Sex-based disparities in ascending aortic aneurysm surgery outcomes: a comprehensive analysis of 1148 consecutive patients with propensity-score matching.

BACKGROUND: Women undergoing cardiac surgery have been historically recognized to carry higher periprocedural mortality risk. We aimed to investigate the influence of sex on clinical presentation, perioperative, and long-term outcomes in patients who undergo surgery for ascending aortic aneurysm. METHODS: We conducted a retrospective review of 1148 consecutive patients (380 [33.1%] female) who underwent thoracic aortic surgery under moderate hypothermic circulatory arrest for ascending aortic aneurysms between 2001 and 2021. Baseline and operative characteristics, in-hospital mortality, and survival were compared between male and female patients before and after propensity-score-matched (PSM) analysis. RESULTS: Women were significantly older (median age: 69 [IQR: 63-75] vs. 67 [IQR: 58-73]; P < 0.001), while men had a higher prevalence of aortic valve stenosis, bicuspid valve and coronary artery disease at the time of surgery (P < 0.05). After PSM, EuroSCORE II (4.36 [2.68; 6.87] vs. 3.22 [1.85; 5.31]; p < 0.001), and indexed aortic diameter were significantly higher in female patients (2.94 [2.68; 3.30] vs. 2.58 [2.38; 2.81] cm/m2, p < 0.001). In the matched cohort, men were more likely to experience postoperative delirium (18.1% vs. 11.5%; P = 0.002), and postoperative neurological deficits (6.7% vs. 3.0%, P = 0.044),. Female patients were more likely to receive postoperative packed red blood cells (p = 0.036) and fresh frozen plasma (p = 0.049). In-hospital and 30-day mortality was similar between both groups. Long-term survival was comparable between both groups with 88% vs. 88% at 5 years, 76% vs. 71% at 10 years, and 59% vs. 47% at 15 years. CONCLUSION: Female patients required more transfusions, while males had a higher incidence of postoperative delirium and neurological deficits. Differences in preoperative age and timing of surgery between the sexes could be attributed to variations in comorbidity profiles and the greater prevalence of concomitant surgery indications in males.

The Best Second Arterial Conduit for Coronary Artery Bypass Grafting: A Meta-Analysis of Reconstructed Individual Patient Data.

Multiple arterial conduit revascularization in coronary bypass surgery is being advocated over the use of venous conduits. However, there is a critical gap regarding the optimal sequence of arterial conduit selection following the left internal thoracic artery. This study is the first individual patient data meta-analysis, which aimed to compare the right internal thoracic artery (RITA) versus the radial artery (RA) as a second-best arterial conduit. A comprehensive literature search was conducted in MEDLINE, Embase, Scopus, and CENTRAL. A forward-backward citation check was performed to identify other relevant studies. The study protocol was registered in the PROSPERO (CRD42023455543). Eligible studies included randomized controlled trials and propensity-score-matched cohort studies reporting long-term outcomes (>3 years) after coronary bypass surgery using the RITA versus RA as the second arterial conduit after left internal thoracic artery. Overall, long-term survival between the RITA and RA groups showed no significant difference. Landmark analyses demonstrated the superiority of RITA as a second arterial conduit at 1 [hazard ratio (HR): 0.86 (95% CI, 0.75-0.99), P = 0.036], 2 [0.83 (95% CI, 0.72-0.96), P = 0.011], and 5 years [HR: 0.80 (95% CI, 0.68-0.95), P = 0.036] post-surgery. Freedom from major cardiovascular events was significantly higher using the RITA conduit [HR: 0.72 (95% CI, 0.59-0.89), P = 0.002]. This study supports the use of RITA, especially when used in a skeletonized in situ fashion, as a second choice following the left internal thoracic artery as it has the potential to enhance long-term survival and outcomes. Further research with standardized surgical techniques is warranted.

Pressure-dimension index and left ventricular sphericity index following HeartMate II and HeartMate 3 implantation.

AIMS: This study aimed to compare the changes in the left ventricle (LV) and right ventricle (RV) geometry and performance after the implantation of HeartMate II (HMII) and HeartMate 3 (HM3). In addition, we investigated whether the echocardiographic parameters LV sphericity index (LVSI) and the novel pressure-dimension index (PDI) can predict post-operative right ventricular failure (RVF). METHODS AND RESULTS: Between 2012 and 2020, 46 patients [HMII (n = 22) and HM3 (n = 24)] met the study's criteria and had echocardiography tests pre-operatively, 6 and 12 months post-operatively. The LVSI and PDI were calculated together with the standard LV and RV echocardiographic parameters. The mean follow-up was 24 ± 7 months. In both groups, the LV end-diastolic diameter (LVEDD) significantly decreased 12 months post-operatively compared with the pre-operative values (HMII: 6.4 ± 1.4 cm vs. 5.7 ± 0.9 cm, P = 0.040; HM3: 6.7 ± 1.3 cm vs. 5.5 ± 0.9 cm, P < 0.01, respectively). RV function 12 months post-operatively was better in the HM3 group than in the HMII group, as indicated by a significantly higher RV fractional area change (RVFAC) in the HM3 group than in the HMII group 12 months post-operatively (35 ± 12% vs. 26 ± 16%, P = 0.039), significantly higher tricuspid annular plane systolic excursion (TAPSE) in the HM3 group 12 months post-operatively compared with the HMII group (13.9 ± 1.9 mm vs. 12.0 ± 2.1 mm, P = 0.002), and the tissue Doppler estimated tricuspid annular systolic velocity (TASV) was also significantly higher in the HM3 group 12 months post-operatively compared with the HMII group (11.5 ± 2.7 mm/s vs. 9.9 ± 1.5 mm/s, P = 0.020). The LVSI value was significantly higher 12 months post-operatively in the HMII group than in the HM3 group (1.2 ± 0.4 vs. 0.8 ± 0.2, P = 0.001, respectively), indicating worse geometric changes. The PDI decreased 12 months post-operatively in the HM3-group compared with the baseline (3.4 ± 1.4 mmHg/cm2 vs. 2.0 ± 0.8 mmHg/cm2, P < 0.001). In the univariate and multivariate analyses, only the pre-operative PDI was a predictor of post-operative RVF [odds ratio: 3.84 (95% CI: 1.53-18.16, P = 0.022)]. The area under the curve for pre-operative PDI was 0.912. The 2 year survival was significantly better in the HM3 group (log-rank, P = 0.042). CONCLUSIONS: The design of HM3 offered better geometrical preservation of the LV and enabled normal PDI values, leading to improved RV function, as indicated by better RVFAC, TAPSE, and TASV values. The use of pre-operative PDI as an additional tool for established risk scores might offer a better pre-operative predictor of RVF.

Stroke outcomes following durable left ventricular assist device implant in patients bridged with micro-axial flow pump: Insights from a large registry.

BACKGROUND: Stroke after durable left ventricular assist device (d-LVAD) implantation portends high mortality. The incidence of ischemic and hemorrhagic stroke and the impact on stroke outcomes of temporary mechanical circulatory support (tMCS) management among patients requiring bridge to d-LVAD with micro-axial flow-pump (mAFP, Abiomed) is unsettled. METHODS: Consecutive patients, who underwent d-LVAD implantation after being bridged with mAFP at 19 institutions, were retrospectively included. The incidence of early ischemic and hemorrhagic stroke after d-LVAD implantation (<60 days) and association of pre-d-LVAD characteristics and peri-procedural management with a specific focus on tMCS strategies were studied. RESULTS: Among 341 patients, who underwent d-LVAD implantation after mAFP implantation (male gender 83.6%, age 58 [48-65] years, mAFP 5.0/5.5 72.4%), the early ischemic stroke incidence was 10.8% and early hemorrhagic stroke 2.9%. The tMCS characteristics (type of mAFP device and access, support duration, upgrade from intra-aortic balloon pump, ECMELLA, ECMELLA at d-LVAD implantation, hemolysis, and bleeding) were not associated with ischemic stroke after d-LVAD implant. Conversely, the device model (mAFP 2.5/CP vs. mAFP 5.0/5.5: HR 5.6, 95%CI 1.4-22.7, p = 0.015), hemolysis on mAFP support (HR 10.5, 95% CI 1.3-85.3, p = 0.028) and ECMELLA at d-LVAD implantation (HR 5.0, 95% CI 1.4-18.7, p = 0.016) were associated with increased risk of hemorrhagic stroke after d-LVAD implantation. Both early ischemic (HR 2.7, 95% CI 1.9-4.5, p < 0.001) and hemorrhagic (HR 3.43, 95% CI 1.49-7.88, p = 0.004) stroke were associated with increased 1-year mortality. CONCLUSIONS: Among patients undergoing d-LVAD implantation following mAFP support, tMCS characteristics do not impact ischemic stroke occurrence, while several factors are associated with hemorrhagic stroke suggesting a proactive treatment target to reduce this complication.

Impact of Diabetes in Patients With Acute Myocardial Infarction Undergoing Coronary Artery Bypass Surgery Within 48 Hours.

BACKGROUND: Diabetic patients with coronary artery disease may benefit from elective coronary artery bypass graft (CABG) surgery. It is unknown whether this merit is transferable to patients with acute myocardial infarction (AMI) undergoing surgery. METHOD: A total of 1,427 patients underwent CABG within 48 hours of being diagnosed with AMI at the current institution between 2001 and 2019. Of these patients, 206 (14.4%) had insulin-dependent diabetes mellitus (IDDM) and 148 (10.4%) had non-insulin dependent diabetes mellitus (NIDDM). Retrospective data analysis was performed. RESULTS: Patients with NIDDM showed the highest perioperative risk profile, with a EuroScore II of 11.6 (±10.3) compared with 7.8 (±8.0) in non-diabetic patients and 8.4 (±7.8) in patients with IDDM (p<0.001). Sub-analysis demonstrated a higher proportion of non-ST-elevation myocardial infarction patients in the NIDDM cohort compared with the IDDM cohort (70.9% vs 56.8%; p=0.005). Postoperatively, NIDDM patients had more sepsis (p<0.01) and longer ventilation times (p<0.001) compared with non-DM and IDDM patients (p<0.01). Wound healing complications were rare, but almost twice as high in NIDDM patients compared with non-DM and IDDM patients (4.7% vs 0.9% vs 2.4%, respectively). The 30-day mortality was highest in the NIDDM cohort (18.3% vs 11.3% vs 7.8%; p=0.012). Analysis of survival for up to 15 years revealed a significantly reduced survival of diabetic patients compared with non-diabetic patients, with lowest survival rates in NIDDM patients (p<0.001). CONCLUSIONS: Non-insulin dependent diabetes mellitus patients undergoing CABG within 48 hours of being diagnosed with AMI are at increased risk of short-term and long-term complications. Therefore, this particular group should undergo a careful evaluation concerning the expected risks and benefits of CABG in this setting.

Incidence Rates of Penn Classes and Class-Specific Mortality in Acute Type A Aortic Dissection Patients: An Epidemiologic Systematic Review and Meta-Analysis.

Acute type A aortic dissection (ATAAD) is a life-threatening emergency that is associated with a high morbidity and mortality rate. One of the complications is end-organ ischemia, a known predictor of mortality. The primary aims of this meta-analysis were to summarize the findings of observational studies investigating the utility of the Penn classification system and to analyze the incidence rates and mortality patterns within each class. The electronic databases PubMed, MEDLINE, and Embase were searched through to April 2023. These were filtered by multiple reviewers to give 10 studies that met the inclusion criteria. The extracted data included patient characteristics, and primary outcomes were the incidence rates of different Penn classes, along with the corresponding mortality for each class. Out of 1,512 studies identified during the initial search, 10 studies, including 4,494 patients, met the inclusion criteria. The pooled incidence of Penn A was highest at 0.55 (95% CI 0.52, 0.58), followed by Penn B at 0.21 (95% CI 0.17, 0.25), and finally Penn C at 0.14 (95% CI 0.11, 0.17). Patients with Penn BC were found to be at the highest risk of death, as their early mortality rates were 0.36 (95% CI 0.31, 0.41). Within those populations, the subtype with the highest individual mortality was Penn C at 0.21 (95% CI 0.15, 0.27), followed by Penn B at 0.19 (95% CI 0.15, 0.23) and Penn A at 0.07 (95% CI 0.05, 0.10). Among patients presenting with ATAAD, class A was most frequently observed, followed by classes B, C, and BC. These findings indicate an incremental increase in mortality rates with the progression of Penn classification.

Tricuspid Regurgitation and TAVR: Outcomes, Risk Factors and Biomarkers.

Background. The significance of concomitant tricuspid regurgitation (TR) in the context of transcatheter aortic valve replacement (TAVR) remains unclear. This study aimed to analyze the severity of TR before and after TAVR with regard to short- and long-term survival and to analyze the influencing factors. Methods. In our retrospective analysis, TR before and after TAVR was examined and patients were classified into groups accordingly. Special attention was paid to patients with post-interventional changes in TR. Mortality after TAVR was considered the primary endpoint of the analysis and major complications according to the Valve Academic Research Consortium 3 (VARC3) were compared. Moreover, biomarkers and risk factors for worsening or improvement of TR through TAVR were analyzed. Results. Among 775 patients who underwent TAVR in our center between January 2009 and December 2019, 686 patients (89%) featured low- and 89 patients (11%) high-grade TR. High-grade pre-TAVR TR was associated with worse short- (30-day), mid- (2-year) and long-term survival up to 8 years. Even though in nearly half of the patients with high-grade TR the regurgitation improved within seven days after TAVR (n = 42/89), this did not result in a survival benefit for this subgroup. On the other hand, a worsening of low-grade TR was seen in more than 10% of the patients (n = 73/686), which was also associated with a worse prognosis. Predictors of worsening of TR after TAVR were adipositas, impaired right ventricular function and the presence of mild TR. Age, atrial fibrillation, COPD, impaired renal function and elevated cardiac biomarkers were risk factors for mortality after TAVR independent from the grade of TR. Conclusions. Not only pre-interventional, but also post-TAVR high-grade TR is associated with a worse prognosis after TAVR. TAVR can change concomitant tricuspid regurgitation, but improvement does not have any impact on short- and long-term survival. Worsening of TR after TAVR is possible and impairs the prognosis.

Case Report: The woman with the big heart-an imaging-guided attempt of surgical reduction.

In a female patient with acute cardiac decompensation, an auxiliary finding of a giant left atrium emerged. The surgical therapy of the atrial reduction, in addition to a mitral valve replacement and a coronary artery bypass grafting, is hereby presented.

Risk Factor Analysis for 30-day Mortality After Surgery for Infective Endocarditis.

BACKGROUND: Infective endocarditis (IE) remains a challenging disease associated with high mortality. Several scores have been suggested to assess surgical risk. None was sufficiently adequate. We therefore analyzed risk factors for 30-day mortality. METHODS: A total of 438 consecutive patients had surgery for IE in our department between 2002 and 2020. Patients were divided into two groups, one consisting of 30-day survivors (362 patients; 82.6%) and one of nonsurvivors (76 patients; 17.4%). Logistic regression analysis on pre- and intraoperative risk factors was performed and the groups were compared by univariable analyses. RESULTS: Patients in mortality group were older (69 [58, 77] vs. 63 [50, 72] years; p < 0.001), EuroSCORE II was higher (24.5 [12.1, 49.0] vs. 8.95 [3.7, 21.2]; p < 0.001) and there were more females. More frequently left ventricular function (below 30%), preoperative acute renal insufficiency, chronic dialysis, insulin-dependent diabetes mellitus, NYHA-class IV (New York Heart Association heart failure class IV), and cardiogenic shock occurred. Patients in the mortality group were often intensive care unit patients (40.8 vs. 22.4%; p < 0.001) or had a preoperative stroke (26.3 vs. 16.0%; p = 0.033). In the nonsurvivor group Staphylococcus aureus was prevalent. Streptococcus viridans was common in the survivor group as was isolated aortic valve endocarditis (32.9 vs. 17.1%; p = 0.006). Prosthetic valve endocarditis (PVE) and abscesses occurred more often in nonsurvivors. In the logistic regression analysis, female gender, chronic dialysis, cardiogenic shock, and NYHA IV and from intraoperative variables PVE, cardiopulmonary bypass time, and mitral valve surgery were the strongest predictors for 30-day mortality. CONCLUSION: This study indeed clearly indicates that significant risk factors for 30-day mortality cannot be changed. Nevertheless, they should be taken into account for preoperative counselling, and they will alert the surgical team for an even more careful management.

Evaluation of myocardial work changes after lung resection-the significance of surgical approach: an echocardiographic comparison between VATS and thoracotomy.

OBJECTIVE: Considering the controversial benefits of video-assisted thoracoscopic surgery (VATS), we intended to evaluate the impact of surgical approach on cardiac function after lung resection using myocardial work analysis. METHODS: Echocardiographic data of 48 patients (25 thoracotomy vs. 23 VATS) were retrospectively analyzed. All patients underwent transthoracic echocardiography (TTE) within 2 weeks before and after surgery, including two-dimensional speckle tracking and tissue Doppler imaging. RESULTS: No notable changes in left ventricular (LV) function, assessed mainly using the LV global longitudinal strain (GLS), global myocardial work index (GMWI), and global work efficiency (GWE), were observed. Right ventricular (RV) TTE values, including tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (TASV), right ventricular global longitudinal strain (RVGLS), and RV free-wall GLS (RVFWGLS), indicated greater RV function impairment in the thoracotomy group than in the VATS group [TAPSE(mm) 17.90 ± 3.80 vs. 21.00 ± 3.48, p = 0.006; d = 0.84; TASV(cm/s): 12.40 ± 2.90 vs. 14.70 ± 2.40, p = 0.004, d = 0.86; RVGLS(%): - 16.00 ± 4.50 vs. - 19.40 ± 2.30, p = 0.012, d = 0.20; RVFWGLS(%): - 11.50 ± 8.50 vs. - 18.31 ± 5.40, p = 0.009, d = 0.59; respectively]. CONCLUSIONS: Unlike RV function, LV function remained preserved after lung resection. The thoracotomy group exhibited greater RV function impairment than did the VATS group. Further studies should evaluate the long-term impact of surgical approach on cardiac function.