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Objective:  Endocarditis as a potentially life-threatening disease with high complication and mortality rates. In recent years, an increase in the incident of endocarditis has been reported throughout Europe. In the aging society, successful treatment is complex and challenging owing to the high rate of multimorbidity., Methods:  We initiated a statewide prospective multicenter endocarditis registry in 2020. Perioperative risk factors, comorbidities, microbiological, laboratory and imaging diagnostics, complications, and mortality including 1-year follow-up were collected. The present midterm analysis includes factors influencing mortality in the first 313 patients., Result:  In-hospital mortality and 1-year mortality were 28.4 and 40.9%, respectively. Preoperative risk factors include age ( p  < 0.001), EuroSCORE II ( p  < 0.001), coronary artery disease ( p  = 0.022), pacemaker probe infection ( p  = 0.033), preoperative left ventricular ejection fraction (LVEF), systemic inflammatory response syndrome (SIRS), pulmonary edema, heart failure, septic emboli, acute renal failure, impaired coagulation, hypalbuminemia ( p  < 0.001), and N-terminal prohormone of brain natriuretic peptide (NTproBNP) ( p  = 0.001). The presence of peri-annular abscess, perforation, and shunt were associated with increased mortality ( p  = 0.004, 0.001, and 0.004, respectively). In addition, cardiopulmonary bypass time influenced mortality ( p  = 0.002). The main postoperative causes of death were multi-organ failure, renal failure, vasoplegia, and low-output syndrome ( p  < 0.001). Previous endocarditis was 7.7%, while 35.5% were prosthetic valve recipients and 33.6% were redo surgeries., Conclusion:  Our first registry data show the complexity of endocarditis patients and the challenging treatment. Some risk factors can be treated preoperatively. For instance, hypalbuminemia and the duration of the procedure can be controlled with adequate albumin substitution and carefully planned procedures restricted to the essential requirements, that is, hybrid approaches with consecutive interventions., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  The increasing presence of female doctors in the field of cardiac surgery has raised questions about their surgical quality compared to their male colleagues. Despite their success, female surgeons are still underrepresented in leadership positions, and biases and concerns regarding their performance persist. This study aims to examine whether female surgeons perform worse, equally well, or better than their male counterparts in commonly performed procedures that have a significant number of female patients., Method:  A retrospective cohort of patients from 2011 to 2020 who underwent isolated coronary artery bypass graft (CABG) and aortic valve surgery was studied. To compare the surgical quality of men and women, a 1:1 propensity score matching (two groups of 680 patients operated by men and women, respectively, factors: age, logarithm of EuroSCORE (ES), elective, urgent or emergent surgery, isolated aortic valve, or isolated CABG) was performed. Procedure time, bypass time, x-clamp time, hospital stay, and early mortality were compared., Results:  After propensity score matching between surgeons of both sexes, patients operated by males (PoM) did not differ from patients operated by females (PoF) in mean age (PoM: 66.72 ± 9.33, PoF: 67.24 ± 9.19 years, p  = 0.346), log. ES (PoM: 5.58 ± 7.35, PoF: 5.53 ± 7.26, p  = 0.507), or urgency of operation (PoM: 43.09% elective, 48.97% urgent, 7.94% emergency, PoF: 40.88% elective, 55.29% urgent, 3.83% emergency, p  = 0.556). This was also the case for male and female patients separately. Female surgeons had higher procedure time (PoM: 224.35 ± 110.54 min; PoF: 265.41 ± 53.60 min), bypass time (PoM: 107.46 ± 45.09 min, PoF: 122.42 ± 36.18 min), and x-clamp time (PoM: 61.45 ± 24.77 min; PoF: 72.76 ± 24.43 min). Hospitalization time (PoM: 15.96 ± 8.12, PoF: 15.98 ± 6.91 days, p  = 0,172) as well as early mortality (PoM: 2.21%, PoF: 3.09%, p  = 0.328) did not differ significantly. This was also the case for male and female patients separately., Conclusion:  Our study reveals that in routine heart surgery, the gender of the surgeon does not impact the success of the operation or the early outcome of patients. Despite taking more time to perform procedures, female surgeons demonstrated comparable surgical outcomes to their male counterparts. It is possible that women's inclination for thoroughness contributes to the longer duration of procedures, while male surgeons may prioritize efficiency. Nevertheless, this difference in duration did not translate into significant differences in primary outcomes following routine cardiac surgery. These findings highlight the importance of recognizing the equal competence of female surgeons and dispelling biases regarding their surgical performance., Competing Interests: None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objective: According to our nationwide registry, total numbers of surgical aortic valve implantation (sAVR) are constantly declining, while transcathether aortic valve implantation (TAVI) indications are widened toward intermediate- and low-risk patients. So, is there still room for conventionally implanted valves? Can results compete with TAVI or will sAVR be marginalized in the near future?, Methods: Between 2011 and 2019, 1,034 patients (67.1% male, mean = 72.2 years) were enrolled receiving stented biological valves with or without concomitant coronary artery bypass grafting (CABG), atrial ablation, or wrapping of the ascending aorta. Odds ratios for the early and late mortality were calculated regarding comorbidities as potential risk factors. Statistical analysis was performed using SPSS., Results: Overall, early mortality (EM) was 6.1%, 1-year mortality was 11.2%, and 5-year mortality was 19.9%. In low-risk patients (EuroSCORE II <4%), it was 1.0, 2.7, and 9.3%. Incidence of EM was significantly increased following decompensation, prosthetic valve, pacemaker carrier, dialysis, and pulmonary hypertension. Postoperative complications, such as systemic inflammatory response syndrome (SIRS), sepsis, multiorgan failure, hepatic failure, dialysis, gastrointestinal bleeding, and ileus, also increased EM. Late mortality was significantly increased by dialysis, hepatic cirrhosis, infected port system, aortic valve endocarditis, prosthetic valve carrier, and chronic hemodialysis., Conclusion: Conventionally implanted aortic valves do well early and late. The fate of the patient is dependent on individual risk-factors. Particularly, in low-risk patients, sAVR can compete with TAVI showing overall good early, as well as late results being even superior in some important aspects such as pacemaker implantation rate. Thus, the time is yet not ripe for TAVI to take over primary indications for AVR in low-risk patient., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Endocarditis is continuously increasing. Evidence exist that the prognosis is adversely affected by the extent of the disease. We looked at risk factors influencing in-hospital mortality (HM)., Patients and Methods: Between 2010 and 2019, 484 patients, 338 males (69.8%) with mean age of 66.1 years were operated on because of proven endocarditis. In a retrospective study, a risk factor analysis was performed., Results: Overall HM was 30.17%. Significant influencing factors (odds ratios [ORs] or p -value) for HM were: age ( p  = 0.004), logistic EuroSCORE ( p < 0.001), gender (OR = 1.64), dialysis (OR = 2.64), hepatic insufficiency (OR = 2.17), reoperation (OR = 1.77), previously implanted valve (OR = 1.97), periannular abscess (OR = 9.26), sepsis on admission (OR = 12.88), and number of involved valves (OR = 1.96). Development of a sepsis and HM was significantly lower if Streptococcus mitis was the main pathogen in contrast to other bacteria ( p < 0.001). Staphylococcus aureus was significantly more often found in patients with a previously implanted prosthesis ( p  = 0.03) and in recurrent endocarditis ( p  = 0.02), while it significantly more often showed peripheral septic emboli than the other pathogens ( p < 0.001)., Conclusion: Endocarditis remains life-threatening. Severe comorbidities adversely affected early outcome, particularly, in presence of periannular abscesses. Patients with suspected endocarditis should be admitted to a specialized heart center as early as possible. Streptococcus mitis appears to be less virulent than S. aureus . Further studies are required to verify these findings., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Atherosclerosis, hypertension, age, and fibrillopathies are well-known risk factors for the development of aortic aneurysm. We discovered that a significant proportion of our patients were previously on chemotherapy treatment or long-term treatment with cytostatic agents or immunosuppressive drugs. Thus, we examined this phenomenon., Methods: A total of 224 patients with thoracic aorta aneurysm were retrospectively analyzed after aortic surgery from 2006 to 2016. Seventy-three patients received aortic wrapping and 151 patients underwent aortic replacement of which 89 had a valve-carrying conduit and 62 a supracoronary ascending replacement. Aortic morphology was assessed by means of compute tomography scan before and after surgery. Demographic data, risk profile, and postoperative complications were collected. Short- and long-term survival analysis was performed. Statistical analysis was performed with SPSS 19.0., Results: Eighty-eight of 224 patients undergoing aortic surgery because of aortic aneurysm had previously or currently been treated with immunosuppressive agents. Dilatation of the ascending aorta was more pronounced in patients without such therapy. Demographic profile, intraoperative, as well as short- and long-term postoperative results did not differ significantly between both groups., Conclusion: The potential effect of immunosuppressant and cytostatic therapies on the development of an aortic aneurysm needs further study. Because of the astoundingly high proportion of these patients being found in an unselected aortic aneurysm cohort with immunosuppressive therapy in the past should be monitored for potential development of aortic aneurysm. If it occurs and requires treatment these patients can fortunately be operated upon with the same short- and long-term outcome than patients without such previous therapy., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Background: Polymeric heart valves are constructed from flexible synthetic materials, therefore aiming to combine the advantageous hemodynamic of biological and the longevity of mechanical valve prostheses. One such valve prototype in development is the PIZZA valve constructed of flexible triangular silicone leaflets on a foldable metal base for perspective transcatheter implantation. Here we present further improvements in its performance through structural modifications., Methods: Structurally modified prototypes were constructed from silicone sheets and stainless-steel wires. Their performance was then tested in a hemodynamic testing device of the type HKP 2.0., Results: Shift from a planar to a cone shape as well as overlapping of the leaflets significantly improved the valves performance, reducing regurgitation as well as systolic pressure gradients., Conclusions: The results of the modified prototypes expressed superior performance and represented a step forward on the road to an easily producible, polymeric transcatheter valvular prosthesis., Competing Interests: J. M. Albes is the inventor of the valve. All commercial rights have been transferred to NVT AG Luzernerstrasse 91, 5630 Muri, Switzerland., (Thieme. All rights reserved.)

Background: Conventional stented valves (CV) remain gold standard for aortic valve disease. Bovine prostheses have been improved and rapid deployment valves (RDV) have arrived in the recent decade. We compare clinical and hemodynamic short-term outcome of six bovine valves., Methods: We retrospectively evaluated 829 consecutive patients (all-comers) receiving bovine aortic valve replacement (AVR). Four CV from different manufacturers (Mitroflow, Crown, Perimount, Trifecta) and two RDV (Perceval, Intuity) were compared in terms of pre-, intra-, and postprocedural data. A risk model for mortality was created., Results: All valves reduced gradients. From 23 mm, all CV showed acceptable gradients. Twenty-one millimeter Mitroflow/Perceval and 19 mm Crown showed above-average gradients. As baseline data differed, we performed propensity matching between aggregated isolated CV and RDV groups. Cardiopulmonary bypass (CPB), clamp, and surgery times were shorter with RDV (87.4 ± 34.0 min vs 111.0 ± 34.2, 54.3 ± 21.1 vs 74.9 ± 20.4, 155.2 ± 42.9 vs 178.0 ± 46.8, p  < 0.001). New pacemaker rate (10.1 vs 1.3%, p  = 0.016) and the tendency toward neurologic events (8.9 vs 2.5%, p  = 0.086) were higher using RDV, induced mainly by the Perceval. Early mortality was equal (2.5 vs 1.3%, p  = 0.560). Revision for bleeding, dialysis, blood products, length-of-stay, gradients, and regurgitation was also equal. Risk analysis showed that low valve size, low ejection fraction, endocarditis, administration of red cells, and prolonged CPB time were predictors of elevated mortality., Conclusion: Isolated bovine AVR has low mortality. Valves ≥ 23 mm show comparable gradients while the valve model matters < 23 mm. RDV should be used with care. Procedure-related times are shorter than those of CV but pacemaker implantation and neurologic events are more frequent (Perceval). Early mortality is low and valve performance comparable to CV., Competing Interests: None., (Thieme. All rights reserved.)

Background: Prosthetic replacement of aneurysms of the ascending aorta is the gold standard in terms of long-term stability. Wrapping seems to be a less invasive procedure. It has not yet been shown if it is as safe in terms of long-term outcome., Methods: We present a single-center analysis of our experience over 13 years. We retrospectively analyzed data from patients who received either aortic prosthetic wrapping (AW) or aortic prosthetic replacement (AR) with or without aortic valve replacement and assessed them through phone calls. We used propensity score matching to adjust the baseline of the groups., Results: Before propensity matching, 144 patients received AW and 91 patients underwent AR. Mean age was 64 ± 11.8 years. After propensity score matching and adjusting for significant differences in age, gender, body mass index, logistic EuroSCORE I, and left ventricular function, 69 patients in each group remained for further analysis. Rate of early reoperation due to tamponade, inhospital mortality, and survival rates did not differ. In both groups, the surgically treated aortic segment did not show enlargement, whereas the nontreated aortic arch showed comparable aneurysmatical progression., Conclusions: AW is safe and feasible and can be used in elderly or frail patients in order to avoid an AR. Progression of the remaining native aortic segments occurs, thus requiring strict life-long follow-up to ensure an elective and thus safe approach for appropriate consecutive surgical measures, if required., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Endocarditis remains one of the most threatening diagnoses in cardiac surgery and is still increasing. Particularly, device-related as well as prosthetic endocarditis appears to be on the rise. Early mortality and periprocedural complications are high jeopardizing the success of surgical efforts. We looked at the development of the numbers and the distribution of endocarditis in an all-comer analysis., Methods:  From 2003 to 2017, 752 patients with endocarditis were transferred to our cardiosurgical institution (mean age 65 ± 13 years; mean logistic EuroSCORE 28.01%; males 74.33%). A total of 89.49% of them were surgically treated; 30.01% redo cases thereof; and 9.17% had been operated previously for acute endocarditis., Results:  While the total number of cardiosurgical procedures remained relatively stable throughout the years, 20 patients were admitted in 2003 and 79 in 2017 yielding more than fourfold increase ( p  < 0.001). Early mortality of all patients was 25.1%. Septic emboli occurred in 23.7% and 43.8% cerebral emboli thereof. A significant increase of aortic, mitral, and tricuspid valves involvement was observed ( p  < 0.001). An increase of device-related endocarditis was also noted ( p  < 0.001)., Conclusion:  Endocarditis remains a serious problem with high early mortality and morbidity. The vast increase of electrophysiological device implantations has resulted in an increase of tricuspid valve involvement. Liberalization of endocarditis prophylaxis, that is, more restrictive use of antibiotics in 2007 may have at least partially contributed to an increase of the individual risk to suffer from acute endocarditis. A renaissance of a stricter endocarditis-prophylaxis may thus be considered., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Transcatheter heart valve (THV) as valve-in-ring is increasingly used in the mitral position. Semi-rigid rings may serve as a more appropriate scaffold for proper anchoring of a THV as they may change from their oval to a round shape thereby fitting to the implanted THV., Methods:  One rigid and five semi-rigid rings of four manufacturers, Edwards Physio I and II, Sorin 3D Memo, Medtronic Simulus, and St. Jude Medical (SJM) Saddle and SJM Sequin, with sizes 28 to 36 mm and Edwards Sapien III THV 23, 26, and 29 mm were used. Preevaluation comprised insertion/inflation of the THV into the ring and visual inspection for the paravalvular gap ≥ 4 mm 2 . Only valves not showing paravalvular gap were then submitted to hemodynamic evaluation with a pulse duplicator. Cusp movement was assessed with a high-speed-camera. Mean transvalvular gradients (TVGs) were measured., Results:  SJM Saddle ring of all sizes and SJM Sequin ring 34 showed marked gaps combined with all THV sizes, thus not undergoing hemodynamic testing. It was further shown that ring sizes ≥ 36 mm did not allow for a proper fit of even the largest THV into the ring of all the manufacturers and were consequently not hemodynamically evaluated. The 23 mm THV was too small for any ring size. The lowest gradients were achieved with the 26 mm THV in 30 and 32 mm and the 29 mm THV in 32 and 34 mm rings., Conclusion:  Not all currently available annuloplasty rings are ideal scaffolds for THV placement. It appears that a more proper fit can be achieved with semi-rigid rings than with rigid ones. Note that 23 mm THV appeared to be too small for an adequate anchoring in even the smallest available ring. Thus, 26 mm as well as 29 mm THV fit properly in ring sizes between 28 and 34 mm. Surgeons may consider to choose from those ring brands and sizes which allow for good placement of a THV in view of possible valve degeneration in the later course., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: MitraClip (Abbott Inc.) is propagated as a palliative option for high-risk patients with mitral insufficiency considered not qualifying for surgical repair. A proportion of patients requires consecutive surgery because of technical failure or inappropriate clinical improvement. Furthermore, surgical reconstruction is impossible in almost all patients after MitraClip implantation. Consequently, these patients receive replacement although primary repair may have been possible. The outcome of those patients compared with patients receiving primary mitral valve replacement (MVR) or mitral valve repair (MVP) was analyzed., Methods: A total of 23 patients were retrospectively analyzed after MVR following MitraClip. Overall, 46 patients with corresponding demographic data and risk profile receiving primary MVR (23 patients) or MVP (23 patients) were retrieved for matched pair analysis., Results: Mean age was 70 years in all groups, log European system for cardiac operative risk evaluation (EuroSCORE) was 22.47% ± 16.30 in MVR after MitraClip (MC), 22.34% ± 16.23 in MVP, and 22.33% ± 16.14 in MVR group. Preoperative left ventricular ejection fraction (LVEF) was 44%, and postoperative LVEF was 48% in all groups. The 30-day mortality was 21.7% in the MitraClip group whereas it was 4.3% in the MVR and 13.0% in the MVP group. The 1-year survival was 56.5% in the MitraClip group while it was 95.6% in the MVR group and 82.6% in the MVP group (Wilcoxon test: p  = 0.007; chi - square test: p  = 0.001 MitraClip vs. MVR; p  = 0.054 MitraClip vs. MVP)., Conclusions: Patients requiring surgical MVR after the previous MitraClip fared worse than matched cohorts receiving primary MVR or MVP. Indication for MitraClip should, therefore, be made very cautiously given the excellent results gained with primary surgery., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)