Aortic Valve Repair with External Annuloplasty in Bicuspid versus Tricuspid Aortic Valve Patients.

Surgical repair for regurgitant bicuspid aortic valve (BAV) is promising but underutilized due to perceived complexities and lack of long-term data. This study evaluated the efficacy of valve-sparing root remodeling (VSRR) or isolated valve repair combined with calibrated external ring annuloplasty in BAV versus tricuspid aortic valve (TAV) patients. All patients operated on for aortic regurgitation and/or aneurysm at our institution between 2014 and 2022 were included and entered into the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR). Patients with successful repair at index surgery (100% in the BAV group, 93% in the TAV group, p = 0.044) were included in a systemic follow-up with echocardiography at regular intervals. Among 132 patients, 58 were in the BAV (44%) and 74 in the TAV group (56%). There were no inter-group differences in preoperative patient characteristics, except BAV patients being significantly younger (47 ± 18 y vs. 60 ± 14 y, p < 0.001) and having narrower aortic roots at the level of sinuses (41 ± 6 mm vs. 46 ± 13 mm, p < 0.001) and sinotubular junctions (39 ± 10 mm vs. 42 ± 11, p = 0.032). No perioperative deaths were recorded. At four years, there was no significant difference in terms of overall survival (96.3% BAV vs. 97.2% TAV, p = 0.373), freedom from valve reintervention (85.2% BAV vs. 93.4% TAV, p = 0.905), and freedom from severe aortic regurgitation (94.1% BAV vs. 82.9% TAV, p = 0.222). Surgical repair of BAV combined with extra-aortic annuloplasty can be performed with low perioperative morbidity and mortality and excellent mid-term results which are comparable to TAV repair.

Enterobacter cloacae septicemia in a triple-cannula extracorporeal membrane oxygenation circulatory support treated with Seraph-100 Microbind affinity blood filter.

Bloodstream infections (BSI) are frequently encountered during extracorporeal membrane oxygenation (ECMO) support. Once septicemia is observed, treatment should be rapid, adequate, and multifaceted, particularly in advanced ECMO configurations. We report on a case of a 60-year-old male patient with acute-on-chronic heart failure due to ischemic cardiomyopathy. The treatment was complicated by cardiogenic shock requiring veno-arterial ECMO support, and, due to persistent pulmonary congestion, an upgrade with an additional left-atrial drainage cannula. After seven days of ECMO support, septicemia with shock ensued. Ex iuvantibus antibiotic treatment was started promptly. We wanted to minimize the likelihood of bacterial biofilm build-up requiring an exchange of the ECMO circuit and cannula, which was expected to be challenging. Therefore, we added a Seraph-100 Microbind affinity blood filter (providing blood purification with the potential for rapid bacterial clearance) to the ECMO circuit. Initial blood cultures tested positive for Enterobacter cloacae. Following a course of Seraph-100 treatment, bacteremia, septicemia, and shock resolved. There was no need for a circuit or cannula exchange. The additional eleven days of ECMO support were uneventful. The patient was successfully bridged to long-term mechanical circulatory support. We believe that the synergistic effect of early implementation of both broad-spectrum antibiotic treatment and blood purification with the potential for rapid bacterial clearance (such as the one provided with the Seraph-100 Microbind affinity blood filter) is crucial in BSI in patients receiving advanced ECMO.

Comparison between OPCABG and CABG Surgical Revascularization Using Transit Time Flow Measurement (TTFM).

OBJECTIVE: To compare the intraoperative quality of coronary anastomoses performed with or without cardiopulmonary bypass using transit time flow measurement (TTFM) parameters. METHODS: We collected data from 588 consecutive patients who underwent surgical revascularization. We retrospectively reviewed data from two groups: 411 with cardiopulmonary bypass (CABG group) and 177 off-pump (OPCABG group). Transit time flow measurement parameters: mean graft flow (MGF), pulsatile index (PI), and diastolic filing (DF) were measured for each graft and patient. RESULTS: Patients in the OPCABG group had higher EuroSCORE compared with the CABG group (3.53 ± 2.32 versus 2.84 ± 2.15, P = .002). Overall comparison of TTFM parameters showed no statistical difference between the two surgical techniques except for PI in circumflex artery territory, which was higher in the OPCABG group for all types of grafts 3.0 ± 4.9 versus 2.4 ± 2.0 in, P = .026. CONCLUSION: The comparison between OPCABG and CABG in this study showed comparable results with both surgical techniques. PI was higher in the OPCABG group in harder-to-reach vessel territories. Measurement of transit time may improve the quality, safety, and efficacy of coronary artery bypass grafting and should be considered as a routine procedure.

The epidemiological and clinical features of odontogenic infective endocarditis.

Antibiotic prophylaxis (AP) of infective endocarditis (IE) in dental practice is a controversial topic. We evaluated the characteristics of the odontogenic IE and assessed the practice and sources of information pertaining to the topic utilized by the Croatian dentists. We conducted a retrospective review of consecutive medical charts of adult patients with IE, admitted to the University Hospital for Infectious Diseases in Zagreb, Croatia, between January 2007 and December 2017. In addition, a cross-sectional, self-reporting questionnaire survey was conducted with participation of 348 Croatian dentists. Of the 811 admissions for suspected IE (40.3% of all Croatian and 92.1% of all Zagreb hospitals), 386 patients were confirmed as definite IE: 68 with odontogenic IE and 318 with IE of other origin. Their first hospital admissions were analyzed. Definite odontogenic IE was defined as a positive echocardiographic result in conjunction with two separate positive blood cultures showing exclusive oral cavity pathogen or Streptococcus viridans associated with current or recent (< 1 month) dental, periodontal, or oral cavity infection. The annual number of new odontogenic IE patients appeared constant over time. In 91.2% of the cases, odontogenic IE was not preceded by a dental procedure; poor oral health was found in 51.5% of patients, and 47.1% had no cardiac condition that increases the IE risk. In-hospital mortality was 5.1% with conservative treatment and 4.5% with cardiac surgery and was much lower for odontogenic IE than in non-odontogenic IE (14.6% and 34.4%, respectively). An increasing number of admissions for non-odontogenic IE were observed in parallel with an increasing number of staphylococcal IE. Surveyed dentists (500 invited, 69.6% responded) were aware of the AP recommendations, but were largely reluctant to treat patients at risk. In people with poor oral health, AP should be considered regardless of cardiac risk factors. Improvement of oral health should be the cornerstone of odontogenic IE prevention.

The Dark Side of the Heart: Cardiovascular Manifestation of Ochronosis.

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.

Immunoglobulin G4 Inflammatory Aortic Aneurysm Mimicking Acute Aortic Syndrome.

Immunoglobulin-G4-related disease (IgG4RD) is a novel clinical entity characterized by lymphoplasmacytic infiltrates presenting as an excessive fibrosis such as retroperitoneal inflammatory pseudotumor but rarely affecting the heart or the aorta. We describe a case of IgG4RD with multifocal aortic involvement presenting as an acute aortic syndrome.

Heart re-transplantation in Eurotransplant.

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.

LETTER TO THE EDITOR.

We read with great interest the report by Dr. Colak and coworkers about utilization of omentoplasty in poststernotomy mediastinitis treatment [Colak 2016]. In our opinion, several points need to be addressed.

Isolated Tricuspid Valve Libman-Sacks Endocarditis in Systemic Lupus Erythematosus with Secondary Antiphospholipid Syndrome.

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.

Successful treatment of annular rupture during transcatheter aortic valve implantation.

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.

Ventricular tachycardia: ominous sign of devastating prosthetic aortic valve dehiscence.

Prosthetic valve endocarditis (PVE) is the most feared complication after valve implantation. It usually results in substantial morbidity and mortality in the postoperative period. An adverse effect on the annulus can cause conduction disturbances in the atrioventricular (AV) node, resulting in a high-degree AV block. This study describes a case of PVE that predominantly presented with sustained monomorphic ventricular tachycardia, which indicated a severe clinical course of PVE caused by a significant displacement of the aortic valve prosthesis. In our opinion, a very pronounced flap valve motion of the dehisced valve probably caused, in the critical moment, coronary artery blood flow limitation by means of coronary microembolization, which produced temporary ischemia and provoked sustained ventricular tachycardia. Furthermore, disturbances of rhythm such as ventricular tachycardia in the setting of endocarditis indicate a high-risk condition and should mandate fast and thorough noninvasive diagnostic procedures to obtain correct diagnosis even in the case of mild, slowly progressing disease.

Cardiac surgery-associated acute kidney injury: risk factors analysis and comparison of prediction models.

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 Role of Standard Echocardiographic Parameters in Endomyocardial Biopsy Proven Cardiac Amyloidosis.

Primary light-chain (AL) amyloidosis is a plasma cell dyscrasia associated with the deposition of immunoglobulin-derived amyloid in multiple organs. In the heart, this results in an infiltrative cardiomyopathy, with increased left ventricular wall thickness, normal or decreased left ventricular (LV) cavity size and congestive heart failure. Cardiac involvement is a major determinant of prognosis of AL amyloidosis. We report a patient with cardiac amyloidosis proven by cardiac biopsy, and aim to point out at transthoracic echocardiography as the hallmark of diagnostics. Echocardiography revealed increased LV thickness at 20mm, impaired LV ejection fraction (EF) at 35%, enlarged atria, transmitral deceleration time at 156 ms and increased E/A ratio at 4.25. Early diagnosis and intervention can have a significant impact on the patient's response to treatment, especially when the underlying condition involves a malignancy or infiltrative disorder. Standard transthoracic echocardiography as a noninvasive diagnostic tool is valuable and has a significant role in diagnosis and prognosis.

Off-pump myocardial revascularization attenuates endothelin-1 expression in systemic, pulmonary, and coronary circulation.

OBJECTIVE: The objective of this study was to evaluate the influence of cardiopulmonary bypass (CPB) on endothelin-1 (ET-1) expression in various circulation compartments in patients undergoing myocardial revascularization. METHODS: A total of 30 patients were randomized to undergo myocardial revascularization with (CABG, n = 15) or without (OPCAB, n = 15) CPB. Samples were taken preoperatively, after establishing CPB and after CPB (CABG group), prior to and after revascularization (OPCAB group), and 6 and 24 h postoperatively. Values of ET-1 were compared between groups at all time points and correlated with postoperative cardioselective enzyme values and clinical parameters. RESULTS: In OPCAB group, ET-1 levels did not significantly vary between time points. In CABG group, ET-1 levels were significantly elevated vs. baseline in arterial: ART-T2 vs. ART-T0 (1.83 ± 1.81 vs. 0.76 ± 1.07 fmol/mL, p = 0.05), pulmonary: SG-T2 vs. SG-T0 (2.70 ± 2.75 vs. 0.39 ± 0.28 fmol/mL, p < 0.001) and SG-T3 vs. SG-T0 (1.56 ± 0.28 vs. 0.39 ± 0.28 fmol/mL, p < 0.001), and coronary circulation CS-T2 vs. CS-T1 (1.12 ± 0.49 vs. 0.27 ± 0.09 fmol/mL, p = 0.01). ET-1 levels were significantly higher in CABG group in all vascular compartments: ART-T2 (1.83 ± 1.81 vs. 0.17 ± 0.16 fmol/mL, p = 0.02), ART-T4 (0.99 ± 0.56 vs. 0.24 ± 0.12 fmol/mL, p = 0.01), SG-T1 (0.59 ± 0.15 vs. 0.25 ± 0.13 fmol/mL, p = 0.01), SG-T2 (2.70 ± 2.75 vs. 0.30 ± 0.24 fmol/mL, p = 0.004), SG-T3 (1.56 ± 0.28 vs. 0.35 ± 0.31 fmol/mL, p < 0.001), SG-T4 (1.34 ± 0.11 vs. 0.34 ± 0.16 fmol/mL, p < 0.001), and CS-T2 (1.12 ± 0.49 vs. 0.12 ± 0.12 fmol/mL, p = 0.004). Coronary sinus ET-1 level after CPB (CS-T2) in CABG group correlated positively with troponin-I level 24 h postoperatively (r(2) = 0.802, p = 0.02) CONCLUSION: Off-pump myocardial revascularization attenuates ET-1 expression in all investigated vascular compartments. Elevated coronary ET-1 levels after CPB in CABG group correlate with troponin-I levels 24 h postoperatively.

Why pulsatility still matters: a review of current knowledge.

Continuous-flow left ventricular assist devices (LVAD) have become standard therapy option for patients with advanced heart failure. They offer several advantages over previously used pulsatile-flow LVADs, including improved durability, less surgical trauma, higher energy efficiency, and lower thrombogenicity. These benefits translate into better survival, lower frequency of adverse events, improved quality of life, and higher functional capacity of patients. However, mounting evidence shows unanticipated consequences of continuous-flow support, such as acquired aortic valve insufficiency and acquired von Willebrand syndrome. In this review article we discuss current evidence on differences between continuous and pulsatile mechanical circulatory support, with a focus on clinical implications and potential benefits of pulsatile flow.

Aortic valve endocarditis in a transplanted heart after urethral instrumentation.

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.

[Recovery after long-term pulsatile mechanical circulatory support in patient with chronic heart failure: a case report]. / Oporavak nakon dugotrajne mehanicke cirkulatorne potpore u bolesnika s kronicnim zatajivanjem srca: prikaz bolesnika.

Use of mechanical circulatory support (MCS) is a part of today's standard therapy in the treatment of end-stage heart failure. In this paper we describe characteristics of Thoratec pVAD device for MCS, implantation techniques, as well as the most important advantages and complications of application of the device. We present a 41-year-old patient with dilatated cardiomyopathy, who was the first recipient ofparacorporeal left ventricular assist device (LVAD) in the Republic of Croatia due to end-stage heart failure. After heart function recovery the patient was successfully weaned from MCS after 130 days of support.

Asymptomatic calcifying fibrous pseudotumor compressing heart cavities.

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.