Autograft Reoperation Following the Ross Procedure: Evolving Strategies and Future Perspectives.

Background: Pulmonary autograft failure remains a cause of reoperation following the Ross procedure. The aim of this study is to describe our evolving approach to autograft reoperations. Methods: Retrospective study of all patients who underwent a pulmonary autograft reoperation following a Ross procedure between June 1997 and July 2022. Results: Two-hundred and thirty-five Ross procedures were performed. Thirty-six patients (15%) plus one referral underwent an autograft reoperation at a median of 7.8 years (IQR 4.6-13.6). The main indication was: neoaortic root dilatation associated with mild/moderate (n = 12) or severe (n = 8) aortic regurgitation; isolated severe aortic regurgitation (n = 6); infective endocarditis (IE) (n = 8); and aortic root pseudoaneurysm with no history of IE (n = 3). The autograft was spared in 29 cases (78%): 9 patients (24%) underwent aortic valve repair or aortic root remodeling, 15 patients (40%) aortic root reimplantation, 5 patients neoaortic root stabilization with a Personalized External Aortic Root Support (PEARS) sleeve. There were no in-hospital deaths. At a median follow up of 37 months (IQR 8-105), all patients were alive, 30 (81%) were asymptomatic. Eight patients (22%) required nine further reoperations. Estimated freedom from further reoperation was 90%, 72%, and 72% at 12-, 36-, and 60-months. Conclusions: Autograft reoperations following the Ross procedure can be safely performed and do not affect overall survival in the early and mid-term. Valve-sparing autograft replacement is technically feasible but remains at risk of further interventions. Alternative strategies, such as the PEARS sleeve, are becoming increasingly available but requires validation in the long term.

Role of the Environment Polarity on the Photophysical Properties of Mesogenic Hetero-Polymetallic Complexes.

New hetero-polynuclear coordination complexes based on a pentacoordinated Zn(II) metal center with tridentate terpyridine-based ligands and monoanionic gallates functionalized with long alkyl chains containing ferrocene units were designed, synthesized and characterized using spectroscopic and analytical methods. The complexes are mesomorphic, exhibiting columnar hexagonal mesophases. The photophysical properties in a solution and in an ordered condensed state were accurately investigated and the influence of the polarity of the solvent was evidenced.

Bimetallic liquid crystal blends based on structurally related 3d-metal coordination complexes.

Hetero-bimetallic liquid crystalline materials, exhibiting a single Colhex mesophase, were obtained by simple chemical blending between two structurally-related Cu(II) and Zn(II) metallomesogens based on 1,10-phenanthroline and two chelating gallate ligands. Mesomorphous and optical properties were modified upon their relative respective proportions. This study highlights the numerous possibilities for the fabrication of new multifunctional polymetallic materials, with the possibility of tuning the properties and controlling supramolecular interactions between metal centres and corresponding synergistic effects.

Hetero-Bimetallic Ferrocene-Containing Zinc(II)-Terpyridyl-Based Metallomesogen: Structural and Electrochemical Characterization.

The synthesis, as well as the mesomorphic and electrochemical properties, of a hetero-bimetallic coordination complex able to self-assemble into a columnar liquid crystalline phase is reported herein. The mesomorphic properties were investigated by polarized optical microscopy (POM), differential scanning calorimetry (DSC) and Powder X-ray diffraction (PXRD) analysis. Electrochemical properties were explored by cyclic voltammetry (CV), relating the hetero-bimetallic complex behaviour to previously reported analogous monometallic Zn(II) compounds. The obtained results highlight how the presence of the second metal centre and the supramolecular arrangement in the condensed state pilot the function and properties of the new hetero-bimetallic Zn/Fe coordination complex.

Outcomes of the Ross procedure in young adults with previous aortic valve interventions.

OBJECTIVES: Contemporarily modified Ross procedure continues to deliver excellent outcomes and remains part of the treatment strategy for aortic valve disease in the young adult population. The aim of this study was to assess whether Ross procedure carried out as a second or subsequent intervention for aortic valve disease carries similar risk and long-term benefit, when compared to Ross procedure for the first-time aortic valve replacement. METHODS: A total of 158 patients aged 16-60 years from a single congenital cardiac centre between 1997 and 2020 were included. The sample was split into 2 subgroups, based on the history of previous aortic valve interventions prior to the Ross procedure. Primary outcomes were defined as survival and pulmonary autograft failure. Coarsened exact matching was used to balance for covariates. RESULTS: A total of 103 patients underwent primary Ross and 55 underwent secondary Ross with a mean follow-up of 7.8 years. Twenty-two patients underwent 28 reoperations during follow-up. Forty-nine well-matched pairs were obtained through matching. Freedom from pulmonary autograft failure at 10 years was 84.5% in the primary group vs 100% in the secondary group (P = 0.021). Five- and ten-year survival were identical, 97.5% in the primary group vs 95.6% in the secondary group (P = 0.53). Male sex and era were found to be predictors of neoaortic root dilatation. CONCLUSIONS: The lower incidence of graft failure seen in secondary Ross could justify a stepwise approach to aortic valve intervention. Ross procedure delivers excellent outcomes in the adult population with no difference in survival for primary or secondary Ross.

Left Atrial Geometry and Phasic Function Determined by Cardiac Magnetic Resonance Are Independent Predictors for Outcome in Non-Ischaemic Dilated Cardiomyopathy.

Left atrial (LA) geometry and phasic functions are frequently impaired in non-ischaemic dilated cardiomyopathy (NIDCM). Cardiac magnetic resonance (CMR) can accurately measure LA function and geometry parameters. We sought to investigate their prognostic role in patients with NIDCM. We prospectively examined 212 patients with NIDCM (49 ± 14.2-year-old; 73.5% males) and 106 healthy controls. LA volumes, phasic functions, geometry, and fibrosis were determined using CMR. A composite outcome (cardiac death, ventricular tachyarrhythmias, heart failure hospitalization) was ascertained over a median of 26 months. LA phasic functions, sphericity index (LASI) and late gadolinium enhancement (LA-LGE) were considerably impaired in the diseased group (p < 0.001) and significantly correlated with impaired LV function parameters (p < 0.0001). After multivariate analysis, LA volumes, LASI, LA total strain (LA-εt) and LA-LGE were associated with increased risk of composite outcome (p < 0.001). Kaplan-Meier analysis showed significantly higher risk of composite endpoint for LA volumes (all p < 0.01), LASI > 0.725 (p < 0.003), and LA-εt < 30% (p < 0.0001). Stepwise Cox proportional-hazards models demonstrated a considerable incremental predictive value which resulted by adding LASI to LA-εt (Chi-square = 10.2, p < 0.001), and afterwards LA-LGE (Chi-Square = 15.8; p < 0.0001). NIDCM patients with defective LA volumes, LASI, LA-LGE and LA-εt had a higher risk for an outcome. LA-εt, LASI and LA-LGE provided independent incremental predictive value for outcome.

Daring discourse: should acute pain medicine be a stand-alone service?

Acute pain medicine (APM) has been incorporated into healthcare systems in varied manners with some practices implementing a stand-alone acute pain service (APS) staffed by consultants who are not simultaneously providing care in the operating room (OR). In contrast, other practices have developed a concurrent OR-APS model where there is no independent team beyond the intraoperative care providers. There are theoretical advantages of each approach primarily with respect to patient outcomes and financial cost, and there is little evidence to instruct best practice. In this daring discourse, we present two opposing perspectives on whether or not APM should be a stand-alone service. While evidence to guide best practice is limited, our goal is to encourage discussion of the varied APS practice models and research into their impact on outcomes and costs.

Outcomes following aortic valve procedures in 201 complex congenital heart disease cases-results from the UK National Audit.

OBJECTIVES: Some patients with complex congenital heart disease (cCHD) also require aortic valve (AoV) procedures. These cases are considered high risk but their outcome has not been well characterized. We aim to describe these scenarios in the current practice, and provide outcome data for counselling and decision-making. METHODS: This was a retrospective study using the UK National Congenital Heart Disease Audit data on cCHD patients undergoing aortic valve replacement, balloon dilation (balloon aortic valvuloplasty) or surgical repair (surgical aortic valve repair) between 2000 and 2012. Coarsened exact matching was used to pair cCHD with patients undergoing AoV procedures for isolated valve disease. RESULTS: A total of 201 patients with a varied spectrum of cCHD undergoing 242 procedures were included, median age 9.4 years (1 day-65 years). Procedure types were: balloon aortic valvuloplasty (n = 31, 13%), surgical aortic valve repair (n = 57, 24%) and aortic valve replacement (n = 154, 63%). Mortality at 30 days was higher in neonates (21.8% vs 5.3%, P = 0.02). Survival at 10 years was 83.1%, freedom from aortic valve replacement 83.8% and freedom from balloon aortic valvuloplasty/surgical aortic valve repair 86.3%. Neonatal age (P < 0.001), single ventricle (P = 0.08), concomitant Fontan/Glenn (P = 0.002) or aortic arch procedures (0.02) were associated with higher mortality. cCHD patients had lower survival at 30 days (93% vs 100%, P = 0.003) and at 10 years (86.4% vs 96.1%, P = 0.005) compared to matched isolated AoV disease patients. CONCLUSIONS: AoV procedures in cCHD can be performed with good results outside infancy, but with higher mortality than in isolated AoV disease. Neonates and patients with single ventricle defects, especially those undergoing concomitant Fontan/Glenn, have worse outcomes.

Clinical and cost-effectiveness of the Ross procedure versus conventional aortic valve replacement in young adults.

Objectives: In young and middle-aged adults, there are three current options for aortic valve replacement (AVR), namely mechanical AVR (mechAVR), tissue AVR (biological AVR) and the Ross operation, with no clear guidance on the best option. We aim to compare the clinical effectiveness and cost-effectiveness of the Ross procedure with conventional AVR in young and middle-aged adults. Methods: This is a systematic literature review and meta-analysis of AVR options. Markov multistate model was adopted to compare cost-effectiveness. Lifetime costs, quality-adjusted life years (QALYs), net monetary benefit (NMB), population expected value of perfect information (EVPI) and expected value of partial perfect information were estimated. Results: We identified 48 cohorts with a total number of 12 975 patients (mean age 44.5 years, mean follow-up 7.1 years). Mortality, bleeding and thromboembolic events over the follow-up period were lowest after the Ross operation, compared with mechAVR and biological AVR (p<0.001). Aortic reoperation rates were lower after Ross compared with biological AVR, but slightly higher when compared with mechAVR (p<0.001). At a willingness-to-pay threshold of £20effective. At a willingness-to-pay threshold of £20, 000 per QALY000 per QALY, the Ross procedure is more cost-effective compared the Ross procedure is more cost-effective compared withwith conventional AVR, with a lifetime incremental NMB of £60 conventional AVR, with a lifetime incremental NMB of £60 952 (952 (££3030 236236 to to ££7979 464). Incremental costs were £12464). Incremental costs were £12 323 (323 (££61086108 to to ££1515 972) and incremental QALYs 3.66 (1.81972) and incremental QALYs 3.66 (1.81 to to 4.76). The population EVPI indicates that a trial costing up to £2.03 million could be cost 4.76). The population EVPI indicates that a trial costing up to £2.03 million could be cost--effective.At a willingness-to-pay threshold of £20 000 per QALY, the Ross procedure is more cost-effective compared with conventional AVR, with a lifetime incremental NMB of £60 952 (£30 236 to £79 464). Incremental costs were £12 323 (£6108 to £15 972) and incremental QALYs 3.66 (1.81 to 4.76). The population EVPI indicates that a trial costing up to £2.03 million could be cost-effective. Conclusions: In young and middle-aged adults with aortic valve disease, the Ross procedure may confer greater quality of life and be more cost-effective than conventional AVR. A high-quality randomised trial could be warranted and cost-effective.

Surgery for Young Adults With Aortic Valve Disease not Amenable to Repair.

Aortic valve replacement is the gold standard for the management of patients with severe aortic stenosis or mixed pathology that is not amenable to repair according to currently available guidelines. Such a simplified approach may be suitable for many patients, but it is far from ideal for young adults considering emerging evidence demonstrating that conventional valve replacement in this cohort of patients is associated with inferior long-term survival when compared to the general population. Moreover; the utilisation of mechanical and bioprosthetic valves can significantly impact on quality and is linked to increased rates of morbidities. Other available options such as stentless valve, homografts, valve reconstruction and Ross operation can be an appealing alternative to conventional valve replacement. Young patients should be fully informed about all the options available - shared decision making is now part of modern informed consent. This can be achieved when referring physicians have a better understanding of the short and long term outcomes associated with every intervention, in terms of survival and quality of life. This review presents up to date evidence for available surgical options for young adults with aortic stenosis and mixed disease not amenable to repair.

Aortic root and hemiarch replacement in a patient with Loeys-Dietz and hypoplastic left heart syndromes.

A 15-year-old patient with hypoplastic left heart syndrome underwent 3-stage palliation by the age of 3 years. He was later diagnosed with Loeys-Dietz syndrome. On follow-up imaging, the neoaorta was dilated at 50 mm in diameter. He underwent aortic root replacement with a composite valve conduit and hemiarch replacement, using a boat-shaped Dacron graft. The uncertainty of how univentricular circulation would tolerate long bypass time steered us away from a total arch replacement. His postoperative recovery was uneventful. Imaging postoperatively demonstrated stable dilatation of the aorta distal to the hemiarch replacement. Considering the risk of reintervention, we elected to monitor the distal aorta. The combination of Loeys-Dietz syndrome and hypoplastic left heart syndrome presents unique challenges, rarely reported in the literature.

A matter of life or limb? A review of traumatic injury patterns and anesthesia techniques for disaster relief after major earthquakes.

BACKGROUND: All modalities of anesthetic care, including conscious sedation, general, and regional anesthesia, have been used to manage earthquake survivors who require urgent surgical intervention during the acute phase of medical relief. Consequently, we felt that a review of epidemiologic data from major earthquakes in the context of urgent intraoperative management was warranted to optimize anesthesia disaster preparedness for future medical relief operations. The primary outcome measure of this study was to identify the predominant preoperative injury pattern (anatomic location and pathology) of survivors presenting for surgical care immediately after major earthquakes during the acute phase of medical relief (0-15 days after disaster). The injury pattern is of significant relevance because it closely relates to the anesthetic techniques available for patient management. We discuss our findings in the context of evidence-based strategies for anesthetic management during the acute phase of medical relief after major earthquakes and the associated obstacles of devastated medical infrastructure. METHODS: To identify reports on acute medical care in the aftermath of natural disasters, a query was conducted using MEDLINE/PubMed, Embase, CINAHL, as well as an online search engine (Google Scholar). The search terms were "disaster" and "earthquake" in combination with "injury," "trauma," "surgery," "anesthesia," and "wounds." Our investigation focused only on studies of acute traumatic injury that specified surgical intervention among survivors in the acute phase of medical relief. RESULTS: A total of 31 articles reporting on 15 major earthquakes (between 1980 and 2010) and the treatment of more than 33,410 patients met our specific inclusion criteria. The mean incidence of traumatic limb injury per major earthquake was 68.0%. The global incidence of traumatic limb injury was 54.3% (18,144/33,410 patients). The pooled estimate of the proportion of limb injuries was calculated to be 67.95%, with a 95% confidence interval of 62.32% to 73.58%. CONCLUSIONS: Based on this analysis, early disaster surgical intervention will focus on surviving patients with limb injury. All anesthetic techniques have been safely used for medical relief. While regional anesthesia may be an intuitive choice based on these findings, in the context of collapsed medical infrastructure, provider experience may dictate the available anesthetic techniques for earthquake survivors requiring urgent surgery.