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Background: Mitochondrial dysfunction is one of key factors causing heart failure. We performed a comprehensive analysis of expression of mitochondrial quality control (MQC) genes in heart failure. Methods: Myocardial samples were obtained from patients with ischemic and dilated cardiomyopathy in a terminal stage of heart failure and donors without heart disease. Using quantitative real‐time PCR, we analysed a total of 45 MQC genes belonging to mitochondrial biogenesis, fusion‐fission balance, mitochondrial unfolded protein response (UPRmt), translocase of the inner membrane (TIM) and mitophagy. Protein expression was analysed by ELISA and immunohistochemistry. Results: The following genes were downregulated in ischemic and dilated cardiomyopathy: COX1, NRF1, TFAM, SIRT1, MTOR, MFF, DNM1L, DDIT3, UBL5, HSPA9, HSPE1, YME1L, LONP1, SPG7, HTRA2, OMA1, TIMM23, TIMM17A, TIMM17B, TIMM44, PAM16, TIMM22, TIMM9, TIMM10, PINK1, PARK2, ROTH1, PARL, FUNDC1, BNIP3, BNIP3L, TPCN2, LAMP2, MAP1LC3A and BECN1. Moreover, MT‐ATP8, MFN2, EIF2AK4 and ULK1 were downregulated in heart failure from dilated, but not ischemic cardiomyopathy. VDAC1 and JUN were only genes that exhibited significantly different expression between ischemic and dilated cardiomyopathy. Expression of PPARGC1, OPA1, JUN, CEBPB, EIF2A, HSPD1, TIMM50 and TPCN1 was not significantly different between control and any form of heart failure. TOMM20 and COX proteins were downregulated in ICM and DCM. Conclusions: Heart failure in patients with ischemic and dilated cardiomyopathy is associated with downregulation of large number of UPRmt, mitophagy, TIM and fusion‐fission balance genes. This indicates multiple defects in MQC and represents one of potential mechanisms underlying mitochondrial dysfunction in patients with heart failure. [ABSTRACT FROM AUTHOR]

Alkaptonuria is rare genetic disorder of tyrosine metabolism manifesting with signs of tissue pigmentation, dark urine, and ochronotic arthropathies. Commonly undiscovered by late adulthood, alkaptonuria can manifest as cardiac ochronosis with cardiovascular disorders such as valvulopathies, but rarely coronary artery disease. This case report describes 2 patients with aortic stenosis and coronary artery disease in whom alkaptonuria was diagnosed during open heart surgery., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Internationally 3% of the donor hearts are distributed to re-transplant patients. In Eurotransplant, only patients with a primary graft dysfunction (PGD) within 1 week after heart transplantation (HTX) are indicated for high urgency listing. The aim of this study is to provide evidence for the discussion on whether these patients should still be allocated with priority. All consecutive HTX performed in the period 1981-2015 were included. Multivariate Cox' model was built including: donor and recipient age and gender, ischaemia time, recipient diagnose, urgency status and era. The study population included 18 490 HTX, of these 463 (2.6%) were repeat transplants. The major indications for re-HTX were cardiac allograft vasculopathy (CAV) (50%), PGD (26%) and acute rejection (21%). In a multivariate model, compared with first HTX hazards ratio and 95% confidence interval for repeat HTX were 2.27 (1.83-2.82) for PGD, 2.24 (1.76-2.85) for acute rejection and 1.22 (1.00-1.48) for CAV (P < 0.0001). Outcome after cardiac re-HTX strongly depends on the indication for re-HTX with acceptable outcomes for CAV. In contrast, just 47.5% of all hearts transplanted in patients who were re-transplanted for PGD still functioned at 1-month post-transplant. Alternative options like VA-ECMO should be first offered before opting for acute re-transplantation., (© 2018 The Authors. Transplant International published by John Wiley & Sons Ltd on behalf of Steunstichting ESOT.)

Libman-Sacks endocarditis, one of the most prevalent cardiac presentations of systemic lupus erythematosus, typically affects the aortic or mitral valve; tricuspid valve involvement is highly unusual. Secondary antiphospholipid syndrome increases the frequency and severity of cardiac valvular disease in systemic lupus erythematosus. We present the case of a 47-year-old woman with lupus and antiphospholipid syndrome whose massive tricuspid regurgitation was caused by Libman-Sacks endocarditis isolated to the tricuspid valve. In addition, we discuss this rare case in the context of the relevant medical literature.

Annular rupture presents a rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). Although it can be subtle and subclinical in presentation, most severe forms present with hemodynamic instability and represent true emergencies requiring a more invasive treatment, even conventional surgery. We present a case of successful treatment of annular rupture by left ventricular outflow tract patch and surgical aortic valve replacement.

Objectives: Cardiac surgery-associated acute kidney injury (AKI) is a well-known factor influencing patients' long-term morbidity and mortality. Several prediction models of AKI requiring dialysis (AKI-D) have been developed. Only a few direct comparisons of these models have been done. Recently, a new, more uniform and objective definition of AKI has been proposed [Kidney Disease: Improve Global Outcomes (KDIGO)-AKI]. The performance of these prediction models has not yet been tested., Methods: Preoperative demographic and clinical characteristics of 1056 consecutive adult patients undergoing cardiac surgery were collected retrospectively for the period 2012-2014. Multivariable logistic regression analysis was used to determine the independent predictors of AKI-D and the KDIGO-AKI stages. Risk scores of five prediction models were calculated using corresponding subgroups of patients. The discrimination of these models was calculated by the c-statistics (area under curve, AUC) and the calibration was evaluated for the model with the highest AUC by calibration plots., Results: The incidence of AKI-D was 3.5% and for KDIGO-AKI 23% (17.3% for Stage 1, 2.1% for Stage 2 and 3.6% for Stage 3). Older age, atrial fibrillation, NYHA class III or IV heart failure, previous cardiac surgery, higher preoperative serum creatinine and endocarditis were independently associated with the development of AKI-D. For KDIGO-AKI, higher body mass index, older age, female gender, chronic obstructive pulmonary disease, previous cardiac surgery, atrial fibrillation, NYHA class III or IV heart failure, higher preoperative serum creatinine and the use of cardiopulmonary bypass were independent predictors. The model by Thakar et al. showed the best performance in the prediction of AKI-D (AUC 0.837; 95% CI = 0.810-0.862) and also in the prediction of KDIGO-AKI stage 1 and higher (AUC = 0.731; 95% CI = 0.639-0.761), KDIGO-AKI stage 2 and higher (AUC = 0.811; 95% CI = 0.783-0.838) and for KDIGO-AKI stage 3 (AUC = 0.842; 95% CI = 0.816-0.867)., Conclusions: The performance of known prediction models for AKI-D was found reasonably well in the prediction of KDIGO-AKI, with the model by Thakar having the highest predictive value in the discrimination of patients with risk for all KDIGO-AKI stages., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study was to assess the recovery of regional myocardial function of the left-ventricular septal wall and the septal site of the mitral valve (MV) annulus by tissue Doppler imaging (TDI)., Methods: In 63 (32 diabetic and 31 control) patients having off-pump coronary artery bypass grafting (OPCABG), including the left internal mammary artery (LIMA) and the left anterior descending coronary artery (LAD), TDI measurements were performed before operation (baseline), 5 min after LIMA-LAD revascularization (early reperfusion) and after completion of all anastomoses (after revascularization)., Results: Compared to the patients with diabetes, the controls had higher peak systolic velocities of the mid septal segments in the early reperfusion measurement (p = 0.002). After revascularization, values of peak systolic strain at the basal (-10.13 vs. -13.36%, p = 0.044) and mid septal segments (-8.25 vs. -12.69%, p = 0.009) were decreased in the diabetic patients compared to the controls. There was no difference between the groups with respect to the velocities acquired at the septal site of the MV annulus., Conclusions: This study demonstrates an insufficient recovery of regional myocardial function in patients with type II diabetes undergoing OPCABG.

Endocarditis represents a rare but life-threatening condition after heart transplantation. Recent American Heart Association guidelines recognize cardiac transplant patients with valvulopathy as high risk for endocarditis, but acknowledge that there were not sufficient data to make a recommendation for prophylaxis. Also, genitourinary procedures were no longer considered a risk factor for endocarditis in the most recent guidelines. We present a patient who acquired aortic valve endocarditis of the intact valve, after multiple urethral instrumentation 2 years after heart transplantation, who was successfully treated by aortic valve replacement and prolonged antibiotic therapy., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Calcifying fibrous pseudotumor is a rare benign lesion composed mostly of dense hyalinized colagen with multiple dystrophic or psammomatous calcifications and variable lymphoplasmacytic infiltrate. Children and young adults are most commonly affected by this tumor of uncertain pathogenesis. This is a case of an asymptomatic young woman with calcifying fibrous pseudotumor of the pericardium compressing heart cavities. Partial resection and marsupialization of the mass was performed., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The etiology of lung injury following cardiopulmonary bypass (CPB) is multifactorial. Our study focused on quantifying the lactate release from the lungs precipitated by extracorporeal circulation at different time points after the insult. This was complemented by an evaluation of the gas exchange at the level of the alveolar-capillary membrane., Methods: Forty consecutive patients (age 61+/-11 years, EuroScore 4.7+/-2.7) undergoing CABG were prospectively analyzed. The data are presented as medians and the interquartile range., Results: The pulmonary lactate release (PLR) increased from a baseline value of 0.033 (range -0.077 to 0.170) to 0.465 mmol/min/m2 (range 0.113-0.922), which was seen 6h postoperatively (P<0.001). The A-a O2 gradient increased from 12.7 (range 8.8-15) to 39.1 kPa (range 30.3-46.5) upon discontinuation of CPB (P<0.001). The systemic arterial lactate (LS) concentration increased from 1.22 (range 1-1.44) to 3.03 mmol/l (range 2.29-4.76) 6h after surgery (P<0.001). The veno-arterial pCO2 difference (V-A dpCO2) rose from 0.6 (range 0.5-0.9) to 0.9 kPa (range 0.7-1) (P=0.014). The mortality in the studied group was 5% (2/40)., Conclusions: The lungs were found to be a significant source of lactate, and this pulmonary lactate flux was accentuated by CPB. The PLR correlated with systemic hyperlactatemia as well as the A-a O2 gradient, and was found to be higher in patients requiring prolonged mechanical ventilatory support. The duration of CPB had a significant impact on the systemic lactate concentrations, V-A dpCO2 and the A-a O2 gradient, but not on the PLR.

Objective: Postoperative bleeding is still one of the most common complications of cardiac surgery. Antifibrinolytic agents successfully reduce bleeding, but there are controversies concerning adverse effects after their systemic use. By topical application of antifibrinolytic agents in pericardial cavity, most of these effects are avoided. We compared the effects of topically applied aprotinin, tranexamic acid and placebo on postoperative bleeding and transfusion requirements., Methods: In this single-center prospective, randomized, double-blind trial, 300 adult cardiac patients were randomized into three groups to receive one million IU of aprotinin (AP group), 2.5g of tranexamic acid (TA group) or placebo (PL group) topically before sternal closure. Groups were comparable with respect to all preoperative and intraoperative variables. Postoperative bleeding, transfusion requirements and hematologic parameters were evaluated., Results: Postoperative bleeding within first 12-h period (AP group 433+/-294 [350; 360]ml, TA group 391+/-255 [350; 305]ml, PL group 613+/-505 [525; 348]ml), as well as cumulative blood loss within 24h (AP group 726+/-432 [640; 525]ml, TA group 633+/-343 [545; 335]ml, PL group 903+/-733 [800; 445]ml), showed statistically significant inter-group differences (both p<0.001). Bleeding rates values were significantly higher in placebo group compared to the groups treated with antifibrinolytic agents (AP and TA groups) concerning both variables. Although TA group showed the lowest values, no statistical differences between TA and AP groups were found. Inter-group difference of blood product requirements was not statistically significant., Conclusions: Topical use of either tranexamic acid or aprotinin efficiently reduces postoperative bleeding. TA seems to be at least as potent as aprotinin, but potentially safer and with better cost-effectiveness ratio.

Recent developments in cardiac surgery and interventional cardiology have led to the installation of integrated operating rooms that allow both surgical and endovascular procedures. These units offer surgical as well as angiographic equipment and personnel and therefore require special planning and design. A variety of integrated procedures can be performed. Hybrid coronary revascularization, percutaneous valve repair, and aortic stent-graft placement are current developments that are ideally performed in a cath-lab operating room. This review by an international working group of cardiac surgeons and cardiologists outlines the challenges involved with implementation of an integrated operating suite and suggests general planning and construction guidelines.

Background: Endoscopic radial artery harvest provides better cosmetic result without compromising the quality of the graft. We sought to compare postoperative harvesting site neurologic and vascular outcome., Methods: From 10/2002 until 10/2004, 50 patients were randomized to have their radial artery harvested for coronary bypass either endoscopically (group A, n = 25) or conventionally (group B, n = 25). Radial arteries were preoperatively evaluated by Doppler echocardiography. Neurologic and functional status was assessed by a self reporting questionnaire with a semiquantitative (1-5) scale. Vascular status of the forearm was assessed by control echocardiography., Results: At an average follow-up of 37 +/- 7 months, patients undergoing endoscopic radial artery harvesting had less overall neurologic complications (11 versus 17 patients, P = .023) and they were less severe (0.8 +/- 1.1 versus 2.2 +/- 1.2; P < .001). Ulnar flow increase was similar among the groups: 13.1 +/- 5.43 cm/s in group A versus 15.9 +/- 4.9 cm/s in group B (P = .147) as well as ulnar artery diameter increase 0.29 +/- 0.16 mm in group A versus 0.29 +/- 0.26 cm in group B (P = .914)., Conclusion: Endoscopic radial artery is safe and does not compromise graft quality or forearm and hand circulation postoperatively. Along with providing a better cosmetic result, endoscopic artery harvesting reduces postoperative harvesting site pain and neurologic complications.

Background: The use of arterial grafts combined with the off-pump coronary artery bypass (OPCAB) procedure offers many advantages, but most of them are still to be proven in long-term studies. We present our 5-year experience in combining these 2 strategies in coronary surgery., Methods: From February 1998 to December 2002 we operated on 155 patients (146 men and 9 women) for multiple arterial graft myocardial revascularization. All procedures were performed as OPCAB grafting using internal mammary and radial arteries. The mean +/- SD was 58 +/- 9 years for patient age, 57% +/- 11% for left ventricle ejection fraction, and 2.3 +/- 1.9 for the EuroSCORE. We reviewed perioperative and postoperative data and in-hospital mortality in our patients., Results: A total of 356 distal anastomoses were created, an average of 2.3 per patient. The left internal mammary artery was used as a graft in 153 patients (98%), the right internal mammary artery was used in 13 patients (8%), and the radial artery was used in 146 patients (94%). No venous grafts were used. There were 4 reopenings (2.6%) because of mediastinal bleeding. Four patients (2.6%) experienced perioperative myocardial infarction, and 2 patients (1.3%) had permanent neurologic dysfunction. Five patients (3.2%) died in the hospital within 30 days of the operation., Conclusion: Our experience shows that arterial myocardial revascularization can be safely performed as an OPCAB procedure, even in the treatment of multiple-vessel coronary disease. The long-term benefit for patients is to be evaluated in the future.

Objective: The concept of cardiac surgery on the beating heart is acceptable rationale for the cardiac surgery in the next millenium. Beating heart (off-pump) coronary artery bypass grafting (CABG) techniques have led us to consider the possibility for performing the aortic and mitral valve surgery (mitral valve repairs and replacements - with or without CABG) on the beating heart with the technique of retrograde oxygenated coronary sinus perfusion., Methods: We used the technique of retrograde oxygenated blood coronary sinus perfusion in 78 patients (Group All) - (36 patients were with extremely low ejection fraction (Group X) - 62% of whom were in New York Heart Association (NYHA) class 4 and 34% of whom were in NYHA class 3). The procedures for the patients were: aortic, mitral and tricuspid valve surgery, in combination with CABG in ischemic patients. CABG was done in all the cases off-pump. In addition, we performed a case match study for 37 patients with good ejection fraction (51.65 +/- 11.88) (Beating Heart Group) operated on the beating heart with most appropriate group of patients (No. 37) operated in our institutions on arrested heart (ejection fraction 51.07 +/- 12.93) (Arrested Heart Group). The case match selection criteria were: gender, left ventricular ejection fraction, atrial fibrillation, hypertension, pulmonary hypertension, and diabetes. The selected beating heart group and selected arrested heart groups were without statistically significant differences for the mentioned criteria., Results: There were statistically significant differences between Beating Heart Group and Arrested Heart Group in the duration of Cardiopulmonary Bypass Time (69.35 +/- 13.52 min. versus 93.59 +/- 28.54 min.), p<0.001, and statistically significant differences in Aortic Cross Clamp Time (46.5 +/- 8.95 min. versus 61.5 +/- 18.34 min.), p<0.001. The values for Creatinin Kinase (CK) and LDH were not statistically different, however the absolute values for Beating Heart Group were lower. There was no statistical difference in complication rate for both the groups for: sternal infection, bleeding, death, atrial fibrillation, AV block and neurological complications. The total early mortality for all the patients was 5.1% (4 out of 78) - for the group X 8.3 % (3 of 36 patients). Two were in-hospital deaths. One patient with triple-vessel disease and acute mitral insufficiency on intra aortic balloon pump (IABP) had been operated on 6 days after acute myocardial infarction (AMI). The cause of the death was systemic meticillin resistant staphylococus aureus (MRSA) infection - (eight days prior to our operation, arthrodesis of the talocrural joint was performed by an orthopedic surgeon). The other death was a female patient who was operated on after previous multiple cerebrovascular infarctions (CVI) (cause of the death was CVI). In addition, one patient died one month after the operation because of prosthetic valve endocarditis (PVE) on aortic and mitral valves (silver-coated silzone aortic and mitral valves were implanted because of chronic latent asymptomatic tibial osteitis). None of these deaths were cardiac related., Conclusions: We conclude that beating heart valve surgery (any combination) with or without CABG significantly lower the cardiopulmonary bypass and aortic cross clamp time. In addition, the advantages of beating-heart surgery are 1) the perfused myocardial muscle, 2) the heart is not doing any work, 3) no reperfusion injury, 4) the possibility for ablation of atrial fibrillation on the beating heart, and 5) testing of the mitral valve repair is done in real physiologic conditions in the state of left ventricle beating tonus. The procedure could be the procedure of choice for the valve operation or combined operations (valve operation and CABG) in high-risk patients with low ejection fractions. There is no doubt that at present day in cardiac surgery exist at least two major factors for mortality and morbidity after cardiac surgery, which are operation - related, namely cardiopulmonary bypass time and its duration and aortic cross clamp time (ischemic time of myocardium). In the last few years a number of different techniques emerged in the field of cardiac surgery, which were directed toward better results in the selected high risk patients or to minimize the deleterious effects of cardiopulmonary bypass (CPB) on the overall postoperative performance [Calafiore 1996, Tasdemir 1998]. Due to the fact, that the cardiac muscle should be protected at most during the cardiac arrest, retrograde blood cardioplegia was successfully introduced [Buckberg 1990], and more - the warm cardioplegia is being used recently [Kawasuji 1997]. The natural status of the human heart is the beating status, so it is reasonable to try to perform the operations on the beating heart. This has been done recently with the MID - CAB and OP - CAB (off-pump CABG) operations [Tasdemir 1998]. The retrograde warm blood cardioplegia has therefore led us to the premise, that with retrograde oxygenated blood perfusion it would be possible to achieve the operations on the beating heart even in the open heart surgery, such as aortic and/or mitral valve surgery. All will agree that the most damaging effect of the cardioplegia is the reperfusion injury [Allen 1997], and it is obvious that with the technique of retrograde continuous oxygenated blood perfusion this effect will be canceled. In this article, we would like to show the how-to technique for the operations on the beating heart in the case of operations on the aortic valve replacement (AVR) with mitral valve repair (MVR) or replacement MVR and with/without concomitant coronary artery bypass (CABG) surgery. The tricuspid valve repair (PTV) is normally done on the beating heart and there it is realized what problems or technical difficulties may arise during procedures on the mitral valve: the walls of the ventricles are not flattened and the exposure of the mitral valve is challenging task. Furthermore, the free walls of the ventricles with interventricular septum are in the state of the tonus, so every force applied to better expose the aortic or mitral valve is not acceptable

The aim of this study was to assess the diagnostic accuracy of transthoracic (TTE) and transesophageal echocardiography (TEE) for the detection of atrial masses. The authors' own experiences with the use of TTE and TEE images in the assessment of atrial masses are reported. These masses included tumors, thrombi, and valvular vegetations. The study groups consisted of 14 consecutive patients (7 women an 7 men), age range 24-72 (mean age 56.6 < +13.4) years. Eleven patients had left atrial tumor, two patients had atrial thrombi, and one patient had vegetation in left atrium detected with TEE. Eight patients had left atrial myoma, two patients had right atrial myxoma, and one patient had right atrial leiomyosarcoma. There was no false negative and no false positive TEE diagnosis, yielding a 100% sensitivity and specificity of TEE in detecting atrial masses. TEE detected atrial masses in six (43%) patients, provided poor images in five (36%) patients, and failed to reveal atrial masses in three (21%) patients. The TEE diagnosis was confirmed by surgery and pathohistology in all patients. The ability of TEE to visualize both atria with great diagnostic accuracy makes it a very valuable procedure in the assessment of atrial masses.