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OBJECTIVE: Obesity and overweight are associated with an increased risk for cardiovascular disease. Since fat mass (FM) and fat‐free mass (FFM) both contribute to total body weight (TBW), we characterized the post–heart transplantation (HT) change in TBW and its implications for outcomes. METHODS: Post‐HT changes in TBW, FM, and FFM were reviewed for 211 HT patients assessed during 1997–2017. Endpoints included cardiac allograft vasculopathy (CAV) and rejection. RESULTS: Median TBW increased by 7.3% at 1 year, with a significant rise in the obese category (28% vs. 13%, p < 0.001) and with FM versus FFM making the main contribution (23% vs. 3%, p < 0.001). When patients were divided according to median TBW change ("high" vs. "low"), Kaplan–Meier analysis showed that 10‐year freedom from CAV (log‐rank p < 0.005) and rejection (log‐rank p < 0.01) was significantly higher for the "low" TBW change group. Consistently, multivariable analyses showed that the "high" group was independently associated with significant 3.5‐fold and 4.2‐fold increased risks for CAV (95% CI 1.4–8.7, p = 0.01) and rejection (95% CI 1.2–15.4, p = 0.03), respectively. CONCLUSIONS: Weight gain, contributed mostly by FM, is independently associated with an increased risk for CAV and rejection. Follow‐up emphasis should be placed on weight gain and preventative measures. [ABSTRACT FROM AUTHOR]

Background: The life expectancy of hemophiliacs is similar to that of the general population. As a result, the prevalence of age-related cardiovascular diseases has increased. We present our experience with hemophilia patients who underwent cardiac surgery in our Medical Center between 2004 and 2019.Methods: All hemophilia patients who underwent cardiac surgery were identified, and their peri-operative data evaluated retrospectively.Results: Ten patients were identified: six with hemophilia-A, one with hemophilia-B, and three with hemophilia-C (factor XI deficiency). Cardiac procedures included ten coronary artery bypass grafts and one aortic valve replacement. Hemophilia-A and B patients were treated with factor substitution, whereas patients with factor XI deficiency were treated with fresh frozen plasma. One patient died, and one patient suffered from non-active gastrointestinal bleeding.Conclusions: While major cardiac surgery can be performed safely on patients with hemophilia, a multidisciplinary team approach and strict postoperative monitoring are essential in order to achieve optimal results. [ABSTRACT FROM AUTHOR]

Background: The war that began on October 7th, 2023, has impacted all major tertiary medical centers in Israel. In the largest cardiac surgery department in Israel there has been a surprising increase in the number of open-heart procedures, despite having approximately 50% of surgeons recruited to military service. The purpose of this study is to characterize this increase in the number of operations performed during wartime and assess whether the national crisis has affected patient outcomes. Methods: The study was based on a prospectively collected registry of 275 patients who underwent cardiac surgery or extracorporeal membrane oxygenation (ECMO) during the first two months of war, October 7th 2023 – December 7th 2023, as well as patients that underwent cardiac surgery during the same period of time in 2022 (October 7th, 2022 – December 7th, 2022). Results: 120 patients (43.6%) were operated on in 2022, and 155 (56.4%) during wartime in 2023. This signifies a 33.0% increase in open-heart procedures (109 in 2022 vs. 145 in 2023, p-value 0.26). There were no significant differences in the baseline characteristics of patients when comparing the 2022 patients to those in 2023. No significant differences between the two groups were found with regards to intraoperative characteristics or the type of surgery. However, compared to 2022, there was a 233% increase in the number of transplantations in the 2023 cohort (p-value 0.24). Patient outcomes during wartime were similar to those of 2022, including postoperative complications, length of stay, and mortality. Conclusions: Patients who underwent cardiac surgery during wartime presented with comparable outcomes when compared to those of last year despite the increase in cardiac surgery workload. There was an increase in the number of transplants this year, attributed to the unfortunate increase in organ donors. [ABSTRACT FROM AUTHOR]

Continued circulation of severe acute respiratory syndrome coronavirus 2 has driven the selection of variants with improved ability to escape preexisting vaccine-induced responses, posing a persistent threat to heart transplant recipients (HTRs). The immunogenicity and safety of the updated XBB.1.5-containing monovalent vaccines are unknown. We prospectively enrolled 52 HTRs who had previously received a 5-dose ancestral-derived monovalent and bivalent messenger RNA (mRNA) vaccination schedule to receive the monovalent XBB.1.5 vaccine. Immunogenicity was evaluated using live virus microneutralization assays. The XBB.1.5 monovalent vaccine elicited potent and diverse neutralizing responses and broadened the reactivity spectrum to encompass newer strains, with the highest increase in neutralization activity being more pronounced against XBB.1.5 (15.8-fold) and JN.1 (13.3-fold) than against BA.5 (6.7-fold) and wild-type (4-fold). Notably, XBB.1.5 and JN.1 were resistant to neutralization by prevaccination sera. There were no safety concerns. Our findings support the updating of coronavirus disease 2019 vaccines to match antigenically divergent variants and exclude ancestral spike-antigen to protect HTRs. [ABSTRACT FROM AUTHOR]

Background: Diabetes mellitus (DM) type 2 is an independent risk factor for atrial fibrillation (AF). Surgical ablation or "maze procedure" is an option for patients with AF undergoing concomitant or isolated cardiac surgery. The aim of this study was to evaluate the impact of DM type 2 on early and long-term outcomes of patients following surgical AF ablation. Methods: We performed an observational cohort study in Israel's largest tertiary care center. All data of patients who underwent surgical AF ablation, between 2006 and 2021 were extracted from our departmental database. Patients were divided into Group I (non-diabetic patients) and Group II (DM type 2 patients). We compared the two groups with respect to freedom from recurrent atrial arrhythmia, and mortality rate. Results: The study population included 606 patients. Group I (non-DM patients), consisting of 484 patients, and Group II (DM type 2 patients), comprised 122 patients. Patients with DM were older, had more hypertension and incidence of cerebrovascular accident (CVA)/transient ischemic attack (TIA), higher EuroSCORE (p <.05 for all), and a longer bypass time—130 ± 40 vs. 122 ± 36 min (p = 0.028). The mean follow-up duration was 39.0 ± 22.7 months. Freedom from atrial fibrillation was similar between the non-DM and DM type 2 groups after a 1-year follow-up, 414 (88.2%) vs. 101 (87.1%) (p = 0.511), after a 3-year follow-up, 360 (86.3%) vs. 84 (79.9%) (p = 0.290) and after a 5-year follow-up, 226 (74.1%) vs. 55 (71.5%) (p = 0.622) respectively. Furthermore, 1- and 3-year mortality was similar between non-DM and DM type 2 groups, 2.5% vs. 4.9%, (p = 0.226) and 5.6% vs. 10.5% (p = 0.076) respectively. 5-year mortality was higher in Group II (DM type 2 patients) compared with Group I (non-DM patients), 11.1% vs. 23.4% (p = 0.009). Conclusion: Surgical ablation had a high success rate, with freedom from recurrent atrial arrhythmia at 1- 3- and 5- years follow-up in both the DM type 2 and non-DM groups. Furthermore,1- and 3-year mortality after surgical ablation was also similar in both groups. However, 5-year mortality was higher in the DM type 2 group. [ABSTRACT FROM AUTHOR]

This study evaluates the efficacy of annuloplasty repair as a standalone procedure for treating bileaflet mitral valve prolapse with mitral regurgitation (MR). Various flexible ring bands for MR of different severities were compared to assess their biomechanical impact and treatment outcomes. Computational beating heart models, based on the Living Heart Human Model, were utilized to simulate annuloplasty repairs. Repairs using bands of varying lengths were modeled on moderate and severe MR cases, considering bileaflet mitral valve prolapse. Key parameters, including regurgitant orifice area (ROA), prolapse severity, coaptation length, leaflet position, and deformation, were computed to compare conditions before and after implantation. Annuloplasty repairs effectively reduced the ROA in both moderate and severe MR cases, achieving complete sealing in selective instances. Additionally, annuloplasty repair corrected bileaflet prolapse, with prolapse severity decreasing as the annular size increased. Successful coaptation was indicated by the expansion of each leaflet's contact area distribution and percentage in contact with the opposing leaflet. The risk of systolic anterior motion, that may obstruct the left ventricular outflow tract, was minimized, as the anterior leaflet was directed towards the posterior position. In conclusion, annuloplasty repair alone can effectively treat MR when an appropriate band length is selected. It facilitates a significant reduction in ROA, correction of bileaflet prolapse, and improvement in leaflet coaptation. These findings have important clinical implications, potentially offering a less complex surgical treatment avenue and reducing complications in the management of MR. [ABSTRACT FROM AUTHOR]

The online version of the original article can be found at https://doi.org/10.1186/s12933-023-01810-x B Correction: Cardiovascular Diabetology (2023) 22:77 b https://doi.org/10.1186/s12933-023-01810-x Following publication of the original article [[1]], the conflict of interest statement has been updated with this correction. Reference 1 Kogan A, Grupper A, Sabbag A. Surgical ablation for atrial fibrillation: impact of Diabetes Mellitus type 2. [Extracted from the article]

Background: We compared the outcomes of aortic root replacement by composite valve grafts (CVG) and valve-sparing root replacement (VSRR) operations, with an emphasis on postoperative conduction block and the need for permanent pacemaker implantation (PPM)., Methods: From 1997 to 2023, 1712 consecutive patients underwent ARR by VSRR (501 [29%]) or CVG (1211 [71%]) at a high-volume aortic center., Results: Patients undergoing CVG were older (59 ± 14 vs 49 ± 14 years, P < .001), with more cardiovascular comorbidities. Compared with CVG, there were more women undergoing VSRR (17% vs. 13%, P = .042) and more patients with connective tissue disease (22% vs 7.3%, P < .001). Multivariable analysis found that the risk for PPM was higher after CVG compared with VSRR (6.5% vs 1.2%; odds ratio [OR], 2.83; 95% CI, 1.23-7.69; P = .024). Other variables associated with PPM include older age (OR, 1.03; 95% CI, 1.01-1.05; P = .006) preoperative renal impairment (OR, 2.69; 95% CI, 1.24-5.6; P = .010), previous operation (OR, 2.76; 95% CI, 1.29-5.62; P = .007), and bicuspid aortic valve (OR, 3.63; 95% CI, 2.13-6.33; P < .001). Among the CVG population, patients who are at increased risk are especially those with some degree of aortic stenosis (OR, 2.06; 95% CI, 1.18-3.61; P = .011). Patients who required PPM had no additive risk for long-term mortality (hazard ratio, 1.01; 95% CI, 0.47-2.17; P = .986); however, they were more likely to have reduced ejection fraction (29.3% vs 16%, P = .014)., Conclusions: The incidence of PPM after ARR is low, but rates were higher after CVG compared with VSRR., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Total aortic arch replacement (TAR) after previous cardiovascular surgery is technically challenging and is becoming more frequent as outcomes for primary arch repair have improved. primary. We analyzed outcomes of reoperative compared with first-time TAR., Methods: The institutional aortic database was queried to identify consecutive patients undergoing TAR between 1997 and 2022. In total, 426 patients underwent TAR, of whom 150 (35%) had previous cardiovascular surgery (reop TAR) and 276 (65%) underwent their first cardiovascular operation., Results: The reop TAR group was younger (61 ± 13 vs 71 ± 11, P < .001) with more comorbidities such as ischemic heart disease (12% vs 4.3%, P = .006), previous stroke (36% vs 14.5%, P < .001), and renal impairment (24% vs 12.7%, P = .004). Reop TAR had longer cardiac ischemic times (119.3 ± 45.5 minutes vs 98 ± 31.9 minutes, P < .001), a greater operative mortality (3.3% vs 0.4%, P = .040), and incurred a 4-fold increased risk of major adverse event (95% confidence interval [CI], 1.41-11.49, P = .009). Ten-year survival was also lower in the reop TAR cohort (76% vs 82.2%; hazard ratio, 1.79; 95% CI, 1.12-2.86, P = .015) and there was greater need for late reinterventions, mainly on the downstream aorta (hazard ratio, 1.29; 95% CI, 1.03-1.62, P = .024)., Conclusions: Reop TAR is a technically challenging operation and is associated with increased operative mortality and adverse events. Gratifying results can be obtained with meticulous surgical planning and focused attention on end-organ protection. Late reinterventions occur in a significantly greater percentage of patients undergoing reop TAR, and future studies should focus attention on identifying those at-risk groups who may benefit from a more aggressive index procedure., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The goal of this study was to evaluate the long-term outcomes of valve-sparing root replacement in patients with connective tissue disease (CTD) and compare them with patients without CTD who underwent valve-sparing root replacement for root aneurysm., Methods: Of 487 patients, 380 (78%) did not have CTD and 107 (22%) had CTD; 97 (91%) with Marfan syndrome, 8 (7%) with Loeys-Dietz syndrome, and 2 (2%) with Vascular Ehlers-Danlos syndrome. Operative and long-term outcomes were compared., Results: The CTD group was younger (36 ± 14 years vs 53 ± 12 years; P < .001), had more women (41% vs 10%; P < .001) and had less hypertension (28% vs 78%; P < .001) and bicuspid aortic valve (8% vs 28%; P < .001). Other baseline characteristics did not differ between the groups. Overall operative mortality was nil (P = 1.000); the incidence of major postoperative complications was 1.2% (0.9% vs 1.3%; P = 1.000) and did not differ between groups. Residual mild aortic insufficiency (AI) was more frequent in the CTD group (9.3% vs 1.3%, P < .001) with no difference in moderate or greater AI. Ten-year survival was 97.3% (97.2% vs 97.4%; log-rank P = .801). Of the 15 patients with residual AI, 1 had none, 11 remained mild, 2 had moderate, and 1 had severe AI on follow-up. Ten-year freedom from moderate/severe AI was 89.6% (hazard ratio, 1.05; 95% CI, 0.8-1.37; P = .750) and 10-year freedom from valve reoperation was 94.9% (hazard ratio, 1.21; 95% CI, 0.43-3.39; P = .717)., Conclusions: The operative outcomes as well as long-term durability of valve-sparing root replacement is excellent in patients with or without CTD. Valve function and durability are not influenced by CTD., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Reoperative aortic root replacement (ARR) is a technically challenging procedure. This study assesses the influence of reoperation on outcomes following ARR, particularly after prior acute type A aortic dissection repair., Methods: Of the 1823 patients in this study, 1592 (87.3%) underwent primary ARR, and 231 (12.7%) underwent reoperative ARR. Within the reoperative ARR group, 69 patients (29.9%) had previous acute type A aortic dissection repair, and 162 patients (70.1%) underwent reoperative ARR for other indications., Results: Reoperative ARR patients exhibited higher rates of ischemic heart disease (13.9% vs 3%; P < .001), diabetes (10% vs 5.3%; P = .009), chronic pulmonary disease (9.1% vs 5%; P = .018), renal impairment (17.7% vs 5.3%; P < .001), and had lower ejection fraction (45.5% ± 8.1% vs 47.6% ± 7.9%; P < .001) compared with primary ARR. The overall operative mortality was 0.4%, with no significant difference between groups (0.9% vs 0.3%; P = .485). At multivariable analysis, previous operation was the most powerful predictor for major adverse events (odds ratio, 3.20; 95% CI, 2.12-4.79; P < .001). Reoperative ARR had a lower 10-year survival compared with primary ARR (67.4% vs 85.9%; log-rank P < .001). Multivariable analysis further confirmed that reoperation was significantly associated with 10-year mortality (hazard ratio, 1.76; 95% CI, 1.01-3.06; P = .044). Among the reoperative ARR group, operative mortality after previous acute type A aortic dissection repair was similar to that for other etiologies (0% vs 1.2%; P = .880)., Conclusions: Patients undergoing reoperative ARR have more comorbidities and extensive aortic disease compared with those undergoing primary surgery. They face a 3.5-fold increased risk of major adverse events but no difference in operative mortality compared with primary ARR., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Urine output is used to evaluate fluid status and is an important marker for acute kidney injury (AKI). Our primary aim was to validate a new automatic urine output monitoring device by comparison to the current practice - the standard urometer., Methods: We conducted a prospective observational study in three ICUs. Urine flow measurements by Serenno Medical Automatic urine output measuring device (Serenno Medical, Yokneam, Israel) were compared to standard urometer readings taken automatically at 5-minutes intervals by a camera, and to hourly urometer readings by the nurses, both over 1 to 7 days. Our primary outcome was the difference between urine flow assessed by the Serenno device and reference camera-derived measurements (Camera). Our secondary outcome was the difference between urine flow assessed by the Serenno device and hourly nursing assessments (Nurse), and detection of oliguria., Results: Thirty-seven patients completed the study, with 1,306 h of recording and a median of 25 measurement hours per patient. Bland and Altman analysis comparing the study device to camera measurements demonstrated good agreement, with a bias of -0.4 ml/h and 95% confidence intervals ranging from - 28 to 27ml/h. Concordance was 92%. The correlation between Camera and hourly nursing assessment of urine output was distinctly worse with a bias of 7.2 ml and limits of agreement extending from - 75 to + 107 ml. Severe oliguria (urine output < 0.3 ml/kg/h) lasting 2 h or more was common and observed in 8 (21%) of patients. Among the severe oliguric events lasting more than 3 consecutive hours, 6 (41%) were not detected or documented by the nursing staff. There were no device-related complications., Conclusion: The Serenno Medical Automatic urine output measuring device required minimal supervision, little ICU nursing staff attention, and is sufficiently accurate and precise. In addition to providing continuous assessments of urine output, it was considerably more accurate than hourly nursing assessments., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Heart transplantation (HT) success rate is limited by a high incidence of cancer post-HT. Data on kidney cancer following solid organ transplantation, especially HT, are limited, and only a few cases have been reported., Objectives: To report a unique case series of detected kidney cancer following HT., Methods: Between 1997 and 2018, 265 patients who underwent HT were enrolled and prospectively followed in the HT registry of the Sheba Medical Center., Results: The series included 5 patients, 4 men and a woman (age range 35-50 years at HT). The patients were diagnosed with kidney tumors 6-11 years after HT (age range at diagnosis 40-72 years). Two of the men were identical twin brothers. At HT four patients received induction therapy with anti-thymocyte globulin and all received an initial immunosuppressive regimen based on cyclosporine. All male HT recipients had a history of heavy smoking. Two male patients developed allograft vasculopathy, but all had preserved heart function. The 72-year-old woman developed a kidney tumor of the native kidney 5 years after re-HT and kidney transplantation. Two patients had features of multifocal papillary renal cell carcinoma (RCC) and eventually underwent bilateral nephrectomy, while another patient underwent left partial nephrectomy with preserved renal function., Conclusions: To the best of our knowledge, this is the first case series study describing kidney tumors following HT. With the improving outcomes and life expectancy of HT patients, a better understanding of the factors that determine cancer risk is of the utmost importance and may have a major impact on the non-cardiac surveillance.

Objective: To assess early and late clinical outcomes in patients who underwent aortic valve repair surgery for aortic valve insufficiency, and to investigate predictors for recurrence., Methods: Of 151 consecutive patients who underwent aortic valve repair surgery for varying degrees of aortic insufficiency (AI) in our department between 2004 and 2018, 60 (40%) underwent aortic root replacement, 71 (47%) aortic cusp plication, 31 (20%) subcommissural annuloplasty, 29 (19%) circular annuloplasty, and 28 (18%) autologous pericardial patch augmentation., Results: One patient died in the hospital (0.7%). Mean clinical and echocardiographic follow-up was 62±43 months (range 1 to 159) and 50 ± 40 months (range 1 to 158), respectively. The overall survival rate was 99.3% at 1 year and 98% at 5 years of follow-up. Seventeen patients (11.3%) had recurrent severe AI, and all of them underwent reoperation with a mean duration to reoperation of 35 ± 39 months. Risk factors for the development of recurrent significant AI (≥3) or reoperation, by univariable analysis, were unicuspid or bicuspid aortic valve (AV) ( P = 0.018), the use of subcommissural annuloplasty ( P = 0.010), the need for cusp repair ( P = 0.001), and the use of pericardial patch augmentation ( P < 0.001). By multivariable analysis only the use of pericardial patch augmentation emerged as a significant independent predictor for the development of recurrent significant AI (≥3) or reoperation ( P = 0.020)., Conclusion: AV repair can be performed with low morbidity and mortality, with good early and late clinical outcomes. However, in our experience there was a significant rate of recurrent AI especially in patients who underwent cusp augmentation using glutaraldehyde-treated autologous pericardial patch.

Objective: We compared early and late outcomes of patients who underwent femoral versus axillary artery cannulation for repair of acute type A aortic dissection., Methods: Between 2004 and 2017, we retrospectively evaluated the clinical outcomes of 135 consecutive patients who underwent emergency surgery for acute type A aortic dissection repair. Patients were divided into 2 groups: those who underwent femoral ( n = 84) and those who underwent right axillary ( n = 51) artery cannulation. Mean patient age was 63 ± 13 years and 88 (65%) were male., Results: Overall operative mortality was 12.6% (axillary 15.7%, femoral 10.7%; P = 0.564). Patients who underwent axillary compared to femoral artery cannulation had a statistically nonsignificant higher operative mortality rate among both stable and unstable patients (13% vs. 6.5%, P = 0.405 and 40% vs. 22.7%, P = 0.818, respectively). While there was no difference in major complication rates, such as stroke, low cardiac output, and surgical revision for bleeding/tamponade, there was a higher incidence of renal failure that required dialysis in patients who underwent axillary cannulation (12% vs. 1%, P = 0.022). Multivariate analysis demonstrated that predictors for the composite endpoint of operative mortality or severe organ malperfusion, such as renal failure or cerebrovascular accident, were hemodynamic instability on admission (OR 3.87; 95% CI, 1.23 to 12.63; P = 0.021), lower preoperative creatinine clearance (OR 0.94; 95% CI, 0.90 to 0.97; P < 0.001); and the use of axillary artery cannulation (OR 4.1; 95% CI, 1.43 to 12.78; P = 0.011). Among those discharged from hospital, the 3-year survival rate was 91% in the axillary group and 87% in the femoral group ( P = 0.772)., Conclusions: Based on our experience, emergent surgery for both stable and unstable patients with acute type A aortic dissection demonstrated similar survival rates and significantly less renal impairment when using the femoral cannulation approach.

The mortality rate after the development of ventricular septal defect (VSD) remains high despite progress in pharmaceutical therapy, invasive cardiology, and surgical techniques. Although early surgical repair of postinfarction VSD is associated with a high mortality rate, in hemodynamic unstable patients surgery cannot always be postponed and surgical repair may be required urgently. We present two cases of patients diagnosed with postinfarction VSD who were in cardiogenic shock with multiorgan failure despite optimal treatment. They were therefore connected to venoarterial extracorporeal membrane oxygenation as a bridge to reparative surgery.