The effect of early follow-up after open cardiac surgery in a student clinic.

Objectives. Readmission rates following open cardiac surgery are high, affecting patients and the cost of care. This study aimed to investigate the effect of early additional follow-up after open cardiac surgery when 5th-year medical students conducted follow-ups under the supervision of physicians. The primary endpoint was unplanned cardiac-related readmissions within one year. The secondary outcomes were the detection of impending complications and health-related quality of life (HRQOL). Methods. Patients undergoing open cardiac surgery were prospectively included. For intervention, additional follow-up visits, including point-of-care ultrasound, were conducted by supervised 5th-year medical students on postoperative days 3, 14 and 25. Unplanned cardiac-related readmissions, including emergency department visits, were registered within the first year of surgery. Danish National Health Survey 2010 questionnaire was used for HRQOL. In standard follow-up, all patients were seen 4-6 weeks postoperative. Results. For data analysis, 100 of 124 patients in the intervention group and 319 of 335 patients in the control group were included. The 1-year unplanned readmission rates did not differ; 32% and 30% in the intervention and control groups, respectively (p = 0.71). After discharge, 1% of patients underwent pericardiocentesis. The additional follow-up initiated scheduled drainage, contrary to more unscheduled/acute drainages in the control group. Pleurocentesis was more common in the intervention group (17% (n = 17) vs 8% (n = 25), p = 0.01) and performed earlier. There was no difference between groups on HRQOL. Conclusion. Supervised student-led follow-up of newly cardiac-operated patients did not alter readmission rates or HRQOL but may detect complications earlier and initiate non-emergent treatment of complications.

Scoring systems in the prediction of atrial fibrillation recurrence after surgical ablation.

INTRODUCTION: More than every third patient experiences recurrent atrial fibrillation after surgical pulmonary vein ablation. However, it remains challenging to predict who will and who will not experience this event. Scoring systems containing baseline risk factors have been proposed as a complementary tool to identify patients at higher risk of experiencing atrial fibrillation recurrence. Therefore, the aim of this study was to assess the value of the scoring systems APPLE, CHA2 DS2 -VASc, and CHADS2 in predicting atrial fibrillation recurrence following surgical ablation. METHODS: In a retrospective study, we identified all patients undergoing concomitant pulmonary vein ablation during cardiac surgery. APPLE-, CHA2 DS2 -VASc-, and CHADS2 scores were calculated for each patient. Subsequently, the predictive value of the scoring systems on atrial fibrillation recurrence 3-12 months postablation was assessed using receiver operating characteristic curves and logistic regression analyses. RESULTS: Receiver operating characteristic curves showed the superiority of the APPLE scoring system with an area under the curve of 0.690 compared to 0.571 for CHA2 DS2 -VASc and 0.569 for CHADS2 , p = .01. Using logistic regression analyses, APPLE and CHA2 DS2 -VASc were predictors of atrial fibrillation recurrence between 3- and 12 months after surgical ablation (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.39-2.67, p < .01 and OR 1.17, 95% CI 1.01-1.36, p = .04, respectively). CONCLUSIONS: The APPLE scoring system is superior to CHA2 DS2 -VASc and CHADS2 in predicting atrial fibrillation recurrence after surgical ablation. It can be used as a complementary tool to select the right candidates for surgical ablation and identify patients who need more frequent clinical and electrocardiogram controls.

Biatrial ablation vs. Pulmonary vein isolation in atrial fibrillation patients undergoing cardiac surgery: a retrospective study.

OBJECTIVES: Surgical ablation is an established treatment for patients with atrial fibrillation undergoing cardiac surgery. This study aimed to compare postoperative rhythm outcomes and pacemaker implantation rates after biatrial ablation or pulmonary vein isolation (PVI) concomitantly with other cardiac surgery. Design: In a retrospective study, we included patients who underwent biatrial ablation or PVI. Postoperative rhythm status was assessed by Holter monitoring. All data on outcomes and patient characteristics were collected retrospectively. Results: In total 109 patients had a biatrial procedure whereas 337 had PVI performed. In patients with persistent/long-standing persistent atrial fibrillation, freedom from atrial fibrillation was more common after biatrial ablation than after PVI (63% and 45%, respectively; p = .039). Postoperative permanent pacemaker implantation was more common after biatrial ablation (12% and 6%, respectively; p = .039), compared to PVI. Age < 65 years (OR:2.0, 95% CI:1.1-3.6) was a predictor of freedom from atrial fibrillation in the biatrial group, whereas absence of left atrial dilatation (OR:1.8, 95% CI:1.1-3.2) and HAS-BLED score < 2 (OR:1.9, 95% CI:1.0-3.8) were significant predictors of freedom from atrial fibrillation in the PVI group. Conclusions: In patients with persistent/long-standing persistent atrial fibrillation, biatrial ablation is more effective than PVI in terms of obtaining freedom from postoperative atrial fibrillation. Although our groups were heterogenic in terms of concomitant surgery, our study also indicates that the risk of needing a permanent pacemaker is higher after biatrial ablation, compared to PVI. Therefore, our study highlights that the decision between biatrial ablation or PVI should be performed on an individual basis.

Long-term neurodevelopmental effects of intraoperative blood pressure during surgical closure of a septal defect in infancy or early childhood.

BACKGROUND: Many children born with congenital heart defects are faced with cognitive deficits and psychological challenges later in life. The mechanisms behind are suggested to be multifactorial and are explained as an interplay between innate and modifiable risk factors. The aim was to assess whether there is a relationship between mean arterial pressure during surgery of a septal defect in infancy or early childhood and intelligence quotient scores in adulthood. METHODS: In a retrospective study, patients were included if they underwent surgical closure of a ventricular septal defect or an atrial septal defect in childhood between 1988 and 2002. Every patient completed an intelligence assessment upon inclusion, 14-27 years after surgery, using the Wechsler Adult Intelligence Scale Version IV. RESULTS: A total of 58 patients met the eligibility criteria and were included in the analyses. No statistically significant correlation was found between blood pressure during cardiopulmonary bypass and intelligence quotient scores in adulthood (r = 0.138; 95% CI-0.133-0.389). Although amongst patients with mean arterial pressure < 40 mmHg during cardiopulmonary bypass, intelligence quotient scores were significantly lower (91.4; 95% CI 86.9-95.9) compared to those with mean arterial pressure > 40 mmHg (99.8; 95% CI 94.7-104.9). CONCLUSIONS: Mean arterial pressure during surgery of ventricular septal defects or atrial septal defects in childhood does not correlate linearly with intelligence quotient scores in adulthood. Although there may exist a specific cut-off value at which low blood pressure becomes harmful. Larger studies are warranted in order to confirm this, as it holds the potential of partly relieving CHD patients of their cognitive deficits.

Preoperative CHA2DS2-VASc Score is Associated With Postoperative Survival Following Surgical Ablation Concomitantly With Other Cardiac Surgery.

BACKGROUND: The CHA2DS2-VASc scoring system has been shown to predict long-term outcomes in patients undergoing catheter ablation but has not yet been investigated for patients undergoing surgical ablation. Therefore, the objective was to evaluate the ability of CHA2DS2-VASc to predict long-term outcomes after surgical ablation. METHOD: In a retrospective study, patients were included if they underwent surgical ablation concomitantly with other cardiac surgery. Patients were divided into low-risk (score 0-1), medium-risk (score 2-4) and high-risk (score ≥5) groups based on their CHA2DS2-VASc score. Data on survival, atrial fibrillation (AF) recurrence, and stroke were collected retrospectively at the end of the follow-up period. RESULTS: A total of 587 patients underwent surgical ablation concomitantly with other cardiac surgery. Survival analysis revealed a difference between the three stratified CHA2DS2-VASc risk groups, (p<0.001). Similarly, there was a difference in AF recurrence rates between stratified CHA2DS2-VASc groups among patients with persistent/long-standing persistent AF (p=0.018). There were no statistically significant differences between stratified CHA2DS2-VASc risk groups in terms of recurrence rates of paroxysmal AF or stroke. Finally, the CHA2DS2-VASc scoring system was an independent predictor of 5-year mortality after adjusting for potential confounders (hazard ratio 1.25; p=0.002). CONCLUSIONS: Preoperative CHA2DS2-VASc scores were associated with postoperative survival in patients undergoing surgical ablation for AF. Post-hoc analyses showed that CHA2DS2-VASc was also a predictor of AF recurrence in patients with persistent/long-standing persistent AF. However, this needs to be confirmed in a prospective study.

Discontinuation of anticoagulants after successful surgical ablation of atrial fibrillation.

BACKGROUND: The decision of whether to continue oral anticoagulation therapy (OAT) after successful surgical ablation of atrial fibrillation is challenging, and current guidelines provide no specific recommendations on whether or not it is safe to terminate OAT. Therefore, the aim of this study was to assess long-term outcomes in patients who either did or did not, receive OAT after surgical ablation of atrial fibrillation. METHODS: In a prospective follow-up study, patients were included if surgical ablation of atrial fibrillation concomitantly with other cardiac surgery was done, between 2004 and 2018 at Aarhus University Hospital, Denmark. After 12 months, OAT was discontinued if: (a) sinus rhythm was documented by electrocardiogram, (b) atrial fibrillation was absent on 5-day Holter monitoring, (c) CHADS2 score ≤2, and (d) no other indications for OAT were present. Follow-up was ended in April 2019. RESULTS: A total of 560 patients underwent surgical ablation of which 436 patients reached the baseline at 12 months; 286 patients received OAT, and 150 had OAT discontinued. Survival analysis revealed no differences between the two groups (P = .723). Mean survival time in the group receiving OAT was 5.3 ± 3.3 years, compared to 5.1 ± 3.0 years in the group where OAT was discontinued (P = .784). There was no difference in major adverse cardiac and cerebrovascular events between the two groups (P = .846). CONCLUSION: Discontinuation of OAT is safe in patients with a CHADS2 score ≤2 following successful surgical ablation and left atrial appendage occlusion. This conclusion needs to be confirmed in randomized trials.

Disappearance of the shunt and lower cardiac index during exercise in small, unrepaired ventricular septal defects.

OBJECTIVES: Clinical studies have revealed decreased exercise capacity in adults with small, unrepaired ventricular septal defects. Increasing shunt ratio and growing incompetence of the aortic and pulmonary valve with retrograde flow during exercise have been proposed as reasons for the previously found reduced exercise parameters. With MRI, haemodynamic shunt properties were measured during exercise in ventricular septal defects. METHODS: Patients with small, unrepaired ventricular septal defects and healthy peers were examined with MRI during exercise. Quantitative flow scans measured blood flow through ascending aorta and pulmonary artery. Scans were analysed post hoc where cardiac index, retrograde flows, and shunt ratio were determined. RESULTS: In total, 32 patients (26 ± 6 years) and 28 controls (27 ± 5 years) were included. The shunt ratio was 1.2 ± 0.2 at rest and decreased to 1.0 ± 0.2 at peak exercise, p < 0.01. Aortic cardiac index was lower at peak exercise in patients (7.5 ± 2 L/minute/m2) compared with controls (9.0±2L l/minute/m2), p<0.01. Aortic and pulmonary retrograde flow was larger in patients during exercise, p < 0.01. Positive correlation was demonstrated between aortic cardiac index at peak exercise and previously established exercise capacity for all patients (r = 0.5, p < 0.01). CONCLUSIONS: Small, unrepaired ventricular septal defects revealed declining shunt ratio with increasing exercise and lower aortic cardiac index. Patients demonstrated larger retrograde flow both through the pulmonary artery and the aorta during exercise compared with controls. In conclusion, adults with unrepaired ventricular septal defects redistribute blood flow during exercise probably secondary to a more fixed pulmonary vascular resistance compared with age-matched peers.

Propofol Attenuates the Myocardial Protection Properties of Desflurane by Modulating Mitochondrial Permeability Transition.

BACKGROUND: Desflurane and propofol are cardioprotective, but relative efficacy is unclear. The aim was to compare myocardial protection of single, simultaneous, and serial administration of desflurane and propofol. METHODS: Sixty New Zealand White rabbits and 65 isolated Sprague Dawley rat hearts randomly received desflurane, propofol, simultaneous desflurane and propofol, or sequential desflurane then propofol. Rabbits were subdivided to receive either ischemia-reperfusion with temporary occlusion of the left anterior descending artery or a time-matched, nonischemic perfusion protocol, whereas rat hearts were perfused in a Langendorff model with global ischemia-reperfusion. End points were hemodynamic, functional recovery, and mitochondrial uptake of H-2-deoxy-D-glucose as an indicator of mitochondrial permeability transition. RESULTS: In rabbits, there were minimal increases in preload-recruitable stroke-work with propofol (P < .001), desflurane (P < .001), and desflurane-and-propofol (P < .001) groups, but no evidence of increases with pentobarbitone (P = .576) and desflurane-then-propofol (P = .374). In terms of end-diastolic pressure-volume relationship, there was no evidence of increase compared to nonischemic controls with desflurane-then-propofol (P = .364), a small but significant increase with desflurane (P < .001), and larger increases with pentobarbitone (P < .001), propofol (P < .001), and desflurane-and-propofol (P < .001).In rat hearts, there was no statistically significant difference in mitochondrial H-activity between propofol and desflurane-and-propofol (165 ± 51 × 10 vs 154 ± 51 × 10 g·mL·min/µmol; P = .998). Desflurane had lower uptake than propofol (65 ± 21 × 10 vs 165 ± 51 × 10 g·mL·min/µmol; P = .039), but there was no statistically significant difference between desflurane and desflurane-then-propofol (65 ± 21 × 10 vs 59 ± 11 × 10 g·mL·min/µmol; P = .999). CONCLUSIONS: Propofol and desflurane are cardioprotective, but desflurane is more effective than propofol. The added benefit of desflurane is lost when used simultaneously with propofol.

Biventricular morphology in adults born with a ventricular septal defect.

Ventricular septal defects - large, surgically closed or small, untreated - have demonstrated lower peak exercise capacity compared with healthy controls. The mechanisms behind these findings are not yet fully understood. Therefore, we evaluated biventricular morphology in adults with a ventricular septal defect using MRI. Adults with either childhood surgically closed or small, untreated ventricular septal defects and healthy controls underwent cine MRI for the evaluation of biventricular volumes and quantitative flow scans for measurement of stroke index. Scans were analysed post hoc in a blinded manner. In total, 20 operated patients (22±2 years) and 20 healthy controls (23±2 years) were included, along with 32 patients with small, unrepaired ventricular septal defects (26±6 years) and 28 controls (27±5 years). Operated patients demonstrated larger right ventricular end-diastolic volume index (103±20 ml/m2) compared with their controls (88±16 ml/m2), p=0.01. Heart rate and right ventricular stroke index did not differ between operated patients and controls. Patients with unrepaired ventricular septal defects revealed larger right ventricular end-diastolic volume index (105±17 ml/m2) compared with their controls (88±13 ml/m2), p<0.01. Furthermore, right ventricular stroke index was higher in unrepaired ventricular septal defects (53±12 ml/minute/m2) compared with controls (46±8 ml/minute/m2), p=0.02, with similar heart rates. Both patient groups' right ventricles were visually characterised by abundant coarse trabeculation. Positive correlations were demonstrated between right ventricular end-diastolic volume indices and peak exercise capacity in patients. Left ventricle measurements displayed no differences between groups. In conclusion, altered right ventricular morphology was demonstrated in adults 20 years after surgical ventricular septal defect repair and in adults with small, untreated ventricular septal defects.

A Pilot Assessment of 3 Point-of-Care Strategies for Diagnosis of Perioperative Lung Pathology.

BACKGROUND: Lung ultrasonography is superior to clinical examination and chest X-ray (CXR) in diagnosis of acute respiratory pathology in the emergency and critical care setting and after cardiothoracic surgery in intensive care. Lung ultrasound may be useful before cardiothoracic surgery and after discharge from intensive care, but the proportion of significant respiratory pathology in this setting is unknown and may be too low to justify its routine use. The aim of this study was to determine the proportion of clinically significant respiratory pathology detectable with CXR, clinical examination, and lung ultrasound in patients on the ward before and after cardiothoracic surgery. METHODS: In this prospective observational study, patients undergoing elective cardiothoracic surgery who received a CXR as part of standard care preoperatively or after discharge from the intensive care unit received a standardized clinical assessment and then a lung ultrasound examination within 24 hours of the CXR by 2 clinicians. The incidence of collapse/atelectasis, consolidation, alveolar-interstitial syndrome, pleural effusion, and pneumothorax were compared between clinical examination, CXR, and lung ultrasound (reference method) based on predefined diagnostic criteria in 3 zones of each lung. RESULTS: In 78 participants included, presence of any pathology was detected in 56% of the cohort by lung ultrasound; 24% preoperatively and 94% postoperatively. With lung ultrasound as a reference, the sensitivity of the 5 different pathologies ranged from 7% to 69% (CXR), 7% to 76% (clinical examination), and 14% to 94% (combined); the specificity of the 5 different pathologies ranged from 91% to 98% (CXR), from 90% to 99% (clinical examination), and from 82% to 97% (combined). For clinical examination and lung ultrasound, intraobserver agreements beyond chance ranged from 0.28 to 0.70 and from 0.84 to 0.97, respectively. The agreements beyond chance of pathologic diagnoses between modalities ranged from 0.11 to 0.64 (CXR and lung ultrasound), from 0.08 to 0.7 (CXR and lung ultrasound), and from 0 to 0.58 (clinical examination and CXR). CONCLUSIONS: Clinically important respiratory pathology is detectable by lung ultrasound in a substantial number of noncritically ill, pre or postoperative cardiothoracic surgery participants with high estimate of interobserver agreement beyond that expected by chance, and we showed clinically significant diagnoses may be missed by the contemporary practice of clinical examination and CXR.

Impaired ventilatory efficiency after closure of atrial or ventricular septal defect.

OBJECTIVES: Atrial and ventricular septal defects are the most common congenital heart defects and the closing procedures share important similarities. Generally, the postoperative outcome is considered benign, but there is growing concern regarding late ventilatory function. Therefore, the aim of this review was to describe the ventilatory function in patients with open as well as percutaneously or surgically closed atrial and ventricular septal defects. METHODS: We performed a search protocol based on the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) guidelines. A data collection form was specifically developed and data were extracted from the included studies by a primary reviewer and cross-checked by the secondary reviewer. RESULTS: We found an increasing evidence of late impairment in ventilatory efficiency, and despite that ventilatory function is commonly normal at rest, abnormalities were disclosed during exercise. There are indices that surgical closure plays an important role. DISCUSSION: Atrial septal defect and ventricular septal defect patients have persisting, long-term impairment in ventilatory efficiency during exercise. Although the pathogenesis behind this finding may be multifactorial, there are indices that the surgical procedure may play an important role. Nevertheless, the literature is this field is sparse, and additional studies are needed.

Permanent chronotropic impairment after closure of atrial or ventricular septal defect.

OBJECTIVES: Atrial and ventricular septal defects are commonly closed surgically with low rates of post-operative morbidity, and the long-term outcome has widely been described as benign. Nevertheless, there is an increasing understanding of late morbidity, and the possibility of postoperative chronotropic impairment is continuously questioned. Furthermore, potentially abnormal chronotropic responses may be associated with the recently demonstrated overrepresentation of late arrhythmias. We conducted this review to methodically describe the potential effects of surgical defect closure on the chronotropic response to exercise. METHODS: We performed a search protocol based on the 'Preferred Reporting Items for Systematic Reviews and Meta- Analyses' (PRISMA) guidelines. A data collection form was specifically developed and data were extracted from the included studies by a primary reviewer and crosschecked by a secondary reviewer. RESULTS: A search of electronic databases revealed 16 publications, which consistently reported an abnormal heart rate responses to exercise after surgical closure. In contrast, these and other studies convincingly showed normal chronotropic response in un-operated patients as well as after percutaneous closure. Potential mechanisms include disturbances in the sinoatrial or atrioventricular conduction system and denervation in the proximity of the aorta during the surgical procedure. DISCUSSION: ASD and VSD patients have abnormal heart rate responses to exercise after surgical closure, which indicates a need of change in the preoperative information given to these patients and their parents before surgical defect closure. Although there may not be any alternatives to surgery, patients should still be informed about potential long-term consequences, including the risk of chronotropic incompetence. Moreover, this review suggests that 'specialized', long-term follow up may be indicated.

Exercise-based cardiac rehabilitation in surgically treated type-A aortic dissection patients.

OBJECTIVES: Surgically treated type-A aortic dissection patients are often restricted from physical exercise due to a lack of knowledge about the blood pressure increase. Our aims were to evaluate the hemodynamic responses during exercise, and to assess changes in peak oxygen uptake, maximal workload, and quality-of-life after completion of an exercise-based cardiac rehabilitation program. DESIGN: Three subgroups were retrospectively identified based on their different eligibility criteria. Group I (n = 10) had performed an exercise-based cardiac rehabilitation program including exercise tests. Group II (n = 9) had followed the program without the tests. Group III (n = 10) had neither been rehabilitated nor tested. For evaluation of hemodynamic parameters, we included a group of surgically treated patients with aortic valve stenosis, group IV (n = 32). Questionnaires were obtained to measure quality-of-life. RESULTS: At baseline the group I and IV mean systolic blood pressure changed from 143 ± 16 mmHg and 150 ± 16 mmHg to 200 ± 32 mmHg and 213 ± 27 mmHg, respectively. The group I mean peak oxygen uptake changed from 23.5 ± 7.9 ml/min/kg before rehabilitation to 28.6 ± 8.4 ml/min/kg, p = .001, after rehabilitation. The mean maximal workload changed from 143 ± 80 W before rehabilitation to 178 ± 97 W, p = .003, after rehabilitation. At follow-up, the groups I-III physical quality-of-life score was 45.1 ± 15.0, 40.0 ± 9.0, and 30.0 ± 11.3, p < .025, respectively, and the mental quality-of-life score was 51.1 ± 6, 41.7 ± 6.7, and 32.5 ± 13.3, p < .001, respectively. CONCLUSIONS: Our results suggest that type-A aortic dissection patients have hemodynamic responses to exercise that are comparable to other cardiovascular patients. Moreover, we found significant increases in peak oxygen uptake, maximal workload, and quality-of-life after ended ECR.

Assessment of Image Quality of Repeated Limited Transthoracic Echocardiography After Cardiac Surgery.

OBJECTIVES: The use of limited transthoracic echocardiography (TTE) has been restricted in patients after cardiac surgery due to reported poor image quality. The authors hypothesized that the hemodynamic state could be evaluated in a high proportion of patients at repeated intervals after cardiac surgery. DESIGN: Prospective observational study. SETTING: Tertiary university hospital. PARTICIPANTS: The study comprised 51 patients aged 18 years or older presenting for cardiac surgery. INTERVENTIONS: Patients underwent TTE before surgery and at 3 time points after cardiac surgery. Images were assessed offline using an image quality scoring system by 2 expert observers. Hemodynamic state was assessed using the iHeartScan protocol, and the primary endpoint was the proportion of limited TTE studies in which the hemodynamic state was interpretable at each of the 3 postoperative time points. MEASUREMENTS AND MAIN RESULTS: Hemodynamic state interpretability varied over time and was highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). This variation in interpretability over time was reflected in all 3 transthoracic windows, ranging from 43% to 80% before surgery and from 2% to 35% on the first postoperative day (p<0.01). Image quality scores were highest with the apical window, ranging from 53% to 77% across time points, and lowest with the subcostal window, ranging from 4% to 70% across time points (p< 0.01). CONCLUSIONS: Hemodynamic state can be determined with TTE in a high proportion of cardiac surgery patients after extubation and removal of surgical drains.

Impaired cardiac output during exercise in adults operated for ventricular septal defect in childhood: a hitherto unrecognised pathophysiological response.

BACKGROUND: Recent studies have demonstrated that surgical ventricular septal defect closure in childhood is associated with reduced functional capacity and disruption of the right ventricular force-frequency relationship during exercise. To further describe long-term cardiac function, we performed a non-invasive assessment of cardiac index during exercise in adults having undergone surgery for ventricular septal defect in early childhood. METHODS: A total of 20 patients (surgical age 2.1±1.4 years, age at examination 22.1±2.2 years) and 20 healthy, matched controls (23.4±2.1 years at examination) underwent continuous supine bicycle ergometry during MRI. Their blood flow was recorded in the ascending aorta and the pulmonary trunk at increasing exercise levels. Cardiac index, retrograde flow, and vessel diameters were determined by blinded, post hoc analyses. RESULTS: The patient group had normal cardiac index at rest (2.9±0.7 L/minute/m2), which was comparable with that of the controls (3.0±0.6 L/minute/m2); however, they had a lower increase in cardiac index during exercise (reaching 7.3±1.3 L/minute/m2 at submaximal exercise) compared with controls (8.2±1.2 L/minute/m2), p<0.05. Patients had a significantly higher ascending aorta retrograde flow than controls at rest and throughout exercise. In the pulmonary artery, the retrograde flow was minimal at rest in both groups, but increased significantly in patients during exercise compared with controls. CONCLUSIONS: Young adults with a surgically closed ventricular septal defect have a reduced cardiac index during exercise compared with healthy, young adults. The impaired cardiac index appears to be related to an increasing retrograde flow in the pulmonary artery with progressive exertion.

Health-related quality-of-life after transapical transcatheter aortic valve implantation.

PURPOSE: Transcatheter aortic valve implantation (TA-TAVI) is a well-established treatment for aortic valve stenosis in high-risk patients and indications have been continuously expanding to also include intermediate-risk patients. However, in low-risk patients, experiences are still sparse and although clinical outcomes have been shown favorable results, HRQoL has remained unexplored. The aim of this report was to describe the long-term health-related quality-of-life (HRQoL) in low-risk patients randomized to TA-TAVI or surgical aortic valve replacement (SAVR). METHODS: In a prospective, randomized trial, patients with aortic valve stenosis were randomized to either TA-TAVI or SAVR. TA-TAVI was performed through a mini thoracotomy with the introduction of prosthesis via the apex of the heart and antegradely advancement over the pre-dilated native valve. SAVR was performed during cardiopulmonary bypass with resection of the native valve and replacement with a prosthesis valve through a median sternotomy. Afterwards, patients were followed yearly with echocardiography and HRQoL assessment. RESULTS: A total of 58 patients were included; 29 patients for TA-TAVI and 29 patients for SAVR. The only difference in HRQoL was found in the physical component summary after 1 year; 44 ± 9 in the TA-TAVI group compared with 36 ± 9 in the SAVR group, p = .03. There were no differences in any of the remaining timepoints in neither physical nor mental component summary, p = .19 and p = .98, respectively, and there were no differences in survival during the 5 years. CONCLUSIONS: In low-risk patients with aortic valve stenosis undergoing TA-TAVI, no differences appeared in HRQoL compared with SAVR during a 5-year follow-up period.

Citric Acid Cycle Metabolites Predict the Severity of Myocardial Stunning and Mortality in Newborn Pigs.

OBJECTIVES: Myocardial infarction and chronic heart failure induce specific metabolic changes in the neonatal myocardium that are closely correlated to outcome. The aim of this study was to examine the metabolic responses to noninfarct heart failure and inotropic treatments in the newborn heart, which so far are undetermined. DESIGN: A total of 28 newborn pigs were instrumented with a microdialysis catheter in the right ventricle, and intercellular citric acid cycle intermediates and adenosine metabolite concentrations were determined at 20-minute intervals. Stunning was induced by 10 cycles of 3 minutes of ischemia, which was performed by occluding the right coronary artery, followed by 3 minutes of reperfusion. Animals were randomized for treatment with epinephrine + milrinone, dopamine + milrinone, dobutamine, or saline. SETTING: University hospital animal laboratory. MAIN RESULTS: Ischemia-reperfusion induced right ventricular stunning and increased the concentrations of pyruvate lactate, succinate, malate, hypoxanthine, and xanthine (all, p < 0.01). During inotrope infusion, no differences in metabolite concentrations were detected between the treatment groups. In nonsurviving animals (n = 8), concentrations of succinate (p < 0.0001), malate (p = 0.009), and hypoxanthine (p = 0.04) increased compared with survivors, while contractility was significantly reduced (p = 0.03). CONCLUSIONS: Accumulation of citric acid cycle intermediates and adenosine metabolites reflects the presence of myocardial stunning and predicts mortality in acute noninfarct right ventricular heart failure in newborn pigs. This phenomenon occurs independently of the type of inotrope, suggesting that citric acid cycle intermediates represent potential markers of acute noninfarct heart failure.

Effects of milrinone and epinephrine or dopamine on biventricular function and hemodynamics in an animal model with right ventricular failure after pulmonary artery banding.

Right ventricular (RV) failure due to chronic pressure overload is a main determinant of outcome in congenital heart disease. Medical management is challenging because not only contractility but also the interventricular relationship is important for increasing cardiac output. This study evaluated the effect of milrinone alone and in combination with epinephrine or dopamine on hemodynamics, ventricular performance, and the interventricular relationship. RV failure was induced in 21 Danish landrace pigs by pulmonary artery banding. After 10 wk, animals were reexamined using biventricular pressure-volume conductance catheters. The maximum pressure in the RV increased by 113% (P < 0.0001) and end-diastolic volume by 43% (P < 0.002), while left ventricular (LV) pressure simultaneously decreased (P = 0.006). Concomitantly, mean arterial pressure (MAP; -16%, P = 0.01), cardiac index (CI; -23%, P < 0.0001), and mixed venous oxygen saturation (SvO2 ; -40%, P < 0.0001) decreased. Milrinone increased CI (11%, P = 0.008) and heart rate (HR; 21%, P < 0.0001). Stroke volume index (SVI) decreased (7%, P = 0.03), although RV contractility was improved. The addition of either epinephrine or dopamine further increased CI and HR in a dose-dependent manner but without any significant differences between the two interventions. A more pronounced increase in biventricular contractility was observed in the dopamine-treated animals. LV volume was reduced in both the dopamine and epinephrine groups with increasing doses In the failing pressure overloaded RV, milrinone improved CI and increased contractility. Albeit additional dose-dependent effects of both epinephrine and dopamine on CI and contractility, neither of the interventions improved SVI due to reduced filling of the LV.

Effects of milrinone and epinephrine or dopamine on biventricular function and hemodynamics in right heart failure after pulmonary regurgitation.

Right ventricular failure (RVF) secondary to pulmonary regurgitation (PR) impairs right ventricular (RV) function and interrupts the interventricular relationship. There are few recommendations for the medical management of severe RVF after prolonged PR. PR was induced in 16 Danish landrace pigs by plication of the pulmonary valve leaflets. Twenty-three pigs served as controls. At reexamination the effect of milrinone, epinephrine, and dopamine was evaluated using biventricular conductance and pulmonary catheters. Seventy-nine days after PR was induced, RV end-diastolic volume index (EDVI) had increased by 33% (P = 0.006) and there was a severe decrease in the load-independent measurement of contractility (PRSW) (-58%; P = 0.003). Lower cardiac index (CI) (-28%; P < 0.0001), mean arterial pressure (-15%; P = 0.01) and mixed venous oxygen saturation (SvO2) (36%; P < 0.0001) were observed compared with the control group. The interventricular septum deviated toward the left ventricle (LV). Milrinone improved RV-PRSW and CI and maintained systemic pressure while reducing central venous pressure (CVP). Epinephrine and dopamine further improved biventricular PRSW and CI equally in a dose-dependent manner. Systemic and pulmonary pressures were higher in the dopamine-treated animals compared with epinephrine-treated animals. None of the treatments improved stroke volume index (SVI) despite increases in contractility. Strong correlation was detected between SVI and LV-EDVI, but not SVI and biventricular contractility. In RVF due to PR, milrinone significantly improved CI, SvO2, and CVP and increased contractility in the RV. Epinephrine and dopamine had equal inotropic effect, but a greater vasopressor effect was observed for dopamine. SV was unchanged due to inability of both treatments to increase LV-EDVI.