Klotho as an Early Marker of Acute Kidney Injury Following Cardiac Surgery: A Systematic Review.

Acute kidney injury is a common complication following cardiac surgery (CSA-AKI). Serum creatinine levels require a minimum of 24-48 h to indicate renal injury. Nevertheless, early diagnosis remains critical for improving patient outcomes. A PRISMA-compliant systematic review of the PubMed and CENTRAL databases was performed to assess the role of Klotho as a predictive biomarker for CSA-AKI (end-of-search date: 17 February 2024). An evidence quality assessment of the four included studies was performed with the Newcastle-Ottawa scale. Among the 234 patients studied, 119 (50.8%) developed CSA-AKI postoperatively. Serum Klotho levels above 120 U/L immediately postoperatively correlated with an area under the curve (AUC) of 0.806 and 90% sensitivity. Additionally, a postoperative serum creatinine to Klotho ratio above 0.695 showed 94.7% sensitivity and 87.5% specificity, with an AUC of 92.4%, maintaining its prognostic validity for up to three days. Urinary Klotho immunoreactivity was better maintained in samples obtained via direct catheterization rather than indwelling catheter collection bags. Storage at -80 °C was necessary for delayed testing. Optimal timing for both serum and urine Klotho measurements was from the end of cardiopulmonary bypass to the time of the first ICU lab tests. In conclusion, Klotho could be a promising biomarker for the early diagnosis of CSA-AKI. Standardization of measurement protocols and larger studies are needed to validate these findings.

Endovascular Treatment of Type A Aortic Dissection: A Systematic Review and Meta-Analysis Using Reconstructed Time-to-Event Data.

OBJECTIVE: The undisputed gold standard of treatment for type A aortic dissections (TAAD) is open surgery. Anecdotal reports have assessed thoracic endovascular aortic repair (TEVAR) as a last resort for highly selected candidates. The present study aims to evaluate endovascular outcomes in TAAD patients who are unsuitable for open surgery whilst having TEVAR-compatible aortic anatomy. METHODS: A PRISMA-compliant systematic search of the PubMed, Scopus, and Cochrane databases was performed up to 19 May 2022. Time-to-event data were reconstructed using Kaplan-Meier curves from the source literature. RESULTS: In 20 eligible studies, 311 patients underwent TEVAR for acute, subacute, or chronic TAAD. Mean age at the time of the operation was 60.70 ± 8.00 years and 75.48% (95% Confidence Interval [CI], 60.33-88.46%) of the included patients were males. Mean operative time was 169.40 ± 30.70 min. Overall, 0.44% (95% CI, 0.00-4.83%) of the cases were converted to salvage open surgery. Technical failure, stroke, and endoleaks occurred in 0.22%, 0.1%, and 8.52% of the cohort, respectively. Thirty-day postoperative complication rate was 7.08% (95% CI, 1.52-14.97%), whereas late complications developed in 16.89% (95% CI, 7.75-27.88%) of the patients. One-, three-, and five-year survival rates were estimated at 87.15%, 82.52% and 82.31%, respectively. Reintervention was required in 8.38% of the cohort over a mean follow-up of 32.40 ± 24.40 months. CONCLUSIONS: TEVAR seems to be feasible in highly selected patients with TAAD who cannot tolerate open surgery. Overcoming technical limitations and acquiring long-term data are warranted to safely define the place of endovascular treatment in the armamentarium of TAAD repair.

Aortic valve neocuspidization using the Ozaki technique: A meta-analysis of reconstructed patient-level data.

BACKGROUND: Aortic valve neocuspidization using the Ozaki technique has shown promising results both in adults and children. METHODS: A systematic search of the PubMed and Cochrane databases was performed up to November 13, 2021. Individual patient data were reconstructed and analyzed from the Kaplan-Meier curves of all eligible studies for time-to-event outcomes. RESULTS: We included a total of 22 studies reporting on 1,891 patients that underwent Ozaki reconstruction. Mean age at the time of surgery was 43.2 ± 24.5 years (65 ± 12.3 years for adult patients and 12.3 ± 3.8 years for pediatric patients). The most common indication was aortic stenosis (46.4%, 95% CI 34.1-58.6). Mean cross-clamp and cardiopulmonary bypass duration were 106.8 ± 24.8 minutes and 135.2 ± 35.1 minutes, respectively. Permanent pacemaker was implanted in 0.7% (95% CI 0.4-1.2) of the patients. At discharge, mean effective orifice area was 2.1 ± 0.5 cm2/m2. At latest follow-up, peak gradient was 15.7 ± 7.4 mm Hg and only 0.25% (95% CI 0-2.3) had moderate aortic insufficiency. In-hospital mortality was 0.7% (95% CI 0.1-1.7). Late mortality was 1.9% during a mean follow-up of 38.1 ± 23.8 months. One-year, 3-year, and 5-year freedom from reoperation rates were 98.0 %, 97.0 % and 96.5%, respectively. More than half of the reoperations were due to infective endocarditis (51.5%, 95% CI 18.3-84.0). In our cohort, the risk of endocarditis per patient per year was 0.5%. CONCLUSIONS: The midterm outcomes of the Ozaki procedure are excellent in terms of hemodynamics, survival, and freedom from reoperation. Acquiring long-term follow-up will help solidify this technique in the cardiac surgery armamentarium.

Multiple-valve Repair Facilitated by Aortic Ring Annuloplasty.

Early and late outcomes of patients undergoing multiple-valve procedures are better if all valves are repaired. Aortic/mitral multiple-valve repair has been limited by an inability to repair the more complex forms of aortic valve insufficiency. With the development of aortic ring annuloplasty 90% to 95% of aortic valve insufficiency pathologies now can be repaired, which opens most aortic/mitral multiple-valve procedures to the better repair outcomes. This report illustrates 4 cases of aortic/mitral ± tricuspid valve disease managed by multiple-valve repair.

Trans-aortic endoscopic ventricular thrombectomy in a patient with HIT and concomitant Aortic and ventricular thromboses.

Dual aortic and ventricular thrombi are rare following myocardial infraction. We report the case of a 56-year-old man who initially denied primary percutaneous coronary intervention as a result of psychological phobia. Initial pharmacological management by thrombolysis and heparin was followed by multiple arterial thromboses including those of the left ventricle and right iliac artery with a subsequent diagnosis of heparin-induced thrombocytopaenia. Ensuing surgical management revealed the unanticipated finding of an additional aortic sinus thrombosis that was excised. The left ventricular thrombus was removed endoscopically to prevent ventricular incisions. This case emphasizes the technical advantages of video-endoscopic management of intracardiac thrombi and highlights the unexpected nature of multiple thromboses associated with heparin-induced thrombocytopaenia.

Right atrial and septal reconstruction after tumor excision: the single-patch technique.

Surgical excision is the only therapy for benign atrial tumors, if serious complications are to be avoided. We propose a simplified technique whereupon a single autologous pericardial patch is used to not only close the septal defect, but to also reconstruct the right atrium. This new technique allows for wide excision of tumors without reduction of the right atrium, distortion of the tricuspid valve or traction on the atrioventricular node. We propose that this new approach will probably reduce the incidence of postoperative arrhythmias.

Combined transapical aortic valve implantation with coronary artery bypass grafting in a young patient with porcelain aorta.

The surgical management of porcelain aorta in patients requiring aortic valve replacement or coronary artery surgery carries a high morbidity and mortality and remains controversial. We report a successful transapical aortic valve implantation in combination with on-pump coronary artery bypass grafting in a young patient with severe aortic stenosis, left main coronary artery disease and porcelain aorta. Transapical aortic valve implantation is a minimally invasive surgical alternative that can be safely performed in combination with coronary artery bypass grafting and may become the treatment of choice, even in young patients with porcelain aorta.

Aortic valve replacement: is there an implant size variation across Europe?

BACKGROUND AND AIMS OF THE STUDY: Prompted by anecdotal evidence and observations by surgeons, an investigation was undertaken into the potential differences in implanted aortic valve prosthesis sizes, during aortic valve replacement (AVR) procedures, between northern and southern European countries. METHODS: A multi-institutional, non-randomized, retrospective analysis was conducted among 2,932 patients who underwent AVR surgery at seven tertiary cardiac surgery centers throughout Europe. Demographic and perioperative variables including valve size and type, body surface area (BSA) and early mortality were collected. Group analysis by patient geographic distribution and by annular diameter of the prosthesis utilized was conducted. Patients with a manufacturer's labeled prosthesis size > or = 21 mm were assigned to the 'large' aortic size subset, while those with a prosthesis size < 21 mm were assigned to the 'small' aortic size subset. Effective orifice area indices were calculated for all patients to assess the geographic distribution of patient-prosthesis mismatch. Univariable and multivariable logistic regression analyses adjusting for possible confounding variables were performed. RESULTS: Prostheses with diameter < 21 mm were implanted at almost twice the rate in southern Europe compared to the north (56.4% versus 26.7%, p < 0.01). The mean valve size was also smaller in southern compared to northern European patients (21.6 +/- 2.1 mm versus 23.4 +/- 2.2 mm, p < 0.01). There were no regional differences in the distribution of either gender or BSA. In the multivariable model, south European patients were seven times more likely to receive a smaller-sized aortic valve (OR = 6.5, 95% CI = 4.82-8.83, p < 0.01), and thus the odds of developing patient-prosthesis mismatch were increased two-fold in southern European patients (OR = 1.9, 95% CI = 1.25-2.80, p = 0.02). However, neither geographic distribution nor valve size were significantly associated with operative mortality. CONCLUSION: The study results demonstrated differences in implanted aortic valve size, between the participating northern and southern European countries. Imbalances in the prevalence of rheumatic heart disease, health resource availability and variations in surgical practice throughout Europe might be possible etiological causes.

Safety and efficacy of off-pump coronary artery bypass grafting in chronic dialysis patients.

Off-pump coronary artery bypass grafting (CABG) has been recently revived, because cardiopulmonary bypass (CPB) appears to worsen the multiple organ dysfunction after conventional CABG. To evaluate the safety and efficacy of the off-pump CABG in chronic dialysis patients, we compared the perioperative morbidity and mortality between 15 dialysis patients who underwent off-pump CABG at our center over the past 8 years with that of a concurrent group of 19 patients who underwent conventional CABG. Patients were selected for off-pump CABG only when complete revascularization was technically feasible. We found that off-pump CABG is as safe and effective as conventional CABG in selected dialysis patients. It might even be beneficial, because it is associated with less hematocrit drop and blood product use, a lower catabolic rate, and fewer dialysis requirements after surgery. However, the impact of off-pump technique on the long-term clinical outcome and resource utilization in renal patients requires further investigation.