 (>6200 MAG and >12,500 SAG) were included in this meta-analysis. MAG was associated with lower long-term mortality (pooled HR: 0.81, 95% CI: 0.72-0.91, P<0.01, I2=64%) in the absence of higher risk of early mortality (pooled OR: 0.74, 95% CI: 0.44 to 1.25, P=0.27, I2=0%). In a meta-regression, MAG survival advantage was more pronounced in studies with a higher MAG usage rate (ß=-0.0052, P=0.021). CONCLUSIONS: Current evidence suggests that advanced age should not limit MAG's use considering its benefits in long-term survival. Of note, an individualized patient selection for this approach is warranted.

Chronic Sildenafil Therapy in the ZSF1 Obese Rat Model of Metabolic Syndrome and Heart Failure With Preserved Ejection Fraction.

Although decreased protein kinase G (PKG) activity was proposed as potential therapeutic target in heart failure with preserved ejection fraction (HFpEF), randomized clinical trials (RCTs) with type-5 phosphodiesterase inhibitors (PDE5i) showed neutral results. Whether specific subgroups of HFpEF patients may benefit from PDE5i remains to be defined. Our aim was to test chronic sildenafil therapy in the young male ZSF1 obese rat model of HFpEF with severe hypertension and metabolic syndrome. Sixteen-week-old ZSF1 obese rats were randomly assigned to receive sildenafil 100 mg·Kg-1·d-1 dissolved in drinking water (ZSF1 Ob SIL, n = 8), or placebo (ZSF1 Ob PL, n = 8). A group of Wistar-Kyoto rats served as control (WKY, n = 8). Four weeks later animals underwent effort tests, glucose metabolism studies, hemodynamic evaluation, and samples were collected for aortic ring preparation, left ventricular (LV) myocardial adenosine triphosphate (ATP) quantification, immunoblotting and histology. ZSF1 Ob PL rats showed systemic hypertension, aortic stiffening, impaired LV relaxation and increased LV stiffness, with preserved ejection fraction and cardiac index. Their endurance capacity was decreased as assessed by maximum workload and peak oxygen consumption (V˙O2) and respiratory quotient were increased, denoting more reliance on anaerobic metabolism. Additionally, ATP levels were decreased. Chronic sildenafil treatment attenuated hypertension and decreased LV stiffness, modestly enhancing effort tolerance with a concomitant increase in peak, ATP levels and VASP phosphorylation. Chronic sildenafil therapy in this model of HFpEF of the young male with extensive and poorly controlled comorbidities has beneficial cardiovascular effects which support RCTs in HFpEF patient subgroups with similar features.

Musculoskeletal anatomy and nomenclature of the mammalian epipubic bones.

Despite the well-established anatomy nomenclature for the marsupial skeleton, there are no names for the epipubic bone structures. Epipubic bones are paired bones articulating with the pubis and projecting cranially in the ventral body wall, present on the pelvic girdle of cynodonts, monotremes and marsupials. These bones were commonly thought to be related to pouch support in marsupials and more recently associated with locomotion. The parts of the epipubic bones have not been named and this has impeded proper morphological analysis. We analyzed the epipubic bones of 302 skeletons comprising American and Australian marsupials, as well as 27 monotreme skeletons, and dissected 10 marsupials for myological attachments analysis. We suggest the following nomenclature for the epipubic bone structures: crest for the cranial end, shaft for the body of the bone, lateral tubercle and the medial articular process. Some markings on the epipubic bone include the oblique line, pertaining to the attachment of external abdominal oblique muscle from the opposite side. The pyramidalis line is the suggested nomenclature for the pyramidalis muscle attachment and the inguinal ligament line for the inguinal ligament attachment. Regarding myology and attachments, based on dissections and review of the literature, the muscles pyramidalis, pectineus, external and internal abdominal oblique, transversus abdominis and rectus abdominis and the structures linea alba, linea semilunaris and the inguinal ligament are connected to the epipubic bone. As has been previously noted, anatomically, epipubic bones are so named due to their position (epi-above, pubic-pubis), and the same applies to structures such as the "epipubic process" or "epipubic cartilage" in amphibians and reptiles. While testing epipubic bone homology in vertebrates is beyond the scope of this work, we believe that using "epipubic bones" or epipubic cartilage/process as standardized terms for the structures found in the most cranial part of the superior ramus of the pubis would facilitate better anatomical communication. This should be valid for other similar terms, such as "epipubes" or "prepubis", that might occur in the literature in relation to this same physiographic position, and it should also be named as epipubic. We believe that this nomenclature will help in future morphologic studies.

Human umbilical cord tissue-derived mesenchymal stromal cells as adjuvant therapy for myocardial infarction: a review of current evidence focusing on pre-clinical large animal models and early human trials.

Although biologically appealing, the concept of tissue regeneration underlying first- and second-generation cell therapies has failed to translate into consistent results in clinical trials. Several types of cells from different origins have been tested in pre-clinical models and in patients with acute myocardial infarction (AMI). Mesenchymal stromal cells (MSCs) have gained attention because of their potential for immune modulation and ability to promote endogenous tissue repair, mainly through their secretome. MSCs can be easily obtained from several human tissues, the umbilical cord being the most abundant source, and further expanded in culture, making them attractive as an allogeneic "of-the-shelf" cell product, suitable for the AMI setting. The available evidence concerning umbilical cord-derived MSCs in AMI is reviewed, focusing on large animal pre-clinical studies and early human trials. Molecular and cellular mechanisms as well as current limitations and possible translational solutions are also discussed.

Arterial Stiffness Changes in Severe Aortic Stenosis Patients Submitted to Valve Replacement Surgery. / Alterações da Rigidez Arterial em Pacientes com Estenose Aórtica Grave Submetidos à Cirurgia de Troca Valvar.

BACKGROUND: Little is known about the impact of severe aortic stenosis (AS) in aortic stiffness and if there is any change after removing AS barrier with aortic valve replacement (AVR) surgery. OBJECTIVE: To estimate carotid-femoral pulse wave velocity (PWV) changes after AVR surgery and to define PWV predictors in severe AS patients. METHODS: Single-center retrospective cohort, including patients with severe AS who underwent AVR surgery with bioprostheses, between February 2017 and January 2019 and performed PWV measurements (Complior®) before and after the procedure (2±1 months). Before and after AVR, PWV values were compared through paired tests. The associations of PWV with clinical data were studied and linear regression models were applied to estimate pre and postoperative PWV independent predictors. The significance level was set at 5%. RESULTS: We included 150 patients in the sample, with mean age of 72±8 years, and 51% being males. We found a statistically significant increase in PWV values after surgery (9.0±2.1 m/s vs. 9.9±2.2, p<0.001, before and after AVR, respectively) and an inverse association with AS severity variables. In the linear regression model, age and systolic blood pressure (SBP) were established as independent predictors of higher pre- and postoperative PWV, while higher mean valvular gradient emerged as a determinant of lower pre-AVR PWV. CONCLUSION: We documented an inverse correlation of arterial stiffness with the severity of AS in patients with AS, and a significant increase in PWV values after AVR surgery. Advanced age and higher SBP were associated with higher PWV values, although arterial function measurements were within the normal range. (Arq Bras Cardiol. 2021; 116(3):475-482).

FUNDAMENTO: Pouco se sabe sobre o impacto da estenose aórtica (EA) grave na rigidez aórtica e se ocorre alguma alteração após a remoção da barreira de EA com a cirurgia de substituição da válvula aórtica (SVA). OBJETIVO: Estimar as mudanças na velocidade de onda de pulso carotídeo-femoral (VOP) após a cirurgia de SVA e definir os preditores de VOP alta em pacientes com EA grave. MÉTODOS: Estudo de coorte retrospectivo unicêntrico, incluindo pacientes com EA grave submetidos à cirurgia de SVA com bioprótese, entre fevereiro de 2017 e janeiro de 2019, e medições da VOP (Complior®) antes e depois do procedimento (2±1 meses). Antes e depois da SVA, os valores da VOP foram comparados por meio de testes pareados. foram analisadas as associações de VOP com dados clínicos, bem como aplicados modelos de regressão linear multivariada para estimar os preditores independentes da VOP pré- e pós-operatória. O nível de significância foi estabelecido em 5%. RESULTADOS: Foram incluídos na amostra 150 pacientes, com média de idade de 72±8 anos, sendo 51% deles do sexo masculino. Identificamos um aumento estatisticamente significativo nos valores de VOP após a cirurgia (9,0 ± 2,1 m/s vs. 9,9 ± 2,2, p<0,001, antes e depois da SVA, respectivamente) e uma associação inversa com as variáveis de gravidade da EA. No modelo de regressão linear multivariada, idade e pressão arterial sistólica (PAS) foram estabelecidas como preditores independentes da VOP pré- e pós-operatória mais alta, enquanto o gradiente valvar médio mais alto foi considerado um determinante da VOP pré-SVA mais baixa. CONCLUSÃO: Identificamos uma correlação inversa da rigidez arterial com a gravidade da EA em pacientes acometidos, e um aumento significativo nos valores da VOP após a cirurgia de SVA. Idade avançada e PAS elevada foram associadas a valores mais altos da VOP, embora as medidas de função arterial estivessem dentro da normalidade. (Arq Bras Cardiol. 2021; 116(3):475-476).

Alterações da Rigidez Arterial em Pacientes com Estenose Aórtica Grave Submetidos à Cirurgia de Troca Valvar / Arterial Stiffness Changes in Severe Aortic Stenosis Patients Submitted to Valve Replacement Surgery

Resumo Fundamento: Pouco se sabe sobre o impacto da estenose aórtica (EA) grave na rigidez aórtica e se ocorre alguma alteração após a remoção da barreira de EA com a cirurgia de substituição da válvula aórtica (SVA). Objetivo: Estimar as mudanças na velocidade de onda de pulso carotídeo-femoral (VOP) após a cirurgia de SVA e definir os preditores de VOP alta em pacientes com EA grave. Métodos: Estudo de coorte retrospectivo unicêntrico, incluindo pacientes com EA grave submetidos à cirurgia de SVA com bioprótese, entre fevereiro de 2017 e janeiro de 2019, e medições da VOP (Complior®) antes e depois do procedimento (2±1 meses). Antes e depois da SVA, os valores da VOP foram comparados por meio de testes pareados. foram analisadas as associações de VOP com dados clínicos, bem como aplicados modelos de regressão linear multivariada para estimar os preditores independentes da VOP pré- e pós-operatória. O nível de significância foi estabelecido em 5%. Resultados: Foram incluídos na amostra 150 pacientes, com média de idade de 72±8 anos, sendo 51% deles do sexo masculino. Identificamos um aumento estatisticamente significativo nos valores de VOP após a cirurgia (9,0 ± 2,1 m/s vs. 9,9 ± 2,2, p<0,001, antes e depois da SVA, respectivamente) e uma associação inversa com as variáveis de gravidade da EA. No modelo de regressão linear multivariada, idade e pressão arterial sistólica (PAS) foram estabelecidas como preditores independentes da VOP pré- e pós-operatória mais alta, enquanto o gradiente valvar médio mais alto foi considerado um determinante da VOP pré-SVA mais baixa. Conclusão: Identificamos uma correlação inversa da rigidez arterial com a gravidade da EA em pacientes acometidos, e um aumento significativo nos valores da VOP após a cirurgia de SVA. Idade avançada e PAS elevada foram associadas a valores mais altos da VOP, embora as medidas de função arterial estivessem dentro da normalidade. (Arq Bras Cardiol. 2021; 116(3):475-476)

Abstract Background: Little is known about the impact of severe aortic stenosis (AS) in aortic stiffness and if there is any change after removing AS barrier with aortic valve replacement (AVR) surgery. Objective: To estimate carotid-femoral pulse wave velocity (PWV) changes after AVR surgery and to define PWV predictors in severe AS patients. Methods: Single-center retrospective cohort, including patients with severe AS who underwent AVR surgery with bioprostheses, between February 2017 and January 2019 and performed PWV measurements (Complior®) before and after the procedure (2±1 months). Before and after AVR, PWV values were compared through paired tests. The associations of PWV with clinical data were studied and linear regression models were applied to estimate pre and postoperative PWV independent predictors. The significance level was set at 5%. Results: We included 150 patients in the sample, with mean age of 72±8 years, and 51% being males. We found a statistically significant increase in PWV values after surgery (9.0±2.1 m/s vs. 9.9±2.2, p<0.001, before and after AVR, respectively) and an inverse association with AS severity variables. In the linear regression model, age and systolic blood pressure (SBP) were established as independent predictors of higher pre- and postoperative PWV, while higher mean valvular gradient emerged as a determinant of lower pre-AVR PWV. Conclusion: We documented an inverse correlation of arterial stiffness with the severity of AS in patients with AS, and a significant increase in PWV values after AVR surgery. Advanced age and higher SBP were associated with higher PWV values, although arterial function measurements were within the normal range. (Arq Bras Cardiol. 2021; 116(3):475-482)

Challenges and satisfaction in Cardiothoracic Surgery Residency Programmes: insights from a Europe-wide survey.

OBJECTIVES: The increasing complexity of surgical patients and working time constraints represent challenges for training. In this study, the European Association for Cardio-Thoracic Surgery Residents' Committee aimed to evaluate satisfaction with current training programmes across Europe. METHODS: We conducted an online survey between October 2018 and April 2019, completed by a total of 219 participants from 24 countries. RESULTS: The average respondent was in the fourth or fifth year of training, mostly on a cardiac surgery pathway. Most trainees follow a 5-6-year programme, with a compulsory final certification exam, but no regular skills evaluation. Only a minority are expected to take the examination by the European Board of Cardiothoracic Surgery. Participants work on average 61.0 ± 13.1 h per week, including 27.1 ± 20.2 on-call. In total, only 19.7% confirmed the implementation of the European Working Time Directive, with 42.0% being unaware that European regulations existed. Having designated time for research was reported by 13.0%, despite 47.0% having a postgraduate degree. On average, respondents rated their satisfaction 7.9 out of 10, although 56.2% of participants were not satisfied with their training opportunities. We found an association between trainee satisfaction and regular skills evaluation, first operator experience and protected research time. CONCLUSIONS: On average, residents are satisfied with their training, despite significant disparities in the quality and structure of cardiothoracic surgery training across Europe. Areas for potential improvement include increasing structured feedback, research time integration and better working hours compliance. The development of European guidelines on training standards may support this.

Early And Midterm Outcomes Following Aortic Valve Replacement With Mechanical Versus Bioprosthetic Valves In Patients Aged 50 To 70 Years.

OBJECTIVES: To compare 7-year survival and freedom from reoperation, as well as early clinical and hemodynamic outcomes, after surgical aortic valve replacement (SAVR) with mechanical or bioprosthetic valves in patients aged 50-70 years. METHODS: single-center retrospective cohort study including adults aged 50-70 years who underwent SAVR in 2012 with a mechanical or bioprosthetic valve. Median follow-up was 7 years. Univariable analyses were performed using Kaplan-Meier curves and Log-Rank tests for survival and freedom from reoperation analyses. Multivariable time-to-event analyses were conducted using Cox Regression. RESULTS: Of a total of 193 patients, 76 (39.4%) received mechanical valves and 117 (60.6%) received bioprosthetic valves. A trend for better survival was found for mechanical prostheses when adjusting for EuroSCORE II (HR: 0.35; 95%CI: 0.12-1.02, p=0.054), but using a backward stepwise Cox regression prosthesis type was not retained by the model as an independent predictor of survival. Moreover, mechanical prostheses showed trends for higher freedom from reoperation (100% vs. 95.5%, Log-Rank, p=0.076), higher median EuroSCORE II (2.52% vs. 1.95%, p=0.06) and early mortality (7.9% vs. 2.6%, p=0.086). However, after adjusting for EuroSCORE II, there was no significant difference in early mortality (OR: 2.3, 95%CI: 0.5-10.5, p=0.272). Regarding hemodynamic performance at follow-up echocardiogram, there were no differences other than left ventricular mass regression, which was not as pronounced in the mechanical group (-12% vs. -21%, p=0.002). CONCLUSION: Mechanical and bioprosthetic aortic valves prostheses showed similar mid-term survival in the 50-70 age group. Further prospective and larger studies are needed to provide evidence-based recommendations on this topic.

Levoatrial cardinal vein with left-to-right shunt in a neonate: Multi-imaging diagnosis.

We present a rare case of a levoatrial cardinal vein identified during the work-up of a patient with coarctation of the aorta. Early diagnosis and repair in the neonatal period prevented future manifestations of left-to-right shunt and the need for reoperations, in contrast with the later-age presentation of this congenital anomaly. An integrative approach was crucial for prompt detection, intraoperative confirmation and complete one-stage repair.

Early dual antiplatelet therapy versus aspirin monotherapy after coronary artery bypass surgery: survival and safety outcomes.

BACKGROUND: There is currently conflicting evidence regarding outcomes of dual antiplatelet therapy (DAPT) in patients following coronary artery bypass grafting (CABG). We aim to compare the survival and safety outcomes of DAPT versus aspirin (ASA) within a 24h window after CABG. METHODS: Single-center retrospective cohort study on consecutive patients undergoing 1st isolated CABG surgery in 2010. Survival analysis (median follow-up 9 years) was performed using Kaplan-Meier curves and multivariable Cox regression using propensity score (PS) as a covariate along with DAPT. Bleeding was assessed through red blood cells' (RBC) transfusion, re-exploration of thorax and drainage. RESULTS: We included 351 patients (251 were DAPT). Kaplan-Meier curves showed similar cumulative survival between groups (9y: 75% DAPT vs. 67% ASA, Log-rank P=0.103), as well as the PS adjusted analysis (HR DAPT: 0.93, 95% CI: 0.57-1.51). We found no differences in early mortality (2 DAPT and 1 ASA). Total median cell-saver transfusion (300 mL vs. 250 mL) and the re-exploration of thorax due to bleeding (1.6% vs. 4%) showed no statistical significance either. On the other hand, postoperative total median chest tube drainage was higher in the ASA group (1220 mL DAPT vs. 1320 mL ASA, P=0.034). There was also a lower frequency of DAPT patients requiring RBC transfusions (≥3 units 4.8% vs. 13%, P=0.009, respectively). Redo-CABG was performed in 3 patients (2 DAPT vs. 1 ASA) during follow-up. CONCLUSIONS: Compared with ASA, DAPT showed a non-significant impact on long-term survival and demonstrated to be a safe option. Further studies are needed to provide recommendations on the therapeutical strategy following CABG.