Search

ObjectivesDifferences in indication and technique make a randomised comparison between valve-sparing root replacement (VSRR) and personalised external aortic root support (PEARS) challenging. We performed a propensity score (PS)-matched comparison of PEARS and VSRR for syndromic root aneurysm.MethodsPatients in the PEARS 200 Database and Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (undergoing VSRR) with connective tissue disease operated electively for root aneurysm ResultsMedian follow-up was 25 and 55 months for 159 PEARS and 142 VSRR patients. Seven (4.4%) patients undergoing PEARS required an intervention for coronary injury or impingement, resulting in one death (0.6%). After VSRR, there were no early deaths, 10 (7%) reinterventions for bleeding and 1 coronary intervention. Survival for matched cohorts at 5 years was similar (PEARS 98% vs VSRR 99%, p=0.99). There was no difference in freedom from valve or ascending aortic/arch reintervention between matched groups. Freedom from AR ≥2/4 at 5 years in the matched cohorts was 97% for PEARS vs 92% for VSRR (p=0.55). There were no type A dissections.ConclusionsVSRR and PEARS offer favourable mid-term survival, freedom from reintervention and preservation of valve function. Both treatments deserve their place in the surgical repertoire, depending on a patient’s disease stage. This study is limited by its retrospective nature and different follow-ups in both cohorts.

Many patients with end-stage heart disease die because of the scarcity of donor hearts. A total artificial heart (TAH), an implantable machine that replaces the heart, has so far been successfully used in over 1,700 patients as a temporary life-saving technology for bridging to heart transplantation. However, after more than six decades of research on TAHs, a TAH that is suitable for destination therapy is not yet available. High complication rates, bulky devices, poor durability, poor biocompatibility and low patient quality of life are some of the major drawbacks of current TAH devices that must be addressed before TAHs can be used as a destination therapy. Quickly emerging innovations in battery technology, wireless energy transmission, biocompatible materials and soft robotics are providing a promising opportunity for TAH development and might help to solve the drawbacks of current TAHs. In this Review, we describe the milestones in the history of TAH research and reflect on lessons learned during TAH development. We summarize the differences in the working mechanisms of these devices, discuss the next generation of TAHs and highlight emerging technologies that will promote TAH development in the coming decade. Finally, we present current challenges and future perspectives for the field.

Objective Quantitative extracellular volume fraction (ECV) mapping with MRI is commonly used to investigate in vivo diffuse myocardial fibrosis. This study aimed to validate ECV measurements against ex vivo histology of myocardial tissue samples from patients with aortic valve stenosis or hypertrophic cardiomyopathy. Materials and methods Sixteen patients underwent MRI examination at 3 T to acquire native T1 maps and post-contrast T1 maps after gadobutrol administration, from which hematocrit-corrected ECV maps were estimated. Intra-operatively obtained myocardial tissue samples from the same patients were stained with picrosirius red for quantitative histology of myocardial interstitial fibrosis. Correlations between in vivo ECV and ex vivo myocardial collagen content were evaluated with regression analyses. Results Septal ECV was 30.3% ± 4.6% and correlated strongly (n = 16, r = 0.70; p = 0.003) with myocardial collagen content. Myocardial native T1 values (1206 ± 36 ms) did not correlate with septal ECV (r = 0.41; p = 0.111) or with myocardial collagen content (r = 0.32; p = 0.227). Discussion We compared myocardial ECV mapping at 3 T against ex vivo histology of myocardial collagen content, adding evidence to the notion that ECV mapping is a surrogate marker for in vivo diffuse myocardial fibrosis.

Heart valve disease is a major cause of mortality and morbidity worldwide with no effective medical therapy and no ideal valve substitute emulating the extremely sophisticated functions of a living heart valve. These functions influence survival and quality of life. This has stimulated extensive attempts at tissue engineering “living” heart valves. These attempts utilised combinations of allogeneic or autologous cells and biological or synthetic scaffolds with practical, regulatory and ethical issues. In situ regeneration depends on scaffolds that attract, house and instruct cells and promote connective tissue formation. However, there is still no agreement about what constitutes the optimal replacement valve. We, here, describe a surgical, tissue-engineered, anatomically precise, off-the-shelf, acellular, synthetic scaffold inducing a unique rapid process of morphogenesis involving relevant cell types, extracellular matrix, regulatory elements including nerves and humoral components. This process relies on specific material characteristics, design and “morphodynamism”.

Introduction: Medical students in the Netherlands have a relatively low exposure to cardiothoracic surgery and cardiology. This results in discrepancies between starting levels of medical residents and expected standards in clinical practice. Another side effect is the international decline in interest in a career in these cardiovascular fields. To compensate for this, extracurricular education programs focused on cardiothoracic surgery and cardiology have been set up. This study aims to evaluate the impact and benefits of an extracurricular education program on students' knowledge of cardiothoracic surgery and cardiology and to explore possible factors involved in (academic) career decision making. Methods: 66 participants were enrolled in the extracurricular education program VECTOR and were included in a cross-sectional cohort study. All participants scored their familiarity with different aspects of cardiothoracic surgery and cardiology prior to and after the course. Data was analyzed using Linear regression and Wilcoxon Signed Rank testing. Results: Participants demonstrated a significant trend towards improved familiarity with cardiothoracic surgery and cardiology after the program (p = p = p = Conclusion: This study highlights the benefit of an extracurricular education program in cardiothoracic surgery and cardiology for undergraduates and could possibly aid students in preparing for clinical practice.

OBJECTIVES Root reimplantation has been the favoured approach for patients with heritable aortic disorder requiring valve-sparring root replacement. In the past few years, root remodelling with annuloplasty has emerged as an alternative to root reimplantation in the general population. The aim of this study was to examine the late outcomes of patients with heritable aortic disorder undergoing valve-sparring root replacement and compare different techniques. METHODS Using the AVIATOR registry (Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry), data were collected from 5 North American and European centres. Patients were divided into 4 groups according to the technique of valve-sparing used (root reimplantation, root remodelling with ring annuloplasty, root remodelling with suture annuloplasty and root remodelling alone). The primary endpoints were freedom from aortic regurgitation (AR) ≥2 and freedom from reintervention on the aortic valve. Secondary endpoints were survival and changes in annular dimensions over time. RESULTS A total of 237 patients were included in the study (reimplantation = 100, remodelling + ring annuloplasty = 76, remodelling + suture annuloplasty = 34, remodelling alone = 27). The majority of patients had Marfan syndrome (83%). Preoperative AR ≥2 was present in 41% of the patients. Operative mortality was 0.4% (n = 1). No differences were found between techniques in terms of postoperative AR ≥2 (P = 0.58), reintervention (P = 0.52) and survival (P = 0.59). Changes in aortic annulus dimension were significantly different at 10 years (P CONCLUSIONS Overall, valve-sparring root replacement is a safe and durable procedure in patients with heritable aortic disorder. Nevertheless, root remodelling alone is associated with late annular dilatation. The addition of an annuloplasty, however, results in similar freedom from AR, reintervention, survival and changes in annulus size compared to reimplantation.

Background Ankylosing spondylitis (AS) is a chronic inflammatory disease of primarily the joints of the spine. In the literature, AS is known to have cardiac manifestations. Most frequently, this is aortic regurgitation. However, in rare cases also mitral valve (MV) disease is observed in AS patients. The extent and mechanism of this involvement are still unclear. We aim to describe a histologically validated case report to add understanding on this topic. Case summary We show the case of a 51-year-old male who suffered since his youth from back pain and uveitis, which was later diagnosed as AS. After a first presentation with combined heart valve disease, the patient recovered on cardiac medical therapy and biologic treatment for AS. Four years later, cardiac complaints worsened mainly due to severe MV stenosis. Surgical treatment was performed with histopathologic analysis of the excised MV validating involvement of AS. Discussion Histopathologic analysis showed chronic fibro inflammatory thickening of the MV leaflets and subvalvular apparatus. These pathological features could fit with the inflammatory nature of AS. Since this is a rare case, the recognition of fibro inflammatory thickening leading to commissural fusion and stenosis may contribute to better understanding of heart valve disease in AS to create a base for better cardiac management in this specific patient group.

OBJECTIVES The European Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery designed a questionnaire to assess the impact of gender bias on a cardiothoracic surgery career. METHODS A 46-item survey investigating gender bias was designed using online survey software from December 2020 to January 2021. All European Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery members and non-members included in the mailing lists were invited to complete an electronic survey. Descriptive statistics and a comparison between gender groups were performed. RESULTS Our overall response rate was 11.5% (1118/9764), of which 36.14% were women and 63.69% were men. Women were more likely to be younger than men (P CONCLUSIONS Women in cardiothoracic surgery reported significantly high rates of experiences with bias that may prevent qualified women from advancing to positions of leadership. Efforts to mitigate bias and support the professional development of women are at the centre of newly formed European committees.

Objectives Aortic valve disease is the most frequent indication for heart valve replacement with the highest prevalence in elderly. Tissue-engineered heart valves (TEHV) are foreseen to have important advantages over currently used bioprosthetic heart valve substitutes, most importantly reducing valve degeneration with subsequent reduction of re-intervention. We performed early Health Technology Assessment of hypothetical TEHV in elderly patients (≥ 70 years) requiring surgical (SAVR) or transcatheter aortic valve implantation (TAVI) to assess the potential of TEHV and to inform future development decisions. Methods Using a patient-level simulation model, the potential cost-effectiveness of TEHV compared with bioprostheses was predicted from a societal perspective. Anticipated, but currently hypothetical improvements in performance of TEHV, divided in durability, thrombogenicity, and infection resistance, were explored in scenario analyses to estimate quality-adjusted life-year (QALY) gain, cost reduction, headroom, and budget impact. Results Durability of TEHV had the highest impact on QALY gain and costs, followed by infection resistance. Improved TEHV performance (− 50% prosthetic valve-related events) resulted in lifetime QALY gains of 0.131 and 0.043, lifetime cost reductions of €639 and €368, translating to headrooms of €3255 and €2498 per hypothetical TEHV compared to SAVR and TAVI, respectively. National savings in the first decade after implementation varied between €2.8 and €11.2 million (SAVR) and €3.2–€12.8 million (TAVI) for TEHV substitution rates of 25–100%. Conclusions Despite the relatively short life expectancy of elderly patients undergoing SAVR/TAVI, hypothetical TEHV are predicted to be cost-effective compared to bioprostheses, commercially viable and result in national cost savings when biomedical engineers succeed in realising improved durability and/or infection resistance of TEHV.

Progressive ascending aortic dilatation has been observed after mechanical aortic valve replacement (mAVR), possibly due to altered blood flow and wall shear stress (WSS) patterns induced by their bileaflet design. We examined the effect of mAVR on WSS in the ascending aorta using time-resolved 4D flow MRI. Fifteen patients with mechanical aortic valve prostheses, 10 patients with bicuspid aortic valve disease and 10 healthy individuals underwent thoracic 4D flow MRI. Peak systolic hemodynamic parameters (velocity and WSS) and vessel diameters were assessed in the ascending aorta. In addition, three-dimensional per-voxel analysis was used to compare velocity and WSS between patient groups and healthy controls. Peak aortic diameters were significantly higher in mAVR and BAV patients compared to healthy controls (p = 0.011). Mean aortic diameters were comparable between mAVR and BAV patients. No differences in 4D flow MRI-derived mean blood flow velocity and peak WSS were found between the three groups. Compared to healthy controls, mean WSS was significantly lower in mAVR patients (p = 0.031). Per-voxel analysis revealed no increased WSS in the ascending aortic wall and significantly lower velocity and WSS values in mAVR patients compared to healthy controls. In contrast, regions of significantly increased outer lumen velocities and WSS in BAV patients compared to healthy controls were found. This study shows that there is no increased ascending aortic WSS after mAVR. Our results suggest that, in contrast to BAV patients, there is no indication for intensified follow-up of the ascending aorta after mAVR.

International audience; Surgical aortic valve replacement (SAVR) is highly effective and can be achieved with relatively low risk in patients with severe aortic stenosis. Bioprostheses have been used most frequently during the past 60 years. However, the function of biological valves usually declines after 10-15 years from implant when structural valve degeneration occurs often mandating a reoperation once valve dysfunction becomes haemodynamically significant. Known for many years by surgeons and cardiologists taking care of patients with SAVR, the issue of postimplant structural valve degeneration has been recently highlighted also in patients with transcatheter aortic valve implant (TAVI). There is growing concern that TAVI valves exhibit structural valve degeneration due to inherent challenges of the deployment mode. The impact on postimplant degeneration of TAVI valves compared to SAVR has still to be understood and defined. Based on the ongoing process of expanding TAVI indications, several potential shortcomings and caveats, learned during the last 60 years of SAVR experience, should be taken into consideration to refine this technique.

BackgroundIn response to an increased need for patient information in congenital heart disease, we previously developed an online, evidence-based information portal for patients with congenital aortic and pulmonary valve disease. To assess its effectiveness, a stepped-wedge cluster randomised trial was conducted.MethodsAdult patients and caregivers of paediatric patients with congenital aortic and/or pulmonary valve disease and/or tetralogy of Fallot who visited the outpatient clinic at any of the four participating centres in the Netherlands between 1 March 2016–1 July 2017 were prospectively included. The intervention (information portal) was introduced in the outpatient clinic according to a stepped-wedge randomised design. One month after outpatient clinic visit, each participant completed a questionnaire on disease-specific knowledge, anxiety, depression, mental quality of life, involvement and opinion/attitude concerning patient information and involvement.Results343 participants were included (221 control, 122 intervention). Cardiac diagnosis (p=0.873), educational level (p=0.153) and sex (p=0.603) were comparable between the two groups. All outcomes were comparable between groups in the intention-to-treat analyses. However, only 51.6% of subjects in the intervention group (n=63) reported actually visiting the portal. Among these subjects (as-treated), disease-specific knowledge (p=0.041) and mental health (p=0.039) were significantly better than in control subjects, while other baseline and outcome variables were comparable.ConclusionEven after being invited by their cardiologists, only half of the participants actually visited the information portal. Only in those participants that actually visited the portal, knowledge of disease and mental health were significantly better. This underlines the importance of effective implementation of online evidence-based patient information portals in clinical practice.

This surgical heritage article provides a historical overview of the most important early advances of vascular- and valvular surgery, that lead to the development of currently used vascular- and valvular prostheses and materials. The first writings describing techniques in vascular surgery mainly focussed on hemorrhage control and date from around 1600 B.C. The strategy of vessel ligation was first mentioned in Western literature around 200 B.C. In the 18supth/supcentury, techniques of ligation were expanded towards attempts of vessel restoration. The first artificial vascular prosthesis was made in 1894. From this time on, vascular prostheses were used in animal experiments and around 1900 for the first time in humans. More than 60 years later, in 1952, the first mechanical heart valve prosthesis was implanted. Four years later, the first successful biological heart valve implantation followed. In 2000, a transcatheter heart valve was successfully implanted in a human for the first time. Over time, procedures and techniques became more efficient and effective. This led to new developments, such as the manufacturing of a tissue engineered blood vessel in 1986. Nowadays, dozens of different valve prostheses have been devised, both mechanical and biological. Still, no ideal model of vascular and heart valve prosthesis exists.

For in situ tissue engineering (TE) applications it is important that implant degradation proceeds in concord with neo-tissue formation to avoid graft failure. It will therefore be valuable to have an imaging contrast agent (CA) available that can report on the degrading implant. For this purpose, a biodegradable radiopaque biomaterial is presented, modularly composed of a bisurea chain-extended polycaprolactone (PCL2000-U4U) elastomer and a novel iodinated bisurea-modified CA additive (I-U4U). Supramolecular hydrogen bonding interactions between the components ensure their intimate mixing. Porous implant TE-grafts are prepared by simply electrospinning a solution containing PCL2000-U4U and I-U4U. Rats receive an aortic interposition graft, either composed of only PCL2000-U4U (control) or of PCL2000-U4U and I-U4U (test). The grafts are explanted for analysis at three time points over a 1-month period. Computed tomography imaging of the test group implants prior to explantation shows a decrease in iodide volume and density over time. Explant analysis also indicates scaffold degradation. (Immuno)histochemistry shows comparable cellular contents and a similar neo-tissue formation process for test and control group, demonstrating that the CA does not have apparent adverse effects. A supramolecular approach to create solid radiopaque biomaterials can therefore be used to noninvasively monitor the biodegradation of synthetic implants.

Jolanda Kluin speaks to Julia Titova, Commissioning Editor at Future Cardiology Jolanda Kluin started her medical training at the Erasmus University Rotterdam in 1989 and obtained her medical degree cum laude in 1996. Thereafter, she worked as a PhD student on the project: “ Photodynamic therapy for Barrett’s esophagus with use of 5-aminolevulinic acid”, receiving her PhD degree cum laude in 1999. In 2006 she finished her residency in cardiothoracic surgery. From 2006 to 2014 she worked as a staff cardiothoracic surgeon at the Department of Cardiothoracic Surgery of the University Medical Center Utrecht and since 2015 she works at the Academic Medical Center, Amsterdam as congenital cardiac surgeon. In 2018 she became a professor in translational cardiothoracic surgery at the University of Amsterdam. Her main interests are grown ups with congenital heart disease cardiac surgery, mitral valve surgery, and reconstructive surgery of the aortic valve and the thoracic aorta. Alongside her clinical tasks, she has started a new line of research in translational cardiothoracic surgery, including tissue engineering of heart valves, valve pathophysiology and the development of a hybrid soft robotic total artificial heart. She is the current chair of the EACTS Women in Cardiothoracic Surgery Committee.

One of the biggest controversies in valvular heart diseases is the best treatment strategy in asymptomatic patients with severe, organic mitral valve regurgitation (MR) and preserved left ventricul...

Objectives: Supravalvar aortic stenosis (SVAS) is a rare congenital anomaly. The “single-patch technique,” “‘two sinus augmentation with an inverted Y-patch” (both nonsymmetrical corrections), “three-patch technique,” and the “slide aortoplasty” (both symmetrical corrections) are the techniques implemented by the majority of surgeons for the correction of SVAS. In the few studies that compared these techniques, no technique was shown to be superior over another. The aim of the present study is to review the 52-year experience with the surgical correction of SVAS in two of four congenital cardiothoracic surgical centers in the Netherlands. Methods: We retrospectively reviewed all patient files of those who underwent an operation to correct their SVAS, between 1962 and 2014 in our centers. Patients were divided according to their operating technique. These groups were compared using the end points freedom from reoperation and mortality. Results: A total of 49 patients were included, 23 (46.9%) patients in the nonsymmetrical group and 26 (53.1%) patients in the symmetrical group. Survival after 20 years in the nonsymmetrical group was 80% (standard error [SE]: 0.091) and in the symmetrical group was 85% (SE: 0.085; P = .163). Freedom from reoperation after 20 years in the nonsymmetrical group was 88% (SE: 0.079) and in the symmetrical group was 71% (SE: 0.107; P = 0.313). Conclusion: In this patient group, there is no significant difference in survival and freedom from reoperation between the different surgical techniques for SVAS repair. Compared to the survival in the general population, the survival of SVAS patients is remarkably low. Apparently, SVAS is not a benign disease and probably patients should be followed more closely for the rest of their lives.

BACKGROUND Use of 4-dimensional flow magnetic resonance imaging (4D-flow MRI) derived wall shear stress (WSS) heat maps enables identification of regions in the ascending aorta with increased WSS. These regions are subject to dysregulation of the extracellular matrix and elastic fiber degeneration, which is associated with aortic dilatation and dissection. PURPOSE To evaluate the effect of the presence of aortic valve stenosis and the aortic diameter on the peak WSS and surface area of increased WSS in the ascending aorta. STUDY TYPE Prospective. SUBJECTS In all, 48 bicuspid aortic valve (BAV) patients (38.1 ± 12.4 years) and 25 age- and gender-matched healthy individuals. FIELD STRENGTH/SEQUENCE Time-resolved 3D phase contrast MRI with three-directional velocity encoding at 3.0T. ASSESSMENT Peak systolic velocity, WSS, and aortic diameters were assessed in the ascending aorta and 3D heat maps were used to identify regions with elevated WSS. STATISTICAL TESTS Comparisons between groups were performed by t-tests. Correlations were investigated by univariate and multivariate regression analysis. RESULTS Elevated WSS was present in 15 ± 11% (range; 1-35%) of the surface area of the ascending aorta of BAV patients with aortic valve stenosis (AS) (n = 10) and in 6 ± 8% (range; 0-31%) of the ascending aorta of BAV patients without AS (P = 0.005). The mid-ascending aortic diameter negatively correlated with the peak ascending aortic WSS (R = -0.413, P = 0.004) and the surface area of elevated WSS (R = -0.419, P = 0.003). Multivariate linear regression analysis yielded that the height of peak WSS and the amount of elevated WSS depended individually on the presence of aortic valve stenosis and the diameter of the ascending aorta. DATA CONCLUSION The extent of increased WSS in the ascending aorta of BAV patients depends on the presence of aortic valve stenosis and aortic dilatation and is most pronounced in the presence of AS and a nondilated ascending aorta. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2018;48:522-530.

The most common types of left‐sided valvular heart disease (VHD) in the Western world are aortic valve stenosis, aortic valve regurgitation, and mitral valve regurgitation. Comprehensive clinical evaluation entails both hemodynamic analysis and structural as well as functional characterization of the left ventricle. Cardiac magnetic resonance imaging (MRI) is an established diagnostic modality for assessment of left‐sided VHD and is progressively gaining ground in modern‐day clinical practice. Detailed flow visualization and quantification of flow‐related biomarkers in VHD can be obtained using 4D flow MRI, an imaging technique capable of measuring blood flow in three orthogonal directions over time. In addition, recent MRI sequences enable myocardial tissue characterization and strain analysis. In this review we discuss the emerging potential of state‐of‐the‐art MRI including 4D flow MRI, tissue mapping, and strain quantification for the diagnosis and prognosis of left‐sided VHD. Level of Evidence: 1 Technical Efficacy Stage: 1 J. Magn. Reson. Imaging 2018. J. MAGN. RESON. IMAGING 2018;48:318–329.

OBJECTIVES: Ultra-high-molecular-weight polyethylene (UHMWPE) fibres are flexible, have high tensile strength, and platelet and bacterial adhesion is low. Therefore, UHMWPE may overcome limitations of current mechanical valves and bioprostheses. In this study, the biocompatibility and functionality of prototype handmade stented valves from woven UHMWPE (U-valve) was assessed in a chronic sheep model with acetylsalicylic acid monotherapy. METHODS: Native pulmonary valves of 23 sheep were replaced by U-valves (n = 18) or Perimount bovine bioprostheses (reference group, n = 5). Sheep received 80 mg of acetylsalicylic acid daily. Follow-up was conducted at 1 week (n = 4), 1 month (n = 5), 3 months (n = 5) and 6 months (n = 4) in the U-valve group and at 3 months (n = 2) and 6 months (n = 3) in the reference group. Epicardial echocardiography and histology were used to assess valve function and tissue deposition, respectively. RESULTS: Seventeen U-valve sheep (94%) and 3 reference sheep (60%) survived the perioperative period. One reference valve sheep was sacrificed after 4 months because of congestive heart failure. At explantation, all U-valves were intact without leaflet tearing. Up to 3 months, U-valves were flexible and free of stenosis. Regurgitation was mostly mild though gradually increasing; histology showed minimal connective tissue near the leaflet base and sparse calcification. At 6 months, connective tissue was diffusely observed on the leaflets with retraction and consecutive regurgitation and leaflet thickening. CONCLUSIONS: Valves made from UHMWPE fibres demonstrated early feasibility in the pulmonary valve position with reasonably good haemodynamics and intact valve materials up to 6 months. Gradual leaflet thickening and retraction were observed after 3 months due to connective tissue overgrowth.

Objectives Surgical repair of coarctation of the aorta (CoA) is often possible through left thoracotomy and without the use of cardiopulmonary bypass. Recent studies reporting the outcome after CoA repair through left thoracotomy are limited. Therefore, the aim of this study is to evaluate the results of CoA repair through left thoracotomy in children who were operated on in our centre over the past 21 years. Methods From January 1995 to December 2016, 292 patients younger than 18 years underwent primary CoA repair through left thoracotomy at our 2 institutions. Peri- and postoperative data and follow-up data collected from our hospital and the referring hospitals were retrospectively reviewed. Results Median age at operation was 64 days (range 2 days-17 years). Most patients underwent the resection of the CoA followed by an (extended) end-to-end anastomosis (93%). Six patients died perioperatively and 2 more patients died during the follow-up, of which 7 patients had other major comorbidities. Actuarial survival was 97% at 5 years, 96% at 10 years and 96% at 15 years. Second arch interventions due to recoarctation were performed in 9.9% (n = 29) of patients, consisting of balloon dilatation in all but 2 patients. Recoarctation occurred significantly more often after initial repair in the neonatal period (21%) and could occur as late as 14 years after initial surgery. There were 7 re-recoarctations, and 14% of patients were on hypertensive medication during the follow-up. Conclusions Repair of CoA through left thoracotomy is a safe procedure with low rates of mortality. The long-term follow-up is necessary due to the significant risk of recoarctation requiring reintervention.

With improved outcomes following cardiac surgery, health related quality of life (HRQoL) gains increasing importance for the better judgement of choosing the preferred treatment strategy in the individual patient. The physician perception of patient preferences can differ considerably from actual patient preferences, underlining the importance of gathering evidence of actual patient preferences before and quality of life after cardiac surgery. The objective of the current review is to provide an overview of current insights into the quality of life measurements after aortic valve and thoracic aortic surgery and to provide starting points for the application of HRQoL measurements toward the future. The amount and level of evidence on HRQoL outcomes after aortic valve and thoracic aortic surgery seems to be insufficient. Little has been investigated about the natural course of HRQoL after cardiac surgery, HRQoL outcomes between different surgical strategies, HRQoL outcomes between surgical patients and the general population, the different factors influencing HRQoL after cardiac surgery, and the effect of HRQoL on healthcare costs. More prospective studies should be performed, taking into account the knowledge gaps that need to be filled. Computerized adaptive testing methods through open source programs can be implemented to keep the burden to the patient as low as possible and catalyze the use of these tools. Our cardiovascular surgery community has the responsibility to deliberate how it can proceed to effectively fill in these knowledge gaps, and use this newfound knowledge to improve shared treatment decision making, patient outcomes, and ultimately optimize health care efficiency.

In an in-situ approach towards tissue engineered cardiovascular replacement grafts, cell-free scaffolds are implanted that engage in endogenous tissue formation. Bioactive molecules can be incorporated into such grafts to facilitate cellular recruitment. Stromal cell derived factor 1α (SDF1α) is a powerful chemoattractant of lymphocytes, monocytes and progenitor cells and plays an important role in cellular signaling and tissue repair. Short SDF1α-peptides derived from its receptor-activating domain are capable of activating the SDF1α-specific receptor CXCR4. Here, we show that SDF1α-derived peptides can be chemically modified with a supramolecular four-fold hydrogen bonding ureido-pyrimidinone (UPy) moiety, that allows for the convenient incorporation of the UPy-SDF1α-derived peptides into a UPy-modified polymer scaffold. We hypothesized that a UPy-modified material bioactivated with these UPy-SDF1α-derived peptides can retain and stimulate circulating cells in an anti-inflammatory, pro-tissue formation signaling environment. First, the early recruitment of human peripheral blood mononuclear cells to the scaffolds was analyzed in vitro in a custom-made mesofluidic device applying physiological pulsatile fluid flow. Preferential adhesion of lymphocytes with reduced expression of inflammatory factors TNFα, MCP1 and lymphocyte activation marker CD25 was found in the bioactivated scaffolds, indicating a reduction in inflammatory signaling. As a proof of concept, in-vivo implantation of the bioactivated scaffolds as rat abdominal aorta interposition grafts showed increased cellularity by CD68+ cells after 7 days. These results indicate that a completely synthetic, cell-free biomaterial can attract and stimulate specific leukocyte populations through supramolecular incorporation of short bioactive SDF1α derived peptides.

Background. Cardiac surgery with the use of cardiopulmonary bypass is associated with a systemic inflammatory response. Intraoperative corticosteroids are administered to attenuate this inflammatory response. The recent Dexamethasone for Cardiac Surgery (DECS) trial could not demonstrate a beneficial effect of dexamethasone on major adverse events in cardiac surgical patients. Previous studies suggest that corticosteroids may affect postoperative coagulation and blood loss, and therefore could influence the risk of surgical reinterventions. We investigated the effects of prophylactic intraoperative dexamethasone treatment on the rate of rethoracotomy after cardiac surgery.Methods. We performed a post-hoc additional data collection and analysis in the DECS trial. A total of 4,494 adult patients undergoing cardiac surgery with cardiopulmonary bypass were randomly assigned to intravenous dexamethasone (1.0 mg/kg) or placebo. The primary endpoint for the present study was the incidence of any rethoracotomy within the first 30 postoperative days. Secondary endpoints included the reason for rethoracotomy and the incidence of perioperative transfusion of blood products.Results. In the dexamethasone group, 217 patients (9.7%) underwent a rethoracotomy, and in the placebo group, 165 patients did (7.3%; relative risk 1.32, 95% confidence interval: 1.09 to 1.61, p = 0.005). The most common reason for rethoracotomy was tamponade in both groups: 3.9% versus 2.1%, respectively (relative risk 1.84, 95% confidence interval: 1.30 to 2.61, p Conclusions. Intraoperative high-dose dexamethasone administration in cardiac surgery was associated with an increased rethoracotomy risk. (C) 2015 by The Society of Thoracic Surgeons

Inflammation is a natural phase of the wound healing response, which can be harnessed for the in situ tissue engineering of small-diameter blood vessels using instructive, bioresorbable synthetic grafts. This process is dependent on colonization of the graft by host circulating cells and subsequent matrix formation. Typically, vascular regeneration in small animals is governed by transanastomotic cell ingrowth. However, this process is very rare in humans and hence less relevant for clinical translation. Therefore, a novel rat model was developed, in which cell ingrowth from the adjacent tissue is inhibited using Gore-Tex sheathing. Using this model, our aim here was to prove that functional blood vessels can be formed in situ through the host inflammatory response, specifically by blood-borne cells. The model was validated by implanting sex-mismatched aortic segments on either anastomoses of an electrospun poly(ɛ-caprolactone) (PCL) graft, filled with fibrin gel, into the rat abdominal aorta. Fluorescent in situ hybridization analysis revealed that after 1 and 3 months in vivo, over 90% of infiltrating cells originated from the bloodstream, confirming the effective shielding of transanastomotic cell ingrowth. Using the validated model, PCL/fibrin grafts were implanted, either or not loaded with monocyte chemotactic protein-1 (MCP-1), and cell infiltration and tissue development were investigated at various key time points in the healing cascade. A phased healing response was observed, initiated by a rapid influx of inflammatory cells, mediated by the local release of MCP-1. After 3 months in vivo, the grafts consisted of a medial layer with smooth muscle cells in an oriented collagen matrix, an intimal layer with elastin fibers, and confluent endothelium. This study proves the regenerative potential of cells in the circulatory system in the setting of in situ vascular tissue engineering.

Background Infective endocarditis ( IE ) after transcatheter pulmonary valve implantation ( TPVI ) in dysfunctioning right ventricular outflow tract conduits has evoked growing concerns. We aimed to investigate the incidence and the natural history of IE after TPVI with the Melody valve through a systematic review of published data. Methods and Results PubMed, EMBASE , and Web of Science databases were systematically searched for articles published until March 2017, reporting on IE after TPVI with the Melody valve. Nine studies (including 851 patients and 2060 patient‐years of follow‐up) were included in the analysis of the incidence of IE . The cumulative incidence of IE ranged from 3.2% to 25.0%, whereas the annualized incidence rate ranged from 1.3% to 9.1% per patient‐year. The median (interquartile range) time from TPVI to the onset of IE was 18.0 (9.0–30.4) months (range, 1.0–72.0 months). The most common findings were positive blood culture (93%), fever (89%), and new, significant, and/or progressive right ventricular outflow tract obstruction (79%); vegetations were detectable on echocardiography in only 34% of cases. Of 69 patients with IE after TPVI , 6 (8.7%) died and 35 (52%) underwent surgical and/or transcatheter reintervention. Death or reintervention was more common in patients with new/significant right ventricular outflow tract obstruction (69% versus 33%; P =0.042) and in patients with non‐streptococcal IE (73% versus 30%; P =0.001). Conclusions The incidence of IE after implantation of a Melody valve is significant, at least over the first 3 years after TPVI , and varies considerably between the studies. Although surgical/percutaneous reintervention is a common consequence, some patients can be managed medically, especially those with streptococcal infection and no right ventricular outflow tract obstruction.

BackgroundClinical decision-making in symptomatic patients after mitral valve (MV) repair remains challenging as echocardiographic reference values are lacking. In native MV disease intervention is recommended for mean transmitral pressure gradient (TPG) >15 mmHg or systolic pulmonary artery pressure (SPAP) >60 mmHg at peak exercise. Insight into standard stress echo parameters after MV repair may therefore aid to clinical decision-making during follow-up.HypothesisStress echocardiography derived parameters in asymptomatic patients after successful MV repair differ from current guidelines for native valves.Material and methodsIn 25 patients (NYHA I) after MV repair stress echocardiography was performed on a semi-supine bicycle. Doppler flow records and MV related hemodynamics at rest and peak were obtained. Linear regression analysis was performed for mean TPG and SPAP at peak, using predetermined variables and confounders.ResultsMean TPG at rest (3.2 ± 1.4 mmHg) significantly increased at peak (15.0 ± 3.4 mmHg) but was always 57 mmHg. Only the indexed MV ring diameter was inversely correlated to mean TPG at peak in a multivariable model.ConclusionIn contrast to current recommendations in native MV disease, our data indicate that the standard value for mean TPG during stress echocardiography in asymptomatic patients after successful MV repair was above the guideline threshold of 15 mmHg in >50%, but always

Background: When profiling health care providers, adjustment for case-mix is essential. However, conventional risk adjustment methods may perform poorly, especially when provider volumes are small or events rare. Propensity score (PS) methods, commonly used in observational studies of binary treatments, have been shown to perform well when the amount of observations and/or events are low and can be extended to a multiple provider setting. The objective of this study was to evaluate the performance of different risk adjustment methods when profiling multiple health care providers that perform highly protocolized procedures, such as coronary artery bypass grafting. Methods: In a simulation study, provider effects estimated using PS adjustment, PS weighting, PS matching, and multivariable logistic regression were compared in terms of bias, coverage and mean squared error (MSE) when varying the event rate, sample size, provider volumes, and number of providers. An empirical example from the field of cardiac surgery was used to demonstrate the different methods. Results: Overall, PS adjustment, PS weighting, and logistic regression resulted in provider effects with low amounts of bias and good coverage. The PS matching and PS weighting with trimming led to biased effects and high MSE across several scenarios. Moreover, PS matching is not practical to implement when the number of providers surpasses three. Conclusions: None of the PS methods clearly outperformed logistic regression, except when sample sizes were relatively small. Propensity score matching performed worse than the other PS methods considered.

Objective: Total aortic root (TRR) and valve-sparing aortic root (VSRR) replacement surgery has improved life expectancy in Marfan disease patients (MFS). Determining the difference in outcomes aft...