Valve Type and Operative Risks in Surgical Explantation of Transcatheter Aortic Valves: A Systematic Review and Meta-Analysis.

Indication to perform surgical explantation of TAVR is becoming increasingly more frequent, due to the higher number of transcatheter procedures performed in patients with longer life expectancy. We proposed to perform a systematic review and meta-analysis with metaregression to identify potential factors that can determine an increase in the high mortality and morbidity that characterize these surgical procedures. MEDLINE and Embase were searched for relevant studies. Twelve studies were eligible according to our inclusion criteria. TAVR explantation was confirmed as a procedure with high 30-day mortality (0.17; 95% CI, 0.14-0.21) and morbidity (stroke incidence 5%; 95% CI, 0.04-0.07; kidney injury incidence 16%; 95% CI, 0.11-0.24). The type of transcatheter valve implanted during the index procedure did not influence the outcomes after surgical explantation. The role of these high-risk operations is growing, and it will likely expand in the coming years. Specific tools for risk stratification are required.

Heart Transplantation.

Heart transplantation (HTx) remains the last therapeutic resort for patients with advanced heart failure. The present work is a clinically focused review discussing current issues in heart transplantation. Several factors have been associated with the outcome of HTx, such as ABO and HLA compatibility, graft size, ischemic time, age, infections, and the cause of death, as well as imaging and laboratory tests. In 2018, UNOS changed the organ allocation policy for HTx. The aim of this change was to prioritize patients with a more severe clinical condition resulting in a reduction in mortality of people on the waiting list. Advanced heart failure and resistant angina are among the main indications of HTx, whereas active infection, peripheral vascular disease, malignancies, and increased body mass index (BMI) are important contraindications. The main complications of HTx include graft rejection, graft angiopathy, primary graft failure, infection, neoplasms, and retransplantation. Recent advances in the field of HTx include the first two porcine-to-human xenotransplantations, the inclusion of hepatitis C donors, donation after circulatory death, novel monitoring for acute cellular rejection and antibody-mediated rejection, and advances in donor heart preservation and transportation. Lastly, novel immunosuppression therapies such as daratumumab, belatacept, IL 6 directed therapy, and IgG endopeptidase have shown promising results.

Artificial Intelligence in Heart Failure: Friend or Foe?

In recent times, there have been notable changes in cardiovascular medicine, propelled by the swift advancements in artificial intelligence (AI). The present work provides an overview of the current applications and challenges of AI in the field of heart failure. It emphasizes the "garbage in, garbage out" issue, where AI systems can produce inaccurate results with skewed data. The discussion covers issues in heart failure diagnostic algorithms, particularly discrepancies between existing models. Concerns about the reliance on the left ventricular ejection fraction (LVEF) for classification and treatment are highlighted, showcasing differences in current scientific perceptions. This review also delves into challenges in implementing AI, including variable considerations and biases in training data. It underscores the limitations of current AI models in real-world scenarios and the difficulty in interpreting their predictions, contributing to limited physician trust in AI-based models. The overarching suggestion is that AI can be a valuable tool in clinicians' hands for treating heart failure patients, as far as existing medical inaccuracies have been addressed before integrating AI into these frameworks.

Pneumomediastinum: Experience with 87 Patients.

OBJECTIVE: The aim of the present series was first to present our experience in the management of 37 patients with spontaneous pneumomediastinum (SPM), and further to indicate the necessity of identifying true SPM cases as they are currently inadequately defined. METHODS: This is a single-center, retrospective study, conducted in a university hospital. Consecutive adult patients with pneumomediastinum (PM) between January 2009 and March 2020 were involved in the series. The data about age, gender, symptoms, signs, treatment, length of hospital stay (LOS), and in-hospital mortality were evaluated. RESULTS: In total, 87 cases with pneumomediastinum (37 with spontaneous and 50 with secondary PM) were analyzed. Patients in both groups were of similar ages (P=0.4). Sufferers with secondary PM were more likely to have: an associated pneumothorax (19% vs 58%, P<0.05), a chest tube placed (18.9% vs 58%, P<0.05), an associated pleural effusion (0% vs 18%, P<0.05). They presented with a longer LOS (3.9 vs 5.3 days, P<0.05), and were more likely to die (0% vs 10%, P<0.05). Additionally they showed a higher prevalence of radiologic subcutaneous emphysema (49% vs 74%, P<0.05). CONCLUSION: Spontaneous pneumomediastinum is an onset of clinical importance with a low mortality rate, short LOS and good longterm prognosis. It often presents with chest pain, dyspnea and/or subcutaneous emphysema. However, secondary causes of mediastinal air must be ruled out, due to their potential devastating outcome if not diagnosed promptly. A consensus aimed at an update of the classification guidelines is more than indispensable.

Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure: Current Evidence and Future Opportunities.

Atrial fibrillation (AF) and heart failure (HF) are highly prevalent cardiac disorders worldwide, and both are associated with poor prognosis. The incidence of AF and HF has been increasing substantially in recent years, mainly due to the progressive aging of the population. These disorders often coexist, and may have a causal relationship, with one contributing to the development or progression of the other. AF is a significant risk factor for adverse outcomes in HF patients, including mortality, hospitalization, and stroke. Although the optimal treatment for AF with HF remains unclear, catheter ablation (CA) has emerged as a promising treatment option. This review provides a comprehensive overview of the current scientific evidence regarding the efficacy of CA for managing AF in HF patients. In addition, the potential benefits and risks associated with CA are also discussed. We will also explore the factors that may influence treatment outcomes and highlight the remaining gaps in knowledge in this field.

Comparative Analysis of Morbidity and Mortality Outcomes in Elderly and Nonelderly Patients Undergoing Elective TEVAR: A Systematic Review and Meta-Analysis.

OBJECTIVE: Due to an ever-increasing ageing population and limited available data around the use of thoracic endovascular aortic repair (TEVAR) in elderly patients, investigating its efficacy and safety in this age cohort is of vital importance. We thus reviewed the existing literature on this topic to assess the feasibility of TEVAR in elderly patients with severe thoracic aortic pathologies. METHODS: We identified all original research studies that assessed TEVAR in elderly patients published up to 2023. Morbidity, as assessed by neurological and respiratory complications, endoleaks, and length of stay, was the primary endpoint. Short-term mortality and long-term survival were the secondary endpoints. The Mantel-Haenszel random and fixed effects methods were used to calculate the odds ratios for each outcome. Further sensitivity and subgroup analyses were performed to validate the outcomes. RESULTS: Twelve original studies that evaluated elective TEVAR outcomes in elderly patients were identified. Seven studies directly compared the use of TEVAR between an older and a younger patient group. Apart from a shorter hospital stay in older patients, no statistically significant difference between the morbidity outcomes of the two different cohorts was found. Short-term mortality and long-term survival results favoured the younger population. CONCLUSIONS: The present meta-analysis indicates that, due to a safe perioperative morbidity profile, TEVAR should not be contraindicated in patients based purely on old age. Further research using large patient registries to validate our findings in elderly patients with specific aortic pathologies and both elective and emergency procedures is necessary.

Differences in long-term survival outcomes after coronary artery bypass grafting using single vs multiple arterial grafts: a meta-analysis with reconstructed time-to-event data and subgroup analyses.

OBJECTIVE: We reviewed the available literature on patients with coronary artery disease undergoing isolated coronary artery bypass grafting (CABG) with either single (SAG) or multiple arterial grafting (MAG). METHODS: Original research studies that evaluated the long-term survival of MAG versus SAG were identified, from 1995 to 2022. The median overall survival (OS) and event-free OS were the primary endpoints. Comparison of median OS between the right internal mammary artery (RIMA) and radial artery (RA) as a second arterial conduit was the secondary endpoint. Subgroup analyses were performed regarding patients older than 70 years, with diabetes mellitus, and females. A sensitivity analysis was performed with the leave-one-out method. RESULTS: Forty-four studies were included in the qualitative and thirty-nine in the quantitative synthesis. After pooling data from 180 to 459 patients, the MAG group demonstrated a higher OS (HR, 0.589; 95% CI, 0.58-0.60; p < 0.0001) and event-free OS compared with the SAG group (HR, 0.828; 95% CI, 0.80-0.86; p < 0.0001). In addition, RITA was associated with superior OS compared with RA as a second arterial conduit (HR, 0.936; 95% CI, 0.89-0.98; p = 0.009). MAG was also superior to SAG in patients over 70 years, females, and patients with diabetes mellitus. Sensitivity analysis demonstrated a small-size study effect on the female subgroup analysis. CONCLUSION: The present meta-analysis indicates that MAG is associated with enhanced survival outcomes compared to SAG for patients undergoing isolated CABG.

Concomitant Valve Replacement and Coronary Artery Bypass Grafting Surgery: Lessons from the Past, Guidance for the Future? A Mortality Analysis in 294 Patients.

OBJECTIVE: The aims of this study were to analyze parameters influencing early and late mortality after concomitant valve replacement and coronary artery bypass grafting surgery, using early and long-term information from an institutionally available data registry, and to discuss the results in relation to the current treatment strategies and perspectives. METHODS: The study population consisted of 294 patients after combined valve replacement with mechanical prosthesis and CABG surgery. RESULTS: There were 201 men (68.4%) and 93 women (31.6%). Concurrent to the coronary artery bypass grafting, 238 patients (80.9%) underwent aortic-, 46 patients (15.6%) mitral- and 10 patients (3.4%) doublevalve replacement. Cumulative duration of follow up was 1007 patient-years (py) with a maximum of 94 months and was completed in 92.2% (271 cases). Overall hospital mortality (30 days) rate was 6.5% (n = 19). It was significantly higher in patients of female gender, older than 70 y, in those suffering preoperative myocardial infarction, presenting with an additive EuroScore > 8 and being hemodynamically unstable after the operation. Cumulative survival rate at 7.6 y was 78.6%. Determinants of prolonged survival were male gender, age at operation < 70 y, preoperative sinus rhythm, normal renal function, additive EuroScore < 8 and the use of internal thoracic artery for grafting. Subsequent multivariate analysis revealed preoperative atrial fibrillation (HR: 2.1, 95% CI: 0.82-5.44, p: 0.01) and risk group of ES > 8 (HR: 3.63, 95% CI: 1.45-9.07, p < 0.01) as independent predictors for lower long-term survival. CONCLUSIONS: Hospital mortality (30 d) was nearly 2.5-fold higher in female and/or older than 70 y patients. Preoperative atrial fibrillation and/ or a calculated ES > 8 were independent predisposing factors of late mortality for combined VR and CABG surgery. Tailoring the approach, with the employment of the newest techniques and hybrid procedures, to the individual patient clinical profile enables favorable outcomes for concomitant valvular disease and CAD, especially in high-risk patients.

Rejection Requiring Treatment within the First Year following Heart Transplantation: The UNOS Insight.

(1) Background: Heart failure is an extremely impactful health issue from both a social and quality-of-life point of view and the rate of patients with this condition is destined to rise in the next few years. Transplantation remains the mainstay of treatment for end-stage heart failure, but a shortage of organs represents a significant problem that prolongs time spent on the waiting list. In view of this, the selection of donor and recipient must be extremely meticulous, considering all factors that could predispose to organ failure. One of the main considerations regarding heart transplants is the risk of graft rejection and the need for immunosuppression therapy to mitigate that risk. In this study, we aimed to assess the characteristics of patients who need immunosuppression treatment for rejection within one year of heart transplantation and its impact on mid-term and long-term mortality. (2) Methods: The United Network for Organ Sharing (UNOS) Registry was queried to identify patients who solely underwent a heart transplant in the US between 2000 and 2021. Patients were divided into two groups according to the need for anti-rejection treatment within one year of heart transplantation. Patients' characteristics in the two groups were assessed, and 1 year and 10 year mortality rates were compared. (3) Results: A total of 43,763 patients underwent isolated heart transplantation in the study period, and 9946 (22.7%) needed anti-rejection treatment in the first year. Patients who required treatment for rejection within one year after transplant were more frequently younger (49 ± 14 vs. 52 ± 14 years, p < 0.001), women (31% vs. 23%, p < 0.001), and had a higher CPRA value (14 ± 26 vs. 11 ± 23, p < 0.001). Also, the rate of prior cardiac surgery was more than double in this group (27% vs. 12%, p < 0.001), while prior LVAD (12% vs. 11%, p < 0.001) and IABP (10% vs. 9%, p < 0.01) were more frequent in patients who did not receive anti-rejection treatment in the first year. Finally, pre-transplantation creatinine was significantly higher in patients who did not need treatment for rejection in the first year (1.4 vs. 1.3, p < 0.01). Most patients who did not require anti-rejection treatment underwent heart transplantation during the new allocation era, while less than half of the patients who required treatment underwent transplantation after the new allocation policy implementation (65% vs. 49%, p < 0.001). Patients who needed rejection treatment in the first year had a higher risk of unadjusted 1 year (HR: 2.25; 95% CI: 1.88-2.70; p < 0.001), 5 year (HR: 1.69; 95% CI: 1.60-1.79; p < 0.001), and 10 year (HR: 1.47; 95% CI: 1.41-1.54, p < 0.001) mortality, and this was confirmed at the adjusted analysis at all three time-points. (4) Conclusions: Medical treatment of acute rejection was associated with significantly increased 1 year mortality compared to patients who did not require anti-rejection therapy. The higher risk of mortality was confirmed at a 10 year follow-up. Further studies and newer follow-up data are required to investigate the role of anti-rejection therapy in the heart transplant population.

Post-Implant Phosphodiesterase-5 Inhibitors in Patients with Left Ventricular Assist Device: A Systematic Review and Meta-Analysis.

Background: Despite the improvement in left ventricular assist device (LVAD) technology and the advent of third-generation LVADs, hemocompatibility-related events remain a significant issue. Therefore, new pharmacological treatments are necessary to optimize patient management and to further reduce hemocompatibility-related events. The purpose of the present systematic review and meta-analysis was to summarize the existing data regarding the safety and efficacy of post-implant phosphodiesterase-5 inhibitors (PDE-5i) on hemocompatibility-related events. Methods: Among the 258 articles in Pubmed, Scopus, and CENTRAL that were retrieved (1990−2022), 15 studies were included in the qualitative synthesis, and 9 studies were included in the quantitative synthesis. The fixed-effects model was used because it is statistically sound for combining a very small number of studies. The primary endpoint of the study was all-cause mortality, whereas the secondary endpoints were ischemic stroke, pump thrombosis, and gastrointestinal bleeding. Results: Mortality was significantly lower in the PDE-5i group vs. the control group (OR: 0.92 [95% CI: 0.85, 0.98]; p = 0.02). The secondary endpoints ischemic stroke (OR: 0.87 [95% CI: 0.78, 0.98]; p = 0.02) and pump thrombosis (OR: 0.90 [95% CI: 0.82, 0.99]; p = 0.04) were also lower in the PDE-5i group. The incidence of gastrointestinal bleeding was significantly higher in patients with LVAD receiving PDE-5i (OR: 1.26 [95% CI: 1.11, 1.44]; p < 0.01). In the overall analysis, the heterogeneity of outcomes was low, except for pump thrombosis. Conclusions: The use of PDE-5i post-implant was associated with lower mortality and thrombotic events but with a higher risk of gastrointestinal bleeding.

Meta-analysis of survival after extrapleural pneumonectomy (EPP) versus pleurectomy/decortication (P/D) for malignant pleural mesothelioma in the context of macroscopic complete resection (MCR).

OBJECTIVE: We reviewed the available literature on patients with MPM undergoing either extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D). METHODS: Original research studies that evaluated long-term outcomes of P/D versus EPP were identified, from January 1980 to February 2022. The 30-days and 90-day mortality, along with the 1-, 2-, 3-, 5-year survival, the median overall survival, the macroscopic complete resection (MCR) rate, and the complications were calculated according to both a fixed and a random effect model. The Q and I2 statistic were used to test for heterogeneity among the studies. Sensitivity analysis was performed including only studies that incorporated the MCR concept. RESULTS: Eighteen studies were included, incorporating a total of 4,852 patients treated with EPP and P/D. The 30-day mortality was significantly higher in the EPP group (OR: 2.79 [95% CI 1.30, 6.01]; p = 0.009). The median overall survival was higher in the P/D group (WMD:-4.55 [-6.05, -3.04]; p < 0.001). No differences were found regarding the 90-day mortality, MCR rate, and the 1-, 2-,3-, 5-year survival between the EPP and P/D groups. These findings were validated by the sensitivity analysis. The incidence of atrial fibrillation, hemorrhage, pulmonary embolism, air leak, and reoperation was significantly increased in the EPP group (p < 0.05). CONCLUSIONS: The present meta-analysis indicates that P/D is associated with enhanced outcomes regarding 30-day mortality, median overall survival, and complications. The P/D approach should be preferred when technically feasible. However, the procedure of choice should be decided based on the goal of MCR in the safest approach for the patient.

Meta-analysis of robot-assisted versus video-assisted McKeown esophagectomy for esophageal cancer.

We aim to review the available literature on patients with esophageal cancer treated with robot-assisted (RAME) or video-assisted McKeown's esophagectomy (VAME), to compare the efficacy and safety of the two approaches. Original research studies that evaluated perioperative and oncologic outcomes of RAME versus VAME were identified, from January 1990 to July 2022. The 90-day mortality, the R0 resection rate, the dissected lymph nodes, the perioperative parameters, and the complications were calculated according to a fixed and a random effect model. The Q statistics and I2 statistic were used to test for heterogeneity among the studies. Seven studies were included, incorporating a total of 1617 patients treated with RAME or VAME. The 90-day mortality was similar between the two groups. No difference was found regarding the R0 resection rate and the number of dissected lymph nodes. In addition, the perioperative parameters, along with the total complications were similar between RAME and VAME. Nonetheless, the incidence of postoperative pneumonia was higher in the VAME group (OR:0.67 [95% CI: 0.49, 0.93]; p = 0.02). Finally, our outcomes were further validated by sensitivity analysis including only studies performing propensity score-matched analysis. Our meta-analysis showed that RAME was equivalent to VAME in terms of safety, feasibility, and oncologic adequacy. These results should be interpreted with caution due to the small number of included studies. New Randomized Controlled trials, that are currently active, will provide further evidence with greater clarity to assess the effectiveness and safety of RAME for esophageal cancer.

Long-Term Survival after Extended Sleeve Lobectomy (ESL) for Central Non-Small Cell Lung Cancer (NSCLC): A Meta-Analysis with Reconstructed Time-to-Event Data.

OBJECTIVE: We conducted a thorough literature search on patients with central non-small cell lung cancer (NSCLC) undergoing either extended sleeve lobectomy (ESL) or pneumonectomy (PN). METHODS: We identified all original research studies that compared the long-term survival of ESL versus PN from 1990 to 2022. The primary endpoints were the median overall survival (OS) and disease-free survival (DFS). Complications, operative mortality, and the reoperation rate were the secondary endpoints. Regarding the primary endpoints, independent patient data were extracted from the included studies, and pooled Kaplan-Meier curves were constructed. A sensitivity analysis was performed using the leave-one-out method. RESULTS: Nine studies were included in the qualitative and seven in the quantitative synthesis, including 431 patients. Patients in the ESL group demonstrated a significantly higher OS compared with the PN group (HR, 0.63; 95% CI, 0.46-0.87; p = 0.005). In addition, patients undergoing ESL presented a significantly higher DFS compared to the PN group (HR, 0.57; 95% CI, 0.40-0.80; p = 0.004). These findings were further validated with a sensitivity analysis. The most common complications in the ESL group were bronchopleural fistula (4.6%), stricture (3.1%), prolonged air leakage (7.3%), sputum retention (4.6%), pneumonia (7.7%), and pulmonary vein thrombosis (1.5%). ESL was associated with a low reoperation rate (1.5%) and operative mortality (1.2%). CONCLUSIONS: The present meta-analysis indicates that ESL is associated with enhanced survival outcomes compared to PN for patients with central NSCLC. Further randomized controlled trials are necessary to validate our findings.

Acute myocardial infarction not attributed to coronary artery disease: A seldom initial presentation of a left ventricular myxoma.

Although myxoma represents the most frequent non-malignant cardiac primary tumor; it is extremely rare met in the left ventricle. Clinical features of the neoplasm extend from symptomless to critical signs of either ischemia or embolism. We describe here an unusual case of a huge left ventricular myxoma in a 68-year-old man, presented with clinical and ECG findings of an inferior wall myocardial infarction. The patient was primarily referred to our institution for coronary angiography, which showed no coronary artery disease. Further examinations revealed a left ventricular mass as the possible source of embolization, thus the patient underwent surgery for tumor excision. The postoperative course was unremarkable. A bibliographical analysis demonstrated that those tumors are rare but treatable causes of embolic myocardial infarction, thus profound clinical intuition, proper utilization of imaging modalities, administration of anticoagulants preoperatively, as well immediate surgical removal are justified.

The current role of surgery in the treatment of cardiac metastases from malignant melanoma: an educational presentation

Abstract A 71 year-old male with a history of multiple excisions of an initial Clark's level V melanoma of the breast followed by combined radiation and interferon treatment, as well as a recurrence, 3 years later, of a BRAF-positive tumor of the shoulder, with subsequent therapy with dabrafenib and trametinib, presented again with progressive intracardiac masses causing significant right ventricular outflow obstruction. Additionally, the patient complained of dyspnea and fatigue on exertion, thus he was scheduled for surgical resection.