Cardiac Valvular Surgery Research Articles

Perioperative parameters-based prediction model for acute kidney injury in Chinese population following valvular surgery.

Acute kidney injury (AKI) is a relevant complication after cardiac surgery and is associated with significant morbidity and mortality. Existing risk prediction tools have certain limitations and perform poorly in the Chinese population. We aimed to develop prediction models for AKI after valvular cardiac surgery in the Chinese population. Models were developed from a retrospective cohort of patients undergoing valve surgery from December 2013 to November 2018. Three models were developed to predict all-stage, or moderate to severe AKI, as diagnosed according to Kidney Disease: Improving Global Outcomes (KDIGO) based on patient characteristics and perioperative variables. Models were developed based on lasso logistics regression (LLR), random forest (RF), and extreme gradient boosting (XGboost). The accuracy was compared among three models and against the previously published reference AKICS score. A total of 3,392 patients (mean [SD] age, 50.1 [11.3] years; 1787 [52.7%] male) were identified during the study period. The development of AKI was recorded in 50.5% of patients undergoing valve surgery. In the internal validation testing set, the LLR model marginally improved discrimination (C statistic, 0.7; 95% CI, 0.66-0.73) compared with two machine learning models, RF (C statistic, 0.69; 95% CI, 0.65-0.72) and XGBoost (C statistic, 0.66; 95% CI, 0.63-0.70). A better calibration was also found in the LLR, with a greater net benefit, especially for the higher probabilities as indicated in the decision curve analysis. All three newly developed models outperformed the reference AKICS score. Among the Chinese population undergoing CPB-assisted valvular cardiac surgery, prediction models based on perioperative variables were developed. The LLR model demonstrated the best predictive performance was selected for predicting all-stage AKI after surgery. Trial registration: Clinicaltrials.gov, NCT04237636.

An In-Hospital Mortality Risk Model for Elderly Patients Undergoing Cardiac Valvular Surgery Based on LASSO-Logistic Regression and Machine Learning.

To preferably evaluate and predict the risk for in-hospital mortality in elderly patients receiving cardiac valvular surgery, we developed a new prediction model using least absolute shrinkage and selection operator (LASSO)-logistic regression and machine learning (ML) algorithms. Clinical data including baseline characteristics and peri-operative data of 7163 elderly patients undergoing cardiac valvular surgery from January 2016 to December 2018 were collected at 87 hospitals in the Chinese Cardiac Surgery Registry (CCSR). Patients were divided into training (N = 5774 [80%]) and testing samples (N = 1389 [20%]) according to their date of operation. LASSO-logistic regression models and ML models were used to analyze risk factors and develop the prediction model. We compared the discrimination and calibration of each model and EuroSCORE II. A total of 7163 patients were included in this study, with a mean age of 69.8 (SD 4.5) years, and 45.0% were women. Overall, in-hospital mortality was 4.05%. The final model included seven risk factors: age, prior cardiac surgery, cardiopulmonary bypass duration time (CPB time), left ventricular ejection fraction (LVEF), creatinine clearance rate (CCr), combined coronary artery bypass grafting (CABG) and New York Heart Association (NYHA) class. LASSO-logistic regression, linear discriminant analysis (LDA), support vector classification (SVC) and logistic regression (LR) models had the best discrimination and calibration in both training and testing cohorts, which were superior to the EuroSCORE II. The mortality rate for elderly patients undergoing cardiac valvular surgery was relatively high. LASSO-logistic regression, LDA, SVC and LR can predict the risk for in-hospital mortality in elderly patients receiving cardiac valvular surgery well.

Platelet Transfusion After Cardiac Surgery

To investigate the independent association of platelet transfusion with hospital mortality and key relevant clinical outcomes in cardiac surgery. A single-center, propensity score-matched, retrospective, cohort study. At an American tertiary teaching hospital data from the Medical Information Mart for Intensive Care III and IV databases from 2001 to 2019. Consecutive adults undergoing coronary artery bypass graft and/or cardiac valvular surgery. Platelet transfusion during perioperative intensive care unit (ICU) admission. Overall, 12,043 adults met the study inclusion criteria. Of these, 1,621 (13.5%) received apheresis-leukoreduced platelets, with a median of 1.19 units per recipient (IQR: 0.93-1.19) at a median of 1.78 hours (IQR: 0.75-4.25) after ICU admission. The platelet count was measured in 1,176 patients (72.5%) before transfusion, with a median count of 120×109/L (IQR: 89.0-157.0), and only 53 (3.3%) had platelet counts below 50×109/L. After propensity matching of 1,046 platelet recipients with 1,046 controls, perioperative platelet transfusion carried no association with in-hospital mortality (odds ratio [OR]: 1.28; 99% CI: 0.49-3.35; p=0.4980). However, it was associated with a pattern of decreased odds of suspected infection (eg, respiratory infection, urinary tract infection, septicaemia, or other; OR: 0.70; 99% CI: 0.50-0.97; p=0.0050), days in the hospital (adjusted mean difference [AMD]: 0.86; 99% CI: -0.27 to 1.98; p=0.048), or days in intensive care (AMD 0.83; 99% CI: -0.15 to 1.82; p=0.0290). Platelet transfusion was not associated with hospital mortality, but it was associated with decreased odds of suspected infection and with shorter ICU and hospital stays.

Neuroprotective effect of remote ischemic preconditioning in patients undergoing cardiac surgery: A randomized controlled trial.

BackgroundThe neuroprotective effect of remote ischemic preconditioning (RIPC) in patients undergoing elective cardiopulmonary bypass (CPB)-assisted coronary artery bypass graft (CABG) or valvular cardiac surgery remains unclear.MethodsA randomized, double-blind, placebo-controlled superior clinical trial was conducted in patients undergoing elective on-pump coronary artery bypass surgery or valve surgery. Before anesthesia induction, patients were randomly assigned to RIPC (three 5-min cycles of inflation and deflation of blood pressure cuff on the upper limb) or the control group. The primary endpoint was the changes in S-100 calcium-binding protein β (S100-β) levels at 6 h postoperatively. Secondary endpoints included changes in Neuron-specific enolase (NSE), Mini-mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA) levels.ResultsA total of 120 patients [mean age, 48.7 years; 36 women (34.3%)] were randomized at three cardiac surgery centers in China. One hundred and five patients were included in the modified intent-to-treat analysis (52 in the RIPC group and 53 in the control group). The primary result demonstrated that at 6 h after surgery, S100-β levels were lower in the RIPC group than in the control group (50.75; 95% confidence interval, 67.08 to 64.40 pg/ml vs. 70.48; 95% CI, 56.84 to 84.10 pg/ml, P = 0.036). Compared to the control group, the concentrations of S100-β at 24 h and 72 h and the concentration of NSE at 6 h, 24 h, and 72 h postoperatively were significantly lower in the RIPC group. However, neither the MMSE nor the MoCA revealed significant between-group differences in postoperative cognitive performance at 7 days, 3 months, and 6 months after surgery.ConclusionIn patients undergoing CPB-assisted cardiac surgery, RIPC attenuated brain damage as indicated with the decreased release of brain damage biomarker S100-β and NSE.Clinical trial registration[ClinicalTrials.gov], identifier [NCT01231789].

Impact of Levosimendan on High Sensitivity Cardiac Troponin-T after Valvular Heart Surgery: A Randomized Clinical Trial

Background: Various measures have been used for maintaining adequate cardiac output after valvular heart surgery. The study aimed to evaluate the impact of levosimendan on high-sensitivity cardiac troponin-T after valvular heart surgery.
 Methods: This prospective randomized clinical trial included 400 patients. All patients above 18 years who underwent elective cardiac valvular surgery were randomly classified into two equal groups. Group A (n= 200) included patients who received levosimendan during weaning from cardiopulmonary bypass, and Group B (n= 200) included patients who did not receive levosimendan.
 Results: Cardiopulmonary bypass, cross-clamp, reperfusion times, and use of inotropes were insignificant between groups. Troponin levels on days 0, 1, and 2 showed a significant decrease in Group A (P˂0.001). Postoperative ejection fraction was significantly higher in Group A (66.10 ± 4.41 vs. 46.60 ± 3.98; P˂0.001). Duration of mechanical ventilation (4.70± 1.16 vs. 10.70± 0.82; P˂ 0.001), intensive care (1.90 ± 0.57 vs. 5.90 ± 1.29; P˂0.001), and hospital stay (6.90 ± 1.91 vs. 13.40 ± 3.10; P˂0.001) were significantly lower in Group A.
 Conclusions: Levosimendan could have cardioprotective effects, resulting in a significant reduction of postoperative high sensitivity cardiac troponin-T release after valvular heart surgery. It could be associated with improved left ventricular ejection fraction, short duration of mechanical ventilation, ICU, and hospital stay.

Decellularized homograft for aortic valve replacement two years after lung transplantation

Cardiac valvular surgery in patients after lung transplantation is a challenging procedure, reports are scarce. We report a 29-year-old patient who underwent concomitant mitral valve reconstruction and implantation of a decellularized aortic homograft two years after bilateral lung transplantation.

Timing, Threshold, and Duration of Intraoperative Hypotension in Cardiac Surgery: Their Associations With Postoperative Delirium

To study the timing, threshold, and duration of intraoperative hypotension (IOH) associated with the risk of postoperative delirium (POD). A single-center retrospective observational study. University teaching hospital. A total of 503 adult patients who underwent cardiac valvular surgery that required cardiopulmonary bypass (CPB). The authors predefined the following 4 periods: (1) during surgery, (2) pre-CPB, (3) during CPB, and (4) post-CPB, and 8 thresholds of mean arterial pressure for IOH according to every 5 mmHg between 50 mmHg and 85 mmHg. The authors calculated the cumulative duration below the 8 thresholds in each period. The primary outcome was delirium defined as a score of ≥4 for at least one Intensive Care Delirium Screening Checklist assessment during 48 h after the surgery. Among 503 patients, POD occurred in 95 patients (18.9%). There was no significant association of POD with all of the thresholds of IOH in the periods of pre-CPB, during CPB, and during surgery. However, in the post-CPB period, the patients with POD had a significantly longer cumulative duration of IOH according to all of the thresholds of mean arterial pressure. In multivariate analyses, 4 IOH thresholds in the post-CPB period were associated independently with POD: <60 mmHg (odds ratio [OR] =1.84 [95% CI 1.10-3.10]), <65 mmHg (OR=1.72 [1.01-2.92]), <70 mmHg (OR=1.83 [1.03-3.26]), and <75 mmHg (OR=1.94 [1.02-3.69]). A longer cumulative duration of IOH with the threshold between <60 and <75 mmHg that occurred after CPB was independently associated with the risk of POD.

Cardiac valvular surgery and history of anorectic drug intake: A retrospective study of a large population of benfluorex-exposed patients

Anorectic drugs are overlooked as a cause of valvular heart disease (VHD). To describe the characteristics of a large population of patients with severe VHD who underwent cardiac surgery and had a history of benfluorex intake. Retrospective observational and cross-sectional study of patients from a large French database (Office National d'Indemnisation des Accidents Médicaux). Clinical, echocardiographic, surgical and pathology findings were comprehensively collected from medical files. From a chart review of 9584 subjects, 1031 patients with VHD underwent cardiac surgery; 453 surgical patients were excluded because of VHD obviously unrelated to benfluorex exposure, six because of missing data and eight declined to participate. The final study population comprised 564 patients who had surgery between 1987 and 2019. Median age was 58 (interquartile range 50-65) years; 85% were female. Median duration of preoperative benfluorex exposure was 5.8 (3.3-10) years. Most patients had aortic and mitral valve disease. Pure or predominant aortic and/or mitral regurgitation were found in 84% of patients (n=471), and aortic or mitral stenosis (pure or combined with regurgitation) in 12% (n=67) and 15% (n=84), respectively. Overall, 403 aortic, 402 mitral and 64 tricuspid valve surgical procedures were collected. Aortic and mitral valves were found to be thickened, rigid and/or restrictive in most cases; restrictive tricuspid valve disease was seldom documented. Pathology was available in half of the population (276 patients); valvular fibrosis suggestive of drug-induced VHD was found in 222 patients, including 146 with expert examination. Mixed VHD aetiologies were discussed in 107 patients, including 54 with available pathology. Drug-induced VHD features are miscellaneous, including well-known restrictive valvular regurgitation, but also stenosis or combined regurgitation and stenosis. Besides a history of drug taking, thorough echocardiography and comprehensive surgical reports, pathology is key in the diagnostic procedure.

Impact of Concomitant Cardiac Valvular Surgery During Implantation of Continuous-Flow Left Ventricular Assist Devices: A European Registry for Patients with Mechanical Circulatory Support (EUROMACS) Analysis

<h3>Purpose</h3> We investigated the clinical outcomes after cardiac valvular surgery procedures concomitant (CCPs) with left ventricular assist device (LVAD) implantation compared to propensity score (PS) matched controls using the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data. <h3>Methods</h3> Between 2006 and 2018, 2760 continuous-flow LVAD patients were identified. Of these, 533 underwent a CCP during the LVAD implant. <h3>Results</h3> Cardiopulmonary bypass time (p < 0.001) and time for implant (p < 0.001) were both significantly longer in the LVAD+CCP group. Hospital mortality was comparable between the two groups from the unmatched population (15.7% vs. 14.1%, p = 0.073). Similarly, short-to-mid-term survival was similar in both groups, with 1-year, 3-year, and 5-year survival rates of 67.9%, 48.2%, and 27.7% versus 66.4%, 46.1%, and 26%, respectively (log-rank, p = 0.25). The results were similar in the PS-matched population. Hospital mortality was comparable between the two groups (18.9% vs. 17.4%, p = 0.074<b>)</b>. The short-to-mid-term Kaplan-Meier survival analysis was similar for both groups, with 1-year, 3-year, and 5-year survival rates of 63.4%, 49.2%, and 24.7% versus 66.5%, 46%, and 25.1%, respectively (log-rank, p = 0.81). In the unmatched population, LVAD+CCP patients had longer intensive care unit (ICU) stays (p < 0.0001), longer mechanical ventilation time (p = 0.001), a higher rate of temporary right ventricular assist device (RVAD) support (p = 0.033), and a higher rate of renal replacement therapy (n = 35, 6.6% vs. n = 89, 4.0%, p = 0.014). In the PS-matched population, the LVAD+CCP patients had longer ICU stays (p = 0.019), and longer mechanical ventilation time (p = 0.002). <h3>Conclusion</h3> The effect of additive valvular procedures (CCPs) does not seem to affect short-term survival, significantly, based on our registry data analysis. However, the decision to perform CCPs should be balanced with projected type of surgery and preoperative characteristics. LVAD+CCP patients remain a delicate population and adverse device-related events should be strictly monitored and managed.

Effects of Pre-Surgical Education and Physical Therapy Training for Dyspnea Prevention in Patients Undergoing Valvular Cardiac Surgery

Objective: To evaluate the Effects of Pre-operative education and physical therapy training for dyspnea prevention in patients undergoing valvular cardiac surgery. Methods: A Prospective RCT was performed on sample size of 40 patients of cardiac valvular disease that were obtain from Faisalabad Institute of cardiology. At the time of admission, all patients were tested by baseline dyspnea index then the subjects were randomly assigned into two groups by computerized random generator. Both groups were having education but treatment group were having additional breathing exercises and functional tasks for 10 minutes in 1st week regularly and 1 hour in 2nd week regularly. Each group were tested again by BDI after the treatment on second post-op day. Tracheal extubation and eye-opening time were also noted as outcome measures of study. Results were compiled on SPSS.20 for finding post-operative dyspnea. Results: Pre-operative and post-operative findings showed that the patients of treatment group performed better than control group as the effects of pre-operative treatment on dyspnea by total baseline dyspnea index is significant (p&lt;0.05) as well as the treatment group had significant reduction in eye-opening and tracheal extubation time in comparison of control group having (p&lt;0.05). Conclusion: The results shows that in patients of valvular cardiac surgery, pre-surgical education and physical therapy training showed significant reduction in post-surgical dyspnea, tracheal extubation and eye-opening time. Keywords: Valvular cardiac surgery, physical therapy training, presurgical education, cardiopulmonary physiotherapy, baseline dyspnea index, rehabilitation.

Risk of Endocarditis in 24,394 Patients who Underwent Cardiac Valve Surgery and Associated Mortality: A Statewide Population-Linkage Cohort Study

Infective endocarditis (IE) is a serious complication after cardiac valvular surgery with high morbidity and mortality. The risk factors for post-valvular surgery endocarditis (PVE) have not been investigated in a large Australian cohort.

Impact of concomitant cardiac valvular surgery during implantation of continuous-flow left ventricular assist devices: A European registry for patients with mechanical circulatory support (EUROMACS) analysis.

We investigated the clinical outcomes after cardiac valvular surgery procedures concomitant (CCPs) with left ventricular assist device (LVAD) implantation compared to propensity score (PS) matched controls using the European Registry for Patients with Mechanical Circulatory Support (EUROMACS) data. Between 2006 and 2018, 2760 continuous-flow LVAD patients were identified. Of these, 533 underwent a CCP during the LVAD implant. Cardiopulmonary bypass time (p<0.001) and time for implant (p<0.001) were both significantly longer in the LVAD+CCP group. Hospital mortality was comparable between the two groups from the unmatched population (15.7% vs. 14.1%, p=0.073). Similarly, short-to-mid-term survival was similar in both groups, with 1-year, 3-year, and 5-year survival rates of 67.9%, 48.2%, and 27.7% versus 66.4%, 46.1%, and 26%, respectively (log-rank, p=0.25). The results were similar in the PS-matched population. Hospital mortality was comparable between the two groups (18.9% vs. 17.4%, p=0.074). The short-to-mid-term Kaplan-Meier survival analysis was similar for both groups, with 1-year, 3-year, and 5-year survival rates of 63.4%, 49.2%, and 24.7% versus 66.5%, 46%, and 25.1%, respectively (log-rank, p=0.81). In the unmatched population, LVAD+CCP patients had longer intensive care unit (ICU) stays (p<0.0001), longer mechanical ventilation time (p=0.001), a higher rate of temporary right ventricular assist device (RVAD) support (p=0.033), and a higher rate of renal replacement therapy (n=35, 6.6% vs. n=89, 4.0%, p=0.014). In the PS-matched population, the LVAD+CCP patients had longer ICU stays (p=0.019) and longer mechanical ventilation time (p=0.002). The effect of additive valvular procedures (CCPs) does not seem to affect short-term survival, significantly, based on our registry data analysis. However, the decision to perform CCPs should be balanced with the projected type of surgery and preoperative characteristics. LVAD+CCP patients remain a delicate population and adverse device-related events should be strictly monitored and managed.

Machine Learning for the Prediction of Complications in Patients After Mitral Valve Surgery.

Background: This study intended to use a machine learning model to identify critical preoperative and intraoperative variables and predict the risk of several severe complications (myocardial infarction, stroke, renal failure, and hospital mortality) after cardiac valvular surgery.Study Design and Methods: A total of 1,488 patients undergoing cardiac valvular surgery in eight large tertiary hospitals in China were examined. Fifty-four perioperative variables, such as essential demographic characteristics, concomitant disease, preoperative laboratory indicators, operation type, and intraoperative information, were collected. Machine learning models were developed and validated by 10-fold cross-validation. In each fold, Recursive Feature Elimination was used to select key variables. Ten machine learning models and logistic regression were developed. The area under the receiver operating characteristic (AUROC), accuracy (ACC), Youden index, sensitivity, specificity, F1-score, positive predictive value (PPV), and negative predictive value (NPV) were used to compare the prediction performance of different models. The SHapley Additive ex Planations package was applied to interpret the best machine learning model. Finally, a model was trained on the whole dataset with the merged key variables, and a web tool was created for clinicians to use.Results: In this study, 14 vital variables, namely, intraoperative total input, intraoperative blood loss, intraoperative colloid bolus, Classification of New York Heart Association (NYHA) heart function, preoperative hemoglobin (Hb), preoperative platelet (PLT), age, preoperative fibrinogen (FIB), intraoperative minimum red blood cell volume (Hct), body mass index (BMI), creatinine, preoperative Hct, intraoperative minimum Hb, and intraoperative autologous blood, were finally selected. The eXtreme Gradient Boosting algorithms (XGBOOST) algorithm model presented a significantly better predictive performance (AUROC: 0.90) than the other models (ACC: 81%, Youden index: 70%, sensitivity: 89%, specificity: 81%, F1-score:0.26, PPV: 15%, and NPV: 99%).Conclusion: A model for predicting several severe complications after cardiac valvular surgery was successfully developed using a machine learning algorithm based on 14 perioperative variables, which could guide clinical physicians to take appropriate preventive measures and diminish the complications for patients at high risk.

Factors associated with acute kidney injury and mortality during cardiac surgery.

Cardiac surgery with cardiopulmonary bypass (CPB) is known to contribute towards the incidence of acute kidney injury (AKI) and peri-operative morbidity and mortality. There are several patient, anaesthetic and surgical factors that contribute to its occurrence. It is imperative to know the profile of a patient who is likely to develop this complication to mitigate for modifiable risks. This study aimed at describing a profile of AKI in an adult patient (over the age of 18 years) following cardiac surgery on CPB. Factors associated with the development of cardiac surgery-associated acute kidney injury (CSA-AKI) are described, as well as the relationship between CSA-AKI and in-hospital mortality. This was a contextual, descriptive and retrospective single-centre study with data of 476 adult patients admitted post cardiac surgery between January 2016 and December 2017. Data were collected from Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in South Africa. All adult patients who presented for elective cardiac surgery (coronary artery bypass graft), valvular, aortic and other cardiac surgery on CPB were included. Peri-operative factors such as patient demographics, baseline renal function, co-morbid factors, length of CPB and aortic cross-clamp time, degree of hypothermia, use of assist devices, and post-operative serum creatinine (SCr) levels were collected. Incomplete essential peri-operative data and data for patients who presented on renal replacement therapy (RRT) already were excluded. AKI was defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria. One hundred and thirty-five (28%) patients developed CSA-AKI and 20, 5 and 3% were in KDIGO 1, 2 and 3, respectively. Older age (p = 0.024), female gender (p = 0.015), higher serum creatinine level (p = 0.025), and lower estimated glomerular filtration rate (eGFR) (p = 0.025) were associated with the development of CSA-AKI, while a history of hypertension was predictive. Forty-six of the 476 patients died. Mortality rates were significantly higher in those with AKI compared to those without [28 (21%) vs 18 (5%), respectively (p = 0.001)]. The incidence was significantly worse in those with severe kidney injury, as evidenced by mortality rates of 44 versus 5% between KDIGO 3 and KDIGO 1 (p < 0.001). Pre-operative eGFR and CSA-AKI requiring RRT were significantly associated with mortality, while pre-operative eGFR was an independent predictor of mortality (hazard ratio 0.99, 95% confidence interval: 0.97-0.99, p = 0.019). A history of hypertension was predictive of the development of CSA-AKI, and pre-operative eGFR was an independent predictor of mortality in this cohort. Both factors are modifiable.

Limb Remote Ischemic Preconditioning Applied During Sevoflurane Anesthesia Does Not Protect the Lungs in Patients Undergoing Adult Heart Valve Surgery.

Two consistent overall cell protective preconditioning treatments should provide more protection. We hypothesized that limb remote ischemic preconditioning (RIPC, second preconditioning stimulus) applied during sevoflurane inhalation (first preconditioning stimulus) would provide more protection to the lungs of patients undergoing adult heart valve surgery. In this randomized, placebo-controlled, double-blind trial, 50 patients were assigned to the RIPC group or the placebo group (1:1). Patients in the RIPC group received three 5-min cycles of 300 mmHg cuff inflation/deflation of the left-side lower limb before aortic cross-clamping. Anesthesia consisted of opioids and propofol for induction and sevoflurane for maintenance. The primary end point was comparison of the postoperative arterial-alveolar oxygen tension ratio (a/A ratio) between groups. Secondary end points included comparisons of pulmonary variables, postoperative morbidity and mortality and regional and systemic inflammatory cytokines between groups. In the RIPC group, the a/A ratio and other pulmonary variables exhibited no significant differences throughout the study period compared with the placebo group. No significant differences in either plasma or bronchoalveolar lavage levels of TNF- α were noted between the groups at 10 min after anesthetic induction and 1 h after cross-clamp release. The percentage of neutrophils at 12 h postoperation was significantly increased in the RIPC group compared with the placebo group (91.34±0.00 vs. 89.42±0.10, P = 0.023). Limb RIPC applied during sevoflurane anesthesia did not provide additional significant pulmonary protection following adult valvular cardiac surgery.

Future of cardiac surgery, introducing the interventional surgeon.

The swift advances in interventional cardiology combined with the increasing risk of cardiac surgical procedures resulted in diminishing volume of coronary and valvular surgery and affected the future of cardiac surgery service and training. Application to cardiac surgery training programs have steadily declined. This cross-sectional study aimed at identifying main weakness facing cardiac surgery and advocating some recommendations to improve the status of current and future of cardiac surgery. Cross-sectional study was authorized by the institutional review board of King Abdulaziz University and performed among cardiac surgeons and cardiologists in the Kingdom of Saudi Arabia, from May to June 2021. Data were collected by sending questionnaires through email to cardiac surgeons and cardiologists in different cardiac centers all over Saudi Arabia. Out of 200 emails sent to our participants only 55 who responded. A total of 55 doctors who participated in the study have completed the self-administered questionnaire by electronic mail. Seventy-six percent of the respondents are cardiac surgeons and 24% are cardiologists. Most of the respondents (72.7%, 63.6%) think that the volume of coronary and valvular cardiac surgery patients nowadays is less than before compared to invasive cardiology patients. Most of the respondents (91%) think that coronary cardiac surgery is better than invasive cardiology in left main disease and complex lesions but carries higher risk. Sixty-nine percent of the respondents think that one cardiac center in each city according to the population will provide better cardiac health services compared to small cardiac units. In the recommendations to improve the future of cardiac surgery, 83% of the respondents agree that residents training in cardiac surgery should be modified to add at least one extra year of training in the Catheterization Laboratory (Cath lab) procedures including coronary, valvular, aortic and arrhythmia, thus introducing the interventional surgeon.

Risk factors of low cardiac output syndrome after cardiac valvular surgery in elderly patients with valvular disease complicated with giant left ventricle

Objective: To explore the risk factors of low cardiac output syndrome (LCOS) after cardiac valvular surgery in elderly patients with valvular disease complicated with giant left ventricle. Methods: This was a retrospective study. The clinical data of patients over 60 years old with giant left ventricle who underwent cardiac valvular surgery in Henan Provincial People's Hospital (Fuwai Central China Cardiovascular Hospital) from January 2016 to January 2020 were collected in this study. Patients were divided into LCOS group and non-LCOS group. The clinical data, preoperative echocardiographic results and surgical data of all patients were collected. Taking LCOS as dependent variable and statistically significant variables in univariate analysis as independent variable, multivariate logistic regression equation was constructed to identify the risk factors of LCOS after cardiac valvular surgery in elderly patients with valvular disease complicated with giant left ventricle. On the basis of logistic regression, the risk factors of continuous variables were put into the regression model for trend test. Results: A total of 112 patients were included, among whom 76 patients were male, the mean age was (65.3±3.8) years. There were 21 cases in LCOS group and 91 cases in non LCOS group. Univariate analysis showed that age≥70 years, preoperative NYHA cardiac function class Ⅳ, preoperative renal dysfunction, preoperative cerebrovascular disease, preoperative LVEF<40%, blood loss/total blood volume>20%, cardiopulmonary bypass (CPB) time>130 minutes and aortic cross-clamp time>90 minutes all had statistically significant differences between the two groups (all P<0.05). Multivariate logistic regression analysis showed that age≥70 years (OR=5.067, 95%CI 1.320-19.456, P=0.018), preoperative NYHA cardiac function class Ⅳ (OR=3.100, 95%CI 1.026-9.368, P=0.045), renal dysfunction (OR=3.627, 95%CI 1.018-12.926, P=0.047), CPB time>130 minutes (OR=4.539, 95%CI 1.483-13.887, P=0.008) were the independent risk factors of LCOS after cardiac valvular surgery in elderly patients with giant left ventricle. Risk of LCOS was significantly higher in patients aged from 65 to 70 years (OR=1.784, 95%CI 0.581-5.476) and aged 70 years and above (OR=4.400, 95%CI 1.171-16.531) than in patients aged from 60 to 65 years. The trend test results showed that the risk of LCOS increased significantly in proportion with the increase of age (P for trend=0.024). Risk of LCOS was significantly higher in patients with CPB time between 90 and 110 minutes (OR=1.917, 95%CI 0.356-10.322), 110 and 130 minutes (OR=1.437, 95%CI 0.114-18.076) and 130 minutes and above (OR=5.750, 95%CI 1.158-28.551) than in patients with CPB time ≤ 90 minutes (P for trend=0.009). Conclusions: The risk factors of LCOS after cardiac valvular surgery are age≥70 years, preoperative NYHA cardiac function class Ⅳ, renal dysfunction, CPB time>130 minutes in elderly patients with giant left ventricle.

Paravalvular leak closure: Still a challenge with unpredictable results

IntroductionParavalvular leak (PVL) is a common serious complication associated with prosthetic valve implantation. ObjectiveThe aim of this study was to report our single-center experience in a retrospective review and to analyze possible predictors of success. MethodsWe performed 33 percutaneous PVL closures in 26 patients (54% female, mean age 65±13 years). All mitral prostheses were studied previously with 3D transesophageal echocardiography (TEE), and aortic prostheses with 2D/3D TEE. 3D TEE and fluoroscopy were used for the assessment, planning, and guidance of the interventions. Twelve patients also underwent computed tomography angiography for better characterization of anatomic details. ResultsEighteen patients (69.2%) were admitted due to heart failure (New York Heart Association [NYHA] III or IV, seven (26.9%) because of heart failure and hemolysis, and one (3.8%) due to hemolysis only. Regarding the leaks, 46.2% were in aortic and 53.8% in mitral prostheses, 88.5% in mechanical and 7.7% in biological prostheses, and 3.8% in transcatheter aortic valve implants. All the aortic patients had severe aortic regurgitation. Furthermore, all mitral patients but one had moderate to severe or severe mitral regurgitation. Closure was successful in 17 patients (65.4%), partially successful in four (15.4%) and unsuccessful in five (19.2%). After the procedure, 69% were in NYHA I-II. Hemolysis worsened in three patients despite successful closure; all required further valvular surgery and two died. Regarding angiographic and echocardiographic procedural success, we analyzed age, gender, type of prosthesis (mechanical or biological), location (aortic or mitral), clinical data, maximum leak diameter, anatomic regurgitant orifice, leak location (anterior, posterior, inferior and lateral for mitral leaks and left, right and non-coronary sinus for aortic leaks), and number of devices (plugs) used for closure. No parameters presented a significant relationship with success excepting previous hemolysis. There was a relationship between clinical improvement and reduction of PVL (p=0.0001). In follow-up, cardiac-related events (new hospital admissions, cardiac valvular surgery, need for transfusion) were more frequent in patients with partially successful or unsuccessful closure (p=0.012). There was a relationship between cardiac-related events and death (p=0.029). ConclusionPercutaneous PVL closure has emerged as an alternative treatment for PVL. Predictors of procedural success are difficult to establish. Survival is related to reduction of regurgitation and improvement in NYHA functional class.

Comparison of the in-vivo effect of two tranexamic acid doses on fibrinolysis parameters in adults undergoing valvular cardiac surgery with cardiopulmonary bypass - a pilot investigation

BackgroundThe blood saving efficacy of TXA in cardiac surgery has been proved in several studies, but TXA dosing regimens were varied in those studies. Therefore, we performed this study to investigate if there is a dose dependent in-vivo effect of TXA on fibrinolysis parameters by measurement of fibrinolysis markers in adults undergoing cardiac surgery with CPB.MethodsA double-blind, randomized, controlled prospective trial was conducted from February 11, 2017 to May 05, 2017. Thirty patients undergoing cardiac valve surgery were identified and randomly divided into a placebo group, low-dose group and high-dose group by 1: 1: 1. Fibrinolysis parameters were measured by plasma levels of D-Dimers, plasminogen activator inhibitor-1 (PAI-1), thrombin activatable fibrinolysis inhibitor (TAFI), plasmin-antiplasmin complex (PAP), tissue plasminogen activator (tPA) and thrombomodulin (TM). Those proteins were measured at five different sample times: preoperatively before the TXA injection (T1), 5 min after the TXA bolus (T2), 5 min after the initiation of CPB (T3), 5 min before the end of CPB (T4) and 5 min after the protamine administration (T5). A Thrombelastography (TEG) and standard coagulation test were also performed.ResultsCompared with the control group, the level of the D-Dimers decreased in the low-dose and high-dose groups when the patients arrived at the ICU and on the first postoperative morning. Over time, the concentrations of PAI-1, TAFI, and TM, but not PAP and tPA, showed significant differences between the three groups (P < 0.05). Compared with the placebo group, the plasma concentrations of PAI-1 and TAFI decreased significantly at the T3 and T4 (P < 0.05); TAFI concentrations also decreased at the T5 in low-dose group (P < 0.05). Compared with the low-dose group, the concentration of TM increased significantly at the T4 in high-dose group.ConclusionsThe in-vivo effect of low dose TXA is equivalent to high dose TXA on fibrinolysis parameters in adults with a low bleeding risk undergoing valvular cardiac surgery with cardiopulmonary bypass, and a low dose TXA regimen might be equivalent to high dose TXA for those patients.Trial registrationChiCTR-IPR-17010303, Principal investigator: Zhen-feng ZHOU, Date of registration: January 1, 2017.

Integrative transcriptomic, proteomic, and machine learning approach to identifying feature genes of atrial fibrillation using atrial samples from patients with valvular heart disease

BackgroundAtrial fibrillation (AF) is the most common arrhythmia with poorly understood mechanisms. We aimed to investigate the biological mechanism of AF and to discover feature genes by analyzing multi-omics data and by applying a machine learning approach.MethodsAt the transcriptomic level, four microarray datasets (GSE41177, GSE79768, GSE115574, GSE14975) were downloaded from the Gene Expression Omnibus database, which included 130 available atrial samples from AF and sinus rhythm (SR) patients with valvular heart disease. Microarray meta-analysis was adopted to identified differentially expressed genes (DEGs). At the proteomic level, a qualitative and quantitative analysis of proteomics in the left atrial appendage of 18 patients (9 with AF and 9 with SR) who underwent cardiac valvular surgery was conducted. The machine learning correlation-based feature selection (CFS) method was introduced to selected feature genes of AF using the training set of 130 samples involved in the microarray meta-analysis. The Naive Bayes (NB) based classifier constructed using training set was evaluated on an independent validation test set GSE2240.Results863 DEGs with FDR < 0.05 and 482 differentially expressed proteins (DEPs) with FDR < 0.1 and fold change > 1.2 were obtained from the transcriptomic and proteomic study, respectively. The DEGs and DEPs were then analyzed together which identified 30 biomarkers with consistent trends. Further, 10 features, including 8 upregulated genes (CD44, CHGB, FHL2, GGT5, IGFBP2, NRAP, SEPTIN6, YWHAQ) and 2 downregulated genes (TNNI1, TRDN) were selected from the 30 biomarkers through machine learning CFS method using training set. The NB based classifier constructed using the training set accurately and reliably classify AF from SR samples in the validation test set with a precision of 87.5% and AUC of 0.995.ConclusionTaken together, our present work might provide novel insights into the molecular mechanism and provide some promising diagnostic and therapeutic targets of AF.