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Objective: Cardiac surgery is known to have high rates of perioperative red blood cell (RBC) transfusions which are associated with increased postoperative mortality and morbidity. Perioperative erythropoietin (EPO) has been suggested to lower perioperative RBC transfusions, and the effect on postoperative morbidity or mortality is unknown., Methods: The registered study protocol is available on PROSPERO (CRD42022314538). We searched the Pubmed, EMbase, and Cochrane CENTRAL databases for randomized controlled trials (RCT) of EPO in cardiac surgery. Outcomes were short-term mortality, acute kidney injury (AKI), re-operation, cerebrovascular accident (CVA), perioperative myocardial infarction (MI), infectious complications, and RBC transfusions. RCT studies of perioperative EPO that reported at least one prespecified outcome of interest were included., Results: A total of 21 RCT's (n = 2,763 patients) were included. Mortality analysis included 17 studies (EPO 1,272 patients, control 1,235) and showed no significant difference (risk difference (RD) 0.0004, 95%CI: -0.016, 0.009). EPO did not reduce the incidence of AKI (RD -0.006, 95% CI: -0.038, 0.026) and reoperation (RD 0.001, 95% CI: -0.013, 0.015). The incidence of CVA (RD -0.004, 95% CI: -0.015, 0.007) and perioperative MI (RD -0.008, 95% CI: -0.021, 0.005) was similar between the groups., Conclusions: Although EPO had been proven to reduce perioperative RBC transfusions, we did not find that it reduces the incidence of postoperative short-term mortality, AKI, and reoperation. The study results support that perioperative EPO is also safe, with no rise in thrombotic events, including CVA and perioperative MI., (Copyright © 2024 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

A transition from nonhuman animal models to engineered microphysiological systems (MPS), such as organoids and organ-on-a-chip technologies, would signal a paradigm shift in biomedical research. Despite MPS' potential to more accurately model human physiology, reduce high failure rates of drugs in clinical trials, and limit unnecessary animal use, widespread adoption is hampered by public opinion and lack of scalability, standardization, and current regulatory uptake. This article suggests how 5 key concepts (awareness, access, education, application, and rewards) could help address these barriers. These concepts are part of a framework that underscores a need to integrate MPS into mainstream biomedical research and to better promote ethical responsibility for the means of biomedical innovation., (Copyright 2024 American Medical Association. All Rights Reserved.)

Background : Sex-based differences in mortality have been previously observed in patients with surgically treated infective endocarditis. We sought to evaluate the risk factors leading to this difference. Methods : A retrospective cohort from three centers in Israel comprising 376 surgically treated patients, comparing short- and long-term mortality rates and risk factors between female and male patients. Results : Compared to male patients, female patients had higher rates of hypertension (62% vs. 48%), higher rates of Gram-negative infections (20% vs. 11%), and more mitral valve replacement (55% vs. 42%). Diabetes and age were the most significant predictors for mortality and did not differ between female and male patients. In-hospital mortality rates did not differ between female and male patients (29% vs. 26%), and the difference in long-term mortality was not statistically significant (46% vs. 36% p = 0.088). Conclusions : No statistical difference was observed in short- and long-term mortality between female and male patients, most likely due to a lack of difference in the rates of important risk factors such as diabetes and age. Mortality rates decreased in the last 10 years, and a good prognosis is observed for patients surviving the initial 30 days after surgery.

Background:  Minimally invasive aortic valve replacement (MiAVR) is an established technique for surgical aortic valve replacement (AVR). Although MiAVR was first described in 1993 and has shown good results compared with full sternotomy AVR (FSAVR) only a minority of patients undergo MiAVR. We recently started using MiAVR via an upper hemisternotomy. We aimed to examine the early results of our initial experience with this technique., Methods:  We compared 55 MiAVR patients with a historical cohort of 142 isolated FSAVR patients (December 2016-December 2022). The primary outcome was in-hospital mortality. Secondary outcomes included cardiopulmonary bypass (CPB) and cross-clamp times, blood product intake, in-hospital morbidity, and length of intensive care unit and hospital stay., Results:  There was no significant difference in preoperative characteristics, including age, laboratory values, and comorbidities. There was no significant difference between the groups regarding in-hospital mortality (FSAVR 3.52 vs. MiAVR 1.82%). There was no significant difference in CPB time (FSAVR 103.5 [interquartile range: 82-119.5] vs. MiAVR 107 min [92.5-120]), aortic cross-clamp time (FSAVR 81 [66-92] vs. MiAVR 90 min [73-99]), and valve size (FSAVR 23 [21-25] vs. MiAVR 23 [21-25]). The incidence of intraoperative blood products transfusion was significantly lower in the MiAVR group (10.91%) compared with the FSAVR group (25.35%, p  = 0.03)., Conclusion:  Our findings further establish the possibility of reducing invasiveness of AVR without compromising patient safety and clinical outcomes. This is true even in the learning curve period and without requiring any significant change in the operative technique and dedicated equipment., Competing Interests: None declared., (Thieme. All rights reserved.)

The mechanical valve was first invented in the 1950s, and since then, a wide variety of prostheses have been developed. Although mechanical valves have outstanding durability, their use necessitates life-long treatment with anticoagulants, which increases the risk of bleeding and thromboembolic events. The current guidelines recommend a mechanical prosthetic valve in patients under 50-60 years; however, for patients aged 50-70 years, the data are conflicting and there is not a clear-cut recommendation. In recent decades, progress has been made in several areas. First, the On-X mechanical valve was introduced; this valve has a lower anticoagulant requirement in the aortic position. Second, a potential alternative to vitamin K-antagonist treatment, rivaroxaban, has shown encouraging results in small-scale trials and is currently being tested in a large randomized clinical trial. Lastly, an innovative mechanical valve that eliminates the need for anticoagulant therapy is under development. We attempted to review the current literature on the subject with special emphasis on the role of mechanical valves in the current era and discuss alternatives and future innovations.

Non-small cell lung cancer (NSCLC) is the most common pulmonary malignancy, frequently diagnosed at an advanced stage (III/IV). Patients in the Locally Advanced Stage Subgroup (IIIA) are relatively few, yet compose heterogenic phenotypes, posing a diagnostic and treating challenge, leading to a lack of clinical guidelines regarding the optimal standard of care. Several approaches exist, with a general agreement that a combined oncological and surgical modality approach is required. In this current retrospective descriptive study, patients with operable stage IIIA NSCLC who underwent surgery between 2013 and 2020 were evaluated on several aspects, including the initial diagnosis, neoadjuvant regimens, outcomes of surgical intervention, and overall survival at 2 years and 5 years following treatment. A total of 35 patients had neoadjuvant oncological treatment (mostly chemoradiation therapy) prior to surgery, out of which 28 patients were diagnosed with stage IIIA NSCLC. In post-operative assessment of pathological staging, downstaging was reported in 19 patients, of which 25% of cases were defined as a complete pathological response. The 2-year overall survival rate was 65% and the 5-year overall survival rate was 62%. The main pattern of disease recurrence was distant metastasis.

Background: We compared the effect of perioperative COVID-19, before and after vaccination, on 30-day mortality after cardiac surgery., Methods: Data was extracted from several national registries. The study period was March 1 st , 2020-March 31 st , 2022., Results: 2594 adult patients underwent cardiac surgery before the availability of a universal COVID-19 vaccine. 33 patients were diagnosed with COVID-19 prior to surgery (mean age 58.3±10.0, mean length of time 73.6±60.1 days) and 7 patients were diagnosed with COVID-19 0-14 days after surgery (age 66.4±7.6). These were compared to 4426 patients who underwent cardiac surgery after the availability of a universal vaccine: 469 patients were diagnosed with COVID-19 prior to surgery (age 62.1±10.1, length of time 175.8±158.2) and 32 patients diagnosed with COVID-19 0-14 days after surgery (age 60.8±14.5). In patients diagnosed with COVID-19 prior to surgery, there was no excess 30-day mortality either before or after vaccination (1 (3.0%) vs. 57 (2.2%), respectively, P <0.8, and 8 (1.7%) vs. 87 (2.2%), respectively, P <0.5). Patients diagnosed with COVID-19 after surgery, but before vaccination, had significantly higher 30-day mortality compared to COVID-19 negative patients (2 (28.6%) vs. 56 (2.2%) respectively, P <0.0001). This excess mortality disappeared after universal vaccination (1 (3.1%) vs. 94 (2.1%) respectively, P <0.7)., Conclusions: COVID-19, when diagnosed in the early post-operative period, was a risk factor for mortality before available vaccinations, but not after vaccination was widely available. Pre-surgery screening and post-surgical isolation is essential until vaccines are available. This data may be useful for patient management in future respiratory pandemics., (© 2023 The Authors.)

Background:  We assessed whether implementation of an immediate preoperative treatment in anemic patients could result in fewer perioperative packed red blood cell (PRBC) transfusions and improved outcomes in a real-world setting., Methods:  From January 1, 2020, to November 31, 2022, we implemented a perioperative protocol for anemic patients (hemoglobin (Hb) level in women <11.5 g/dL, men <12.5 g/dL), which included subcutaneous erythropoietin α, intravenous Iron, and intramuscular vitamin B12 (all given preoperatively) and per os iron and folic acid given once a day postoperatively. We retrospectively compared all patients receiving the protocol to all eligible patients who were operated upon in the 4 years prior to implementation of the protocol. Primary outcome was amount of PRBC transfusions during surgery and index admission., Results:  In the months after protocol implementation, 114 patients who received the treatment protocol were compared with 236 anemic patients in the 4 years prior to who did not receive the protocol. The treatment reduced total PRBC use (control group median 4 [2-7] units vs. treatment 2 [1-3] units, p  < 0.0001) and the incidence of postoperative blood products transfusions (treatment group 58 patients, 50.88% vs. control group 177 patients, 75%, p  < 0.0001). Hb prior to discharge was higher among the protocol group (treatment median 9 g/dL [8.3-9.5 g/dL] vs. control 8.6 g/dL [8.1-9.1 g/dL], p  = 0.0081)., Conclusion:  Despite some differences compared with previously described protocols, the implementation of a perioperative treatment protocol for anemic patients was associated with a reduction in PRBC transfusion in a real-world setting., Competing Interests: None declared., (Thieme. All rights reserved.)

There are few reports on short-term changes in renal function after surgical aortic valve replacement, and data are scarce regarding its impact on long-term outcomes. This is a retrospective study of patients who underwent isolated aortic valve replacement between 2009 and 2020 in four medical centers. Patients with end-stage renal disease were excluded. Renal function was assessed based on short-term changes. Multivariable regression models were used to identify predictors of improvement/deterioration. Cox proportional hazard models were used to assess survival trends. The study included 2402 patients, with a mean age of 69.3 years and a mean eGFR of 82.3 mL/min/1.73 m 2 . Short-term improvement rates were highest in stage 4 (24.4%) and stage 3 (16.8%) patients. Deterioration rates were highest in stage 1 (38.1%) and stage 2 (34.8%) patients. Deterioration in the chronic kidney disease stage was associated with a higher ten-year mortality ( p < 0.001, HR 1.46); an improved stage trended toward improved survival ( p = 0.14, HR 0.722). Patients with stage 3 and 4 kidney disease tended to remain stable or improve in the short term after aortic valve replacement while patients at stages 1 and 2 were at increased risk of deteriorating.

Background: High-sensitivity Troponin I (hs-cTnI) has largely replaced conventional troponin assays in an effort to improve detection of myocardial infarction. However, the mean displacement of hs-cTnI following coronary artery bypass graft (CABG) and the optimal threshold to detect perioperative myocardial infarction (MI) is unclear. Our objective is to describe mean hs-cTnI values at 6-12 h post-CABG and to determine the highest specificity while maintaining 100% sensitivity hs-cTnI cut-off values for diagnosis of perioperative or type-5 MI., Methods: Between 2016 and 2018, 374 patients underwent non-emergent, isolated CABG. Pre-operative and 6 h post-operative hs-cTnI values were recorded as well as ECG, echocardiographic and angiographic data., Results: Of 374 patients, 151 (40.3%) had normal and 224 (59.7%) had elevated preoperative hs-cTnI. Patients with normal preoperative hs-cTnI had a mean 6 h hs-cTnI of 9193 ng/l or 270X the upper normal value. Eleven patients (7.3%) presented with post-operative MI with a mean 6 h hs-cTnI of 50,218 ng/l or 1477X the upper normal value. Patients with elevated preoperative hs-cTnI had a mean 6 h hs-cTnI of 9449 ng/l or 292X the upper normal value. Eleven patients (4.9%) who presented with post-operative MI had a mean 6 h hs-cTnI of 26,823 ng/l or 789X the upper normal value., Conclusions: We suggest hs-cTnI threshold of 80-fold in patients with normal pre-operative hs-cTnI and 2.7-fold in patients with elevated pre-operative hs-cTnI. These results have important implications for perioperative care and for surgical trial reporting., (© 2023. The Author(s).)

Objectives: The role of the underlying etiology in isolated tricuspid valve surgery has not been investigated extensively in current literature. Aim of this study was to analyse outcomes of patients undergoing surgery due to endocarditis compared to other pathologies., Methods: The SURTRI study is a multicenter study enrolling adult patients who underwent isolated tricuspid valve surgery (n = 406, 55 ± 16 y.o.; 56% female) at 13 international sites. Propensity weighted analysis was performed to compare groups (IE group n = 107 vs Not-IE group n = 299)., Results: No difference was found regarding the 30-day mortality (Group IE: 2.8% vs Group Not-IE = 6.8%; OR = 0.45) and major adverse events. Weighted cumulative incidence of cardiac death was significantly higher for patients with endocarditis (p = 0.01). The composite endpoint of cardiac death and reoperation at 6 years was reduced in the Group IE (63.2 ± 6.8% vs 78.9 ± 3.1%; p = 0.022). Repair strategy resulted in an increased late survival even in IE cases., Conclusions: Data from SURTRI study report acceptable 30-day results but significantly reduced late survival in the setting of endocarditis of the tricuspid valve. Multi-disciplinary approach, repair strategy and earlier treatment may improve outcomes., Competing Interests: Declaration of Competing Interest Dr. Andreas and Prof. Laufer disclose financial relationship with Edwards, Abbott, Medtronic and LSI. Dr. Taramasso is consultant for Abbott, Boston Scietific, 4tech and receives fees from Edwards. Prof. Maisano discloses relationship with Abbott, Medtronic, Edwards Lifesciences, Biotronik, Boston Scientific Corporation, NVT, Terumo, Xeltis, Cardiovalve, Occlufit, Simulands. Others authors have no conflict of interest to state., (Copyright © 2022. Published by Elsevier B.V.)

Objectives: The interest in isolated tricuspid valve disease has rapidly increased recently. However, clinical trials and registry data are rare in the surgical literature. This study aimed to describe the early and long-term outcomes of a real-world experience in isolated tricuspid procedures comparing repair and replacement strategies., Methods: The Surgical-Tricuspid study is a multicentre retrospective study that enrolled adult patients who had undergone isolated tricuspid valve surgery at 13 international sites. Propensity score-matched analysis was used to compare repair versus replacement., Results: A cohort of 426 patients was enrolled [mean age: 55 (16) years; 56% female]. After matching, 175 comparable pairs were analysed. Preoperative left ventricular ejection fraction was 55(9) vs 56(9) (P = 0.8) while moderate-severe tricuspid regurgitation was present in 95% of cases. The 30-day mortality rate was 4.0% vs 8.0% in the repair and replacement groups, respectively (P = 0.115). The rates of re-exploration for bleeding (6.9% vs 13.1% P = 0.050), permanent pacemaker implantation (5.1% vs 12.0%; P = 0.022) and blood transfusion (46% vs 62%; P = 0.002) were higher in the replacement group. Cumulative survival rates at 3, 5 and 7 years in the repair group were 84 (3)%, 75 (4)% and 56 (9)% vs 71 (4)%, 66 (5)% and 58 (5)% in the replacement group (P = 0.001) while cumulative incidence for reoperation at 10 years did not differ between groups [repair 10 (1)% vs replacement 9 (1)%; P = 0.469]., Conclusions: The data from the Surgical-Tricuspid study reported a high risk for patients undergoing tricuspid surgery. Isolated valve repair offered reduced early and late mortality with no difference regarding reoperation rate when compared with replacement., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The choice of a bioprosthetic valve (BV) over a mechanical valve (MV) in middle-aged adults in the mitral position is still under debate. Each valve type has benefits and drawbacks. We examined the mid-term survival of patients aged 50-70 years after BV versus MV mitral valve replacement (MVR)., Methods: We conducted a multicentre, retrospective analysis of patients aged 50-70 years undergoing MVR from 2005 to December 2018 in 4 medical centres in Israel. To control for between-group differences, we used propensity-adjusted analysis. The primary end point was all-cause mortality. Secondary end points included reoperation, cerebrovascular accident and bleeding., Results: During the study period, 2125 MVR procedures were performed. Of these, 796 were eligible for inclusion [539 (67.8%) MV replacement and 257 (32.2%) BV]. The mean age was 61.0 ± 5.4. There were 287 deaths during 4890 person-years of follow-up. The adjusted hazard ratio was (1.13 [0.85-1.49], P = 0.672). There was also no difference in the secondary end points. Subgroup analysis of patients aged 50-64 years showed a higher risk of mortality with BV (hazard ratio = 1.50 [1.07-2.1], P = 0.018). Reoperation was a strong predictor of mortality during the study period (72.2%)., Conclusions: In patients aged 50-70 years, we found an interaction between age and MV or BV outcomes-those younger than 65 years gained a mortality advantage with MV, while outcomes were similar in the 65-70 age group. this supports the current guidelines recommending using MV in patients <65 years of age., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: End-stage renal disease (ESRD) has been shown to be associated with increased mortality in patients undergoing cardiac surgery. We aimed to compare the short- and mid-term mortality after cardiac surgery of patients with dialysis-dependent ESRD (DD-ESRD) to patients with normal renal function (NRF), using national registries: the ESRD registry, the adult cardiac surgery registry (ACSR), and the National Mortality Registry., Methods: The study population comprised 8207 adult patients who underwent either isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement (MVR), or CABG + valve-related procedure, between January 2017 and April 2019. Data were retrospectively extracted and reported to the ACSR by the department of medical records of each medical center., Results: One hundred and four DD-ESRD patients (mean age 63.2 ± 8.8 years, 83.7% males) were compared with 8103 NRF patients (mean age 64.9 ± 9.8 years, 77.6% males). Median follow-up for the total cohort was of 32.0 months (IQR; 25.0, 40.0). In DD-ESRD compared to NRF patients, 30-day mortality was higher (14.4% vs. 2.3%, respectively, p = 0.0001) and 4-year survival was significantly lower (44% ± 0.06 vs. 91% ± 0.04, respectively, p = 0.0001). Fifty-three percent of DD-ESRD 30-day mortality was caused by sepsis. Risk factors associated with reduced midterm survival included: DD-ESRD patients (HR = 4.7, 95% CI; 1.2-18.2), MVR procedure (HR = 1.5, 95% CI; 1.04-2.1) and combined CABG + valve-related procedure (HR = 1.6, 95% CI; 1.2-2.04)., Conclusions: Preoperative DD-ESRD was associated with a significant increase in 30-day and mid-term mortality after cardiac surgery. The highest mortality rate was observed in valvular and combined procedures., (© 2022 Wiley Periodicals LLC.)

Klippel-Trenaunay syndrome is characterized by a combination of vascular abnormalities and limb hypertrophy. Pleural effusion as a manifestation of this syndrome is almost never mentioned in the literature. We present a case of persistent bilateral pleural effusion in a patient with Klippel-Trenaunay syndrome and share our experiences treating this scenario., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: The choice between mechanical valves (MVs) and bioprosthetic valves (BVs) in patients undergoing aortic valve surgery is complex, requiring a balance between the inferior durability of BV and the indicated long-term anticoagulation therapy with MV. This is especially challenging in the middle age group (< 70 years), which has seen an increased use of BV over recent years., Methods: A meta-analysis of randomised controlled trials (RCTs), observational studies using propensity score matching (PSM) and inverse probability weighting (IPW) was conducted to examine the clinical outcomes of patients < 70 years of age undergoing aortic valve replacement. The primary outcome was overall long-term mortality. Secondary outcomes included bleeding events, reoperation, systemic thromboembolism, and cerebrovascular accident., Results: Fifteen studies (1 RCT, 12 PSM studies, and 2 IPW studies; aggregated sample size 16,876 patients) were included. Median follow-up was 7.8 years. Mortality was higher with BVs vs MVs (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.00-1.49), as was reoperation (HR 3.05, 95% CI 2.22-4.19). Bleeding risk was lower with BVs (HR 0.58, 95% CI 0.48-0.69), and the risk of stroke was similar in both valve types (HR 0.96, 95% CI 0.83-1.11) CONCLUSIONS: This broadest meta-analysis comparing BV and MV suggests a survival benefit for MVs in patients < 70 years of age. This should lead to reassessment of current patterns used in the choice of valves for patients < 70 among the cardiothoracic surgery community., (Copyright © 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Isolated tricuspid valve replacement (TVR) is considered high-risk surgery. We investigated our outcomes of TVR with the aim of identifying variables that may influence morbidity and mortality of isolated TVR compared with combined TVR and left-sided valve surgery., Methods: Retrospective analysis of patients undergoing TVR surgery. The primary endpoint was long-term mortality. The association of postoperative outcomes with isolated compared with combined replacement was analyzed. The association between type of surgery and mortality over time was evaluated using Cox proportional hazards regression models to estimate the hazard ratio., Results: Overall, 70 patients underwent TVR. Mean age was 61 ± 12 years and 74% (52 of 70) were women. About two thirds (61%) of the study population had a diagnosis of rheumatic heart disease and 8% (6 of 70) had previous infectious endocarditis. Atrial fibrillation was prevalent (86%, 60 of 70). Comorbidities were similar between groups. Tricuspid valve replacement combined with left-sided valvular surgery was performed in 37 patients (53%), and isolated replacement in 33 patients (47%). Previous cardiac surgery was common (40 patients, 57%). One-month survival rate was 94.3% (66 of 70). During a median follow-up period of 3.6 years, 12 patients (17%) died. The cumulative 5-year survival tended to be lower among patients with isolated TVR compared with patients having combined surgery., Conclusions: We showed that TVR can be performed with good outcomes. Isolated TVR did not increase morbidity and mortality when patients are referred for surgery early, including after previous sternotomy. This finding should perhaps lead to a more aggressive approach toward patients requiring isolated replacement., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Isolated tricuspid valve (TV) surgery is a rare procedure generally considered at high risk for perioperative mortality and poor long-term outcomes. Surgical treatment can be performed with either an arrested heart (AH) or beating heart (BH) technique. The aim of this study was to compare the outcomes of isolated tricuspid surgery with 2 different approaches., Methods: The Surgical-Tricuspid Study is a multicenter international retrospective study enrolling adult patients who underwent isolated TV procedures (n = 406; age 56 ± 16 years; 56% female) at 13 international sites. The AH and BH strategies were performed in 253 and 153 patients, respectively. Propensity score-matched analysis was used to compare groups., Results: After matching, 129 pairs were obtained and analyzed. The 30-day mortality rate was 6.2% versus 5.0% in the AH and BH groups, respectively (P = .9). The rates of acute renal failure requiring replacement therapy (10% versus 3%; P = .02) and stroke (1.6% versus 0%; P = .08) were numerically higher in the AH group. The 6-year survival rate was 67% ± 6% versus 78% ± 5% in the AH and BH groups, respectively (P = .18), whereas freedom from cardiac death was 75% ± 5% versus 84% ± 4% (P = .21). The 6-year composite cardiac end point of cardiac death and reoperation rate was 60% ± 9% versus 86% ± 5% (P = .024) comparing AH-TV replacement and BH-TV repair groups., Conclusions: Isolated TV surgery performed with a BH strategy is a safe option and resulted in a trend of increased long-term survival and freedom from reoperation compared with the standard AH technique. Patients undergoing BH valve repair had the best long-term outcome., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Atrial fibrillation is a common arrhythmia with a large impact on society and on patients. Rheumatic valve disease is still prevalent in low- and medium-income countries. Performing surgical ablation during surgery for mitral valve disease has been shown to restore sinus rhythm in most patients., Aims, Materials and Methods: In this issue of the Journal of Cardiac Surgery, Ma et al., publish a meta-analysis of surgical ablation in patients with rheumatic heart disease (RHD)., Results: They found no difference in short-term outcomes with a higher incidence of restoration to sinus rhythm. In mid- to long-term follow-up, there was no difference in mortality with a signal towards more permanent pacemaker implantation., Discussion and Conclusion: Despite some inherent limitations and some methodological flows, this meta-analysis has important insights and is valuable for surgeons taking care of patients with RHD., (© 2021 Wiley Periodicals LLC.)

Background:  Risk factors control and secondary prevention measures are often reported to be suboptimal in patients undergoing coronary artery bypass grafting (CABG) and may lead to worse clinical outcomes. We aimed to examine potentially modifiable risk factors in patients undergoing CABG and investigate their association with long-term coronary events., Methods:  Cardiovascular risk factors were recorded preoperatively in the setting of a cardiac catheterization laboratory and were analyzed in relation to long-term coronary events, defined as acute coronary syndrome (ACS) or revascularization after CABG., Results:  Study population included 1,125 patients undergoing CABG without previous revascularization. Modifiable risk factors included hypertension (71%), hyperlipidemia (67%), diabetes (42%), obesity (28%), and smoking (21%). Only 8% did not have any of the five risk factors. During the mean follow-up of 93 ± 52 months after CABG, 179 patients (16%) experienced a coronary event. Incidence rates were higher in patients with than without the presence of each of the modifiable risk factors, except obesity. Active smoking (hazard ratio [HR]: 1.51; 95% confidence interval [CI]: (1.07-2.13); p  = 0.020), presence of diabetes (HR: 1.61; 95% CI: 1.18-2.18; p  = 0.002), and hyperlipidemia (HR: 2.13; 95% CI: 1.45-3.14; p  < 0.001) were independent predictors of future coronary events after CABG; they also displayed a progressive stepwise increment in the risk of long-term coronary events when cumulatively present., Conclusions:  In patients undergoing CABG, diabetes, hyperlipidemia, and smoking, as documented preoperatively, were potentially modifiable risk factors that were independently and cumulatively associated with long-term risk of ACS or coronary revascularization, highlighting the importance of early identification and risk factors control for improving cardiovascular health after CABG., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Chronic kidney disease and anemia often coexist and may accompany diabetes; all 3 conditions are associated with worse cardiovascular outcomes. This study investigated the prognostic implications of anemia and chronic kidney disease for mortality among patients undergoing coronary artery-bypass grafting surgery and examined whether outcomes are related to the presence of diabetes., Methods: This retrospective study included 1180 patients undergoing coronary artery-bypass grafting. Long-term mortality (mean follow-up, 8.6 ± 4.2 years) was examined in relation to preoperative anemia, chronic kidney disease, and diabetes. Prognostic interplay of the 3 risk factors was evaluated., Results: Chronic kidney disease, anemia, and diabetes (20%, 25%, and 43% of patients, respectively), were independent risk predictors for mortality. Compared with patients with neither chronic kidney disease nor anemia, the adjusted hazard ratios (HRs) for mortality were 1.87 (95% confidence interval [CI], 1.35 to 2.59) in chronic kidney disease only, 1.75 (95% CI, 1.30 to 2.35) in anemia only, and 2.69 (95% CI, 1.91 to 3.78) in patients with both conditions. The pattern of association of chronic kidney disease and anemia with mortality was similar in patients with and without diabetes. However, mortality risk was higher in patients with diabetes in each risk category-neither chronic kidney disease nor anemia: HR, 1.69 (95% CI, 1.20 to 2.39) vs HR, 1 (reference); chronic kidney disease only: HR, 2.68 (95% CI, 1.59 to 4.52) vs HR, 2.10 (95% CI, 1.38 to 3.20); anemia only: HR, 2.73 (95% CI, 1.83 to 4.07) vs HR, 1.94 (95% CI, 1.23 to 3.08); and both chronic kidney disease and anemia: HR, 4.44 (95% CI, 2.88 to 6.85) vs HR, 2.72 (95% CI, 1.58 to 4.69)., Conclusions: In patients undergoing coronary artery-bypass grafting, anemia and chronic kidney disease have significant prognostic implications for long-term mortality. Their effect on mortality was cumulatively associated with adverse impacts of diabetes., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Esophageal perforation is a serious disease which entails significant morbidity and mortality. Barogenic perforation (Boerhaave's type perforation) is considered as having a relatively poor prognosis. We present a case of barogenic perforation treated initially with surgery for primary repair leading to the formation of a control fistula. The esophageal fistula was treated successfully with endoscopic vacuum-assisted closure (VAC) system therapy. This case presents a complex condition of esophageal perforation initially treated with surgery for primary repair. After surgery the patient developed a control fistula from the esophagus to the operative drain in the pleural space. We treated the fistula with a VAC (Vacuum Assisted Closure) system that was endoscopically placed in the esophagus at the level of the fistula.

Background: Patients with low-gradient (LG) severe aortic stenosis (AS) have worse outcome following surgical aortic valve replacement (SAVR) than patients with high-gradient AS. We hypothesized that transcatheter aortic valve replacement (TAVR) may be a better treatment option for these patients. The aim of this study was to compare outcomes of patients with LG AS referred for TAVR and SAVR., Methods: We analysed clinical, echocardiographic and outcome data in 50 consecutive patients (age 81 ± 6 years, 50% females) with LG AS (aortic valve area ≤ 1 cm 2 , mean aortic valve pressure gradient <40 mmHg and peak aortic jet velocity < 4 m/s) who underwent TAVR, and compared them with 80 patients (age 76 ± 7 years, 35% females) who underwent SAVR., Results: Over 4 years of follow-up there was no difference in survival free of stroke, long-term dialysis or urgent rehospitalization and overall survival between patients undergoing TAVR or SAVR (12% and 61% vs. 19% and 67%, p = 0.9 and 0.8, respectively), even though TAVR patients were significantly older, had more comorbidities and had a higher EuroSCORE II. After adjustment for these covariates, TAVR was associated with better event-free survival (adjusted HR: 0.63, 95% CI 0.40-0.97, p = 0.044)., Conclusion: Patients with LG AS had better adjusted event-free survival when referred to TAVR rather than to SAVR., Summary: Symptomatic patients with low-gradient severe aortic stenosis are at high risk for surgical aortic valve replacement. In this study, Transcatheter, as compared to surgical aortic valve replacement, was associated with better adjusted event free survival in patients with low gradient aortic stenosis., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Current guidelines for choosing between revascularization modalities may not be appropriate for young patients., Objectives: To compare outcomes and guide treatment options for patients < 40 years of age, who underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) between 2008 and 2018., Methods: Outcomes were compared for 183 consecutive patients aged < 40 years who underwent PCI or CABG between 2008 and 2018, Outcomes were compared as time to first event and as cumulative events for non-fatal outcomes., Results: Mean patient age was 36.3 years and 96% were male. Risk factors were similar for both groups. Drug eluting stents were implemented in 71% of PCI patients and total arterial revascularization in 74% of CABG patients. During a median follow-up of 6.5 years, 16 patients (8.6%) died. First cardiovascular events occurred in 35 (38.8%) of the PCI group vs. 29 (31.1%) of the CABG group (log rank P = 0.022), repeat events occurred in 96 vs. 51 (P < 0.01), respectively. After multivariate adjustment, CABG was associated with a significantly reduced risk for first adverse event (hazard ratio [HR] 0.305, P < 0.01) caused by a reduction in repeat revascularization. CABG was also associated with a reduction in overall repeat events (HR 0.293, P < 0.01). There was no difference in overall mortality between CABG and PCI., Conclusions: Young patients with coronary disease treated by CABG showed a reduction in the risk for non-fatal cardiac events. Mortality was similar with CABG and PCI.

Introduction: There is paucity of data regarding lipid goal attainment after coronary-artery bypass graft surgery (CABG) and its impact on adverse outcomes. We aimed to investigate the attainment of lipid goals and the association between plasma lipid levels achieved after CABG and mortality., Methods: Retrospective analysis of 1230 patients undergoing CABG. Mortality was examined in relation to most-recent lipid levels attained, categorized by clinically-relevant thresholds, and according to the improvement from pre-operative levels., Results: Low-density lipoprotein cholesterol (LDL-C) < 70 mg/dL was attained by 44% of the patients. After multivariable adjustment, the hazard ratio for long-term mortality was 1.33 (95% confidence interval, 1.05-1.67) and 1.97 (1.55-2.50) for patients attaining LDL-C 70-100 mg/dL and >100 mg/dL, respectively, compared with LDL-C < 70 mg/dL. The hazard ratio was 1.42 (1.07-1.88) and 1.73 (1.33-2.23) for patients attaining high-density lipoprotein cholesterol (HDL-C) 40-50 mg/dL and <40 mg/dL, respectively, compared with HDL-C > 50 mg/dL; and 1.11 (0.85-1.45) and 4.28 (1.89-9.68) for patients with triglycerides 200-500 mg/dL and >500 mg/dL compared with triglycerides <200 mg/dL. A progressive stepwise association was seen between the cumulative status of the lipid measures achieved and long-term mortality, with the lowest risk observed in those with optimal level of all lipid measures ( p < 0.0001). Improvement in any of the lipid measures from pre-operative to latest documented levels was associated with reduced mortality., Conclusions: Lack of attainment of optimal levels of routine lipid measures after CABG was common and associated both independently and additively with long-term mortality, emphasizing the importance of addressing plasma lipid profile as both a risk marker and a treatment target after CABG.

The trend toward personalized approaches to health and medicine has resulted in a need to collect high-dimensional datasets on individuals from a wide variety of populations, in order to generate customized intervention strategies. However, it is not always clear whether insights derived from studies in patient populations or in controlled trial settings are transferable to individuals in the general population. To address this issue, a longitudinal analysis was conducted on blood biomarker data from 1032 generally healthy individuals who used an automated, web-based personalized nutrition and lifestyle platform. The study had two main aims: to analyze correlations between biomarkers for biological insights, and to characterize the effectiveness of the platform in improving biomarker levels. First, a biomarker correlation network was constructed to generate biological hypotheses that are relevant to researchers and, potentially, to users of personalized wellness tools. The correlation network revealed expected patterns, such as the established relationships between blood lipid levels, as well as novel insights, such as a connection between neutrophil and triglyceride concentrations that has been suggested as a relevant indicator of cardiovascular risk. Next, biomarker changes during platform use were assessed, showing a trend toward normalcy for most biomarkers in those participants whose values were out of the clinically normal range at baseline. Finally, associations were found between the selection of specific interventions and corresponding biomarker changes, suggesting directions for future study.

Rapid progression of valvular stenosis in the setting of infective endocarditis is extremely rare. Here we describe a patient with Bartonella endocarditis on a bioprosthetic aortic valve that caused rapidly progressive aortic stenosis without regurgitation. At operation the bioprosthetic valve was severely fibrotic and calcified, with markedly thickened and distorted leaflets and circular partial detachment from the aortic ring. The patient underwent aortic root replacement with aortic bioprosthesis and aortic grafting with reimplantation of the coronary ostia., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)