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Objectives Perivalvular abscesses with destruction of the aortomitral junction (AMJ) are a severe complication of infective endocarditis (IE) and are associated with high mortality and complex management. The Hemi-Commando procedure is a mitral valve (MV) sparing alternative to the Commando procedure in suitable patients with complex IE and paravalvular destruction. This study reviews the mid-term outcomes in patients undergoing the Hemi-Commando procedure for treating IE with destruction of the AMJ. Methods The clinical outcomes of patients with IE and AMJ involvement who underwent the Hemi-Commando procedure between 2015 and 2021 at the Leipzig Heart Center were retrospectively analyzed. Primary outcomes were 30-day mortality and 1-year survival. Secondary outcome was 1-year freedom from reoperation. Results A total of 22 patients underwent the Hemi-Commando procedure during the study period. The patients’ mean age was 59.8 ± 18.3 years. The study population was predominantly male (86.4%). Preoperative-sepsis was present in 6 (27.3%) patients, and the median EuroScore II was 28.5%. Almost two-thirds (N = 14; 63.6%) of the patients presented with native IE. Streptococci were the most common pathogens (N = 8; 36.4%). Paravalvular abscess was found intraoperatively in 16 (72.7%) patients. The 30-day mortality was 13.6%. The estimated 1- and 3-year survival rates were 77.5% and 66.4%, respectively. The estimated freedom from reoperation at 1 and 3 years was 92.3%. Conclusion The Hemi-Commando procedure offers an acceptable mid-term survival chance with low reoperation rates and is, therefore, a reasonable MV-sparing alternative to the Commando procedure in suitable patients with extensive IE and perivalvular involvement.

Objective In transcatheter aortic valve implantation (TAVI), intraprocedural complications, which are only manageable by conversion to emergency open-heart surgery (E-OHS), occasionally occur. Contemporary data on the incidence and outcome of TAVI patients undergoing E-OHS are scarce. Methods Data of all patients undergoing transfemoral TAVI between 2006 and 2020 at the Heart Centre Leipzig were analyzed. The study time was divided into 3 periods: 2006–2010 (P1), 2011–2015 (P2), 2016–2020 (P3). Patients were grouped according to their surgical risk (high risk: EuroSCORE II ≥ 6%, low/intermediate risk: EuroSCORE II Results During the study period, a total of 6903 patients underwent transfemoral TAVI. Among them, 74 (1.1%) required E-OHS [high risk, n = 66 (89.2%); low/intermediate risk, n = 8 (10.8%)]. The rate of patients requiring E-OHS was 3.5% (20/577 patients), 1.8% (35/1967 patients), and 0.4% (19/4359 patients) in study periods P1-P3, respectively (p Conclusions In-hospital and 1-year survival rates following E-OHS are higher in low/intermediate risk than high risk TAVI patients. An on-site cardiac surgical department with immediately available E-OHS capabilities is an important component of the TAVI team.

Mitral valve prolapse (MVP) is a cardiac valve disease that not only affects the mitral valve (MV), provoking mitral regurgitation, but also leads to maladaptive structural changes in the heart. Such structural changes include the formation of left ventricular (LV) regionalized fibrosis, especially affecting the papillary muscles and inferobasal LV wall. The occurrence of regional fibrosis in MVP patients is hypothesized to be a consequence of increased mechanical stress on the papillary muscles and surrounding myocardium during systole and altered mitral annular motion. These mechanisms appear to induce fibrosis in valve-linked regions, independent of volume-overload remodeling effects of mitral regurgitation. In clinical practice, quantification of myocardial fibrosis is performed with cardiovascular magnetic resonance (CMR) imaging, even though CMR has sensitivity limitations in detecting myocardial fibrosis, especially in detecting interstitial fibrosis. Regional LV fibrosis is clinically relevant because even in the absence of mitral regurgitation, it has been associated with ventricular arrhythmias and sudden cardiac death in MVP patients. Myocardial fibrosis may also be associated with LV dysfunction following MV surgery. The current article provides an overview of current histopathological studies investigating LV fibrosis and remodeling in MVP patients. In addition, we elucidate the ability of histopathological studies to quantify fibrotic remodeling in MVP and gain deeper understanding of the pathophysiological processes. Furthermore, molecular changes such as alterations in collagen expression in MVP patients are reviewed.

There is a lack of information about cardiac surgery training and professional practice in Latin American (LATAM) countries. This study is the first comparative analysis of cardiac surgical training and professional practice across LATAM and provides the fundamentals for future academic projects of the Latin American Association of Cardiac and Endovascular Surgery (LACES).International survey-based comparative analysis of the training and professional practice of cardiac surgeons across LATAM. Trainees (residents/fellows) and staf (graduated) surgeons from LATAM countries were included.A total of 289 respondents (staf surgeons N=221 [76.5%]; residents/fellows N=68 [23.5%]) from 18 different countries participated in the survey. Most surgeons (N=92 [45.3%]) reported being unsatisfied with their salaries. Most respondents (N=181 [62.6%]) stated that it was difficult to obtain a leadership position, and 149 (73.8%) stated that it was difficult to find a job after completing training. Only half of the trainee respondents (N=32 [47.1%]) reported that their program had all resident spots occupied. Only 22.1% (N=15) of residents/fellows were satisfied with their training programs. The majority (N=205 [70.9%]) of respondents would choose cardiac surgery as their specialty again. Most surgeons (N=129 [63.9%]) and residents/fellows (N=52 [76.5%]) indicated that the establishment of a LATAM cardiac surgery board examination would be beneficial.Modernization and standardization of training, as well as greater access to opportunities, may be required in LATAM to increase professional satisfaction of cardiac surgeons and to reduce disparities in the specialty. Such changes may enhance the regional response to the dynamic challenges in the feld.

OBJECTIVES The severity of acute papillary muscle (PM) rupture varies according to the extent and site of the rupture. However, the haemodynamic effects of different rupture variations are still poorly understood. Using a novel ex vivo model, we sought to study acute PM rupture to improve clinical management. METHODS Using porcine mitral valves (n = 32) mounted within an ex vivo left heart simulator, PM rupture was simulated. The mitral valve was divided into quadrants for analysis according to the PM heads. Acute PM rupture was simulated by incrementally cutting from 1/3 to the total number of chordae arising from 1 PM head of interest. Haemodynamic parameters were measured. RESULTS Rupture >2/3 of the chordae from 1 given PM head or regurgitation fraction >60% led to markedly deteriorated haemodynamics. Rupture at the anterolateral PM had a stronger negative effect on haemodynamics than rupture at the posteromedial PM. Rupture occurring at the anterior head of the anterolateral PM led to more marked haemodynamic instability than rupture occurring at the other PM heads. CONCLUSIONS The haemodynamic effects of acute PM rupture vary considerably according to the site and extent of the rupture. Rupture of ≤2/3 of chordae from 1 PM head or rupture at the posteromedial PM lead to less marked haemodynamics effects, suggesting a higher likelihood of tolerating surgery. Rupture at the anterolateral PM, specifically the anterior head, rupture of >2/3 of chordae from 1 PM head or regurgitation fraction >60% led to marked haemodynamic instability, suggesting the potential benefit from bridging strategies prior to surgery.

OBJECTIVES Severe left ventricular dysfunction (LVD) is associated with increased risk following coronary artery bypass grafting (CABG). Due to a dearth of reports on the choice of CABG technique in patients with LVD, this study aims to compare the outcomes of off-pump CABG (OPCAB) and conventional CABG (ONCAB) in such patients. METHODS Retrospective single-centre propensity-matched analysis comparing early- and long-term outcomes of OPCAB and ONCAB in patients with severe LVD. Primary outcome was long-term all-cause mortality. RESULTS Between 2002 and 2014, a total of 1161 consecutive patients with severe LVD underwent isolated CABG [442 patients underwent OPCAB and 719 ONCAB (430 matched pairs)]. Incomplete revascularization was observed more frequently among OPCAB than ONCAB patients (35.3% vs 21.6%; P CONCLUSIONS OPCAB is safe and effective in patients with severe LVD. Although incomplete revascularization is more commonly observed in patients undergoing OPCAB, it is not associated with increased late mortality.

Introduction: Since the coronavirus disease 2019 (COVID-19) pandemic, cardiac surgeries in patients with previous infection by COVID-19 were suspended or postponed, which led to surgeries performed in patients with an advanced stage of their disease and an increase in the waiting list. There is a heterogeneous attitude in Latin America on the optimal timing to cardiac surgery in patients with previous COVID-19 infection due to scarce data on its outcome. Two Latin American associations joined to establish common suggestions on the optimal timing of surgery in patients with previous COVID-19 infection. Methods: Data collection was performed using a pre-established form, which included year of publication, objective, type of study (prospective/retrospective, descriptive/analytical), number of patients, year of study, waiting time between infection and surgery, type of surgery, morbidity, mortality, and conclusions regarding the association between mortality and morbidity. Final recommendations were approved by the board of directors of Latin American Association of Cardiac and Endovascular Surgery (LACES) and Latin American Confederation of Anesthesia Societies (CLASA). Results: Of the initial 1,016 articles, 11 comprised the final selection. Only six of them included patients who underwent cardiac surgery. According to the analyzed literature, optimal timing for cardiac surgery needs to consider the following aspects: deferable surgery, symptomatic COVID-19 infection, completeness of COVID-19 vaccination. Conclusion: These recommendations derive from the analysis of the scarce literature published at present on outcomes after cardiac surgery in patients with previous COVID-19 infection. These are to be taken as a dynamic recommendation in which Latin American reality was taken into consideration.

OBJECTIVES The aim of this study was to analyse the early- and mid-term outcomes after redo surgical aortic valve replacement (SAVR) in patients with previous transcatheter aortic valve implantation (TAVI). METHODS Retrospective single-centre analysis of early- and mid-term outcomes following redo SAVR in patients with previous TAVI between 2013 and 2020. Primary outcomes were in-hospital mortality and mid-term survival. RESULTS During the study period, a total of 5756 patients underwent TAVI. Among them, 28 (0.5%) patients required redo SAVR after TAVI. During periods 2013–2016 and 2017–2020, 4/2184 (0.2%) patients and 24/3572 (0.7%) patients required SAVR after TAVI, respectively. The median logistic EuroSCORE was significantly higher at the time of SAVR than at the time of the index TAVI (5.9% vs 11.6%; P CONCLUSIONS SAVR can be successfully performed in patients with prior TAVI despite the increased surgical risk and technical difficulty. IE is associated with decreased mid-term survival.

BACKGROUND Severe pulmonary hypertension is a relative contraindication for isolated tricuspid valve (TV) surgery. However, some patients may still benefit from TV surgery. We hypothesized that pulmonary pressure alone is an inadequate predictor of outcomes post-TV surgery, and that aorto-pulmonary pressure quotient (AoP/PAP) is a better predictor. METHODS From 2005 to 2019, a total of 122 patients (mean age: 68.5±10.5 years; 43.3% male) with isolated TV regurgitation and preoperative right heart catheterization referred to our institution for isolated TV surgery were included. Patients with concomitant procedures were excluded from this analysis. All data were retrospectively analyzed. Follow-up was 97% complete. RESULTS The mean follow-up time was 4.3±3.6 years. The mean preoperative New York Heart Association (NYHA) class was 2.9±0.7, left ventricular ejection fraction was 52.3±11.3%, creatinine level was 124.8±102.6μmol/l, mean pulmonary artery pressure was 25.5±9.4mmHg, mean MELD-XI score 13.5±4.2, and mean AoP/PAP was 4.1±1.9 mmHg. Thirty-day mortality was 10.9%, and 5-years survival was 56.6±4.9%. Cox regression analysis revealed age (p=0.001; HR: 1.058; CI 95%: 1.023-1.094), the mean arterial pressure (p=0.002; HR: 0.969; CI 95%: 0.950-0.988) and systolic pulmonary artery pressure (p=0.035; HR: 1.054; CI 95%: 1.004-1.107), as well as mean AoP/PAP > 4 (p=0.001; HR: 6.678; CI 95%: 2.197-20.294) as predictors for long-term mortality. CONCLUSIONS Regardless of the degree of pulmonary hypertension, a mean AoP/PaP quotient >4 impacts the postoperative survival of patients undergoing isolated TV surgery. However, further research is still required to verify this finding.

Background Mitral valve (MV) repair with annuloplasty is the standard of care in patients with primary degenerative mitral regurgitation (DMR). Newer generations of annuloplasty rings have been developed with the goals of closer reproduction of native annular geometry and easier implantation. This study investigates the short-term and 5-year clinical outcomes of MV repair with the Carpentier-Edwards (CE) Physio II annuloplasty ring. Methods This is an observational study including a total of 486 patients who underwent MV repair for DMR using the CE Physio II annuloplasty ring between 2011 and 2016. Results Mean age was 54.8 ± 12.1 years, 364 patients (74.9%) were males, and 84 patients (17.3%) presented with atrial fibrillation. Mean left ventricular ejection fraction was 62.3 ± 7.3%. Mean logistic EuroSCORE was 2.7 ± 2.4%. New York Heart Association functional class III–IV symptoms were present in 134 (27.6%) patients preoperatively. Isolated MV repair was performed via a right-sided mini-thoracotomy in 479 patients (98.6%). Concomitant procedures included ablation for atrial fibrillation in 83 patients (17.1%) and closure of atrial septum defect in 88 patients (18.1%). Median size of implanted annuloplasty rings was 34 mm (interquartile range: 34–38 mm). Mean cardiopulmonary bypass time was 116 ± 34 minutes and mean cross-clamp time was 74 ± 25 minutes. Thirty-day mortality was 0.4%. The Kaplan–Meier 4-year survival was 98.5%. Freedom from MV reoperation was 96.2 and 94.0% at 1 and 4 years. Conclusion MV repair with the CE Physio II annuloplasty ring is associated with excellent midterm clinical outcome.

OBJECTIVES Assessment of early outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) in whom venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted for postcardiotomy cardiogenic shock (PCCS) during the first postoperative 48 h. METHODS Retrospective single-centre analysis in adult patients with normal LVEF, who received VA-ECMO support for PCCS from May 1998 to May 2018. The primary outcome was 30-day perioperative mortality during the index hospitalization. RESULTS A total of 62 125 adult patients underwent cardiac surgery at our institution during the study period. Among them, 173 patients (0.3%) with normal preoperative LVEF required VA-ECMO for PCCS. Among them, 71 (41.1%) patients presented PCCS due to coronary malperfusion and in 102 (58.9%) patients, no evident cause was found for PCCS. Median duration of VA-ECMO support was 5 days (interquartile range 2–8 days). A total of 135 (78.0%) patients presented VA-ECMO-related complications and the overall 30-day perioperative mortality was 57.8%. Independent predictors of mortality were: lactate level just before VA-ECMO implantation [odds ratio (OR) 1.27; P CONCLUSIONS Mortality rates of VA-ECMO in PCCS patients are high, even in those with preoperative normal LVEF. Coronary problems are an important cause of PCCS; however, the aetiology remains unknown in the vast majority of the cases. The implantation of VA-ECMO before development of tissue hypoperfusion and the control of VA-ECMO-associated complications are the most important prognostic factors in PCCS patients. Lactate levels may help guide timing of VA-ECMO implantation and define the extent of therapeutic effort.

OBJECTIVES With the expansion of transcatheter aortic valve replacement (TAVR) into intermediate and low risk, the number of TAVR procedures is bound to rise and along with it the number of cases of infective endocarditis following TAVR (TIE). The aim of this study was to review a multicentre experience of patients undergoing surgical intervention for TIE and to analyse the underlying indications and operative results. METHODS We retrospectively identified and analysed 69 patients who underwent cardiac surgery due to TIE at 9 cardiac surgical departments across Germany. The primary outcome was operative mortality, 6-month and 1-year survival. RESULTS Median age was 78 years (72–81) and 48(69.6%) were male. The median time to surgical aortic valve replacement was 14 months (5–24) after TAVR, with 32 patients (46.4%) being diagnosed with early TIE. Cardiac reoperations were performed in 17% of patients and 33% underwent concomitant mitral valve surgery. The main causative organisms were: Enterococcus faecalis (31.9%), coagulase-negative Staphylococcus spp. (26.1%), Methicillin-sensitive Staphylococcus aureus (15.9%) and viridians group streptococci (14.5%). Extracorporeal life support was required in 2 patients (2.9%) for a median duration of 3 days. Postoperative adverse cerebrovascular events were observed in 13 patients (18.9%). Postoperatively, 9 patients (13.0%) required a pacemaker and 33 patients (47.8%) needed temporary renal replacement therapy. Survival to discharge was 88.4% and survival at 6 months and 1 year was found to be 68% and 53%, respectively. CONCLUSIONS Our results suggest that TIE can be treated according to the guidelines for prosthetic valve endocarditis, namely with early surgery. Surgery for TIE is associated with acceptable morbidity and mortality rates. Surgery should be discussed liberally as a treatment option in patients with TIE by the ‘endocarditis team’ in referral centres.

Severe mitral annular calcification (MAC) may represent a challenging issue which can lead to poor outcomes and serious issues such as patient-prosthesis mismatch (PPM). The potential harmful effect of PPM must be prevented through the use of alternative techniques that allow mitral valve replacement with adequately sized bioprostheses in patients with MAC. PPM should be recognized as a contraindication for transcatheter valve-in-valve replacement as it leads to poor outcomes and early prosthetic degeneration.

OBJECTIVES Destruction of the intervalvular fibrous body (IFB) due to infective endocarditis (IE) warrants a complex operation involving radical debridement of all infected tissue, followed by double valve replacement (aortic and mitral valve replacement) with patch reconstruction of the IFB. This study assesses the 5-year outcomes in patients undergoing this complex procedure for treatment of double valve IE with IFB involvement. METHODS A total of 127 consecutive patients underwent double valve replacement with reconstruction of the IFB for active complex IE between January 1999 and December 2018. Primary outcomes were 3-year and 5-year survival, as well as 5-year freedom from reoperation. RESULTS Patients’ mean age was 65.3 ± 12.9 years. Preoperative cardiogenic shock and sepsis were present in 17.3% and 18.9%, respectively. The majority of patients (81.3%) had undergone previous cardiac surgery. Overall, 30-day and 90-day mortality rates were 28.3% and 37.0%, respectively. The 3- and 5-year survival rates for all patients were 45.3 ± 5.1% and 41.8 ± 5.8%, and for those who survived the first 90 postoperative days 75.8 ± 6.1% and 70.0 ± 8.0%, respectively. The overall 5-year freedom from reoperation was 85.1 ± 5.7%. Preoperative predictors for 30-day mortality were Staphylococcus aureus [odds ratio (OR) 1.65; P = 0.04] and left ventricular ejection fraction (LVEF) CONCLUSIONS Double valve replacement with reconstruction of the IFB in patients with complex IE is a challenging operation associated with high morbidity and mortality, particularly in the first 90 days after surgery. Survival and freedom from reoperation rates are acceptable thereafter, particularly considering the severity of disease and complex surgery.

Introduction: We designed a novel mitral annuloplasty ring based on healthy human imaging to allow for the mitral valve (MV) annular conformational changes while restricting the anteroposterior (AP) distance. The objectives were to evaluate ex vivo biomechanics of the novel ring and to validate the annular dynamics after ring implantation in vivo. Methods: Cardiac MRI exams were obtained for 3 healthy volunteers. The MV annulus was tracked (Fig. A-C). Based the imaging data, a novel ring was manufactured (Fig. D-F). An ex vivo annular dilation model of mitral regurgitation was used in a left heart simulator (Fig. G, H) to measure hemodynamics and chordal forces at dilated baseline and after repair using the novel, rigid, and flexible rings in 5 porcine MVs. Novel (n = 6) or rigid rings (n = 5) were implanted into male Dorset sheep. Pre- and post-operative cardiac MRI exams were analyzed. Results: Repair using the novel, rigid, and flexible ring reduced regurgitation fraction from 30.0 ± 5.8% at dilated baseline to 4.7 ± 2.7%, 2.4 ± 3.2%, and 17.8 ± 10.0% ( p < .0001, Fig. I-N ). Peak forces on the primary chordae decreased after ring annuloplasty repair ( p < .0001, Fig. O ). The novel ring also showed lower peak forces compared to the rigid ring (p = .03) in secondary chordae ( Fig. P ). MV annular motion was preserved in vivo using the novel ring but restricted to a planar geometry using the rigid ring ( Fig. Q-S ). Annular height to intercommissure ratio at midsystole were similar pre-repair (0.2 ± 0.1) and after novel ring repair (0.2 ± 0.0, p = .89). The variance of AP distance during the cardiac cycle was similar between the novel (0.4 ± 0.3) and rigid ring (0.5 ± 0.1, p = .58). Conclusions: This novel mitral annuloplasty ring demonstrated excellent capability in reducing AP dimension and repairing regurgitation with a superior chordal force profile while facilitating the annular flexible motion. Future studies will focus on evaluating repair durability and effect on left ventricular remodeling.

The field of heart valve biomechanics is a rapidly expanding, highly clinically relevant area of research. While most valvular pathologies are rooted in biomechanical changes, the technologies for studying these pathologies and identifying treatments have largely been limited. Nonetheless, significant advancements are underway to better understand the biomechanics of heart valves, pathologies, and interventional therapeutics, and these advancements have largely been driven by crucial in silico, ex vivo, and in vivo modeling technologies. These modalities represent cutting-edge abilities for generating novel insights regarding native, disease, and repair physiologies, and each has unique advantages and limitations for advancing study in this field. In particular, novel ex vivo modeling technologies represent an especially promising class of translatable research that leverages the advantages from both in silico and in vivo modeling to provide deep quantitative and qualitative insights on valvular biomechanics. The frontiers of this work are being discovered by innovative research groups that have used creative, interdisciplinary approaches toward recapitulating in vivo physiology, changing the landscape of clinical understanding and practice for cardiovascular surgery and medicine.

Background: The benefits of perioperative mechanical circulatory support (MCS) in cardiac surgery patients are still uncertain. This study aims to review early outcomes of perioperative temporary MCS using the Impella device in cardiac surgery patients. Methods: Retrospective, single center analysis in cardiac surgery patients presenting with cardiogenic shock (CS) in whom Impella was used for perioperative temporary MCS, whether as single device therapy or as left ventricular (LV) venting strategy for concomitant extra corporeal membrane oxygenation (ECPELLA). Study outcomes were 30-day mortality and occurrence of complication composite outcome. Results: Between 2016 and 2019, a total of 33 consecutive patients were supported with Impella [single-device therapy in 19 (57.6%) patients and ECPELLA in 14 (42.4%) patients]. The 30-day mortality of Impella-alone and ECPELLA groups was 15.8% and 50.0% (P=0.03).The 30-day mortality according to pre-, intra- and postoperative implantation was 12.5%, 60.0% and 28.6% (P=0.04), and it was significantly lower in those patients in whom a left ventricular assist device was implanted in comparison to all other surgical procedures (P

Background Patients with tricuspid valve (TV) disease and indication for TV surgery frequently have permanent pacemaker (PM) or defibrillator (AICD) leads, placed in the right ventricle (RV). The aim of this study was to analyse postoperative results and mid-term outcomes after isolated TV surgery (with no further concomitant cardiac procedures) in the presence of permanent RV leads. Methods From January 2005 to January 2019 a total of 80 patients (mean age: 67.7±10.3 yrs; 56.3% male) with isolated TV disease and presence of at least one permanent RV lead in place were referred to our institution for isolated TV repair / replacement; patients with concomitant procedures were excluded for this analysis. All data were retrospectively analysed. The follow-up was 98% complete. Results Mean follow-up time was 4.3±3.9 years. Mean preoperative clinical NYHA status was 3.0±0.8, left ventricular ejection fraction 50.7±12.9%, mean pulmonary artery pressure 23.8±9.3mmHg, creatinine 125.7±57.5μmol/l, mean MELD-XI Score (Model of Endstage-Liver Disease excluding INR) was 14.6±5.0 μmol/l. Thirty-day mortality was 6.3% with a 5-years survival of 58.2±6.0%. Cox regression analysis revealed the MELD-XIScore as the only highly significant predictor for postoperative mortality (p=0.002). Conclusions In conclusion, Hepatorenal dysfunction-possibly indicating long lasting TV failure- could be a factor for limited postoperative survival in our patient cohort. This finding could unterline our hypothesis, that early TV surgery may achieve better postoperative survival, even in patients with TV disease caused by RV leads. Further investigations are needed.

Minimally invasive mitral valve (MV) repair is being increasingly performed over the last 2 decades due to the constantly growing patient demand, since it offers a shorter recovery, less restriction and faster return to normal physical activities, reduction in pain, and superior cosmetic results. However, such procedures have to be performed through small incisions which limit visualization and the freedom of movement of the surgeon, in contrast to conventional operations that are performed through a sternotomy. Therefore, special long surgical instruments are required, and visualization is usually enhanced with advanced port-access two-dimensional (2D) or three-dimensional (3D) thoracoscopic cameras. This makes performance of a minimally invasive MV repair more challenging for the surgeon and is thereby associated with a steep learning curve. Nonetheless, the vast majority of patients who require MV repair are usually good candidates for this less invasive technique, though adequate patient selection is of utmost importance for success. Concomitant cardiac procedures such as ablation surgery for atrial fibrillation or right-sided interventions such as tricuspid valve surgery, heart tumor resection, and atrial septal defect closure can easily be performed using this approach. Short- and long-term results after minimally invasive MV repair are excellent and comparable with those achieved through a sternotomy approach. There are few drawbacks associated with minimally invasive MV repair such as the high technical demands of working through a constrained space and development of complications associated with peripheral cannulation and seldom unilateral pulmonary edema. Nonetheless, high-volume centers have been able to achieve similar operating times, postoperative complication rates, and mid-/long-term outcomes to those obtained through conventional sternotomy. Up-to-date evidence is needed in order to improve recommendations supporting minimally invasive MV repair. Future innovations should concentrate on decreasing complexity and improving reproducibility of minimally invasive procedures in low-volume centers.

Purpose: This study aims to analyze the clinical outcomes after isolated mitral valve (MV) repair in patients with reduced left ventricular ejection fraction (LVEF

OBJECTIVES Reoperative tricuspid valve (TV) surgery is considered high risk even in the absence of additional concomitant cardiac procedures. The purpose of this study was to evaluate preoperative clinical parameters as predictors for survival after isolated reoperative TV surgery. METHODS From January 2005 to January 2019, 85 patients (mean age: 66.7 ± 10.3 years, 34 male) with severe isolated TV regurgitation and prior cardiac surgery were referred to our centre for elective or urgent TV repair/replacement; patients with endocarditis were excluded. We retrospectively analysed preoperative hepatorenal function [reflected by widely used clinical and laboratory parameters and the Model of End-stage-Liver Disease excluding International Normalized Ratio (MELD-XI) score] as a predictor for postoperative survival. RESULTS At hospital admission, the patients’ average preoperative New York Heart Association class was 2.9 ± 0.6, left ventricular ejection fraction 52.5 ± 10.6%, mean pulmonary artery pressure 24.7 ± 8.0 mmHg, creatinine 115.4 ± 66.6 μmol/l, bilirubin 20.0 ± 19.6 μmol/l and the mean MELD-XI score was 13.3 ± 4.0 μmol/l. The mean follow-up was 5.4 ± 4.2 years. Thirty-day mortality was 5%, 5-year survival was 60.6 ± 5.4% and 10-year survival was 42.9 ± 6.5%. The multivariable Cox regression analysis evaluated the MELD-XI score [hazard ratio (HR 1.144, confidence interval 95% 1.0–1.3, P = 0.005] and diabetes mellitus (HR 2.27, confidence interval 95% 1.0–5.0, P = 0.04) as significant predictors for excess mortality while age and mean pulmonary artery pressure did not reliably predict clinical outcome. CONCLUSIONS Hepatorenal dysfunction was one main factor accounting for limited postoperative survival in our patient cohort. The MELD-XI score is easy to calculate and seems to reliably predict the perioperative risk in patients with prior cardiac surgery and indication for TV surgery.

Establishment of the Heart Team concept in the field of cardiovascular medicine has resulted in quality improvement in the management of heart valve disease and heart failure. Similarly, the concept of an Endocarditis Team would be important in improving outcomes in patients with infective endocarditis (IE), given it is an uncommon clinical entity with general practitioners and low-volume centers lacking sufficient experience in its management. A multidisciplinary approach can substantially reduce the still unacceptably high morbidity and mortality in patients with IE, as it allows early diagnosis and appropriate comprehensive management. Decision-making within the Endocarditis Team must follow a standard protocol that is based on current clinical guidelines for the management of IE. If surgery is indicated, it is best performed sooner than later in most instances. Communication between referring hospitals and reference centers with an established Endocarditis Team must be smooth and definite protocols for transfer to experienced endocarditis centers with surgical facilities is essential. Follow-up and outpatient care following hospital discharge is crucial due to the possibility of residual infection and risk of development of recurrent endocarditis or heart failure, particularly within the first 2 years. Patient and health-care provider education is the mainstay for the accurate implementation of the Endocarditis Team concept. The following Keynote Lecture offers an overview of the current literature supporting the multidisciplinary management of IE and addresses multiple aspects related to the Endocarditis Team, highlighting its importance and necessity for the comprehensive treatment of this complex disease.

Mitral regurgitation (MR) is an important complication of ischemic heart disease and is associated with increased mortality, even when mild in extent. 1 Understanding the pathophysiology of ischemi...

Robotic and minimally invasive mitral valve (MV) procedures have been performed with increasing frequency over time. These alternatives offer similar efficacy to that achieved via standard median sternotomy, particularly in large volume centers, along with low perioperative morbidity and mortality rates. Moreover, patient acceptance is oftentimes increased due to less postoperative pain and shorter recovery times, as well as superior cosmetic results. However, these techniques are technically complex and associated with a significant learning curve. The following review offers an overview of the most relevant aspects related to minimally invasive and robotic MV repair. Although these techniques are well established in referral centers, future innovations should concentrate on decreasing complexity and improving reproducibility of these procedures.

OBJECTIVES Mitral valve (MV) annuloplasty ring dehiscence with subsequent recurrent mitral regurgitation represents an unusual but challenging clinical problem. Incidence, localization and outcomes for this complication have not been well defined. METHODS From 1996 to 2016, a total of 3478 patients underwent isolated MV repair with ring annuloplasty at the Leipzig Heart Centre. Of these patients, 57 (1.6%) underwent reoperation due to annuloplasty ring dehiscence. Echocardiographic data, operative and early postoperative characteristics as well as short- and long-term survival rates after MV reoperation were analysed. RESULTS Occurrences of ring dehiscence were acute (1 year) in 44%, 33% and 23% of patients, respectively. Localization of annuloplasty ring dehiscence was found most frequently in the P3 segment (68%), followed by the P2 (51%) and the P1 segments (47%). The 30-day mortality rate and 1- and 5-year survival rates after MV reoperation were 2%, 89% and 74%, respectively. During reoperation, MV replacement was performed in 38 (67%) and MV re-repair in 19 (33%) patients. CONCLUSIONS Annuloplasty ring dehiscence is clinically less common, localized more frequently on the posterior annulus and occurs mostly acutely or early after MV repair. MV reoperation can be performed safely in such patients.

OBJECTIVES The goal of this study was to quantify the mitral valve (MV) annulus, the MV shape and the anatomical MV orifice area throughout the cardiac cycle using 4-dimensional MV analysis software in patients with primary mitral regurgitation (PMR) and secondary mitral regurgitation (SMR) in comparison to a healthy control group. METHODS Three-dimensional transoesophageal echocardiograms of the MV were acquired for 29 patients with PMR, for 28 patients with SMR and for 18 healthy control subjects. The MV was quantified with regards to anterior-posterior and lateromedial diameter, annular area and circumference, intertrigonal (IT) distance, annular sphericity index, annular height to commissural width ration, and anatomical MV orifice area throughout the cardiac cycle using 3-dimensional transoesophageal echocardiography-based 4-dimensional MV advanced analysis software. RESULTS Normal annulus dynamics display a systolic enlargement followed by an early-diastolic plateau phase and a late-diastolic contraction. The IT distance showed a linear association with the anterior-posterior diameter (= 1.11 × IT distance) and lateromedial diameter (= 1.44 × IT distance) in the control subjects. Mitral regurgitation is associated with a less dynamic, planar and dilated annulus with small variations between PMR and SMR. The IT distance was less affected by mitral regurgitation compared to the control subjects. CONCLUSIONS The novel 4-dimensional MV analysis allows new insights into the dynamic MV geometry in patients with PMR and SMR compared to the control subjects. The IT distance may be used to predict annuloplasty ring sizing.

Right-sided infective endocarditis (RSIE) encompasses 5–10% of all infective endocarditis (IE) cases. Among them, about 90% involve the tricuspid valve (TV) (1). Major risk factors for TV infective endocarditis (TVIE) are intravenous drug use, pacemaker (PM) leads and indwelling vascular accesses (1,2). Only between 5–16% of RSIE cases require surgical intervention. Surgery for TVIE is indicated in the presence of TV vegetations >20 mm, decompensated right heart failure with severe tricuspid regurgitation (TR), recurrent pulmonary septic embolism and persistent bacteremia or sepsis due to aggressive and/or resistant microorganisms such as fungi and Staphylococcus aureus (3). Mortality of isolated TVIE is 0–15% (1). TV repair is the preferred surgical strategy; however, it is not always possible. This article presents the case of a patient with TVIE and focuses on the decision-making process and the TV operative techniques in the setting of TVIE.