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Objective: To explore the safety and efficacy of low-intensity anticoagulation in patients after On-X mechanical aortic valve replacement. Methods: A total of 104 patients undergoing aortic valve replacement in Cardiac Surgery Department of Sichuan Provincial People's Hospital from December 2018 to December 2021 were randomly divided into low-intensity anticoagulant (INR:1.5-2.0) and high-intensity anticoagulant (INR:2.0-2.5) to compare the incidence of adverse events related to postoperative anticoagulation between the two groups. Results: Fifty-three patients were included in the low-intensity anticoagulation group (INR 1.5-2.0), and 51 patients were included in the high-intensity group (2.0-2.5). There was no significant difference in baseline data and surgical index between the two groups (P > 0.05); there were statistically significant differences in PT, INR and bleeding events (P < 0.05), but no significant difference in embolic events (P > 0.05). Conclusion: For patients requiring On-X mechanical aortic valve replacement who have no risk factors for thromboembolism, it is appropriate to control the INR in the target range 1.5-2.0, which can reduce the incidence of bleeding adverse events and significantly improve the quality of life, without increasing the risk of thromboembolic adverse events. [ABSTRACT FROM AUTHOR]

Background: Our objective was to investigate patient-reported maternal and perinatal outcomes and survival among women undergoing aortic valve and/or aortic root replacement (AVR/ARR). Methods: This was a single-center observational study of U.S. women identified in our surgical/obstetric databases who underwent AVR/ARR between 1967 and 2019. Available, consenting patients participated in a telephone survey detailing patient-reported outcomes. The status of remaining individuals was verified through the Alabama Department of Public Health. Date of death, immediate and underlying cause of death, and death location were abstracted from death certificates. Results: Of 317 patients, 72 were confirmed living, 86 were deceased, and 159 were of unknown status. Mean age at first aortic valve replacement was 43 years. Of patients with known status (n = 158), 33% were Black, and the majority received a mechanical valve (58%). Of 57 participants completing the survey, reported complications included miscarriage (30%), preterm birth (12%), preeclampsia (14%), antepartum maternal intensive care unit admissions (6%), and congenital heart disease in the neonate (8%). Most pregnancies preceded AVR (78%). Among 86 decedents, the average age of death was 52.5 years; the average time from AVR/ARR to death was 7 years. Of those who died, a higher proportion were Black (75%) and had aortic insufficiency (72%). Conclusions: Patients who underwent aortic valve surgery report high rates of maternal and perinatal complications, and death certificate data confirm high rates of racial disparities and death within a decade of surgery. Interventions are urgently needed to improve maternal and perinatal outcomes in individuals with aortic valve disease and to eliminate preventable racial disparities. [ABSTRACT FROM AUTHOR]

This case report details the interdisciplinary care provided to a 48-year-old male patient with severe aortic valve stenosis who underwent transcatheter aortic valve replacement in a community hospital setting. Focus is placed on the interdisciplinary team model demonstrated in the care of this patient, including interventional cardiology and cardiothoracic surgery from the outpatient to the inpatient setting. The use of decision-making tools, including the Society of Thoracic Surgeons Risk Calculator, and a collaborative, shared decision-making approach will be discussed. The care and evaluation of the patient will be presented and compared with the American College of Cardiology/American Heart Association guidelines. [ABSTRACT FROM AUTHOR]

• 744 patients underwent SAVR at a single institution. • Short term mortality did not differ significantly between valve types. • 15 year mortality did not differ significantly between valve types. • Reoperation did not differ significantly between valve types up to 10 years. • Reoperation at 15 years favored mechanical valves. Aortic valve disease(AVD) accounts for 33 % of valvular heart disease(VHD) but causes over 60 % of VHD mortality. For surgical AVR, mechanical valves are recommended for patients <50 years old and bioprosthetic valves for those >70 years old. To investigate the long-term differences following AV replacement(AVR) comparing bioprosthetic and mechanical valves in patients aged 50–70. 4,927 patients underwent AVR, 744 of which were propensity-matched 2:1 for bioprosthetic and mechanical valves. Outcomes included mortality, morbidity, and rates of reoperation. The average age of the propensity-matched groups was 57 and 56.7 years, and female sex accounted for 26.4 % and 25.0 % for the bioprosthetic and mechanical valve groups, respectively. Other baseline demographics and comorbidities were similar between the groups. There were no deaths at 30 days and complication rates did not differ between groups(p > 0.05). Mortality at 1, 5, and 15 years was similar between groups. Reoperation rates at 5 and 10 years did not significantly differ between bioprosthetic and mechanical valves(p = 0.84, p = 0.31), although at 15-year follow-up, patients with bioprosthetic valves were more likely to require reoperation(21.2 % versus 9.7 %, adjusted hazard ratio 3.65, 95 % confidence interval 1.07–12.5, p = 0.0.39). Patients receiving AVR from 50 to 70 years old have similar long-term outcomes irrespective of whether they received bioprosthetic or mechanical valves, with only reoperation being significantly different at 15 years follow-up. With low rates of reoperation, mortality, and avoidance of anticoagulation, bioprosthetic valves are a reasonable option for patients 50–70 years old, although mechanical valves still provide a durability benefit for young patients. [ABSTRACT FROM AUTHOR]

Background: Takayasu arteritis is a large-vessel vasculitis, in addition to giant cell arteritis. Various post-operative complications associated with the cardiac macrovasculature have been reported. Detachment of the prosthetic valve, pseudoaneurysm formation, and dilatation of the aortic root are well-known post-operative complications associated with vasculitis syndromes, including Takayasu arteritis. Here, we report a rare complication involving aortic bioprosthetic valve dislodgement in the left ventricular outflow tract due to Takayasu arteritis. Case presentation: A 76-year-old female underwent aortic valve replacement with a 21-mm Carpentier–Edwards Perimount valve for severe aortic regurgitation and a coronary artery bypass graft from the left internal thoracic artery to the left anterior descending artery for ischemic heart disease. Fourteen years after the initial surgery, echocardiography revealed severe aortic valve sclerosis due to structural valve deterioration of the bioprosthesis. Upon scrutiny, the bioprosthetic aortic valve was found to have dislodged into the left ventricular outflow tract. We performed re-implantation of the bioprosthetic aortic valve and replacement of the ascending aorta. Conclusions: Although dislodgement of the bioprosthetic aortic valve is an extremely rare complication associated with Takayasu arteritis, the possibility that it could occur should be considered when treating the post-operative patients. [ABSTRACT FROM AUTHOR]

Background: Aortic valvuloplasty for bicuspid aortic valve carries a risk of postoperative stenosis. We evaluated the haemodynamic differences between aortic valvuloplasty for bicuspid aortic valve, tricuspid aortic valve, and aortic valve replacement by echocardiography. We also assessed whether a higher postoperative pressure gradient affects the outcomes of aortic valvuloplasty for bicuspid aortic valve. Methods: From 2014 to 2021, patients undergoing aortic valvuloplasty were classified into aortic valvuloplasty for bicuspid aortic valve (Group-PB) and aortic valvuloplasty for tricuspid aortic valve (Group-PT). We also enrolled patients undergoing aortic valve replacement (Group-R) between 2002 and 2021. Mid-term outcomes were compared within Group-PB based on peak pressure gradients of ≥20 mmHg (subgroup-H) and <20 mmHg (subgroup-L). Results: Group-PB included 42 patients and Group-PT included 70 patients. Both 7-day and 1-year echocardiography showed the highest peak/mean pressure gradients in Group-PB (n = 41) and the lowest values in Group-PT (n = 67). Propensity scoring analysis yielded similar results to an unadjusted analysis. The mid-term outcomes were not significantly different between subgroup-H (n = 20) and subgroup-L (n = 22), with rates of freedom from aortic regurgitation >II at 5 years of 94.4% vs. 94.4% (p = 0.749) and freedom from reoperation of 94.4% vs. 100.0% (p = 0.317), respectively. Conclusions: Aortic valvuloplasty for tricuspid aortic valve shows favourable valve function in the early postoperative period, whereas aortic valvuloplasty for bicuspid aortic valve has a risk of postoperative stenosis. However, a high pressure gradient (peak pressure gradient of ≥20 mmHg) after aortic valvuloplasty for bicuspid aortic valve does not impact mid-term outcomes. [ABSTRACT FROM AUTHOR]

Background: The association of body mass index (BMI) and an "obesity paradox" with cardiovascular risk prediction is controversial. This study aimed to evaluate the impact of elevated BMI on the outcome of transcatheter aortic valve replacement (TAVR) for aortic stenosis. Methods: This retrospective study included 1019 patients with a BMI of ≥18.5 kg/m² divided into 3 groups: 1) normal BMI (18.5-24.9 kg/m²), 2) overweight (25-29.9 kg/m²), and 3) obese (≥30 kg/m²). Propensity score matching was used to compare normal BMI with overweight and normal BMI with obese. Results: The median age of the cohort was 82 years, and 348 patients had a normal BMI, while 319 and 352 patients were overweight and obese, respectively. After 1 : 1 propensity score matching, 258 and 192 pairs between normal BMI and overweight, and normal BMI and obese patients, respectively, were analyzed. Both overweight and obese patients had higher post-transaortic mean gradients and lower indexed effective orifice areas compared to normal BMI patients. During a median follow-up of 25 (range: 0.1-72) months, all-cause mortality was similar between overweight or obese patients and patients with a normal BMI. However, in a subgroup analysis of patients with moderate/severe chronic lung disease, all-cause mortality was significantly higher in obese patients compared with normal BMI patients (hazard ratio = 3.49, 95% confidence interval, 1.21-10.0, P = .021). Conclusions: In this study, the "obesity paradox" was not observed in patients undergoing TAVR; rather, in patients with significant lung disease, obesity may be associated with worse mid-term outcomes after TAVR. [ABSTRACT FROM AUTHOR]

Introduction: This study reports of the use of a rigid-plate fixation (RPF) system designed for sternal closure after minimally invasive cardiac surgery (MICS). Methods: This retrospective analysis included all patients undergoing MICS with RPF (Zimmer Biomet, Jacksonville, FL, USA) at our institution. We analyzed in-hospital complications, as well as sternal complications and sternal pain at discharge and at follow-up 7 to 14 months after surgery. Results: Between June and December 2023, 12 patients underwent RPF during MICS, of which 9 patients were included in the study. The median (IQR) age was 64 years (63 to 71) and two patients (22%) were female. All patients underwent aortic valve replacement, with two patients (22%) undergoing concomitant aortic surgery. RPF was successfully performed in all patients. ICU and in-hospital stay were 1 day (1 to 1) and 9 days (7 to 13), respectively. Patients were first mobilized in the standing position on postoperative day 2 (2 to 2). Four patients (44%) required opiates on the general ward. In-hospital mortality was 0%. At discharge, rates of sternal pain, sternal instability or infection were 0%. After a follow-up time of 343.6 days (217 to 433), median pain intensity using the Visual Analog Scale was 0 (0 to 2). Forty-four percent (n = 4) of patients reported pain at rest. No sternal complications (sternal dehiscence, sternal mal-union, sternal instability, superficial wound infections and deep sternal wound infections) were reported. Conclusions: In the evolving landscape of cardiac therapies with incentives to reduce surgical burden, RPF showed safety and feasibility. It might become an important tool for sternal closure in minimally invasive cardiac surgery. [ABSTRACT FROM AUTHOR]

OBJECTIVES The transaxillary concept for minimally invasive cardiac surgery-aortic valve replacement is a new and versatile approach with nearly no visible scars. Due to its novelty, available data in literature are scarce. This study reports clinical outcomes of 1000 consecutive patients. METHODS Between 2019 and 2023, 4394 patients underwent elective isolated aortic valve procedures, with 2958 (67.5%) transcatheter aortic valve implantation's and 1436 patients surgical aortic valve replacement's (32.5%). Within this period, 1st consecutive 1000 transaxillary isolated minimally invasive cardiac surgery-aortic valve replacement were enrolled. Endocarditis, redo's or combined procedures were excluded. Mean age was 67.9 ± 8.3 years, STS-PROM 1.39 ± 2.89% and EuroScore II 1.65 ± 1.12%. RESULTS Use of the transaxillary access increased from 18.7% (2019) to 97.8% (2023). Mean procedure time was 127 ± 31 min, and average cross-clamp time was 43 ± 14 min. Used prostheses were rapid deployment (81.1%), sutured biologic (14.5%) or sutured mechanical valves (4.1%). Conversion rate was 1.9%. No patient died intraoperatively. Thirty-day major adverse cardiac and cerebrovascular event was 1.9% including 0.9% mortality, 0.8% perioperative stroke and 0.6% myocardial infarction. Multivariate factors for major adverse cardiac and cerebrovascular event are intraoperative conversion [OR 1.08 (1.00–1.16); P  = 0.04], intraoperative transfusions [OR 1.21 (1.07–1.38); P  < 0.01] and respiratory failure [OR 1.39 (1.30–1.49); P  < 0.01]. Corresponding factors for mortality are diabetes on insulin [OR 1.02 (1.00–1.04); P  = 0.03], pure aortic regurgitation for primary indication [OR 1.03 (1.01–1.05); P  < 0.01], intraoperative conversion [OR 1.11 (1.07–1.16); P  < 0.01], renal failure [OR 1.08 (1.05–1.10); P  < 0.01] and respiratory failure [OR 1.22 (1.17–1.26); P  < 0.01]. CONCLUSIONS Transaxillary minimally invasive cardiac surgery-aortic valve replacement is a safe, effective and cosmetically convincing method for surgical aortic valve replacement, having the potential for >95.0% minimally invasive cardiac surgery rate in selected patients. [ABSTRACT FROM AUTHOR]

Key summary points: Aim: This study is the first to explore the implications of diagnosing sarcopenia through ultrasound in older adults with severe aortic stenosis, introducing an ultrasound-guided assessment that adheres to the recommendations of the European Working Group on Sarcopenia in Older People. Findings: 1) Symptomatic severe aortic stenosis is a heart valve disease with a poor prognosis that often leads to serious clinical complications in older patients, with a highly invasive treatment of choice. 2) The existence of other conditioning factors, such as sarcopenia, that worsen the prognosis is frequent and produces greater uncertainty regarding the outcomes of these patients. 3) Sarcopenia assessment using ultrasound has not been previously explored in this clinical context, despite the technique being increasingly used, noninvasive, and relatively simple. 4) In our sample, the diagnosis of sarcopenia was associated with an independent increase in the risk of hospital admission and mortality due to cardiological causes after six months. Message: Given its potential usefulness in planning follow-up and treatment, ultrasound-guided sarcopenia assessment is highly recommended for older adults with aortic stenosis who are candidates for aortic valve replacement. Background: Muscle ultrasound is increasingly popular thanks to its advantages over other techniques. However, its usefulness in the diagnosis of sarcopenia in older adults with aortic stenosis (AS) has not been studied to date. Objectives: to analyze the prevalence of sarcopenia using muscle ultrasound and its impact on the health outcomes in older patients with AS. Methods: The single-center FRESAS (FRailty-Evaluation-in-Severe-Aortic-Stenosis) registry was used to study patients over 75 years with severe AS susceptible to valve replacement. Sarcopenia was suspected in those individuals with diminished grip strength, and the diagnosis was confirmed in the presence of reduced ultrasound quadriceps muscle thickness, following the recommendations of the EWGSOP2 (European-Working-Group-on-Sarcopenia-in-Older-People). The primary composite endpoint was urgent hospital admission and mortality of cardiac cause 6 months after the diagnosis. Results: Of the 150 patients studied, 55.3% were females, and only 17.3% were frail; the mean age was 83.4 years. Sarcopenia was diagnosed in 42 patients (28%). The overall survival rate at 6 months was 92%. The primary endpoint was recorded in 23.2% of the cases and was more frequent in the sarcopenic patients (33.3%) than in the non-sarcopenic individuals (17.6%) (p = 0.01). The regression analysis found that sarcopenia was associated with an increased risk of the primary endpoint (HR: 2.25; 95% CI 1.19–4.45; p = 0.02), adjusting for potential confounding factors. Conclusions: The incidence of serious cardiac complications in older patients with sarcopenia and severe AS is significant. The present study describes a noninvasive, ultrasound-guided diagnostic technique that may prove efficient in its predictive capacity. [ABSTRACT FROM AUTHOR]

Key summary points: Aim: The objective of this survey was to investigate geriatricians' role in the management of older patients with aortic stenosis, over the last decade. Findings: Our results indicate that aortic stenosis is a common disease at older age and frequently coexists with geriatric syndromes. Nevertheless, geriatricians' role in multidisciplinary assessment of aortic stenosis is scarce, similarly to what reported in a previous survey conducted a decade ago. Message: More efforts should be devoted to implement geriatricians' involvement in aortic stenosis management and multidisciplinary heart teams. Introduction: Increasing evidence supports the implementation of geriatric assessment in the workup of older patients with aortic stenosis (AS). In 2012, an online European survey revealed that geriatricians were rarely involved in the assessment of candidates for transcatheter aortic valve implantation (TAVI). After a "call to action" for early involvement of geriatricians in AS evaluation, the survey was repeated in 2022. Our aim was to investigate whether geriatricians' role changed in the last decade. Methods: Online survey conducted between December 16th, 2021, and December 15th, 2022. All members of the European Geriatric Medicine Society were invited to participate. The survey included 26 questions regarding geriatricians' experience with AS and TAVI. Results: Among 193 respondents (79.8% geriatricians), 73 (38%) reported to be involved in AS evaluation at least once a week. During 2 years prior to the survey, 43 (22.3%) had referred > 50% of their patients with severe AS for TAVI. Age influenced TAVI referral in a considerable proportion of respondents (36.8%). TAVI candidates were mainly referred to specialised cardiac centres with multidisciplinary teams (91.8%), including (47.2%) or not including (44.6%) a geriatrician. A total of 38.9% of respondents reported to be part of a multidisciplinary heart team. Geriatricians were less frequently involved (37%) than cardiologists (89.6%) and surgeons (53.4%) in pre-procedural TAVI management. Cardiologists were more frequently involved (85.5%) than geriatricians (33.7%) and surgeons (26.9%) in post-procedural management. Conclusions: Geriatricians' involvement in AS management and multidisciplinary heart teams remains scarce. More efforts should be devoted to implement geriatricians' role in AS decision-making. [ABSTRACT FROM AUTHOR]

The hemodynamic performance of different prosthetic heart valves is difficult to compare among studies due to a variety of test conditions and experimental techniques. Existing studies are typically limited to one family of valves (biological or mechanical) and testing conditions of 5l/min and often lack sufficient spatial resolution. To address these limitations, a pulse duplicator with a multi-view imaging system (Tomo-PIV) was employed to investigate the three-dimensional flow field in the aortic root of three different valves: a tri-leaflet mechanical heart valve (TRIFLO, Novostia), a bi-leaflet mechanical heart valve (On-X, Artivion), and a biological heart valve (Perimount, Edwards Lifesciences). The valves were tested at low (3 l/min), normal (5 l/min), and elevated (7 l/min) cardiac output (C O) under hypotensive (40/60mmHg), normotensive (80/120mmHg), and moderate hypertensive (105/170mmHg) pressure conditions, respectively. Compared to the Perimount, peak mean velocity was − 33%, − 24%, − 18% for the TRIFLO and − 32%, − 20%, − 11% for the On-X at low, moderate, and elevated CO , respectively. Corresponding peak TKE values decreased by − 66%, − 57%, − 44% (TRIFLO) and − 60%, − 50%, − 36% (On-X). At low CO , EOA was lower for Perimount (1.07cm2) than for TRIFLO (1.47cm2) and On-X (1.52cm2), while it increased for elevated CO to 2.75cm2 (TRIFLO) and 2.16cm2 (Perimount and On-X). For all valves, increasing CO led to increased flow velocities, higher E O A , and higher levels of turbulence, and the spatial influence of the valve on the flow field in the ascending aorta was extended. TKE peaked closer to the STJ than for TRIFLO and Perimount. [ABSTRACT FROM AUTHOR]

Background Bicuspid aortic valve (BAV) is the most common congenital heart defect (reported incidence of 0.5%–2%) and is commonly associated with proximal aortic dilation. Patients with severe aortic stenosis (AS) of BAV have been shown to have worse pre-operative left ventricular (LV) function as well as a higher incidence of post-operative heart failure hospitalization when compared with analogous patients with tri-leaflet aortic valve disease. While surgical aortic valve replacement (SAVR) may be favoured over transcatheter aortic valve implantation (TAVI) due to anatomical factors or concomitant aortopathy and coronary artery disease, surgical candidacy is often limited by prohibitive operative risk. Case summary We report on three cases of severe AS in BAV with concomitant aortopathy and severe left ventricular dysfunction in whom we proceeded with SAVR with a priori planned venoarterial extracorporeal membrane oxygenation (VA-ECMO) support and inotrope-assisted wean. All patients had severe LV dysfunction (ejection fraction < 25%) at baseline with gradual substantial improvement or normalization after successful SAVR. Discussion These cases demonstrate the utility of planned VA-ECMO with SAVR and aortic root replacement as an integral component of the operative strategy for high surgical risk patients with severe BAV AS not amenable to TAVI. Appropriate pre-operative planning and consent for VA-ECMO as well as a multi-disciplinary approach involving anaesthesia, intensive care, and heart failure cardiology are the key to offering this option as an alternative to palliative medical therapy to a selected group of patients. [ABSTRACT FROM AUTHOR]

Background and Objectives: This study aims to assess the postoperative outcomes and complications of sutureless and sutured aortic valve replacement in patients with infective endocarditis. Materials and Methods: A total of 58 patients who underwent redo aortic valve replacement for bacterial or non-bacterial endocarditis between January 2018 and March 2023 were included in our study. Surgical procedures were performed through a full median sternotomy due to redo cases and to provide optimal access. Demographic characteristics, operative times, postoperative complications and some echocardiographic data were compared. All cases were meticulously evaluated preoperatively by a cardiac team to select the best treatment option. Results: The mean ICU length of stay was significantly shorter in the sutureless valve group at 5.4 ± 3.9 days compared to 7.9 ± 4.1 days in the sutured valve group (p = 0.029). However, the sutureless group had a mean operation time of 164.7 ± 37.3 min, while the sutured group had a mean operation time of 197.7 ± 45.6 min (p = 0.044). Again, the difference in cardiopulmonary bypass times between the two groups was statistically significant (p = 0.039). And again, four (14.2%) patients in the sutureless group underwent reoperation due to bleeding, while eight (26.6%) patients in the sutured group underwent postoperative bleeding control (p = 0.048). Conclusions: Our study suggests that sutureless aortic valve replacement may offer advantages in terms of operative efficiency and postoperative recovery compared to conventional sutured valves, with some significant differences in terms of some complications. [ABSTRACT FROM AUTHOR]

Objective: To compare outcomes of aortic valve replacement (AVR) in patients with pure aortic stenosis (Pure AS) and those with pure aortic regurgitation (Pure AR) or mixed AS and AR (MAVD) in the COMMENCE trial. Methods: Of 689 patients who underwent AVR in the COMMENCE trial, patients with moderate or severe AR with or without AS (Pure AR + MAVD; n = 135) or Pure AS (n = 323) were included. Inverse probability of treatment weighting Kaplan-Meier survival curves were used for time-to-event endpoints, and longitudinal changes in hemodynamics were evaluated using mixed-effects models. Echocardiographic outcomes were assessed by an echo core laboratory and clinical outcomes adjudicated by a clinical events committee. The mean duration of follow-up was 5.3 ± 2.2 years. Results: At 5 years, adjusted safety endpoints were not statistically different between groups; no structural valve deterioration (SVD) event occurred in either group. After adjustment, the Pure AR + MAVD group had a greater change in body surface area–corrected left ventricular (LV) mass reduction (P = .03) compared to the Pure AS patients. Those patients with a baseline LV ejection fraction (LVEF) >55% continued to demonstrate preserved contractility compared to patients with an LVEF ≤55% at baseline (P

Objective: Iron supplementation may reduce postoperative anemia, blood transfusions, and infections in patients undergoing surgery. We sought to assess efficacy and safety of prophylactic intravenous iron supplementation in patients without anemia undergoing cardiac surgery. Methods: In this investigator-initiated industry-sponsored single-center randomized double-blind parallel group trial, we enrolled patients undergoing coronary bypass, aortic or mitral valve or ascending aortic surgery who fulfilled prespecified iron blood test safety criteria. Patients were randomized to receive either a single intravenous 1000 mg dose of ferric carboxymaltose (FCM) or placebo (saline only). Independent unblinded study nurse administered the infusion with masked lines and cannula 2 to 21 days before surgery. Primary efficacy end point was a composite of in-hospital blood transfusions >2 U and nosocomial infection. The trial was registered in Eudract (2017-004901-41). Results: Altogether 171 patients were screened and 78 randomly assigned to FCM (n = 39) or placebo (n = 39). Trial was prematurely discontinued for futility with regard to reaching the primary end point by the recommendation of the independent data monitoring committee. The primary end point occurred in 3 (7.7%) versus 3 (7.7%) (P = 1.00) of patients assigned to FCM and placebo, respectively, with no difference in blood transfusions >2 U. Fewer hospital readmissions by 3 months follow-up (1 [2.6%] vs 8 [20.5%]; P = .028) were noted in FCM group in a post hoc analysis. Ferritin levels were higher in the FCM group at 3 months indicating more preserved iron stores. Conclusions: Prophylactic treatment with FCM was safe but did not reduce the need for blood transfusions or postoperative infections at index hospitalization in patients without anemia undergoing cardiac surgery.

Abstract Aims Combined coronary artery bypass grafting (CABG) and aortic valve replacement (AVR), and female sex are associated with increased perioperative mortality in clinical risk scores. This study investigated male–female differences in short‐term outcome stratified by age groups. Methods and results All patients undergoing AVR and CABG between January 2001 and June 2021 at our institution were included. 1963 patients were grouped by decades into: 59 years and younger (n = 127), 60–69 (n = 471), 70–79 (n = 1070), and 80 years and older (n = 295). The primary end points of this study were 30 and 180 days mortality. Secondary end points were influence of preoperative risk factors and impact of sex on survival and postoperative major adverse events. Female patients showed higher 30 and 180 days mortality after combined CABG and AVR surgery (8.3% vs. 4.2%, P

Abstract Background Patients with a bicuspid aortic valve carry an increased risk for developing an ascending aortic aneurysm due to intrinsic aortic wall alterations. A lower threshold for aortic surgery may therefore be considered in these patients, especially in those who require aortic valve surgery. This study aimed to compare the outcomes of an isolated aortic valve replacement with that of an aortic root replacement in bicuspid aortic valve patients with an indication for aortic valve surgery. Methods Patients were included in retrospect from a tertiary academic hospital. Included patients received an elective aortic valve (AVR) or a composite valve-graft conduit (both mechanical and biological) between 2006 and 2021 without any concomitant procedure. Mortality data were retrieved from a national database and comparisons, including survival analyses, were performed between both groups. Results A total of 132 isolated AVR and 149 aortic root replacements were included. Patients who received an isolated AVR were significantly older than the aortic root replacement group (62.9 vs. 57.7 year respectively, p

Abstract Background Aortic valve infective endocarditis (IE) is associated with significant morbidity and mortality. We aimed to describe the clinical profile, risk factors and predictors of short- and long-term mortality in patients with aortic valve IE treated with aortic valve replacement (AVR) compared with a control group undergoing AVR for non-infectious valvular heart disease. Methods Between January 2008 and December 2013, a total of 170 cases with IE treated with AVR (exposed cohort) and 677 randomly selected non-infectious AVR-treated patients with degenerative aortic valve disease (controls) were recruited from three tertiary hospitals with cardiothoracic facilities across Scandinavia. Crude and adjusted hazard ratios (HR) were estimated using Cox regression models. Results The mean age of the IE cohort was 58.5 ± 15.1 years (80.0% men). During a mean follow-up of 7.8 years (IQR 5.1-10.8 years), 373 (44.0%) deaths occurred: 81 (47.6%) in the IE group and 292 (43.1%) among controls. Independent risk factors associated with IE were male gender, previous heart surgery, underweight, positive hepatitis C serology, renal failure, previous wound infection and dental treatment (all p

Abstract Aortic valve replacement (AVR) leads to reverse cardiac remodeling in patients with aortic stenosis (AS). The aim of this secondary pooled analysis was to assess the degree and determinants of changes in myocardial perfusion post AVR, and its link with exercise capacity, in patients with severe AS. A total of 68 patients underwent same-day echocardiography and cardiac magnetic resonance imaging with adenosine stress pre and 6–12 months post-AVR. Of these, 50 had matched perfusion data available (age 67 ± 8 years, 86% male, aortic valve peak velocity 4.38 ± 0.63 m/s, aortic valve area index 0.45 ± 0.13cm2/m2). A subgroup of 34 patients underwent a symptom-limited cardiopulmonary exercise test (CPET) to assess maximal exercise capacity (peak VO2). Baseline and post-AVR parameters were compared and linear regression was used to determine associations between baseline variables and change in myocardial perfusion and exercise capacity. Following AVR, stress myocardial blood flow (MBF) increased from 1.56 ± 0.52 mL/min/g to 1.80 ± 0.62 mL/min/g (p

Resumen: Introducción y objetivo: Determinar diferencias clínicas y quirúrgicas entre pacientes con válvula aórtica tricúspide (VAT) y válvulas aórticas bicúspides (VAB). Métodos: Se revisaron retrospectivamente 429 pacientes adultos que se sometieron a cirugía valvular aórtica ± cirugía de aorta ascendente ± revascularización miocárdica desde septiembre de 2019 hasta septiembre de 2023. Resultados: De los 429 pacientes revisados, 298 (69,5%) tenían VAT y 131(30,5%) presentaban VAB. Los pacientes con VAB eran significativamente más jóvenes que los pacientes con VAT (edad media 55,3 ± 10,6 años frente a 67,6 ± 9,2 años, p

Patient-prosthesis mismatch (PPM) is the situation in which the area of an artificial valve is smaller than that of a healthy native valve it replaces. By this definition, all artificial valves demonstrate PPM, but large observational studies and several meta-analyses suggest that it is present in 30-50% of patients after surgical aortic valve replacement (SAVR). PPM has an impact on outcomes only when the indexed aortic valve area (AVAi) is ≤0.85cm2/m2 (moderate PPM) or 0.65cm2/m2 (severe PPM), particularly in patients with reduced LVEF. In transcatheter aortic valve replacement, the prevalence of PPM may be as low as 0.1%, and its impact on hard outcomes is not clear. We present a review of the relevant literature together with a framework for the differential diagnosis of increased pressure gradient and reduced area in prosthetic aortic valves and different strategies to reduce the risk of PPM with SAVR.

Background: The management of mitral regurgitation during aortic valve replacement remains a complex question. Secondary mitral regurgitation often improves post-aortic valve replacement without mitral valve surgery, but residual mitral regurgitation can significantly affect long-term outcomes. This study investigates the natural history of mitral regurgitation following isolated aortic valve replacement and identifies prognostic factors for persistent mitral regurgitation. Methods: A retrospective study was conducted on 108 patients who underwent isolated aortic valve replacement. Patients were categorized based on mitral regurgitation improvement. Additionally, patients were divided into patient-prosthesis mismatch and non-patient-prosthesis mismatch groups based on the aortic prosthesis. Preoperative and postoperative echocardiographic data were analyzed. Results: In total, 63% of patients showed mitral regurgitation improvement. The improved functional MR group showed significant reductions in peak and mean transvalvular pressure gradients. In contrast, the patient-prosthesis mismatch group had persistent mitral regurgitation improvement in 59.2% of patients. The non-patient-prosthesis mismatch group exhibited significant structural improvements and a reduction in mitral regurgitation severity in 68.6% of patients. Conclusions: The study shows that aortic valve replacement could significantly improve MR when patient-prosthesis mismatch is avoided. This approach maximizes hemodynamic outcomes, mitigates the risk of residual or worsening mitral regurgitation, and potentially reduces the need for additional mitral valve interventions. [ABSTRACT FROM AUTHOR]

AbstractBackgroundMaterial and methodsResultsConclusionsFull sternotomy is the standard approach for combined surgery. Evidence of the minimally invasive approach’s advantages for aortic and mitral valve surgery has been reported. Our aim was to report our experience with minithoracotomy for elective patients presenting with aortic valve stenosis associated with right coronary artery disease.Between January 2016 and August 2021, 17 patients underwent concomitant aortic valve replacement and right coronary artery bypass grafting by right anterior thoracotomy.The mean age was 73.3 years and the mean EuroSCORE 2 was 2.07 ± 1.24. Mean cardiopulmonary bypass and aortic cross-clamp times were 148 ± 29 min and 111 ± 20 min. Thirteen patients (76.0%) had femoral cannulation. Nine saphenous veins (53%), seven right internal thoracic arteries (41%), and one radial artery (6%) were used as a graft. Twelve patients benefited from ultrasonic flow measurements to control the graft. The mean flow rate was 47 ± 39 ml/min, and the mean pulsatility index was 2.4 ± 1.2. The mean postoperative transvalvular gradient was 10.9 ± 4 mmHg. Two patients presented with Grade 1 aortic insufficiency (12%). There was no 30-day mortality.Combined aortic valve replacement and right coronary artery bypass grafting through right anterior thoracotomy is reliable and reproducible in selected patients. [ABSTRACT FROM AUTHOR]

Aortic stenosis (AS) affects about 12% of people aged ≥75 years. Accumulating evidence on the prognostic importance of cardiac damage in patients with asymptomatic and less than severe AS supports the proposition of advancing aortic valve replacement (AVR) to earlier disease stages. Potential benefits of earlier treatment, including prevention of cardiac damage progression and reduced cardiovascular hospitalizations, need to be balanced against the earlier procedural risk and subsequent lifetime management after AVR. Two small, randomized trials indicate that early surgical AVR may improve survival in patients with asymptomatic severe AS, and observational data suggest that AVR may reduce mortality even in patients with moderate AS. A clear understanding of the pathophysiology of cardiac damage secondary to AS is needed to develop strategies to select patients for earlier AVR. Noninvasive imaging can detect early cardiac damage, and indices such as fibrosis, global longitudinal strain, and myocardial work index have potential use to guide stratification of patients for earlier AVR. Ongoing randomized trials are investigating the safety and efficacy of AVR for patients with asymptomatic severe AS and those with moderate AS who have symptoms/evidence of cardiac damage. Pathophysiological considerations and accumulating evidence from clinical studies that support earlier timing of AVR for AS will need to be corroborated by the results of these trials. This review aims to evaluate the evidence for earlier AVR, discuss strategies to guide stratification of patients who may benefit from this approach, highlight the relevant ongoing randomized trials, and consider the consequences of earlier intervention. [Display omitted] [Display omitted] • Secondary cardiac damage impacts adversely on the prognosis of patients with AS and starts before the onset of symptoms or impaired LV ejection fraction. • Pathophysiological considerations and accumulating clinical evidence support earlier timing of AVR for patients with asymptomatic severe AS and those with upstream cardiac damage secondary to AS. This concept needs to be corroborated by ongoing trials. • Further research is needed to refine criteria for the selection of the most appropriate patients for earlier AVR. [ABSTRACT FROM AUTHOR]

The development of aortic insufficiency (AI) during HeartMate 3 durable left ventricular assist device (dLVAD) support can lead to ineffective pump output and recurrent heart failure symptoms. Progression of AI often comingles with the occurrence of other hemodynamic-related events encountered during LVAD support, including right heart failure, arrhythmias, and cardiorenal syndrome. While data on AI burdens and clinical impact are still insufficient in patients on HeartMate 3 support, moderate or worse AI occurs in approximately 8% of patients by 1 year and studies suggest AI continues to progress over time and is associated with increased frequency of right heart failure. The first line intervention for AI management is prevention, undertaking surgical intervention on the insufficient valve at the time of dLVAD implant and avoiding excessive device flows and hypertension during long-term support. Device speed augmentation may then be undertaken to try and overcome the insufficient lesion, but the progression of AI should be anticipated over the long term. Surgical or transcatheter aortic valve interventions may be considered in dLVAD patients with significant persistent AI despite medical management, but neither intervention is without risk. It is imperative that future studies of dLVAD support capture AI in clinical end-points using uniform assessment and grading of AI severity by individuals trained in AI assessment during dLVAD support. [Display omitted] [ABSTRACT FROM AUTHOR]

Background/Objectives: Minimally invasive cardiac surgery is often avoided in patients with obesity due to exposure and surgical access concerns. Nonetheless, these patients have elevated periprocedural risks. Minimally invasive transaxillary aortic valve surgery offers a sternum-sparing "nearly no visible scar" alternative to the traditional full sternotomy. This study evaluated the clinical outcomes of patients with obesity compared to a propensity score-matched full sternotomy cohort. Methods: This retrospective cohort study included 1086 patients with obesity (body mass index [BMI] of >30 kg/m2) undergoing isolated aortic valve replacement from 2014 to 2023. Two hundred consecutive patients who received transaxillary minimally invasive cardiac lateral surgery (MICLAT-S) served as a treatment group, while a control group was generated via 1:1 propensity score matching from 886 patients who underwent full sternotomy. The final sample comprised 400 patients in both groups. Outcomes included major adverse cardio-cerebral events, mortality, and postoperative complications. Results: After matching, the clinical baselines were comparable. The mean BMI was 34.4 ± 4.0 kg/m2 (median: 33.9, range: 31.0–64.0). Despite the significantly longer skin-to-skin time (135.0 ± 37.7 vs. 119.0 ± 33.8 min; p ≤ 0.001), cardiopulmonary bypass time (69.1 ± 19.1 vs. 56.1 ± 21.4 min; p ≤ 0.001), and aortic cross-clamp time (44.0 ± 13.4 vs. 41.9 ± 13.3 min; p = 0.044), the MICLAT-S group showed a shorter hospital stay (9.71 ± 6.19 vs. 12.4 ± 7.13 days; p ≤ 0.001), lower transfusion requirements (0.54 ± 1.67 vs. 5.17 ± 9.38 units; p ≤ 0.001), reduced postoperative wound healing issues (5.0% vs. 12.0%; p = 0.012), and a lower 30-day mortality rate (1.5% vs. 6.0%; p = 0.031). Conclusions: MICLAT-S is safe and effective. Compared to traditional sternotomy in patients with obesity, MICLAT-S improves survival, reduces postoperative morbidity, and shortens hospital stays. [ABSTRACT FROM AUTHOR]

Objectives: The American College of Cardiology (ACC) guidelines recommend the same imaging frequency for all bioprosthetic valves, but some have demonstrated poor durability. We aimed to assess mortality differences between small (19–21 mm) and large (23–29 mm) in Mitroflow and Carpentier‐Edwards Perimount aortic valves. Methods: A retrospective observational study was conducted by all patients undergoing isolated surgical aortic valve replacement with Mitroflow or Perimount in Western Denmark between 1999 and 2014 and followed until January 2024. The primary endpoint was all‐cause mortality. Secondary endpoints were cardiovascular mortality and sudden cardiac death. A propensity score‐matched analysis was performed. Results: A total of 1150 patients were analyzed, with 496 (43%) receiving Mitroflow valves and 654 (57%) receiving Perimount valves. In the Mitroflow group, 108 (22%) had a valve size of 19–21 mm, and 388 (78%) in the size range of 23–29 mm. In the Perimount group, the distribution was 99 (15%) and 555 (85%), respectively. The compromised survival of Mitroflow valves was attributed to the valve type, regardless of the valve sizes. Larger Mitroflow valves exhibited the same compromised late mortality as smaller valves, 66.7% vs 61.5%, respectively (p = 0.95). The same pattern of mortality was observed in the matched population, with Perimount demonstrating significant lower risk of mortality. Conclusion: Mitroflow valves were associated with a poorer prognosis compared to Perimount valves. Additionally, larger Mitroflow valves were not associated with an improved prognosis compared to smaller valve sizes. EuroSCORE2 had a significant impact on patient survival. [ABSTRACT FROM AUTHOR]

There is a scarcity of data on the prevalence of abnormal findings on preprocedural computed tomography (CT) before aortic valve replacement (AVR) in patients with aortic stenosis (AS). Among consecutive 593 patients with severe AS who were planned to undergo AVR, we evaluated the prevalence of clinically significant incidental noncardiac findings on preprocedural CT. Clinically significant incidental noncardiac findings were defined as newly detected abnormalities that required therapy, consultation for expert, further investigation, or clinical follow-up. The mean age was 82.0 years and 39.5 % of the patients were men. Of those, 78.4 % of the patients were treated with transcatheter aortic valve implantation (TAVI) and 21.6 % of the patients were treated with surgical AVR (SAVR). There were 271 clinically significant incidental noncardiac findings in 227 patients (38.3 %) including 2.5 % of malignancy. The prevalence of clinically significant incidental noncardiac findings were higher in the TAVI group than in the SAVR group (40.2 % versus 31.3 %). The prevalence of clinically significant incidental noncardiac findings were lower in patients under 60 years of age (10.0 %) than in patients over 60 years of age (60–69 years: 40.0 %, 70–79 years: 34.3 %, 80–89 years: 39.7 %, and ≥90 years: 42.1 %). Clinically significant incidental noncardiac findings were newly identified on preprocedural CT in approximately 40 % of patients with severe AS undergoing AVR including 2.5 % of malignancy. [Display omitted] • Noncardiac findings on preprocedural computed tomography in severe aortic stenosis before aortic valve replacement were evaluated. • Clinically significant noncardiac findings were newly identified in 38.3 % of patients. • Malignancy was newly identified in 2.5 % of patients. [ABSTRACT FROM AUTHOR]

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The present article presents a case report and literature review concerning the Streptococcus equi subspecies zooepidemicus (SEZ), a rare zoonotic pathogen in humans. The case involves a 62-year-old man with no prior heart disease, presenting with endocarditis, pneumonia, and meningitis following close contact with a horse. The patient underwent urgent aortic valve replacement due to severe valvular damage caused by the infection. Blood and cerebrospinal fluid cultures confirmed the presence of SEZ, and the patient was treated with a combination of antibiotics, followed by a successful step-down to oral therapy using linezolid. A review of 25 additional Streptococcus equi endocarditis cases highlights the rarity of the condition, its association with animal contact, and its tendency to cause multi-site infections, such as pneumonia and meningitis. Early diagnosis, appropriate antibiotic therapy, and, in severe cases, surgical intervention are critical for a favorable outcome. This report emphasizes the importance of recognizing zoonotic infections in at-risk populations and the potential need for public health surveillance in these scenarios. [ABSTRACT FROM AUTHOR]

Objective: There is little evidence regarding the most beneficial choice between a mechanical and a bioprosthetic valve in the aortic position in dialysis patients. This meta-analysis compares the survival and freedom from reintervention rates between mechanical and bioprosthetic valves in patients on dialysis undergoing aortic valve replacement surgery. Methods: Two databases were searched, and the systematic review was performed in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. We conducted one-stage and two-stage meta-analysis with Kaplan–Meier-derived individual patient data and meta-analysis with random-effects model. Results: Eight studies were included, providing data about 1215 dialysis patients receiving mechanical valves and 1851 patients receiving bioprosthetic valves. During a mean follow-up of 43.1 months, overall survival rates were significantly improved in the mechanical valve group in comparison to the bioprosthetic one (hazard ratio [HR]: 0.76, 95% confidence interval [CI]: 0.69–0.84, p < 0.001). This was confirmed by the two-stage meta-analysis (HR: 0.72, 95% CI: 0.62–0.83, p = 0.00, I 2 = 17.79%). Regarding freedom from reintervention, no arm offered a statistically significant advantage, according to the two-stage generated analysis (HR: 1.025, 95% CI: 0.65–1.61, p = 0.914). Similarly, there was no evident superiority of a valve type for perioperative outcomes. Conclusions: Mechanical valves are likely to be associated with a better survival outcome compared to bioprosthetic valves for patients on dialysis undergoing aortic valve replacement. However, freedom from reoperation rates and perioperative outcomes were comparable between the two valve types, with no arm exhibiting a statistically significant advantage. [ABSTRACT FROM AUTHOR]

Background: Aortic root rupture is a rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). Herein, we report a case of aortic root rupture during TAVI that was successfully managed with partial aortic root repair and aortic valve replacement. Case presentation: An 83-year-old woman with severe bicuspid aortic stenosis underwent transfemoral TAVI using a 26 mm SAPIEN 3 Ultra RESILIA valve. Soon after valve implantation, transesophageal echocardiography detected pericardial effusion, which was accompanied by immediate hemodynamic instability. Subxiphoid pericardial drainage was performed, and extracorporeal membrane oxygenation was promptly initiated. Owing to the eruptive hemorrhage, we converted to open-heart surgery. Direct visualization enabled the detection of the aortic root rupture and the performance of partial aortic root repair using bovine pericardium and aortic valve replacement using a 19 mm INSPIRIS RESILIA valve. The patient was transferred to a different hospital 60 days after surgery without complications and is currently doing well as an outpatient. Conclusions: In the present case, prompt treatment decisions and smooth cooperation among the institutional heart team led to the successful repair of aortic root rupture during TAVI and good clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: The treatment of patients with severe aortic stenosis (SAS) who concomitantly present with abdominal aortic aneurysm (AAA) is not defined. Aortic valve replacement surgery, performed alone, increases the risk of AAA rupture. Transcatheter aortic valve replacement (TAVR) and endovascular abdominal aortic aneurysm repair (EVAR) in the same intervention, especially in high-risk patients, is a safe alternative. Purpose: We report a case of simultaneous endovascular treatment of SAS and AAA and a mini literature review of nineteen cases with similar characteristics. Research design: Case report and literature review. Data Collection: An electronic search of PubMed and Scopus was performed from inception to December 2023. Results: Nineteen case reports of simultaneous transcatheter aortic valve repair and endovascular aneurysm repair for SAS and symptomatic AAA were identified published in the literature. Conclusions: We regard the simultaneous endovascular approach to both pathologies as a promising treatment alternative for selected patients with severe aortic stenosis and abdominal aortic aneurysm. We highlight the need to conduct randomized clinical trials in this patient population. [ABSTRACT FROM AUTHOR]

Implantation of bioprosthetic valves is more common as the population ages and there is a shift towards implanting bioprosthetic aortic valves in an increasingly younger surgical population. Bioprosthetic heart valve insertion, however, carries the long-term risk of valve failure through structural valve degeneration. Re-operative surgical aortic valve replacement has historically been the only definitive management option for patients with prosthetic valve dysfunction, however, data on the short- and long-term outcomes following re-operative surgery in Australia and New Zealand is limited. Data on all patients who underwent redo aortic valve surgery, over a 20-year period (up to 2021) was obtained from the Australian and New Zealand Society of Cardiothoracic Surgery Registry. A total of 1,199 patients (770 males; 64.2% and 429 females; 35.8%) were included in the overall analysis. The 30-day mortality was 6.4% with operative urgency status the most important risk factor for peri-operative mortality. The long-term survival rate of 1,145 patients was 90.5% (95% confidence interval [CI] 88.8%–92.3%), 77% (95% CI 73.9%–80.2%) and 57.2% (95% CI 55.2%–62.8%) at 1-, 5- and 10-years post-procedure, respectively, with a median survival of 12.7 years. Pre-existing chronic kidney disease was strongly associated with poorer long-term survival. For patients under 70 years of age the 1-, 5- and 10-year survival rates were 92.9% (95% CI 90.9%–95.1%), 83.6% (95% CI 80.1%–87.3%) and 73.1% (95% CI 67.4%–79.3%), respectively. The results from this registry study indicate that in Australia and New Zealand, a repeat surgical aortic valve replacement can result in a relatively low mortality rate, serving as a reference point for medical procedures in these regions. [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve implantation (TAVI) has emerged as a potential alternative for aortic valve surgery to treat aortic valve stenosis. There is limited evidence on the comparative outcomes of TAVI access approaches, specifically the percutaneous (PC) vs surgical cutdown (SC) approach. This study aimed to assess the short-term outcomes in patients undergoing PC vs SC access for transfemoral transcatheter aortic valve replacement. PubMed, SCOPUS, and EMBASE were searched to identify relevant studies. The primary outcomes were short-term all-cause mortality, bleeding, vascular complications, and length of in-hospital stay for patients who underwent transfemoral TAVI. Both matched and unmatched observational studies were included and subgroup analyses were performed. This systematic review and meta-analysis was performed in line with the PRISMA guidelines. Fifteen observational studies involving 7,545 patients (3,033 underwent the PC approach and 2,466 underwent the SC approach) were included. There were no clinically significant between-group differences in short-term mortality, bleeding, length of in-hospital stay, or major vascular complications. However, minor vascular complications were significantly higher in patients who underwent PC-TAVI (p=0.007). In the matched subgroup, all outcomes were comparable between both groups, with the largest difference being observed in minor vascular complications more frequently occurring in the PC group (p=0.08). The evidence shows that outcomes were comparable between the two methods of access, rendering both the PC and SC approaches equally effective for transfemoral TAVI. However, it is worth noting that minor vascular complications were more pronounced in the PC group. [ABSTRACT FROM AUTHOR]

OBJECTIVES Previous reports suggest that betablockers appear non-beneficial after surgical aortic valve replacement (SAVR). This study aims to clarify the associations between betablockers and long-term outcome after SAVR. METHODS All patients with isolated SAVR due to aortic stenosis in Sweden between 2006 and 2020, alive at 6 months after surgery, were included. Patients were identified in the SWEDEHEART registry, and records were merged with data from 3 other mandatory national registries. Association between dispensed betablockers and major adverse cardiovascular events (MACE) (all-cause mortality, myocardial infarction and stroke) was analyzed using Cox proportional hazards models, with time-updated data on medication and adjusted for age, sex and comorbidities at baseline. RESULTS In total, 11 849 patients were included [median follow-up 5.4 years (range 0–13.5)]. Betablockers were prescribed to 79.7% of patients at baseline, decreasing to 62.2% after 5 years. Continuing treatment was associated with higher risk of MACE [adjusted hazard ratio 1.14 (95% confidence interval, CI 1.05–1.23)]. The association was consistent over subgroups based on age, sex and comorbidities except atrial fibrillation [hazard ratio (HR) 1.05 (95% CI 0.93–1.19)]. A sensitivity analysis including time-updated data on comorbidites attenuated the difference between the groups [HR 1.04 (95% CI 0.95–1.14, P  = 0.33)]. CONCLUSIONS Treatment with betablockers did not appear to be associated with inferior long-term outcome after SAVR, when adjusting for new concomitant diseases. Thus, it is likely that it is the underlying cardiac diseases that are associated with MACE rather than betablocker treatment. [ABSTRACT FROM AUTHOR]

OBJECTIVES To compare isolated primary bioprosthetic surgical aortic valve replacement (SAVR) with isolated redo surgical aortic valve replacement (rSAVR) due to structural valve deterioration (SVD). METHODS Clinical data of consecutive patients who underwent primary isolated SAVR and isolated rSAVR due to SVD between 1 January 2011 and 31 December 2022, at Leipzig Heart Center were retrospectively compared with regard to the primary outcome of all-cause mortality or stroke during hospitalization. Secondary outcomes of interest included myocardial infarction, re-exploration for bleeding, and permanent pacemaker implantation. RESULTS A total of 2620 patients, 39.5% females, with a median EuroSCORE II of 1.7 [interquartile range (IQR) 1.1–2.7] were identified, of which rSAVR was performed in 174 patients (6.6%). Patients undergoing primary SAVR were older (69 vs 67 years of age, P  = 0.001) and were less likely to have a history of prior stroke (0.9% vs 4.0%, P  = 0.003). Although both all-cause death and death or stroke occurred less often following primary SAVR (0.5% vs 5.8%, and 2.2% vs 6.9%, respectively; P  < 0.001), prior surgery was not associated with adverse clinical outcome in multivariable analysis. In a matched comparison of 322 patients, rates of death or stroke did not differ between groups (4.8% for both rSAVR and SAVR, P  = 1.0). CONCLUSIONS Although redo surgery for SVD is associated with increased rates of early mortality and stroke by univariate analysis, much of this increased risk can be accounted for by comorbidities. Patients undergoing rSAVR on an elective basis can expect an outcome similar to that of primary SAVR. [ABSTRACT FROM AUTHOR]

Evaluation of noninvasive left ventricular (LV) myocardial work (MW) enables insights into cardiac contractility and efficacy beyond conventional echocardiography. However, there is limited intraoperative data on patients undergoing surgical aortic valve replacement (AVR). The aim of this study was to describe the feasibility and the intraoperative course of this technique of ventricular function assessment in these patients and compare it to conventional two (2D)- and three-dimensional (3D) echocardiographic measurements and strain analysis. Prospective observational study. Single university hospital. Twenty-five patients scheduled for isolated AVR with preoperative preserved left and right ventricular function, sinus rhythm, without significant other heart valve disease or pulmonary hypertension, and an uneventful intraoperative course. Transesophageal echocardiography was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Evaluation was performed in stable hemodynamics, in sinus rhythm or atrial pacing and vasopressor support with norepinephrine ≤ 0.1 µg/kg/min. EchoPAC v206 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2D and 3D LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global work index (GWI), LV global constructive work (GCW), LV global wasted work (GWW), and LV global work efficiency (GWE). Estimation of myocardial work was feasible in all patients. Although there was no significant difference in the values of 2D and 3D EF, GWI and GCW decreased significantly after AVR (T1 v T2, 1,647 ± 380 mmHg% v 1,021 ± 233 mmHg%, p < 0.001; T1 v T2, 2,095 ± 433 mmHg% v 1,402 ± 242 mmHg%, p < 0.001, respectively), while GWW remained unchanged (T1 v T2, 296 mmHg% [IQR 178-452) v 309 mmHg% [IQR 255-438), p = 0.97). This resulted in a decreased GWE directly after bypass (T1 v T2, 84% ± 6% v 78% ± 5%, p < 0.001), but GWE already improved at the end of surgery (T2 v T3, 78% ± 5% v 81% ± 5%, p = 0.003). There was no significant change in the values of GWI, GCW, or 2D and 3D LVEF before and after sternal closure (T2 v T3). LV MW analysis showed a reduction of LV workload after bypass in our group of patients, which was not detected by conventional echocardiographic measures. This evolving technique provides deeper insights into cardiac energetics and efficiency in the perioperative course of aortic valve replacement surgery. [ABSTRACT FROM AUTHOR]

Aims: Combined coronary artery bypass grafting (CABG) and aortic valve replacement (AVR), and female sex are associated with increased perioperative mortality in clinical risk scores. This study investigated male–female differences in short‐term outcome stratified by age groups. Methods and results: All patients undergoing AVR and CABG between January 2001 and June 2021 at our institution were included. 1963 patients were grouped by decades into: 59 years and younger (n = 127), 60–69 (n = 471), 70–79 (n = 1070), and 80 years and older (n = 295). The primary end points of this study were 30 and 180 days mortality. Secondary end points were influence of preoperative risk factors and impact of sex on survival and postoperative major adverse events. Female patients showed higher 30 and 180 days mortality after combined CABG and AVR surgery (8.3% vs. 4.2%, P < 0.01; 15.8% vs. 9.4%, P < 0.01). Stratified by age groups, 30 and 180 days mortality remained significantly higher in septuagenarians (9.6% vs. 2.5%, P < 0.01; 16.3% vs. 7.7%, P < 0.01). Females were significantly older, had better preserved left ventricular function, and higher incidence of diabetes mellitus compared with male patients in this subgroup (P < 0.01; P = 0.01; P < 0.01). Additionally, females received significantly less internal mammary artery (IMA) conduits (P < 0.01). Female sex (OR: 3.33, 95% CI: [1.76–6.31]; 1.93, [1.22–3.06]), higher age (1.28, [1.13–1.45]; 1.16, [1.06–1.26]), diabetes mellitus (1.93, [1.03–3.60]; 1.70, [1.08–2.67]) and LVEF <30% (3.26, [1.48–7.17]; 2.23, [1.24–4.02]) were correlated with 30 and 180 days mortality, respectively. Upon multivariable testing, sex (1.77, [1.21–2.58]) and LVEF <30% (3.71, [2.39–5.76]) remained independent predictors for major adverse postoperative events. Infrequent use of IMA grafts was associated with increased 30 and 180 days mortality as well as adverse events (0.47, [0.25–0.87]; 0.46, [0.29–0.72]; 0.61, [0.42–0.88]). Conclusions: Sex disparities in baseline characteristics may delay operative intervention in female patients. The inherent risk profiles might be responsible for outcome differences in septuagenarians. [ABSTRACT FROM AUTHOR]

Background: Patients with a bicuspid aortic valve carry an increased risk for developing an ascending aortic aneurysm due to intrinsic aortic wall alterations. A lower threshold for aortic surgery may therefore be considered in these patients, especially in those who require aortic valve surgery. This study aimed to compare the outcomes of an isolated aortic valve replacement with that of an aortic root replacement in bicuspid aortic valve patients with an indication for aortic valve surgery. Methods: Patients were included in retrospect from a tertiary academic hospital. Included patients received an elective aortic valve (AVR) or a composite valve-graft conduit (both mechanical and biological) between 2006 and 2021 without any concomitant procedure. Mortality data were retrieved from a national database and comparisons, including survival analyses, were performed between both groups. Results: A total of 132 isolated AVR and 149 aortic root replacements were included. Patients who received an isolated AVR were significantly older than the aortic root replacement group (62.9 vs. 57.7 year respectively, p < 0.001). Survival analyses showed a comparable long-term mortality between both groups (8.1% vs. 9.1%, p = 0.321). Conclusion: This study shows that performing an aortic root replacement with a composite valve-graft conduit in bicuspid aortic valve patients does not impair the survival outcomes. In the light of preventing potential future aortic complications within this patient group with a congenitally and structurally weakened aortic wall, a more aggressive approach towards the treatment of BAV aortopathy might be considered. [ABSTRACT FROM AUTHOR]

Background One of the most important and relatively frequent complications of aortic valve replacement is atrioventricular block. It typically occurs by direct injury of the infranodal conduction system due to intra-operative manipulation and persists post-operatively, necessitating permanent pacemaker implantation in many cases. Case summary A 66-year-old man presented to our hospital after experiencing syncope while walking after drinking. He had experienced two episodes of alcohol-induced syncope several years earlier. His electrocardiogram (ECG) and transthoracic echocardiogram revealed complete atrioventricular block and severe aortic stenosis, respectively. He received a temporary pacemaker on the day of admission and underwent surgical aortic valve replacement on hospital Day 9. The native aortic valve was bicuspid. Unexpectedly, the ECG immediately after aortic valve replacement showed complete restoration of atrioventricular conduction during temporary atrial pacing. The atrioventricular block did not recur, and he was discharged to home on post-operative Day 13. Discussion This remarkably rare clinical course, complete restoration from complete and persistent atrioventricular block after surgical aortic valve replacement, can be explained by multifactorial mechanisms: (i) surgical removal of the aortic annulus calcification directly hindering the infranodal conduction system; (ii) relief from the ventricular pressure overload stressing the conduction system within the septum; and (iii) improvement of substantial autonomic dysregulation as manifested by alcohol-sensitive syncope in the present patient, which was a result of unloading of the intraventricular pressure affecting the left ventricular mechanoreceptor. [ABSTRACT FROM AUTHOR]