Mechanistic investigations of polyaza[7]helicene in photoredox and energy transfer catalysis.

Organic photocatalysts frequently possess dual singlet and triplet photoreactivity and a thorough photochemical characterization is essential for efficient light-driven applications. In this article, the mode of action of a polyazahelicene catalyst (Aza-H) was investigated using laser flash photolysis (LFP). The study revealed that the chromophore can function as a singlet-state photoredox catalyst in the sulfonylation/arylation of styrenes and as a triplet sensitizer in energy transfer catalysis. The singlet lifetime is sufficiently long to exploit the exceptional excited state reduction potential for the activation of 4-cyanopyridine. Photoinduced electron transfer generating the radical cation was directly observed confirming the previously proposed mechanism of a three-component reaction. Several steps of the photoredox cycle were investigated separately, providing deep insights into the complex mechanism. The triplet-excited Aza-H, which was studied with quantitative LFP, is formed with a quantum yield of 0.34. The pronounced triplet formation was exploited for the isomerization reaction of (E)-stilbene to the Z-isomer and the cyclization of cinnamyl chloride. Catalyst degradation mainly occurs through the long-lived Aza-H triplet (28 µs), but the photostability is greatly increased when the triplet efficiently reacts in a catalytic cycle such that turnover numbers exceeding 4400 are achievable with this organocatalyst.

Habitat conditions filter stronger for functional traits than for phenology in herbaceous species.

An increasing number of studies in botanical gardens are investigating species' responses to climate change. However, the influence of local environmental or habitat conditions such as soil nutrient status or microclimate on phenology and the link between morpho-physiological functional traits and phenological stages are poorly understood, making it difficult to extrapolate patterns from botanical gardens to natural environments. Therefore, we selected herbaceous species growing in two semi-natural habitats, namely, semi-dry grasslands (SDGs) and mesophilic grasslands (MGs) and the botanical garden of Jena (Germany) to investigate the influence of habitat conditions on interspecific and intraspecific patterns in phenology, functional traits and their associations. For 16 species, we monitored leaf and flowering phenology weekly for 133 populations from the three habitats, measured morpho-physiological traits (i.e., whole plant, leaf and reproductive traits), as well as habitat conditions and compared the measurements across habitats. Multivariate analyses revealed that morpho-physiological traits conspicuously showed stronger differences between habitats compared to phenological traits. Populations on MG showed temporal niche segregation, whereas populations on SDG showed flowering synchrony. Boosted Regression Trees showed that morpho-physiological traits, especially reproductive traits, strongly influenced phenological traits and that the trait-phenology relationships were highly habitat-specific. We conclude that species phenology is broadly similar between botanical gardens and local habitats. However, phenological responses to the environment may be constrained by a certain suite of correlated traits due to ecological plant strategies that vary across habitats. The effect of habitat conditions on morpho-physiological functional traits and phenology-trait relationships is important and should not be neglected at local scales, implying consequences at larger scales.

Balloon-expandable transcatheter heart valves for treatment of aortic valve stenosis in patients with large aortic annuli: Evaluation of deployment balloon overfilling strategies.

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) using balloon-expandable (BE) transcatheter heart valves (THV) in aortic annuli above 29 mm includes particular procedural steps, mainly involving overfilling of the deployment balloon. Data on overfilling strategies in clinical daily practice is scarce. We herein aimed for a retrospective description of utilized overfilling strategies in those patients. METHODS: Between January 2016 and December 2022, 45 patients (100% male, 76.9 ± 6.1 years) received TAVI in aortic annuli above 29 mm using a BE THV. Overfilling volumina of the deployment balloon were left to operators' discretion. Clinical and multislice computed tomography data were retrospectively collected. Clinical endpoints were adjudicated in accordance with the updated standardized VARC-3 definitions. RESULTS: Profound overfilling (+4/5 mL) was used in patients with a mild calcium burden (˂750 mm³) even in aortic annuli of 29.0-30.0 mm. Nominal/slight overfilling (+1 mL) was used in aortic annuli up to 32.5 mm but an intermediate to severe calcific burden (>750-3200 mm³). Accordingly, a low calcification group (˂750 mm³, n = 17) compared to a significant calcification group (≥750 mm³, n = 28), presented with higher overfilling volumina (2.1 ± 1.4 vs. 0.8 ± 1.0; p ˂ 0.001), although aortic annulus diameter was not different (29.8 ± 0.8 vs. 29.9 ± 0.9 mm; p = 0.7). All-cause 30-day mortality was 0%. Device success was 97.8%. Transvalvular mean pressure gradient at discharge was 9.5 ± 3.6 mmHg. No case of PVL >mild was documented. CONCLUSION: Extent of overfilling of the deployment balloon largely depends on calcification burden in addition to aortic annulus diameter with significant and profound overfilling particularly in patients with a calcification burden of the aortic valve complex ˂750 mm³.

Direct Observation of Triplet States in the Isomerization of Alkenylboronates by Energy Transfer Catalysis.

Alkenylboronates are versatile building blocks for stereocontrolled synthesis owing to the traceless nature of the boron group that can be leveraged to achieve highly selective geometric isomerization. Using thioxanthone as an inexpensive photocatalyst, the photoisomerization of these species continues to provide an expansive platform for stereodivergent synthesis, particularly in the construction of bioactive polyenes. Although mechanistic investigations are consistent with light-driven energy transfer, direct experimental evidence remains conspicuously absent. Herein, we report a rigorous mechanistic investigation using two widely used alkenylboronates alongside relevant reference compounds. Through the combination of irradiation experiments, transient absorption spectroscopic studies, kinetic modeling, and DFT calculations with all isomers of the model compounds, it has been possible to unequivocally detect and characterize the perpendicular triplet generated by energy transfer. Our results serve not only as a blueprint for mechanistic studies that are challenging with organic sensitizers, but these guidelines delineated have also enabled the development of more sustainable reaction conditions: for the first time, efficient organocatalytic isomerization under sunlight irradiation has become feasible.

Tutors´ and Students' Agreement on Social and Cognitive Congruence in a Sonography Peer-assisted-learning Scenario.

Purpose: Peer-assisted learning has become an integral part within medical education and has been proven to be effective in teaching medical skills. Cognitive and social congruence are important factors that explain the effectiveness of peer-assisted learning. However, although theory suggests this, there is no study to date that demonstrates that students and tutors agree upon the level of cognitive and social congruence. Thus, we compared tutors' and students' perception of cognitive and social congruence and their agreement on the causes of congruence. Methods: 36 students and 9 tutors from 9 courses were asked to answer questionnaires for their perception of cognitive and social congruence in a peer-assisted learning sonography scenario. Results: Students and tutors experienced cognitive congruence (t = 0.8277, df = 8, p = .4318, 95% CI = [-0.232; 0.491]) and social congruence (t = 0.962, df = 8, p = .364, 95% CI = [-0.145; 0.354]) similarly. In contrast, students and tutors disagreed on causes of cognitive congruence (agreement = 53.90%) and social congruence (agreement = 58.49%). Tutors rated their empathy and interest toward students as the main cause. Students rated the helpfulness, effectiveness, and approachableness of the tutor as the main cause. Conclusions: Our study filled the gap in previous research on cognitive and social congruence. Consistent with theoretical considerations, it was shown that students and tutors do indeed experience cognitive and social congruence similarly. Nevertheless, differences also emerged that may carry more or less weight depending on the research question. Future studies should therefore carefully examine whether the assessment of cognitive and social congruence of students and tutors is necessary.

Neurocognitive effects of androgen deprivation therapy and new hormonal agents in a sample of patients with metastatic prostate cancer.

INTRODUCTION: Although the growing treatment landscape for metastatic prostate cancer (mPC) has revealed new opportunities, it has also provided challenges, such as undesirable side effects. The aim of the present study was to provide further data on domain-specific cognitive impairments in mPC patients with androgen deprivation therapy (ADT) and new hormonal agents. METHODS: Fifty-eight patients (71 ± 8 years) with mPC were investigated using a cross-sectional design. All patients had received some form of ADT (93% had received luteinizing hormone-releasing hormone (LHRH) analogs/antagonists), 66% had received chemotherapy, and 84% had received anti-resorptive therapy. We evaluated learning and memory, processing speed, and executive functions, as recommended by the International Cognition and Cancer Task Force, to determine neurocognitive deficits. RESULTS: Patients treated with ADT scored significantly lower on all neurocognitive tests and showed significantly more neurocognitive deficits (38-62%) than age-adjusted reference samples (16%, p < 0.05). Cognitive deficits were mild in most cases and predominantly affected visuomotor processing speed (48%). Moderate and severe deficits were found in 11% and 5% of patients, respectively, with word fluency as the predominant deficit (23%). No associations were found between the type or duration of treatment and the severity of cognitive deficits. CONCLUSIONS: Treatment of mPC with ADT is correlated with neurocognitive deficits in several cognitive domains. Language skills and processing speed were most frequently impaired. However, a consistent pattern of cognitive impairment was not identified. Neurocognitive deficits should be considered in phase III and IV trials. TRIAL REGISTRATION: The study was registered in the German Clinical Trials Registry (DRKS00017727).

The Effects of Peroxisome Proliferator-Activated Receptor-Delta Modulator ASP1128 in Patients at Risk for Acute Kidney Injury Following Cardiac Surgery.

Introduction: Peroxisome proliferator-activated receptor δ (PPARδ) plays a central role in modulating mitochondrial function in ischemia-reperfusion injury. The novel PPARδ modulator, ASP1128, was evaluated. Methods: A randomized, double-blind, placebo-controlled, biomarker assignment-driven, multicenter study was performed in adult patients at risk for acute kidney injury (AKI) following cardiac surgery, examining efficacy and safety of a 3-day, once-daily intravenous dose of 100 mg ASP1128 versus placebo (1:1). AKI risk was based on clinical characteristics and postoperative urinary biomarker (TIMP2)•(IGFBP7). The primary end point was the proportion of patients with AKI based on serum creatinine within 72 hours postsurgery (AKI-SCr72h). Secondary endpoints included the composite end point of major adverse kidney events (MAKE: death, renal replacement therapy, and/or ≥25% reduction of estimated glomerular filtration rate [eGFR]) at days 30 and 90). Results: A total of 150 patients were randomized and received study medication (81 placebo, 69 ASP1128). Rates of AKI-SCr72h were 21.0% and 24.6% in the placebo and ASP1128 arms, respectively (P = 0.595). Rates of moderate/severe AKI (stage 2/3 AKI-SCr and/or stage 3 AKI-urinary output criteria) within 72 hours postsurgery were 19.8% and 23.2%, respectively (P = 0.609). MAKE occurred within 30 days in 11.1% and 13.0% in the placebo and ASP1128 arms (P = 0.717), respectively; and within 90 days in 9.9% and 15.9% in the placebo and ASP1128 arms (P = 0.266), respectively. No safety issues were identified with ASP1128 treatment, but rates of postoperative atrial fibrillation were lower (11.6%) than in the placebo group (29.6%). Conclusion: ASP1128 was safe and well-tolerated in patients at risk for AKI following cardiac surgery, but it did not show efficacy in renal endpoints.

Increased sea ice melt as a driver of enhanced Arctic phytoplankton blooming.

Phytoplankton primary production in the Arctic Ocean has been increasing over the last two decades. In 2019, a record spring bloom occurred in Fram Strait, characterized by a peak in chlorophyll that was reached weeks earlier than in other years and was larger than any previously recorded May bloom. Here, we consider the conditions that led to this event and examine drivers of spring phytoplankton blooms in Fram Strait using in situ, remote sensing, and data assimilation methods. From samples collected during the May 2019 bloom, we observe a direct relationship between sea ice meltwater in the upper water column and chlorophyll a pigment concentrations. We place the 2019 spring dynamics in context of the past 20 years, a period marked by rapid change in climatic conditions. Our findings suggest that increased advection of sea ice into the region and warmer surface temperatures led to a rise in meltwater input and stronger near-surface stratification. Over this time period, we identify large-scale spatial correlations in Fram Strait between increased chlorophyll a concentrations and increased freshwater flux from sea ice melt.

Multimodal treatment and immune checkpoint inhibition in sinonasal mucosal melanoma: real-world data of a retrospective, single-center study.

PURPOSE: Local failure and distant metastases occur frequently in sinonasal mucosal melanoma (SNMM). Response rates to chemotherapy are low and targetable mutations are rarely detected. However, there is increasing data indicating efficacy of immune checkpoint inhibition (ICI). The aim of this retrospective monocenter study was to assess the mutational landscape and to evaluate the outcome of surgical treatment and ICI in SNMM in a real-world setting. METHODS: Thirty-eight SNMM patients being treated between 1999 and 2020 at our institution were retrospectively reviewed. Survival curves were generated according to Kaplan-Meier and compared by the log-rank test. RESULTS: Local failure was seen in 60% of patients treated in a curative intent. Overall, 24% of all patients suffered from regional and 66% from distant metastases. Next generation sequencing revealed mutations of BRAF, NRAS and KRAS. One out of three patients treated with a primary ICI showed a complete response (CR) and two showed progressive disease. Eleven patients received ICI as a palliative treatment. CR could be observed in three patients and stable disease in one patient. In the whole study population, the 5-year overall survival rate (OS) was 26%. OS was better for patients who received ICI during the course of disease. CONCLUSIONS: Recurrences and distant metastases are frequent in SNMM. Durable CR could be observed after primary and palliative ICI. Therefore, ICI in a palliative, adjuvant or even neoadjuvant setting might play a promising role in SNMM therapy while targetable mutations are rarely detected.

Geometric Isomerisation of Bifunctional Alkenyl Fluoride Linchpins: Stereodivergence in Amide and Polyene Bioisostere Synthesis.

Amide groups are pervasive across the chemical space continuum, where their structural and pharmacological importance, juxtaposed with the hydrolytic vulnerabilities, continues to fuel bioisostere development. Alkenyl fluorides have a venerable history as effective mimics (Ψ[CF=CH]) owing to the planarity of the motif and intrinsic polarity of the C(sp2 )-F bond. However, emulating the s-cis to the s-trans isomerisation of a peptide bond with fluoro-alkene surrogates remains challenging, and current synthetic solutions only enable access to a single configuration. Through the design of an ambiphilic linchpin based on a fluorinated ß-borylacrylate, it has been possible to leverage energy transfer catalysis to affect this unprecedented isomerisation process: this provides geometrically-programmable building blocks that can be functionalised at either terminus. Irradiation at λmax =402 nm with inexpensive thioxanthone as a photocatalyst enables rapid, effective isomerisation of tri- and tetra-substituted species (up to E/Z 98 : 2 in 1 h), providing a stereodivergent platform for small molecule amide and polyene isostere discovery. Application of the methodology in target synthesis and initial laser spectroscopic studies are disclosed together with crystallographic analyses of representative products.

A new green-to-blue upconversion system with efficient photoredox catalytic properties.

The design and development of new triplet-triplet annihilation upconversion (TTA-UC) systems combining triplet sensitizers with acceptor compounds have attracted considerable interest. In this vein, sensitizers made from purely organic dyes rather than transition-metal complexes appear to be more convenient from an environmental point of view. BODIPYs are a very well-known class of dyes with applications in a widespread range of scientific areas. Owing to the versatility of BODIPYs, we present herein a new asymmetric BODIPY with excellent photophysical properties to be used as an appropriate sensitizer in a bimolecular TTA-UC system. Detailed spectroscopic measurements demonstrated the ability of this new design to sensitize TTA-UC by combination with a suitable acceptor such as 2,5,8,11-tetra-tert-butylperylene (TBPe), allowing a successful conversion of green to blue light. The singlet-excited TBPe so obtained is capable of activating aryl chlorides reductively which initiated the functionalization of N-methylpyrrole (Meerwein-type arylation) and formation of both substituted triarylethylenes (Mizoroki-Heck reaction) and heteroarene phosphonates (photo-Arbuzov reaction). Product yields reveal that our TTA-UC system behaved as a highly efficient photocatalytic entity.

Visible-to-UV Photon Upconversion: Recent Progress in New Materials and Applications.

Ultraviolet (UV, λ<400 nm) light is essential for various photochemical reactions, but its intensity in the solar spectrum is very low, and light sources that artificially generate high-energy UV light are inefficient and environmentally unfriendly. A solution to this problem is photon upconversion (UC) from visible (vis, λ>400 nm) light to UV light. Among several mechanisms, UC based on triplet-triplet annihilation (TTA-UC) in particular has made remarkable progress in recent years. The development of new chromophores has enabled highly efficient conversion of low-intensity visible light into UV light. In this review, we summarize the recent development of visible-to-UV TTA-UC, from the development of chromophores and their production into films to their application in various photochemical processes such as catalysis, bond activation and polymerization. Finally, challenges and opportunities in future material development and applications will be discussed.

Single- and Multiple-dose Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of ASP1128, a Novel Peroxisome Proliferator-activated Receptor δ Modulator, in Healthy Participants.

Peroxisome proliferator-activated receptor δ (PPARδ) plays a central role in modulating mitochondrial function in ischemia-reperfusion injury. ASP1128, a potent and selective modulator of PPARδ, is currently under investigation for treating acute kidney injury. This randomized, first-in-human study assessed the safety, tolerability, pharmacokinetics, and pharmacodynamics of ASP1128 administered intravenously in healthy participants. Forty-nine participants received a single dose of ASP1128 0.3-10 mg (n = 37) or placebo (n = 12) and 53 received daily (7 days) doses of ASP1128 3-100 mg (n = 39) or placebo (n = 14), including a cohort aged ≥65 years (ASP1128 100 mg, n = 3; placebo, n = 2). Treatment-emergent adverse events occurred in 37.8%, 59.0%, and 33.3%-35.7% of participants in the single ASP1128, multiple ASP1128, and placebo groups, respectively. All were mild in severity, and the frequency of adverse events did not appear to be dose-related. One participant (multiple ASP1128 3 mg group) withdrew with an infusion site erythema, possibly related to study drug. Exposure was roughly dose-proportional, and elimination was generally consistent across doses (mean t½ 14.6-17.4 hours in the 10, 30, and 100 mg groups on day 7). There was little accumulation in plasma following multiple dosing; steady state was reached after ∼4 days. ASP1128 treatment led to rapid and dose-related upregulation of six fatty acid oxidation-related PPARδ target genes at ≥10 mg, which lasted >24 hours postdose. In conclusion, single and multiple intravenous doses of ASP1128 were generally well tolerated, with dose-dependent pharmacokinetics and target gene engagement in healthy participants.

Impact of Surgeon Experience and Centre Volume on Outcome After Off-Pump Coronary Artery Bypass Surgery: Results From the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) Registry.

AIM: The aim of this study was to assess the impact of surgeon experience and centre volume on early operative outcomes in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. METHOD: Of 7,352 patients in the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry, 1,549 underwent OPCAB and were included in the present analysis. Using adjusted regression analysis, we compared major early adverse events after procedures performed by experienced OPCAB surgeons (i.e., ≥20 cases per year; n=1,201) to those performed by non-OPCAB surgeons (n=348). Furthermore, the same end points were compared between procedures performed by OPCAB surgeons in high OPCAB volume centres (off-pump technique used in >50% of cases; n=894) and low OPCAB volume centres (n=307). RESULTS: In the experienced OPCAB surgeon group, we observed shorter procedure times (ß -43.858, 95% confidence interval [CI] -53.322 to -34.393; p<0.001), a lower rate of conversion to cardiopulmonary bypass (odds ratio [OR] 0.284, 95% CI 0.147-0.551; p<0.001), a lower rate of prolonged inotrope or vasoconstrictor use (OR 0.492, 95% CI 0.371-0.653; p<0.001), a lower rate of early postprocedural percutaneous coronary interventions (OR 0.335, 95% CI 0.169-0.663; p=0.002), and lower 30-day mortality (OR 0.423, 95% CI 0.194-0.924; p=0.031). In high OPCAB volume centres, we found a lower rate of prolonged inotrope use (OR 0.584, 95% CI 0.419-0.814; p=0.002), a lower rate of postprocedural acute kidney injury (OR 0.382, 95% CI 0.198-0.738; p=0.004), shorter duration of intensive care unit (ß -1.752, 95% CI -2.240 to -1.264; p<0.001) and hospital (ß -1.967; 95% CI -2.717 to -1.216; p<0.001) stays, and lower 30-day mortality (OR 0.316, 95% CI 0.114-0.881; p=0.028). CONCLUSIONS: Surgeon experience and centre volume may play an important role on the early outcomes after OPCAB surgery.

Blue-to-UVB Upconversion, Solvent Sensitization and Challenging Bond Activation Enabled by a Benzene-Based Annihilator.

Several energy-demanding photoreactions require harsh UV light from inefficient light sources. The conversion of low-energy visible light to high-energy singlet states via triplet-triplet annihilation upconversion (TTA-UC) could offer a solution for driving such reactions under mild conditions. We present the first annihilator with an emission maximum in the UVB region that, combined with an organic sensitizer, is suitable for blue-to-UVB upconversion. The annihilator singlet was successfully employed as an energy donor in subsequent FRET activations of aliphatic carbonyls. This hitherto unreported UC-FRET reaction sequence was directly monitored using laser spectroscopy and applied to mechanistic irradiation experiments demonstrating the feasibility of Norrish chemistry. Our results provide clear evidence for a novel blue light-driven substrate or solvent activation strategy, which is important in the context of developing more sustainable light-to-chemical energy conversion systems.

Environmental issues hidden in medical education: What are the effects on students' environmental awareness and knowledge?

INTRODUCTION: Global warming is one of the major challenges faced by society. To raise students' awareness related to these issues, we embedded environmental learning goals in mandatory courses. The aim of this initiative was to determine whether the integration of environmental topics into a seminar focussing on non-environmental issues facilitates changes in the environmental knowledge and awareness of students. METHODS: Third-year molecular medicine students (intervention group, IG) were assigned short environment-related tasks in a not environment-related scientific writing seminar. Using standardized questionnaires before and after the seminar, students were assessed with a set of up to 48 questions relating to environmental affect, cognition, behavioral intention and knowledge as well as specific personal aspects. The comparison group (CG) consisted of third-year dentistry students who were assessed twice during an equivalent pre-post time period and who did not attend the seminar. The analysis was carried out with 15 students from the IG and 14 from the CG. RESULTS: Integrating environmental topics into a scientific writing seminar focussing on non-environmental issues led to a significantly increased level of awareness of the threats from climate change in the IG (p<0.05). No further significant changes in other areas of environmental awareness were observed in either group. In addition, the environmental knowledge of the IG students (p≤0.01) but not of the CG students (p=0.285) was significantly enhanced. DISCUSSION AND CONCLUSION: This study shows that factual environmental knowledge on the issues addressed can be increased by a cautious approach of environmental communication. However, more deep-seated personal attitudes and environmental awareness cannot be sustainably changed using this low intervention dose.

Suicidal ideation in patients with cancer: Its prevalence and results of structural equation modelling.

OBJECTIVE: Patients with cancer have a higher risk of suicidal ideation (SI) and suicidality than the general population. This study was designed to investigate the prevalence of SI and its association with psychosocial and sociodemographic factors and tumour entity. METHODS: In this observational cross-sectional study, 4372 adult patients with different cancer entities were enrolled. We assessed the outcome variables (i.e. SI, depressive and anxiety symptoms, mental and physical fatigue and sociodemographic data) using self-report questionnaires. Data were analysed via descriptive statistics, binomial logistic regression and structural equation modelling (SEM). RESULTS: Among all patients, 627 (14.3%) reported SI, of whom 12.8% reported SI on several days, 0.9% on half of the days and 0.6% nearly every day. Age, anxiety, mental fatigue and the Patient Health Questionnaire-9 items 'feeling down, depressed and hopeless', 'feeling bad about oneself' and 'slowing or agitation' were significant predictors of SI. SEM, including all significant predictors with a latent depressiveness-demoralisation variable, explained 30.3% variance of SI, showing a good fit. CONCLUSIONS: Our results showed that a significant number of patients with cancer show SI. Future long-term studies are needed to address the differential contribution of depression and demoralisation on SI in patients with cancer.

Risk factors for impaired neurological outcome after thoracic aortic surgery.

Background: We aimed to identify risk factors for an impaired postoperative neurological outcome after thoracic aortic surgery. Methods: Data from all patients undergoing thoracic aortic surgery between 2010 and 2020 at our institution were collected and analyzed retrospectively. Logistic regression analysis was used to identify independent risk factors for permanent postoperative neurological deficit (ND) (stroke), which was defined as a ND lasting at least seven days. Results: Thoracic aortic surgery was performed in 1,334 patients. Of these, 286 (21.4%) underwent emergency surgery. The mean EuroSCORE II was 8.6±10.1. A perioperative stroke occurred in 94 patients (7.0%). Of all strokes, 62.8% (n=59) were considered of embolic and 24.5% (n=23) of hemodynamic origin. In elective procedures, stroke rates ranged from 0.5% after valve-sparing root replacement to 8.1% after arch surgery. Adjusted logistic regression identified advanced age [>70 years; odds ratio (OR), 1.83; P=0.009], acute type A dissection (ATAD) (OR, 1.69; P=0.0495), aortic arch surgery (OR, 3.24; P<0.001), concomitant coronary artery bypass grafting (CABG) (OR, 2.19; P=0.005), and high extracorporeal circulation (ECC) time (>230 min; OR, 1.70; P=0.034) as independent risk factors for all strokes. Secondary endpoint analyses revealed that risk factors for hemodynamic stroke were arch surgery, advanced age (>70 years), atherosclerosis, and ATAD. Risk factors for embolic stroke were arch surgery, concomitant CABG and preoperative cerebral malperfusion. Conclusions: Identified independent risk factors for all strokes were advanced age, ATAD, arch surgery, concomitant CABG, and high ECC time. Hemodynamic and embolic strokes show distinct risk profiles.

Contemporary Outcome Trends in Transcatheter Aortic Valve-in-Valve Implantation Versus Redo Aortic Valve Replacement.

As valve-in-valve (ViV) transcatheter aortic valve implantation is still an evolving method, we evaluated the development of early and midterm outcomes after ViV and conventional redo-surgical aortic valve replacement (SAVR) over the past 2 decades. In-hospital databases were retrospectively screened for patients ≥60 years treated for failing bioprosthetic aortic valves at our center. Clinical and follow-up characteristics were compared between patients who underwent ViV or redo-SAVR according to valve academic research consortium-2 (VARC-2) definitions. The comparison of outcome parameters was adjusted for baseline differences between groups. Between June 2002 and April 2020, 209 patients with ViV and 65 redo-SAVR patients met inclusion criteria. No significant differences were found in 30 days (ViV 3.8%, SAVR 3.1%, p = 0.778) or 6-month mortality (ViV 14.0%, SAVR 7.5%, p = 0.283). As patients with ViV less frequently experienced acute kidney injury (stage II or III) and life-threatening bleeding, they more frequently reached the 30-day VARC-2 combined safety end point (79.2% vs 61.5%, odds ratio [OR] 2.540, p = 0.023). Patients with ViV less frequently reached clinical efficacy (68.3% vs 84.6%, OR 0.408, p = 0.041) and device success (79.9% vs 92.3%, OR 0.311, p = 0.040) end points, because of higher frequency of postprocedural transvalvular gradients >20 mm Hg. However, over the past decade, VARC-2 clinical efficacy and device success rates continuously increased in ViV cases. In conclusion, ViV and SAVR were associated with similar acute mortality and different beneficial and adverse outcome profiles in this single-center cohort. Results after ViV procedures have continuously improved over the past years.