Myocardial Ischemic Time Research Articles

Intracoronary ECG ST-segment shift remission time during reactive myocardial hyperemia: a new method to assess hemodynamic coronary stenosis severity.

Fractional flow reserve (FFR) measurements are recommended for assessing hemodynamic coronary stenosis severity. Intracoronary ECG (icECG) is easily obtainable and highly sensitive in detecting myocardial ischemia due to its close vicinity to the myocardium. We hypothesized that the remission time of myocardial ischemia on icECG after a controlled coronary occlusion accurately detects hemodynamically relevant coronary stenosis. This retrospective, observational study included patients with chronic coronary syndrome undergoing hemodynamic coronary stenosis assessment immediately following a strictly 1-min proximal coronary artery balloon occlusion with simultaneous icECG recording. icECG was used for a beat-to-beat analysis of the ST-segment shift during reactive hyperemia immediately following balloon deflation. The time from coronary balloon deflation until the ST-segment shift reached 37% of its maximum level, i.e., icECG ST-segment shift remission time (τ-icECG in seconds), was obtained by an automatic algorithm. τ-icECG was tested against the simultaneously obtained reactive hyperemia FFR at a threshold of 0.80 as a reference parameter. From 120 patients, 139 icECGs (age, 68 ± 10 yr old) were analyzed. Receiver operating characteristic (ROC) analysis of τ-icECG for the detection of hemodynamically relevant coronary stenosis at an FFR of ≤0.80 was performed. The area under the ROC curve was equal to 0.621 (P = 0.0363) at an optimal τ-icECG threshold of 8 s (sensitivity, 61%; specificity, 67%). τ-icECG correlated inversely and linearly with FFR (P = 0.0327). This first proof-of-concept study demonstrates that τ-icECG, a measure of icECG ST segment-shift remission after a 1-min coronary artery balloon occlusion accurately detects hemodynamically relevant coronary artery stenosis according to FFR at a threshold of ≥8 s.NEW & NOTEWORTHY Invasive hemodynamic measurements are recommended by the current cardiology guidelines to guide percutaneous coronary interventions in the setting of chronic coronary syndrome. However, those pressure-derived indices demonstrate several theoretical and practical limitations. Thus, this study demonstrates the accuracy of a novel, pathophysiology-driven approach using intracoronary ECG for the identification of hemodynamically relevant coronary lesions by quantitatively assessing myocardial ischemia remission.

Results of surgical treatment of aortic stenosis in patients with a narrow aortic root after Ozaki surgery and bioprosthetics: A retrospective single-center study

BACKGROUND: Aortic stenosis (AS) itself is a common disease in patients of older populations, and its combination with a narrow aortic root puts the surgeon in front of choosing the most optimal option. The advantages of Ozaki's operation include hemodynamics close to the native aortic valve (AV) and the absence of the need for lifelong anticoagulant therapy. AIM: To evaluate the hospital and long-term results of surgical treatment of patients with AS and a narrow fibrous ring who underwent Ozaki surgery or AV prosthetics with a biological prosthesis. MATERIALS AND METHODS: In total, 836 isolated Ozaki operations or combined interventions of this kind were performed at the Federal Center for Cardiovascular Surgery (Penza). This retrospective single-center study included 150 patients with critical AC (effective opening area ≤1 cm2) in whose surgical treatment tactics Ozaki surgery or prosthetics with a biological prosthesis were used. RESULTS: In the early postoperative period, group 1 patients had significantly lower values of the average and maximum gradients on the aortic valve and a larger area of the effective opening of the aortic valve. Also, in group 1 patients, the postoperative period of stay in intensive care is significantly higher, which is a consequence of the longer duration of the operation, the time of artificial circulation and myocardial ischemia. Long-term mortality is higher in the group with prosthetics of AV (Log Rank=0.006). Freedom from re-operation according to the analysis, there was no significant difference between the groups (Log Rank=0.226). CONCLUSION: Ozaki surgery demonstrates the best hemodynamic characteristics on AV in comparison with a biological prosthesis in patients with a narrow fibrous ring of AV in the early and long-term follow-up periods.

Preoperative blood urea nitrogen-to-serum albumin ratio for prediction of in-hospital mortality in patients who underwent emergency surgery for acute type A aortic dissection

The study aimed to assess the predictive value of blood urea nitrogen (BUN)-to-albumin ratio (BA-R) for in-hospital mortality in patients undergoing emergency surgery for acute type A aortic dissection (ATAAD). Patients who were diagnosed with ATAAD and underwent emergency surgery within 48 hours of onset at our hospital between January 2015 and December 2021 were included in this study. The primary endpoint of this study was postoperative in-hospital mortality (POIM). The data of the survivors and non-survivors were retrospectively compared analyses. A total of 557 ATAAD patients were included, with 505 survivors and 52 non-survivors. The preoperative BA-R of the non-survivor group was significantly higher than that of the survivor group (P < 0.001). Univariate regression analysis showed that preoperative BA-R, serum creatinine level, SA level, D-dimer level, age, myocardial ischemia, cerebral ischemia, and aortic clamp time were risk factors for POIM. In addition, multivariable regression analysis showed that preoperative BA-R ≥ 0.155 mmol/g was a risk factor for POIM (odds ratio, 6.815 [3.582–12.964]; P < 0.001). Receiver operating characteristic curve indicated that the cut-off point for preoperative BA-R was ≥0.155 mmol/g (area under the curve =0.874). The sensitivity and specificity of preoperative BA-R in predicting the POIM of patients who underwent emergency surgery for ATAAD were 84.6% and 71.3%, respectively (95% confidence interval, 0.829–0.919; P < 0.001). In conclusion, Preoperative BA-R is a simple, rapid, and potentially useful prognostic indicator of POIM in patients with ATAAD.BAR: Blood urea nitrogen-to-albumin ratio, BUN: Blood urea nitrogen, SA: Serum albumin, REF: Reference. The aim of this study was to evaluate the prognostic value of BA-R for the prediction of postoperative in-hospital mortality in patients who underwent emergency surgery for ATAAD. A total of 557 patients with ATAAD were enrolled, and 505 survived while 52 did not. The preoperative BA-R of the non-survivor group was significantly higher than that of the survivor group (0.27 [0.18, 0.46] vs. 0.12 [0.10, 0.16]mmol/g; P < 0.001). The study showed that preoperative BA-R ≥ 0.155 mmol/g was a risk factor for POIM (odds ratio, 6.815 [3.582–12.964]; P < 0.001). ROC curve indicated that the cut-off point for preoperative BA-R was ≥0.155 mmol/g (AUC = 0.874) and the sensitivity and specificity were 84.6% and 71.3%, respectively (95% CI, 0.829–0.919; P < 0.001). We believe that our study makes a significant contribution to the literature because we found preoperative BA-R to be a simple, rapid, and potentially useful prognostic indicator of postoperative in-hospital mortality in patients with ATAAD.

Symptom-to-balloon time and risk of ventricular arrhythmias in patients with STEMI undergoing percutaneous coronary intervention: The VERY-STEMI study

BackgroundVentricular arrhythmias (VAs) mainly occur in the early post-myocardial infarction (MI) period. However, studies examining the association between total myocardial ischemia time interval and the risk of new-onset VAs during a long-term follow-up are scarce. MethodsThis study (symptom-to-balloon time and VEntricular aRrhYthmias in patients with STEMI, VERY-STEMI study) was a multicenter, observational cohort and real-world study, which included patients with ST-segment elevation MI (STEMI) undergoing percutaneous coronary intervention (PCI). The primary endpoint was cumulative new-onset VAs during follow-up. The secondary endpoints were the major adverse cardiovascular events (MACE) and changes in left ventricular ejection fraction (ΔLVEF, %). ResultsA total of 517 patients with STEMI were included and 236 primary endpoint events occurred. After multivariable adjustments, compared to patients with S2BT of 24 h-7d, those with S2BT ≤ 24 h and S2BT > 7d had a lower risk of primary endpoint. RCS showed an inverted U-shaped relationship between S2BT and the primary endpoint, with an S2BT of 68.4 h at the inflection point. Patients with S2BT ≤ 24 h were associated with a lower risk of MACE and a 4.44 increase in LVEF, while there was no significant difference in MACE and LVEF change between the S2BT > 7d group and S2BT of 24 h-7d group. ConclusionsS2BT of 24 h-7d in STEMI patients was associated with a higher risk of VAs during follow-up. There was an inverted U-shaped relationship between S2BT and VAs, with the highest risk at an S2BT of 68.4 h.

Direct aortic cannulation versus femoral arterial cannulation for early outcomes in acute type A aortic dissection: A study-level meta-analysis.

To investigate the impact of direct aortic cannulation (DAC) versus femoral arterial cannulation (FAC) on clinical outcomes of surgery for acute type A aortic dissection. PubMed/MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were searched until August 25, 2023, to conduct a meta-analysis. Primary endpoints of the study were operative mortality and postoperative stroke. Secondary endpoints were cardiopulmonary bypass time, myocardial ischemic time, hypothermic circulatory arrest time, temporary neurological dysfunction (TND), combined stroke and TND, re-exploration for bleeding, and need for renal replacement therapy. A random-effect model was used to estimate the pooled effect size, and a leave-one-out method was used for the primary endpoints for sensitivity analysis. 15 studies met our eligibility criteria, including a total of 7941 samples. Operative mortality was significantly lower in the DAC group with a pooled odds ratio (OR) of 0.72 [95% confidence interval (CI): 0.61-0.85)]. Incidence of postoperative stroke was also lower in the DAC group with a pooled OR of 0.79 (95% CI: 0.66-0.94). However, after excluding one study with the greatest weight, the difference became nonsignificant. DAC was also associated with a lower incidence of postoperative TND, and re-exploration for bleeding with a pooled OR of 0.52 (95% CI: 0.37-0.73), and 0.60 (95% CI: 0.47-0.77), respectively. This meta-analysis showed that patients who underwent ATAAD repair with DAC had a lower incidence of operative mortality, postoperative stroke, TND, and re-exploration for bleeding compared to those who underwent FAC.

Transferring Surgical Expertise: Analyzing the Learning Curve of Robotic Cardiac Surgery Operative Time Reduction When Surgeon Moves from One Experienced Center to Another.

Robotically assisted cardiac surgery is performed in a team setting and is well known to be associated with learning curves. Surgeon and operative team learning curves are distinct entities, with total operative time representing the entire operative team (surgery, anesthesia, nursing, and perfusion) and cross-clamp time representing mainly the surgical team. Little is known about how a team learning curve evolves when an experienced surgeon transitions from one surgical center to another. This study investigates the dynamics of the team learning curve expressed as total operative time in the case of a surgeon with previous experience transitioning to a new team. A retrospective analysis was conducted on robotic cardiac surgeries performed by a surgeon who transitioned from one experienced surgical center to another. Operative time data were collected and categorized to assess the evolution of the learning curve. Statistical analysis, including learning curve modeling and linear regression analysis, was used to evaluate changes in total time in the operating room per case. 103 cases were included in Weill Cornell Medicine (2019-2023). The median patient age was 63 years, 68% were males, 90.3% of cases were repaired for degenerative mitral valve disease, and the median body mass index was 23.87. Operative time (ORT) decreased from a median of 5.00 h [95%CI: 4.76, 6.00] in the first 30 cases to 4.83 [95%CI: 4.10, 5.27] thereafter, with the apparent curve plateauing indicative of the adaptation period to the new surgical environment (p = 0.01). Subgroup analysis among mitral cases (n = 93) showed a decrease in ORT from 5.00 [95%CI: 4.71, 5.98] in the first 26 cases to 4.83 [95%CI: 4.14, 5.30] (p = 0.045). There was no difference between the initial 30 cases and subsequent cases regarding cardiopulmonary bypass time, myocardial ischemia time, reoperation for bleeding, prolonged ventilation, reintubation, renal failure, need for an intra-aortic balloon pump, readmission to the ICU, reoperation for valvular dysfunction within 30 days, pneumonia, and deep venous thrombosis. Multivariate significant predictors of longer operative time were the first 30 cases, resection-based repairs, and MAZE as a concomitant procedure. Total operative time can be expected to decrease after about 30 cases when an experienced robotic surgeon moves between centers. Complications and cross-clamp times are less susceptible to a learning curve phenomenon in such a circumstance, as these depend primarily on the operating surgeon's level of experience. Understanding these dynamics can inform the planning and management of surgical transitions, ensuring optimal patient care and continued improvement in surgical outcomes.

Comparison of different porcine models simulating myocardial cold ischemia of pediatric donor hearts.

Our team previously identified a stem cell-derived cardioprotective additive that can be added to standard cardioplegia to extend myocardial viability during prolonged myocardial cold ischemic time (CIT) in rodent models. The purpose of this study was to utilize a porcine model to compare in-vivo versus ex-vivo porcine simulation of CIT that accompanies cardiac transplantation in humans, in order to determine an optimal method for translation of our studies to larger animals. Eight 39-55kg Yorkshire X pigs were randomly assigned to either in-vivo or ex-vivo simulation. After administration of general anesthesia and endotracheal intubation, baseline measurement of left ventricular performance was obtained via transesophageal echocardiography (TEE). After midline sternotomy and heparin administration, the aorta was cross-clamped and twoliters of HTK-Custodiol were introduced via the aortic root. The in-vivo method utilized cold ischemic heart storage in the chest cavity while supporting the experimental animal with cardiopulmonary bypass (CPB). The ex-vivo method involved standard cardiac procurement, cold ischemic storage outside of the body, and subsequent cardiac reperfusion utilizing cardiac reanimation in a Langendorff heart perfusion mode. After CIT, measurements of post-ischemic left ventricular performance were obtained via echocardiography. Results are presented as: Mean ± Standard Deviation (Median, Minimum-Maximum). Weight (kilograms) was similar in the in-vivo group and the ex-vivo group: 44 ± 1.8 (44, 42-46) versus 44 ± 5.1 (43.5, 39-51), respectively. Cold ischemic time (minutes) was longer in the ex-vivo group: 360 ± 0 (360, 360-360) versus 141 ± 26.7 (149, 102-163). Temperature (degrees Celsius) was colder in the ex-vivo group: 8 ± 0 (8, 8-8) versus 16.5 ± 4.2 (16, 12-16).In the in-vivo group, baseline ejection fraction and ejection fraction after CIT were: 48.25% ± 14.95% (48.5%, 33%-63%) and 41.25% ± 22.32% (41.5%, 20%-62%), respectively. In the ex-vivo group, baseline ejection fraction and ejection fraction after CIT were: 56.4% ± 5.9% (57%, 50%-67%) and 60.4% ± 7.7% (61.5%, 51.9%-67%), respectively. The ex-vivo technique is suitable to evaluate cardioplegia additives that may substantially extend myocardial tolerance to cold ischemia.

Autologous inclusion technique versus Dacron inclusion technique in modified Ross surgery in adults: a retrospective single-center study

The Ross procedure has been shown to have excellent long-term outcomes. However, pulmonary autografts remain at risk of dilation in the long-term period. Therefore, the autologous inclusion technique (AIT) and the Dacron inclusion technique (DIT) have been developed. No direct comparison up to date has been reported of these two techniques.Aim: To compare immediate and medium-term results performing various modified techniques of the Ross operation.Material and Methods. The following retrospective study included 43 patients (AIT: 22; DIT: 21) aged 18 years and older with an aortic valve (AV) pathology who underwent modified Ross procedures (AIT and DIT) from January 2014 to December 2019, performed by a single surgeon. The main endpoints were: in-hospital mortality, postoperative AV pressure gradients, time of myocardial ischemia and cardiopulmonary bypass, postoperative complications (resternotomy due to bleeding, perioperative myocardial infarction, stroke, sternal infection, conduction disorder requiring implantation of a permanent pacemaker, acute renal failure requiring hemodialysis) and mid-term outcomes (freedom from reoperation, freedom from aortic dilatation ≥ 5 cm). The median follow-up period was 23 (12–68) months.Results. The main indication for surgery was aortic regurgitation in 32 patients (74.4%). Bicuspid aortic valve was diagnosed in 29 (67.4%) patients. There were 33 (76.7%) males with an average age of 40 ± 11.7 years. There were no lethal outcomes in both groups. There was also no significant difference in postoperative complications. The peak and mean gradients on the AV were significantly lower in the AIT group than in the DIT group (6 and 4 mmHg vs 8 and 7 mmHg, p = 0.04). Five-year overall survival, freedom from reoperation on AV and PV, and freedom from dilatation of the ascending aorta ≥ 5 cm after modified Ross operation were 97.4%, 100%, and 100%, respectively. There was no statistically significant difference between groups in terms of overall survival (p = 0.66).Conclusion. Both techniques, autologous inclusion and Dacron inclusion, provide excellent immediate and mid-term outcomes in terms of overall survival, freedom from reoperation and freedom from aortic dilation

Reoperations after Ross procedure: a retrospective study

Aim. To analyze the immediate outcomes of reinterventions after Ross procedure.Material and methods. From April 2009 to December 2022, 224 Ross operations in adults were performed at the Federal Center for Cardiovascular Surgery. The retrospective study included 17 patients who required repeated interventions (14 men/3 women). The mean age of the patients was 38±11 years, with a minimum age of 21 and a maximum of 54 years. A history of infective endocarditis was revealed in 4 (23,5%) patients, hypertension — in 3 (17,6%) patients. Of the 17 included patients, 15 patients underwent the classic Ross operation ("full root replacement"), while 2 — a modified technique (1 — wrapping with aorta, 1 — wrapping with a Dacron graft). Annulus enhancement was previously performed in 3 patients.Results. Interventions on the pulmonary autograft and homograft were performed in 16 and 4 cases, respectively. The main indication for pulmonary autograft intervention was aortic regurgitation in 15 cases, and neoaortic aneurysm in 14 cases. In 3 patients, there was pulmonary homograft stenosis, while in 1 case — thrombosis. Two patients required interventions on other valves: 1 — mitral valve stenosis, 1 — severe tricuspid regurgitation. Mean reoperation, cardiopulmonary bypass and myocardial ischemia time were 289±62, 126±35 and 98±22 min, respectively. Combined interventions were performed in 6 cases. David valve-sparing procedure was performed in 9 patients, Bentall-de Bono technique — in 3, aortic valve repair — in 2, mechanical aortic valve replacement — in 2, supracoronary ascending aorta replacement — in 2, pulmonary homograft replacement — in 2, pulmonary homograft thrombectomy — in 1, pulmonary homograft repair — in 1 patient, mitral valve replacement — in 1 patient, tricuspid valve repair — in 1 patient. One patient required resternotomy for bleeding. There were no postoperative complications (perioperative myocardial infarction, acute kidney injury, stroke, sternal infection, cardiac tamponade) and deaths. The median length of stay in intensive care unit was 21 [16-23] hours.Conclusion. Reoperations after the Ross procedure may be required for different pathologies, but all can be performed surgically with a high safety in experienced operator.

Zone 2 arch repair for acute type A dissection: Evolution from arch-first to proximal-first repair.

With growing experience of acute type A aortic dissection repair, Zone 2 arch repair has been advocated. The aim of this study is to compare the outcome between "proximal-first" and "arch-first" Zone 2 repair. From January 2015 to March 2023, 45 patients underwent Zone 2 arch repair out of 208 acute type A aortic dissection repairs: arch-first, N=19, and proximal-first technique, N=26, since January 2021. Indications were aortic arch or descending tear, complex dissection in neck vessels, cerebral malperfusion, or aneurysm of the aortic arch. The lowest bladder temperature was higher in the proximal-first technique (24.9 °C vs 19.7 °C, P<.001). Cardiopulmonary bypass (230 vs 177.5minutes, P<.001), myocardial ischemic (124 vs 91minutes, P<.001), and lower-body circulatory arrest (87 vs 28minutes, P<.001) times were shorter in the proximal-first technique. The arch-first group required more packed red blood cells (arch-first, 2 units vs proximal-first, 0 units, P=.048), platelets (arch-first, 4 units vs proximal-first, 2 units, P=.003), and cryoprecipitates (arch-first, 2 units vs proximal-first, 1 unit, P=.024). Operative mortality and major morbidities were higher in the arch-first group (57.9% vs 11.5%, P=.001). One-year survival was comparable (arch-first, 89.5% ± 7.0% vs proximal-first, 92.0% ± 5.5%, P=.739). Distal intervention was successfully performed in 5 patients (endovascular, N=3, and open repair, N=2). Zone 2 arch repair using the proximal-first technique for acute type A aortic dissection repair yields shorter lower-body ischemic time with a warmer core temperature, resulting in shorter cardiopulmonary bypass time, less blood product use, and fewer morbidities when compared with the arch-first technique.

Myocardial Priority Promotes Cardiovascular Recovery for Acute Type A Aortic Dissection Combined with Coronary Artery Disease Undergoing Aortic Arch Surgery.

The optimal surgical strategy for acute type A aortic dissection (ATAAD) with coronary artery disease (CAD) remains unclear. The goal of this study was to investigate the cardiovascular protective effects of the myocardial priority (MP) strategy or traditional selective cerebral perfusion (SCP) in ATAAD with CAD. A total of 214 adults were analyzed retrospectively, of which 80 underwent the MP strategy intraoperatively. Seventy-nine pairs were propensity-score-matched and divided into SCP and MP groups. The follow-up period ranged from 6 to 36 months. The MP group had a significantly shorter myocardial ischemic time, higher perfusion flow, higher radial artery pressure, and lower incidence of NIRS decrease >20% of the base value, but a longer lower limb circulatory arrest and bypass time than the SCP group. Although similar adverse cardiac and cerebrovascular events were observed in both groups, a shorter posthospital stay, less blood loss and transfusion, higher postoperative hemoglobin, lower creatinine, and higher PaO2/FiO2 were observed in the MP group. Subgroup analysis showed that when the TIMI Risk Score was <4, the MP group had a lower incidence of low cardiac output and lower postoperative cTnI level. The follow-up patients had similar morbidities between the two groups. The novel MP strategy is associated with a shortened myocardial ischemic time, better maintained perfusion of vital organs, and postoperative recovery after surgery for ATAAD combined with non-severe CAD.

Efficiency and Safety of Temperatures Management in Aortic Arch Surgery: A System Review and Meta-Analysis

Objective. The study evaluates the safety and efficacy of hypothermic cardiac arrest (HCA) at various temperatures in aortic arch surgeries. Methods. We conducted a literature search in PubMed, Google Scholar, and Embase databases. For single proportion assessments, we employed fixed-effect and random-effect models in the general linear mixture model and the inverse variance model for other computations. We analyzed factors such as age, sex, operation time, and postoperative complications, with subgroup and metaregression analyses. We used funnel plots to depict potential publication bias. Results. Our research incorporated 43 papers with 34,797 cases. HCA temperatures were divided into five groups (A: 30–32°C, B: 28–30°C, C: 26–28°C, D: 24–26°C, and E: &lt;24°C). There is no statistically significant difference in myocardial ischemia time ( P = 0.90) and isolated cerebral perfusion (ICP) time ( P = 0.95). Groups A and C have the best performance in avoiding postoperative complications including transient nerve injury (TNI), permanent nerve injury (PNI), renal failure (RF), and mortality occurrence rate. Group A has the lowest occurrence rate in PNI (3%) and mortality (3%). Group C has the lowest RF incidence (5%). Conclusion. Maintaining temperatures of 30–32°C in en bloc anastomosis or 26–28°C during arch replacement with separate grafts can significantly reduce complications including PNI, RF, and in-hospital mortality.

Effect of the "door-to-balloon" time on the results of treatment of patients with ST-segment elevation myocardial infarction, depending on the duration of the pre-hospital delay.

Aim To analyze the effect of the door-to-balloon time on treatment outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI) depending on the duration of pre-hospital delay.Material ad methods The study used data of the hospital registry of percutaneous coronary interventions (PCI) in STEMI from 2006 through 2017. The analysis included 1333 patients. All patients were divided into two groups. The first group included 574 (43.1%) patients with the time from the pain syndrome onset to admission was ≤120 min. The second group consisted of 759 (56.9 %) patients with the time of pre-hospital delay exceeding 120 min. Results of the treatment were analyzed for each group depending on the door-to-balloon time, ≤60 min or &gt;60 min.Results In the group of patients with the prehospital delay less than 120 min and the door-to-balloon time ≤60 min vs. patients with the door-to-balloon time &gt;60 min, the following was observed: decreased in-hospital mortality (1.3 % vs. 6.8 %, p=0.001), reduced incidence of major adverse cardiac effects (МАСЕ) (3.2 % vs. 8.3 %, p=0.008), and reduced incidence of the no-reflow phenomenon (3.9 % vs. 9.4 %, p=0.007). Also, immediate angiographic success of PCI was more frequently achieved in these patents (94.5 % vs. 87.5 %, p=0.003). In addition, in the group with the prehospital delay ≤120 min and the door-to-balloon time ≤60 min, a higher ejection fraction was noted at discharge from the hospital (48 [43; 51] % vs. 46 [42; 51] %, р=0.038). Comparison of treatment outcomes between the groups with different door-to-balloon time (≤60 min or &gt;60 min) and a prehospital delay &gt;120 min did not show any significant intergroup differences. According to a multivariate analysis, the door-to-balloon time ≤60 min did not predict in-hospital mortality. There was a strong correlation between the time of prehospital delay and the total time of myocardial ischemia (r=0.87; р&lt;0.001) while the correlation between the door-to-balloon time and the total time of myocardial ischemia was moderate (r=0.41; р&lt;0.001). At the same time, there was no correlation between the time of prehospital delay and the door-to-balloon time.Conclusion In STEMI patients with a prehospital delay less than 120 min from the pain syndrome onset, a decrease in the door-to-balloon time was associated with better outcome of the hospital treatment. When the duration of prehospital delay was more than 120 min, a decrease in door-to-balloon time did not influence the treatment outcome. The time of prehospital delay strongly correlated with the total time of myocardial ischemia.

CARD23: Comparison of Different Porcine Models Simulating Myocardial Cold Ischemia of the Pediatric Donor Heart

Background: Our team previously identified a stem cell-derived cardioprotective additive that can extend myocardial viability during prolonged myocardial cold ischemic time (CIT) in rodent models. The purpose of this study was to utilize a porcine model to compare in-vivo versus ex-vivo simulation of CIT in porcine models in order to determine an optimized method for extension of our studies into larger animals. Methods: Eight 39-55kg Yorkshire X pigs were randomly assigned to either in-vivo or ex-vivo simulation. After administration of general anesthesia and endotracheal intubation, baseline measurement of left ventricular performance was obtained via transesophageal echocardiography (TEE). After midline sternotomy and heparin administration, the aorta was cross-clamped and 2 liters of HTK-Custodiol was introduced via the aortic root. After CIT, measurements of post-ischemic left ventricular performance were obtained. Results are presented as: Mean ± Standard Deviation (Median, Minimum–Maximum). Results: Weight (kilograms) was similar in the in-vivo and ex-vivo group: 44±1.8(44, 42–46) versus 44 ± 5.1(43.5, 39–51), respectively. Cold ischemic time (minutes) was longer in the ex-vivo group: 360±0,(360–360) versus 141±26.7(149, 102–163). Temperature (OCelsius) was colder in the ex-vivo group: 8±0(8, 8–8) versus 16.5±4.2(16, 12–16) In the in-vivo group, baseline ejection fraction and ejection fraction after CIT were: 48.25%±14.95%(48.5%, 33%–63%) and 41.25%±22.32%(41.5%, 20%–62%), respectively. In the ex-vivo group, baseline ejection fraction and ejection fraction after CIT were: 56.4%±5.9%(57%, 50%–67%) and 60.4%±7.7%(61.5%, 51.9%–67%), respectively. Conclusion: The ex-vivo technique is suitable to evaluate cardioplegia additives that may substantially extend myocardial tolerance to cold ischemia.

The Results of Surgical Treatment of Patients with Many Valve Defects in Combination with Coronary Pathology

The objective: to analyze the impact of various surgical management on the duration of the ischemic period and the quality of myocardial protection during simultaneous combined correction of two-three heart valves and myocardial revascularization. Materials and methods. The results of the treatment of single-stage multivalve correction in combination with coronary artery bypass grafting in 93 patients, which was performed at the M.M. Amosov National Institute of Cardiovascular Surgery for the period from 2014 to 2021, were studied. Depending on the methods and the sequence of surgical manipulations, the patients were divided into three groups. I group – 42 patients who had the correction of heart valves firstly and then aortocoronary shunting in conditions of pharmaco-cold cardiac arrest, II group – 36 patients who first had aortocoronary bypass surgery, then valve correction in conditions of pharmaco-cold cardiac arrest, III group – 15 patients, who at the first stage had coronary artery bypass grafting on a working heart, then – correction of valve damage in conditions of pharmaco-cold cardiac arrest. Results. The use of the technique of primary restoration of coronary blood flow by shunting coronary arteries in a working heart before clamping the aorta (before pharmaco-cold cardiac arrest and the start of artificial blood circulation) allows to reduce the duration of artificial blood flow and ischemic time, which positively affects the heart rhythm in the postoperative period. Conclusions. The technique of performing aortocoronary shunting on a working heart is more effective than when performing aortocoronary shunting in conditions of pharmaco-cold cardiac arrest. This technique requires more time to perform and is technically more difficult, but it can statistically significantly reduce the time of myocardial ischemia, which reduces the frequency of severe heart failure and the frequency of postoperative complications.

Continuous Myocardial Perfusion during Distal Anastomosis of Acute Type A Aortic Dissection.

The effect of continuous myocardial perfusion (CMP) on the surgical results of acute type A aortic dissection (ATAAD) remains unclear. From January 2017 to March 2022, 141 patients who underwent ATAAD (90.8%) or intramural hematoma (9.2%) surgery were reviewed. Fifty-one patients (36.2%) received proximal-first aortic reconstruction and CMP during distal anastomosis. Ninety patients (63.8%) underwent distal-first aortic reconstruction and were placed in traditional cold blood cardioplegic arrest (CA; 4°C, 4:1 blood-to-Plegisol) throughout the procedure. The preoperative presentations and intraoperative details were balanced using inverse probability of treatment weighting (IPTW). Their postoperative morbidity and mortality were analyzed. The median age was 60 years. The incidence of arch reconstruction in the unweighted data was higher in the CMP compared with the CA group (74.5 vs 52.2%, p = 0.017) but was balanced after IPTW (62.4 vs 58.9%, p = 0.932, standardized mean difference = 0.073). The median cardiac ischemic time was lower in the CMP group (60.0 vs 130.9 minutes, p < 0.001), but cerebral perfusion time and cardiopulmonary bypass time were similar. The CMP group did not demonstrate any benefit in the reduction of the postoperative maximum creatine kinase-MB ratio (4.4 vs 5.1% in CA, p = 0.437) or postoperative low cardiac output (36.6 vs 24.8%, p = 0.237). Surgical mortality was comparable between groups (15.5% in CMP vs 7.5% in the CA group, p = 0.265). Application of CMP during distal anastomosis in ATAAD surgery, irrespective of the extent of aortic reconstruction, reduced myocardial ischemic time but did not improve cardiac outcome or mortality.

Is a four-branched prosthesis advantageous over a straight prosthesis in Frozen elephant trunk surgery?

For years, the elephant trunk (ET) technique has been applied to extended aortic arch pathology facilitating staged downstream open- or endovascular completion. The recent use of a stentgraft as so-called frozen ET enables even single-stage repair, or its use as a scaffold in an acutely or chronically dissected aorta. Hybrid prosthesis have since been introduced, available as either a 4-branch graft or a straight graft for reimplantation of the arch vessels using the classic island technique. Both techniques are known to have technical advantages and disadvantages in specific surgical scenarios. In this paper we will discuss whether a 4-branch graft hybrid prosthesis is advantageous over a straight hybrid prosthesis. Our considerations in terms of mortality, cerebral embolic risk, myocardial ischemia time, cardiopulmonary bypass (CPB) time, hemostasis and exclusion of supra-aortic entries in the case of acute dissection will be shared. The 4-branch graft hybrid prosthesis conceptually facilitates reduced systemic-, cerebral-, and cardiac arrest time. Additionally, atherosclerotic ostial debris, intimal re-entries, and fragile aortic tissue in genetic disease can be excluded by using a branched graft instead of the island technique for reimplantation of the arch vessels. Despite many conceptual technical advantages of the 4-branch graft hybrid prosthesis, literature data do not show significantly better outcomes when compared to the straight graft, to support its routine use in all cases.

Preventive chronotherapy of diltiazem in old patients with ischemic heart disease, stable stenocardia II–III functional classes

BACKGROUND: This study developed a new variant of chronotherapy preventive chronotherapy with a calcium antagonist of prolonged action diltiazem, which is provided before the onset of myocardial ischemia (painful and pain-free) in accordance with ECG monitoring data in older patients with stable angina pectoris.&#x0D; AIM: This study aimed to examine the effectiveness of preventive chronotherapy with diltiazem in older patients with coronary heart disease and stable angina pectoris of IIIII functional classes in comparison with traditional treatment with diltiazem without taking into account the onset of myocardial ischemia during the day.&#x0D; MAATERIALS AND METHODS: The study included two randomized groups of patients with coronary heart disease, i.e., stable angina pectoris. Group 1 included patients (n=15) receiving preventive chronotherapy with diltiazem. Group 2 consisted of patients (n=10) with angina pectoris of 23 functional classes treated with diltiazem by the traditional method. EchoСG was used in the work. ECGHolter monitoring and bimanual physical activity were conducted. The course of treatment was 10 days.&#x0D; RESULTS: The results indicated the advantage of preventive chronotherapy with diltiazem in comparison with traditional treatment. This is confirmed by a more pronounced therapeutic effect in the form of an improvement in myocardial contractile function, decrease in myocardial energy expenditure, increase in exercise tolerance and antianginal, anti-ischemic, and vasodilating effects of diltiazem used in preventive chronotherapy mode (i.e., with an increase in the occurrence time of myocardial ischemia).&#x0D; CONCLUSION: The study data obtained made it possible to establish more pronounced antianginal, anti-ischemic, and hypotensive effects of preventive chronotherapy with diltiazem than these effects of traditional treatment. Moreover, preventive chronotherapy was associated with a greater tolerance to physical activity and a decrease in myocardial energy expenditure.

Transmitral Septal Myectomy and Mitral Valve Surgery via Right Mini-Thoracotomy.

Transmitral myectomy for symptomatic hypertrophic obstructive cardiomyopathy is possible with existence of substantial mitral valve disease. We present herein our experience of minimally invasive transmitral septal myectomy combined with mitral valve surgery through right anterior mini-thoracotomy in the past 4 years at our institution. Between March 2017 and October 2020, 14 patients with hypertrophic obstructive cardiomyopathy and mitral valve disease required minimally invasive transmitral septal myectomy combined with mitral valve reconstruction or replacement at our institution. Mean age of patients was 54.2 ± 11.4 and 42.9% (n = 6) were female. Twelve patients (85.1%) were in New York Heart Association class III to IV and 6 patients (42.9%) presented with persistent atrial fibrillation. Clinical data were prospectively entered into our institutional database. Cardiopulmonary bypass time accounted for 140.2 ± 32.6 minutes and the myocardial ischemic time was 78.5 ± 12.4 minutes. Thirty-day mortality and overall mortality were zero. Peak ventricular outflow gradient decreased from 75.2 ± 12.7 to 9.4 ± 2.3 mm Hg (p < 0.0001). Simultaneously, mitral valve reconstruction and replacement were performed in 11 (78.6%) and 3 (21.4%) patients, respectively. No systolic anterior motion was seen in patients with mitral valve repair. No conversion to full sternotomy and/or rethoracotomy was noted. During a mean follow-up period of 24 ± 13 months, no patient required reoperation, no recurrence mitral regurgitation, and left ventricular outflow tract obstruction. Transmitral septal myectomy combined with mitral valve surgery through right anterior mini-thoracotomy can be performed safely with excellent surgical outcomes.

Reconsidering treatment guidelines for acute myocardial infarction during the COVID-19 pandemic

BackgroundCOVID-19 affects healthcare resource allocation, which could lead to treatment delay and poor outcomes in patients with acute myocardial infarction (AMI). We assessed the impact of the COVID-19 pandemic on AMI outcomes.MethodsWe compared outcomes of patients admitted for acute ST-elevation MI (STEMI) and non-STEMI (NSTEMI) during a non-COVID-19 pandemic period (January–February 2019; Group 1, n = 254) and a COVID-19 pandemic period (January–February 2020; Group 2, n = 124).ResultsFor STEMI patients, the median of first medical contact (FMC) time, door-to-balloon time, and total myocardial ischemia time were significantly longer in Group 2 patients (all p < 0.05). Primary percutaneous intervention was performed significantly more often in Group 1 patients than in Group 2 patients, whereas thrombolytic therapy was used significantly more often in Group 2 patients than in Group 1 patients (all p < 0.05). However, the rates of and all-cause 30-day mortality and major adverse cardiac event (MACE) were not significantly different in the two periods (all p > 0.05). For NSTEMI patients, Group 2 patients had a higher rate of conservative therapy, a lower rate of reperfusion therapy, and longer FMC times (all p < 0.05). All-cause 30-day mortality and MACE were only higher in NSTEMI patients during the COVID-19 pandemic period (p < 0.001).ConclusionsCOVID-19 pandemic causes treatment delay in AMI patients and potentially leads to poor clinical outcome in NSTEMI patients. Thrombolytic therapy should be initiated without delay for STEMI when coronary intervention is not readily available; for NSTEMI patients, outcomes of invasive reperfusion were better than medical treatment.