Contemporary experience with the Commando procedure for anterior mitral anular calcification.

Objective: Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. Methods: From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). Results: Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). Conclusions: The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

The decreasing risk of reoperative aortic valve replacement: Implications for valve choice and transcatheter therapy.

OBJECTIVE: Increasing use of bioprostheses for surgical aortic valve replacement (SAVR) in younger patients, together with wider use of transcatheter aortic valve replacement, necessitates understanding risks associated with surgical valve reintervention. Therefore, we sought to identify risks of reoperative SAVR compared with those of primary isolated SAVR. METHODS: From January 1980 to July 2017, 7037 patients underwent nonemergency isolated SAVR, with 753 reoperations and 6284 primary isolated operations. These 2 groups were propensity score-matched on 46 preoperative variables, yielding 581 patient pairs for comparing outcomes. RESULTS: Among propensity score-matched patients, aortic clamp time (median 63 vs 52 minutes; P < .0001), cardiopulmonary bypass time (median 88 vs 67 minutes; P < .0001), and postoperative stay (median 7.1 vs 6.9 days; P = .003) were longer for reoperative SAVR than primary isolated SAVR. Hospital mortality after reoperative SAVR decreased from 3.4% in 1985 to 1.3% in 2011, similar to that of primary isolated SAVR. Occurrence of stroke, deep sternal wound infection, and new renal dialysis was similar. Blood transfusion (67% vs 36%; P < .0001) and reoperations for bleeding/tamponade (6.4% vs 3.1%; P = .009) were more common after reoperative SAVR. Survival at 1, 5, 10, and 20 years was 94%, 82%, 64%, and 33% after reoperative SAVR and 95%, 86%, 72%, and 46% after elective primary isolated SAVR. CONCLUSIONS: Risk of mortality and morbidity after reoperative SAVR has declined and is now similar to that of primary isolated SAVR. Decisions regarding prosthesis choice and SAVR versus transcatheter aortic valve replacement should be made in the context of lifelong disease management rather than avoidance of reoperation.

Improvements in Outcomes and Expanding Indications for the Commando Procedure. Comment on Giambuzzi et al. Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results. J. Clin. Med. 2021, 10, 3163.

We read with interest the authors' review and metanalysis of the Commando procedure in "Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results" [...].

Blood compatibility of human amniotic membrane compared with heparin-coated ePTFE for vascular tissue engineering.

Amniotic membrane (AM), a placenta-derived natural biomaterial, has several characteristics which make it a potential substitute for blood vessels. However, there are no reports on the effects of the AM on blood components. The aim of this study was to evaluate the blood compatibility of the epithelial and mesenchymal surfaces of the amnion for potential use in vascular tissue engineering. The activation of intrinsic and extrinsic pathways of the clotting system, haemolysis and platelet adhesion were studied and the results were compared with heparin-coated expanded polytetrafluoroethylene (ePTFE) as a standard synthetic vascular graft. Prothrombin time (PT), activated partial thromboplastin time (aPTT), clotting time (CT) and haemolysis (%) tests showed that both the epithelial and mesenchymal sides of the AM are haemocompatible. Platelet aggregation and P-selectin production from the platelets showed that the epithelial surface of the AM has less induction of platelet activation than ePTFE. The results of scanning electron microscopy (SEM) demonstrated that platelets in contact with ePTFE had a higher rate of adhesion than with the epithelial and mesenchymal surfaces of the AM. Moreover, the morphological distribution of the platelets showed that the majority of platelets were round, while a large number of cells on ePTFE were dendritic. These results suggest that the AM which contains epithelial and mesenchymal stem cells has appropriate haemocompatibility to be employed in vascular tissue engineering, especially as a vein substitute. Copyright © 2015 John Wiley & Sons, Ltd.

Assessment of patients' awareness of their rights in teaching hospitals in Iran.

INTRODUCTION: Respecting patients' rights is an essential component in health care. Passing a regulation is not a guarantee for the protection of patients' rights. This article aimed to assess patients' awareness of the contents of the Patient's Bill of Rights in Iran and to determine if they had received a service compatible with their rights charter. METHODS: This is a descriptive study in 202 hospitalised patients. A questionnaire was used, and associations between variables were examined using Pearson's correlation test. The significance level was p < .05. RESULTS: The patients' ages ranged from 18 to 87 years of age, 33% were male and 79% were married. Patients' knowledge was lowest regarding the need for consent for the treatment process and was highest regarding the patient's right to know the expertise of the treatment team. The mean of patients' knowledge was 77.56%. As for patients' exercising their rights, the highest score belonged to the patient's right for attending doctors and treatment team's confidentiality; the lowest score belonged to the right to receive necessary information about probable complications, other treatment options and participation in the final selection of treatment method. The mean score of patient satisfaction was 8.06 (out of 11). There was no significant relationship with their education level or the number of admissions. CONCLUSION: Health-care professionals can provide care based on patients' rights, and their knowledge of patients' rights needs to be evaluated. Educational programmes, leaflets, booklets and posters can be helpful in this regard. In addition, professional organisations and the Ministry of Health need to be more sensitive to this issue.

Extract of fetal membrane would inhibit thrombosis and hemolysis.

The innermost layer of fetal membranes is amnion which has anti-adhesive, anti-inflammation and viscoelastic properties, as well as low immunogenicity. Amniotic membrane has been employed in variety of clinical fields as a natural biomaterial. Amniotic epithelial cells possess stem cell characteristics and capability to differentiate into endothelial cells. The basement membrane of amnion is an extracellular matrix enriched scaffold to support adhesion of endothelial cells. The matrix of amniotic membrane contains two kinds of glycosaminoglycans including perlecan (a heparan sulfate proteoglycan) and hyaluronic acid which both inhibit blood coagulation. Moreover, the other ingredients of amniotic membrane such as pigment-epithelium derived factor (PEDF), IL-10, MMP-9 inhibit platelet aggregation. Based on some biochemical and biomechanical evidences, we hypothesized in this paper that amniotic membrane could prevent thrombosis and hemolysis; therefore, has the capability to be applied in blood contacting devices and implants.