Postoperative Left Ventricular Dysfunction Research Articles

Early outcomes of moderate-to-high-risk pediatric congenital cardiac surgery and predictors of extracorporeal circulatory life support requirement.

Cardiopulmonary failure refractory to medical management after moderate-to-high-risk congenital cardiac surgery may necessitate mechanical support with veno-arterial extracorporeal membrane oxygenation (ECMO). On the extreme, ECMO can also be initiated in the setting of cardiac arrest (extracorporeal cardiopulmonary resuscitation, ECPR) unresponsive to conventional resuscitative measures. This was a single-center retrospective cohort study of patients (n = 510) aged <3 years old who underwent cardiac surgery with cardiopulmonary bypass with a RACHS-1 score ≥3 between 2011 and 2014. Perioperative factors were reviewed to identify predictors of ECMO initiation and mortality in the operating room (OR) and the intensive care unit (ICU). A total of 510 patients with a mean surgical age of 10.0 ± 13.4 months were included. Among them, 21 (4%) patients received postoperative ECMO-12 were initiated in the OR and 9 in the ICU. ECMO cannulation was associated with cardiopulmonary bypass duration, aortopulmonary shunt, residual severe mitral regurgitation, vaso-inotropic score, and postprocedural lactate (p < 0.001). Of the 32 (6%) total deaths, 7 (22%) were ECMO patients-4 were elective OR cannulations and 3 were ICU ECPR. Prematurity [hazard ratio (HR): 2.61, p < 0.01), Norwood or Damus-Kaye-Stansel procedure (HR: 4.29, p < 0.001), postoperative left ventricular dysfunction (HR: 5.10, p = 0.01), residual severe tricuspid regurgitation (HR: 6.06, p < 0.001), and postoperative ECMO (ECPR: HR: 15.42, p < 0.001 vs. elective: HR: 5.26, p = 0.01) were associated with mortality. The two patients who were electively cannulated in the ICU survived. Although uncommon, postoperative ECMO in children after congenital cardiac surgery is associated with high mortality, especially in cases of ECPR. Patients with long cardiopulmonary bypass time, residual cardiac lesions, or increased vaso-inotropic requirement are at higher risk of receiving ECMO. Pre-emptive or early ECMO initiation before deterioration into cardiac arrest may improve survival.

Relationship between fragmented QRS complex and early left ventricular dysfunction after mitral valve repair

BackgroundPreoperative left ventricular (LV) ejection fraction (PreLVEF) and preoperative LV end-systolic diameter (PreESD) are known predictors for postoperative LV dysfunction after mitral valve repair (MVR). Fragmented QRS (fQRS) evaluated in 12-derivation electrocardiography has widely been accepted as a sign of myocardial fibrosis.In the present study, we aimed to evaluate the relationship between fQRS in preoperative 12‑lead electrocardiography (ECG) and postoperative LV dysfunction that develop after MVR in patients with severe primary mitral regurgitation (MR) due to mitral valve prolapse (MVP). MethodsFrom 2019 to 2022, 49 patients who had undergone successful MVR surgery for severeMR caused by MVP were enrolled in the study. The preoperative and postoperative echocardiographic data were collected retrospectively. We analyzed the demographic, echocardiographic, operative and postoperative parameters to assess the relationship between fQRS and early postoperative LV dysfunction, defined as an LVEF<60%. ResultsPreLVEF of all patients were ≥ %65. A total of 22 patients had fQRS (44.9%) and postoperative LV dysfunction was found to be 36.7%. A significantly higher rate of fQRS was observed in the group with postoperative LV dysfunction compared to the group without (12 (66.7%) vs 10 (32.3%), p: 0.036). In multivariate analysis for fQRS, PreESD, preoperative pulmonary artery systolic pressure (PrePASP), preoperative atrial fibrillation (PreAF), and male gender, only fQRS was found to be a significant predictor of postoperative LV dysfunction (p: 0.003, OR: 4.28, 95% CI (1.15–15.96). ConclusionfQRS was found to be a predictor of postoperative LV dysfunction in the early period after MVR. fQRS may be a readily available and cost-effective test that can be used in clinical practice to predict postoperative LV dysfunction in patients undergoing MVR.

Timing of Surgery for Asymptomatic Primary Mitral Regurgitation: Possible Value of Early, Serial Measurements of Left Ventricular Sphericity.

Asymptomatic primary mitral regurgitation due to myxomatous degeneration of the mitral valve leaflets may remain so for long periods, even as left ventricular function progresses to a decompensated stage. During the early compensated stage, the ventricle's initial response to the volume overload is an asymmetric increase in the diastolic short axis dimension, accomplished by a diastolic shift of the interventricular septum into the right ventricular cavity, creating a more spherical left ventricular diastolic shape, increasing diastolic filling and stroke volume. Early valve repair is recommended to reduce postoperative left ventricular dysfunction. Early serial measurements of left ventricular sphericity index [LV-Si]. during the compensated stage of mitral regurgitation might identify subtle changes in left ventricular shape and assist in determining the optimal earliest timing for surgical intervention.

Prenatal features and postnatal follow-up of congenital ventricular outpouching: A retrospective study of two centers in China.

Congenital ventricular outpouching (CVO) is a rare cardiac malformation that can manifest as congenital ventricular aneurysm (CVA) and/or congenital ventricular diverticula (CVD). In this study, we describe the prenatal features and postnatal follow-up of 27 cases of CVO. The clinical data of 27 patients with CVO who attended Sir Run Run Shaw Hospital Affiliated to the Medical College of Zhejiang University (Zhejiang Province, China) and Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University (Zhejiang Province, China) from April 2013 to October 2022 were retrospectively analyzed. The patients were also followed up by telephone. The prenatal characteristics and postnatal outcomes of the patients with CVO were evaluated. CVO was detected in 26 cases prenatally, 14 (51.85%) were diagnosed with CVA, nine (33.33%) were diagnosed with CVD, three (11.11%) were equivocal for CVA/CVD, and one (3.70%) was detected with CVA postnatally. Six patients underwent follow-up fetal echocardiography approximately 4weeks after the initial echocardiography examination, and a significant difference in CVO size was observed between the two examinations (P=.02). Eight patients (29.63%) demonstrated cardiovascular dysfunction, and the median CVO size in fetuses with and without cardiovascular dysfunction was 205 (range: 169-396) mm2 and 124 (range: 92-154.5) mm2 , respectively (P=.01). Correlation was found between CVO size and fetal cardiac dysfunction (p=.000, r=.778). Eight patients (29.63%) had cardiac/extracardiac defects. Thirteen patients were live born, 12 were terminated pregnancies, and two were lost to follow-up. The postpartum size of the CVOs remained stable in six patients, decreased in two patients, dissolved in three patients, and were surgically removed in two patients. With the exception of one patient with CVA complicated with complex congenital cardiac malformation who underwent surgical treatment after birth and who had postoperative left ventricular dysfunction (Case 1), the prognosis of all of the patients was good. CVO is often associated with cardiac malformations. The size of prenatal CVOs can increase with gestational development, and cardiovascular dysfunction is significantly related to CVO size. The postpartum prognosis of patients with CVO is good. Echocardiography plays a key role in the diagnosis of congenital ventricular outpouching. Prenatal counseling should be cautious regarding the diagnosis and the prognosis although our cases had a favorable prognosis.

Determinants of post-operative left ventricular dysfunction in degenerative mitral regurgitation

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Saudi Arabian Cultural Bureau. Background Chronic degenerative mitral regurgitation leads to volume overload causing left ventricular (LV) enlargement and eventually LV impairment. Current guidelines determining thresholds for intervention are based on LV diameters and ejection fraction. There is sparse data examining the value of LV volumes and newer markers of LV performance on outcomes of surgery in mitral valve prolapse. Purpose Identify the best markers of LV impairment after mitral valve surgery. Methods Prospective, observational study of patients with mitral valve prolapse undergoing mitral valve surgery. Pre-operative LV diameters, volumes, ejection fraction (LVEF), global longitudinal strain (GLS) and myocardial work measured. Post-operative LV impairment defined as LVEF &amp;lt; 50% at 1 year post-surgery. Results Eighty-seven patients included. 13% developed post-operative LV impairment. Patients with post-operative LV dysfunction showed significantly larger indexed LV end-systolic diameters (LVESD), volumes (LVESV), lower LVEF and more abnormal GLS than patients without post-operative LV dysfunction. In multivariate analysis, indexed LVESV (Odds ratio 1.11 (95% CI 1.01 – 1.23), p = 0.039) and GLS (odds ratio 1.46 (95% CI 1 – 2.14), p = 0.054) were the only independent predictors of post-operative LV dysfunction. The optimal cut-off of 36.3 ml/m2 for indexed LVESV had a sensitivity of 82% and specificity of 78% for detection of post-operative LV impairment. Conclusion Post-operative LV impairment is common. Indexed LV volumes (36.3ml/m2) provided the best marker of post-operative LV impairment.

Prognostic value of forward flow indices in primary mitral regurgitation due to mitral valve prolapse.

Degenerative mitral regurgitation (DMR) due to mitral valve prolapse (MVP) is a common valve disease associated with significant morbidity and mortality. Timing for surgery is debated for asymptomatic patients without Class I indication, prompting the search for novel parameters of early left ventricular (LV) systolic dysfunction. To evaluate the prognostic impact of preoperative forward flow indices on the occurrence of post-operative LV systolic dysfunction. We retrospectively included all consecutive patients with severe DMR due to MVP who underwent mitral valve repair between 2014 and 2019. LVOTTVI, forward stroke volume index, and forward LVEF were assessed as potential risk factors for LVEF <50% at 6 months post-operatively. A total of 198 patients were included: 154 patients (78%) were asymptomatic, and 46 patients (23%) had hypertension. The mean preoperative LVEF was 69 ± 9%. 35 patients (18%) had LVEF ≤ 60%, and 61 patients (31%) had LVESD ≥40 mm. The mean post-operative LVEF was 59 ± 9%, and 21 patients (11%) had post-operative LVEF<50%. Based on multivariable analysis, LVOTTVI was the strongest independent predictor of post-operative LV dysfunction after adjustment for age, sex, symptoms, LVEF, LV end systolic diameter, atrial fibrillation and left atrial volume index (0.75 [0.62-0.91], p < 0.01). The best sensitivity (81%) and specificity (63%) was obtained with LVOTTVI ≤15 cm based on ROC curve analysis. LVOTTVI represents an independent marker of myocardial performance impairment in the presence of severe DMR. LVOTTVI could be an earlier marker than traditional echo parameters and aids in the optimization of the timing of surgery.

Prediction of Left Ventricle Function from Pre-Operative Left Ventricle End-Systolic Dimension in Mitral Valve Replacement

Rheumatic heart disease is an endemic in developing countries. The most common valve affected is the mitral valve for which mitral valve replacement is done. Left Ventricle Function (LVEF) is used to measure the prognosis of patients after MVR. Patients with a good LVEF perform better with less morbidity and mortality in comparison to patients with low post-operative EF. Therefore, prediction of post-operative EF is mandatory in patient’s selection and post-operative management. Objective: To determine the effect of pre-operative left ventricular end-systolic dimension in predicting postoperative LV function in mitral valve replacement. Methods: A total of 100 patients with mitral valve replacement were selected for the research. The study was conducted at the cardiac surgery department of National Institute of Cardiovascular Diseases, Karachi from April 2022 to October 2022. Results: The mean age of patients was 37 ± 10 years, LVESD: 34.7 ± 8.4mm, LVEDD: 51.1 ± 9.1mm, PASP: 44 ± 11mmHg, and EF of 55 ± 9%. Patients having Left ventricular end-systolic dimension (LVESD)&gt; 38 mm had a significant post-operative left ventricular dysfunction after mitral valve replacement than patients having a pre-operative LVESD &lt; 38mm (p= 0.003). Moreover, patients having a pre-operative LV dysfunction (EF &lt;55%) were more prone to post-operative LV dysfunction(p=0.02). However, pre-operative LVESD is a more sensitive predictor of post-operative LV dysfunction than pre-operative LVEF (0.003&lt;0.02). Conclusion: Left Ventricular End-Systolic Dimension (LVESD) is a more sensitive parameter as compared to pre-operative LV ejection fraction (LVEF) in predicting post-operative LV ejection fraction (LVEF) after mitral valve replacement (MVR).

Impact of mitral regurgitation on left ventricular remodeling and function in children with rheumatic heart disease.

The impact of mitral regurgitation (MR) from pediatric rheumatic heart disease (RHD) and its effect on left ventricular (LV) remodeling and function following surgical intervention is uncertain. The objective is to explore the impact of mitral valve (MV) surgeries on myocardial mechanics, remodeling and function and identify pre-operative predictors of post-operative dysfunction which may contribute to the optimal timing of intervention. A retrospective review of echocardiographic data was performed of eighteen pediatricpatients with RHD (median 9yrs, IQR 6-12) who underwent MV surgery. Echocardiograms pre-operatively and a median of 13.5months (IQR 10.2-15) following intervention were compared to controls. Pre-operative LV end-diastolic indexed volumes (LVEDVi) were significantly increased compared to controls and remained persistently larger post-operatively. LV ejection fraction (LVEF) (pre 62.6% ± 6.1, post 51.7% ± 9.7, p = 0.002), and global longitudinal strain (GLS) (pre -24.3 ± 4.1, post -18.2 ± 2.6, p < 0.001) decreased post-operatively at mid-term follow-up. Pre-operative LVEDVi was a significant predictor of post-operative LVEF, with a cut-off of ≥ 102ml/m2 associated with LV dysfunction (LVEF < 55%; sensitivity 70%, specificity 75%). Pre-operative LVEDVi also negatively correlated with GLS (r = -0.58, p = 0.01). LV dimensions and volumes remain persistently larger than controls while LV function decreases post-surgical alleviation of MR in paediatric RHD. Pre-operative LVEDVi predicted post-operative LV dysfunction and utilising LV indexed volumes in directing timing of surgical planning should be considered. Further studies are required to investigate whether timely alleviation of MR before significant LV dilatation and remodeling occur may substantially prevent LV dysfunction and improve outcomes.

Survival and left ventricular dysfunction post lung transplantation for pulmonary arterial hypertension

PurposeBilateral lung transplantation for end-stage pulmonary arterial hypertension (PAH) is traditionally associated with higher early post-transplant mortality when compared with other indications. Changes in perioperative management, including the growing use of perioperative extracorporeal membrane oxygenation (ECMO) and an increased awareness of postoperative left ventricular dysfunction (LVD), have resulted in outcomes that are uncertain. Materials and methodsWe conducted a single-center, retrospective observational study at a lung transplantation center in Melbourne, Australia, from 2006 to 2019. ECMO use was categorized as preoperative, prophylactic, or rescue. Postoperative LVD was defined as a reduction in left ventricular function on echocardiography or using strict clinical criteria. Results50 patients underwent lung transplantation for PAH. 12-month survival was 48/50 (96%). ECMO was used in 26 (52%) patients, and the use of prophylactic VA-ECMO increased over the study period. Postoperative LVD was diagnosed in 21 (42%) patients. 12-month survival and left ventricular function was no different between LVD and non-LVD groups. ConclusionsThis study showed that high survival rates can be achieved following lung transplantation for PAH. We found that ECMO utilization was common, and indications have changed over time. LVD was common but did not impact 12-month survival.

Retrospective assessment of the early and medium outcomes of on-pump beating-heart versus off-pump CABG in patients with moderate left ventricular dysfunction (LVEF)

Aim: To compare the early and medium outcomes of on-pump beating-heart (OPBH) coronary artery bypass grafting (CABG) and off-pump CABG (OPCABG) in patients with left ventricular ejection fraction (LVEF) between 30% and 40%. Material &amp; Methods: This study was conducted as a retrospective observation over a period of 1 year at the Department of Cardiothoracic and Vascular Surgery, Indira Gandhi Institute of medical Sciences, Patna, Bihar, India.130 patients were selected for this study. All patients were divided into 2 groups, according to the revascularization method: OPCABG group and OPBH group. Results: LVEF before discharge significantly improved from 34.39 ± 4.21 to 44.27 ± 7.29 in the OPBH group and from 34.27±4.61 to 42.66 ± 8.20in the OPCABG group (P&lt;0.001). All survival patients have been echocardiographically examined after 6 months which showed a significant higher early postoperative LVEF in the OPBH group than in the OPCABG group (45.28 ± 6.10 versus 44.42 ± 7.08%, respectively; P=0.002). Conclusion: The OPBH technique was a safe and an acceptable alternative for surgical revascularization in patients with moderate left ventricular dysfunction which provided better midterm MACE-free survival compared with OPCABG.

Surgery for Primary Cardiac Tumors in Children: Successful Management of Large Fibromas.

BackgroundPediatric primary cardiac tumors (PCTs) are rare. Its clinical features and prognoses are not well defined. The management of asymptomatic patients with cardiac fibromas remains controversial.ObjectiveWe aimed to examine our experience in surgical resection of pediatric PCT, with specific focuses on the management of large fibromas.MethodsThis study included all the children who underwent surgical resection of PCT in our institution between December 2008 and June 2021. The last follow-up was performed between June 1st and August 26th, 2021. Kaplan–Meier method was used to estimate the postoperative survival, freedom from reoperation, event-free survival, and also related risk factors. The tumor volume and volume index (volume divided by body surface area) were measured for cardiac fibromas.ResultsOf the 39 patients with median operative age of 9.5 [interquartile range (IQR): 1.2–16.5] years, 35 (89.7%) had benign tumors (fibromas for 15, myxomas for 13, and others for 7). The length and volume of fibromas were independent of age and symptoms (Ps > 0.05). The fibroma volume index was negatively correlated with age (P = 0.039), with a mean value of 105 ± 70 ml/m2. Of the 15 patients with fibromas, 5 were asymptomatic, 4 received partial resection, 4 required transmural resection, and 4 presented postoperative left ventricular (LV) dysfunction (ejection fraction <50%). During the median follow-up period of 3.1 years and maximum of 12.5 years, adverse events included 2 early and 1 late death, 4 reoperations, 4 tumor recurrences, and 1 LV dysfunction lasting over one year. The 8-year survival, freedom from reoperation, and event-free survival rates were 90.4, 81.8, and 64.2%, respectively. Malignant tumor (P < 0.001) was associated with more adverse events. Transmural resection (P = 0.022) and larger tumor volume index than LV end-diastolic volume (P = 0.046) were risk factors for LV dysfunction following fibromas resection.ConclusionPediatric surgery for PCT can be performed with low mortalities and few adverse events. The size of cardiac fibroma in children relatively decreases with the increase of age. Larger tumor volume index than LV end-diastolic volume index and transmural tumor resection predicts postoperative LV dysfunction.

Proadrenomedullin in Patients with Preserved Left Ventricular Systolic Function Undergoing Coronary Artery Bypass Grafting.

IntroductionA potentially new marker of cardiovascular diseases — proadrenomedullin is the precursor of adrenomedullin, which is a multifunctional peptide hormone, produced in most of the tissues in response to cellular stress, ischemia, and hypoxia.MethodsNinety-three people, aged 51-79 years, were included in the study. Exclusion criteria were severe or corrected valvular disease, acute coronary syndrome, age ≥ 80 years, glomerular filtration rate < 45 ml/min, active infectious diseases, and cancer. The subjects were observed for adverse events, including reduced left ventricular ejection fraction (LVEF) by ≥ 10%, first incidence of atrial fibrillation (AF), and the necessity of using dopamine during hospitalization.ResultsUse of pressure amines, occurrence of the first AF episode, and left ventricular dysfunction defined by a decrease in LVEF by at least 10% compared to the value before surgery were reported in the perioperative period. No death, sudden cardiac arrest with effective resuscitation, non-ST-elevation myocardial infarction, ST-elevation myocardial infarction, or heart failure were observed. Significantly higher proadrenomedullin concentration was observed in the group with reduced postoperative LVEF (1.68 vs. 0.77 nmol/l, P=0.005). The relative risk of a decrease in ejection fraction in the group of patients with proadrenomedullin concentration ≥ 0.77 nmol/l was more than twelve-fold higher (95% confidence interval 1.69-888.33; P=0.013) than in the group of patients with a concentration of proadrenomedullin < 0.77 nmol/l.ConclusionThe higher baseline concentration of proadrenomedullin has a predominantly predictive value of postoperative left ventricular systolic dysfunction.

665 Longitudinal strain impairment in organic mitral regurgitation: look beyond the valve

Abstract Aims Global longitudinal strain (GLS) is a hallmark of cardiac damage in mitral regurgitation (MR). GLS &amp;gt; −18% in patients with severe organic MR (OMR) and normal LV ejection fraction (LVEF) is an independent predictor of postoperative LV dysfunction. While it is known that GLS is impaired in less than severe functional ischaemic MR (FMR), the value of GLS in less than severe OMR is not known. We aimed to determine prevalence and determinants of any GLS impairment in OMR, in comparison to FMR. Methods We retrospectively evaluated 51 consecutive patients (33 OMR and 18 FMR) with mild-to-moderate, moderate and moderate-to-severe MR (Table*). Overall, GLS was higher in OMR than FMR (17.9±4.5 vs. 10.3±5.3, P&amp;lt;0.001), with rate of impairment of 45% in OMR and 89% in FMR (P= 0.0024). Results However, no significant difference was found in GLS between mild-to-moderate, moderate and moderate-to-severe MR patients within OMR (17.7±4.7 vs. 16.9±3.9 vs. 22.4±3, respectively, P&amp;gt;0.05), as well as FMR (9.8±6.6 vs. 10.7±5.3 vs. 10.4±5.3, respectively, P&amp;gt;0.05) groups. GLS correlated directly with left ventricular (LV) ejection fraction (EF) in both OMR (r=0.69, P&amp;lt;0.001) and FMR (r=0.90, P&amp;lt;0.001), and inversely with LV mass indexed for body surface area (LVMi) in both OMR (r = −0.50, P=0.005) and FMR (r = −0.48, P=0.042). While correlation with LVEF was better for FMR than OMR (Z − 1.95, P=0.026), correlation with LVMi was similar for OMR and FMR groups (Z − 0.082, P&amp;gt;0.05). Conclusions In patients with OMR, GLS may be reduced, despite normal LVEF, in less than severe MR. Prevalence and degree of GLS impairment in OMR is less than in FMR. In OMR, as well as in FMR, GLS impairment is independent of entity of MR, but rather correlates with LVMi, maybe reflecting impact of myocardial fibrosis derived by increased LVMi on GLS.

Forward Left Ventricular Ejection Fraction as a Predictor of Postoperative Left Ventricular Dysfunction in Patients with Degenerative Mitral Regurgitation.

Background: Left ventricular dysfunction (LVD) can occur immediately after mitral valve repair (MVr) for degenerative mitral regurgitation (DMR) in some patients with normal preoperative left ventricular ejection fraction (LVEF). This study investigated whether forward LVEF, calculated as left ventricular outflow tract stroke volume divided by left ventricular end-diastolic volume, could predict LVD immediately after MVr in patients with DMR and normal LVEF. Methods: Echocardiographic and clinical data were retrospectively evaluated in 234 patients with DMR ≥ moderate and preoperative LVEF ≥ 60%. LVD and non-LVD were defined as LVEF < 50% and ≥50%, respectively, as measured by echocardiography after MVr and before discharge. Results: Of the 234 patients, 52 (22.2%) developed LVD at median three days (interquartile range: 3–4 days). Preoperative forward LVEF in the LVD and non-LVD groups were 24.0% (18.9–29.5%) and 33.2% (26.4–39.4%), respectively (p < 0.001). Receiver operating characteristic (ROC) analyses showed that forward LVEF was predictive of LVD, with an area under the ROC curve of 0.79 (95% confidence interval: 0.73–0.86), and an optimal cut-off was 31.8% (sensitivity: 88.5%, specificity: 58.2%, positive predictive value: 37.7%, and negative predictive value: 94.6%). Preoperative forward LVEF significantly correlated with preoperative mitral regurgitant volume (correlation coefficient [CC] = −0.86, p < 0.001) and regurgitant fraction (CC = −0.98, p < 0.001), but not with preoperative LVEF (CC = 0.112, p = 0.088). Conclusion: Preoperative forward LVEF could be useful in predicting postoperative LVD immediately after MVr in patients with DMR and normal LVEF, with an optimal cut-off of 31.8%.

Risk Factors for Left Ventricular Dysfunction Following Surgical Management of Cardiac Fibroma.

Surgical resection of cardiac fibromas in children reduces hemodynamic and arrhythmia burden; however, little is known about postoperative left ventricular (LV) function. We aimed to evaluate factors associated with postoperative LV dysfunction. In this retrospective observational cohort study, imaging data were reviewed from 41 patients who had undergone surgical resection of a cardiac fibroma. Tumor volume was indexed to body surface area (tumor volume index). Right ventricular tumors were excluded from analysis of postoperative ventricular function. Postoperative regional wall motion abnormality score was defined as number of wall segments with regional wall motion abnormality, and LV dysfunction was defined as LV ejection fraction <50%. Cardiovascular magnetic resonance-derived strain was low if <5%ile by previously published normative data. Of 41 patients who underwent resection at a median age of 2.1 years (range, 0.5-19), 37 fibromas were in the LV, (29 free wall and 8 septal), and 4 in the right ventricle. Preoperative median tumor volume index was 66 mL/m2 (range, 11-376). Of 37 patients with LV tumors, younger patients had larger tumor volume index and higher grades of preoperative mitral regurgitation (P<0.001). Larger tumor volume index correlated with higher postoperative regional wall motion abnormality score (P<0.001). By paired pre- and post-operative cardiovascular magnetic resonance (n=14), LV end-diastolic volume increased (mean 76 versus 101 mL/m2, P=0.011), with decreased LV ejection fraction (mean 60% versus 55%, P=0.014), a higher prevalence of low global circumferential strain (36% versus 64%, P=0.045), and decreased cardiac index (mean 4.8 versus 3.9 L/[min·m2], P=0.039). More than mild preoperative mitral regurgitation was the only independent predictor of predischarge LV dysfunction (odds ratio, 22 [95% CI, 2.8-179], P=0.008). Surgical resection of LV fibroma is associated with regional wall motion abnormality, increased LV volume, and reduced systolic function. Children with significant preoperative mitral regurgitation are at highest risk for LV dysfunction and warrant ongoing close surveillance.

Presence of fragmented QRS is associated with left ventricular systolic dysfunction after surgery in patients with severe aortic regurgitation.

Chronic severe aortic regurgitation (AR) is associated with progressive accumulation of interstitial fibrosis and disruption of myocardial structure. After aortic valve replacement (AVR), the negative remodeling process reverses, and left ventricular ejection fraction (LVEF) improves but not in all patients. In this study, we aimed to investigate the association of fragmented QRS (F-QRS), which is a possible marker of myocardial fibrosis, with postoperative left ventricular (LV) systolic dysfunction. A total of 147 consecutive patients with AVR were included in this study. F-QRS was identified by the presence of various RSR' patterns (QRS duration <120 ms) such as additional R wave (R prime)or notching of the R or S wave in at least two consecutive leads. Patients were compared in two groups based on the presence or absence of F-QRS. A logistic regression model was used to determine independent predictors of postoperative LV systolic dysfunction (LVEF <50%). Patients with F-QRS were associated with poor recovery of LV systolic function after AVR compared to the patients without F-QRS, regardless of preoperative LVEF (p = .008). F-QRS was found to be an independent predictor of postoperative LV systolic dysfunction (LVEF <50%). Lower preoperative LVEF and increased LV end diastolic diameter index were also found as independent risk factors for postoperative LV systolic dysfunction. As a possible marker of myocardial fibrosis, F-QRS was associated with postoperative LV systolic dysfunction. Therefore, as a simple and convenient clinical parameter, F-QRS may be used to predict poor recovery of LVEF after AVR.

Global longitudinal strain by speckle-tracking echocardiography and feature-tracking cardiac magnetic resonance predicting left and right ventricular performance after mitral regurgitation repair

Preoperative accurate assessment of biventricular systolic function is, essential for the decision of the operative timing in patients with MR. This study sought to compare the value of 2-dimensional (2D) left ventricular (LV) speckle tracking (STE) and feature tracking (FT) against cardiac magnetic resonance (CMR) LV ejection fraction (EF) on predicting postoperative LV dysfunction and in the other hand, evaluate the remodeling of the RV after mitral valve repair. A total of 85 patients with degenerative mitral regurgitation (57,51±9,96 of age, 21,2% women) underwent LV and RV function assessment using CMR and 2D echocardiography a few days before and 7,7 months after mitral valve repair. Pre- and postoperative indexed LV and RV end-diastolic (EDV), end-systolic volumes (ESV), ejection fraction (EF), Echocardiographic GLS, GCS, and CMR GLS, GCS, GRS were measured. Prior to surgery LV volumes were significantly larger, 2D LV and RV STE and FT lower than normal volunteers. After a median follow-up of 7,7 after mitral repair, not only left and right ventricular volume indexed: LV EDVi, ESVi; RV EDVi, atrial volume but also STE (LVGLS-GCS) and FT (LVGLS, GCS, GRS) were significantly decreased (all P < 0,0001) while RV EF significantly improved ( P :0,01). In univariate analysis, preoperative GLS echo, CS MRI, ESV, and preoperative LV EF were significantly correlated with postoperative LV dysfunction; GLS and LV ESV were independent clinical predictors of postoperative LV dysfunction. 2D LV GLS provides strong additionaL value to predict postoperative LV dysfunction in degenerative mitral regurgitation, with higher predictive value than CMR-LVEF, CMR-FT-LVGLS, or FAC. This supports the use of STE-LVGLS to find the best surgical timing in patients with severe MR to prevent LV dysfunction and allow RV recovery.

Perioperative Outcomes of Thrombectomy Patients Using Venovenous Bypass and Suction Filtration With General Anesthesia

AngioVac (Angiodynamics, Latham, NY) is a novel drainage system that offers a less-invasive approach compared with open surgical thromboembolectomy to remove intracardiac and intravascular thrombotic and embolic material. For this study, the authors' single-center experience with patients undergoing thromboembolectomy using the AngioVac system was reviewed retrospectively to evaluate anesthetic management and postoperative complications. Retrospective, observational study. Single institution, quaternary care hospital. The study comprised 20 consecutive patients whose treatment included the AngioVac between January 2016 and November 2019. None. Twenty patients underwent AngioVac suction filtration. The mean age was 56 years, and women comprised 35% of the patient cohort. Indications for AngioVac suction filtration included deep venous thrombosis involving the inferior vena cava (n = 12 [60%]), right atrial mass/thrombus (n = 11 [55%]), right ventricular mass/thrombus (n = 3 [15%]), and pulmonary embolism(n = 2 [10%]). All patients required vasopressor support, and nine patients (45%) required blood transfusion during the procedure. There was no intraoperative death or cardiac arrest associated with the procedure. The 30-day mortality was zero, and in-hospital mortality was 5% (1/20). Significant postoperative complications occurred in 11/20 patients (55%). Postoperative left ventricular dysfunction (36% v 0%; p < 0.05), preoperative shock requiring vasopressors (36% v 0%; p < 0.05), postoperative blood transfusion (100% v 56%; p < 0.05), and having undergone recent surgery (64% v 11%; p < 0.05) were associated with increased odds of experiencing postoperative complications. The rate of intraoperative complication during AngioVac suction filtration is low, but vasopressors and blood transfusions often are required. Patients at increased risk of developing postoperative complications potentially can be identified as having undergone recent surgery, experiencing preoperative shock requiring vasopressors or postoperative left ventricular dysfunction, and requiring postoperative blood transfusion.

Timing of Valve Repair for Asymptomatic Mitral Regurgitation and Preserved Left Ventricular Function

According to current guidelines, mitral valve repair is reasonable in asymptomatic patients with severe degenerative mitral regurgitation and preserved left ventricular (LV) function. However, the surgical timing is challenging. This study aims to identify risk factors and delineate a quantitative threshold for predicting postoperative outcomes. In all, 623 asymptomatic degenerative mitral regurgitation patients with left ventricular ejection fraction (LVEF) 60% or greater and LV end-systolic diameter less than 40 mm who underwent mitral valve repair were retrospectively reviewed. Logistic regression analysis and receiver-operating characteristics curves were used to analyze predictors for early postoperative LV dysfunction (LVEF less than 50%), and mid to long-term outcomes were analyzed by Kaplan-Meier analysis. The postoperative inhospital mortality was 0.96%. Survival at 1, 3, 5, and 10 years was 98.8%, 97.7%, 94.5%, and 90.4%, respectively; and freedom from moderate or severe mitral regurgitation at 1, 3, 5, and 10 years was 98.6%, 95%, 92.4%, and 83.6%, respectively. Logistic regression analysis indicated that early postoperative LV dysfunction was associated with preoperative LVEF (hazard ratio 0.933; 95% confidence interval, 0.891 to 0.977; P= .003) and left atrial volume index (hazard ratio 1.212; 95% confidence interval, 1.106 to 1.329; P < .001). Receiver-operating characteristics curve analysis identified preoperative LVEF 65% (area under the curve 0.765; P < .001) and left atrial volume index 53 mL/m2 (area under the curve 0.733; P < .001) as the best cutoff values for predicting early postoperative LV dysfunction. Furthermore, midterm to long-term survival was significantly lower among patients with early postoperative LV dysfunction than among patients with normal LV function (hazard ratio 3.19; 95% confidence interval, 1.41 to 7.23; P= .005). Preoperative LVEF and left atrial volume index were the predictors for early postoperative LV dysfunction, which further lead to poor long-term survival after mitral valve repair in asymptomatic degenerative mitral regurgitation patients with preserved LV function. Surgery intervention should be encouraged before onset of LVEF less than 65% or left atrial volume index 53 mL/m2 or more.

Outcomes of complete mitral valve excision and replacement with tilting disc (TTK Chitra) valve for rheumatic mitral valve stenosis

Background: Mitral valve (MV) disease is one of the earliest diseases of the heart, and rheumatic MV disease is one of the first discovered in the world dating back to the 19th century. Rheumatic heart disease (RHD) is declining in other countries, but it is still prevalent in the rural parts of India especially in lower economic group. In our hospital, we have operated 50 cases of rheumatic mitral stenosis for whom mitral valve replacement (MVR) with tilting disc (TTK Chitra valve) was done. Most of the MV cases have MV score >12 and the subvalvular apparatus was severely affected. In all the cases we have operated, we have excised complete valve and no posterior leaflet preservation or chordal tethering and repair was done. Objectives of the study: To study MVR outcomes with tilting disc TTK Chitra valve and to compare pre- and postoperative valve gradient across tilting disc prosthetic valves and also study the left ventricular (LV) dimensions pre and post MVR and to study ejection fraction (EF) pre and post valve replacement and complications arising from posterior leaflet excision. Materials and Methods: Fifty patients with chronic RHD Chronic Rheumatic heart Disease (CRHD) with severe mitral stenosis were taken up for the study who were operated in this department from May 2016 to April 2019. All the patients were evaluated with 2D echo, electrocardiogram, and coronary angiogram (when they were >35 years old). Results: Out of 50 patients operated in our hospital, 34 were females, that is, 68% of the patients, and 16 patients were males, that is, 32%. As per age, 20 patients were between 41 and 50 years of age, that is, 40% belonged to 41–50 years of age; 39 patients were below 50 years, that is, 78% of patients were below 50 years; 4% are below 20 years; and 22% were above 50 years. As per the combined age and sex ratio also among both males and females, most Mitral Stenosis (MS) presumed below 50 years only. As per the valve area, the most common valve by preoperative echo was 66% below and equal to 1 cm[2] by Pressure half time (PHT) and Planimetry. About 60% of the patients had preoperative EF of more than 55% and less than 10% had between 36% and 40%. Preoperatively, 40% of the patients had severe pulmonary arterial hypertension (PAH), 30% of the patients had moderate PAH, and 30% of the patients had mild PAH. All these patients had been operated for MV where posterior leaflet was excised and no subvalvular apparatus was conserved and no chordal repair was done, but apparently no postoperative LV dysfunction was found in these patients. All these patients had taken up for MVR and TTK Chitra valve between 27 and 31 was used. In 70% of the patients, 29 and 31 TTK Chitra valve was used. This study is based on the echocardiographic analysis of the preoperative mean gradient across MV and postoperative mean gradient across MV which shows a considerable, comparable, and acceptable mean gradient postoperatively. Conclusion: Whenever rheumatic mitral stenosis is present, complete valve can be reasonably excised without even sparing or preserving the subvalvular apparatus and it does not affect the EF and LV function. Native tilting disc valve, that is, TTK Chitra valve, can be safely used and it can give comparable results with the recent generation valves. Better outcomes are encountered with 29-mm size and above valves. Pulmonary artery hypertension decreases significantly if mitral stenosis is operated regardless of the advancement of disease process. There is no significant change in the LV parameters, and pre- and postoperatively EF remained the same.