Case Report: Totally endoscopic minimally invasive mitral valve surgery during pregnancy: a case series.

A totally endoscopic minimally invasive approach is widely used for cardiac valve surgery in normal adults. However, minimally invasive cardiac surgery during pregnancy is rarely reported. In addition to traditional median thoracotomy, totally endoscopic minimally invasive approaches can now be used for pregnant patients. We describe our experience with totally endoscopic cardiac valve surgery (TECVS) during pregnancy, which is safe for both mothers and fetuses.

B-type natriuretic peptide levels at admission predict the prognosis of patients with infective endocarditis undergoing cardiac surgery.

Purpose: The objective of this study was to explore the relationship between elevated B-type natriuretic peptide (BNP) levels and the prognosis of patients with infective endocarditis (IE) undergoing cardiac surgery. Methods: In total, 162 IE patients with recorded BNP levels upon admission were included in the present study. The primary end point was all-cause mortality. Results: Multivariate Cox analysis revealed a significant association between log BNP and all-cause mortality. Kaplan-Meier analysis revealed a poorer prognosis for patients with BNP levels ≥ the 75th percentile. Furthermore, the linear trend test indicated a significant link between BNP quartiles and the primary end point within the models. Conclusion: Elevated BNP levels upon admission could predict all-cause mortality in IE patients undergoing cardiac surgery.

Infective endocarditis (IE) refers to an infection affecting the heart lining, heart valves or blood vessels. Despite advancements in medical and surgical interventions, the overall mortality rate remains high among IE patients after surgery. B-type natriuretic peptide (BNP) is a peptide released in response to increased stress on the ventricular and atrial walls and is commonly used as a biomarker for heart failure. This study was aimed to assess the potential of BNP in predicting all-cause mortality in IE patients. The results indicate that elevated BNP levels upon admission could predict a worse prognosis following endocarditis surgery. Additionally, elevated BNP levels upon admission were associated with an increased risk of death.

Long-Term Atrioventricular Block Following Valve Surgery: Electrocardiographic and Surgical Predictors.

BACKGROUND: Bradyarrhythmia requiring pacemaker implantation among patients undergoing valve surgery may occur even after several years, with unclear predictors. Our aim was to investigate the incidence of pacemaker implantation at different follow-up times and identify associated predictors. METHODS: We conducted a retrospective study evaluating 1046 consecutive patients who underwent valve surgery at the Cardiac Surgery Division of Bologna University Hospital from 2005 to 2010. RESULTS: During 10 ± 4 years of follow-up, 11.4% of these patients required pacemaker implantation. Interventions on both atrioventricular valves independently predicted long-term pacemaker implantation (SHR 2.1, 95% CI 1.2-3.8, p = 0.014). Preoperative atrioventricular conduction disease strongly predicted long-term atrioventricular block, with right bundle branch block as the major predictor (SHR 7.0, 95% CI 3.9-12.4, p < 0.001), followed by left bundle branch block (SHR 4.9, 95% CI 2.4-10.1, p < 0.001), and left anterior fascicular block (SHR 3.9, 95% CI 1.8-8.3, p < 0.001). CONCLUSION: Patients undergoing valvular surgery have a continuing risk of atrioventricular block late after surgery until the 12-month follow-up, which was clearly superior to the rate of atrioventricular block observed at long-term. Pre-operative atrioventricular conduction disease and combined surgery on both atrioventricular valves are strong predictors of atrioventricular block requiring pacemaker implantation.

A machine learning-based prediction model for postoperative delirium in cardiac valve surgery using electronic health records.

BACKGROUND: Previous models for predicting delirium after cardiac surgery remained inadequate. This study aimed to develop and validate a machine learning-based prediction model for postoperative delirium (POD) in cardiac valve surgery patients. METHODS: The electronic medical information of the cardiac surgical intensive care unit (CSICU) was extracted from a tertiary and major referral hospital in southern China over 1 year, from June 2019 to June 2020. A total of 507 patients admitted to the CSICU after cardiac valve surgery were included in this study. Seven classical machine learning algorithms (Random Forest Classifier, Logistic Regression, Support Vector Machine Classifier, K-nearest Neighbors Classifier, Gaussian Naive Bayes, Gradient Boosting Decision Tree, and Perceptron.) were used to develop delirium prediction models under full (q = 31) and selected (q = 19) feature sets, respectively. RESULT: The Random Forest classifier performs exceptionally well in both feature datasets, with an Area Under the Curve (AUC) of 0.92 for the full feature dataset and an AUC of 0.86 for the selected feature dataset. Additionally, it achieves a relatively lower Expected Calibration Error (ECE) and the highest Average Precision (AP), with an AP of 0.80 for the full feature dataset and an AP of 0.73 for the selected feature dataset. To further evaluate the best-performing Random Forest classifier, SHAP (Shapley Additive Explanations) was used, and the importance matrix plot, scatter plots, and summary plots were generated. CONCLUSIONS: We established machine learning-based prediction models to predict POD in patients undergoing cardiac valve surgery. The random forest model has the best predictive performance in prediction and can help improve the prognosis of patients with POD.

[A wearable six-minute walk-based system to predict postoperative pulmonary complications after cardiac valve surgery: an exploratory study].

In recent years, wearable devices have seen a booming development, and the integration of wearable devices with clinical settings is an important direction in the development of wearable devices. The purpose of this study is to establish a prediction model for postoperative pulmonary complications (PPCs) by continuously monitoring respiratory physiological parameters of cardiac valve surgery patients during the preoperative 6-Minute Walk Test (6MWT) with a wearable device. By enrolling 53 patients with cardiac valve diseases in the Department of Cardiovascular Surgery, West China Hospital, Sichuan University, the grouping was based on the presence or absence of PPCs in the postoperative period. The 6MWT continuous respiratory physiological parameters collected by the SensEcho wearable device were analyzed, and the group differences in respiratory parameters and oxygen saturation parameters were calculated, and a prediction model was constructed. The results showed that continuous monitoring of respiratory physiological parameters in 6MWT using a wearable device had a better predictive trend for PPCs in cardiac valve surgery patients, providing a novel reference model for integrating wearable devices with the clinic.

The occurrence of early atrial fibrillation after cardiac valve operation and the establishment of a nomogram model.

Background: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery, which is associated with age and massive bleeding. However, whether thyroid hormone (TH) level can affect POAF remains controversial. Aim: To investigate the occurrence and risk factors of POAF, in particular, the preoperative TH level of patients was introduced into this study as a variable for analysis, and a column graph prediction model of POAF was constructed. Methods: Patients who underwent valve surgery in Fujian Cardiac Medical Center from January 2019 to May 2022 were retrospectively analyzed and divided into POAF group and NO-POAF group. Baseline characteristics and relevant clinical data were collected from the two groups of patients. Independent risk factors for POAF were screened using univariate analysis and binary logistic regression analysis, and a column line graph prediction model was established based on the regression analysis results, and the diagnostic efficacy and calibration of the model were evaluated using the Receiver Operating Characteristic Curve (ROC) and calibration curve. Results: A total of 2,340 patients underwent valve surgery, excluding 1,751 patients, a total of 589 patients were included, including 89 patients in POAF group and 500 patients in NO-POAF group. The total incidence of POAF was 15.1%. The results of the Logistics regression analysis showed that gender, age, leukocytes and TSH were risk factors of POAF. The area under the ROC curve of the nomogram prediction model for POAF was 0.747 (95% CI: 0.688-0.806, P < 0.001), with a sensitivity of 74.2% and specificity of 68%. Hosmer-Lemeshow test showed χ 2 = 11.141, P = 0.194 > 0.05, the calibration curve was well fitted. Conclusion: The results of this study show that gender, age, leukocyte and TSH are risk factors of POAF, and the nomogram prediction model has a good prediction effect. Due to the limited sample size and included population, more studies are needed to validate this result.

Benefits of sacubitril/valsartan use in patients with chronic heart failure after cardiac valve surgery: a single-center retrospective study.

OBJECTIVES: To evaluate the efficacy of sacubitril/valsartan for the treatment of patients with chronic heart failure (CHF) after cardiac valve surgery (CVS). METHODS: Data were collected from 259 patients who underwent CVS due to valvular heart disease and were admitted to the hospital with CHF from January 2018 to December 2020. The patients were divided into Group A (treatment with sacubitril/valsartan) and Group B (treatment without sacubitril/valsartan). The duration of treatment and follow-up was 6 months. The two groups' prior and clinical characteristics, post-treatment data, mortality, and follow-up data were analysed. RESULTS: The effective rate of Group A was higher than that of Group B (82.56% versus 65.52%, P < 0.05). The left ventricular ejection fraction (LVEF, %) was improved in both groups. The final value minus the initial value was (11.14 ± 10.16 versus 7.15 ± 11.18, P = 0.004). The left ventricular end-diastolic/-systolic diameter (LVEDD/LVESD, mm) in Group A decreased more than in Group B. The final value minus the initial value was (-3.58 ± 9.21 versus - 0.27 ± 14.44, P = 0.026; -4.21 ± 8.15 versus - 1.14 ± 12.12, P = 0.016, respectively). Both groups decreased the N-terminal prohormone of B-type natriuretic peptide (NT-proBNP, pg/ml). The final value minus initial value was [-902.0(-2226.0, -269.5) versus - 535.0(-1738, -7.0), P = 0.029]. The systolic and diastolic blood pressure (SBP/DBP, mmHg) in Group A decreased more than in Group B. The final value minus the initial value was (-13.13 ± 23.98 versus - 1.81 ± 10.89, P < 0.001; -8.28 ± 17.79 versus - 2.37 ± 11.41, P = 0.005, respectively). Liver and renal insufficiency, hyperkalaemia, symptomatic hypotension, angioedema, and acute heart failure had no statistical differences between the two groups. CONCLUSIONS: Sacubitril/valsartan can effectively improve the cardiac function of patients with CHF after CVS by increasing LVEF and reducing LVEDD, LVESD, NT-proBNP, and BP, with good safety.

A wearable six-minute walk-based system to predict postoperative pulmonary complications after cardiac valve surgery: an exploratory study / 生物医学工程学杂志

In recent years, wearable devices have seen a booming development, and the integration of wearable devices with clinical settings is an important direction in the development of wearable devices. The purpose of this study is to establish a prediction model for postoperative pulmonary complications (PPCs) by continuously monitoring respiratory physiological parameters of cardiac valve surgery patients during the preoperative 6-Minute Walk Test (6MWT) with a wearable device. By enrolling 53 patients with cardiac valve diseases in the Department of Cardiovascular Surgery, West China Hospital, Sichuan University, the grouping was based on the presence or absence of PPCs in the postoperative period. The 6MWT continuous respiratory physiological parameters collected by the SensEcho wearable device were analyzed, and the group differences in respiratory parameters and oxygen saturation parameters were calculated, and a prediction model was constructed. The results showed that continuous monitoring of respiratory physiological parameters in 6MWT using a wearable device had a better predictive trend for PPCs in cardiac valve surgery patients, providing a novel reference model for integrating wearable devices with the clinic.

Predictive Value of the Transthoracic Echocardiography Index for Acute Kidney Injury after Cardiac Valve Surgery.

Background: We aimed to demonstrate whether the preoperative transthoracic echocardiography index (TTEI) could improve the predictive value of clinical parameters for cardiac valve surgery-associated acute kidney injury (CVS−AKI). Methods: A total of 213 patients who underwent surgical CVS at Renmin Hospital of Wuhan University were consecutively recruited in this retrospective study. TTE assessments were performed within 7 days before surgery and logistic regression was used to determine TTEI. A nomogram was constructed by integrating TTEI and clinical features, and the net reclassification index (NRI) and integrated discrimination improvement (IDI) were applied to evaluate the improvement in TTEI for CVS−AKI. Results: Among them, 66 patients (30.9%) developed CVS−AKI. The TTEI was calculated as follows: −6.579 + 0.068 × pulmonary artery systolic pressure (mmHg) −0.742 × LVEF (>55%, yes or no) + 0.346 × left ventricle posterior wall thickness (mm). The nomogram based on the TEEI and other clinical factors possessed excellent performance (C-index = 0.880), had great calibration and discrimination, and was clinically useful. Furthermore, NRI (0.07, 95% confidence interval, 95%CI, 0.01−0.12, p = 0.02) and IDI (0.08, 95%CI, 0.01−0.20, p = 0.02) indicated that TTEI could significantly improve the predictive value of clinical features for CVS−AKI. Conclusions: As a simple access and cost-effective parameter, the preoperative TTEI may be a reliable and useful factor for CVS−AKI.

Prognostic Effect of Thoracic Sarcopaenia on Short- and Long-Term Clinical Outcomes in Patients Who Underwent Cardiac Valve Surgery.

BACKGROUND: As the proportion of elderly patients increases, higher incidence of malnutrition is found among patients with valvular heart disease. Sarcopaenia is one of the main manifestations of malnutrition. Studies have shown the certain predictive effect of sarcopaenia on the clinical outcome in different cases. This study aims to clarify the impact of computed tomography (CT)-derived thoracic sarcopaenia on clinical outcomes of patients who underwent cardiac valve surgery. METHODS: The clinical data of 216 patients who underwent cardiac valve surgery from December 2015 to June 2020 were retrospectively collected. Skeletal muscle mass at 12th thoracic vertebra level was measured to diagnose thoracic sarcopaenia. Postoperative complications and follow-up data were collected. Medium follow-up was 3.2 years. RESULTS: The prevalence of thoracic sarcopaenia was 16.7% in this study. The incidence of total complications and in-hospital mortality were higher in thoracic sarcopaenia group (p=0.024 and p=0.014, respectively). Multivariate analysis revealed that thoracic sarcopaenia is a significant predictor for postoperative complications (OR 2.319; 95% CI 1.003-5.366; p=0.049). Decreased long-term survival was observed in patients with thoracic sarcopaenia. Thoracic sarcopaenia (HR 4.178; 95% CI 2.062-8.465; p<0.001) was determined to be an independent risk factor for late mortality. CONCLUSION: Thoracic sarcopaenia defined by chest CT was independently associated with higher incidence of postoperative complications and long-term mortality. Routine preoperative evaluation of thoracic sarcopaenia deserves further consideration to enhance the predictive performance for operation risk.

Surgical treatment of patients with infective endocarditis: changes in temporal use, patient characteristics, and mortality-a nationwide study.

BACKGROUND: Valve surgery guidelines for infective endocarditis (IE) are unchanged over decades and nationwide data about the use of valve surgery do not exist. METHODS: We included patients with first-time IE (1999-2018) using Danish nationwide registries. Proportions of valve surgery were reported for calendar periods (1999-2003, 2004-2008, 2009-2013, 2014-2018). Comparing calendar periods in multivariable analyses, we computed likelihoods of valve surgery with logistic regression and rates of 30 day postoperative mortality with Cox regression. RESULTS: We included 8804 patients with first-time IE; 1981 (22.5%) underwent surgery during admission, decreasing by calendar periods (N = 360 [24.4%], N = 483 [24.0%], N = 553 [23.5%], N = 585 [19.7%], P = < 0.001 for trend). For patients undergoing valve surgery, median age increased from 59.7 to 66.9 years (P ≤ 0.001) and the proportion of males increased from 67.8% to 72.6% (P = 0.008) from 1999-2003 to 2014-2018. Compared with 1999-2003, associated likelihoods of valve surgery were: Odds ratio (OR) = 1.14 (95% CI: 0.96-1.35), OR = 1.20 (95% CI: 1.02-1.42), and OR = 1.10 (95% CI: 0.93-1.29) in 2004-2008, 2009-2013, and 2014-2018, respectively. 30 day postoperative mortalities were: 12.7%, 12.8%, 6.9%, and 9.7% by calendar periods. Compared with 1999-2003, associated mortality rates were: Hazard ratio (HR) = 0.96 (95% CI: 0.65-1.41), HR = 0.43 (95% CI: 0.28-0.67), and HR = 0.55 (95% CI 0.37-0.83) in 2004-2008, 2009-2013, and 2014-2018, respectively. CONCLUSIONS: On a nationwide scale, 22.5% of patients with IE underwent valve surgery. Patient characteristics changed considerably and use of valve surgery decreased over time. The adjusted likelihood of valve surgery was similar between calendar periods with a trend towards an increase while rates of 30 day postoperative mortality decreased.

Oral bacteria in infective endocarditis requiring surgery: a retrospective analysis of 134 patients.

OBJECTIVES: It has been reported that bacteria associated with infective endocarditis originate from the oral cavity in 26-45% of cases. However, little is known on the counts and species of periodontal microbiota in infected heart valves. The aim of this study was to identify these aspects of periodontal microbiota in infective endocarditis and to potentially initiate a dental extraction concept for periodontally compromised teeth concerning patients requiring heart valve surgery. MATERIALS AND METHODS: The retrospective study group consisted of tissue samples from infected heart valves of 683 patients who had undergone heart valve surgery. Before patients had undergone cardiac surgery, the following laboratory tests confirmed the occurrence of endocarditis in all patients: blood cultures, echocardiography, electrocardiography, chest X-ray, and electrophoresis of the serum proteins. The specimens were aseptically obtained and deep frozen immediately following surgery. Microbiological diagnosis included proof of germs (dichotomous), species of germs, and source of germs (oral versus other). RESULTS: Microbiota was detected in 134 (31.2%) out of 430 enrolled patients. Oral cavity was supposed to be the source in 10.4% of cases, whereas microbiota of the skin (57.5%) and gastrointestinal tract (GIT, 24.6%) were detected considerably more frequently. Moreover, periodontal bacteria belonged mostly to the Streptococci species and the yellow complex. None of the detected bacteria belonged to the red complex. CONCLUSION: Most frequently, the skin and GIT represented the site of origin of the microbiota. Nevertheless, the oral cavity represented the source of IE in up to 10%. Consequently, it needs to be emphasized that a good level of oral hygiene is strongly recommended in all patients undergoing heart valve surgery in order to reduce the bacterial load in the oral cavity, thereby minimizing the hematogenous spread of oral microbiota. The prerequisites for conservative dental treatment versus radical tooth extraction must always be based on the patient's cooperation, and the clinical intraoral status on a sense of proportion in view of the overall clinical situation due to the underlying cardiac disease. CLINICAL RELEVANCE: The oral cavity is a source of oral microbiota on infected heart valves. Patients requiring heart valve surgery should always undergo a critical evaluation of dental treatment affecting periodontally compromised teeth, favoring a systematic, conservative-leaning recall.

Elevated pulsatility index of the superior mesenteric artery indicated prolonged mechanical ventilation in patients after cardiac valve surgery.

Purpose: This study examined whether alterations in Doppler parameters of superior mesenteric artery (SMA) are associated with prolonged mechanical ventilation (PMV) in patients who underwent cardiac valve surgery. Methods: Hemodynamic and SMA Doppler parameters were collected at intensive care unit(ICU) admission. The duration of mechanical ventilation was monitored. PMV was defined as mechanical ventilation ≥96 h. Results: A total of 132 patients admitted to ICU after cardiac valve surgery were evaluated for enrollment, of whom 105 were included. Patients were assigned to the control (n = 63) and PMV (n = 42) groups according to the mechanical ventilation duration. The pulsatility index(SMA-PI) and resistive index of SMA (SMA-RI) were 3.97 ± 0.77 and 0.88 (0.84-0.90) in the PMV group after cardiac valve surgery, which was lower than the SMA-PI (2.95 ± 0.71, p < 0.0001) and SMA-RI of controls (0.8, 0.77-0.88, p < 0.0001). SMA-PI at admission had favorable prognostic significance for PMV (AUC = 0.837, p < 0.0001). Conclusions: An elevated SMA-PI is common in patients after cardiac valve surgery with PMV. Increased SMA-PI could help predict PMV after cardiac valve surgery. Using point-of-care ultrasound to measure SMA-PI at ICU admission is an acceptable and reproducible method for identifying patients with PMV.

Recent advances in exercise training in cardiac rehabilitation of patients after cardiac valve surgery / 中国实用护理杂志

Patients after cardiac valve surgery generally suffered from low exercise capacity, and lack of exercise can cause impaired exercise tolerance, reduced quality of life, and prolonged length of hospital stay, increased the risk of death. Exercise, as the core of cardiac rehabilitation, played an irreplaceable role in improving the cardiopulmonary function, exercise capacity, and health-related quality of life of patients after cardiac valve surgery. This article mainly reviewed the types and methods of exercise training after cardiac valve surgery, and the strategies for promoting exercise intervention, so as to provide references for medical staff to perform exercise interventions for patients after cardiac valve surgery.

The effect of in-hospital physiotherapy on handgrip strength and physical activity levels after cardiac valve surgery: a randomized controlled trial.

BACKGROUND: Patients who undergo cardiac valve surgery undertake routine physical therapy program. Despite its routine use, its influence on physical activity level post- surgery has not been illustrated. This study was to investigate whether 5 days of in-hospital physiotherapy could improve physical activity levels after cardiac valve surgery. METHODS: The study is a single-blind randomized controlled trial which performed in Cardiothoracic Surgery Department. Patients who underwent cardiac valve surgery (n=34) for confirmed cardiac valve disorders were assessed during hospitalization. The intervention group received a daily post-operative physiotherapy intervention, consisting of individualized mobilization, breathing exercises, ambulation with or without a walking aid. There was no physiotherapy treatment in the control group. Measurements: physical activity was assessed with the handgrip strength test and the timed up and go test. RESULTS: The treatment group showed significantly greater handgrip strength [20.58 (7.17) vs. 12.96 (4.65) kg] and less time on the timed up and go test [5.92 (2.91) vs. 6.53 (1.60) s] compared to the control group on the 5th post-operative day. Whilst there was no significant difference on the timed up and go test between the 2 groups, handgrip strength on the 5th post-operative day was significantly different between the 2 groups. CONCLUSIONS: Patients who received physiotherapy during hospitalization showed increased levels of handgrip strength and physical activity on the 5th day after cardiac valve surgery compared to the control group. The clinical value of increased levels of physical activity after in-hospital physiotherapy following cardiac valve surgery requires further investigation.

Cardiac valve operations after solid organ transplantation: A single-center experience.

OBJECTIVE: Cardiac valve operations in patients who have undergone solid organ transplantation (ie, kidney, liver, pancreas, heart, and lung) pose unique challenges due to patient comorbidities and to the need for immunosuppressive therapy. The aim of this retrospective study was to present our experience with patients with solid-organ transplant who had cardiac valve operation at the time or after transplantation. METHODS: Records of patients who had undergone cardiac valve operations after solid organ transplantation between January 1998 and January 2019 were retrospectively reviewed. Follow-up amounted to a median of 51 months (interquartile range, 5-88 months). RESULTS: Among the 14,465 patients who underwent treatment for a cardiac valvular pathology during the study period, 127 patients (0.9%) had undergone a solid organ transplantation (kidney: n = 9 [76%]; liver: n = 12 [9%]; pancreas: n = 4 [3%]; heart: n = 16 [13%]; lung: n = 9 [7%]). Postoperatively, 14 patients (11%) underwent rethoracotomy for bleeding and 24 patients (19%) required new dialysis treatment. Twenty-five patients (20%) died in-hospital. Postoperative course was worse in patients operated for endocarditis or undergoing concomitant transplantation and valve surgery. Overall survival was 59%, 47%, and 40%, but survival conditioned to hospital discharge was 73%, 58%, and 50% at 5-, 10-, and 15-year follow-up, respectively. Freedom from major valve-related events amounted to 77%, 56%, and 46%, respectively. CONCLUSIONS: Although the high prevalence of postoperative complications, especially in patients with endocarditis or concomitant transplantation and valve surgery, survival conditioned to hospital discharge was satisfactory in patients undergoing valve surgery after solid organ transplantation.

Effect of intraoperative dexmedetomidine infusion on delirium in adult patients following cardiac valve surgery: a protocol of a randomized, double-blinded, and placebo-controlled study.

BACKGROUND: Delirium is an acute status of brain dysfunction that commonly occurs in patients who have undergone cardiac surgery, and increases morbidity and mortality. It is associated with risk factors, such as older age, use of narcotics, cardiopulmonary bypass, and hypothermia. Dexmedetomidine infusion might exert a neuroprotective effect. However, the effect of perioperative administration of dexmedetomidine on the incidence of postoperative delirium (POD) in patients undergoing cardiac or non-cardiac surgery is yet controversial. The present study aimed to reveal the effect of intraoperative dexmedetomidine administration on the incidence of delirium in adult patients following cardiac surgery. METHODS: This single-center, randomized, double-blinded, and placebo-controlled trial consisted of 652 patients randomly divided into two groups: dexmedetomidine and placebo. 0.6 µg/kg dexmedetomidine will be infused 10 min after central vein catheterization, followed by a continuous infusion at a speed of 0.4 µg/kg/h until the end of surgery in the dexmedetomidine group, while normal saline will be administered at the same rate in the placebo group. The primary outcome is the incidence of POD during the first 7 days post-surgery. The secondary outcomes include duration of mechanical ventilation after surgery, duration of stay in the intensive care unit and the hospital after surgery, incidence of hypotension during or after dexmedetomidine infusion, acute kidney injury and sudden arrhythmia during the hospital stay postoperatively, and all-cause mortality in 30 and 90 days after surgery, respectively. DISCUSSION: This study was approved by the Ethics Committee of the Chinese Academy of Medical Sciences Fuwai Hospital on 6 March 2019 (2019-1180). The results will be disseminated at academic conferences and submitted to peer-reviewed publications. Either positive or negative results will provide guidance for clinical practice. TRIAL REGISTRATION: The Chinese Clinical Trial Registry ( http://www.chictr.org.cn ) ChiCTR1900022583. Registered on 17 April 2019.

Single-dose del Nido cardioplegia used in adult minimally invasive valve surgery.

BACKGROUND: To analyze the protective effect of single-dose del Nido cardioplegia (DNC) in adult minimally invasive valve surgery. METHODS: From January to December 2017, 165 consecutive adult patients who underwent minimally invasive valve surgery by the same team of surgeons were divided into two cohorts based on the type of cardioplegia administered during surgery: (I) single-dose DNC (DNC group (n=76, male 41, female 35) used in patients from May to December, 2017 and (II) intermittent standard 4:1 blood cardioplegia based on St.Thomas solution (SBC group, n=89, male 45, female 44) used in patients from January to April, 2017. Preoperative baseline demographics, preoperative comorbidities, operative variables, postoperative complications, and patient outcomes were collected and compared between the two groups. RESULTS: Preoperative characteristics were shown to be similar between the two groups before and after propensity matching. Patients in the DNC group required a significantly lower volume of cardioplegia. The volume of ultrafiltration in the DNC group was substantially higher than that in the SBC group. The spontaneous return of heartbeat rate in the DNC group was considerably higher than that in the SBC group (97.0% vs. 78.8%, P=0.006). The Euroscore II in the DNC group was markedly lower than that in the SBC group (2.00 vs. 3.00, P<0.05). The level of blood urea nitrogen (BUN) in the DNC group was significantly lower than that in the SBC group (6.20 vs. 6.95, P<0.05). There were no differences in surgery procedure, cross-clamp time, bypass time, Apache score, troponin T (cTnT), brain natriuretic peptide (BNP), liver and renal function, postoperative complications or patient outcomes between two groups. Regression analysis showed that cTnT increased with the prolongation of myocardial ischemia time, and was closely related to the type of operation, but had no significant correlation with the type of cardioplegia. CONCLUSIONS: In our initial experience, single-dose DNC in adult minimally invasive valve surgery in which the cross-clamp time was mostly less than 90 min, achieved equivalent myocardial protection and clinical outcomes when compared with standard whole blood cardioplegia. In addition, single-dose DNC made the minimally invasive valve surgery procedure progress in a smoother and more convenient fashion.

Is left ventricular hypertrophy a friend or foe of patients with aortic stenosis?

Left ventricular hypertrophy (LVH) is traditionally considered a physiological compensatory response to LV pressure overload, such as hypertension and aortic stenosis (AS), in an effort to maintain LV systolic function in the face of an increased afterload. According to the Laplace law, LV wall thickening lowers LV wall stress, which in turn would be helpful to preserve LV systolic performance. However, numerous studies have challenged the notion of LVH as a putative beneficial adaptive mechanism. In fact, the magnitude of LVH is associated with higher cardiovascular morbidity and mortality, especially when LVH is disproportionate to LV afterload. We have briefly reviewed: first, the importance of non-valvular factors, beyond AS severity, for total LV afterload and symptomatic status in AS patients; second, associations of excessive LVH with LV dysfunction and adverse outcome in AS; third, prognostic relevance of the presence or absence of pre-operative LVH in patients referred for aortic valve surgery; fourth, time course, determinants and prognostic implications of LVH regression and LV function recovery after surgical valve replacement and transcatheter aortic valve implantation (TAVI) with a focus on TAVI-specific effects; fifth, the potential of medical therapy to modulate LVH before and after surgical or interventional treatment for severe AS, a condition perceived as a relative contraindication to renin-angiotensin system blockade.