Indication For Cardiac Surgery Research Articles

Long-term follow-up after infective endocarditis: comparison of patients who have undergone cardiac surgery versus a conservative therapy with and without an indication for cardiac surgery

Abstract Background Infective endocarditis (IE) is still a serious disease, with a high mortality despite cardiac surgery and modern conservative therapy. However, data on long-term follow-up are sparse. Methods Retrospective single centre registry on the hospital course and long-term follow-up of patients with IE who have undergone cardiac surgery or a conservative therapy with and without an indication for cardiac surgery. Results Between 1/2013 and 12/2016, 171 IE patients were treated at our hospital. A follow-up with either patient contact, review of hospital charts or physician contact was performed in 2022. Due to lost to follow-up (n=4) or refusal to participate after discharge (n=1), the final evaluation was performed with 166 patients (97.1%). They were followed-up for a median 2385.0 (between 2156 and 2773) days. 139 (81.3%) of the patients were operated (surgery) and 32 (18.7%) were treated conservatively. Amongst the conservatively treated group, 34.4% (11/32) of the patients had an indication for surgery, but it was decided not to perform it (cons-with) and 65.6% (21/32) had no indication for surgery (cons-without). Operated patients were younger compared to cons treated patients (65.1 ± 13.0 vs 72.8 ± 15.7, p = 0.00016). Whereas hospital mortality was not different between both groups (21.6 % vs 21.9 %, p = 0.97112), calculated 5y mortality was higher in der cons treated group (71.0 % vs 49.6 %, p=0.03168). Conclusions These data on long-term follow-up after IE show a high total mortality amongst all patients regardless of type of therapy, but higher mortality rate after 5 years amongst conservative treated patients (71%) compared toa surgical treated (49.6% p= 0.03168). The highest mortality rate after 5 years (100%) was detected in the cons-with compared to 55% in the cons-without group. More than 2/3 of deaths were due to IE. However, operated patients were younger and had less co-morbidities. Furthermore, rehospitalisation rate for recurrent IE was also high.

Critically ill patients with infective endocarditis, neurological complications and indication for cardiac surgery: a multicenter propensity-adjusted study

BackgroundThe benefit–risk balance and optimal timing of surgery for severe infective endocarditis (IE) with ischemic or hemorrhagic strokes is unknown. The study aim was to compare the neurological outcome between patients receiving surgery or not.MethodsIn a prospective register-based multicenter ICU study, patients were included if they met the following criteria: (i) left-sided IE with an indication for heart surgery; (ii) with cerebral complications documented by cerebral imaging before cardiac surgery; (iii) with Sequential Organ Failure Assessment score ≥ 3. Exclusion criteria were isolated right-sided IE, in-hospital acquired IE and patients with cerebral complications only after cardiac surgery. In the primary analysis, the prognostic value of surgery in term of disability at 6 month was assessed by using a propensity score-adjusted logistic regression.Results192 patients were included including ischemic stroke (74.5%) and hemorrhagic lesion (15.6%): 67 (35%) had medical treatment and 125 (65%) cardiac surgery. In the propensity score-adjusted logistic regression, a favorable 6-month neurological outcome was associated with surgery (odds ratio 13.8 (95% CI 6.2–33.7). The 1-year mortality was strongly reduced with surgery in the fixed-effect propensity-adjusted Cox model (hazard ratio 0.18; 95% CI 0.11–0.27; p < 0.001). These effects remained whether the patients received delayed surgery (n = 62/125) or not and whether they were deeply comatose (Glasgow Coma Scale ≤ 10) or not.ConclusionsIn critically ill IE patients with an indication for surgery and previous cerebral events, a better propensity-adjusted neurological outcome was associated with surgery compared with medical treatment.

Study on the role of vis (vasoactive - inotropic score) as a predictor of a poor clinical outcome in children after congenital heart surgery with cardiopulmonary bypass

Objectives: Many authors showed that the VIS (vasoactive-inotropic score) has a strong correlation with morbidity and mortality after cardiac surgery in children, but the conclusions are not completely unified. We therefore performed this study to determine the relationship between the VIS score and clinical outcomes in children undergoing cardiac surgery with extracorporeal circulation.&#x0D; Method: Prospective cohort study. A total of 100 pediatric patients from birth to 2 years of age with indications for cardiac surgery with extracorporeal circulation at the Anesthesiology Department of the Heart Institute of Ho Chi Minh City from January 1, 2021, to December 31, 2021, were included in the study. Hourly doses of all vasoactive medications were recorded for the first 48 hours after admission to cardiothoracic intensive care unit and a vaso-active inotropic score was calculated. The VIS scale is calculated by the formula: VIS = dopamine dose (µg/kg/min) + dobutamine dose (µg/kg/min) + 100 × adrenaline dose (µg/kg/min) + 10 × milrinone dose (µg/min) kg/min) + 10000 × vasopressin dose (U/kg/min) + 100 × noradrenaline dose (µg/kg/min). The max and mean values of VIS in the first 24 hours and the max and mean values of VIS in the subsequent 24 hours after admission (from 25th to 48th hour) were calculated.&#x0D; Results: The rate of patients with low cardiac output syndrome was 38.0%. There were 20/100 cases (20.0%) with a poor outcome, of which 19 cases required peritoneal dialysis, 4/100 cases (4.0%) had cardiac arrest, 2/100 cases (2.0%) had seizures, 1/100 (1.0%) had to run ECMO and 4/100 (4.0%) died after surgery. Patients in the high VIS group (mean 48- hour VIS ≥ 11.06) compared with the low VIS group (mean 48- hour VIS &lt; 11.06) were associated with prolonged duration of mechanical ventilation, prolonged CICU length of stay in the ICU, prolonged time to negative fluid balance.&#x0D; Conclusions: The high VIS after surgery was a good predictor of a poor clinical outcome, prolonged duration of mechanical ventilation, prolonged CICU length of stay outcomes in children undergoing cardiac surgery with extracorporeal circulation

Cardiac resynchronization therapy: potential for arrhythmic risk modification

Aim. To evaluate the impact of cardiac resynchronization therapy (CRT) on the risk of sustained ventricular tachyarrhythmias (VT) in patients with heart failure (HF) with a implantable cardioverter-defibrillator (ICD) for the primary prevention of sudden cardiac death.Material and methods. This single-center prospective clinical study included 470 patients (men, 84%) with HF at the age of 57 (51-62) years with a left ventricular ejection fraction (LVEF) of 29 (25-33)%. There were following exclusion criteria: indications for cardiac surgery, known channelopathies, previously registered VT. Depending on intraventricular conduction disorders, dual-chamber ICDs (42%) or CRT-D (58%) were implanted. After ICD implantation, patients were followed up for 24 months to register the end point — a first-time sustained paroxysm of VT detected by the ICD. A positive response to CRT was established in the case of an increase in LVEF by ≥5% of the initial level.Results. A total of 388 patients underwent full postoperative follow-up. The studied arrhythmic endpoint occurred on average 21 (0,6) months after implantation in 104 patients (27%) with higher frequency in the ICD group. However, the differences in the VT rate in the study groups were statistically unreliable (30% in the ICD group versus 24% in the CRT-D group, p=0,142). It was found that the VT rate was reliably lower in CRT-responders (118 patients, 53%): 15% compared to 32% in the group of inefficient CRT. A 5% increase in the LFEF reduced the probability of VT occurrence by 3 times (odds ratio [OR]=0,34; 95% of CI: 0,13-0,86; p=002). Significant modification of arrhythmic risk was verified by increasing LFEF to 36-40% (OR=0,72; 95% CI: 0,63-0,82; p=0,04).Conclusion. The results obtained indicate that effective CRT has the potential to modify arrhythmic risk in patients with HF, especially with an increase in LVEF to the level of 36-40%.

Prediction of post-operative atrial fibrillation in patients after cardiac surgery using heart rate variability

PurposePost-operative atrial fibrillation (PoAF) occurs in ~ 30% of patients after cardiac surgery. The etiology of PoAF is complex, but a disbalance in autonomic systems plays an important role. The goal of this study was to assess whether pre-operative heart rate variability analysis can predict the risk of PoAF.MethodsPatients without a history of AF with an indication for cardiac surgery were included. Two-hour ECG recordings one day before surgery was used for the HRV analysis. Univariate and multivariate logistic regression, including all HRV parameters, their combination, and clinical variables, were calculated to find the best predictive model for post-operative AF.ResultsOne hundred and thirty-seven patients (33 women) were enrolled in the study. PoAF occurred in 48 patients (35%, AF group); the remaining 89 patients were in the NoAF group. AF patients were significantly older (69.1 ± 8.6 vs. 63.4 ± 10.5 yrs., p = 0.002), and had higher CHA2DS2-VASc score (3 ± 1.4 vs. 2.5 ± 1.3, p = 0.01). In the multivariate regression model, parameters independently associated with higher risk of AF were pNN50, TINN, absolute power VLF, LF and HF, total power, SD2, and the Porta index. A combination of clinical variables with HRV parameters in the ROC analysis achieved an AUC of 0.86, a sensitivity of 0.95, and a specificity of 0.57 and was more effective in PoAF prediction than a combination of clinical variables alone.ConclusionA combination of several HRV parameters is helpful in predicting the risk of PoAF. Attenuation of heart rate variability increases the risk for PoAF.

1994. The use of whole body PET scans in management of infective endocarditis

Abstract Background Whole-body 18F-FDG PET/CT (WBP) can have diagnostic utility in evaluating extracardiac sites of metastatic infection in patients with infective endocarditis (IE). However, the IE patient population that most benefits from this test is not certain. The purpose of this study is to investigate the clinical characteristics of patients with IE who had WBP performed and to evaluate how WBP results impacted management. Methods We performed a retrospective cohort study at a tertiary care center evaluating patients with suspected IE who were discussed at an internal multidisciplinary endocarditis conference between June 2018 and January 2022. Adult patients with suspected IE who also had a WBP during their inpatient stay were included. Patient demographics, IE risk factors, and WBP details were collected. Results 114 patients with suspected IE had a WBP out of 431 (26.5%). The majority (n=107, 93.9%) had definite or possible IE by mDuke criteria. Prosthetic valves and endocardial devices were present in 83 (72.8%) and 34 (29.8%) patients respectively. There were 67 (60.5%) patients with 2 or more days of bacteremia and 21 (22.1%) patients with over 7 days of bacteremia. Causative pathogens included S. aureus (n=26, 24.2%), Enterococcus (n=26, 24.2%), and Streptococcus species (n=24, 22.4%). Among the 70 (61.4%) patients with indications for cardiac surgery, 38 (54%) had cardiac surgery performed. Common WBP findings were bone/joint infections (n=18, 15.8%), pulmonary infection (n=32, 28.1%), and skin/soft tissue infection (n=15, 13.2%). WBP changed the management in 44.7% (n=51) of patients, including antibiotic change (n=11, 9.7%), source control procedure (n=12, 10.5%), and further workup of infectious or non-infectious findings (n=33, 29.0%). Six-month all-cause mortality was 25% and hospital readmission was 48.1%. Conclusion Many patients who underwent WBP had prolonged bacteremia, a history of cardiac prostheses, and had complicated IE with indications for cardiac surgery. WBP results changed treatment in some cases, but true clinical impact on morbidity and mortality is uncertain. We plan to do further research to compare outcomes between patients who get WBP and those who do not and to determine which patients may most benefit from this test. Disclosures All Authors: No reported disclosures.

1986. Multicenter evaluation of Staphylococcus aureus prosthetic valve infective endocarditis with and without gentamicin treatment: Is it time to revisit?

Abstract Background Staphylococcus aureus prosthetic valve infective endocarditis (SA-PVIE) is associated with high mortality. Gentamicin (GEN) with anti-staphylococcal antibiotics and rifampin are guideline recommendations for SA-PVIE extrapolated from in vitro data. GEN can lead to acute kidney injury (AKI), meanwhile, the clinical benefit on infection-related outcomes remains unclear. Therefore, we evaluated the impact of GEN on outcomes in SA-PVIE. Methods This is a multicenter, retrospective cohort conducted at HonorHealth and UCHealth systems. Adults admitted between January 2014-2022 with definite/possible SA-PVIE by Duke Criteria were included if they received ≥2 days of treatment within 2 days of index culture. Cohorts were stratified by GEN receipt. The primary outcome was 90-day all-cause mortality. The secondary outcomes were treatment failure (change in antimicrobials, abscess development, new indication for cardiac surgery), 30-day all-cause mortality, and incidence of AKI by KDIGO Criteria. Results Overall, 38 patients with definite (40%) and possible SA-PVIE (60%) met inclusion (13 GEN, 25 without GEN [no-GEN]). At baseline, 15 (40%) patients were in an ICU, median Pitt bacteremia score was 2, and methicillin-susceptible S. aureus predominated (71%). A total of 10 (26%) patients had valve surgery; median bacteremia duration was similar between GEN and no-GEN (4 vs 3 days, p = 0.26). Common antibiotics were vancomycin (95%), cefazolin (63%), and nafcillin (21%); rifampin was more common in GEN than no-GEN (20% vs 77%, p &amp;lt; 0.001). Baseline AKI (44% vs 46%) and renal impairment (8% vs 0%) were not different between GEN and no-GEN, respectively. GEN was initiated a median 3 days after index culture, most commonly as intermittent strategy (69%) with 3 mg/kg daily equivalent (84.6%). There was no statistical difference in treatment failure (23% vs 24%, p=0.17), 30-day mortality (20% vs 39%, p=0.22), or 90-day mortality (28% vs 43%, p=0.263) between GEN and no-GEN, respectively. Three in the (23%) GEN group experienced AKI, compared to 10 (40%) in no-GEN. Conclusion We did not find that the addition of GEN to SA-PVIE therapy enhanced mortality benefit, yet patients without GEN may live to experience adverse events. Further studies were warranted. Disclosures All Authors: No reported disclosures.

546 DETECTION OF INFECTIVE ENDOCARDITIS COMPLICATION: USEFULNESS OF ELECTROCARDIOGRAM

Abstract We report the case of an abscess complication of infective endocarditis detected by electrocardiogram (ECG). A 51-year-old man was admitted to the Emergency Department for fever (39 C°) and asthenia from few days. About 2 months earlier he had undergone cardiac surgery for aortic valve replacement with biological valve for severe aortic stenosis. Vital signs included low blood pressure and high respiratory rate; he was also pyretic. On cardiac auscultation he had a systolic murmur on aortic focus. He underwent blood gas analysis, which showed an increase in serum lactate, ECG, which detected a I grade atrioventricular block, and blood sampling, which showed severe increases in white blood cells, C-reactive protein and procalcitonin. Chest x-ray was normal. An echocardiogram was therefore performed: thickened and hyperechogenic cusps of the aortic biological prosthesis were detected; masses, with character of mobility at the level of the left coronary cusp (maximum size of 1.4×1cm) were also described; there was also a slight increase in transprosthetic gradients and mild valve insufficiency. The first diagnostic hypothesis was therefore that of infective endocarditis (IE), further supported by a recent odontogenic procedure for dental abscesses to which the patient would have undergone a few weeks after heart surgery (possible IE according to the Duke modified criteria). Blood cultures were performed on three samples and empirical antibiotic therapy was initiated until Streptococcus mitis was isolated (definite IE according to the Duke modified criteria) and thus Ceftriaxone was started. During hospitalization in the cardiology ward the patient presented dysarthria and left hemiplegia. A cerebral angio-computed tomography and neurological consultation were conducted and an ischemic stroke of thromboembolic origin from biological valve endocarditis was diagnosed. However, in view of the extensive ischemic hypodensity, acute reperfusion treatment was not indicated. The patient therefore underwent cardiac surgery consultancy but, due to his severe comorbidities and expired clinical conditions, there was no indication for cardiac surgery. After few days, during daily ECG recording, left main coronary artery (LMCA) stenosis-like ECG modifications were detected, with ST elevation in lead aVR in addition to marked ST depression in leads V3 through V6 and in peripherals leads (Fig.). A troponin sample was immediately taken, which would have been increased. He immediately underwent new echocardiogram which revealed a new periprosthetic abscess across left coronary cusp. Given the course of LMCA through the abscess, we believe that the acute coronary syndrome that has occurred to the patient may be due either to a compression of the LMCA by the periprosthetic abscess or to embolization of abscess material in the le LMCA. It was not possible to perform coronary angiography neither to perform cardiac surgery as the patient died a few hours later due to septic shock.

LONG-TERM ORAL SUPPRESSIVE ANTIBIOTIC THERAPY FOR PROSTHETIC VALVE ENDOCARDITIS WITH PERIVALVULAR EXTENSION

LONG-TERM ORAL SUPPRESSIVE ANTIBIOTIC THERAPY FOR PROSTHETIC VALVE ENDOCARDITIS WITH PERIVALVULAR EXTENSION

Surgical Timing in Patients With Infective Endocarditis and With Intracranial Hemorrhage: A Systematic Review and Meta-Analysis.

BackgroundIntracranial hemorrhage (ICH) is one of the main causes for lack of surgery in patients with infective endocarditis (IE), despite the presence of surgical indications. We aimed to evaluate the impact of early surgery in patients with IE and with ICH on postoperative neurological deterioration and all‐cause mortality and to elucidate the risk of 30‐day mortality in patients who were denied surgery.Methods and ResultsThree libraries (MEDLINE, EMBASE, and Cochrane Library) were assessed. The primary outcome was all‐cause mortality, and the secondary outcome was neurological deterioration. Inverse variance method and random model were performed. We identified 16 studies including 355 patients. Nine studies examined the impact of surgical timing (early versus late) and were included in the meta‐analysis. Only one study examined the fate of patients with IE and with ICH who were treated conservatively despite having an indication for cardiac surgery, showing higher mortality rates than those who underwent surgery (11.8% versus 2.5%). We found no significant association between early surgery, regardless of its definition, and a higher mortality (odds ratio [OR], 1.69; 95% CI, 0.95–3.02). Early surgery was associated with higher risk for neurological deterioration (OR, 2.00; 95% CI, 1.10–3.65).ConclusionsCardiac surgery for IE within 30 days of ICH was not associated with higher mortality, but with an increased rate of neurological deterioration. The 30‐day mortality in patients with IE and with ICH who were denied surgery has not yet been sufficiently investigated. This patient group should be analyzed in future studies in more detail.

Is Asymptomatic Severe Aortic Stenosis Still a Waiting Game?

Is Asymptomatic Severe Aortic Stenosis Still a Waiting Game?

Abstract WMP73: Surgical Timing In Infective Endocarditis Patients With Intracranial Hemorrhage -a Systematic Review And Meta-analysis

Background and Purpose: Cardiac surgery is indicated in more than half of patients with infective endocarditis (IE); however, it is performed in only 60% of the indicated cases. Majority of patients with surgical indications who were denied surgery due to certain reasons die within 30 days. Intracranial hemorrhage (ICH) is one of the main causes for denial of surgery despite the presence of surgical indications. We aimed to evaluate the impact of early surgery (within 30 days) in IE-patients with ICH on postoperative outcome and to elucidate the risk of 30-day mortality in patients for whom surgery was denied. Methods: Three libraries (MEDLINE, EMBASE and Cochrane Library) were assessed for studies evaluating the postoperative outcome in early vs. late surgery in IE-patients with preoperative ICH. The primary outcome was all-cause mortality, and the secondary outcome was neurological deterioration. Inverse variance method and random model were performed. Results: We identified 16 studies including 355 patients. Nine studies examined the impact of surgical timing (early vs. late) and were included in the meta-analyses. Only one study examined the fate of IE-patients with ICH who were treated conservatively despite of having an indication for cardiac surgery, showing higher mortality rates than those who were operated (11.8 % vs. 2.5 %). We found no significant association between early surgery, regardless of its definition, and a higher mortality (relative risk [RR]= 1.46; 95% confidence interval [CI]: 0.98-2.17). However, early surgery was associated with higher risk for neurological deterioration (RR= 1.97; 95% CI: 1.15-3.38). Conclusions: Cardiac surgery for IE within 30 days of ICH was not associated with higher mortality, but with increased rate of neurological deterioration. Thirty-day mortality in IE-patients with ICH for whom surgery was denied has not yet been sufficiently investigated. This patient group should be analysed in future studies in more detail.

691. Infective Endocarditis with an Indication for Cardiac Surgery in a Tertiary Care Educational Hospital: Does Cardiac Surgery Improve Outcomes?

BackgroundIn this retrospective cohort study, it was aimed to compare the clinical characteristics and outcomes of IE cases without and with an indication for cardiac surgery in terms of whether they have been operated or not, in a tertiary-care educational hospital. MethodsPatients that were followed up for definite IE (diagnosed according to modified Duke criteria between March 2007 and November 2020) with an indication for cardiac surgery according to European Society of Cardiology Guidelines, comprised the study group. Subjects were evaluated in terms of whether these cases have been operated or not, demographic features, underlying diseases, risk factors, clinical and laboratory findings, therapy responses, complications, and mortality. The timing of surgery is defined as emergency; surgery performed within 24 hours, urgent; within a few days, elective; after at least one-two weeks of antibiotic therapy. Statistical analysis was performed via Chi square and Student T tests and a p value < 0.05 was considered significant.ResultsA total of 90 patients with an indication for surgery, 33.3% patients in underwent surgery, 66.6% patients in not underwent surgery group fulfilled the study criteria. The most frequently seen complaints in patients were fever (91.1%), cold-shiver (56.6%), weight-loss (27.7%), dyspnea (25.5%), and tachycardia (20%). Heart murmur was detected during cardiac auscultation of 44 patients. Mean blood leukocyte count, C-reactive protein and erythrocyte sedimentation rate were 12324 ± 6558/mm3 (1408-30330), 11.46 ± 8.38 mg/dl (0.18-34.6) and 61.43 ± 33.4 mm/h (2-130), respectively. There was no significant difference between two groups in terms of cardiac/non-cardiac risk factors, age, gender, etiologic agents, laboratory findings, septic embolisms and complaints (Table 1). In total IE with an indication for surgery mortality was 27.7%. Mortality rate was significantly less and heart murmur was significantly higher in cases who underwent surgery than those did not undergo surgery (p: 0.0447). Table 1. Comparison of basic characteristics of patients in the two operated / unoperated cohorts. ConclusionThese data support the importance of the guidelines’ criteria for cardiac surgery in the management of IE. Assuming that only 1/3 of the surgery needing cases received surgery, more interventions are needed to decrease the barriers against surgery. Disclosures All Authors: No reported disclosures

Infective Endocarditis in Patients with Hypertrophic Cardiomyopathy

A literature review is presented, reflecting the incidence, etiology, hemodynamics, localization, clinical manifestations, outcomes and treatment of infective endocarditis (IE) in patients with hypertrophic cardiomyopathy (HCM). Despite the relative rarity of IE in patients with HCM, the combination of these pathologies is characterized by mutual aggravation and poor prognosis. The addition of IE increases the risk of death in patients with obstructive HCM, deteriorating circulatory disorders, increasing the likelihood of uncontrolled sepsis and embolism. Conservative treatment of IE in patients with HCM does not differ from that without HCM. Interdisciplinary interaction is needed in the management of patients with IE against the background of HCM in determining the indications for cardiac surgery and choosing the optimal method. Antibacterial prophylaxis of IE before invasive medical manipulations in patients with HCM is not recommended by the current consensus documents, however, the decision for each patient should be made individually, with a mandatory assessment of the risk of IE, the severity of hemodynamic disorders and prognosis.

Factors for the development of atrial fibrillation after open heart surgery

Aim. To identify the factors influencing the development of postoperative atrial fibrillation (POAF).Methods. The study included 100 patients with indications for cardiac surgery, aged 53 to 82 years (mean age 67.2±17 years). The group included patients who had no history of AF before surgery. Cardiac surgery in the group was presented in 63 patients by coronary artery bypass grafting, and in 37 – by intervention on the heart valves. All respondents were divided into 2 groups: the first included 39 people (39%) who had AF paroxysms lasting more than 30 seconds in the early postoperative period, with a peak at 1–2 days, in 13 (33.3%) cases of AF relapsed. The second group of patients was represented by 61 patients (61%) without cardiac arrhythmias after surgery.Results. The dependence of the development of POAF on age, the concentration of C-reactive protein in the peripheral blood taken on the day of cardiac surgery, the longitudinal size of the left atrium before surgery was revealed.Conclusion. It was found out that a number of factors such as age, preoperative left atrium size, C-reactive protein level in the first days after surgery suggest the development of POAF. The use of the predictors obtained can make it possible to develop an effective strategy for the prevention of POAF.

Open surgical ablation of ventricular tachycardia: Utility and feasibility of contemporary mapping and ablation tools.

BackgroundVentricular tachycardia (VT) catheter ablation success may be limited when transcutaneous epicardial access is contraindicated. Surgical ablation (SurgAbl) is an option, but ablation guidance is limited without simultaneously acquired electrophysiological data.ObjectiveWe describe our SurgAbl experience utilizing contemporary electroanatomic mapping (EAM) among patients with refractory VT storm.MethodsConsecutive patients with recurrent VT despite antiarrhythmic drugs (AADs) and prior ablation, for whom percutaneous epicardial access was contraindicated, underwent open SurgAbl using intraoperative EAM guidance.ResultsEight patients were included, among whom mean age was 63 ± 5 years, all were male, mean left ventricular ejection fraction was 39% ± 12%, and 2 (25%) had ischemic cardiomyopathy. Reasons for surgical epicardial access included dense adhesions owing to prior cardiac surgery, hemopericardium, or pericarditis (n = 6); or planned left ventricular assist device (LVAD) implantation at time of SurgAbl (n = 2). Cryoablation guided by real-time EAM was performed in all. Goals of clinical VT noninducibility or core isolation were achieved in 100%. VT burden was significantly reduced, from median 15 to 0 events in the month pre- and post-SurgAbl (P = .01). One patient underwent orthotopic heart transplantation for recurrent VT storm 2 weeks post-SurgAbl. Over mean follow-up of 3.4 ± 1.7 years, VT storm–free survival was achieved in 6 (75%); all continued AADs, although at lower dose.ConclusionSurgical mapping and ablation of refractory VT with use of contemporary EAM is feasible and effective, particularly among patients with contraindication to percutaneous epicardial access or with another indication for cardiac surgery.

LONG TERM OUTCOMES OF EPICARDIAL PACING LEADS

Transvenous implantation of a left ventricular (LV) pacing lead is the standard approach to deliver cardiac resynchronization therapy (CRT) but fails in 5-10% of procedures. Surgical implantation of a LV epicardial lead represents an alternative approach to deliver CRT to patients with failed transvenous lead insertion or to individuals with other indications for cardiac surgery and anticipated need for CRT or pacing in the future. Long-term data on the performance and safety of epicardial pacing leads remain scarce.

Reverse remodeling after percutaneous transluminal septal myocardial ablation in severe but asymptomatic LVOT obstruction (RASTA) study: Rationale and design of transcatheter septal reduction in asymptomatic patients with severe hypertrophic obstructive cardiomyopathy.

The aim of this study is to evaluate the impact of percutaneous transluminal septal myocardial ablation (PTSMA) on remodeling in asymptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) and severe left ventricular outflow tract (LVOT) obstruction. Symptoms justify invasive treatment in HOCM patients with LVOT obstruction. Adverse structural and functional changes (remodeling) in the heart occur preceding heart failure and sudden cardiac death. Early invasive treatment in asymptomatic patients may reverse adverse remodeling to the same extent as in symptomatic patients. Reverse remodeling after PTSMA in severe but asymptomatic LVOT obstruction (RASTA) study is a prospective single-blind randomized trial (ClinicalTrials.gov number: NCT04230551). Ten asymptomatic HOCM patients with an exertional LVOT gradient ≥50 mmHg (or >30 mmHg in rest) are randomized 1:1 to PTSMA versus conservative therapy, in the absence of mitral valve disease or other indications for cardiac surgery. Five symptomatic (reference group) will undergo PTSMA according to the current guidelines. Remodeling is assessed using extensive cardiac imaging with transthoracic echocardiography and late gadolinium enhancement cardiac magnetic resonance at baseline and during follow-up at 1, 12, and 24 months. Extracellular volume fraction, global, and regional strain analysis, geometry, pressure gradients and changes in four-dimensional velocity mapping are primary parameters to study (reversal of) adverse remodeling. The RASTA study gives insight in cardiac remodeling that may occur in asymptomatic patients after PTSMA. It will provide arguments whether to pursue (or not) a larger trial with clinical endpoints in asymptomatic HOCM patients with severe LVOT obstruction.

Abstract MP173: Loss of DCHS1 Promotes Mitral Valve Prolapse Through Cytoskeleton Destabilization

Introduction: Mitral valve prolapse (MVP) is a major source of morbidity and mortality and is becoming one of the most common indications for cardiac surgery. Our group has previously reported that MVP is associated with missense mutations in DCHS1 , a gene widely implicated in tissue development and organization. Purpose: We recently performed two-hybrid screens and co-immunoprecipitation assays that define a novel complex between DCHS1, LIX1L, and SEPT9 (DLS). Our current studies investigate the role of this interaction in mitral valve morphogenesis. Methods: Wild-type (WT), DCHS1, and/or LIX1L heterozygous neonate murine heart tissue was isolated for primary culture of cardiac fibroblasts (CFs) and analyzed with immunocytochemistry, collagen, compaction, fibrin pillar to post assays, and actin sedimentation assays. Nuclear morphology and chromatin density were conducted for functional read-outs of cytoskeletal aberrations. Morphologic and functional analyses of murine mitral valves were completed. Results: Loss of actin architecture and collagen compaction capability were seen in CFs deficient of DCHS1 and/or LIX1L. Delivery of a peptide that disrupted the LIX1L-SEPT9 binding domain likewise destroyed actin architecture and reduced ECM compaction. In-vivo epistasis studies support these findings as mitral valve enlargement was exacerbated in DCHS1/LIX1L compound heterozygote mice compared to DCHS1 and LIX1L heterozygotes. Echocardiography of 11-month DCHS1/LIX1L compound heterozygote mice revealed pronounced MVP and increased left atrium diameter relative to DCHS1 and LIX1L heterozygotes. Filamentous SEPTIN9 localized to the actin ultrastructure and was also lost with disturbance of the DLS complex. Nuclei stretch and chromatin compaction were reduced in DCHS1/LIX1L compound heterozygote CFs. Further, histone H4 modifications were observed in DCHS1 KO mouse embryonic fibroblasts that indicate reductions in gene expression. Conclusion: DCHS1, through its interaction with the septin cytoskeleton, must regulate and stabilize actin dynamics in mitral VICs leading to proper valve development. Non-surgical interventions for MVP may be identified through establishing the downstream effects of DCHS1 mutations in our model.

Immunity and Its Effect on the Incidence of Multiple Organ Failure in Patients after the Heart Surgery

The purpose of the study is to identify the components of immunity, which might predict the development of multiple organ failure in patients after heart surgery.Material and methods. The study included 40 patients who were operated in cardiac surgery Department. The inclusion criteria were the presence of indications for cardiac surgery. The exclusion criteria were the presence of infective endocarditis in patients. Before the operation and after 24 hours we studied the blood level of leukocytes and lymphocytes. We analyzed the phenotype of immune cells using monoclonal antibodies, serum levels of procalcitonin and C3 and C4 complement components. All patients were evaluated for multiple organ disfunction (MOD) using the SOFA scale.The results showed that cardiac surgery leads to the development of MOD, statistically significant multidirectional changes in both quantitative and qualitative composition of all cells of the immune system, significant changes in the level of C3 and C4 components of the cascade of complement and plasma level of pro-calcitonin. ROC analysis was revealed that the relative content of monocytes is less than 7.1% of the number of leukocytes as well as the absolute content of monocytes with the CD14 + HLA-DR + phenotype less than 0.32_109/l in the preoperative period, and the C3 level of the complement component less than 0.52 g/l, as well as the maximum SOFA score in the postoperative period, were the best predictors of MOD after the procedures.Conclusion. The components of innate immunity make it possible to predict the complication of the cardiac surgery, earlier than the SOFA scale.