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Valve repair is the procedure of choice for congenital aortic valve disease. With increasing experience, the surgical armamentarium broadened from simple commissurotomy to more complex techniques. We report our 30-year experience with pediatric aortic valve repair. A retrospective chart review of all patients aged less than 18 years who underwent aortic valve repair from May 1985 to April 2020 was conducted. Mortality was cross-checked with the national health insurance database (96% complete mortality follow-up in April 2020). Primary study endpoints were survival and incidence of reoperations. From May 1985 until April 2020, 126 patients underwent aortic valve repair at a median age of 1.8 years (interquartile range, 0.2-10). Early mortality was 5.6% (7 of 126). All early deaths occurred in neonates with critical aortic stenosis undergoing commissurotomy. No early deaths were observed after 2002. Kaplan-Meier estimated survival was 90.8% (95% CI, 84.0-94.8) at 10 years, 86.9% (95% CI, 78.7-92.2) at 20 years, and 83.5% (95% CI, 71.7-90.6) at 30 years. The cumulative incidence of aortic valve replacement was 37% (95% CI, 27.7-46.3) at 10 years, 62.2% (95% CI, 50.1-72.1) at 20 years, and 67.4% (51.2-79.2) at 30 years. Nine patients had undergone re-repair of the aortic valve. The majority of valve replacements were Ross procedures. Our results support a repair-first strategy for patients with congenital heart disease and underline that aortic valve reconstruction can be a successful long-term solution. Longevity did not differ between aortic valve commissurotomy and complex aortic valve reconstruction. [Display omitted] [ABSTRACT FROM AUTHOR]

The optimal antiplatelet therapy for patients with chronic kidney disease (CKD) undergoing coronary artery bypass graft surgery remains unknown. This post hoc analysis of the Ticagrelor in Coronary Artery Bypass (TiCAB) trial examined the efficacy and safety of ticagrelor vs aspirin in patients with and patients without CKD. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), namely, the composite of cardiovascular death, stroke, myocardial infarction, or revascularization at 1 year after coronary artery bypass graft surgery. Secondary endpoints included individual components of the primary endpoint, all-cause death, and major bleeding. Chronic kidney disease was present in 276 of 1843 randomized patients (15%). Patients with CKD vs patients without CKD had higher 1-year rates of MACCE (13% vs 8.3%, hazard ratio [HR] 1.63; 95% confidence interval [CI], 1.12 to 2.39; P =. 01) and major bleeding (5.6% vs 3.1%, HR 1.84; 95% CI, 1.03 to 3.28; P =. 04). The 1-year rate of MACCE was increased with ticagrelor vs aspirin in patients with CKD (18.2% vs 8.9%, HR 2.15; 95% CI, 1.08 to 4.30; P =. 03), but not in patients without CKD (8.5% vs 8.1%, HR 1.05; 95% CI, 0.74 to 1.49; P =. 79; P interaction =.067). There was no difference in the 1-year rate of major bleeding with ticagrelor vs aspirin in patients with CKD (6.6% vs 4.7%, HR 1.44; 95% CI, 0.52 to 3.97; P =. 48) and patients without CKD (3.3% vs 2.9%, HR 1.14; 95% CI, 0.64 to 2.01; P =. 65). Among patients with CKD and coronary artery bypass graft surgery, those who received ticagrelor had a higher incidence of MACCE but a similar incidence of major bleeding compared with those who received aspirin. [ABSTRACT FROM AUTHOR]

Copeptin is a cleavage product of vasopressin. This study aimed to figure out if copeptin would be a suitable biomarker in patients with congenital heart disease in the postoperative course. The primary outcome endpoint of this study was the change in copeptin concentration perioperatively in patients with congenital heart disease after surgery, with the use of a cardiopulmonary bypass. Three blood samples were taken from 81 patients up to 6 years of age in order to evaluate changes in copeptin concentration. Significant increase of copeptin concentration was shown between the first and second blood draws as well as between the first and third blood draws (P s <.001). Additionally, positive and significant correlations (r ≥.27) between the cardiopulmonary bypass times, The Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery mortality category, the inotropic score, the duration of mechanical ventilation, the length of stay at the intensive care unit (ICU), the length of stay at the hospital, and the preoperative as well as the ICU copeptin levels were found. Copeptin showed a tendency to predict the clinical outcome of patients after congenital heart surgery. Patients with higher copeptin levels underwent more complex procedures, had longer cardiopulmonary bypass times, required more catecholamine support, needed longer time of invasive ventilation, and had longer overall stay and ICU stay. [ABSTRACT FROM AUTHOR]

Giant coronary artery aneurysms (GCAAs) are rare cardiovascular malformations that necessitate a multimodal, interdisciplinary diagnostic and individualized interventional approach. This report describes the case of a young, healthy patient with an idiopathic GCAA with pseudoaneurysmal protrusion into the right atrium that caused syncope, cardiac decompensation, and arrhythmia, which subsided postoperatively. [ABSTRACT FROM AUTHOR]

Unlike the vast amount of animal data available on the recellularization of allogenic decellularized heart valves (DHVs), there have only been sporadic histologic reports on such grafts in humans. Two experienced cardiac pathologists independently evaluated human specimens obtained during reoperation between December 2010 and April 2017 DHVs in seven categories after automated staining (scores: 0 to 6) in comparison with published data. An optimal result of 42 points was classified as 100%. We found that 364 DHVs, 236 decellularized pulmonary homografts (DPHs), and 128 decellularized aortic homografts (DAHs) were implanted, and freedom from explantation was 96.1% (DAH) and 98.7% (DPH). Reoperations were because of (suspected) endocarditis in 5 of 11 patients, stenosis at the subvalvular or valvular or supravalvular level in 3 of 11 patients, planned staged reoperation in 2 of 11 patients, and 1 heart transplantation. Good reader agreement was reflected by an interagreement weighted κ of 0.783 (95% confidence interval: 0.707 to 0.859). The relative histologic score in nonendocarditis specimens was 76% ± 4.3% (maximum 81%). Intracellular procollagen type 1 production was found in recipient mesenchymal cells within the transplanted grafts. In endocarditis specimens the histologic score was significantly lower with 48% ± 7.3% (minimum 41%, p = 0.0004) because of leucocyte infiltration and matrix degradation. One DPH showed immune system-mediated graft failure. Grafts obtained during the first 12 months after implantation were not evenly repopulated with less recellularization in the inner parts; no difference was found between DAH and DPH with respect to extent of recellularization. Substantial in vivo recellularization with noninflammatory cells was observed in this study. Spontaneous recellularization appears to require multiple months, which correspondingly has an impact on size selection for growing patients. [ABSTRACT FROM AUTHOR]

Few reports have described associations between a bleeding revision and outcomes after implantation of a continuous-flow left ventricular assist device (LVAD). We retrospectively analyzed all adult recipients of a continuous-flow LVAD who were operated on between January 2006 and December 2016 at the Division of Cardiac Surgery, Medical University of Vienna (N = 257). LVAD types were HeartWare HVAD (Medtronic, Minneapolis, MN), HeartMate II (Abbott [Thoratec], Abbott Park, IL), and HeartMate 3 (Abbott [Thoratec]). The primary outcome variable was survival during LVAD support. Secondary outcome variables were rates of prolonged ventilation, intensive care unit stay, hospital stay, renal replacement therapy, and stroke. We additionally investigated risk factors for a bleeding revision. Thirty-six patients (14%) underwent surgical revision for bleeding. In a multivariable Cox proportional hazards model, bleeding revision was associated with significantly reduced survival during LVAD support (3 months: hazard ratio [HR], 2.04; 95% confidence interval [CI], 1.20 to 3.48; 6 months: HR, 1.63; 95% CI, 0.95 to 2.82; 12 months: HR, 1.30; 95% CI, 0.69 to 2.46; 24 months: HR, 1.04; 95% CI 0.48 to 2.26; overall p = 0.007). Rates of secondary outcome variables were substantially higher in the revision group compared with patients who survived the hospital stay without a bleeding revision. Concomitant implantation of a temporary right ventricular assist device (p = 0.002) and age (p = 0.028) were independent risk factors for a bleeding revision. A bleeding revision is associated with significantly reduced survival and substantially increased morbidity during LVAD support. Preoperative, intraoperative, and postoperative prophylactic strategies may help to prevent this life-threatening complication. [ABSTRACT FROM AUTHOR]

Background: The aim of this analysis was to assess short and mid-term results of patients undergoing thoracic endovascular aortic repair (TEVAR) for 4 different indications. Methods: From 1996 to 2010, 300 patients (80 female, 220 male, median age 67 years [20 to 88]) underwent TEVAR at our department. Among them were 137 descending thoracic aneurysms (DTA), 80 type B dissections (60 acute, 20 chronic), 59 perforating aortic ulcer (PAU), and 24 traumatic aortic transections (ATAT). Hospital mortality and mid-term survival among different indications for TEVAR were evaluated. Results: Overall hospital mortality in our series was 5% (n = 15). Seven patients with DTA (5%), 4 patients with type B dissections (5%), 2 patients with PAU (3.4%), and 2 ATAT (8%) patients died during their hospital stay. Kaplan-Meier survival analysis revealed significant differences in survival rates according to the various indications for TEVAR (p < 0.001). Overall long-term mortality was 86%, 63%, and 44% at 1, 5, and 10 years. Early and late endoleak rate was 18% and 8%, respectively. Conclusions: The TEVAR has evolved into a safe and effective therapy for different aortic pathology resulting in promising long-term results. Nevertheless, the indication for TEVAR has direct impact on the success of the procedure. Patients with acute type B aortic dissections and acute traumatic aortic lesions seem to benefit the most from TEVAR. [ABSTRACT FROM AUTHOR]

A 56-year-old male patient underwent robotically assisted totally endoscopic left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafting. After protamine administration complete heart block developed in the patient. On intraoperative angiography the LIMA to LAD graft was perfectly patent but an acute occlusion of the right coronary artery (RCA) was noted. We performed an immediate on table percutaneous coronary angioplasty and stent placement to the RCA. The heart regained sinus rhythm and the wall motion abnormalities on the back wall of the heart resolved. No clinical symptoms indicating ongoing myocardial ischemia were noted postoperatively. This case demonstrates that a hybrid procedure of robotic totally endoscopic coronary artery bypass grafting and catheter based coronary intervention is feasible in one simultaneous session. [Copyright &y& Elsevier]

Background: The indication for epiaortic scanning during coronary artery operation is still a matter of debate. Whether this test should be carried out selectively or on a routine basis is unclear. The aim of this study was to determine factors that predict the presence of atherosclerotic ascending aortic wall thickening in patients undergoing coronary artery bypass grafting (CABG).Methods: A total of 500 CABG patients underwent epiaortic scanning using a high-frequency linear ultrasonic probe. Maximum ascending aortic wall thickness was measured and correlated with patient-related variables.Results: Maximum ascending aortic wall thickness significantly correlated with age (p < 0.001), preoperative creatinine level (p = 0.004), European system for cardiac operative risk evaluation (EuroSCORE, p < 0.001), and maximum descending aortic wall thickness (p < 0.001). Body mass index and left ventricular ejection fraction showed no correlation with maximum ascending aortic wall thickness. Of the categorical variables, hypertension (p = 0.02), unstable angina (p = 0.04), chronic obstructive pulmonary disease (p = 0.02), cerebrovascular disease (p < 0.001), and peripheral vascular disease (p < 0.001) were associated with increased ascending aortic wall thickness whereas sex, diabetes, acute cases, and previous cardiac operation were not. Multivariate analysis revealed maximum descending aortic wall thickness (p < 0.001), cerebrovascular disease (p = 0.03), and peripheral vascular disease (p = 0.04) as independent variables significantly associated with maximum ascending aortic wall thickness.Conclusions: If epiaortic scanning is not carried out routinely for detection of ascending aortic arteriosclerosis it should at least be performed in patients with old age, hypertension, unstable angina, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, elevated creatinine levels, higher EuroSCOREs, and increased wall thickness of the descending aorta. [Copyright &y& Elsevier]

Background: Acute right ventricular failure after heart transplantation is a life-threatening condition, and sometimes the use of mechanical circulatory support is inevitable. The aim of this retrospective study was to investigate the effectiveness of two different mechanical circulatory support systems for this indication.Methods: From 1984 to 2003, 28 heart transplant recipients exhibited right ventricular failure resistant to drug therapy. Right ventricular assist device (n = 15) or extracorporeal membrane oxygenation (n = 13) was implanted to support the failing heart.Results: Overall in-hospital survival was 43%. In the right ventricular assist device group, only 2 patients (13%) could be weaned from mechanical circulatory support compared with 10 patients (77%) in the extracorporeal membrane oxygenation group (p = 0.001). Retransplantation was necessary in 6 patients in the right ventricular assist device group and in 1 patient in the extracorporeal membrane oxygenation group (p = 0.049). There was no difference in patient survival between groups, but graft survival was significantly better in the extracorporeal membrane oxygenation group (p = 0.005).Conclusions: In view of these results, extracorporeal membrane oxygenation seems to be the better option as mechanical circulatory support for right ventricular failure in heart transplantation. [Copyright &y& Elsevier]

: BackgroundRapamycin is an immunosuppressive agent which also exhibits marked antiproliferative properties. Rapamycin coated stents have been demonstrated to suppress restenosis in experimental and clinical studies of percutaneous coronary catheter intervention. We investigated whether rapamycin can reduce neointima formation in a mouse model of vein graft disease.: MethodsC57BL6J mice underwent interposition of the inferior vena cava from isogenic donor mice into the common carotid artery using a previously described cuff technique. In the treatment group, 100 μg or 200 μg of rapamycin was applied locally in pluronic gel. The control group did not receive local treatment. Grafts were harvested at 1, 2, 4, and 6 weeks and underwent morphometric analysis as well as immunohistochemical analysis.: ResultsIn grafted veins without treatment (controls), median intimal thickness was 9.6 (6.4 to 29)μm, 11.9 (7.9 to 39.9)μm, 46.6 (12.4 to 57.7)μm, and 57.5 (32.5 to 71.1)μm after 1, 2, 4, and 6 weeks, respectively. Treatment with 100 μg or 200 μg rapamycin showed a dose dependant reduction of intimal thickness. In the 200 μg rapamycin treatment group the intimal thickness was 4.3 (3.4 to 5.6)μm, 3.8 (3.2 to 6.3)μm, 17.1 (4.8 to 63)μm, and 33.9 (11.3 to 80.3)μm after 1, 2, 4, and 6 weeks, respectively. This difference of intimal thickness of 200 μg treated animals compared with controls was statistically significant at 1 and 2 weeks. Immunohistochemically the reduction of intimal thickness was associated with a decreased amount of infiltration of CD-8 positive cells and a decreased amount of metallothionein positive cells in the rapamycin treated grafts.: ConclusionsWe conclude that perivascular application of rapamycin inhibits neointimal hyperplasia of vein grafts in a mouse model. These results suggest that rapamycin may have a therapeutic potential for the treatment of vein graft disease. [Copyright &y& Elsevier]

: BackgroundSuccessful treatment of destructive aortic valve endocarditis with annular abscess formation requires extensive surgical debridement and reconstruction of the left ventricular outflow tract and aortic root. Homograft aortic roots are the conduits of choice, but because they are not available in all cases, alternative conduits are needed.: MethodsOwing to its features, which are comparable to those of homografts, the Freestyle aortic root xenograft was used in 10 consecutive patients aged between 32 and 77 years. All patients had extensive abscess formation, 5 presented with prosthetic valve endocarditis, 2 had additional mitral valve endocarditis requiring partial leaflet resection and reconstruction, 1 patient had an additional fistula into the right atrium, and 1 required coronary bypass. One patient developed a septic ventricular septal defect and fistula into the right atrium with tricuspid valve endocarditis.: ResultsNone of the patients required reoperation for bleeding. Two (20%) patients died in the postoperative period, 1 due to multiorgan failure, and 1 due to preexisting invasive pulmonary aspergillosis. At autopsy, neither had evidence of intrapericardial hematoma or suture dehiscence. One patient died 13 months postoperatively without clinical signs of valve dysfunction or recurrent endocarditis. All other patients are well at 12 to 42 months after surgery. Clinical examination and echocardiography at the most recent follow-up showed no signs of valve dysfunction, recurrent fistulation, or endocarditis.: ConclusionsThe Freestyle aortic root appears to be an acceptable alternative to homografts in the treatment of severe endocarditis. Long-term valve durability in younger patients, however, remains to be determined. [Copyright &y& Elsevier]

One year after aortic bioprosthetic valve replacement with a 23-mm Epic bioprosthesis (St. Jude Medical, St. Paul, MN) with concomitant coronary artery bypass grafting, early valve degeneration with leaflet calcification and stiffening was documented in a 61-year-old man. A possible reason for this extremely early deterioration could not be identified, although a xenograft reaction could be a plausible hypothesis. Consequently, a successful redo aortic valve replacement with a 21-mm Magna Ease (Carpentier-Edwards, Irvine, CA) was performed. [Copyright &y& Elsevier]

We report the echocardiographic detection of microbubbles in the outflow prosthesis of a HeartWare HVAD left ventricular assist device using transthoracic echocardiography. In this case it was a specific sign associated with device thrombosis that resolved after successful treatment with systemic thrombolysis. [ABSTRACT FROM AUTHOR]