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Background: The optimal timing of cardiac operations in patients with infective endocarditis continues to be debated. This observational study analyzed the profile and outcome of patients with active infective endocarditis undergoing operations. Methods: Between June 2000 and June 2006, 95 surgically treated patients with definite infective endocarditis by the modified Duke criteria were included. Results: Fifty-eight patients were operated on within the first 7 days after diagnosis of infective endocarditis and 37 at more than 7 days after diagnosis up to immediately after completion of antibiotic treatment. Staphylococci predominated and were significantly associated with embolism, abscess, and septic shock. The most frequent indication for operation was severe regurgitation with heart failure. The 6-month mortality was 15%. Early operation showed a trend towards increased mortality vs late operation. In univariable analysis, factors associated with 6-month mortality included staphylococci and septic shock. Multivariable analysis revealed that septic shock predicted 6-month mortality. Despite early operation in patients experiencing septic shock, 57% died. No patients without heart failure died after undergoing (early or late) procedures for severe regurgitation. Conclusions: The prognosis in surgically treated patients was determined by the occurrence of septic shock. The outcome in patients who underwent late operations was favorable compared with the early group. This difference was probably not due to the timing of the surgical intervention but to the severity of infective endocarditis. In patients with severe regurgitation without heart failure, early operation may offer benefit in length of hospitalization and prevention of development of new heart failure. [Copyright &y& Elsevier]

Preserving donor organs in optimal condition is a prerequisite for successful transplantation. The donor organ is subjected to a multitude of stresses. In this review, we will discuss the consequences of brain death on donor organs. The effects of an extended ischaemic period followed by the reperfusion necessary for the harvest, storage and implantation of transplant organs will be evaluated. As progressively more is known about the underlying pathophysiological mechanisms, focused and efficient therapeutic interventions can be developed. We will review current organ protection techniques and look at possible future strategies to further improve the final donor organ quality. [Copyright &y& Elsevier]

We examined the relative usefulness of parameters to determine left ventricular contractility in mice invasively. The optimal parameter must be sensitive to changes in inotropy and insensitive to changes in loading. Furthermore, it should be able to confirm or reject the hypothesis of altered myocardial contractility after a limited number of experiments. Left ventricular function was assessed in closed-chest mice using a microtip pressure-conductance catheter at baseline and after increases in preload, afterload, or contractility. The parameters are differentially influenced by loading conditions and inotropic state. Only those parameters that could differentiate between basal and increased contractility with a power of 0.85 in ten or less experiments were considered useful. Ejection fraction, preload-recruitable stroke work (PRSW), and dP/dtmax/ V ed could demonstrate the smallest changes in contractility. Stroke work, maximal power and dP/dtmax were most influenced by preload. End-systolic elastance, ejection fraction, and stroke work were afterload-dependent. Dividing the magnitude of the effect of inotropic stimulation to that of load changes gives an index for the usefulness for each parameter. A high ratio indicates that the change in parameter reflects inotropic rather than load change. This ratio was highest for PRSW, which seems to be the best parameter for judging contractility differences in mice. [ABSTRACT FROM AUTHOR]

Objective: Durability assessment of mitral valve repair for degenerative valve incompetence is limited to reoperation as a primary indicator and valve-related risk factors for late death as a secondary indicator. We assessed serial echocardiographic follow-up of valve function as an indicator of the durability of mitral valve repair. Methods and Results: In 348 patients having undergone mitral valve repair for degenerative valve incompetence, clinical outcome was excellent: 10 years after repair, survival was 80.1% and freedom from reoperation 94.4%. However, freedom from mitral regurgitation (>2/4), 98.7% at 1 month, decreased to 82.2% at 5 years and 64.9% at 10 years. The linearized recurrence rate of mitral regurgitation (>2/4) was 3.2% per year. Recurrence rate was higher in patients with Barlow disease (6.0%) and lower in those with fibroelastic deficiency (2.6%) (P = .01). Performing chordal shortening, the nonuse of sliding plasty and the nonuse of an annuloplasty ring were determined to be factors predicting recurrence of mitral regurgitation. In reconstructions avoiding these risk factors, recurrence rate decreased to 2.4%. There was no difference between Barlow disease and fibroelastic deficiency: 2.9% versus 2.2% (P > .05). Recurrent regurgitation is characterized by leaflet prolapse, thickening, and calcification. Conclusion: When optimal surgical techniques are used, the residual recurrence rate of mitral valve regurgitation remains between 2% and 3% per year and is related to progressive degeneration of the chordae and the leaflets. Long-term results of mitral valve repair in Barlow disease are essentially the same as in fibroelastic deficiency. [Copyright &y& Elsevier]

Aims: Type II diabetes, often associated with abdominal obesity, frequently leads to heart failure. Clinical and epidemiological evidence suggests that supplemental dyslipidaemia and hypertension, as clustered in the metabolic syndrome, aggravate the cardiovascular outcome. The differential impact of type II diabetes and the metabolic syndrome on left ventricular function, however, remains incompletely defined. [ABSTRACT FROM PUBLISHER]

Background: In patients with infective endocarditis (IE), detection of abscess remains difficult. We investigated abscess detection by transesophageal echocardiography (TEE) and predictors of abscess and death in patients with IE. Methods: A 5-year study included 115 patients with definite IE according to the modified Duke criteria who underwent TEE and cardiac surgery. Results: Abscess was found perioperatively in 44 patients (38%). Twenty-one abscesses (48%) were detected by TEE. Sixty-one percent of missed abscesses were localized on the posterior mitral annulus. In 64% of unrecognized mitral valve abscesses, the abscess was localized around calcification in the posterior mitral annulus. Fourteen patients (54%) had prosthetic valve dehiscence, and 8 (57%) had abscess as well. Overall 6-month mortality was 17% and predictable by age (odds ratio 1.1, 95% CI 1-1.001, P = .01), abscess (odds ratio 5.3, 95% CI 1.5-19, P = .01), and the causative microorganism (P = .035), in particular staphylococci. In patients with a missed abscess, surgical delay was significantly longer (P = .04) and mortality was nonsignificantly higher (P = .2) than in patients with a preoperatively detected abscess. Conclusions: Detection of abscess by TEE seemed to be underestimated. In most cases, abscess was missed in the presence of calcification in the posterior mitral annulus. Age, abscess, and staphylococcal infection predicted 6-month mortality. Early surgery may improve outcome in patients with an abscess. [ABSTRACT FROM AUTHOR]

Influx of Ca2+ ions through α-amino-3-hydroxy-5-methylisoxazole- 4-propionic acid (AMPA) receptors contributes to neuronal damage in stroke, epilepsy, and neurodegenerative disorders such as ALS. The Ca2+ permeability of AMPA receptors is largely determined by the glutamate receptor 2 (GIuR2) subunit, receptors lacking GIuR2 being permeable to Ca2+ ions. We identified a difference in GIuR2 expression in motor neurons from two rat strains, resulting in a difference in vulnerability to AMPA receptor-mediated excitotoxicity both in vitro and in vivo. Astrocytes from the ventral spinal cord were found to mediate this difference in GIuR2 expression in motor neurons. The presence of ALS-causing mutant superoxide dismutase 1 in astrocytes abolished their GIuR2-regulating capacity and thus affected motor neuron vulnerability to AMPA receptor-mediated excitotoxicity. These results reveal a mechanism through which astrocytes influence neuronal functioning in health and disease. [ABSTRACT FROM AUTHOR]

Invasive aspergillosis (IA) is an emerging infectious disease in different groups of immunocompromised patients. In transplant recipients, intensification of immunosuppressive therapy to treat allograft rejection poses a major risk factor for IA. We present the clinical features, diagnostic findings and outcome of a kidney transplant recipient who developed pulmonary aspergillosis complicated by endocarditis of his native tricuspid valve. Despite replacement of the valve and treatment with combined antifungal therapy, the patient died of an acute pulmonary bleeding. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) is a life-saving procedure in patients with severe respiratory failure, unresponsive to conventional therapy. We reviewed our series of 70 ECMO runs (April 1997 to December 2005) in patients with respiratory distress, refractory to standard ventilation. Survival at 90 days was 42.7%. Besides age, we found no statistical significant difference in patient demographics or preoperative patient data between survivors and nonsurvivors. Univariate analyses indicated that pH values at 24 and 48 h after onset of ECMO were significantly higher in survivors. In multivariate analysis, age and pH at 48 h remained independent predictors of survival. ECMO in respiratory failure saves lives. No other demographic or preoperative, patient-related parameter than age was identified as predictor of survival. Although there was no difference in pH at onset of ECMO, blood gas analysis at 48 h revealed pH as an independent predictor of survival. [ABSTRACT FROM AUTHOR]

Aims The aim here is to analyse epidemiology, optimal treatment, and predictors of 6-month mortality in infective endocarditis (IE). [ABSTRACT FROM PUBLISHER]

Objective: We determined the possible effects of age, antimineralization treatments, circulatory implant conditions, prosthesis design, and valve-related structural aspects on valve calcification in adolescent sheep. Methods: Calcium content was measured by means of atomic absorption spectrometry in bioprostheses implanted in 120 sheep (age <1 year) for a period of 3 or 6 months. Results: Bioprostheses calcified significantly in adolescent sheep, but the extent of calcification was multifactorial. Multivariate analysis of the calcium content reveals that age, mitral or pulmonary implant position, prosthesis design (stented or stentless), structure (porcine or pericardial, wall portion or cusp), and antimineralization treatment are independent factors influencing calcification; implant duration beyond 3 months was not. In juvenile sheep (age 5 months) the wall portion, as well as the cusps of the prosthesis, calcified significantly more than in adolescent sheep (age 11 months). Irrespective of age, the cusps of valves implanted in the mitral position calcified more than those in the pulmonary position. The wall portion of stentless valves calcified more than that of stented valves, and pericardial valves calcified less than porcine valves. The surfactant (Tween 80, No-React, and α-amino-oleic acid) and alcohol (ethanol and octanediol) treatment significantly reduced cusp calcification; sodium dodecylsulfate did not. None of the anticalcification treatments was able to prevent wall calcification in stentless porcine valves. Conclusion: These findings suggest that tissue valve calcification is determined by many independent factors, which can be identified by using adolescent sheep as a preclinical in vivo model. [Copyright &y& Elsevier]

Tight blood glucose control with insulin reduces morbidity and mortality of critically ill patients. However, the relative impact of maintaining normoglycemia and of glycemia-independent actions of insulin remains unknown. We therefore independently manipulated blood glucose and plasma insulin levels in burn-injured, parentally fed rabbits over 7 days to obtain four study groups: two normoglycemic groups with either normal or elevated insulin levels and two hyperglycemic groups with either normal or elevated insulin levels. We studied the relative impact of glycemia and glycemia-independent effects of insulin on survival; myocardial contractility in an open chest preparation; endothelial function in isolated aortic rings; and liver, kidney, and leukocyte function in a rabbit model of critical illness. Mortality was significantly lower in the two normoglycemic groups independent of insulin levels. Maintaining normoglycemia, independent of insulin levels, prevented endothelial dysfunction as well as liver and kidney injury. To increase myocardial systolic function, elevated insulin levels and prevention of hyperglycemia were required concomitantly. Leukocyte dysfunction was present in the two hyperglycemic groups, which could in part be rescued by insulin. The results suggest that the observed benefits of intensive insulin therapy required mainly maintenance of normoglycemia; whereas glycemia-independent actions of insulin exerted only minor, organ-specific impact. [ABSTRACT FROM AUTHOR]

Abstract: Background: Atrial fibrillation (AF) is associated with extracellular matrix remodeling involving atrial fibrosis and atrial dilatation. Angiotensin II mediated pathways and matrix metalloproteinases (MMPs) have been implicated in these processes. Our aim was to study atrial structural remodeling and the expression of the angiotensin receptor subtypes and MMPs and their inhibitors (TIMPs) in patients with mitral valve disease with and without AF. Methods and results: Biopsies from right and left atrial appendages (RA and LA) were taken from patients undergoing CABG (n =9, all in sinus rhythm (SR)) or mitral valve surgery (MVS; n =19; 9 with permanent AF and 10 in SR). Patients with MVS and AF had significantly larger atria (versus MVS and SR: p =0.02; versus CABG: p &#60;0.01). The MVS patients had significantly more fibrosis than the control CABG group. Fibrosis was increased in both the AF and SR MVS groups in the LA, but only in the MVS–AF group in the RA. These AF patients had significantly more tricuspid regurgitation than SR patients. MMP-1 was down-regulated in LA of MVS patients (p =0.02) independent of the underlying rhythm (SR or AF; p =0.95). In RA biopsies, MMP-1 was down-regulated only in the MVS and AF group. MMP-9 was down-regulated in the MVS patients compared to CABG both in the RA and LA, and without a difference between the SR and AF groups. Protein expression of AT-1, AT-2, MMP-2, TIMP-1, -2 and -4, TNF-α, and TNF-α-converting enzyme did not differ significantly between the 3 groups. Conclusions: Concordant changes between MMP-expression and fibrosis during mitral valve disease, both in LA and RA, suggest involvement of MMPs in structural atrial remodeling. AF itself did not contribute to altered fibrosis or MMP-expression in the LA. The association between AF and RA changes may be precipitated by greater hemodynamic load due to tricuspid regurgitation in these patients. [Copyright &y& Elsevier]

Objectives. The role of reactive oxygen species (ROS) in the mechanism of myocardial stunning was investigated. Material and methods. Isolated Langendorff-perfused rabbit hearts were subjected to 15&ThickSpace;min normothermic ischemia followed by 10&ThickSpace;min reperfusion with Krebs-Henseleit solution±mannitol or histidine. Results. In hearts reperfused without free radical scavenger the left ventricular developed pressure as well as its maximal positive and negative first derivatives (+dP/dt, -dP/dt) was significantly depressed, whereas end diastolic pressure (LVEDP) increased when compared to preischemic values. Treatment with mannitol had little protective effects, whereas singlet oxygen scavenger histidine significantly improved the recovery of LVEDP and -dP/dt. Sarcolemmal Na + , K + -ATPase activity (control, 400±41 nmol P i .min -1 .mg -1 ) was depressed in untreated stunned hearts (260±27 nmol P i .min -1 .mg -1 ), but was almost completely recovered in hearts pretreated with histidine (364±27 nmol P i .min -1 .mg -1 ). The inhibition of Na + , K + -ATPase was only slightly prevented by mannitol (302±29 nmol P i .min -1 .mg -1 l). Conclusions. The results suggest that ROS-induced inhibition of Na + , K + -ATPase activity is involved in the mechanism of postischemic contractile dysfunction and support the view that singlet oxygen may be one of the major causes of oxidative injury during ischemia and reperfusion. [ABSTRACT FROM AUTHOR]

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Objective: Ischemic preconditioning (IP) describes the adaptation of the myocardium to ischemic stress preceded by short periods of ischemia and reperfusion. However, its cardioprotective mechanisms are not completely understood. We assessed the effect of IP on ventricular energetics in an in-vivo sheep model. Methods: IP was performed in six sheep by three 5 min aortic cross-clamping periods interspersed with 5 min of reperfusion during cardiopulmonary bypass and with six sheep as time-matched controls. Global myocardial ischemia was subsequently achieved by 30 min aortic cross-clamping with left ventricular unloading during normothermic cardiopulmonary bypass. Weaning from cardiopulmonary bypass was performed 40 min after reperfusion. At baseline, after treatment (IP or time-matched cardiopulmonary bypass), and up to 100 min after reperfusion, left ventricular pressure–volume loops were measured using a conductance catheter during a right heart bypass preparation. Contractility, diastolic function, and ventriculo–arterial coupling were evaluated. Ventricular energetics [the relation between myocardial oxygen consumption (MVO2) and systolic pressure–volume area (PVA)] was also evaluated. A right heart bypass was instituted to control the preload and to decompress the right ventricle completely, thereby eliminating parallel conductance variation and minimizing the contribution of the right ventricle to MVO2. Results: IP reduced unloaded MVO2 (PVA-independent MVO2). Contractility, diastolic function, and ventriculo–arterial coupling in the IP group were better preserved than in the control group after ischemia-reperfusion. Conclusions: IP reduces unloaded MVO2, and preserves contractility, diastolic function, and ventriculo–arterial coupling after 30 min global myocardial ischemia in an in-vivo sheep model. [Copyright &y& Elsevier]

Objectives: Ischemic preconditioning has been used to induce the myocardium to adapt to ischemic stress preceded by short periods of ischemia and reperfusion. We used a sheep right heart bypass model with a conductance catheter to assess the cardioprotective effect of ischemic preconditioning on 30-minute normothermic global myocardial ischemia. Methods: Ischemic preconditioning was conducted in 6 sheep in 3 5-minute aortic cross-clampings intersperesed with 5 minutes of reperfusion during cardiopulmonary bypass, with 6 sheep as time-matched controls. Global myocardial ischemia was subsequently achieved in 30-minute aortic cross-clamping with left ventricular unloading during normothermic cardiopulmonary bypass. Weaning from cardiopulmonary bypass was conducted 40 minutes after reperfusion. Before ischemia and 40, 70, and 100 minutes after reperfusion, left ventricular pressure-volume loops were measured using a conductance catheter during right heart bypass preparation. Left ventricular contractility, diastolic function, and mechanical efficiency were then evaluated. Right heart bypass was instituted to control the preload and to decompress the right ventricle completely, thereby eliminating parallel conductance variation. Results: No differences in the studied parameters were seen between ischemic-preconditioning and control groups before ischemia. Left ventricular contractility, diastolic function, and mechanical efficiency in the ischemic-preconditioning group were significantly superior to those in the control group after reperfusion. Conclusions: Ischemic preconditioning attenuates postischemic myocardial dysfunction in a sheep model using 30-minute unloaded normothermic global myocardial ischemia. Ischemic preconditioning would thus be clinically significant when the ischemic damage is severe. [ABSTRACT FROM AUTHOR]

Objective: Brain death induces important haemodynamic changes in rats, with a drop in arterial blood pressure, left ventricular developed pressure and dP/dtmax to less than 50% of its control value. Myocardial damage was reported to contribute to this paradigm. The role of potential underlying pathogenetic mechanisms, such as a circulating cardiodepressant factor, NO, endogenous opioid peptides, vagal or β-adrenergic activation, or hypophyseal dysfunction, were explored, but none of them could be demonstrated as the culprit. This study investigated whether functionally important intrinsic myocardial damage was induced by brain death in the rat, and whether coronary endothelial cell dysfunction, possibly causing multifocal ischaemia, contributed to this. Methods: Brain death was induced in rats by sudden inflation of an intracranial balloon. Extensive haemodynamic measurements, including heart rate, arterial blood pressure, central venous pressure, left ventricular pressure, and cardiac output, were performed. Hearts excised 1 and 4 h after brain death were examined histologically. The contractile reserve of these hearts was tested by administration of increasing doses of adrenaline (10−9 to 10−6 mol/l) in a Langendorff system. The coronary endothelium was tested with regard to its barrier function for macromolecules by determining the extravasation of injected Evans blue, and with regard to its vasoactive function by testing the effects of serotonin and nitroglycerin in a Langendorff system. Results: The haemodynamic measurements suggested that the cardiovascular collapse consisted mainly in alterations in afterload. Contractile reserve, as tested with increasing adrenaline doses, revealed a normal dose–response curve. No histological myocardial damage was found after brain death in rats. No abnormal extravasation of Evans blue was seen. Coronary vasoreactivity towards nitroglycerin and serotonin was normal. Conclusion: Myocardial damage, if present at all, contributes only minimally to the changes in haemodynamic profile seen after brain death in the rat, and the coronary endothelium appears to preserve its barrier and vasoactive function. [ABSTRACT FROM PUBLISHER]

Objective: Brain death-induced haemodynamic collapse in rats is not caused by intrinsic myocardial damage as shown in the accompanying paper. We investigated whether this collapse could be caused by the withdrawal of the basal adrenergic tone. Methods: Heart rate and blood pressure variability was studied in rats before and after brain death. The effect of high doses of phentolamine, propranolol or their combination administered before or after brain death was assessed. Results: Heart rate variability in the respiratory frequency range significantly increased, whereas in the low-frequency range it tended to decrease after brain death. Systolic and diastolic blood pressure variability up to 0.18 Hz largely disappeared, but stayed unchanged in the respiratory frequency range. High-dose combined phentolamine and propranolol pretreatment induced a haemodynamic picture comparable to the situation seen after brain death without pharmacological intervention. Brain death did not further deteriorate the haemodynamic situation after combined pretreatment. On the other hand, once the haemodynamic collapse after brain death had settled, adrenergic blockade had no important influence any more. Conclusion: We conclude that the haemodynamic situation seen after brain death is one of profound sympathetic withdrawal. [ABSTRACT FROM PUBLISHER]

Background: Accurate localization and sizing of a myocardial infarction are necessary for clinical decision making and even more in research. Gd-Mesoporphyrin enhanced magnetic resonance imaging (MRI) was recently shown to specifically delineate necrosis in liver tumors, renal and muscle necrosis and myocardial infarction in rats. In this study, we investigated this technique's potential to accurately delineate myocardial infarction in a larger animal species, the dog. Methods: Myocardial infarction was induced in 8 dogs by ligation of the left anterior descending coronary artery, 4 of which were reperfused after 3 hr. Gd-Mesoporphyrin (0.05 mmol/kg) was injected intravenously 210 min after the onset of ischemia (n = 6) or after 24 hr in 2 dogs with non-reperfused infarctions. MRI was performed 10 hr. after administration of Gd-Mesoporphyrin. In vivo MRI consisted of EKG-triggered, respiratory gated T1-weighted spin echo and segmented turboFLASH long and short axis measurements. Post-mortem, a spin echo short axis measurement was repeated. Infarct size was determined planimetrically by TTC staining of left ventricular slices. Results: In all instances, there was a very close qualitative agreement between the MRI and TTC defined myocardial infarction. Quantitatively, the linear regression from post-mortem MRI to TTC determined infarct size yielded a result very close to the line of identity (regression coefficient: 0.980 ± 0.026, p<0.000001, adjusted R2 = 0.964). Conclusion: We conclude that Gd-Mesoporphyrin enhanced MRI is a promising tool for the accurate delineation of myocardial infarction. [ABSTRACT FROM AUTHOR]

Cardiovascular disease associated with metabolic syndrome has a high prevalence, but the mechanistic basis of metabolic cardiomyopathy remains poorly understood. We characterised the cardiac transcriptome in a murine metabolic syndrome (MetS) model (LDLR−/−; ob/ob, DKO) relative to the healthy, control heart (C57BL/6, WT) and the transcriptional changes induced by ACE-inhibition in those hearts. RNA-Seq, differential gene expression and transcription factor analysis identified 288 genes differentially expressed between DKO and WT hearts implicating 72 pathways. Hallmarks of metabolic cardiomyopathy were increased activity in integrin-linked kinase signalling, Rho signalling, dendritic cell maturation, production of nitric oxide and reactive oxygen species in macrophages, atherosclerosis, LXR-RXR signalling, cardiac hypertrophy, and acute phase response pathways. ACE-inhibition had a limited effect on gene expression in WT (55 genes, 23 pathways), and a prominent effect in DKO hearts (1143 genes, 104 pathways). In DKO hearts, ACE-I appears to counteract some of the MetS-specific pathways, while also activating cardioprotective mechanisms. We conclude that MetS and control murine hearts have unique transcriptional profiles and exhibit a partially specific transcriptional response to ACE-inhibition. [ABSTRACT FROM AUTHOR]

The article presents a commentary on a study performed by D.H. Kang and colleagues on conventional treatment versus early surgery of infective endocarditis (IE). It informs that the study included examination of 134 patients with definite IE. The study found that early surgery can be performed without a recurrence of IE and complication rate decreases significantly.

The article presents a case study in which a 59-year-old immune-compromised woman after nonmyeloablative allogeneic stem cell transplantation for myelodysplastic syndrome, was admitted with methicillinresistant Staphylococcus aureus sepsis related to a Hickman catheter. The coronal maximum intensity projection image findings are characteristic of infective endocarditis with septic pulmonary embolisms and metastatic muscle abscesses and septic arthritis.

Abstract: Objectives: The value of the right heart morphology is not well established for the evaluation of elevated pulmonary artery pressure (PAP). We aimed (1) to assess the relationship between right heart morphology and PAP and (2) to evaluate whether morphology can help to exclude elevated PAP. Methods: From 11-2010 until 01-2011, 1640 consecutive patients were included from the database of echocardiography. Tricuspid regurgitation (TR) severity, right ventricular (RV) dilatation and right atrial (RA) dilatation were evaluated for (1) tricuspid regurgitant gradient (TRG)≤30mmHg; (2) TRG=30–40mmHg, and (3) TRG>40mmHg. A weighted score model was developed to diagnose TRG>30mmHg. The model was validated with data from right heart catheterization in 100 patients. Results: TR severity and RA diameter increased significantly from group 1 to group 2 and to group 3 whereas RV diameter differed only significantly from group 2 to group 3. To integrate TR severity, RA dilatation and RV dilatation, a point-based model was constructed. A total score≥3 was associated with a sensitivity and specificity of 95% and 31% and with a positive and negative likelihood ratios of 1.37 and 0.17, respectively to diagnose TRG>30mmHg. Negative predictive value for TRG>30mmHg was 92%. Prediction numbers could be reproduced when right heart catheterization was used as a reference standard. Conclusions: Increasing TRG is characterized by a steady increase in TR severity and RA dilatation. However, the RV dilates only significantly when TRG is markedly elevated. Integrating morphological parameters could reliably exclude the presence of elevated TRG and thus can be useful in screening for elevated PAP. [Copyright &y& Elsevier]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Increasing evidence suggests that aortic valve (AV) repair may have better long-term outcomes than AV replacement for aortic insufficiency. However, most literature is limited to centres of excellence and has not sufficiently been replicated in nascent programs. This single-centre experience of a newly established AV repair program aims to compare short-term outcomes of AV sparing versus replacement surgery. METHODS A retrospective cohort study of patients who underwent elective surgery for aortic regurgitation or aortic root dilatation at the Leuven University Hospital between 2013 and 2018 was performed. Patients with a critically ill presentation, endocarditis, aortic stenosis or requiring redo surgery were excluded. Patients were assigned to repair versus replacement based on preoperative intention to preserve the AV. Nearest neighbour propensity score matching was performed to compare both groups. Safety (mortality, morbidity), efficiency (cross-clamp and bypass times) and efficacy end points (repair rate, postoperative echocardiography) were compared. RESULTS One hundred and seven patients underwent AV surgery (48 repair, 59 replacement), from which 2 groups of 23 matched patients were created. There were 1 death and 2 reoperations after repair and no death and 1 reoperation after replacement. Extracorporeal circulation and aortic cross-clamp time were significantly longer while ventilation and total hospital stay were significantly shorter after AV repair. Echocardiographic follow-up showed comparable aortic regurgitation but lower transvalvular gradients after repair. Freedom from major complications was comparable in both cohorts. CONCLUSIONS Early results suggest the feasibility of replicating experienced centres' perioperative and short-term outcomes in nascent programs. [ABSTRACT FROM AUTHOR]

Background International electives benefit training of medical residents due to exposure to an increased scope of pathologies, improved physical examination skills, communication across cultural boundaries and more efficient resource utilization. Currently there is no mechanism for Belgian surgical residents to participate in international training opportunities and little research has addressed the international mobility of Belgian residents. The goal of this study was to examine the attitudes of Belgian residents towards international training among surgical residents. Methods An anonymous, structured electronic questionnaire was sent to a cohort of Belgian residents, including surgical residents, by e-mail and social media. Results In total, 342 respondents filled out the questionnaire out of a total of 5906 Belgian residents. The results showed that 334 of the residents came from Flanders (10.8%) and 8 came from French-speaking Brussels and Wallonia (0.28%). Surgical specialties represented 46% of respondents and included surgical, obstetric and anaesthesiology residents. The majority (98%) were interested in an international rotation, both in low- and middle-income countries (LMICs) and in high-income countries. A total of 84% were willing to conduct an international rotation during holidays and 91% would participate even when their international stay would not be recognised as part of their residency training. A minority (38%) had undertaken an international rotation in the past and, of those, 5% went to an LMIC. Conclusion The majority of surgical residents consider an international rotation as educationally beneficial, even though they are rarely undertaken. Our survey shows that in order to facilitate foreign rotations, Flemish universities and governmental institutions will have to alleviate the regulatory, logistical and financial constraints. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) remains a severe disease with high mortality. Most studies report on short-term outcome while real world long-term outcome data are scarce. This study reports reinfection rates and mortality data during long-term follow-up. A total of 270 patients meeting the modified Duke criteria for definite IE admitted to a tertiary care center between July 2000 and June 2007 were analyzed retrospectively. Early reinfection was defined as a new IE episode within 6 months; late reinfection as a new IE episode beyond 6 months follow-up. Median follow-up was 8.5 years. Early reinfection occurred in 10 patients (3.7%), late reinfection in 18 patients (6.7%). Staphylococci (39.7%) were the most frequent causative microorganisms, followed by Streptococci (30.0%) and Enterococci (17.8%). Independent predictors of any reinfection were heart failure (HR 3.02, 95% CI 1.42–6.41), peripheral embolization (HR 4.00, 95% CI 1.58–10.17) and implanted pacemakers (HR 3.43, 95% CI 1.25–9.36). Survival rates were 71.1%, 55.2% and 43.3% at respectively 1-, 5- and 10-years follow-up. Independent predictors for mortality were age (HR 1.03, 95% CI 1.01–1.04), diabetes mellitus (HR 2.24, 95% CI 1.46–3.45), hemodialysis (HR 2.70, 95% CI 1.37–5.29), heart failure (HR 1.64, 95% CI 1.19–2.26), stroke (HR 1.73, 95% CI 1.18–2.52), antimicrobial treatment despite surgical indication (HR 5.53, 95% CI 3.59–8.49) and non- Streptococci causative microorganisms (HR 1.84, 95% CI 1.28–2.64). Contemporary mortality rates of infective endocarditis remain high, irrespective of reinfection. Heart failure, peripheral embolization and presence of a pacemaker were predictors of reinfection. • Real world long-term outcome data in infective endocarditis is scarce. • Early reinfection rate was 3.7%, whereas late reinfection rate was 6.7%. • Survival rates were 71.1% at 1 year and 43.3% at 10-years follow-up. [ABSTRACT FROM AUTHOR]

Background: Vagus nerve (VN) stimulation is currently evaluated as a novel approach to treat immune‐mediated disorders. The optimal stimulation parameters, however, largely depend on the VN composition potentially impacting on its clinical translation. Hence, we evaluated whether morphological differences exist between the cervical and abdominal VNs across different species. Materials and methods: The cervical and abdominal VNs of mouse, pig, and humans were stained for major basic protein and neurofilament F to identify the percentage and size of myelinated and non‐myelinated fibers. Results: The percentage of myelinated fibers was comparable between species, but was higher in the cervical VN compared with the abdominal VN. The cervical VN contained 54 ± 4%, 47 ± 7%, and 54 ± 7% myelinated fibers in mouse, pig, and humans, respectively. The myelinated fibers consisted of small‐diameter (mouse: 71%, pig: 80%, and humans: 63%), medium‐diameter (mouse: 21%, pig: 18%, and humans: 33%), and large‐diameter fibers (mouse: 7%, pig: 2%, and humans: 4%). The abdominal VN predominantly contained unmyelinated fibers (mouse: 93%, pig: 90%, and humans: 94%). The myelinated fibers mainly consisted of small‐diameter fibers (mouse: 99%, pig: 85%, and humans: 74%) and fewer medium‐diameter (mouse: 1%, pig: 13%, and humans: 23%) and large‐diameter fibers (mouse: 0%, pig: 2%, and humans: 3%). Conclusion: The VN composition was largely similar with respect to myelinated and unmyelinated fibers in the species studied. Human and porcine VNs had a comparable diameter and similar amounts of fibrous tissue and contained multiple fascicles, implying that the porcine VN may be suitable to optimize stimulation parameters for clinical trials. [ABSTRACT FROM AUTHOR]

Background: The optimal aortic substitute in extensive aortic valve active infective endocarditis (AIE) continues to be debated. To determine the surgical approach in aortic valve AIE with infection extension beyond the leaflets, we evaluated the outcome of reconstructive surgery with various valve substitutes in those patients.Methods: During 2000-2013, 168 patients had surgery for extensive aortic valve AIE. Patients were categorised based on aortic valve substitute: Group A: Stented aortic valve replacement (AVR), Group B: Stented AVR with patch support, Group C: Stentless valve, Group D: Aortic allograft, and Group E: Composite valve graft. Outcome parameters were mortality, postoperative cardiogenic or septic shock, stroke, or reinfection.Results: Stented valves with patch support were more frequently utilised in cases of native valve endocarditis (p<0.001). Postoperative complications were comparable among groups. Concomitant preoperative extension of infection in the mitral valve predicted reinfection (OR 3.6; confidence interval 1.46-8.66; p=0.005). Survival was not affected by operative group (log rank=0.6). Univariable preoperative predictors of mortality were: septic shock (hazard ratio 8.3; 95% confidence interval 3.6-19.2; p<0.001), ejection fraction (hazard ratio 0.96; 95% confidence interval 0.93-0.99; p=0.006), preoperative cardiogenic shock (hazard ratio 1.9; 95%CI 1.1-3.6, p=0.02) and concomitant mitral valve surgery (hazard ratio 1.8; 95% confidence interval 1.2-2.5; p=0.002).Conclusions: Surgical treatment of extensive aortic valve infective endocarditis remains a challenge. Outcomes were not affected by the surgical complexity of aortic reconstruction procedure or valve substitute. Surgical approach should be tailored to individual patient's characteristics. [ABSTRACT FROM AUTHOR]

Background: Pelvic organ prolapse affects half of vaginally parous women. Several animal models are used to study its pathophysiology and treatment. Sheep are interesting because they develop spontaneously prolapse with similar risk factors as women and can be used for vaginal surgery. This study describes ovine pelvis anatomy and compares it to women's pelvis to provide anatomical tools for translational researchers.Methods: MRI, pelvic dissections, and histology were used for detailed macro- and microscopic analysis of relevant anatomical structures in 6 nulliparous ewes.Results: Although sheep are quadrupeds, the gross and microscopic anatomies are similar to the female pelvis. Principal differences are the shape and its orientation, the absence of the sacrospinous ligament and the internal obturator. The levator ani (except for the puborectalis) and the coccygeus muscle are present, yet the latter is more developed - coinciding with the tail. The dimensions and morphology of the ovine vagina is comparable. The retropubic and the rectovaginal space are accessible transvaginally. There is a wide expression of estrogen receptors with low or absent immunoreactivity in the urethral epithelium, bladder, anus and internal anal sphincter.Conclusion: The ovine pelvic floor has many anatomical and ultrastructural similarities to the female pelvic floor. [ABSTRACT FROM AUTHOR]

We have characterized both acute and long-term vascular and metabolic effects of unilateral common carotid artery occlusion in mice by in vivo magnetic resonance imaging and positron emission tomography. This common carotid artery occlusion model induces chronic cerebral hypoperfusion and is therefore relevant to both preclinical stroke studies, where it serves as a control condition for a commonly used mouse model of ischemic stroke, and neurodegeneration, as chronic hypoperfusion is causative to cognitive decline. By using perfusion magnetic resonance imaging, we demonstrate that under isoflurane anesthesia, cerebral perfusion levels recover gradually over one month. This recovery is paralleled by an increase in lumen diameter and altered tortuosity of the contralateral internal carotid artery at one year post-ligation as derived from magnetic resonance angiography data. Under urethane/a-chloralose anesthesia, no acute perfusion differences are observed, but the vascular response capacity to hypercapnia is found to be compromised. These hemispheric perfusion alterations are confirmed by water [15O]-H2O positron emission tomography. Glucose metabolism ([18F]-FDG positron emission tomography) or white matter organization (diffusion-weighted magnetic resonance imaging) did not show any significant alterations. In conclusion, permanent unilateral common carotid artery occlusion results in acute and long-term vascular remodeling, which may have immediate consequences for animal models of stroke but also vascular dementia. [ABSTRACT FROM AUTHOR]

Background Pulmonary outflow tract obstruction (POTO) reduces systemic atrioventricular valve (SAVV) regurgitation severity in congenitally corrected transposition of the great arteries (ccTGA). Therefore, pulmonary artery banding is proposed as a palliative intervention. We aimed to investigate the effect of native or surgically induced POTO on event-free survival, defined as the composite of all-cause mortality, heart transplantation, or congestive heart failure (CHF). Methods and results Patients with ccTGA (n = 62; median age 27.5 (IQR 18.4–39.4) years; 39% with POTO) were selected from the Adult Congenital Heart Disease database of a tertiary hospital. At first visit, SAVV regurgitation ≥ 3/4, systemic RV dysfunction ≥ moderate, and CHF were present in 26%, 26%, and 15% of patients, respectively. Over a mean follow-up time of 10.1 ± 6.1 years, all-cause mortality, rate of heart transplantation, and CHF were 18%, 8% and 40%, respectively. SAVV regurgitation (HR: 1.99; 95% CI: 1.01–3.92; P = 0.048) and systemic RV dysfunction severity (HR: 1.89; 95% CI: 1.05–3.37; P = 0.033) were associated with the composite endpoint, independently of age at baseline, POTO, Ebstein-like malformation, and systemic RV dilatation. Patients with POTO had lower risk for developing SAVV regurgitation ≥ 3/4 (HR: 0.18; 95% CI: 0.05–0.58; P = 0.004) and moderate systemic RV dysfunction (HR: 0.34; 95% CI: 0.15–0.78; P = 0.011). When POTO was present, the mean progression-free interval for the composite endpoint increased from 11.2 to 18.1 years ( P = 0.035). Conclusions POTO is associated with an improved event-free survival in adults with ccTGA. [ABSTRACT FROM AUTHOR]