Prosthesis-prosthesis anastomosis using barbed sutures compared to conventional sutures under high, long-term pressure; in vitro extracorporeal circulation setup.

BACKGROUND: While barbed sutures have been extensively utilized in other disciplines, they have not been widely adopted in cardiac surgery. The lack of safety and feasibility data has limited its use within the field. To aide in the further understanding of how cardiac surgeons can use barbed sutures, we sought to develop a high-pressure in vitro simulation model. We compared knotless barbed sutures in a highly pressurized anastomosis to conventional sutures. METHODS: Ten specimens in total were utilized in prosthesis anastomosis, using 34 mm Gelweave Plexus (Terumo Aortic, Sunrise, FL 33325, USA) and 34 mm Hemabridge (Intergard Woven Hemabridge, Getinge, Göteborg, Sweden). Five models of size 3-0 barbed suture anastomoses using non-absorbable, barbed, self-retaining, monofilament polypropylene sutures (Filbloc® 3-0, Assut Europe, Rome, Italy) were compared against five conventional anastomoses using size 4-0 polypropylene monofilament (Ethicon, USA). The systems were connected using a novel-designed extracorporeal circulation system. Pressure was rapidly increased in the specimen to a mean pressure of 300-350 mmHg, running then for a minimum of 48 hours to assess anastomosis strength and endurance. RESULTS: No anastomotic dehiscence or rupture was recorded. Complex, angular anastomosis required extra stitch leakage sutures in both conventional and barbed suture specimens. CONCLUSION: Using knotless barbed sutures with an additional self-locking maneuver for prosthesis-prosthesis anastomosis in cardiac surgery is feasible in an in vitro model under long term, high-mean pressure when compared to conventional sutures. In vivo trials should be performed to further validate the in vitro findings.

Reoperation for bleeding after cardiac surgery.

BACKGROUND: Postoperative cardio-surgical haemostatic management is centre-specific and experience-based, which leads to a variability in patient care. This study aimed to identify which postoperative haemostatic interventions may reduce the need for reoperation after cardiac surgery in adults. METHODS: A retrospective case-control study in a tertiary centre. Adult, elective, primary cardiac surgical patients were selected (n = 2098); cases (n = 42) were patients who underwent reoperation within 72 h after the initial surgery. Interventions administered to control surgical bleeding were compared for the need to re-operate using multiple logistic regression. RESULTS: Rate of cardiac surgical reoperation was 2% in the study population. Three variables were found to be associated with cardiac reoperation: preoperative administration of fresh frozen plasma (OR 5.45, CI 2.34-12.35), cumulative volume of chest tube drainage and cumulative count of packed red blood cells transfusion on ICU (OR 1.98, CI 1.56-2.51). CONCLUSION: No significant difference among specific types of postoperative haemostatic interventions was found between patients who needed reoperation and those who did not. Perioperative transfusion of fresh frozen plasma, postoperative transfusion of packed cells and cumulative volume of chest tube drainage were associated with reoperation after cardiac surgery. These variables could help predict the need for reoperation.

Midterm clinical outcome following Edwards SAPIEN or Medtronic Corevalve transcatheter aortic valve implantation (TAVI): Results of the Belgian TAVI registry.

OBJECTIVE: To assess midterm (3 years) clinical outcomes of transcatheter aortic valve implantation (TAVI) in Belgium using the Edwards SAPIEN valve or the Medtronic CoreValve transcatheter heart valve (THV). BACKGROUND: Medium and long term follow-up data of both THVs are still relatively scarce, although of great clinical relevance for a relatively new but rapidly expanding treatment modality. Therefore, reporting mid- and long term clinical outcome data, coming from large "real world" national registries, remains contributive. METHODS: Between December 2007 and March 2012, 861 "real world" patients who were not candidates for surgical aortic valve replacement as decided by the local heart teams, underwent TAVI at 23 sites. Eleven sites exclusively used SAPIEN THV (n = 460), while 12 exclusively used CoreValve THV (n = 401). Differences in clinical outcomes by valve system were assessed, according to access route and baseline EuroSCORE risk profile (<10%: low, 10-20%: intermediate and >20%: high risk). RESULTS: Overall cumulative survival at 3 years was 51% for SAPIEN vs. 60% for CoreValve (P = 0.021). In transfemorally treated patients, SAPIEN and CoreValve had similar survival at 3 years for each of the baseline EuroSCORE cohorts (low risk: 72% vs. 76%, P = 0.45; intermediate risk: 62% vs. 59%, P = 0.94; high risk: 48% vs. 53%, P = 0.65). CONCLUSION: Cumulative midterm 3 year survival after transfemoral TAVI in "real world" patients refused for surgery with similar baseline EuroSCORE risk profile is not different between SAPIEN or CoreValve.

The FORGOTTEN (TRICUSPID) VALVE; THIRD TIME, RIGHT TIME.

Tricuspid regurgitation (TR) remains a challenging condition, the indication, timing and type of surgery for which are not yet well established. A 42-year-old woman was referred to the authors' institution with recurrent, symptomatic TR at one year after she had undergone tricuspid valve repair for an Ebstein's anomaly. At 14 months after the first surgery a bioprosthesis was implanted for a detached annuloplasty ring, and she made a complete recovery. However, at 15 months after valve replacement she presented again with right heart failure and massive TR due to rare early pannus formation. A re-redo tricuspid valve replacement was performed. Tricuspid valve replacement with a bioprosthesis is a valid option if repair is unsuccessful. However, there is a need to be aware of concomitant problems such as a requirement for pacemaker implantation, the risk for prosthesis thrombosis or pannus formation, and the importance of anticoagulation therapy. Annual transthoracic echocardiographic follow up is advisable to exclude subclinical TR.

Preprocedural CT evaluation of transcatheter aortic valve replacement: what the radiologist needs to know.

Aortic valve stenosis is the most common valvular heart disease in the Western world. When symptomatic, aortic valve stenosis is a debilitating disease with a dismal short-term prognosis, invariably leading to heart failure and death. Elective surgical valve replacement has traditionally been considered the standard of care for symptomatic aortic valve stenosis. However, several studies have identified various subgroups of patients with a significantly elevated risk for surgery-related complications and death. Thus, not every patient is a suitable candidate for surgery. Recent developments in transcatheter-based therapies have provided an alternative therapeutic strategy for the nonsurgical patient population known as transcatheter aortic valve replacement (TAVR) (also called transcatheter aortic valve implantation or percutaneous aortic valve replacement). In TAVR, the native aortic valve is replaced with a bioprosthetic valve via a nonsurgical endovascular, transaortic, or transapical pathway. Nevertheless, several anatomic and technical criteria must be met to safeguard patient eligibility and procedural success. Therefore, noninvasive imaging plays a crucial role in both patient selection and subsequent matching to a specific transcatheter valve size in an effort to ensure accurate prosthesis deployment and minimize peri- and postprocedural complications. The authors review the relevant anatomy of the aortic root, emphasizing the implications of anatomic pitfalls for correct reporting of imaging-derived measurements and important differences between findings obtained with different imaging modalities. They also discuss the evolving role of computed tomography and the role of the radiologist in patient triage in light of current viewpoints regarding patient selection, device size selection, and the preprocedural evaluation of possible access routes. Online supplemental material is available for this article.

Transcatheter aortic valve replacement: postoperative CT findings of Sapien and CoreValve transcatheter heart valves.

Transcatheter aortic valve replacement represents one of the most exciting medical technical developments in recent years, offering a much-needed therapeutic alternative for patients with severe aortic valve stenosis who, due to comorbidities and advanced age, are considered to be inoperable or at high surgical risk. The efficacy of this procedure compared with standard surgical intervention has been properly validated in multicenter randomized controlled trials (PARTNER A and B trials), leading to widespread clinical implementation, with over 50,000 procedures currently being performed worldwide each year. Although much of the attention has rightly focused on the potential role of computed tomography (CT) in the preprocedural assessment of the aortic root and the establishment of imaging-guided valve-sizing algorithms, less is known regarding the postprocedural CT characteristics of transcatheter heart valves (THVs). However, given the increasing worldwide recognition and clinical implementation of these devices, they will no doubt be encountered with increasing frequency in patients referred for thoracic CT, either for postprocedural evaluation of the aortic root or for unrelated reasons. Familiarity with these devices and their CT characteristics will increase diagnostic confidence and the value of the radiology report. The authors describe the physical and imaging properties of the currently commercially available THVs, their normal postprocedural imaging appearances, and potential complications that can be detected at CT. In addition, they discuss the relative strengths and weaknesses of CT and echocardiography in this setting.

Tumour necrosis factor-alpha serum level is an independent predictor of medium-term all-cause mortality after transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a suitable treatment for patients with severe aortic stenosis and severely increased operative risk. There is need for a better preoperative risk assessment for TAVI candidates. AIM: To determine whether Tumour necrosis factor-alfa (TNFα) is an independent predictor of survival 500 days after TAVI. METHODS: Sixty patients undergoing TAVI were enrolled in the study. TNFα was determined. The CT measured low-density muscle fraction (LDM%) of the psoas muscle was determined. Operative risk assessment by Logistic EuroSCORE, EuroSCORE II, and STS score was performed. Frailty scores (FRAIL scale and Barthel index) were determined. RESULTS: Mean age was 81.01 ± 7.54 years. Twenty-six (43.3%) of the patients were males. In the univariable analyses, FRAIL scale and Barthel index were no predictors of survival after TAVI. In the multivariable analysis, including EuroSCORE II, LDM% and TNFα serum concentration, TNFα serum level was an independent predictor of survival 500 days after TAVI (HR: 3.167; 95%: 1.279-7.842; p = 0.013). The multivariable analysis, including TNFα as a categorical variable, showed that compared to patients in the conjugated first and second TNFα serum level tertile, patients in the third tertile had a hazard ratio (HR) of 10.606 (95%CI: 1.203 - 93.467) (p = 0.033). CONCLUSION: TNFα is an incremental independent predictor of long-term survival after TAVI.

Case report: inadvertent intrathecal placement of a pulmonary artery catheter introducer.

We present a case of unintended intrathecal cannulation by a pulmonary artery catheter introducer in a patient scheduled for coronary surgery. This complication was likely due to multiple attempts of placing the guidewire. Switching to the straight tip of the guidewire may have created a false route, facilitating entrance in the subarachnoid space. A lumbar intrathecal catheter was placed to maintain a low pressure at the cervical dural puncture site by draining 10 mL cerebrospinal fluid per hour. After removal of the lumbar drain, the patient experienced symptoms consistent with postdural puncture headache. Magnetic resonance imaging of the spine could not reveal the location of the possible leak. A lumbar epidural blood patch alleviated all complaints. One month later the patient underwent surgery successfully. We hypothesize that ultrasound imaging may have prevented this complication.

Hospitalization costs ofTAVI in one Belgian university hospital.

OBJECTIVE: Considering the sizeable cost of transcatheter aortic valve implantation (TAVI) and conflicting cost-effectiveness studies, it is useful to gain more insight into the cost structure of the TAVI hospitalization. This study provides such a cost analysis and starts to evaluate options to soften the hospitalization cost burden in order to make TAVI economically more feasible. METHODS: Costs forTAVI hospitalization in the University Hospital of Antwerp were analysed uni- and bivariately. Graphical and numerical displays of the data are supplemented with the non-parametric Wilcoxon rank sum statistic and Spearman rank rho correlation. RESULTS: Overall, 47 percent of the cost could be attributed to the implanted valve and 21 percent was accounted for by the room costs. Further, costs seemed highly insensitive to pre-existing patient characteristics. Only patients with pulmonary hypertension were characterized with systematically higher costs (Wilcoxon rank sum P-value of 0.049). Complications related to TAVI had a significant upward impact on the costs and there was also evidence for a learning effect on total costs. CONCLUSIONS: In general the analyses showed that only limited options remain for cost reduction of the TAVI hospitalization cost. The most promising option is the reduction of the valve price. Avoidance of complications is hard to achieve given the current state of the art although this would significantly reduce overall costs.

Variable clinical expression of a Belgian TGFB3 founder variant suggests the presence of a genetic modifier.

Background: TGFB3 variants cause Loeys-Dietz syndrome type 5, a syndromic form of thoracic aortic aneurysm and dissection. The exact disease phenotype is hard to delineate because of few identified cases and highly variable clinical representation. Methodology: We provide the results of a haplotype analysis and a medical record review of clinical features of 27 individuals from 5 different families, originating from the Campine region in Flanders, carrying the NM_003239.5(TGFB3):c.787G>C p.(Asp263His) likely pathogenic variant, dbSNP:rs796051886, ClinVar:203492. The Asp263 residue is essential for integrin binding to the Arg-Gly-Asp (RGD) motif of the TGFß3-cytokine. Results: The haplotype analysis revealed a shared haplotype of minimum 1.92 Mb and maximum 4.14 Mb, suggesting a common founder originating >400 years ago. Variable clinical features included connective tissue manifestations, non-aneurysmal cardiovascular problems such as hypertrophic cardiomyopathy, bicuspid aortic valve, mitral valve disease, and septal defects. Remarkably, only in 4 out of the 27 variant-harboring individuals, significant aortic involvement was observed. In one family, a 31-year-old male presented with type A dissection. In another family, the male proband (65 years) underwent a Bentall procedure because of bicuspid aortic valve insufficiency combined with sinus of Valsalva of 50 mm, while an 80-year-old male relative had an aortic diameter of 43 mm. In a third family, the father of the proband (75 years) presented with ascending aortic aneurysm (44 mm). Conclusion: The low penetrance (15%) of aortic aneurysm/dissection suggests that haploinsufficiency alone by the TGFB3 variant may not result in aneurysm development but that additional factors are required to provoke the aneurysm phenotype.

Q fever infection: inflammatory aortic root aneurysm in an HIV positive patient.

We describe a case of Q fever infection with an inflammated proximal ascending aortic aneurysm in an HIV-infected patient. The patient was treated with aortic root replacement and medication for Q fever, a combination of doxycycline and hydroxychloroquine in addition to highly active antiretroviral therapy. The combination of Q fever and HIV infection has rarely been documented. A case of Q fever infection of a proximal ascending aorta aneurysm in a patient with HIV co-infection has never been described before.

Computed tomography measured psoas muscle attenuation predicts mortality after transcatheter aortic valve implantation.

AIMS: The aim of this study was to determine if computed tomography (CT) psoas muscular attenuation measurements may predict all-cause mortality in patients undergoing TAVI. METHODS: Ninety-four consecutive patients undergoing TAVI were analysed. The CT axial slice at the level of the fourth lumbar vertebra was selected. The psoas muscle areas were manually contoured. The circumferential surface area (CSA) of both psoas muscles was determined by selecting the voxels with attenuation values, ranging from 0 to 100 Hounsfield Units (HU). The mean CT attenuation coefficient of the psoas muscle (Psoas mean HU) was measured. The muscle was subdivided into a low-density muscle (LDM) (0-29 HU) and high-density muscle (HDM) (30-100 HU) portion. The HDM/LDM ratio was calculated. We searched for a correlation between HDM/LDM, CSA LDM (%), Psoas mean HU and all-cause mortality. RESULTS: The mean age was 81.2 ±â€Š7.5 years. Thirty patients had adverse outcome (all-cause mortality). Compared with patients with the lowest CSA LDM (%), patients in the third and second tertiles had an increased hazard ratio for mortality (2.871; 95% confidence interval 0.880-9.371 and 5.044; 95% confidence interval 1.641-15.795, respectively) in a multivariable model with EuroSCORE II, Barthel frailty index and CSA LDM (%) (P = 0.231, 0.097 and 0.019, respectively). HDM/LDM and Psoas mean HU (as continuous variable) were also independent predictors of all-cause mortality (P = 0.019, P = 0.013, respectively). CONCLUSION: CSA LDM (%), Psoas mean HU and HDM/LDM are independent and incremental predictors of all-cause mortality in patients undergoing TAVI.

Adiponectin serum level is an independent and incremental predictor of all-cause mortality after transcatheter aortic valve replacement.

BACKGROUND: Quantifiable biomarkers may be useful for a better risk and frailty assessment of patients referred for transcatheter aortic valve implantation (TAVI). HYPOTHESIS: To determine if adiponectin serum concentration predicts all-cause mortality in patients undergoing TAVI. METHODS: 77 consecutive patients, undergoing TAVI, were analyzed. The CT axial slices at the level of the fourth lumbar vertebra were used to measure the psoas muscle area, and its low-density muscle fraction (LDM (%)). To assess the operative risk, the STS (Society of Thoracic Surgeons Predicted Risk of Mortality) score, Log. Euroscore, and Euroscore II were determined. A clinical frailty assessment was performed. ELISA kits were used to measure adiponectin serum levels. We searched for a correlation between serum adiponectin concentration and all-cause mortality after TAVI. RESULTS: The mean age was 80.8 ± 7.4 years. All-cause mortality occurred in 22 patients. The mean follow-up was 1779 days (range: 1572-1825 days). Compared with patients with the lowest adiponectin level, patients in the third tertile had a hazards ratio of all-cause mortality after TAVI of 4.155 (95% CI: 1.364-12.655) (p = .004). In the multivariable model, including STS score, vascular access of TAVI procedure, LDM (%), and adiponectin serum concentration, serum adiponectin level, and LDM(%) were independent predictors of all-cause mortality after TAVI (p = .178, .303, .042, and .017, respectively). Adiponectin level was a predictor of all-cause mortality in females and males (p = .012 and 0.024, respectively). CONCLUSION: Adiponectin serum level is an independent and incremental predictor of all-cause mortality in patients undergoing TAVI.

Diagnostic yield of genetic testing in heart transplant recipients with prior cardiomyopathy.

BACKGROUND: The importance of genetic testing for cardiomyopathies has increased in the last decade. However, in heart transplant patients with former cardiomyopathy, genetic testing in retrospect is not routinely performed. We hypothesize that the yield of genetic testing in this population is considerable, and will have a major impact for both patients and relatives. METHODS: Patients that underwent heart transplantation (HTx) between 1995 and 2020 and were still in follow-up, were offered genetic testing if the primary etiology was non-ischemic cardiomyopathy. Next generation sequencing (NGS) of known cardiomyopathy genes was performed and variants were classified as variant of unknown significance (class 3), likely pathogenic (class 4) or pathogenic (class 5) variant. RESULTS: Of the 99 HTx patients in active follow-up, only 6 patients had a genetic diagnosis at the time of HTx. In this study, 31 selected patients with prior non-ischemic cardiomyopathy underwent genetic testing post HTx. 23/31 patients (74.2%) carried a variant that was classified as class 3 or higher. In 12/31 patients a class 4/5 variant (38.7%) was identified, and in 11/31 patients (35.5%) a class 3 variant. Class 5 Variants in TTN were the most prevalent (7/31), followed by class 5 variants in MYBPC3 (2/31). A positive family history was present in 21/31 (67.7%) and a second precipitating factor (e.g., alcohol abuse, pregnancy) was present in 17/31 patients (54.8%). Diagnostic yield of genetic testing was similar between patients with or without familial history and/or second hit. Through cascade screening 48 family members were screened for presence of a class 4/5 variant, of whom 19 (39.6%) were genotype positive, of whom 10 (52.6%) showed a cardiac phenotype. Appropriate follow-up was offered. CONCLUSIONS: Genetic testing for cardiomyopathy genes established a molecular diagnosis in 38.7% of patients post HTx. These results highlight the importance of genetic testing in this population as it is still often overlooked in patients that already underwent HTx in the past. Genetic testing is highly recommended, independent of family history or second precipitating factors, as it might identify relatives at risk.

Late infective endocarditis of an atrial septal occluder device presenting as a cystic mass.

We report an atypical echocardiographic presentation of a vegetation in a patient with late infective endocarditis of an atrial septal defect (ASD) occluder device. Transesophageal echocardiography demonstrated a penduculated mass attached to the left atrial side of the occluder device. This mass presented as an oscillating echo free area surrounded by a membrane attached to the device by a thin stalk. At time of surgical excision, the lesion did not present as a spherical cyst. It was assumed that the content of the echo free mass had already emptied into the left atrium. Histopathology diagnosed the mass as a vegetation. The contribution of contrast echocardiography to the evaluation of intracardiac masses is briefly discussed.

The deleterious effects of smoking resumption after heart transplantation.

AIMS: Smoking is linked to disease and survival in the general and transplant population. We studied the smoking history, disease and survival of patients after heart transplantation. METHODS: A total of 130 patients who underwent heart transplantation between 1995 and 2019 received a questionnaire to document their smoking history. We assessed patient characteristics, comorbidities and survival. RESULTS: Sixty-five per cent of patients were active or former smokers prior to heart transplantation. All patients stopped smoking; 26% of the former smokers resumed smoking after transplantation. Patients who resumed smoking were younger at the time of transplantation, used fewer statins and were more likely to be treated with azathioprine after transplantation. The mean follow-up for all patients was 11 ± 5.5 years. Patients who resumed smoking were more likely to develop solid organ cancers (45%) compared to those who remained abstinent (23%) and those who never smoked (13%) (p 0.014). A Cox proportional hazards regression analysis identified smoking resumption, with a RR of 2.31 (1.14-4.68, p 0.02), and age at transplantation, with a RR of 1.03 (1-1.06, p 0.034), as significant for survival. Patients resuming smoking after transplantation had a significantly higher risk of dying from solid organ cancer, with a RR of 2.54 (1.03, 6.28; p 0.04) with a short median survival time (25th-75th percentile) of (1 (0-5) months, p 0.007). CONCLUSION: Patients who resume smoking after heart transplantation have worse survival and are at higher risk of dying from solid organ cancer. Implementing a smoking cessation plan throughout the post-transplant period is important.

Study design and rationale of the pAtients pResenTing with cOngenital heaRt dIseAse Register (ARTORIA-R).

AIM: Due to improved therapy in childhood, many patients with congenital heart disease reach adulthood and are termed adults with congenital heart disease (ACHD). ACHD often develop heart failure (HF) as a consequence of initial palliative surgery or complex anatomy and subsequently require advanced HF therapy. ACHD are usually excluded from trials evaluating heart failure therapies, and in this context, more data about heart failure trajectories in ACHD are needed to guide the management of ACHD suffering from HF. METHODS AND RESULTS: The pAtients pResenTing with cOngenital heaRt dIseAse Register (ARTORIA-R) will collect data from ACHD evaluated or listed for heart or heart-combined organ transplantation from 16 countries in Europe and the Asia/Pacific region. We plan retrospective collection of data from 1989-2020 and will include patients prospectively. Additional organizations and hospitals in charge of transplantation of ACHD will be asked in the future to contribute data to the register. The primary outcome is the combined endpoint of delisting due to clinical worsening or death on the waiting list. The secondary outcome is delisting due to clinical improvement while on the waiting list. All-cause mortality following transplantation will also be assessed. The data will be entered into an electronic database with access to the investigators participating in the register. All variables of the register reflect key components important for listing of the patients or assessing current HF treatment. CONCLUSION: The ARTORIA-R will provide robust information on current management and outcomes of adults with congenital heart disease suffering from advanced heart failure.

Depressed expression of MuRF1 and MAFbx in areas remote of recent myocardial infarction: a mechanism contributing to myocardial remodeling?

Ventricular remodeling following myocardial infarction (MI) includes myocardial hypertrophy, a process requiring increased protein synthesis and sarcomere assembly. The anti-hypertrophic effect of MuRF1/MafBx, both muscle-specific E3-ubiquitin ligases, has been demonstrated in animal experiments and in cultured cardiomyocytes. We assessed MuRF1/MAFbx expression in myocardium remote of recently (<2 weeks) infarcted regions (MI), compared with patients undergoing coronary artery bypass surgery, with normal systolic function and without previous infarction (control or Con). Left ventricular myocardial biopsies were obtained from the contralateral normal zone in MI (n = 14) patients and from the Con (n = 12) group. MuRF-1/MAFbx expression was assessed using RT-PCR and Western blot (WB). In addition, the myocardial expression of TNF-alpha was measured (RT-PCR) and troponin I, beta-myosin and phosphorylated Akt/Akt (pAkt/Akt) were quantified (WB). MuRF1 and MAFbx expression (mRNA and protein level) were significantly reduced in biopsies from MI patients. TNF-alpha was significantly higher in MI and exhibited a negative correlation with MuRF1 and MAFbx. The expression of troponin I and cardiomyocyte size were increased in MI in comparison to Con, whereas beta-myosin expression was not altered. When compared with Con, pAkt/Akt was elevated. The results of the present study suggest that the atrogenes MuRF1/MAFbx are involved in regulating the hypertrophic response, characteristic of the early post-infarction remodeling phase. Reduced expression of MuRF1 and MAFbx in the myocardium might permit hypertrophy, which is supported by the elevation of troponin I. A regulatory role of TNF-alpha needs to be confirmed in further experiments.