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Background: Third-generation transcatheter heart valves (THVs) are designed to improve outcomes. Data on the new intra-annular self-expanding NAVITOR are scarce. Aims: The aim of this analysis was to compare outcomes between the PORTICO and the NAVITOR systems. Methods: Data from 782 patients with severe native aortic stenosis treated with PORTICO (n = 645) or NAVITOR (n = 137) from 05/2012 to 09/2022 were evaluated. The clinical and hemodynamic outcomes of 276 patients (PORTICO, n = 139; NAVITOR, n = 137) were evaluated according to VARC-3 recommendations. Results: Rates of postprocedural more-than-mild paravalvular leakage (PVL) were significantly lower for NAVITOR than for PORTICO (7.2% vs. 1.5%, p = 0.041). In addition, severe bleeding rates (27.3% vs. 13.1%, p = 0.005) and major vascular complications (5.8% vs. 0.7%, p = 0.036) were lower in the NAVITOR group. The mean gradients (7 vs. 8 mmHg, p = 0.121) and calculated aortic valve areas (1.90 cm2 vs. 1.99 cm2, p = 0.235) were comparable. Rates of PPI were similarly high in both groups (15.3 vs. 21.6, p = 0.299). Conclusions: The NAVITOR demonstrated favorable in-hospital procedural outcome data, with lower rates of relevant PVL, major vascular complications, and severe bleeding than its predecessor the PORTICO and preserved favorable hemodynamic outcomes.

Aims The objective of the study was to determine the effect of renin–angiotensin system inhibitors (RASI) on the survival of subgroups of patients with aortic stenosis after transcatheter aortic valve implantation (TAVI) and to assess the impact of types and dosages of RASI on outcomes. Methods and results This single-centre, retrospective analysis included 2862 patients (n = 2227 with RASI and n = 635 without RASI) after successful TAVI. Propensity score matching established comparable patient populations (n = 625 per group). Survival was analysed by Kaplan–Meier curves and Cox regression and was corrected for baseline, procedural, and medical parameters. Self-reported adherence to RASI therapy 3 months after hospital discharge was 94%. Three-year all-cause mortality rates were 12.3% and 20.2% for patients with or without RASI, respectively (log-rank Conclusions The beneficial association between RASI after TAVI and improved survival during follow-up is particularly evident in high-risk patients and may be dose dependent. No superiority was noted in the effectiveness of ACEI or ARB.

Background: Severe calcification of the ascending aorta increases the peri-operative risk for neurological complications in patients with severe aortic stenosis. Transcatheter aortic valve implantation (TAVI) seems to be an optimal treatment option in these patients. However, the impact of the extent of aortic calcification on procedural and neurological outcomes during TAVI is unclear. Methods: Data from 3010 patients with severe native aortic valve stenosis treated with ACURATE neo/neo2 from May 2012 to July 2022 were evaluated and matched by 2-to-1 nearest-neighbor matching to identify one patient with porcelain aorta (PA) (n = 492) compared with two patients without PA (n = 984). PA was additionally subdivided into circumferential (classic PA) (n = 89; 3.0%) and non-circumferential (partial PA) (n = 403; 13.4%) calcification. We compared outcomes according to VARC-3 criteria among patients with and without PA and identified predictors for occurrence of stroke in the overall population. Results: Technical success (88.5% vs. 87.4%, p = 0.589) and device success at 30 days (82.3% vs. 81.5%, p = 0.755) after transcatheter ACURATE neo/neo2 implantation according to VARC-3 definition was high and did not differ between non-calcified aortas or PA. The rate of in-hospital complications according to VARC-3-definitions was low in both groups. Rates of all stroke (3.2% (n = 31) vs. 2.6% (n = 13), p = 0.705) or transitory ischemic attacks (1.1% vs. 1.2%, p = 1.000) did not differ significantly. Thirty-day all-cause mortality did not differ (3.0% vs. 3.2%, RR 1.1; p = 0.775). Overall device migration/embolization (OR 5.0 [2.10;11.87]), severe bleeding (OR 1.79 [1.11;2.89]), and major structural cardiac complications (OR 3.37 [1.32;8.57]) were identified as independent predictors for in-hospital stroke in a multivariate analysis after implantation of ACURATE neo/neo2. Conclusion: A porcelain aorta does not increase the risk of neurological complications after transfemoral ACURATE neo/neo2 implantation. Based on these findings, transfemoral ACURATE neo/neo2 implantation is safe in these particularly vulnerable patients.

Few data exist on immediate outcomes of the next-generation Acurate neo2 prosthesis (Boston Scientific), which is distinguished by an active sealing mechanism. We sought to determine procedural outcomes of transfemoral transcatheter aortic valve replacement using the neo2 in comparison with its predecessor, the Acurate neo.In this retrospective analysis, consecutive neo2 and neo cases were compared from 2 high-volume centers. The primary outcome of interest was the rate of relevant paravalvular regurgitation (PVR), defined as PVR ≥ moderate, or valve-in-valve and/or surgical aortic valve replacement for PVR ≥ moderate. Secondary outcomes of interest were assessed according to Valve Academic Research Consortium (VARC)-3 criteria. Logistic regression analysis was used to identify predictors of relevant PVR.A total of 810 neo2 and 2055 neo cases comprised the study cohort. The rate of relevant PVR was significantly lower in the neo2 group (2.7% vs 4.5%; P=.04). The technical success rate was numerically higher in the neo2 group (91.5% vs 89.3%; P=.10) and the rate of device success at 30 days was significantly higher (86.5% vs 82.9%; P=.02). In the neo group, a greater amount of aortic valve calcification (AVC), the presence of eccentric AVC, less oversizing, and a higher sinotubular junction annulus index were predictors of relevant PVR, whereas in the neo2 population only the presence of eccentric AVC, less oversizing, and a higher sinotubular junction annulus index was predictive.The neo2 valve shows superior outcomes over the neo valve, with a lower burden of PVR and a higher device success rate at 30 days.

OBJECTIVES The goal of this study was to investigate the association between the localization of the distal anastomosis (zone 2/3), the stent graft length (100–160 mm), the position of the distal end of the hybrid prosthesis and the need for secondary aortic intervention (SAI) in acute and chronic thoracic aortic disease after the frozen elephant trunk procedure. METHODS From 2009 through 2020, a total of 232 patients (137 men; mean age, 61.7 ± 13.8 years) were treated with the frozen elephant trunk procedure. The main indications were acute aortic dissection type A (n = 106, 46%), chronic aortic dissection type A (n = 52, 22%) and degenerative thoracic aortic aneurysm (n = 74, 32%). RESULTS The rate of SAI was significantly higher when we performed a distal anastomosis in zone 2 rather than in zone 3, whereas the rate of SAI was less frequent if the distal positioning of the hybrid prosthesis was below TH 4–5. Combining the zone 2 concept and the short stent graft length (100 mm) was associated with a significantly higher rate of SAIs. Patients with a distal anastomosis in zone 2 were significantly less likely to have a recurrent laryngeal nerve injury (P CONCLUSIONS Rates of SAIs are highest in patients who were treated with a distal anastomosis in zone 2 and a short stent graft (100 mm) with the distal end of the hybrid prosthesis at vertebral level TH 2–3.

ObjectivePostoperative atrial fibrillation (POAF) is a common complication affecting approximately one-third of patients after cardiac surgery and valvular interventions. This umbrella review systematically appraises the epidemiological credibility of published meta-analyses of both observational and randomised controlled trials (RCT) to assess the risk and protective factors of POAF.MethodsThree databases were searched up to June 2021. According to established criteria, evidence of association was rated as convincing, highly suggestive, suggestive, weak or not significant concerning observational studies and as high, moderate, low or very low regarding RCTs.ResultsWe identified 47 studies (reporting 61 associations), 13 referring to observational studies and 34 to RCTs. Only the transfemoral transcatheter aortic valve replacement (TAVR) approach was associated with the prevention of POAF and was supported by convincing evidence from meta-analyses of observational data. Two other associations provided highly suggestive evidence, including preoperative hypertension and neutrophil/lymphocyte ratio. Three associations between protective factors and POAF presented a high level of evidence in meta-analyses, including RCTs. These associations included atrial and biatrial pacing and performing a posterior pericardiotomy. Nineteen associations were supported by moderate evidence, including use of drugs such as amiodarone, b-blockers, glucocorticoids and statins and the performance of TAVR compared with surgical aortic valve replacement.ConclusionsOur study provides evidence confirming the protective role of amiodarone, b-blockers, atrial pacing and posterior pericardiotomy against POAF as well as highlights the risk of untreated hypertension. Further research is needed to assess the potential role of statins, glucocorticoids and colchicine in the prevention of POAF.PROSPERO registration numberCRD42021268268.

A 46-year-old male patient presented with cardiac decompensation due to a giant left ventricular aneurysm combined with a severely reduced left ventricular function after a silent myocardial infarction. Left ventricular unloading was performed with a microaxial pump as a bridge to surgery. Myocardial function in the basal segments was preserved and surgical ventricular reconstruction was performed successfully.

The left axillary artery is an attractive alternative access route for transcatheter aortic valve replacement (TAVR) and may provide better outcomes compared to other alternatives. Nevertheless, there remain concerns about vascular complications, lack of compressibility, and thorax-related complications. Between March 2019 and March 2021, 13 patients underwent transaxillary TAVR for severe aortic stenosis at the University Hospital Bonn. The puncture was performed with a puncture at the distal segment of the axillary artery through the axilla, with additional femoral access for applying a safety wire inside the axillary artery. Device success was defined according to the VARC 2 criteria. The study participants were advanced in age (77 ± 9 years old), and 54% were female, with an intermediate risk for surgery (STS risk score 4.7 ± 2.0%). The average diameter of the distal segment of the axillary artery was 5.8 ± 1.0 mm (i.e., the puncture site) and 7.6 ± 0.9 mm for the proximal axillary artery. Device success was achieved in all patients. 30-day major adverse cardiac and cerebrovascular events were 0%. With complete percutaneous management, stent-graft implantation was performed at the puncture site in 38.5% of patients. Minor bleeding was successfully managed with manual compression. Moreover, no thorax-related complications, hematomas, or nerve injuries were observed. Percutaneous trans-axilla TAVR was found to be feasible and safe. This modified approach may mitigate the risk of bleeding and serious complications in the thorax and be less invasive than surgical alternatives.

Summary Mitral valve regurgitation is detected in up to 75% of patients with heart failure. Interventional mitral valve therapies can be used to treat mitral regurgitation with very low morbidity and mortality rates and minimal invasiveness. Devices intended for the replacement of the mitral valve still require significant development and refinement before entering clinical practice on a large scale. The derived benefit of these therapies, the priority (repair over replacement) and the therapeutic role in patients with secondary mitral regurgitation due to heart failure remain to be investigated.

Background Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR). Materials and Methods In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol (n = 188) and nonmannitol (n = 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at p Results Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%; p = 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours; p = 0.021), higher reintubation rate (11.3 vs. 2.7%; p = 0.009), ICU readmission (12.7 vs. 4.8%; p = 0.026), prolonged ICU (112 vs. 70 hours; p = 0.040), and hospital stay (17.8 vs. 12.6 days; p Conclusion Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.

Background: Out-of-center extracorporeal membrane oxygenation (ECMO) and extracorporeal life support (ECLS) implantation for the treatment of acute cardiorespiratory failure with subsequent transport to a tertiary care center has been introduced successfully into the medical practice. However, due to the very specific and resource intensive nature of this therapeutic concept, it seems important to generate algorithms for adequate patient selection. The aim of our study was to analyze the impact of patients’ gender on early clinical outcome in this specific therapeutic scenario. Methods: Ninety-seven consecutive patients treated by out-of-center ECMO/ECLS implantation and subsequent transport and treatment in our tertiary care cardiovascular center within the Hallesche Extracorporeal Life Support Program (HELP) retrospectively were analyzed, regarding the impact of patients’ gender on early clinical outcome. Results: Mechanical circulatory support successfully was weaned in two-thirds of the male patients. This result was achieved in only one-third of the female patients (59.4% in male vs. 33.3% in female, P = .0267). Overall survival significantly was higher in the male group (62.5% in male versus 30.3% in female, P = .0052). In uni- and multivariate logistic regression analysis, female gender was an independent predictor of in-hospital mortality (uni: OR:3.833, CI:1.597-9.745, P = .0034; multi: OR:3.477, CI:1.146-11.494, P = .0322). Worse outcome also was associated with following independent predictors, age, SOFA score, lactate and ventilation time pre-ECMO/ECLS implantation. Conclusion: The current study demonstrates a worse early survival for women, following emergent out-of-center ECMO/ECLS implantation and subsequent transport and treatment in our tertiary care cardiovascular center. Gender should be included in patient selection algorithms while basic research approaches are needed to better understand the mechanisms underlying these gender-specific outcome disparities.

We aimed to detect alterations and deficits in hemostasis during cardiac surgery with cardiopulmonary bypass (CPB) using point-of-care-supported coagulation analysis (rotational thromboelastometry, impedance aggregometry), in addition to single factor assays for the measurement of fibrinogen (FI) and factor XIII (FXIII) levels. Forty-one patients scheduled for elective cardiac surgery with CPB were enrolled in this observational study. Perioperative measurement (pre-, postheparin, 30-minutes before the end of bypass, 1-hourpostoperatively) of standard laboratory variables, additional rotational thromboelastometry (ROTEM; International GmbH, Munich, Germany), Multiplate analysis (Roche, Switzerland), and an assay of FXIII activity were performed as well as the collection of epidemiological data and blood loss. The FI and FXIII levels as well as the measured ROTEM and Multiplate parameters correlated weakly with the blood loss. Clotting time and maximum clot firmness (MCF) of the intrinsically activated ROTEM showed a good correlation ( rCT-INTEM = 0.378; P < .05, rMCF-INTEM = 0.305; P < .05) with postoperative drainage loss, suggesting a dependence of blood loss on the initial intrinsic activity. Additionally, perioperative FI or FIBTEM levels and the FXIII levels correlated with each other. Intrinsically activated ROTEM showed a good correlation with postoperative drainage loss, thus suggesting a dependence of blood loss on the initial intrinsic activity and therefore facilitating clinicians to assess postoperative bleeding complications. Based on the FI level or the MCFFIBTEM measured by ROTEM, it may also be possible to assess the FXIII concentration. Especially in chronically ill and massive bleeding cardiac surgery patients with significantly decreased FXIII levels, the knowledge of FXIII deficiency may help clinicians to treat coagulation disorders more adequately.

Mitral valve surgery and particularly minimally invasive mitral valve surgery has experienced constant evolution and improvement. To date, a broad and effective armamentarium of surgical techniques for mitral valve repair exists. Conventional and minimally invasive mitral valve surgeries are proven methods for achieving excellent and durable results by a minimized surgical risk. Minimally invasive mitral valve surgery additionally provides reduced morbidity by means of bleeding, transfusions, re-exploration, and impaired wound healing. Reduced postoperative pain is a major benefit of minimally invasive mitral valve surgery. This beneficial effect additionally can be enhanced by implementation of a non-rib-spreading, fully endoscopic approach. The reduction of postoperative pain translates into improved patient satisfaction, shorter length of stay, and lower health care expenditures. This review gives a detailed outline of the past and present of minimally invasive mitral valve surgery, results, outcomes and durability.

An 83-year-old woman presented with progressive dyspnea. She underwent an edge-to-edge mitral repair with the MitraClip-NTR system (Abbott Vascular, Santa Clara, California) for severe mitral regurgitation (MR) that was caused by posterior leaflet prolapse ([Figures 1A to 1C][1]) with calcification

OBJECTIVES The aim of this study was to evaluate whether additional cusp interventions and valve types affect aortic valve-related reoperation and mortality rates after the David procedure. METHODS Between 1997 and 2018, a total of 449 patients {372 males; mean age 54.2 [standard deviation (SD) 15.2] years, range: 12.7–79.9 years} underwent elective valve-sparing aortic root replacement (David procedure) for aortic regurgitation and were prospectively followed up clinically and echocardiographically. RESULTS The follow-up was 94% complete. Cumulative follow-up time was 2268 patient-years [mean follow-up time 5.1 (4.3 SD) years]. Thirty-day mortality was 2.2% (n = 10). Late (>30 days) survival did not differ from that of the age- and gender-matched general population. Freedom from reoperation in patients without additional cusp reconstruction was 94% [95% confidence interval (CI) 91–98] and 92% (95% CI 88–97) at 5 and 10 years, respectively, which was not significantly different (P = 1) for patients who did require additional cusp reconstruction 98% (95% CI 95–100) and 89% (95% CI 81–99). In patients with tricuspid aortic valves (n = 338), freedom from reoperation was 96% (95% CI 94–99) and 93% (95% CI 88–97) at 5 and 10 years, respectively. Patients with bicuspid aortic valves (n = 111) had a freedom from reoperation of 94% (95% CI 89–99) at 5 years and 88% (95% CI 79–98) at 10 years (P = 0.021 for the comparison to tricuspid aortic valve). Overall, 23 patients (5%; 1%/patient-year) required reoperation with a mean interval of 4.5 (4.8 SD) months. CONCLUSIONS The David procedure revealed low mid-term reoperation risk and excellent survival independent of adjunctive cusp interventions/valve morphology and is comparable with that of the age- and gender-matched general population.

OBJECTIVES: Conventional aortic valve replacement (AVR) in young, active patients represents a suboptimal solution in terms of long-term survival, durability and quality of life. The aim of the present work is to present an update on the multicentre experience with the pulmonary autograft procedure in young, adult patients. METHODS: Between 1990–2013, 1779 adult patients (1339 males; 44.7 ± 11.6 years) underwent the pulmonary autograft procedure in 8 centres. All patients underwent prospective clinical and echocardiographic examinations annually. The mean follow-up was 8.3 ± 5.1 years (range 0–24.3 years) with a total cumulative follow-up of 14 288 years and 662 patients having a follow-up of at least 10 years. RESULTS: The early (30-day) mortality rate was 1.1% (n= 19). Late (>30 day) survival of the adult population was comparable with the ageand gender-matched general population (observed deaths: 101, expected deaths: 91; P= 0.29). Freedom from autograft reoperation at 5, 10 and 15 years was 96.8, 94.7 and 86.7%, respectively, whereas freedom from homograft reoperation was 97.6, 95.5 and 92.3%, respectively. The overall freedom from reoperation was 94.9, 91.1 and 82.7%, respectively. Longitudinal modelling of functional valve performance revealed a low (

Objectives This study aimed to identify how accurately the current clinical atrial fibrillation (AF) classifications reflect its temporal persistence. Background Clinical classification of AF is employed to communicate its persistence, to select appropriate therapies, and as inclusion criterion for clinical trials. Methods Cardiac rhythm histories of 1,195 patients (age 73.0 ± 10.1 years, follow-up: 349 ± 40 days) with implantable devices were reconstructed and analyzed. Patients were classified as having paroxysmal or persistent AF by physicians at baseline in accordance with current guidelines. AF burden, measured as the proportion of time spent in AF, was obtained from the device. Additionally we evaluated the agreement between clinical and device-derived AF classifications. Results Patients within the same clinical class were highly heterogeneous with regards to AF temporal persistence. Agreement between the clinical AF classification and the objective device-derived assessments of AF temporal persistence was poor (Cohen's kappa: 0.12 [95% CI: 0.05 to 0.18]). Patient characteristics influenced the clinical decision to classify AF as paroxysmal or persistent. Higher ejection fraction (odds ratio: 0.97/per unit [95% CI: 0.95 to 0.98/per unit]; p < 0.0001) and presence of coronary artery disease (odds ratio: 0.53 [95% CI: 0.32 to 0.88]; p = 0.01) were independently associated with a lower probability of being classified as persistent AF for the same AF burden level. Conclusions The currently used clinical AF classifications poorly reflect AF temporal persistence. Patient characteristics significantly influence the physician's classification of AF. Patients classified in identical clinical categories may be inherently heterogeneous with regard to AF temporal persistence. Further study is required to determine if patient selection on the basis of objective criteria derived from rigorous AF monitoring can improve reported outcomes and better identify responders and non-responders to treatments. (OMNI Study–Assessing Therapies in Medtronic Pacemaker, Defibrillator, and Cardiac Resynchronization Therapy Devices; [NCT00277524][1]; TRENDS: A Prospective Study of the Clinical Significance of Atrial Arrhythmias Detected by Implanted Device Diagnostics; [NCT00279981][2]) [1]: http://www.clinicaltrials.gov/ct2/show/NCT00277524?term=NCT00277524%26rank=1 [2]: http://www.clinicaltrials.gov/ct2/show/NCT00279981?term=NCT00279981%26rank=1

OBJECTIVES: Since blood flow impairment by aortic valve prosthesis is characteristically dynamic, this dynamic component is best and thoroughly appreciated by exercise Doppler echocardiography. We sought to determine the haemodynamics of a new pericardial aortic bioprosthesis [Trifecta™-aortic valve bioprosthesis (T-AVB), St Jude Medical, MN, USA] at rest and during exercise and a 10-min recovery period in comparison with alternative aortic valve prostheses, e.g. Ross operation (RO), stentless aortic valve [Medtronic freestyle-aortic valve bioprosthesis (MF-AVB)] and a healthy control group (CO). METHODS: Haemodynamics at rest and during supine exercise stress testing and a 10-min recovery period were evaluated in 32 patients (mean age: 70.8±6.7 years) with T-AVB (mean follow-up: 5±2 months), 49 with RO (mean age: 43.5±13.7 years), 39 with an MF-AVB (mean age: 64.6±9.4 years) and 26 healthy patients (mean age: 39±9 years). Measurements included mean outflow tract gradient (δp mean, mmHg), effective orifice area index (EOAI, cm 2 /m 2 ) and valvular resistance (vR, dyn s cm −5 ). RESULTS: Mean body surface area for T-AVB was 1.93±0.24 m 2 (median 1.97 m 2 ). Mean δp mean at rest was 7.2±3.4 mmHg, mean EOAI 0.86±0.23 cm 2 /m 2 and mean vR 50.7±23.2 dyn s cm −5 . Supine stress testing did increase the mean EOAI to 0.98±0.27 cm 2 /m 2 ,t he mean vR to 62.6±25.3 dyn s cm −5 and the mean δp mean to 10.21±4.7 mmHg, respectively (P

Background: The Ross operation provides the advantage of growth potential of the pulmonary autograft in the aortic position. However, development of autograft dilatation and regurgitation may occur. We sought to assess the progression of autograft diameters and aortic regurgitation (AR) with regard to patient age at the time of the Ross operation. Methods: Autograft echo dimensions from 48 children Results: The mean z values of all patients showed a significant increase with follow-up time at the sinus (0.5 ± 0.1/year, P < .001) and the sinotubular junction (0.7 ± 0.2/year, P < .001) but not at the annulus (0.1 ± 0.1/year, P = .59). There was no significant difference in the z values of sinus and the sinotubular junction between younger and older children at implantation and with time. The initial annulus z value was significantly larger in younger children ( P < .0001), whereas the annual increase was significantly higher in older children ( P = .021). Age at operation has no impact on the initial AR grade ( P = .60). The AR tends to increase more quickly in older patients ( P = .040). Sinus and sinotubular junction dilate with time, regardless of patient age. Conclusions: Young children show larger initial annulus sizes than older children. However, annulus diameters tend to normalize in young children, whereas they increase in older children. Autograft regurgitation develops slowly, but significantly, and predominantly in older children. Stabilizing measures to prevent autograft root dilatation are warranted in adolescents, but they are not required in young children.

The bicuspid aortic valve (BAV) is associated with various cardiovascular malformations, most predominantly with dilatation of the aortic root and ascending aorta. After sporadic observations of various BAV-associated mitral valve pathologies, we sought to systematically examine the mitral valve morphology in patients with a BAV.Forty-four operated patients with a BAV (type I L/R) and 40 operated patients with a tricuspid aortic valve (TAV) as well as 20 healthy subjects (Normal) were examined by means of transthoracic echocardiography. In all patients, the primary operative indication was aortic valve pathology (stenosis/regurgitation), and no patients with degenerative mitral valve pathology were included.In patients with a BAV, the anterior mitral leaflet (AML) was significantly elongated in comparison with patients with a TAV and Normal subjects (33.2 ± 6.6 vs 27.7 ± 3.2 vs 27.0 ± 1.9 mm; P0.001). Regression analysis revealed that patients with a BAV had significantly elongated AML (P0.001) even after correcting for the mitral annulus (MA) diameter and somatometric characteristics (weight, height, body surface area, age). Furthermore, patients with a BAV and concomitant aortic valve insufficiency had significantly elongated AML in comparison with the other groups (35.2 ± 7.6 vs 28.4 ± 3.7 mm; P0.001). This difference persisted even after correcting for MA diameter and somatometric differences (P0.001). AML heights32 mm in patients undergoing aortic root/valve procedures were highly predictive of the presence of a BAV [specificity: 90%, positive predictive value: 82%, area under curve: 0.80 (95% CI: 0.71-0.88)].We provide evidence that the cardiovascular alterations observed in the BAV are not limited to the aortic valve or ascending aorta but also involve the AML, and seem to be more pronounced in patients with a BAV with concomitant, clinically significant aortic regurgitation.

Modern analyses of data for scientific reporting and healthcare management purposes require standardized and consistent definitions, something which also holds true for aortic root surgery, as part of the cardiovascular surgery spectrum. The aim of the present study was to investigate the currently employed nomenclature of the aortic root components. A questionnaire was constructed on the terminology of aortic root components, providing a list of common definitions including anatomical descriptions, as well as fields for custom responses. Responses were received from 534 cardiothoracic surgeons registered at www.ctsnet.org. Remarkable variations in definitions were detected. The most unanimously accepted terms were: 'aortic leaflets', the freely moving parts (52.6% of responses); 'commissures', the distal part of the leaflet attachments plus the peripheral area of the free edges of the leaflets (52.2%); 'semi-lunar leaflet attachment', the anatomic site of leaflet attachment (58%); 'annulus', the circular line defined by the nadirs of the leaflets (38%); 'interleaflet triangle', the tissue between two leaflets and annulus (23%); 'aortic valve', the three leaflets only (55%); 'aortic root' as composed of sinuses, tissue between the leaflets, sinutubular junction, leaflets and their wall attachment (63%). The remarkable variability on the everyday-used definitions of the aortic root components can potentially lead to misinterpretation of data. More stringent adoption of consistent, standardized definitions of aortic root components is necessary in the modern era of data collection and management.

Background— It is suggested that in young adults the Ross procedure results in better late patient survival compared with mechanical prosthesis implantation. We performed a propensity score–matched study that assessed late survival in young adult patients after a Ross procedure versus that after mechanical aortic valve replacement with optimal self-management anticoagulation therapy. Methods and Results— We selected 918 Ross patients and 406 mechanical valve patients 18 to 60 years of age without dissection, aneurysm, or mitral valve replacement who survived an elective procedure (1994 to 2008). With the use of propensity score matching, late survival was compared between the 2 groups. Two hundred fifty-three patients with a mechanical valve (mean follow-up, 6.3 years) could be propensity matched to a Ross patient (mean follow-up, 5.1 years). Mean age of the matched cohort was 47.3 years in the Ross procedure group and 48.0 years in the mechanical valve group ( P =0.17); the ratio of male to female patients was 3.2 in the Ross procedure group and 2.7 in the mechanical valve group ( P =0.46). Linearized all-cause mortality rate was 0.53% per patient-year in the Ross procedure group compared with 0.30% per patient-year in the mechanical valve group (matched hazard ratio, 1.86; 95% confidence interval, 0.58 to 5.91; P =0.32). Late survival was comparable to that of the general German population. Conclusions— In comparable patients, there is no late survival difference in the first postoperative decade between the Ross procedure and mechanical aortic valve implantation with optimal anticoagulation self-management. Survival in these selected young adult patients closely resembles that of the general population, possibly as a result of highly specialized anticoagulation self-management, better timing of surgery, and improved patient selection in recent years.

OBJECTIVES: The Ross operation in the setting of a bicuspid aortic valve (BAV) remains controversial. Using data from the German Ross Registry, we sought to investigate the effect of the presence of a BAV on autograft function and diameters over time after the Ross operation compared with the presence of a tricuspid aortic valve (TAV). METHODS: A total of 1277 patients (mean age 42.2 + or - 15.3 years) with intra-operatively documented aortic valve morphology during the Ross operation were analysed in the present study (sub-coronary technique, n=648, root replacement technique, n=629 patients). A BAV was present in 70.9% of patients. Clinical and echocardiographic follow-up was performed preoperatively and at pre-specified intervals (mean follow-up 5.7 + or - 3.8 years, 6806 patient-years). Hierarchical multilevel modelling techniques were used for the statistical analysis of serial measurements and comparisons among groups. RESULTS: Initial neo-aortic regurgitation was lower in the BAV group (0.52 vs 0.62 aortic insufficiency (AI) grades, p=0.008), whereas the annual increase of it did not differ among groups. In both surgical techniques, no significant development of neo-aortic regurgitation (

Objective To define the function of the "Ross valves" and its clinical meaning in a practical valve performance classification as part of the outcome analysis. Methods From 1994 to 2017, 630 consecutive patients underwent the subcoronary Ross procedure at our institution. The valve performance classification combines hemodynamics, symptoms, and management criteria. Median follow-up was 12.5 years (maximum 22.3 years, 7404 patient-years, 99.4% completeness). Results The mean age of the patients was 44.7 ± 11.9 years. Hospital deaths was 0.3% (n = 2). Twenty years after the operation survival was 73.1% (95% confidence interval [CI], 65.4%-81.6%) and statistically not different from the age- and gender-matched general population; freedom from reoperation was 85.9% (95% CI, 80.2%-92.0%; 0.6% per patient-year), 89.8% (95% CI, 84.3%-95.7%) for autograft, and 91.0% (95% CI, 86.3%-96.0%) for homograft. Preoperative annulus diameter, aortic regurgitation, annulus reinforcement, sinotubular junction reinforcement, and bicuspid aortic valve type were no significant risk factors for reoperation. At 20 years the probability of a patient being in valve performance class I to IV was 5%, 74%, 19%, and 1%, respectively. Time to reoperation was not different in bicuspid and tricuspid aortic valves; preoperative aortic stenosis tended to have better outcome of autograft function. Conclusions These up to 22 years data show that the subcoronary Ross procedure continues to provide an excellent tissue aortic valve replacement. The suggested valve performance classification emerged as a practical concept for outcome analysis with the probability of 79% being in the favorable class I or II at 20 years.

This study aims to fine-tune the decision making for ascending aorta treatment in bicuspid aortic valve surgery.A total of 1693 patients with a primary indication for aortic valve surgery were investigated retrospectively with respect to a multifactorial decision-making policy including the z score and the clinical outcome in relation to different techniques for ascending aorta treatment (no intervention n = 1116; intervention n = 577 either by ascending aorta replacement n = 404 or aortoplasty n = 173). Follow-up was 99.5% complete (mean 7.0 ± 4.4 years, range 0-17.7 years, 11,895 patient-years).Hospital mortality was 1.2% for the no-intervention group and 0.9% for the intervention group and was not different between groups (P = .629). Survival compared with the adjusted normal population was lower for both groups (no intervention: P .001) but not by such a great margin for the intervention group (P = .27). Determinants for death were not related to the ascending aorta treatment. Aortoplasty led to significantly more reoperations (P = .002). The z score thresholds for intervention on the ascending aorta were greater for younger patients, intervention was more liberal in young age, depicted in nomograms.In our study, ascending aorta intervention could be performed with low hospital mortality and obviously did not add to the overall mortality compared with no intervention. Ascending aorta replacement was the most definite intervention. The multifactorial decision for ascending aorta intervention including the z score of the ascending aorta was more liberal in younger patients compared to the simple aortic size guidelines and provided excellent results. However, generalizability needs further data.

BackgroundAcute aortic dissection (AAD) is a life-threatening condition with high mortality and a relatively unclarified pathophysiological mechanism. Although differentially expressed genes in AAD have been recognized, interactions between these genes remain poorly defined. This study was conducted to gain a better understanding of the molecular mechanisms underlying AAD and to support the future development of a clinical test for monitoring patients at high risk.Materials and MethodsAortic tissue was collected from 19 patients with AAD (mean age 61.7 ± 13.1 years), and from eight other patients (mean age 32.9 ± 12.2 years) who carried the mutated gene for Marfan syndrome (MS). Six patients (mean age 56.7 ± 12.3 years) served as the control group. The PIQOR™ Immunology microarray with 1076 probes in quadruplicates was utilized; the differentially expressed genes were analysed in a MedScan search using PathwayAssist software. Quantitative reverse transcription-polymerase chain reaction (qRT-PCR) and protein analysis were performed.ResultsInteractions of MS fibrillin-1 (FBN1) in the MedScan pathway analysis showed four genes, fibulin-1 (FBLN1), fibulin-2 (FBLN2), decorin (DCN) and microfibrillar associated protein 5 (MFAP5), which were differentially expressed in all tissue from AAD. The validation of these genes by qRT-PCR revealed a minimum of three-fold downregulation of FBLN1 (0.5 ± 0.4 vs. 6.1 ± 2.3 fold, p = 0.003) and of DCN (2.5 ± 1.0 vs. 8.5 ± 4.7 fold, p = 0.04) in AAD compared to MS and control samples.ConclusionsDownregulation of fibrillin-1 (FBN1) may weaken extracellular components in the aorta and/or interfer with the transmission of cellular signals and eventually cause AAD. Additional research on these four identified genes can be a starting point to develop a diagnostic tool.

Background. Infants and neonates with severe left ventricular outflow tract obstruction may require pulmonary autograft replacement of the aortic root. In this retrospective multicenter cohort study, we present our experience with the Ross procedure in neonates and infants with a focus on midterm survival and pulmonary autograft durability. Methods. A retrospective observational study was performed in 76 infants (aged less than 1 year) operated on in six congenital cardiac centers in The Netherlands and Germany between 1990 and 2013. Results. Patients had a pulmonary autograft replacement of the aortic valve with (68%) or without (32%) septal myectomy. Median patient age was 85 days (range, 6 to 347). Early mortality (n = 13, 17%) was associated with neonatal age, preoperative use of intravenous inotropic drugs, and congenital aortic arch defects. Five patients (9%) died during follow-up. Freedom from autograft reintervention was 98% at 10 years. Echocardiography demonstrated good valve function, with no or trace regurgitation in 73% of patients. Freedom from right ventricular outflow tract reintervention was 51% at 10 years. Univariable analysis demonstrated superior freedom from reintervention of pulmonary homografts compared with aortic homografts or xenografts. Conclusions. Pulmonary autograft replacement of the aortic valve in neonates and infants is a high-risk operation but offers a durable neoaortic valve. Midterm durability reflects successful adaptation of the autograft to the systemic circulation. Late mortality associated with heart failure was an unexpected finding. (C) 2015 by The Society of Thoracic Surgeons

Background Autograft valve preservation at reoperation may conserve some of the advantages of the Ross procedure. However, results of long-term follow-up are lacking. In this retrospective multicenter study, we present our experience with valve-sparing reoperations after the Ross procedure, with a focus on long-term outcome. Methods A total of 86 patients from 6 European centers, who underwent valve-sparing reoperation after the Ross procedure between 1997 and 2013, were included in the study. Results Reoperation was performed a median of 9.1 years after the Ross procedure in patients with a median age of 38.4 years (interquartile range: 27.1-51.6 years). Preoperative severe autograft regurgitation (grade ≥3) was present in 46% of patients. In-hospital mortality was 1%. During a median follow-up of 4.3 years, 3 more patients died of noncardiac causes, resulting in a cumulative survival at 8 years of 89% (95% confidence interval: 65%-97%). Fifteen patients required a reintervention after valve-sparing reoperation, mostly owing to prolapse or retraction of autograft cusps. Freedom from reintervention was 76% (95% confidence interval: 57%-87%) at 8 years. The reintervention hazard was increased in patients who had isolated and/or severe aortic regurgitation at valve-sparing reoperation. In patients without reintervention after valve-sparing autograft reoperation (n = 63), severe aortic regurgitation was present in 3% at last follow-up. Conclusions Valve-sparing autograft reoperations after the Ross procedure carry a low operative risk, with acceptable reintervention rates in the first postoperative decade. Patients with isolated and/or severe autograft regurgitation have an increased hazard of reintervention after valve-sparing reoperation; for these patients, careful preoperative weighing of surgical options is required.

OBJECTIVES: Patients with a bicuspid aortic valve (BAV) present with various phenotypes of the valve, the aortic root (AoR) and/or the ascending aorta (AAo) and various valve haemodynamics (vHs). The aim of the present study was to investigate the association between the above parameters. METHODS: Between February 1999 and April 2014, the preoperative aortographies of 828 surgical patients with BAV were evaluated. The exact BAV type was classified intraoperatively according to the number and spatial orientation of the raphes. RESULTS: On analysis of BAV phenotypes and aortic configurations, a weak pattern was revealed (P = 0.01) only for BAV type 0 and AoR dilatation. Including haemodynamics, certain significant patterns emerged: in insufficient BAVs, AoR dilatation was significantly more frequent in type 0, type 1 LR and type 1 RN, whereas AoR + AAo dilatation was more frequent in BAV type 1 LR. In stenotic BAVs, AAo dilatation alone was observed significantly more frequently in BAV type 1 LR and type 0. Combined vHs were associated with AAo and AoR + AAo dilatation in BAV type 2/unicuspid only. CONCLUSIONS: Associations between the two parameters, BAV type and aortic configuration, were only weak. With the inclusion of haemodynamics significant associations emerged but were not exclusive. In stenotic BAVs, aortic dilatation was more localized to AAo only, supporting the valve-related flow turbulence theory. Insufficient (even trace insufficient) BAVs and also combined lesions in BAV type 2/unicuspid were associated with a more extensive aortopathy (AoR + AAo) in younger patients, indicating a more aggressive gene-related aortopathy.

Introduction Acute kidney injury (AKI) is a frequent complication after cardiac surgery and is associated with a poor prognosis. Mechanical ventilation is an important risk factor for developing AKI in critically ill patients. Ventilation with high tidal volumes has been associated with postoperative organ dysfunction in cardiac surgical patients. No data are available about the effects of the duration of postoperative respiratory support in the immediate postoperative period on the incidence of AKI in patients after cardiac surgery. Method We performed a secondary analysis of 584 elective cardiac surgical patients enrolled in an observational trial on the association between preoperative cerebral oxygen saturation and postoperative organ dysfunction and analyzed the incidence of AKI in patients with different times to extubation. The latter variable was graded in 4 h intervals (if below 16 h) or equal to or greater than 16 h. AKI was staged according to the AKI Network criteria. Results Overall, 165 (28.3%) patients developed AKI (any stage), 43 (7.4%) patients needed renal replacement therapy. Patients developing AKI had a significantly (P

Objective Although atrial fibrillation (AF) recurrence is unpredictable in terms of onset and duration, current intermittent rhythm monitoring (IRM) diagnostic modalities are short-termed and discontinuous. The aim of the present study was to investigate the necessary IRM frequency required to reliably detect recurrence of various AF recurrence patterns. Methods The rhythm histories of 647 patients (mean AF burden: 12±22% of monitored time; 687 patient-years) with implantable continuous monitoring devices were reconstructed and analyzed. With the use of computationally intensive simulation, we evaluated the necessary IRM frequency to reliably detect AF recurrence of various AF phenotypes using IRM of various durations. Results The IRM frequency required for reliable AF detection depends on the amount and temporal aggregation of the AF recurrence (p95% sensitivity) of AF recurrence required higher IRM frequencies (>12 24-hour; >6 7-day; >4 14-day; >3 30-day IRM per year; p

OBJECTIVES: The fate of the aortic dimensions in patients with a bicuspid aortic valve (BAV) after aortic valve replacement (AVR) is unclear. We investigated the evolution of aortic root and ascending aorta dimensions in patients with a BAV after AVR. To neutralize the effect of pathological transvalvular haemodynamics on aortic dimensions, we evaluated our hypotheses in patients with normal transvalvular haemodynamics after a subcoronary autograft procedure, which preserves intact the native aortic wall. METHODS: We excluded patients operated on for endocarditis; who developed autograft insufficiency > trivial and who required autograft reoperation during the follow-up. We included 448 patients (361 with BAV; 340 males; 44.6 ± 11.4 years; mean follow-up: 7.5 ± 3.9 years). Valve phenotype was determined during surgery. Annual echocardiographic examinations (n= 3336) were performed (follow-up completeness: 98%). To allow for somatometric, gender and age influences, z-values of measurements were calculated from the general population (GP) and analysed using longitudinal methods. RESULTS: The increase in ascending aorta did not differ from that expected in the GP (0.04 z-values/year; P= 0.06). No difference could be observed in diameter increase rates between BAV and tricuspid aortic valve patients (TAV) (0.04 vs 0.06 z-values/year; P= 0.3), as well as between BAV phenotypes. The sinus increase did not differ from that expected in the GP (0.03 z-values/year; P= 0.1), and no significant differences could be observed between BAV phenotypes. In patients undergoing aortoplasty (n= 70), no significant difference in the rates of ascending aorta and sinus increase could be observed, compared with the GP. CONCLUSION: For the time period of this study and in patients with normal aortic root haemodynamics after AVR, ascending aorta dimensions over time are similar to that of the matched GP. Patients with a BAV did not exhibit higher rates of ascending aorta dilatation after AVR than patients with TAV. At least for the first postoperative decade, transvalvular haemodynamics appear to exhibit a greater influence than the genetic component of BAV on the development of the BAV aortopathy.

This study aimed to identify how accurately the current clinical atrial fibrillation (AF) classifications reflect its temporal persistence.Clinical classification of AF is employed to communicate its persistence, to select appropriate therapies, and as inclusion criterion for clinical trials.Cardiac rhythm histories of 1,195 patients (age 73.0 ± 10.1 years, follow-up: 349 ± 40 days) with implantable devices were reconstructed and analyzed. Patients were classified as having paroxysmal or persistent AF by physicians at baseline in accordance with current guidelines. AF burden, measured as the proportion of time spent in AF, was obtained from the device. Additionally we evaluated the agreement between clinical and device-derived AF classifications.Patients within the same clinical class were highly heterogeneous with regards to AF temporal persistence. Agreement between the clinical AF classification and the objective device-derived assessments of AF temporal persistence was poor (Cohen's kappa: 0.12 [95% CI: 0.05 to 0.18]). Patient characteristics influenced the clinical decision to classify AF as paroxysmal or persistent. Higher ejection fraction (odds ratio: 0.97/per unit [95% CI: 0.95 to 0.98/per unit]; p 0.0001) and presence of coronary artery disease (odds ratio: 0.53 [95% CI: 0.32 to 0.88]; p = 0.01) were independently associated with a lower probability of being classified as persistent AF for the same AF burden level.The currently used clinical AF classifications poorly reflect AF temporal persistence. Patient characteristics significantly influence the physician's classification of AF. Patients classified in identical clinical categories may be inherently heterogeneous with regard to AF temporal persistence. Further study is required to determine if patient selection on the basis of objective criteria derived from rigorous AF monitoring can improve reported outcomes and better identify responders and non-responders to treatments. (OMNI Study-Assessing Therapies in Medtronic Pacemaker, Defibrillator, and Cardiac Resynchronization Therapy Devices; NCT00277524; TRENDS: A Prospective Study of the Clinical Significance of Atrial Arrhythmias Detected by Implanted Device Diagnostics; NCT00279981).

There are certain aortic root pathologies where only one or two of the aortic sinuses are diseased. We aimed to evaluate our mid-term results after a partial remodeling of the aortic root. A total of 220 patients underwent a valve-sparing operation at our institution. In 29 patients (mean age: 62+/-10 years), two (n=22) or one (n=7) native aortic sinuses were preserved. Operative indication was type A aortic dissection (n=12) or aortic root aneurysm (n=17). Preoperative aortic valve regurgitation was 1.8+/-1.1 grades. Mean follow-up time was 46+/-32 months. At the latest follow-up, 23 patients were alive and asymptomatic. One ascending aorta re-operation was observed due to late aortic graft infection. Echocardiographic measurements at latest follow-up were excellent: aortic regurgitation: 0.6+/-0.5 grades; aortic valve area: 2.7+/-0.7 cm2; aortic root dimensions: anulus 23+/-3mm, sinus 34+/-5mm, sinotubular junction 28+/-5mm and ascending aorta: 30+/-2mm. Longitudinal analysis revealed no development of clinically significant aortic regurgitation (

Stand-alone surgical ablation for symptomatic atrial fibrillation (AF) is a well-recognized alternative to catheter ablation in patients who desire this technique or in whom interventional approaches are contraindicated [1]. Both approaches, surgical or interventional, ought to be performed with the highest possible success and lowest possible complication rates. In this issue of the Journal, Beukema et al. [2] show clearly that minimally invasive epicardial pulmonary vein isolation (PVI) results in a high failure rate, with 68% of their patients having some kind of AF recurrence (symptomatic as well as asymptomatic). One or more additional postoperative catheter procedures were required in order to restore and maintain a stable sinus rhythm, with a final 87% of patients being AF free. Pursuing restoration of sinus rhythm via subsequent catheter interventions in patients with significant recurrence of AF after ablation procedures as reported by Beukema et al. [2] is another good example of a successful heartteam approach in AF patients. As physicians, surgeons and scientists, we ought to continuously evaluate our results, and draw conclusions from our successes and failures. A reduction of AF burden to a mean of 6.4 ± 23.5% might be classified as a success [1] and a secondary/tertiary success rate of 87% sinus rhythm restoration is likely to be acceptable. However, our main goal in AF therapy should be the primary high-grade efficiency of surgical ablation. Such reports are not rare in the literature: The groups of Weimar et al. [3] and Ad et al. [4] have presented high and long-lasting success rates of sinus rhythm stabilization with up to 90% of patients in sinus rhythm after surgical stand-alone ablation procedures. These much convincing results were achieved with an extended surgical endocardial approach, the biatrial Cox Maze IV procedure, with the use of extracorporeal circulation and cardioplegic arrest. Although this treatment modality incorporates more invasive surgery, the complication rates were low and the patients’ commitment to this more invasive surgical approach was high. In case the use of extracorporeal circulation is not warranted, at least a first-line extended epicardial left atrium only approach as described by Weimar et al. [5] ought to be considered. This approach also results in high rates of procedural mid-term success, and additionally includes the possibility to treat the left atrial appendage. Another important issue, albeit not the primary focus of the work by Beukema, was the use of an implantable event recorder for continuous rhythm monitoring of their patients. These devices allowed the authors to examine the real success rate of their ablation strategy. Furthermore, these devices allow physicians to detect AF recurrence even in asymptomatic patients [6] and this technology has improved and will further improve with time [7] offering now very low false-positive or -negative rates (AF versus premature atrial or ventricular contractions). We now know that the traditional follow-up methods for AF patients (symptoms, intermittent ECG capture of any duration) are unreliable [8–10]. AF recurrence is a dynamic phenomenon with significant qualitative, quantitative and temporal aspects. Any evaluation of AF recurrence while ignoring one or more of these three aspects will inevitably lead to biased inferences. Novel implantable devices as well as the upcoming revolution of wearable electronics provide the physician and the researcher for the first time the opportunity to evaluate and research AF recurrence while taking into consideration the above-mentioned aspects of AF recurrence with great accuracy and precision. Interestingly, our electrophysiology colleagues, at least in larger clinical trials, already use these devices more often than cardiac surgeons for accurate AF detection and evaluation of therapeutic interventions as well as for intensifying and individualizing post-therapeutic patient management. Poor outcomes, less than meticulous patient follow-up and suboptimal study designs are poorly received among the scientific community. In that context, surgical ablation techniques with poor success outcome and outdated follow-up methods in surgical AF-ablated patients will lead to a loss of interest in this field. Our primary aim should be to provide stable and convincing surgical AF ablation results as first-line therapy and to evaluate our therapeutic success by ruling out chance findings utilizing the novel, continuous heart rhythm monitoring technologies that are already available. It is only with high success rates after surgical AF ablation—especially in ‘stand-alone’ procedures—that our therapies will reach an acceptance among AF patients as well as among the electrophysiological society, which still considers surgical ablation far too invasive. Only thus we will be able to create a new and necessary level of trust and confidence among patients and our

Remodeling of the dilated valve annulus with a prosthetic ring for repair of valve insufficiency is a well-established concept in mitral and tricuspid valve surgery and may also be suitable for aortic valve reconstruction. A novel rigid aortic annuloplasty ring was tested in vitro.Ten fresh porcine aortic roots were investigated in a pulsatile flow simulator before surgery (group N), after patch dilatation of the annulus (group D), and after reconstruction using a rigid annuloplasty ring (group R). The ring was designed to (1) prevent contact with the leaflets, reducing the risk of contact injury, (2) be applicable to all valve phenotypes, (3) prevent injury to the conduction bundle, and (4) be implantable from inside the aortic root (subvalvular). For each group pressure gradient, leakage volume, and coaptation height were measured.With the annuloplasty ring, regurgitation volume decreased from -8.50 ± 1.91 mL (group D) to -4.75 ± 1.66 mL (group R; p0.0003), not different from group N. Coaptation height of the leaflets increased from 0.62 ± 0.08 mm (group D) to 0.77 ± 0.11 mm (group R; p0.005), similar to group N. Mean pressure gradient increased from 2.98 ± 0.38 mm Hg (group D) to 3.72 ± 0.40 mm Hg (group R; p0.0001).This novel aortic annuloplasty ring has the potential for supporting aortic valve reconstruction by remodeling the subvalvular area.

Background The enthusiasm about the advantages of a viable autologous transplant faded with recent reports of autograft deterioration and associated reoperations after the Ross procedure. This report evaluates predictors for autograft failure and outcomes extending into the second decade after a Ross procedure. Methods From 1995 through 2012, 645 consecutive patients (mean age, 42.3 ± 14.2 years; 76% males) underwent a Ross operation using mainly the root replacement technique (98%). They were prospectively followed up with clinical and echocardiographic evaluations. Total follow-up was 5,349 patient-years and was 96% complete. Mean follow-up duration was 8.4 ± 4.6 years (range, 0 to 17.4 years). Results Early mortality was 0.9% (n = 6). Cumulative survival at 15 years was 92.7% (95% confidence interval, 90.1% to 95.3%) and did not differ from the general German population ( p = 0.261). Freedom from reoperation on the autograft or the pulmonary allograft at 12 years was 91.6% (95% confidence interval, 88.5% to 94.9%) and 95.0% (95% confidence interval, 92.8% to 97.2%), respectively. Sixty-five patients (10.1%) required a total of 78 valve-related reoperations after a Ross procedure (1.5%/patient-year) with a reoperative hospital mortality of 3.8% (n = 3). Forty-seven autograft reoperations were observed in 44 patients (0.87%/patient-year); 22 of them (47%) could be performed as a valve-sparing procedure. Preoperative aortic valve regurgitation and an aortic annulus of at least 26 mm were identified as predictors for autograft failure. Conclusions In this large series, the Ross procedure resulted in excellent long-term survival rates with a low risk of valve-related morbidity and a considerably low rate of reoperations in young and middle-aged patients and should be considered as an important treatment option in this cohort.

Objectives Despite progress in the treatment of cardiopulmonary organ failure, the mortality rate for patients with acute respiratory distress syndrome (ARDS) and cardiogenic shock remains high. Extracorporeal membrane oxygenation (ECMO) is a promising treatment option, but long-term outcomes and health-related quality of life (HRQOL) are unknown. Methods Detailed information related to pre- and post-device data and outcomes from a consecutive sample of 71 patients treated with ECMO was analysed. Long-term survivors were given a detailed follow-up examination after a median time of 31 months that included multiple scoring systems for HRQOL assessment. Results Seventy-one patients received a portable out-of-centre-implanted ECMO system. The survival rate at hospital discharge was 48%. Median HRQOL scores were 80% on the Karnofsky index (normal ≥80%), 80% on the Euroqol-5D (normal ≥75%) and 73.1% on the quality-of-life index (normal ≥70%). Mental scores were 96.7% on the Mini-Mental State Examination (normal ≥90.0%), 77.8% on the DemTect (normal ≥72.0%), 87.0% on the test for early detection of dementia with depression demarcation (TFDD; normal ≥74.0%) and confirmed good mental state and HRQOL for patients at follow-up. Univariate analysis for in-hospital mortality indicated that ventilation time before device implantation, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, higher lactate level at the time of ECMO implantation and female gender were associated with adverse outcomes. Conclusions In our cohort of patients, survivors of out-of-hospital ECMO implantation demonstrated good mental and quality-of-life conditions with well-recovered cardiopulmonary function during long-term follow-up. The indicators for adverse outcomes, pre-implantation lactate levels, pre-ventilation time and APACHE II score, should be considered before implantation of an ECMO device. Clinical trial This study is registered at DRKS (Deutsches Register Klinischer Studien) under the code DRKS00009735 and was submitted to the WHO.