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Abstract Granular multiparticle ensembles are of interest from fundamental statistical viewpoints as well as for the understanding of collective processes in industry and in nature. Extraction of physical data from optical observations of three-dimensional (3D) granular ensembles poses considerable problems. Particle-based tracking is possible only at low volume fractions, not in clusters. We apply shadow-based and feature-tracking methods to analyze the dynamics of granular gases in a container with vibrating side walls under microgravity. In order to validate the reliability of these optical analysis methods, we perform numerical simulations of ensembles similar to the experiment. The simulation output is graphically rendered to mimic the experimentally obtained images. We validate the output of the optical analysis methods on the basis of this ground truth information. This approach provides insight in two interconnected problems: the confirmation of the accuracy of the simulations and the test of the applicability of the visual analysis. The proposed approach can be used for further investigations of dynamical properties of such media, including the granular Leidenfrost effect, granular cooling, and gas-clustering transitions.

Background Cancer seems to have an independent adverse prognostic effect on COVID-19-related mortality, but uncertainty exists regarding its effect across different patient subgroups. We report a population-based analysis of patients hospitalised with COVID-19 with prior or current solid cancer versus those without cancer.Methods We analysed data of adult patients registered until 24 May 2020 in the Belgian nationwide database of Sciensano. The primary objective was in-hospital mortality within 30 days of COVID-19 diagnosis among patients with solid cancer versus patients without cancer. Severe event occurrence, a composite of intensive care unit admission, invasive ventilation and/or death, was a secondary objective. These endpoints were analysed across different patient subgroups. Multivariable logistic regression models were used to analyse the association between cancer and clinical characteristics (baseline analysis) and the effect of cancer on in-hospital mortality and on severe event occurrence, adjusting for clinical characteristics (in-hospital analysis).Results A total of 13 594 patients (of whom 1187 with solid cancer (8.7%)) were evaluable for the baseline analysis and 10 486 (892 with solid cancer (8.5%)) for the in-hospital analysis. Patients with cancer were older and presented with less symptoms/signs and lung imaging alterations. The 30-day in-hospital mortality was higher in patients with solid cancer compared with patients without cancer (31.7% vs 20.0%, respectively; adjusted OR (aOR) 1.34; 95% CI 1.13 to 1.58). The aOR was 3.84 (95% CI 1.94 to 7.59) among younger patients (

Multivariate classification is used in neuroimaging studies to infer brain activation or in medical applications to infer diagnosis. Their results are often assessed through either a binomial or a permutation test. Here, we simulated classification results of generated random data to assess the influence of the cross-validation scheme on the significance of results. Distributions built from classification of random data with cross-validation did not follow the binomial distribution. The binomial test is therefore not adapted. On the contrary, the permutation test was unaffected by the cross-validation scheme. The influence of the cross-validation was further illustrated on real-data from a brain–computer interface experiment in patients with disorders of consciousness and from an fMRI study on patients with Parkinson disease. Three out of 16 patients with disorders of consciousness had significant accuracy on binomial testing, but only one showed significant accuracy using permutation testing. In the fMRI experiment, the mental imagery of gait could discriminate significantly between idiopathic Parkinson's disease patients and healthy subjects according to the permutation test but not according to the binomial test. Hence, binomial testing could lead to biased estimation of significance and false positive or negative results. In our view, permutation testing is thus recommended for clinical application of classification with cross-validation.

Event-related potentials (ERP) have been proposed to improve the differential diagnosis of non-responsive patients. We investigated the potential of the P300 as a reliable marker of conscious processing in patients with locked-in syndrome (LIS). Eleven chronic LIS patients and ten healthy subjects (HS) listened to a complex-tone auditory oddball paradigm, first in a passive condition (listen to the sounds) and then in an active condition (counting the deviant tones). Seven out of nine HS displayed a P300 waveform in the passive condition and all in the active condition. HS showed statistically significant changes in peak and area amplitude between conditions. Three out of seven LIS patients showed the P3 waveform in the passive condition and 5 of 7 in the active condition. No changes in peak amplitude and only a significant difference at one electrode in area amplitude were observed in this group between conditions. We conclude that, in spite of keeping full consciousness and intact or nearly intact cortical functions, compared to HS, LIS patients present less reliable results when testing with ERP, specifically in the passive condition. We thus strongly recommend applying ERP paradigms in an active condition when evaluating consciousness in non-responsive patients.

Space exploration and exploitation face a major challenge: the handling of granular materials in low-gravity environments. Indeed, grains behave quite differently in space than on Earth, and the dissipative nature of the collisions between solid particles leads to clustering. Within poly-disperse materials, the question of segregation is highly relevant but has not been addressed so far in microgravity. From parabolic flight experiments on dilute binary granular media, we show that clustering can trigger a segregation mechanism, and we observe, for the first time, the formation of layered structures in the bulk.

Emerging neural theories of consciousness suggest a correlation between a specific type of neural dynamical complexity and the level of consciousness: When awake and aware, causal interactions between brain regions are both integrated (all regions are to a certain extent connected) and differentiated (there is inhomogeneity and variety in the interactions). In support of this, recent work by Casali et al (2013) has shown that Lempel-Ziv complexity correlates strongly with conscious level, when computed on the EEG response to transcranial magnetic stimulation. Here we investigated complexity of spontaneous high-density EEG data during propofol-induced general anaesthesia. We consider three distinct measures: (i) Lempel-Ziv complexity, which is derived from how compressible the data are; (ii) amplitude coalition entropy, which measures the variability in the constitution of the set of active channels; and (iii) the novel synchrony coalition entropy (SCE), which measures the variability in the constitution of the set of synchronous channels. After some simulations on Kuramoto oscillator models which demonstrate that these measures capture distinct 'flavours' of complexity, we show that there is a robustly measurable decrease in the complexity of spontaneous EEG during general anaesthesia.

In order to study the dynamical behavior and the handling properties of granular materials under microgravity conditions, ESA is developing the VIP-Gran instrument whose multiple functionalities allow for the study of Vibration Induced Phenomena in Granular media in low gravity. Here, we present an overview of VIP-Gran’s evolution, from the original idea to the latest encouraging and fascinating results. At first, we give a description of the instrument and the different investigated topics. Then, we present numerical simulations that we performed in order to prepare our experiments and tackle fundamental questions concerning granular gases. Finally, we give an insight on the first experimental results from parabolic flight campaigns and confront them with preliminary works and theoretical models.

Zolpidem produces paradoxical recovery of speech, cognitive and motor functions in select subjects with severe brain injury but underlying mechanisms remain unknown. In three diverse patients with known zolpidem responses we identify a distinctive pattern of EEG dynamics that suggests a mechanistic model. In the absence of zolpidem, all subjects show a strong low frequency oscillatory peak ∼6–10 Hz in the EEG power spectrum most prominent over frontocentral regions and with high coherence (∼0.7–0.8) within and between hemispheres. Zolpidem administration sharply reduces EEG power and coherence at these low frequencies. The ∼6–10 Hz activity is proposed to arise from intrinsic membrane properties of pyramidal neurons that are passively entrained across the cortex by locally-generated spontaneous activity. Activation by zolpidem is proposed to arise from a combination of initial direct drug effects on cortical, striatal, and thalamic populations and further activation of underactive brain regions induced by restoration of cognitively-mediated behaviors.

Whether unique to humans or not, consciousness is a central aspect of our experience of the world. The neural fingerprint of this experience, however, remains one of the least understood aspects of the human brain. In this paper we employ graph-theoretic measures and support vector machine classification to assess, in 12 healthy volunteers, the dynamic reconfiguration of functional connectivity during wakefulness, propofol-induced sedation and loss of consciousness, and the recovery of wakefulness. Our main findings, based on resting-state fMRI, are three-fold. First, we find that propofol-induced anesthesia does not bear differently on long-range versus short-range connections. Second, our multi-stage design dissociated an initial phase of thalamo-cortical and cortico-cortical hyperconnectivity, present during sedation, from a phase of cortico-cortical hypoconnectivity, apparent during loss of consciousness. Finally, we show that while clustering is increased during loss of consciousness, as recently suggested, it also remains significantly elevated during wakefulness recovery. Conversely, the characteristic path length of brain networks (i.e., the average functional distance between any two regions of the brain) appears significantly increased only during loss of consciousness, marking a decrease of global information-processing efficiency uniquely associated with unconsciousness. These findings suggest that propofol-induced loss of consciousness is mainly tied to cortico-cortical and not thalamo-cortical mechanisms, and that decreased efficiency of information flow is the main feature differentiating the conscious from the unconscious brain.

Mechanisms of propofol-induced loss of consciousness remain poorly understood. Recent fMRI studies have shown decreases in functional connectivity during unconsciousness induced by this anesthetic agent. Functional connectivity does not provide information of directional changes in the dynamics observed during unconsciousness. The aim of the present study was to investigate, in healthy humans during an auditory task, the changes in effective connectivity resulting from propofol induced loss of consciousness. We used Dynamic Causal Modeling for fMRI (fMRI-DCM) to assess how causal connectivity is influenced by the anesthetic agent in the auditory system. Our results suggest that the dynamic observed in the auditory system during unconsciousness induced by propofol, can result in a mixture of two effects: a local inhibitory connectivity increase and a decrease in the effective connectivity in sensory cortices.

Changes in conscious level have been associated with changes in dynamical integration and segregation among distributed brain regions. Recent theoretical developments emphasize changes in directed functional (i.e., causal) connectivity as reflected in quantities such as 'integrated information' and 'causal density'. Here we develop and illustrate a rigorous methodology for assessing causal connectivity from electroencephalographic (EEG) signals using Granger causality (GC). Our method addresses the challenges of non-stationarity and bias by dividing data into short segments and applying permutation analysis. We apply the method to EEG data obtained from subjects undergoing propofol-induced anaesthesia, with signals source-localized to the anterior and posterior cingulate cortices. We found significant increases in bidirectional GC in most subjects during loss-of-consciousness, especially in the beta and gamma frequency ranges. Corroborating a previous analysis we also found increases in synchrony in these ranges; importantly, the Granger causality analysis showed higher inter-subject consistency than the synchrony analysis. Finally, we validate our method using simulated data generated from a model for which GC values can be analytically derived. In summary, our findings advance the methodology of Granger causality analysis of EEG data and carry implications for integrated information and causal density theories of consciousness.

Recent studies in patients with disorders of consciousness (DOC) tend to support the view that awareness is not related to activity in a single brain region but to thalamo-cortical connectivity in the frontoparietal network. Functional neuroimaging studies have shown preserved albeit disconnected low level cortical activation in response to external stimulation in patients in a vegetative state or unresponsive wakefulness syndrome. While activation of these primary sensory cortices does not necessarily reflect conscious awareness, activation in higher order associative cortices in minimally conscious state patients seems to herald some residual perceptual awareness. PET studies have identified a metabolic dysfunction in a widespread fronto-parietal global neuronal workspace in DOC patients including the midline default mode network, ‘intrinsic’ system, and the lateral frontoparietal cortices or ‘extrinsic system’. Recent studies have investigated the relation of awareness to the functional connectivity within intrinsic and extrinsic networks, and with the thalami in both pathological and pharmacological coma. In brain damaged patients, connectivity in all default network areas was found to be non-linearly correlated with the degree of clinical consciousness impairment, ranging from healthy controls and locked-in syndrome to minimally conscious, vegetative, coma and brain dead patients. Anesthesia-induced loss of consciousness was also shown to correlate with a global decrease in cortico-cortical and thalamo-cortical connectivity in both intrinsic and extrinsic networks, but not in auditory or visual networks. In anesthesia, unconsciousness was also associated with a loss of cross-modal interactions between networks. These results suggest that conscious awareness critically depends on the functional integrity of thalamo-cortical and cortico-cortical frontoparietal connectivity within and between intrinsic and extrinsic brain networks.

The authors sought to characterize the functional and structural myocardial phenotypes of patients with moderate-to-severe aortic stenosis (AS) and to determine whether severe paradoxical low-gradient AS (LG-AS) is specifically associated with left ventricular (LV) remodeling and fibrosis. Recently, it was suggested that severe paradoxical LG-AS is a more advanced form of AS, with greater reduction of longitudinal deformation, adverse LV remodeling, and more interstitial fibrosis. The study population includes 147 patients with moderate-to-severe AS and a normal LV ejection fraction, and 75 normal control subjects. They prospectively underwent 2-dimensional speckle-tracking echocardiography and cardiac magnetic resonance to evaluate myocardial deformation, LV remodeling, and age- and sex-adjusted extravascular volume fraction (ECV, %). Among AS patients, 18 had moderate AS, 74 had severe high-gradient AS (HG-AS), and 55 had severe paradoxical LG-AS. Reduced longitudinal and circumferential deformation was observed in 21% and 6% of the AS patients, respectively. Multivariate analyses identified increased ECV (ß = 1.99; p = 0.001) and the absence of normal LV geometry (ß = −1.37; p = 0.007) and as independent predictors of reduced longitudinal deformation. Increased ECV was an independent predictor of reduced circumferential deformation (ß = 2.19; p = 0.001). Over a median follow-up of 29 months, reduced longitudinal deformation (hazard ratio: 0.82; p = 0.023) and higher transvalvular gradients (hazard ratio: 1.05; p < 0.001) increased the risk of death or need for aortic valve replacement. LV hypertrophy was more frequently observed among patients with severe HG-AS (65%) than among the other AS patients (14%; p < 0.001). On average, ECV was within normal limits and did not differ among gradient-area subgroups. When present, increased ECV was associated with reduced longitudinal deformation. This study's data show that patients with severe paradoxical LG-AS less frequently display reduced longitudinal deformation, LV hypertrophy, or myocardial fibrosis than patients with HG-AS. Also, interstitial fibrosis only occurs when reduced longitudinal deformation and severe HG-AS are present together. Finally, this study suggests that reduced longitudinal deformation and higher transvalvular gradients adversely affect patients' outcomes. [ABSTRACT FROM AUTHOR]

The present study examines whether improvements have reduced the negative impact of guideline triggers on postoperative outcomes. European and American guidelines for the management of severe aortic regurgitation (AR) define the triggers for AR surgery. These triggers are based on the results of studies performed in the 1990s analyzing outcomes of patients who underwent AR surgery in the 1980s. Although these triggers are used to indicate surgery, they have all been associated with poorer postoperative outcomes. In the meantime, innovations in operative techniques, including aortic valve repair, have allowed reducing the risk of surgery. A total of 356 consecutive patients undergoing surgical correction of severe AR were included in this study. Among them, 204 were operated on for a Class I, 17 for a Class IIa, 49 for a Class IIb, and 86 without any guideline triggers. Cox proportional hazards regression models and Kaplan-Meier survival curves were used to compare postoperative outcomes in the different groups. Inverse probability weighing was used to adjust for mismatched baseline characteristics. Adjusted 10-year survival was better among patients without operative triggers (89 ± 4%) or with Class II triggers (85 ± 6%) than in patients with Class I triggers (71 ± 4%, p = 0.010). Similar results were obtained for cardiovascular survival and hospitalizations for heart failure. Spline function analyses indicated that mortality started to increase for left ventricular (LV) ejection fraction <55% and LV end-systolic dimensions >20 to 22 mm/m2. LV end-diastolic dimensions did not influence outcomes. Guideline-based Class I triggers for AR surgery carry major risks for long-term outcomes. This suggests that patients with severe AR should be operated on before the onset of these triggers; that is, at an asymptomatic stage, before LV ejection fraction falls below 55% or LV end-systolic dimensions exceeds 20 to 22 mm/m2. [ABSTRACT FROM AUTHOR]

To analyze our long-term experience with valve-sparing reimplantation technique for the treatment of isolated root aneurysm, aneurysm with significant aortic regurgitation, and for isolated aortic regurgitation. Between 1999 and 2017, 440 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 49 ± 15 years. Time-to-event analysis was performed with the Kaplan-Meier method, whereas significant predictors of late outcomes were explored with Cox proportional hazard model. In-hospital mortality was 0.7% (n = 3). Four hundred fourteen patients were available for long-term analysis. Median duration of follow-up was 5 years (interquartile range, 2-8.5 years). Thirty-six patients (8.5%) died during follow-up; therefore, survival was 79.7% ± 3.8% at 10 years. During follow-up we observed a linearized rate of 0.37%, 0.73%, and 0.2% patient-year, respectively, for major bleeding, thromboembolic events, and infective endocarditis. Nineteen patients required late aortic valve reoperation and freedom from valve reoperation was 89.6% ± 2.9% at 10 years and was not significantly different between groups or between tricuspid or bicuspid valve phenotypes. Our study shows that valve-sparing reimplantation is associated with low perioperative mortality, a remarkably low rate of valve-related complications, and excellent long-term durability. Further, it can be safely performed also in patients with isolated aortic regurgitation and the durability of valve repair is similar regardless of the indication for surgery of valve phenotype. [ABSTRACT FROM AUTHOR]

Objectives To validate aortic valve calcium (AVC) load measurements by multidetector row computed tomography (MDCT), to evaluate the impact of tube potential and slice thickness on AVC scores, to examine the accuracy of AVC load in distinguishing severe from nonsevere aortic stenosis (AS) and to investigate its effectiveness as an alternative diagnosis method when echocardiography remains inconclusive. Methods We prospectively studied 266 consecutive patients with moderate to severe AS who underwent MDCT to measure AVC load and a comprehensive echocardiographic examination to assess AS severity. AVC load was validated against valve weight in 57 patients undergoing aortic valve replacement. The dependence of AVC scores on tube potential and slice thickness was also tested, as well as the relationship between AVC load and echocardiographic criteria of AS severity. Results MDCT Agatston score correlated well with valve weight (r = 0.82, p < 0.001) and hemodynamic indices of AS severity (all p < 0.001). Ex-vivo Agatston scores decreased significantly with increasing tube potential and slice thickness (repeated measures ANOVA p < 0.001). Multivariate analysis identified mean gradient, the indexed effective orifice area, male gender and left ventricular outflow tract cross-sectional area as independent correlates of the in-vivo AVC load. Conclusions MDCT-derived AVC load correlated well with valve weight and hemodynamic indices of AS severity. It also depends on tube potential and slice thickness, thus suggesting that these parameters should be standardized to optimize reproducibility and accuracy. [ABSTRACT FROM AUTHOR]

Background--Bilateral internal thoracic arteries (BITA) have demonstrated superior patency and improved survival in patients undergoing coronary artery bypass grafting. However, the optimal configuration for BITA utilization and its effect on long-term outcome remains uncertain. Methods and Results--We randomly assigned 304 patients undergoing coronary artery bypass grafting using BITA to either in situ or Y grafting configurations. The primary end point was 3-year angiographic patency. Secondary end points included major adverse cardiac and cerebrovascular events (ie, death from any cause, stroke, myocardial infarction, or repeat revascularization) at 7 years. More coronary targets were able to be revascularized using internal thoracic arteries in patients randomized to Y grafting versus in situ group (3.2±0.8 versus 2.4±0.5 arteries/patient; P<0.01). The primary end point did not show significant differences in graft patency between groups. Secondary end points occurred more frequently in the in situ group (P=0.03), with 7-year rates of 34±10% in the in situ and 25±12% in the Y grafting groups, driven largely by a higher incidence of repeat revascularization in the in situ group (14±4.5% versus 7.4±3.2% at 7 years; P=0.009). There were no significant differences in hospital mortality or morbidity or in late survival, myocardial infarction, or stroke between groups. Conclusions--Three-year systematic angiographic follow-up revealed no significant difference in graft patency between the 2 BITA configurations. However, compared with in situ configuration, the use of BITA in a Y grafting configuration results in lower rates of major adverse cardiovascular and cerebrovascular events at 7 years. [ABSTRACT FROM AUTHOR]

Objectives The management of asymptomatic patients with severe aortic regurgitation remains controversial. Accordingly, the aim of the present study was to assess the long-term outcomes and incidence of cardiac complications among asymptomatic patients with severe aortic regurgitation who underwent operation early, in the absence of any class I or class IIa guideline triggers, or were managed conservatively and eventually underwent operation whenever these triggers appeared. Methods A total of 160 consecutive asymptomatic patients (50 ± 17 years) with severe aortic regurgitation were prospectively followed up for a median of 7.2 years. Overall and cardiovascular survivals and the need for repeat aortic regurgitation surgery were evaluated in an “early surgery” group (n = 91) and a “conservatively managed” group (n = 69). Results Ten-year overall (91% ± 4% vs 89% ± 5%, P = .87) and cardiovascular (96% ± 2% vs 96% ± 3%, P = .79) survivals were similar among the early surgery and conservatively managed groups. Conservatively managed patients were further sub-stratified according to the regularity and quality of their follow-up. Patients who were regularly followed up by a certified cardiologist had a better 10-year overall survival than patients undergoing no or a looser follow-up (95% ± 5% vs 79% ± 10%, P = .045). Multivariate Cox proportional hazards analysis identified age ( P = .003) and male gender ( P = .024) as independent predictors of survival. Early surgical management was not a predictor of outcome ( P = .45). Conclusions Our results show that the outcome of asymptomatic patients with severe aortic regurgitation is not different between an early surgical and a more conservative strategy, provided that the conservatively managed patients are regularly followed up and timely referred to surgery as soon as operative triggers develop. This suggests that surgery should not be recommended in patients with aortic regurgitation who do not meet current guidelines for intervention. [ABSTRACT FROM AUTHOR]

Background To enhance the reproducibility of aortic valve–sparing reimplantation and annuloplasty, we analyzed the topographic relationship between the ventriculoaortic junction (VAJ), basal ring (BR), and sinotubular junction (STJ). The root base thickness is also quantified. Method Fifty-eight fresh human aortic valves were analyzed. The root was dissected to the limit where the aortic wall terminates into the cardiac structures (VAJ). Root height was measured externally from the STJ to the VAJ and internally from the STJ to the BR defined as the plane passing through the cusps nadir. The root base thickness was measured at the BR and orthogonal to the internal wall; except at the right coronary sinus, where it was measured between the BR internally and the VAJ externally. Measurements were taken at the middle of the 3 sinuses and commissures. Results The VAJ is at the same level as the BR from the noncoronary sinus (−0.1 ± 0.9 mm) to the left coronary sinus (0.5 ± 1.3 mm); it is above the BR from the left/right commissure (4.6 ± 1.4 mm) to the right/non commissure (2.5 ± 1.6 mm). The external root height was highest at the non/left commissure (21.5 ± 2.6 mm) followed by the right/non commissure (19.2 ± 2.3 mm) then the left/right commissure (15.7 ± 2.2 mm) ( P < .05). The mean root base thickness was 3.2 mm, ranging from 1 ± 0 mm at the left/non commissure to 6.2 ± 1.2 mm at the right coronary sinus ( P < .001). Conclusions The VAJ is not planar; it is above the level of the BR from the left/right to the right/non commissure. As a consequence, the external height of the non/left commissure is greater than the other 2 commissures. These findings should be taken into consideration when performing aortic valve–sparing reimplantation or external annuloplasty. [ABSTRACT FROM AUTHOR]

Background For patients with aortic regurgitation (AR), aortic valve (AV) repair represents an attractive alternative to AV replacement (AVR), because it does not expose patients to the risk of prosthetic valve complications. Although the durability of AV repair has been documented, its prognosis has not yet been compared with prognosis of AVR. Methods We performed a propensity score analysis to match patients who underwent surgical correction of severe AR by either AVR or AV repair between 1995 and 2012. After matching, 44 pairs of patients were compared regarding baseline characteristics; overall survival; operative survival; cardiac events, including reoperations; recurrent AR; and New York Heart Association functional class at final follow-up. Results Operative mortality was similar in the AV repair and AVR groups (2% vs 5%; P = .56). Kaplan-Meier survival analysis indicated a significantly better overall 9-year survival after AV repair than after AVR (87% vs 60%; P = .007). Cox proportional survival analysis demonstrated that the choice of treatment was an independent predictor of postoperative survival. Finally, AV repair resulted in a slight increase, albeit not statistically significant, in reoperation rate (8% vs 2%; log rank P = .35). Conclusions AV repair significantly improves postoperative outcomes in patients with AR and whenever feasible should probably be the preferred mode of surgical correction. [ABSTRACT FROM AUTHOR]

Objective To evaluate the short- and long-term outcomes of concomitant aortic (AVr) and mitral (MVr) valve repair. Methods This retrospective analysis of prospectively collected data identified patients who had undergone AVr and MVr surgery from March 1996 to October 2009. Patients were included if they had undergone combined repair on the aortic and mitral valves. Excluded were those <18 years in whom valve replacement was performed. Data were collected on the short-term morbidity and mortality (<30 postoperative days), long-term survival, and freedom from valve-related events and echocardiographic outcomes. Results A total of 65 patients underwent AVr and MVr (mean age, 56.4 ± 15.8 years, 46 men). Preoperatively, 30 patients (46.1%) had aortic insufficiency (AI) >2+, 20 patients had AI ≥2+ with aortic dilatation (30.7%), and 4 patients (6.1%) had aortic dilatation only. Of the 65 patients, 57 had tricuspid (87.6%) and 8 had bicuspid aortic valves (12.3%). All patients had mitral insufficiency preoperatively. One in-hospital death occurred (1.5%). At discharge, no patient had AI >2+ versus 30 patients preoperatively (P < .001), and 7 patients had AI >1+ versus 61 patients preoperatively (P < .001). At discharge, the mean left ventricular end-diastolic diameter was 48 ± 7 mm versus 59 ± 9 mm preoperatively (P < .007), and the mean left ventricular end-systolic diameter was 33 ± 5 mm versus 38 ± 14 mm preoperatively (P = .36). The mean clinical follow-up duration was 62 ± 45 months (median, 50; range, 1-177). At the latest follow-up visit, 17 patients were New York Heart Association class ≥2 versus 52 patents preoperatively (P < .001). Four cardiac deaths occurred, and at 1, 5, and 10 years, the freedom from cardiac death was 100%, 93.4% ± 3.7%, and 88.5% ± 5.9%, respectively. Eight valve reinterventions were required, and the freedom from valve reintervention at 1, 5, and 10 years was 95.3% ± 2.6%, 91.6% ± 3.6%, and 78.4% ± 8.0%, respectively. At 1, 5, and 10 years, the freedom from AI 2+ was 98.2% ± 1.7%, 93.4% ± 3.7%, and 88.3% ± 5.8% and the freedom from mitral insufficiency 2+ was 96.4% ± 2.4%, 93.3% ± 3.8%, and 93.3% ± 3.8%, respectively. Conclusions Concomitant AVr/MVr is associated with acceptable survival and freedom from valve reintervention. [ABSTRACT FROM AUTHOR]

Background: The impact of symptoms on the natural history of patients with severe aortic stenosis (SAS) has been well documented. By contrast, the implications of preoperative symptoms on postoperative outcomes remain poorly defined. Methods: The long-term survival of 812 patients greater than 65 years old with SAS undergoing bioprosthetic aortic valve replacement (AVR) was analyzed according to their preoperative symptoms. Results: Operative mortality was larger in New York Heart Association (NYHA) III-IV than in NYHA I-II patients (10% vs 6%, p = 0.036). Abrupt symptomatic deterioration from NYHA I to NYHA III-IV within the month preceding surgery was observed in 18% of NYHA III-IV patients and resulted in an increased operative mortality (17% vs 5% in NYHA I, p = 0.035). Long-term survival was also significantly worse in NYHA III-IV than in NYHA I-II patients (56% vs 72%, p = 0.002). Reduced long-term survival of NYHA III/IV patients was observed in subgroups with a left ventricular ejection fraction (LVEF) 0.50 or greater (58 vs. 74%, p = 0.008) and in those with a systolic pulmonary artery pressure (SPAP) less than 40 mm Hg (60% vs 74%, p = 0.014). By contrast, the presence of class III-IV symptoms did not influence outcome in patients with a LVEF less than 0.50 (51 vs. 55%, p = 0.34) or with a SPAP 40 mm Hg or greater (43% vs 48%, p = 0.78). Conclusions: In patients with SAS, preoperative NYHA III-IV symptoms, particularly of recent onset, are independently associated with excess short- and long-term postoperative mortality. This was particularly evident in patients with normal LV function or pulmonary artery pressures. These findings plead in favor of an earlier surgical correction of SAS, before the onset of severe symptoms, especially in low-risk patients. [Copyright &y& Elsevier]

Background: The impetus for aortic valve (AV) repair is to decrease valve-related complications in comparison to prosthetic valve replacement. However, relatively few data are available to confirm this hypothesis. We analyzed valve-related complications in a large series of patients undergoing AV repair. Methods: Between 1995 and 2010, 475 patients underwent elective AV repair for aortic insufficiency or aortic aneurysm. The mean age was 53 years, and 81% were male. Valve-related outcomes were defined as per published guidelines. Survival and freedom from valve-related events were reported using the Kaplan-Meier method and linearized event rates. Clinical follow-up was 98.3% complete with a mean follow-up time of 4.6 years. Results: Thirty-day mortality was 0.8% (n = 4). At 10 years, overall survival was 73% ± 5%, freedom from cardiac death was 81% ± 4%, and freedom from valve-related death was 90% ± 3%. Freedom from significant aortic insufficiency was 84% ± 3%. A total of 28 patients needed early (n = 7) or late (n = 21) AV reoperation; all of them survived reoperation, and 8 had repeat repair. Ten-year freedom from AV reoperation was 86% ± 3%, and freedom from AV replacement was 90% ± 3%. Freedom from AV reoperation was similar in tricuspid and bicuspid valve. During the follow-up period, linearized rate of thromboembolic event, bleeding, and AV endocarditis was 1.1%, 0.23%, and 0.19% per year, respectively. Ten-year freedom from valve-related events including AV reoperation, thromboembolic event, bleeding, and endocarditis was 74% ± 3%. Conclusions: The current findings confirm that AV repair is associated with low mortality, acceptable durability, and a low risk of valve-related events. [ABSTRACT FROM AUTHOR]

Objectives: To assess root replacement and annular stabilization in bicuspid aortic valve repair, we compared results of reimplantation technique versus subcommissural annuloplasty or no annuloplasty. Methods: Between 1995 and 2010, 161 consecutive patients underwent bicuspid aortic valve repair. Patients undergoing subcommissural annuloplasty or no annuloplasty (group 1, n = 87) had larger root dimensions and less aortic insufficiency than did patients undergoing reimplantation technique (group 2, n = 74). We matched groups 1 to 1 on basis of those criteria. After matching (n = 106, n = 53 per group), root dimensions (41.5 ± 5 vs 40 ± 4 mm; P = .2) and degree of insufficiency (2.6 ± 1.2 vs 2.7 ± 1; P = .6) were similar between groups. Results: Techniques of cusp repair were similar between groups. Group 2 had smaller preoperative left ventricular size (P = .02), fewer concomitant procedures (P = .02), and shorter follow-up (41 ± 30 vs 63 ± 40 months; P = .003). There were no in-hospital deaths. At discharge, residual aortic insufficiency was similar between groups, but peak gradient greater than 25 mm Hg was more frequent in group 1 (13% vs 30%; P = .04). At 6 years, overall survival was 98% ± 3% in both groups. Freedoms from reoperation and aortic insufficiency greater than 2+ were significantly better in group 2 (100% vs 90% ± 8%; P = .03; 100% vs 77% ± 14%; P = .002). Conclusions: In bicuspid aortic valve repair, root replacement with the reimplantation technique stabilizes the ventriculoaortic junction, improves valve mobility (low gradient), and is associated with improved outcomes. [ABSTRACT FROM AUTHOR]