Active Endocarditis Research Articles

Short-term outcome after isolated tricuspid valve surgery: prognostic role of right ventricular strain.

To assess the incremental prognostic value of right ventricular free wall longitudinal strain over conventional risk scores in predicting the peri-operative mortality in patients with severe tricuspid regurgitation (TR) undergoing isolated tricuspid valve (TV) surgery. We retrospectively enrolled 110 consecutive patients with severe TR who underwent isolated TV surgery between November 2016 and July 2022 at San Raffaele Hospital, Milan, Italy. Exclusion criteria were previous TV surgery, urgent surgery, complex congenital heart disease, active endocarditis and inadequate acoustic window. Baseline clinical data were included, as well as laboratory tests and clinical risk score, as TRI-SCORE and MELD-XI. The clinical outcome was peri-operative mortality, defined as all-cause mortality within 30 days. The final cohort included 79 patients. The endpoint occurred in 7 patients (9%), who died within 30-days after isolated TV surgery. ROC curves analysis showed that, among parameters of right ventricular function, right ventricular free wall longitudinal strain was the best parameter to predict peri-operative mortality (AUC: 0.854, 95% CI 0.74-0.96, p = 0.005, sensitivity 68%, specificity 100%) At univariable analysis, left ventricular ejection fraction, diabetes mellitus, creatinine, estimated glomerular filtration rate, serum sodium, MELD-XI, TRI-SCORE, right ventricular areas, right ventricular global longitudinal strain, right ventricular free wall longitudinal strain, fractional area change and the ratio between right ventricular free wall longitudinal strain/pulmonary arterial systolic pressure were significantly associated with the endpoint. The combination of TRI-SCORE and right ventricular Strain, evaluating right ventricular systolic function with speckle-tracking echocardiography, outperformed classic TRI-SCORE in outcome prediction (AUC 0.874 vs 0,787, p value=0.05). Right ventricular free wall longitudinal strain has an incremental prognostic value over conventional parameters and significantly improves the ability of clinical scores to predict peri-operative mortality in patients undergoing isolated TV surgery.

Minimally Invasive Video-Assisted Surgery for Concomitant Ascending Aorta and Aortic Valve Replacement via Right Infra-Axillary Thoracotomy.

This study aims to assess the safety, efficacy, and esthetic outcomes of an innovative 4 cm right infra-axillary incision approach for concomitant ascending aorta and aortic valve replacement (AAR and AVR), with a specific focus on achieving optimal surgical outcomes while ensuring minimal visible scarring. We retrospectively examined all elective cases of concomitant AAR and AVR surgery performed at our institution from July 2021 to June 2023. Exclusions encompassed emergency surgery, acute type A aortic dissection, active aortic valve endocarditis, redo cardiac surgery, the necessity for concurrent mitral valve replacement, or left ventricular assist device implantation. We collected and analyzed perioperative data for the patients. The study comprised 24 consecutive patients. Cardiopulmonary bypass time and aortic cross-clamp time averaged 215.0 (interquartile range [IQR], 38.0) and 158.0 (IQR, 37.0) min, respectively. No instances of reoperation due to postoperative bleeding or need for permanent pacemaker implantation were recorded. Initial 24-h postoperative drainage volume averaged 186.9 ± 76.9 mL. Average follow-up duration was 21.7 ± 6.2 months (range, 5 to 30 months). Throughout short-term follow-up, no occurrences of valve dysfunction, paravalvular leak, cardiovascular events necessitating readmission, or mortality were observed. The right infra-axillary incision approach effectively yields secure, successful, and cosmetically pleasing outcomes for concomitant AAR and AVR. Further research and comparisons are warranted to validate these findings.

Durability of Right Ventricular Conduits in the Ross Procedure

ObjectivesRight ventricular (RV) conduit availability and degeneration are potential limitations of the Ross procedure. Pulmonary homografts are the gold standard but their limited availability drives the need for alternatives. The aim of this study was to compare results of different RV conduits. MethodsBetween 1995 and 2023, 315 consecutive patients (mean age:37±12years, 73% male) underwent a Ross procedure using a homograft (n=211), bovine jugular vein (‘BJV’) (n=34) or xenograft (n=70) as RV conduit. Mean follow-up was 5.7±6.7years and was 96% complete (1631 patient-years). ResultsTwelve patients (homograft 8/211, BJV 3/34, xenograft 1/70) required RV conduit reintervention, four patients (homograft) within 4 years. Indications for reintervention were degeneration (n=8) and active endocarditis (n=4).Reinterventions included RV conduit replacement (n=6, homograft n=3, xenograft n=1, BJV n=2) and transcatheter valve implantation (n=6, homograft n=5, BJV n=1).At 15years, freedom from RV conduit reintervention was 88%; freedom from reoperation was 93%. Freedom from reintervention at 15years was similar between homografts (89%), BJV (89%), and xenografts (100%)(p=0.812). Progression of mean RV conduit gradient was lowest for the BJV (1.45mmHg/year) and similar between the homograft (2.6mmHg/year) and xenograft (2.9mmHg/year).Age at surgery (<18years; p<0.001; HR 1.9) was a predictive risk factor for reintervention. There was no difference between RV conduits (p=0.606; HR 1.198). ConclusionsThe incidence of reintervention after 15years is similar between homografts, xenograft, and BJV. Interestingly, homografts may fail in the first few years, possibly related to inflammatory phenomena. Thus, the use of xenografts may be an option if homografts are not available.

Demographics and outcomes of patients younger than 75years undergoing aortic valve interventions in Rotterdam.

Transcatheter aortic valve implantation (TAVI) is considered asafe and effective alternative to surgical aortic valve replacement (SAVR) for elderly patients across the operative risk spectrum. In the Netherlands, TAVI is reimbursed only for patients with ahigh operative risk. Despite this, one fifth of TAVI patients are < 75years of age. We aim to compare patient characteristics and outcomes of TAVI and SAVR patients < 75years. This study included all patients < 75years without active endocarditis undergoing TAVI or SAVR for severe aortic stenosis, mixed aortic valve disease or degenerated aortic bioprosthesis between 2015 and 2020 at the Erasmus University Medical Centre. Dutch authority guidelines were used to classify operative risk. TAVI was performed in 292 patients, SAVR in 386 patients. Based on the Dutch risk algorithm, 59.6% of TAVI patients and 19.4% of SAVR patients were at high operative risk. There was no difference in 30-day all-cause mortality between TAVI and SAVR (2.4% vs 0.8%, p = 0.083). One-year and 5‑year mortality was higher after TAVI than after SAVR (1-year: 12.5% vs 4.3%, p < 0.001; 5‑year: 36.8% vs 12.0%, p < 0.001). Within risk categories we found no difference between treatment strategies. Independent predictors of mortality were cardiovascular comorbidities (left ventricular ejection fraction < 30%, atrial fibrillation, pulmonary hypertension) and the presence of malignancies, liver cirrhosis or immunomodulatory drug use. At the Erasmus University Medical Centre, in patients < 75years, TAVI is selected for higher-risk phenotypes and overall has higher long-term mortality than SAVR. We found no evidence for worse outcome within risk categories.

Early Valve Surgery for Endocarditis After Acute Embolic Stroke

BackgroundPatients with active endocarditis often suffer acute stroke, with increased risk for hemorrhagic conversion at the time of valve repair or replacement. Controversy persists about timing of operative intervention. MethodsAn institutional Society of Thoracic Surgeons database of all patients with endocarditis was reviewed for patients undergoing valve surgery (2016-2024). Electronic medical records were reviewed for detailed stroke information and longitudinal follow-up. Descriptive statistics and Kaplan-Meier survival curves evaluated outcomes and survival. ResultsOperations for acute active infective endocarditis were performed in 656 patients. Preoperative stroke occurred in 98 patients (14.9%); 86 strokes (87.8%) were embolic, and 16 patients (18.6%) had microhemorrhagic and 12 (12.2%) had hemorrhagic strokes. Median time between preoperative stroke diagnosis and surgery was 5.5 days. The overall incidence of postoperative stroke was 2.1% (14 of 656), with no statistically significant difference in postoperative stroke between patients with vs without preoperative stroke (n = 4 of 98 [4.1%] vs n = 10 of 558 [1.8%]; P = .148). However, the proportion of patients with postoperative hemorrhagic strokes was higher in the preoperative stroke group (3.1% vs 0.5%, P = .016). Finally, of patients with preoperative stroke, early surgery ≤72 hours (n= 38 [38.8%]) was not associated with increased stroke (2.6% vs 5.0%, P = .564). ConclusionsThese contemporary data highlight the feasibility of an early valve surgery strategy for acute endocarditis in the setting of acute stroke, with noninferior postoperative stroke risk.

The Role of Microbes in Surgical Decision Making for Infective Endocarditis: Mitral Valve Repair or Replacement?

The benefits of mitral repair versus replacement for endocarditis are inconclusive. This study compares outcomes of patients with infective endocarditis undergoing mitral valve repair versus replacement and investigates the impact of microbial etiology. All 251 patients undergoing mitral valve surgery for active endocarditis between 2010 and 2023 were enrolled, 180 (71.7%) replacement and 71 (28.3%) repair. To adjust for imbalances, inverse probability of treatment weighting was applied and 187 patients were obtained. The analysis between groups, following the application of inverse probability of treatment weighting, showed no statistically significant differences across all considered outcomes. Early and late death was observed respectively in 6 (8.5%) and 11 (15.5%) patients in the repair group versus 24 (13.3%) and 45 (25.0%) in the replacement group without statistical significance (p = 0.221 and p = 0.446). Relapse occurred in six patients (8.5%) in the repair group after a median time of 4.0 months and in six (3.3%) in the replacement after 6.9 months (p = 0.071). Surgical strategy in mitral endocarditis has no effect on major postoperative complications, mortality, or medium/long-term survival. Staphylococcus aureus and Coagulase-negative Staphylococci represent a risk for early mortality and relapse. However, mitral valve repair for endocarditis can be pursued when it ensures the complete eradication of all infected tissue, particularly in cases caused by Streptococcus infection, in young patients, and after a minimum of 18 days of antibiotic therapy.

Tricuspid valve surgery for acute infective endocarditis can be performed with very low operative mortality

ObjectiveTricuspid valve surgery historically has been perceived as having elevated operative risk, prompting the recent development of transcatheter therapies including aspiration vegetectomy for endocarditis. The opioid epidemic has exacerbated tricuspid valve endocarditis, particularly in people who inject drugs. We sought to evaluate contemporary outcomes of tricuspid valve surgery in real-world practice. MethodsAn institutional multidisciplinary endocarditis database inclusive of clinical, microbiologic, and echocardiographic data was analyzed for those undergoing isolated or concomitant tricuspid valve surgery for acute active endocarditis. Consecutive patients between 2016 and 2021 were followed for longitudinal outcomes. ResultsA total of 283 patients with tricuspid valve endocarditis underwent tricuspid valve repair (n = 137, 48.4%) or replacement (n = 146, 51.6%). Median age was 31 (27-37) years, 63.1% were female, and 257 (90.8%) were active people who inject drugs. The leading indications for surgery were severe valvular insufficiency (71.2%), vegetation size greater than 2 cm (51.3%), or septic shock (23.3%). Concomitant procedures were performed in 44 patients (15.5%). In patients who underwent isolated tricuspid valve surgery (n = 239), no patient required permanent pacemaker after tricuspid valve repair, whereas 13.3% required permanent pacemaker after tricuspid valve replacement. Overall and isolated tricuspid valve surgery operative mortality were 1.8% and 1.3%, respectively. Overall and isolated tricuspid valve surgery 1-year survivals were 89.3% and 89.7%, respectively. ConclusionsTricuspid valve surgery for endocarditis has low operative mortality. When feasible, repair is preferred over replacement. In an era of promulgation of investigational therapies, heart teams should note that tricuspid valve surgery is low risk and remains the first-line beyond antibiotics.

Surgery for Active Infective Endocarditis on Mitral Valve: Anatomical, Surgical, and Disease Factors as Long-Term Outcome Modifiers.

Background and Objectives: Determinants of long-term outcomes after surgery for native mitral valve endocarditis have not been thoroughly investigated. The aim of this study was to assess anatomical, disease, and surgical risk factors for long-term mortality and need of reintervention, in patients undergoing mitral valve surgery for active endocarditis. Materials and Methods: Patients who underwent surgery for active native mitral valve endocarditis at three academic centres, between 2000 and 2022, were analysed. The primary outcome was long-term survival. The secondary outcome was the freedom from mitral reoperation. Survival curves were constructed with Kaplan-Meier methodology. Multivariable Cox regression was used to identify demographic, anatomical, disease, and surgical factors associated with late mortality and reoperation. Results: 335 consecutive patients with active mitral endocarditis were analysed. Two hundred and one patients (70.5%) had infection confined to the valve cusp whereas 89 (25.6%) had invasive disease extended to the annulus and surrounding tissues. Preoperative neurological events occurred at the diagnosis in 52 cases. Streptococci were the most common causative organisms followed by Staphylococcus aureus, Coagulase-negative Staphylococcus, and Enterococcus. Valve repair was performed in 108 patients (32.2%). Survival at 5 and 10 years was 70.1% and 59.2%, respectively. Staphylococcus emerged as an independent predictor of late mortality, along with age, chronic obstructive pulmonary disease, and previous cardiac surgery. Survival was considerably reduced in patients with S. aureus compared with those without (log rank p < 0.001). The type of surgery (repair vs. replacement) did not emerge as a risk factor for late mortality and reoperation. Seventeen patients underwent mitral reoperation during the follow-up. The 5- and 10-year freedom from reoperation was 94.7% and 91.8%, respectively. Conclusions: Active mitral valve endocarditis remains a life-threatening disease with impaired survival. While lesion characteristics influenced surgical decision-making and intraoperative management, their impact on long-term survival and freedom from reintervention appears to be moderated by other factors such as infecting pathogens and patient comorbidities.

THE “SANDWICH” TECHNIQUE IN MITRAL ANNULAR CALCIFICATION

Abstract Objective To assess the feasibility and safety of the “Sandwich” technique in case of massive mitral annular calcification (MAC). MAC is a multifactorial chronic disease and a challenging clinical entity to the surgeon: both respecting and resecting techniques have been developed, in order to prevent eventual annular ruptures. Methods Twelve patients underwent mitral valve replacement (MVR) between January and September 2023, mainly because of steno–insufficiency of the mitral valve, in presence of MAC. Their mean age was 76 ± 4.5, their BMI was 27.2 ± 2.8 and their surgery was mostly elective, except for one urgent active endocarditis; their mean EUROscore II was 8.2 ± 2.9. Results We performed 12 MVR with biological valve, through full sternotomy approach. The cardiopulmonary bypass and aortic cross–clamp time were 195 ± 57 and 155 ± 42 minutes respectively. We perform a double line suture respectful of the annular calcium, in order to reinforce the mitral annulus, before fixing the prosthesis. Surgical stiches on the anterior annulus were ordinarily put; on the posterior annulus, which is usually the most calcified part, a teflon band underneath the calcium was fixed as first, through separate prolene 2–0 U–stitches. Then the usual 2–0 ticron stitches with pledget were put between the posterior annulus and the atrial wall. Both 2–0 prolene and ticron were passed through the prosthesis sewing ring: prolene was placed more externally than ticron. No leakages were found, both intraoperative and postoperative. There were no in–hospital deaths. No strokes, thromboembolic or coronary complications were observed. Conclusions The “Sandwich” technique is reproducible, feasible and safe and it does not imply a long surgical learning curve. It is not a disruptive approach, avoiding annulus failure and it is respectful of the cardiac structures.

Navigating the challenges of minimally invasive mitral valve surgery: a risk analysis and learning curve evaluation

BackgroundThis study aimed to report the risk and learning curve analysis of a minimally invasive mitral valve surgery program performed through a right mini-thoracotomy at a single institution.MethodsFrom January 2013 through December 2019, 266 consecutive patients underwent minimally invasive mitral valve surgery in our department and were included in the current study. Multiple logistic regression analysis was used for the adverse event outcome. Distribution over time of perioperative complications, defined as clinical endpoints in the Valve Academic Research Consortium-2 (VARC-2) consensus document, as well as CUSUM charts for assessment of cardiopulmonary bypass and aortic cross-clamping duration over time, has been performed for learning curve assessment.ResultsOverall incidences of postoperative stroke (1.1%), myocardial infarction (1.1%), and thirty-day mortality (1.5%) were low. The mitral valve reconstruction rate in our series was 95%. Multivariable analysis revealed that concomitant tricuspid valve surgery (OR 4.44; 95%CI 1.61–11.80; p = 0.003) was significantly associated with adverse event outcomes. Despite a trend towards adverse event outcomes in patients with preexisting active mitral valve endocarditis (OR 2.69; 95%CI 0.81–7.87; p = 0.082), mitral valve pathology did not significantly impact postoperative morbidity and mortality. Distribution over time of perioperative complications, defined as clinical endpoints in the VARC-2 consensus document, showed a trend towards an improved complication rate after the initial 65–100 procedures.ConclusionsMitral valve surgery via right-sided mini-thoracotomy can be implemented safely with low perioperative morbidity and mortality rates. Careful patient selection regarding isolated mitral valve surgery in the presence of degenerative mitral valve disease may represent a significant safety issue during the learning curve.Trial Registration: The cantonal ethics commission of Zurich approved the study (registration ID 2020-00752, date of approval 24 April 2020).

Surgical Treatment of Active Endocarditis Pre- and Post-COVID-19 Pandemic Onset.

Despite advanced diagnosis and treatment, infective endocarditis (IE) is a potentially life-threatening condition. The impact of COVID-19 on the diagnosis and outcome of the surgical treatment of IE is uncertain. The aim of this study was to analyze the incidence, characteristics, and outcomes of surgically treated IE before and after the COVID-19 pandemic. This study retrospectively analyzed the data of 535 patients who underwent valve surgical procedures for IE between January 2010 and December 2022 in a single cardiac surgery center. Patients were divided into two groups depending on the date of their operation: before (n = 393) and after (n = 142) COVID-19 onset. In order to balance the groups, inverse probability of treatment weighting (IPTW) calculated from the propensity score (PS) was applied. Weighted univariate logistic regressions were reported for outcomes; weights were derived from IPTW. Interrupted time series analysis (ITSA) according to Linden's method was used to evaluate the changes in the manifestation of IE after 11 March 2020. Patients from the post-COVID-19 cohort (after 11 March 2020) had a greater number of comorbidities such as diabetes (29.6% vs. 16.3% p = 0.001), hypertension (71.1% vs. 59.5% p = 0.015), and preoperative kidney injury requiring dialysis (9.2% vs. 2.5% p = 0.002), but the median additive and logistic EuroSCORE were not statistically different. In the post-COVID-19 group, we observed a greater prevalence of Staphylococcus aureus-related endocarditis (24.5% vs. 15.4% p = 0.026), a consequent reduction in Staphylococcus non aureus-related endocarditis (12.2% vs. 20.1% p = 0.048), and a decrease in aortic valve replacements (43.0% vs. 53.9%), while the number of mitral valve replacements and repair was greater (21.1% vs. 15.0% and 6.3% vs. 4.3%, respectively). No differences were found in the two groups concerning early death, death, or relapse at 1 year after surgery. Data obtained by multivariable analysis identified preoperative renal dysfunction requiring dialysis as the only common risk factor for early mortality via stratifying by time periods in analysis. The incidence of surgically treated IE significantly increases after the COVID-19 pandemic with a higher incidence of mitral valve involvement with respect to the aortic valve. Although a delay in surgical timing occurred during the COVID-19 pandemic, data in terms of mortality and outcomes were largely unaffected.

Incidental Finding of Subannular Perfused Aortic Root Abscess.

An 83-year-old female presented with aortic valve stenosis requiring surgery, which was diagnosed with a transthoracic echocardiography three years ago. However, the patient declined the surgery at that time due to personal reasons. Three years later she presented again with signs of dizziness and weakness and progression of the aortic valve stenosis. Cardiac catheterization and a computed tomography scan were performed before the planned surgery. Surprisingly, a huge subannular perfused abscess hole around the aortic root companying a pericardial effusion was revealed. The patient underwent an urgent aortic root replacement with a tissue valve and an aortic ascending replacement without any complications. Intraoperative inspection confirmed an active aortic root and valve endocarditis.

Long-Term Clinical and Echocardiographic Outcomes Following the Ross Procedure

The Ross procedure as treatment for adults with aortic valve disease (AVD) has been the subject of renewed interest. To evaluate the long-term clinical and echocardiographic outcomes following the Ross procedure for the treatment of adults with AVD. This post hoc analysis of a randomized clinical trial included adult patients (age <69 years) who underwent a Ross procedure for the treatment of AVD, including those with active endocarditis, rheumatic AVD, decreased ejection fraction, and previous cardiac surgery. The trial, conducted from September 1, 1994, to May 31, 2001, compared homograft root replacement with the Ross procedure at a single center. Data after 2010 were collected retrospectively in November and December 2022. Ross procedure. The primary end point was long-term survival among patients who underwent the Ross procedure compared with that in the age-, country of origin- and sex-matched general population. Secondary end points were freedom from any reintervention, autograft reintervention, or homograft reintervention and time-related valve function, autograft diameter, and functional status. This study included 108 adults (92 [85%] male) with a median age of 38 years (range, 19-66 years). Median duration of clinical follow-up was 24.1 years (IQR, 22.6-26.1 years; 2488 patient-years), with 98% follow-up completeness. Of these patients, 9 (8%) had active endocarditis and 45 (42%) underwent reoperations. The main hemodynamic lesion was stenosis in 30 (28%) and regurgitation in 49 (45%). There was 1 perioperative death (0.9%). Twenty-five year survival was 83.0% (95% CI, 75.5%-91.2%), representing a relative survival of 99.1% (95% CI, 91.8%-100%) compared with the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%); from autograft reintervention, 80.3% (95% CI, 71.9%-89.6%); and from homograft reintervention, 86.3% (95% CI, 79.0%-94.3%). Thirty-day mortality after the first Ross-related reintervention was 0% and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2% (95% CI, 89.0%-100%). This study found that the Ross procedure provided excellent survival into the third decade postoperatively that was comparable to that in the general population. Long-term freedom from reintervention demonstrated that the Ross procedure may be a durable substitute into late adulthood, showing a delayed but progressive functional decline. isrctn.org Identifier: ISRCTN03530985.

Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement.

Nowadays, one of the main goals of aortic valve surgery is to reduce the biological impact, mortality, and complications. It is well-known that long operative times in terms of the extracorporeal circulation, but above all, of the aortic cross-clamp time (ACC), represent a risk factor for mortality in patients undergoing cardiac surgery. In order to shorten the aortic cross-clamp time, many technological improvements, such as sutureless prostheses, have been introduced, but their actual effectiveness has not been proven yet. The aim of this study was to assess the 30-day outcomes of patients undergoing aortic valve replacement surgery, focusing on the ACC length. All 3139 patients undergoing aortic valve replacement between January 2013 and July 2022 at our institution were enrolled. The data were retrospectively collected and the baseline characteristics and intraoperative variables were recorded. In order to adjust the results according to the differences in the baseline characteristics, propensity score matching was performed and four groups of 351 patients were obtained based on the first, second, third, and fourth quartile of the ACC time. The patient population included 132 redo surgeries (9.4%) and 61 cases of active endocarditis (4.3%), with an overall median EuroSCORE II of 1.8 (IQR 1.2-3.1). An increase across the groups was observed in terms of the acute kidney failure (p < 0.001) incidence, the number of blood transfusions (p = 0.022), prolonged hospital stays (p < 0.001), the and respiratory failure (p < 0.001) incidence. A p of < 0.1 was found for the 30-day mortality (p = 0.079). The predictors of an early 30-day mortality were standard full sternotomy (OR 2.48, 95% CI 1.14-5.40, p = 0.022), EuroSCORE II (OR 1.10, 95% CI 1.05-1.16, p < 0.001), and a trend for a longer ACC time (Q4 vs. Q1: OR 2.62, 95% CI 0.89-7.68, p = 0.080). Shortening the operative times resulted in marked improvements of the patients' outcomes. The combined use of minimally invasive approaches and sutureless aortic valve prostheses allows for a lower 30-day events rate. New technologies should be assessed to obtain the best results with the least risk.

Surgical Treatment of Active Mitral Valve Endocarditis

Surgical Treatment of Active Mitral Valve Endocarditis

Aortic valve replacement after previous TAVI

Endovascular surgery for aortic valve defects has proven itself well in elderly patients with severe comorbidities competing with the underlying disease. However, the risk of dysfunction resulting from structural degeneration of bioprosthetic heart valve and prosthetic valve endocarditis remains high. Repeated surgeries are associated with complications, but open surgery is the only method of treatment in this group of patients.Objective: to describe a series of reinterventions for prosthetic valve dysfunction occurring after TAVI.Material and methods. From 2015 to 2022, at the Department of Emergency Surgery for Acquired Heart Diseases (Head, Professor R.M. Muratov), Bakulev Research Center for Cardiovascular Surgery, 6 reoperations were performed in patients who had previously undergone transcatheter aortic valve implantation (TAVI). The average age of patients at the time of TAVI and at the time of reoperation was 70.6 years (62–83) and 74.3 years (70–84), respectively. The EuroSCORE II predicted risk of mortality at the time of reintervention was 42.2% (21.7–87.6). The mean time to reoperation was 42 months. Indications for reoperation were early active prosthetic endocarditis (4 cases) and structural valve degeneration (2 cases).Results. At the hospital stage, 1 patient died of acute heart failure; the operation was performed for vital indications in conditions of extreme initial severity. In three patients, the early postoperative period was uneventful. One patient required intra-aortic balloon counterpulsation (IABP) due to heart failure, and 1 patient was implanted with permanent pacemaker. The average time of hospitalization was 14 days. Patients with active prosthetic endocarditis received a 6-week course of antibiotic therapy. The function of the implanted valves was satisfactory.Conclusions. Aortic valve replacement after previous TAVI is an emergency operation and represents the only way to treat valve dysfunction. Under active prosthetic endocarditis, timely surgery can save this patient cohort.

P45 MINITHORACOTOMY APPROACH FOR MITRAL VALVE REDO SURGERY

Abstract Objective Redo cardiac surgery through median sternotomy still represents a challenging procedure due to the high risk of graft injuries, the presence of dense adhesions and complex valve exposure. The use of a minithoracotomy approach may reduce the surgical complexity. We report our experience performing redo mitral valve surgery through a right–sided mini–thoracotomy. Methods From march 2010 to May 2022, 58 patients (Median age 68 years (IQR 56–76) and 41.4% females) underwent redo mitral valve surgery through right anterior thoracotomy at our institution. Median EuroSCORE II was 3.83 (IQR 2.54–7.28). Results The median time from the original operation to redo surgery was 6.1 (1.0–10.3) years. First surgery was mitral repair in 60% of patients, mitral valve replacement in 15%, Coronary Artery Bypass Grafting in 12% and Aortic valve Replacement in nearly 9% of our population. Four patients (6.9%) were affected by active endocarditis at the time of surgery. Median cardiopulmonary bypass and cross–clamp times were 120 (IQR 80–148) minutes and 81 (IQR 59.5–114) minutes, respectively. No conversion to full sternotomy was necessary. Twenty–eight patients (48.3%) required transfusions with packed blood cells. Post–operative atrial fibrillation was observed in 6 patients (10.3%) and 7 patient (12.1%) required Pace–maker implantation due to third degree AV block. Moreover, we observed 1 rethoracotomy for bleeding (1.7%). One patient (1.7%) required re–intubation, dialysis and Extracorporeal Life Support, for a septic shock that finally caused exitus. Median ventilation time was 7 hours (IQR 4–13). Median ICU and in–hospital length of stay were 2 (IQR 2–3) days and 10 (IQR 8–15) days respectively. In–hospital and 30–days mortality was 1.7%. Conclusions In our experience, a minimally invasive approach through right thoracotomy for redo mitral valve procedures is safe and feasible, with acceptable CPB and Cross–clamp times and good in–hospital outcomes. Therefore, it can be an attractive option for patients with previous cardiac surgery, above all for patients with patent grafts. Further studies are needed with a bigger population and a comparison to full sternotomy results.

Concomitant intra-aortic balloon pump and veno-arterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

We aimed to compare the outcomes of ECMO with and without IABP for postcardiotomy cardiogenic shock. The study included 103 patients who needed ECMO for postcardiotomy cardiogenic shock. Patients were grouped according to the use of IABP into ECMO without IABP (n = 43) and ECMO with IABP (n = 60). The study endpoints were hospital complications, successful weaning, and survival. Patients with IABP had lower preoperative ejection fraction (p = 0.002). There was no difference in stroke (p = 0.97), limb ischemic (p = 0.32), and duration of ICU stay (p = 0.11) between groups. Successful weaning was non-significantly higher with IABP (36 (60%) vs 19 (44.19%); p = 0.11). Predictors of successful weaning were inversely related to the high pre-ECMO lactate levels (OR: 0.89; p = 0.01), active endocarditis (OR: 0.06; p = 0.02), older age (OR: 0.95; p = 0.02), and aortic valve replacement (OR: 0.26; p = 0.04). There was no difference in survival between groups (p = 0.80). Our study did not support the routine use of IABP during ECMO support.

How to counteract the lack of donor tissue in cardiac surgery? Initial experiences with a newly established homograft procurement program

Homograft heart valves may have significant advantages and are preferred for the repair of congenital valve malformations, especially in young women of childbearing age, athletes and in patients with active endocarditis. A growing problem, however, is the mismatch between tissue donation and the increasing demand. The aim of this paper is to describe the initiation process of a homograft procurement program to attenuate the shortage of organs. A comprehensive description of the infrastructure and procedural steps required to initiate a cardiac and vascular tissue donation program combined with a prospective follow-up of all homografts explanted at our institution. Between January 2020 and May 2022, 28 hearts and 12 pulmonary bifurcations were harvested at our institution and delivered to the European homograft bank. Twenty-seven valves (19 pulmonary valves, 8 aortic valves) were processed and allocated for implantation. The reasons for discarding a graft were either contamination (n = 14), or morphology (n = 13) or leaflet damage (n = 2). Five homografts (3 PV, 2 AV) have been cryopreserved and stored while awaiting allocation. One pulmonary homograft with a leaflet cut was retrieved by bicuspidization technique and awaits allocation, as a highly requested small diameter graft. The implementation of a tissue donation program in cooperation with a homograft bank can be achieved with reasonable additional efforts at a transplant center with an in-house cardiac surgery department. Challenging situations with a potential risk of tissue injury during procurement include re-operation, harvesting by a non-specialist surgeon and prior central cannulation for mechanical circulatory support.

Epidemiology, risk factors and outcomes of norepinephrine use in cardiac surgery with cardiopulmonary bypass: a multicentric prospective study

BackgroundThe present study was designed to describe the prevalence of norepinephrine use, the factors associated with its use, and the incidence of postoperative complications according to norepinephrine use, in patients undergoing cardiac surgery with cardiopulmonary bypass. MethodWe performed a prospective, multicenter, observational study in 4 University-affiliated medico-surgical cardiovascular units. We analyzed all patients treated with cardiac surgery after excluding pre-ECMO surgery, LVAD implantation, heart transplantation and intra-operative hemorrhage. ResultsOf 9316 patients screened during the study period, 2862 were included and 2510 were analyzed. Among them, 1549 (61%) were treated with norepinephrine with a median maximal dose of 0.11 [0.06−0.2] μg.kg−1.min−1 and a median duration of 10 h [2–24]. Norepinephrine was most often started in the operating room before cardiopulmonary bypass. The multiple regression logistic analysis identified several modifiable (haematocrit, maintenance of beta-blocker, cardiopulmonary bypass time, glucose-insulin-potassium, Custodiol cardioplegia, Delnido cardioplegia, and fibrinogen transfusion) and non-modifiable factors (age, ASA score, chronic high blood pressure, coronary disease, dyslipidemia, right ventricular dysfunction, left ventricular dysfunction, active endocarditis, and valvular aortic surgery) associated with norepinephrine use. Mortality, morbidity (neurological and renal complications, death) and length of stay in the ICU were higher in patients treated with norepinephrine. ConclusionNorepinephrine is often used in cardiac surgical patients but for <24 h with a low dose. Many preoperative and surgical factors are associated with norepinephrine use. Patients supported by norepinephrine have a higher incidence of major postoperative events.