Valve Surgery Research Articles

Do anomalous aortic origin of a coronary artery patients have higher risk of myocardial ischaemia and adverse cardiac events during aortic and mitral valve replacements?

We assessed the effect of anomalous aortic origin of a coronary artery on the risk of early and late postoperative events after aortic or mitral valve replacement in adults. Between 2005 and 2022, 29,579 adults underwent surgical aortic or mitral valve replacement at Cleveland Clinic. Among these, 29 had an unrepaired coronary artery rising anomalously from the aorta that was not intervened upon during valve surgery, 19 (65%) an anomalous circumflex, and 9 (31%) an anomalous right. Operative outcomes were compared between the 29 patients with anomalous coronary arteries and 87 balancing score (1:3) matched patients with normal coronary origin. Median follow-up was 6.5 years. Among matched groups, major morbidity and mortality 24% (n = 7) in patients with anomalous coronaries and 20% (n = 17) among patients with normal coronary origin (P = .7). Ten-year freedom from coronary reintervention was 83% versus 100% (P[log-rank] = .005), and 10-year survival was 59% versus 53% (P[log-rank] = .8). One patient experienced a coronary injury from valve surgery, in which the incidentally found anomalous retroaortic circumflex was immediately repaired without further complication. There was no coronary reintervention after discharge in the normal coronary origin group and three in the anomalous coronary group; however, only one of these patients required intervention on the anomalous coronary. Anomalous coronaries were uncommon in surgical valve replacement patients at a high-volume centre. The origin and course of each coronary should be assessed before valve replacement. With careful planning, valve replacement does not result in a significantly higher prevalence of postoperative ischaemia, mortality, or reintervention.

Endo-Aortic Clamp for Minimally Invasive Redo Mitral Valve Surgery: Early Outcome

Objective: Redo mitral valve surgery still represents a challenging and high-risk procedure in cardiac surgery. The incidence of cardiac structural injuries during re-sternotomy remains consistent and is reported to be an independent risk factor for hospital mortality. Minimally invasive cardiac surgery with retrograde femoral arterial perfusion and endo-aortic clamping avoids re-entry injuries and reduces the requirement for dissection of adhesions and the risk of damage to cardiac structures. The aim of this study is to analyze redo patients undergoing mitral valve surgery with retrograde arterial perfusion and endo-aortic clamping setting. Methods: A retrospective analysis was performed on patients undergoing surgery from 2006 to 2022. Exclusion criteria were more than mild aortic regurgitation, moderate-to-severe peripheral vascular disease, dilated ascending aorta, and a lack of preoperative vascular screening. The primary outcome was perioperative mortality. Results: Two hundred eighty-five patients were analyzed. Mean age was 63.8 ± 13.3 years, mean EuroSCORE was 16.5 ± 14.5%, and one quarter of the patients had undergone two or more previous procedures via sternotomy. Perioperative mortality was 3.9% (11/285). Stroke was reported in six (2.1%) patients. Median intensive care unit and hospital length of stay were 1 and 8 days, respectively. Conclusions: Endo-aortic clamping setting in redo MV surgery avoids re-entry injuries and allows the surgeon to clamp the aorta and deliver the cardioplegia with minimal dissection of adhesions. In high-volume and experienced centers, this approach can be applied safely and effectively and may in the near future become the standard of care for redo mitral valve surgery.

Robotic Versus Thoracoscopic Minimally Invasive Mitral Valve Surgery: A Systematic Review and Meta-Analysis of Matched Studies.

Mitral regurgitation is the most prevalent form of valvular heart disease, impacting over 24 million people globally. Robotic and thoracoscopic minimally invasive mitral valve repair (MIMR) techniques have emerged as viable alternatives to traditional open-heart surgery. However, the comparative effectiveness and safety of these 2 approaches remain underexplored. This systematic review and meta-analysis, conducted according to Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, aimed to compare robotic and thoracoscopic MIMR outcomes. A literature search was performed across PubMed, Scopus, and Embase databases to identify studies comparing these 2 surgical techniques. Eligible studies included randomized controlled trials and cohort studies. Six propensity score-matched studies and 1 retrospective cohort study, involving 11,823 patients, were included, with 5851 undergoing robotic mitral valve repair and 5972 receiving thoracoscopic MIMR. No significant differences were found in perioperative mortality [risk ratio (RR): 0.97, 95% confidence interval (CI): 0.65-1.45] or pump/clamp times. Robotic surgery was associated with longer operative times (mean difference: 33.01 minutes) and higher intraoperative transfusion rates (RR: 1.53, 95% CI: 1.07-2.18), but a lower risk of atrial fibrillation (RR: 0.89, 95% CI: 0.83-0.95). In conclusion, robotic and thoracoscopic MIMR show comparable mortality and overall safety profiles. However, robotic surgery may require longer operative times and increased transfusion needs, while reducing the risk of atrial fibrillation. Further high-quality, randomized studies are warranted to validate these findings.

Fault Detection Technology for Ultrapure Water Plant using Virtual Sensors for Pressure Control Valve and Indicators in Return Line

Objectives:This study aims to propose a technology that utilizes virtual sensors to quickly and accurately diagnose faults in valves and measurement devices that may occur in the return line of an ultrapure water plant.Methods:The empirical equations were derived, and the error range was calculated using operational data collected from three pieces of equipment (pressure control valve, pressure transmitter, and flow transmitter) in the recovery system of the ultrapure water process. Based on this, a virtual sensor is established.Results and Discussion:It was confirmed that the utilization of 24-hour data collected from the operation of the ultrapure water plant was enough to establish virtual sensors and could also estimate monthly data with high accuracy. In Phase 1, the fault diagnosis technology was found to estimate values more accurately and had a meaningful margin of error compared to Phase 2.Conclusion:It was possible to develop a fault detection technology using the virtual sensor derived from the empirical equation. The technology showed high performance in detecting anomalies in the flow meter and pressure control valve opening but had limitations in estimating consistently pressure values. Additionally, considering that there was no issue in estimating monthly data using the equations derived using 24 hours operational data. The fault detection algorithm could be used continuously if the empirical equations are updated by collecting a day's data when operating conditions change.

Minimally Invasive Aortic Valve Replacement for High-Risk Populations: Transaxillary Access Enhances Survival in Patients with Obesity

Background/Objectives: Minimally invasive cardiac surgery is often avoided in patients with obesity due to exposure and surgical access concerns. Nonetheless, these patients have elevated periprocedural risks. Minimally invasive transaxillary aortic valve surgery offers a sternum-sparing “nearly no visible scar” alternative to the traditional full sternotomy. This study evaluated the clinical outcomes of patients with obesity compared to a propensity score-matched full sternotomy cohort. Methods: This retrospective cohort study included 1086 patients with obesity (body mass index [BMI] of >30 kg/m2) undergoing isolated aortic valve replacement from 2014 to 2023. Two hundred consecutive patients who received transaxillary minimally invasive cardiac lateral surgery (MICLAT-S) served as a treatment group, while a control group was generated via 1:1 propensity score matching from 886 patients who underwent full sternotomy. The final sample comprised 400 patients in both groups. Outcomes included major adverse cardio-cerebral events, mortality, and postoperative complications. Results: After matching, the clinical baselines were comparable. The mean BMI was 34.4 ± 4.0 kg/m2 (median: 33.9, range: 31.0–64.0). Despite the significantly longer skin-to-skin time (135.0 ± 37.7 vs. 119.0 ± 33.8 min; p ≤ 0.001), cardiopulmonary bypass time (69.1 ± 19.1 vs. 56.1 ± 21.4 min; p ≤ 0.001), and aortic cross-clamp time (44.0 ± 13.4 vs. 41.9 ± 13.3 min; p = 0.044), the MICLAT-S group showed a shorter hospital stay (9.71 ± 6.19 vs. 12.4 ± 7.13 days; p ≤ 0.001), lower transfusion requirements (0.54 ± 1.67 vs. 5.17 ± 9.38 units; p ≤ 0.001), reduced postoperative wound healing issues (5.0% vs. 12.0%; p = 0.012), and a lower 30-day mortality rate (1.5% vs. 6.0%; p = 0.031). Conclusions: MICLAT-S is safe and effective. Compared to traditional sternotomy in patients with obesity, MICLAT-S improves survival, reduces postoperative morbidity, and shortens hospital stays.

Patient perspectives on health care models in cardiac surgery: a qualitative evaluation

BackgroundThe implementation of ERAS represents a promising solution to improve treatment efficiency and facilitate patient involvement. This innovative care model aims to optimize recovery processes following surgeries by adopting a holistic, interprofessional approach. At our hospital, ERAS was implemented in minimally invasive heart valve surgery, offering two distinct ERAS models. Additionally, there is also the standard of care without ERAS. The objective of the study is to gain insight into patient satisfaction and perceived differences across these various care models.MethodsPatients were interviewed using semi-structured interviews approximately two to three months after undergoing surgery. The data were analysed using qualitative content analysis in accordance with the methodology proposed by Kuckartz. Four main categories were established: Preoperative care, postoperative care and communication, patient participation and involvement, and rehabilitation and post-clinical course.ResultsComprehensive preoperative education and seamless communication throughout the perioperative care journey were identified as fundamental to patient satisfaction and optimal care processes. Patients in the ERAS + model reported higher overall satisfaction with their care compared to patients in the standard of care and ERAS groups.ConclusionPreoperative education establishes the foundation for patients’ subsequent behaviours and expectations regarding their treatment. Physical activity, nutrition, and mental health are significant aspects. The active involvement and participation of patients and their families in the treatment process facilitated superior postoperative care, intensive physiotherapy, mental support, and faster recovery. A functional flow of information throughout the entire care process is vital. Moreover, having a dedicated point of contact had a beneficial impact on patients´ well-being. The integration of innovative ERAS concepts, which encompass interprofessional preoperative patient education and psychosomatic support, represents a promising approach from a patient perspective, offering benefits to a broad spectrum of cardiac surgical patients.

Determination of Static Flow Characteristics of A Prototypical Differential Valve Using Computational Fluid Dynamics

Abstract The paper describes the numerical calculations of a conceptual air brake valve of a trailer equipped with a differential section, which is intended to shorten response time and braking distance. The static flow characteristics have been determined using computational fluid dynamics (CFD). Mixed (global and local) computational meshes were used in the paper to determine the static flow characteristics of the valve sections. The use of the local mesh was relevant for valve openings smaller than 0.5mm. Using CFD, it was possible to determine the static flow characteristics of the main, auxiliary feed and the differential sections, which were linear, degressive and progressive depending on the section. The analyzes, which have not yet been described in the literature, showed a significant difference in the MFR of the additional and main feed tracts, which reached 52.29%.The results are applicable to the configuration of the braking system. Further research will include performing dynamic simulations using dedicated software and building a test rig to validate the CFD calculation results.

A Risk Prediction Model for Prolonged Length of Stay After Minimally Invasive Valve Surgery.

Minimally invasive surgery determines shorter postoperative hospital length of stay (LOS) even in cardiac surgery. Potential preoperative factors affecting LOS are still not known in minimally invasive heart valve surgery (MIVS). We aimed to identify preoperative variables influencing prolonged LOS in MIVS. We reviewed 189 patients who underwent MIVS via minithoracotomy at our institution. Prolonged LOS was defined as more than 7 postoperative days. Poisson and logistic regression were used to screen the predictors. The mean postoperative LOS was 9.13 days, and 64 patients (33.9%) experienced a prolonged LOS. These patients were older, more frequently in New York Heart Association (NYHA) class III or IV, showed worse left ventricular ejection function (LVEF), and had a higher incidence of reoperation and chronic kidney disease (CKD). At univariate analysis, the most significant preoperative factors affecting prolonged LOS were age (odds ratio [OR] = 1.04), NYHA class III or IV (OR = 3.03), reduced LVEF (OR = 3.22), CKD (OR = 2.7), and redo surgery (OR = 3.6). After adjustment, the most significant preoperative factors predicting prolonged LOS were age (OR = 1.03, 95% CI: 1.01 to 1.06, P = 0.02) and redo surgery (OR = 3.33, 95% CI: 1.29 to 8.9, P = 0.01). The most important factors affecting prolonged LOS after MIVS were represented by age and redo surgery, although other preoperative characteristics such as reduced LVEF, NYHA class III or IV, and CKD play a significant role in delaying recovery after MIVS. Further larger studies are needed to better identify potential preoperative predictors of prolonged LOS after MIVS.

Unidirectional Flow Through Time-Dependent Cross-Sectional Areas of a Compliant Tube and a Valve: A Nonlinear Model

This work investigates the conditions for net flow generation by a straight tube with a cross-sectional area harmonically varying in time that connects two tanks—a problem that is mainly found in the design of impedance pumps. By assuming a quasi-one-dimensional flow and applying continuity and momentum equations, a first-order differential equation with respect to the flow rate is derived and presented for the first time, including a nonlinear term that is responsible for net flow rate generation. Namely, the net flow rate is found to be nonzero (as is the nonlinear term) if the cross-sectional areas of the two tanks are unequal and one of them is smaller than that of the straight tube. In this case, the flow is directed from the smaller to the larger tank and the net flow rate increases with the frequency of the tube’s cross-sectional area variation. In contrast, when the tanks’ cross-sections are equal, the net flow is generated only if a valve is installed, e.g., at one end of the tube, due to the large asymmetries imposed in the hydraulic losses with respect to the tube mid-length. Compared with constant valve opening, the net flow rate is augmented significantly if the valve opening is time-dependent. By employing the same equation, the flow rate of an intra-aortic counter-pulsating balloon pump is also examined, in which the valve (representing the aortic valve) opens during the shrinkage of the tube, and it is shown that the net flow rate increases with the frequency and amplitude of the tube’s cross-sectional area. Conclusively, the harmonic oscillation in time of a tube’s wall can cause unidirectional flow only if asymmetric losses are present with respect to its mid-length.

Quadricuspid aortic valve with complete heart block: a double whammy

BackgroundDevelopmental abnormalities of aortic valve cusps are relatively common with the bicuspid valve being the most frequently encountered congenital heart disease. However, the quadricuspid aortic valve (QAV) is an exceedingly rare abnormality.Case presentationWe report a case involving a young, otherwise healthy male who presented with non-exertional syncope and was subsequently diagnosed with complete heart block (CHB). Further evaluation revealed the coexistence of a rare quadricuspid aortic valve and CHB. This combination, in the absence of surgery or infective endocarditis, has only been reported once before in the literature.The patient underwent successful permanent pacemaker implantation and continues to be monitored for aortic regurgitation.ConclusionsThe coexistence of a QAV with CHB, in the absence of infective endocarditis or aortic valve surgery, is extremely rare and necessitates careful evaluation and follow-up.

Clinical Management and Pathophysiology of Infective Endocarditis: An Updated Review of Diagnostic Challenges and Therapeutic Approaches

Infective endocarditis (IE) is a severe and life-threatening condition characterized by infection of the endocardial surface of the heart, primarily affecting the heart valves. Despite advances in diagnostic techniques and antimicrobial therapies, IE remains associated with significant morbidity and mortality due to its complex pathogenesis and clinical variability. This article reviews the most recent developments in the pathophysiology, diagnostic criteria, and management strategies of infective endocarditis. Key issues such as microbial etiology, including common pathogens like Staphylococcus aureus and Streptococcus species, are discussed alongside less frequent organisms and their association with specific patient populations. The article emphasizes the importance of early diagnosis using advanced imaging modalities, such as echocardiography and PET-CT, and laboratory findings, particularly blood cultures. We explore both medical and surgical management strategies, highlighting the role of antibiotic therapy and the indications for valve surgery. A focus is given to the management of complex cases, including prosthetic valve endocarditis and infections in immunocompromised patients. The article aims to provide clinicians with a comprehensive understanding of the evolving landscape of infective endocarditis and its implications for patient outcomes.

Mid-regional pro-adrenomedullin is an independent predictor of cardiovascular outcomes in cardiac surgery, a prospective cohort study in 500 patients

Abstract Background MR-proADM (mid-regional pro-adrenomedullin) is a stable pro-peptide of Adrenomedullin, which is expressed in various cell types such as heart, lung, and renal tissue. It is a prognostic parameter for heart failure (HF) and sepsis as well as all-cause and cardiovascular (CV) mortality. Purpose Considering the characteristics of MR-proADM as a reliable biomarker for adverse events, we aimed to investigate the prognostic impact of MR-proADM in patients undergoing elective cardiac surgery. Methods We prospectively enrolled patients undergoing elective cardiac bypass and/or valve surgery at the department of cardiac surgery between May 2013 and August 2018. Blood samples were taken one day prior to surgery. MR-proADM was measured using an automated immunofluorescence assay. Patients were followed prospectively until endpoints were reached. The primary endpoint was the composite of hospitalization for heart failure (HHF) or CV mortality, the secondary endpoint was postoperative atrial fibrillation (POAF). The multivariate regression model was adjusted for age, sex, NT-proBNP, type of surgery, and CRP-level at baseline. Results A total of 500 patients (146 female [29.2%]; median age 69.8 years [IQR 60.6-75.5]) were followed over a median of 4.6 years (IQR 3.0–5.8). Valve surgery was performed in 214 (42.8%) patients, 160 (32%) underwent a bypass operation and 126 (25.2%) a combined valve and bypass surgery. The median MR-proADM value of the entire study population was 0.58 nmol/L (IQR: 0.44-0.79 nmol/L). Patients were stratified in risk categories based on their MR-proADM values (Low Risk ≤0.63nmol/L, Intermediate Risk 0.63-0.83nmol/L, High Risk >0.84nmol/L). Patients in the highest category presented with higher rates of diabetes mellitus (p <0.001), COPD (p <0.001), HF (p=0.009) and either bypass surgery (p=0.039) or the combination of bypass and valve surgery (p=0.008), compared to patients in the lowest tertile. We observed a significant increase in 5-year’s event rates for HHF/ CV Mortality in patients in higher risk groups (Low Risk 8.6% vs High Risk 37.7%, p <0.001, Figure 1). The adjusted Cox regression model found that MR-pro ADM was independently associated with a risk increase for HHF/ CV Mortality (adjusted HR of 4.45, 95% CI 2.55-8.09; p<0.001, Figure 2) comparing the High Risk to the Low Risk Group. A comparable risk increase could be observed in POAF, with an adjusted HR of 2.61 (High Risk Group vs Low Risk Group, 95% CI 1.46-4.67, p<0.001). Conclusion Within the prospective investigation, MR-pro ADM was found to be an independent predictor for HHF and CV mortality in patients undergoing cardiac bypass and/or valve surgery. Furthermore, there was a consistent predictive potential for POAF. In the era of personalized medicine, preoperative MR-pro ADM levels could help to identify patients at risk for serious adverse events, in order to apply intensified secondary prevention and reduce mortality and morbidity.

Postoperative heart valve infection, when and which bacteria: a nationwide cohort study

Abstract Background In patients undergoing heart valve surgery, subsequent bacteremia and infective endocarditis are feared events due to the associated high mortality. Knowledge on the incidence and specification of bacteremia following left-sided valve surgery are sparse and may have implications for prophylactic strategies and follow-up. Purpose To examine the six months incidence of bacteremia and infective endocarditis following left-sided heart valve surgery. Methods In the period from January 2010 to December 2021 all patients undergoing left-sided valve surgery were identified using Danish nationwide registries. Patients were followed until a maximum of six months, end of study, emigration, death, or outcome of interest (i.e., bacteremia or infective endocarditis). Cumulative incidence curves were computed with death as a competing risk stratified on bacterial species and for subgroups of interest: type of valve surgery, age, and sex. Results A total of 14,305 patients were included in the study. The majority of the study population were male (68.6%), and the median age was 70.2 years (25th-75th percentile 62.0-76.0 years). In total, 10,469 (73.2%) of the study population underwent aortic valve surgery, 3,497 (24.5%) underwent mitral valve surgery, while 339 (2.4%) underwent surgery on both valves. The cumulative incidence of bacteremia at six months of follow-up was 2.4% (95% CI 2.2-2.7%), Figure 1. For the overall study population, the most frequently occurring bacteremia was with Coagulase-negative Staphylococci (28%) and Staphylococcus aureus (14%). Within 30 days 0.35% of the patients had bacteremia with coagulase-negative staphylococci while this was 0.68% at six months of follow-up. For Staphylococcus aureus this was 0.19% and 0.34%, respectively. The cumulative incidence of infective endocarditis at six months of follow up was 1.0% (95% CI 0.8-1.2%). The majority of the infective endocarditis incidents were blood culture negative (27%) or caused by Enterococci (19%), Streptococci (17%) or Coagulase-negative Staphylococci (17%) while Staphylococcus aureus accounted for 14%. In crude analysis, simultaneous surgery on the mitral and aortic valve was associated with a statistically significant higher rate of bacteremia (P=0.004). Similarly, higher age was associated with a statistically significant higher rate of bacteremia (P<0.001). On the contrary, in crude analysis, no difference in the risk of bacteremia was found between sexes (P=0.9). Conclusions Bacteremia following left-sided heart valve surgery occurred in little over 2%. The majority was with Staphylococci, and half of these occurred within 30 days of the surgery. There is a continued need to optimize prophylactic strategies.

Impact of atrial fibrillation on mortality and non-fatal clinical outcomes in 28 492 patients who had undergone open-heart aortic versus mitral valve surgery: a statewide population-linkage study

Abstract Background Postoperative atrial fibrillation (AF) is common after cardiac surgery and has been associated with increased mortality and morbidity. Few studies have defined the impact of AF status (New-AF versus Prior-AF) on clinical outcomes during long-term follow-up and compared AF-related clinical outcomes between patients who had undergone isolated aortic valve surgery (AVSx) or mitral valve surgery (MVSx). Purpose This study aims to examine the impact of AF status on clinical outcomes in patients who had undergone AVSx versus MVSx using a statewide-population administrative database. Methods Patients who had open-heart cardiac valve surgery (1 January 2003 to 31 March 2021) identified from the Admitted-Patient-Data-Collection database in an Australian state, were stratified by AF status (No-AF vs New-AF vs Prior-AF during index admission for valve surgery) and followed up to 31 March 2022. A linkage look-back to year-2001 was performed to identify prior-AF history. Kaplan-Meier and multivariable Cox regression were performed to assess the impact of AF status on all-cause mortality. Fine-Gray competing risk analysis to account for the competing death events was used to assess non-fatal clinical outcomes. Results The overall cohort comprised 28 492 patients (median age 71.6yrs [interquartile range (IQR) 62.7–78.3yrs; 65.6% males): AVSx, n=18949; MVSx, n=9543 (Table 1). During a median follow-up of 6.6yrs (3.42–10.5yrs), Prior-AF and New-AF patients had significantly higher all-cause mortality (AVSx – Prior-AF: 1771 (57.9%) vs New-AF: 2854 (41.5%) vs No-AF: 2961 (32.8%); MVSx – Prior-AF: 1126 (41.0%) vs New-AF: 1034 (29.8%) vs No-AF: 747 (22.4%) (both Kaplan-Meier logrank P<0.001). After adjusting for differences in baseline characteristics and admission year-groups, in the AVSx subgroup, both new-AF and prior-AF were independently associated with all-cause mortality (aHR=1.16, 95%CI=1.10–1.22; aHR=1.69, 95%CI=1.59–1.79 respectively, both P<0.001) compared to no-AF patients. In the MVSx subgroup, only prior-AF was associated with increased risk of all-cause mortality (aHR=1.47, 95% CI=1.33–1.61, P<0.001). Competing risk analyses showed higher rehospitalisation rates for AF and congestive cardiac failure for new-AF and prior-AF groups compared to No-AF patients after both AVSx and MVSx, whereas the rehospitalisation rate for ischemic stroke was only significantly higher in the AVSx new-AF and prior-AF subgroups (all p < 0.05) (Table 2). Conclusions Patients undergoing open-heart aortic or mitral valve surgery are at risk of significant adverse clinical outcomes including death, heart failure and ischaemic stroke, with the target valve and baseline AF status having a differential impact on clinical outcomes. Drivers behind these high rates of adverse outcomes should be explored further and strategies should be developed and tailored accordingly to different surgical patient groups to improve their prognosis.

The mechanical environment regulates the extent of aortic valve calcification and thickness: an ex vivo whole mouse heart study

Abstract Background Aortic stenosis (AS) is a narrowing of the aortic valve opening due to calcification and thickening of the leaflets. Calcifications are mostly located at regions with high mechanical stress and disturbed flow suggesting that mechanical environment is important in the regulation of calcification. However, direct evidence linking valve calcification and mechanical stress is still lacking. Recently, we established an ex vivo calcification model for whole mouse hearts (Miniature Tissue Culture System MTCS) which allows the study of the mechanical environment underlying aortic valve calcification. Purpose Aim of this study was to investigate the role of mechanical stress on aortic valve calcification and thickening using the MTCS. Methods Whole mouse hearts were cultured in the MTCS with 2 distinct configurations: 1) medium flowing from the aorta towards the aortic valve to create a continuous closed aortic valve (n=28) and 2) medium flowing from the left ventricle through the aortic valve towards the aorta to create a continuous open aortic valve (n=17) (Figure1). The hearts were subjected to low (300 ul/min) or high (3000 ul/min) flow speed in the presence of calcifying medium (3mM phosphate buffer). After culture for 1 week, the hearts were isolated and fixed overnight with 4% PFA/PBS. Alizarin red staining was performed to determine calcification presence. Quantifications were performed using Caseviewer software. Results Aortic valves in closed configuration exposed to a high flow speed, exhibited significant increase in calcification compared to aortic valves in the closed configuration exposed to low flow speed or aortic valve cultured in the open position (p<0.01, Figure2A). Of interest, the extent of calcification in the aortic valve in closed position exposed to high flow speed strongly correlated with the diameter of the aortic annulus (R²=0.86, p<0.0001, Figure2B). Conversely, leaflet thickness was significantly lower in the closed aortic valve configuration as compared with the open aortic valves configuration (p<0.05, p<0.001, Figure2C). Conclusion Our study demonstrates the influence of mechanical environment on aortic valve calcification and thickening. The presence of calcification in the closed but not the open aortic valve configuration exposed to high flow suggests that increased pressure promotes calcification. The correlation of the extent of aortic valve calcification with the diameter of the aortic annulus implies that configuration of the valve is an important determinator of calcification, with potential implications for the results of aortic valve repair. The presence of a minimal amount of mechanical stress as experienced by aortic valves in the open position, however, resulted in thicker aortic valves, indicating that the right balance of mechanical stresses is required to maintain normal valve morphology. These findings provide valuable insights into AS pathogenesis, guiding future therapeutic approaches.ex vivo cultured aortic valvesCalcification in ex vivo aortic valves

Clinical outcomes according to clinical and surgical risk scores for tricuspid regurgitation

Abstract Background TRIO score, the clinical risk score in significant tricuspid regurgitation (TR), and TRI-SCORE, the surgical mortality risk for tricuspid valve (TV) surgery, have been proposed. We aimed to investigate the correlation and distribution of two risk scores, and to define the clinical benefit of TV surgery in patients with low or intermediate TRIO score and TRI-SCORE. Methods In a total of 10,054 patients diagnosed with moderate to severe TR between January 2008 to December 2020, TRIO score and TRI-SCORE were stratified into low, intermediate, and high-risk groups. Patients of all etiologies of TR were included and patients who underwent prior tricuspid valve surgery were excluded. The clinical outcome was all-cause death. Results TRI-SCORE and TRIO scores were moderately correlated (r =0.39, p<0.001). 9,104 (90.6%) patients (age 67 ± 14 years, 42% male) had low or intermediate TRI and TRIO score. During 12.6 ± 10.1 years, 885 (9.7%) underwent TV surgery and 1,268 (13.9%) experienced clinical outcomes. Kaplan-Meier analysis revealed significant differences in clinical outcomes according to TV surgery in both low and intermediate TRIO score patients (log-rank, p<0.001) and sub-analyzed them according to the TRI-SCORE group (Figure). In multivariable Cox regression analysis, TV surgery (HR 0.37, 95% CI 0.28-0.49, p<0.001) were significantly associated with clinical outcomes after adjusting confounding factors. Conclusions TV surgery is clinically beneficial in moderate to severe TR patients with a low or intermediate TRIO score and TRI-SCORE.

Predictors of progression to significant atrial functional tricuspid regurgitation in patients with paroxysmal or persistent atrial fibrillation

Abstract Background Atrial functional tricuspid regurgitation (atrial TR) has received growing recognition as a TR entity with a distinct cause owing to its independence from valvular tethering as the predominant mechanism underlying TR. Atrial fibrillation (AF) is highly prevalent in patients with AFTR and is considered a major contributor to its development. However, evidence on predictors of progression to significant atrial function TR in patients with diagnosed AF is lacking. Methods At a single tertiary university hospital, we studied 11445 patients who underwent echocardiograms at least 1 year apart between 2010 and 2023. Patients with moderate or greater TR at the initial examination (n=432) were excluded to ensure that only subjects with confirmed progression to atrial functional TR were included. Only those with EF > 50%, no other moderate or severe valve stenosis or regurgitation, no valve surgery, and RVSP < 40mmHg were subsequently identified (n= 8159). Patients diagnosed with AF 3 months before or after the echocardiogram were included. The final analysis included 629 patients, 44 progressed to moderate or worse TR during follow-up. Results The mean age of the patients was 68 (62-74) years and 57% were male. The mean time to progression to severe TR was 5.7 years. There was no difference in left ventricle size, ejection fraction of LV, right atrium, and right ventricle size on the initial echocardiogram between the group that progressed to significant TR (group 1) and the group that did not progress (group 2). LA diameter (LAAP), LAV(LA volume), and LAVi were significantly larger in group 1. In particular, the Kaplan-Meier graph of TR progression divided into two groups based on LAV 75ml and LAVi 45ml/m2 showed a significant difference, and in particular, LAVi was a significant predictor compared to other factors. Conclusion In patients with AF, the most common cause of atrial functional TR, an initial LAVi >45ml/m2 was shown to be a predictor of progression to significant TR.cumulative survival rate

Surveillance of surgical site infections using artificial intelligence

Abstract Background Surgical site infection (SSI) is a major health problem associated with high morbidity and mortality, the consequences of which can be very serious for the patient and costly for the organisation. Surveillance systems provide insight into the incidence of SSI, the analysis of which enables improvement plans to be established to reduce it. Traditionally, surveillance systems have been based on manual medical record review for evidence of the presence of surgical infection. Objectives To create and validate a global SSI diagnostic algorithm and to optimise the SSI workload of Preventive Medicine services. Methods The study population included patients undergoing surgical procedures of rectal surgery, colon surgery, knee replacement surgery, hip replacement surgery, coronary bypass and valve surgery, at the Hospital Universitario Vinalopó in Elche (n = 1240). Data mining was used to collect clinical, microbiological and postoperative follow-up values from the electronic medical record. Machine Learning techniques were used to train (n = 1054) and validate the model (n = 186). Time spent on SSI surveillance of the preventive medicine service was measured. Results Model performance after validation was: sensitivity of 0.83 specificity of 0.87, accuracy of 0.87, an F1 score of 0.45, and an area under the curve of 0.87. The time spent by preventive medicine staff in identifying patients with surgical site infection decreased from 168 person-hours per procedure per quarter to 34 person-hours, a 77% reduction in the workload allocated to this task. Conclusions This project not only improves surveillance efficiency, but also optimises the workload in Preventive Medicine services very significantly. Key messages • This project improves the efficiency of surgical site infection surveillance and significantly optimises the workload in preventive medicine departments. • It makes it possible to extend surveillance to new surgical procedures and to work more intensively on preventive measures.

New insights into the pathophysiology of rheumatic valve disease based on different genetic and proteomics profiles

Abstract Introduction Rheumatic heart disease (RHD) pathogenesis is not fully understood. Purpose The protein profile in rheumatic heart disease may have a different fingerprint in the aortic and mitral valves, which results in different evolution in terms of valve damage. Methods To evaluate the genetic profile in symptomatic RHD, 4 simultaneous mitral and aortic valves were obtained during valve replacement, as well as 4 "normal" valves from cadavers (Control Group). The expression of 90 genes was evaluated using a customized RT-PCR array kit. A second experiment was carried out to evaluate proteomics. Then, 7 mitral and aortic valves, from the same patient, were also collected during valve surgery. The Control Group consisted of 6 mitral and aortic valves obtained from explanted hearts during heart transplantation due to non-valvular pathologies. Additionally, histopathological and sectoral proteomic analysis of amyloid deposits, found in some mitral and aortic valves, from the second experiment, were also reported. Results Mitral rheumatic valves exhibited higher expression of genes linked to calcification and immuno-inflammation compared to aortic rheumatic valves (Figure 1). Proteomic analysis, visualized through PCA graphs, highlighted differences in proteomic patterns. Despite having the same genetic pattern, control valves exhibited different proteomic profiles (Figure 1) Rheumatic mitral and aortic valves, even from the same individual, showed distinct proteomic fingerprint (Figure 1). A total of 49 significant proteins were identified in distinguishing healthy mitral and aortic valves from the same individual (Figure 1). The aortic valve displayed a richer extracellular matrix and higher levels of housekeeping proteins that maintain valve homeostasis compared to the mitral valve (Figure 1). The dominant proteomic pattern in valvular rheumatic disease was identified as alterations in critical mitochondrial metabolic activities related to proteostasis. (Figure 2). Particularly notable was the upregulation of pathways associated with lipid metabolism (Figure 2). Finally, amyloid deposits suggested APOA1 as a potential deposit protein in RHD (Figure 2). Conclusion The study confirms distinct constitutional differences between mitral and aortic valves affecting rheumatic disease progression. It emphasizes the role of altered proteostasis and altered proteins deposit, mitochondrial metabolic changes, and inflammatory responses in the disease's pathophysiology, highlighting the complexity of valvular rheumatic disease involvement.For the first time amyloid deposition has been reported as a likely consequence of significant disruption in valvular proteostasis and the proteins potentially comprising this deposit within a rheumatic valve.Genomic and proteomic overviewproteomic fingerprint of RHD and amyloid

Prognostic impact of left ventricular myocardial work in patients undergoing surgery for primary mitral regurgitation

Abstract Background Although left ventricular ejection fraction (LVEF) is widely used as a parameter for the assessment of LV systolic function, LVEF can overestimate LV systolic function in patients with severe mitral regurgitation (MR) due to its high load-dependency. Echocardiography-based, left ventricular myocardial work (LVMW) can assess LV function by incorporating LV afterload. Purpose This study aims to evaluate the prognostic value of LVMW indices in patients with primary MR undergoing mitral valve surgery. Methods Individuals who underwent mitral valve surgery for severe primary MR were included. All patients underwent transthoracic echocardiography before surgery. LVMW was derived from a vendor-specific package which integrates LV global longitudinal strain with sphygmomanometric blood pressure to construct pressure-strain loops during the cardiac cycle. (Figure 1) For the LVMW indices, previously-established normal values were used as thresholds. The primary endpoint was all-cause mortality after mitral valve surgery. Results A total of 309 patients (mean age 63 ± 12 years, 68% male) with severe, primary MR who underwent surgery, were included. The mean LV global work index (LVGWI) was 1977 ± 537 mmHg% and 132 (43%) patients had impaired LVGWI (≤ 1900 mmHg%). During a median follow-up of 5.0 years (interquartile range, 2.5-8.9), 27 (8.7%) patients died after mitral valve surgery. Patients with impaired LVGWI or LV GLS (≤ 20%) had lower survival rates compared to the group with preserved LVGWI (p <0.01) or LVGLS (p = 0.02), whereas there was no significant difference in the survival rate between patients with LVEF ≤ 60% and > 60%. (Figure 2) Furthermore, LVGWI ≤ 1900 mmHg% demonstrated incremental prognostic value over LVGLS (p = 0.049) for all-cause mortality. Conclusions In patients with severe, primary MR who underwent surgery, impaired pre-operative LVGWI was associated with a higher mortality risk. In addition, impaired LVGWI had incremental prognostic value over LVGLS. Based on these findings, LVMW is a promising parameter for predicting postoperative outcome and determining the optimal timing of valve surgery in patients with severe, primary MR.Fig1.Echo-derived Myocardial workFig2.Kaplan-Meier curves