Valve Surgery In Patients Research Articles

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

Left atrial reservoir strain as a prognostic indicator for cardiovascular events after mitral valvuloplasty

Abstract Background In patients after mitral valvuloplasty (MVP), assessing valve function and heart failure (HF) is crucial for prognostic predictions. Left ventricular diastolic function assessed by transthoracic echocardiography (TTE) plays an important role in the evaluation of HF in general practice. However, post-mitral valve surgery patients are excluded from the left ventricular diastolic function assessment guidelines proposed by the American Society of Echocardiography in 2016 due to their low correlation with left ventricular diastolic function indices. On the contrary, the left atrial reservoir strain (LARS) before MVP is considered as a prognostic factor, reflecting left atrial dysfunction caused by mitral regurgitation. Nevertheless, there are limited reports on the relationship between LARS and cardiovascular (CV) events after MVP. Purpose The study aims to investigate the utility of LARS in predicting CV events after MVP. Methods The study included 249 patients who underwent TTE between January 2011 and January 2023 after MVP at our hospital. Patient background data, including NYHA classification, medical history, medications, blood tests, and TTE data, were collected at the time of follow-up TTE. LARS, left ventricular global longitudinal strain (LV-GLS), and right ventricular free wall strain (RV-FWSL) analysis were performed using a vender-independent external strain analysis software for all patients in the cohort. The primary endpoints were cardiovascular death and HF rehospitalization. The predictor of cardiovascular events was assessed using the Cox proportional hazards model and Kaplan-Meier curve (KMC). Results The mean age was 61±14 years, and 159 patients (64%) were male. The median time from surgery to TTE was 4.8 (1.0-6.8) years, 32 patients (13%) had events within 8.5 (3.7-10.8) years after TTE. The event groups had higher age, NYHA classification, and NT-pro BNP compared to the non-event group. TTE parameters such as left ventricular mass index, left ventricular end-diastolic volume and end-systolic volume were larger, and LV-GLS and LARS were significantly lower in the event group. In multivariate Cox proportional hazards models showed that LARS was also a prognostic indicator even after adjustment for several variables (Table 1). The KMC showed that LARS was associated with events regardless of left atrial volume index (Log-rank p <0.001, chi-square:31.03) (Figure 1). Conclusion LARS was strongly associated with CV events after MVP. We consider LARS to be a useful prognostic indicator after MVP.

The effect of pulmonary hypertension and right ventricular dysfunction on early mortality and morbidity in patients undergoing mitral valve replacement

IntroductionThe indications for concominant tricuspid valve surgery in patients undergoing mitral valve surgery for rheumatic reasons are limited. The aim of our study was to investigate the effects of severe pulmonary hypertension and low TAPSE values on early-term mortality and morbidity in patients undergoing mitral valve replacement.MethodsThe data of all patients who underwent mitral valve replacement between January 2013 and August 2020 were examined retrospectively. Patients were divided into 2 groups according to pulmonary artery pressure (PAP ≥ 50 and PAP < 50). The group with PAP > 50 was then divided into 2 subgroups according to TAPSE (1.5 ≥ or < 1.5) values. The early-term mortality and morbidity rates of these groups were compared.ResultsSeventy-nine patients who underwent mitral valve replacement were included in the study. Fifty-four (68%) of them were female, and 25 (32%) were male. During the preoperative period, the TAPSE was 16.8 ± 3.0 mm, and the PAP was 52.1 ± 14.1 mmHg. There were 53 patients with PAP > 50 and 26 patients with PAP < 50. In the PAP > 50 group, the rates of tricuspid regurgitation (p < 0.001), blood transfusion (p < 0.001), intensive care unit stay (p < 0.001), need for CPAP (p = 0.043), reintubation (p = 0.048), acute renal failure (p = 0.028), and mortality (p = 0.026) were found to be significantly different.ConclusionIn conclusion, we believe that in patients with mitral valve pathology, early referral for surgical intervention, before the pulmonary pressures significantly increase and right ventricular function deteriorates, can enhance survival outcomes.

Clinical impacts of concomitant left atrial appendage occlusion during mitral valve surgery in patients with mitral regurgitation

Surgical occlusion of the left atrial appendage (LAA) during cardiac surgery in patients with atrial fibrillation (AF) is known to reduce thromboembolism. However, data on the clinical significance of LAA occlusion (LAAO) in patients with mitral regurgitation (MR) are lacking. A total of 237 AF patients with chronic severe MR who underwent mitral valve (MV) surgery were retrospectively analyzed. Patients were divided into two groups according to concomitant LAAO or LAA preservation. The primary outcome was a composite of all-cause death and thromboembolic events (ischemic stroke or systemic embolism). The LAA was surgically occluded in 98 (41%) patients and preserved in 139 (59%) patients. During the follow-up period (median, 37 months), 29 primary outcomes occurred. In the Kaplan–Meyer analysis, the LAA preservation group showed a greater cumulative incidence of the primary outcome (P = 0.002) and thromboembolic events (P = 0.003) than the LAAO group. In the univariate Cox regression analysis, coronary artery disease, CHA2DS2-VASc score, a cauliflower-shaped LAA, Maze, and no LAAO were significantly associated with the primary outcome. In the multivariate Cox regression analysis, concomitant LAAO was significantly linked to the primary outcome (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.10–0.91, P = 0.033) and thromboembolic events (HR: 0.19, 95% CI: 0.04–0.87, P = 0.032). These benefits from LAAO were consistent, even after propensity score–matched analysis. For patients undergoing surgery for chronic MR who also have AF, concomitant surgical LAAO is associated with favorable clinical outcome.

Relationship between Preoperative Red Cell Distribution Width and Prolonged Postoperative Use of Catecholamines in Minimally Invasive Mitral Valve Surgery Patients: A Retrospective Cohort Study.

Background/Objectives: Elevated RDW has emerged in cardiac surgery as a potential means of preoperative risk stratification with the capacity to predict short- and long-term postoperative mortality, acute kidney injury, and postoperative atrial fibrillation. The question as to whether perioperative hemodynamic instability may be predicted by such a marker remains a topic of ongoing debate. The aim of this study was to explore the relationship between preoperative RDW and prolonged postoperative catecholamine use in minimally invasive mitral valve surgery. Methods: We performed a retrospective monocentric cohort study in an academic hospital; we enrolled patients who had undergone minimally invasive mitral valve surgery (including both robot-assisted and non-robot-assisted procedures) between January 2019 and December 2022. We considered the use of inotropes and/or vasopressors for at least twelve hours after post-surgery ICU admission to qualify as the prolonged postoperative use of catecholamines (PPUC). The RDW was obtained from the routine full blood count analysis performed upon admission or a maximum of 72 h before surgery. We also performed a multivariable logistic regression analysis with PPUC as the dependent variable. Results: We finally enrolled 343 patients. Upon multivariate analysis, RDW >14.4% was independently associated with prolonged postoperative catecholamine use when compared to the reference group (OR 2.62 [1.06-4.84]; p = 0.03). Moreover, the EuroSCORE II score (OR 1.38 [1.03-1.85]; p = 0.03), the cross-clamp time (OR 1.01 [1.01-1.02]; p < 0.01), and robot-assisted mitral valve surgery (OR 0.53 [0.30-0.93]; p < 0.03) were independently associated with the prolonged postoperative use of catecholamines. Conclusions: This study identified that an elevated preoperative RDW (>14.4%), the EuroSCORE II score, and the cross-clamp time independently predict prolonged postoperative catecholamine use in minimally invasive mitral valve surgery patients. Conversely, the robot-assisted approach was associated with a smaller hemodynamic impairment.

Commentator Discussion: Mitral valve surgery in patients with Marfan syndrome

Commentator Discussion: Mitral valve surgery in patients with Marfan syndrome

Outcomes following heart valve surgery in patients with infective endocarditis and preoperative septic cerebral embolism: insights from the CAMPAIGN study group.

This study aimed to analyse the impact of preoperative septic cerebral embolism on early and late postoperative outcomes in patients with infective endocarditis undergoing valve surgery. Retrospective multicentric study based on the Clinical Multicentric Project for Analysis of Infective Endocarditis in Germany (CAMPAIGN) registry comprising patients with infective endocarditis who underwent valve surgery between 1994 and 2018 at 6 German centres. Patients were divided into 2 groups for statistical comparison according to the presence or absence of preoperative septic cerebral embolism. Propensity score matching was performed for adjusted comparisons of postoperative outcomes. Primary outcomes were 30-day mortality and estimated 5-year survival. A total of 4917 patients were included in the analysis, 3909 (79.5%) patients without and 1008 (20.5%) patients with preoperative septic cerebral embolism. Patients with preoperative septic cerebral embolism had more baseline comorbidities. Mitral valve endocarditis (44.1% vs 33.0% P < 0.001), large vegetations >10 mm (43.1% vs 30.0%, P < 0.001), and Staphylococcus species infection (42.3% vs 21.3%, P < 0.001) were more frequent in the cerebral embolism group. Among patients with preoperative cerebral embolism, 286 (28.4%) patients had no stroke signs (silent stroke). After matching (1008 matched pairs), there was no statistically significant difference in 30-day mortality (20.1% vs 22.8%; P = 0.14) and 5-year survival (47.8% vs 49.1%; stratified log-rank P = 0.77) in patients with and without preoperative cerebral embolism, respectively. Preoperative septic cerebral embolism in patients with infective endocarditis requiring valve surgery does not negatively affect early or late mortality; therefore, it should not play a major role in deciding if surgery is to be performed.

Minimally Invasive Surgery through Right Mini-Thoracotomy for Mitral Valve Infective Endocarditis: Contraindicated or Safely Possible?

Background: Mitral valve infective endocarditis (IE) still has a high mortality. Minimally invasive mitral valve surgery (MIMVS) is technically more challenging, especially in patients with endocarditis. Here, we compare the early postoperative outcome of patients with endocarditis and other indications for MIMVS. Methods: Two groups were formed, one consisting of patients who underwent surgery because of mitral valve endocarditis (IE group: n = 75) and the other group consisting of patients who had another indication for MIMVS (non-IE group: n = 862). Patients were observed for 30 postoperative days. Data were retrospectively reviewed and collected from January 2011 to September 2023. Results: Patients from the IE group were younger (60 vs. 68 years; p < 0.001) and had a higher preoperative history of stroke (26% vs. 6%; p < 0.001) with neurological symptoms (26% vs. 9%; p < 0.001). No difference was seen in overall surgery time (211 vs. 206 min; p = 0.71), time on cardiopulmonary bypass (137 vs. 137 min; p = 0.42) and aortic clamping time (76 vs. 78 min; p = 0.42). Concerning postoperative data, the IE group had a higher requirement of erythrocyte transfusion (2 vs. 0; p = 0.041). But no difference was seen in the need for a mitral valve redo procedure, bleeding, postoperative stroke, cerebral bleeding, new-onset dialysis, overall intubation time, sepsis, pacemaker implantation, wound healing disorders and 30-day mortality. Conclusions: Minimally invasive mitral valve surgery in patients with mitral valve endocarditis is feasible and safe. Infective endocarditis should not be considered as a contraindication for MIMVS.

Concomitant tricuspid valve surgery in patients with significant tricuspid regurgitation undergoing left ventricular assist device implantation: A systematic review and meta-analysis.

Significant tricuspid regurgitation (TR) is a predictor of right heart failure (RHF) and increased mortality following left ventricular assist device (LVAD) implantation, however the benefit of tricuspid valve surgery (TVS) at the time of LVAD implantation remains unclear. This study compares early and late mortality and RHF outcomes in patients with significant TR undergoing LVAD implantation with and without concomitant TVS. A systematic search of four electronic databases was conducted for studies comparing patients with moderate or severe TR undergoing LVAD implantation with or without concomitant TVS. Meta-analysis was performed for primary outcomes of early and late mortality and RHF. Secondary outcomes included rate of stroke, renal failure, hospital and ICU length of stay. An overall survival curve was constructed using aggregated, reconstructed individual patient data from Kaplan-Meier (KM) curves. Nine studies included 575 patients that underwent isolated LVAD and 308 patients whom received concomitant TVS. Both groups had similar rates of severe TR (46.5% vs. 45.6%). There was no significant difference seen in risk of early mortality (RR 0.90; 95% CI, 0.57-1.42; p = 0.64; I2 = 0%) or early RHF (RR 0.82; 95% CI, 0.66-1.19; p = 0.41; I2 = 57) and late outcomes remained comparable between both groups. The aggregated KM curve showed isolated LVAD to be associated with overall increased survival (HR 1.42; 95% CI, 1.05-1.93; p = 0.023). Undergoing concomitant TVS did not display increased benefit in terms of early or late mortality and RHF in patients with preoperative significant TR. Further data to evaluate the benefit of concomitant TVS stratified by TR severity or by other predictors of RHF will be beneficial.

Minimally-invasive valve surgery in patients with valvular heart disease with comorbidities: A single centre experience

Minimally-invasive valve surgery in patients with valvular heart disease with comorbidities: A single centre experience

Volatile versus propofol sedation after cardiac valve surgery: a single-center prospective randomized controlled trial

BackgroundOptimal intensive care of patients undergoing valve surgery is a complex balancing act between sedation for monitoring and timely postoperative awakening. It remains unclear, if these requirements can be fulfilled by volatile sedations in intensive care medicine in an efficient manner. Therefore, this study aimed to assess the time to extubation and secondary the workload required.MethodsWe conducted a prospective randomized single-center trial at a tertiary university hospital to evaluate the postoperative management of open valve surgery patients. The study was randomized with regard to the use of volatile sedation compared to propofol sedation. Sedation was discontinued 60 min after admission for critical postoperative monitoring.ResultsWe observed a significantly earlier extubation (91 ± 39 min vs. 167 ± 77 min; p < 0.001), eye-opening (86 ± 28 min vs. 151 ± 71 min; p < 0.001) and command compliance (93 ± 38 min vs. 164 ± 75 min; p < 0.001) using volatile sedation, which in turn was associated with a significantly increased workload of a median of 9:56 min (± 4:16 min) set-up time. We did not observe any differences in complications. Cardiopulmonary bypass time did not differ between the groups 101 (IQR 81; 113) versus 112 (IQR 79; 136) minutes p = 0.36.ConclusionsUsing volatile sedation is associated with few minutes additional workload in assembling and enables a significantly accelerated evaluation of vulnerable patient groups. Volatile sedation has considerable advantages and emerges as a safe sedation technique in our vulnerable study population.Trial registration: Clinical trials registration (NCT04958668) was completed on 1 July 2021.

Atrioventricular valve surgery in patients with univentricular heart and two separate atrioventricular valves.

Atrioventricular valve regurgitation in patients with univentricular heart is a well-known risk factor for adverse outcomes and atrioventricular valve repair remains a particular surgical challenge. We reviewed all surgical atrioventricular valve procedures in patients with univentricular heart and two separate atrioventricular valves who underwent surgical palliation. Endpoints of the study were reoperation-free survival and cumulative incidence of reoperation. Between 1994 and 2021, 202 patients with univentricular heart and two separate atrioventricular valve morphology underwent surgical palliation, with 15.8% (32/202) requiring atrioventricular valve surgery. Primary diagnoses were double inlet left ventricle (n = 14, 43.8%), double outlet right ventricle (n = 7, 21.9%), and congenitally corrected transposition of the great arteries (n = 7, 21.9%). Median weight at valve surgery was 10.6 kg (interquartile range, 7.9-18.9). Isolated left or right atrioventricular valve surgery was required in nine (28.1%) and 22 patients (68.8%), respectively. Concomitant left and right atrioventricular valve surgery was performed in one patient (3.1%). Closure of the left valve was conducted in four patients (12.5%) and closure of the right valve in three (9.4%). Operative and late mortality were 3.1% and 9.7%, respectively. Reoperation-free survival and cumulative incidence of reoperation at 10 years after surgery were 62.3% (standard error of the mean: 6.9) and 30.9% (standard error of the mean: 9.6), respectively. In patients with univentricular heart and two separate atrioventricular valves, surgical intervention on these valves is required in a minority of patients and is associated with low mortality but high incidence of reoperation.

Mitral valve surgery in patients with Marfan syndrome

ObjectiveTo review the pathology of the mitral valve (MV) and long-term outcomes of surgery in patients with Marfan syndrome (MFS). Patients and MethodsFrom 1988 through 2020, 60 patients with MFS had surgery to correct mitral regurgitation (MR): 19 had isolated MV surgery, 32 had combined MV and aortic root surgery, and 9 had MV surgery after aortic root surgery. Follow-up was complete for a median of 16.1 years. ResultsMV pathology was myxomatous degeneration in all patients and of advanced degree in 78.6% with bileaflet prolapse in 65.5%, mitral annulus disjunction in 57.5%, and mitral annulus calcification in 8.2% of patients. The MV was repaired in 47 patients and replaced in 13. Kaplan–Meier estimates of cumulative mortality at 20 years 21.3% for all patients, 6.7% after MV repair, and 57.8% after replacement (P < .001). MV reoperations were performed in 5 patients: 2 after repair and 3 after replacement. The cumulative incidence rate of reoperations on the MV was 3.8% at 10 years and 11.0% at 20 years in the entire cohort. Among 47 patients who had MV repair, moderate MR developed in 11 patients and severe in 2. Both patients with severe MR underwent MV reoperation. The cumulative incidence rate of recurrent moderate or severe MR after MV repair was 20.4% at 10 years, and 36.5% at 20 years. ConclusionsMV repair was associated with better survival than MV replacement, but recurrent MR after repair occurred in approximately one-third of the patients at 20 years after surgery.

Early and mid-term outcomes of tricuspid valve surgery in patients with functional tricuspid regurgitation induced by atrial fibrillation.

The strategy of treatment for tricuspid regurgitation (TR) induced by atrial fibrillation (AF) has not been established. The aim of this study was to evaluate the outcomes of surgical treatment for TR induced by AF. From 2000 to 2021, a total of 1,301 patients underwent tricuspid valve (TV) surgery. Among them 43 patients who diagnosed as AF induced TR were enrolled. The tricuspid valve-related events (TVRE) included cardiac death, TV reoperation, development of moderate or greater TV disease, congestive heart failure requiring re-admission, and major bleeding or thrombosis. The median follow-up duration was 42.0 months. The interval from diagnosis of AF to more than moderate TR was 61.2 months, and the interval from initial diagnosis of severe TR to surgery was 2.4 months. Concomitant Cox-maze III procedure was performed in 39 patients. The operative mortality occurred in 1 patient, and there was no permanent pacemaker implantation. Overall survival rates at 1- and 5-year were 90.6% and 79.3%, respectively. The cumulative incidence of TVRE at 1- and 5-year were 16.3% and 26.5%, respectively. The cumulative incidences of AF recurrence at 1- and 3-year in the patients with surgical ablation were 29.7% and 67.6%. The TVRE was significantly associated with the longer interval from diagnosis of severe TR to surgery (hazard ratio: 1.023, 95% confidence interval: 1.005-1.042). TV surgery for TR induced by AF showed low surgical mortality and favorable mid-term outcomes. For these patients, early surgery after progress to severe TR can be helpful to decrease the occurrence of TVRE.

Aortopathy and aortic valve surgery in patients with bicuspid aortic valve with and without raphe

AimTo evaluate the association between raphe in bicuspid aortic valve (BAV) patients and valve dysfunction, aortopathy and aortic valve surgery in the REBECCA registry [REgistro della valvola aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging (SIECVI)]. MethodsPrevalence of aortic valve dysfunction and aortopathy was investigated in BAV patients with and without raphe. Aortic valve dysfunction (regurgitation or stenosis) was categorized as mild, moderate and severe. Aortopathy was defined as annulus ≥14 mm/m2; root ≥20 mm/m2; sinotubular junction ≥16 mm/m2; ascending aorta ≥17 mm/m2, and classified in Type A, isolated ascending aorta dilatation; Type B, aortic root and ascending aorta dilatation; and Type C, isolated aortic root dilatation. ResultsOverall, 695 patients with BAV were enrolled; 520 (74.8%) with raphe and 175 (25.2%) without raphe. BAV patients with raphe presented more frequently with moderate or severe aortic stenosis than BAV patients without raphe (183 [35.2%] vs 34 [19.4%], p < 0.001). A higher prevalence of aortopathy, particularly Type B, was observed in patients with vs without raphe. At multivariable analysis, raphe was a predictor of aortic valve surgery at three-year follow-up (odds ratio 2.19, 95% confidence interval 1.08–4.44, p < 0.001). ConclusionsPatients with BAV and raphe have a higher prevalence of significant aortic stenosis, aortopathy, especially Type B, and a higher risk of undergoing aortic valve surgery at three-year follow-up.

Risk Factors for Higher Postoperative Myocardial Injury in Minimally Invasive Mitral Valve Surgery Patients: A Cohort Study.

Background: Postoperative myocardial injury, as detected by an elevated concentration of high-sensitivity cardiac troponin I (hs-cTnI), is a common complication in cardiac surgery that may be linked to mortality. The primary aim of this study was to assess the risk factors associated with increased myocardial injury in patients undergoing minimally invasive mitral valve surgery. Methods: In this retrospective monocentric cohort study, we analyzed all patients who underwent elective minimally invasive mitral valve surgery between January 2019 and December 2022 and were subsequently admitted to our intensive care unit. The study population was divided into two groups based on the peak hs-cTnI level: the "lower myocardial injury" group comprised patients whose peak serum hs-cTnI level was less than 499 times the 99th percentile, while the "higher myocardial injury" group included those patients who exhibited hs-cTnI levels equal to or greater than 500 times the 99th percentile. A multivariable logistic regression analysis was performed to identify independent risk factors associated with higher myocardial injury. Results: In our final analysis, we enrolled 316 patients. Patients with higher myocardial injury (48; 15%) more frequently had a preoperative New York Heart Association (NYHA) class ≥3 compared to those with lower myocardial injury [33 (69%) vs. 128 (48%); p < 0.01-OR 2.41 (95% CI 1.24-4.64); p < 0.01]. Furthermore, cardiopulmonary bypass and aortic cross-clamp time were significantly longer in the higher myocardial injury group compared to the lower myocardial injury group [117 (91-145) vs. 86 (74-100) min; p < 0.01-OR 1.05 (95% CI 1.03-1.06); p < 0.01]. Moreover, patients who underwent robotic-assisted mitral valve surgery experienced lower myocardial injury rates [9 (19%) vs. 102 (38%); p = 0.01-OR 0.38 (95% CI 0.18-0.81); p = 0.01] than others. These findings remained consistent after adjustment in multivariate logistic regression. In terms of postoperative outcomes, patients with higher myocardial injury exhibited the highest lactate peak in the first 24 h, a higher incidence of postoperative acute kidney injury and a longer duration of mechanical ventilation. Although no patients died in either group, those with higher myocardial injury experienced a longer hospital length of stay. Conclusions: Higher myocardial injury is relatively common after minimally invasive mitral valve surgery. Prolonged aortic cross-clamp duration and higher NYHA class were independently associated with myocardial injury, while robotic-assisted mitral valve surgery was independently associated with lower postoperative myocardial injury.

Early and long-term outcomes following redo mitral valve surgery in patients with prior minimally invasive mitral valve surgery.

The frequency of minimally invasive mitral valve surgery (MVS) has steadily increased over the last decades and therefore surgeons are now encountering an increasing number of patients requiring mitral valve (MV) reoperations post-minimally invasive MVS. The aim of this study was to analyse the early postoperative outcomes and the long-term survival in patients who undergo reoperative MVS following previous minimally invasive surgery. Patients who underwent redo MVS following prior minimally invasive MVS between January 2002 and December 2021 were included in our analysis. Study data were prospectively collected and retrospectively analysed. The primary outcomes were 30-day mortality and long-term survival. Among the 187 included patients, 34 (18.2%) underwent repeat MV repair and 153 (81.8%) MV replacement. The median age was 66 years (interquartile range 56-74) and 80 (42.8%) patients were female. Redo MVS was performed through median sternotomy in 169 patients (90.4%). A total of 77 (41.2%) patients had additional concomitant procedures. The median intensive care unit stay was 1 day (1-5). The 30-day mortality was 6.4% (12/187). Estimated survival at 5 and 12 years was 61.8% and 38.3%, respectively. Preoperative stroke (hazard ratio 3.28, 95% confidence interval 1.37-7.85, P = 0.007) as well as infective endocarditis (hazard ratio 1.85; 95% confidence interval 1.09-3.11, P = 0.021) were independent predictors of long-term mortality. Redo MVS following prior minimally invasive MVS can be performed safely with low early perioperative mortality and acceptable long-term survival. Preoperative stroke, infective endocarditis and concomitant tricuspid valve surgery are independent predictors of long-term mortality.

Six-minute walk test distance at time of hospital discharge is strongly and independently associated with all-cause mortality following cardiac surgery

We investigated the impact of distance covered in the six-minute walk test (6mWT) before being discharged from the hospital after cardiac surgery on the risk of all-cause mortality. Our study included 1127 patients who underwent cardiac surgery and then took part in a standardised physiotherapist-supervised inpatient rehabilitation programme during 2007–2017. The percentage of the predicted 6mWT distance, and the lower limit of normal distance was calculated based on individual patients’ age, sex, and body mass index. We used Cox regression with adjustment for confounders to determine multivariable-adjusted hazard ratios (HRs) for mortality. Over a median follow-up period of 6.4 (IQR: 3.5–9.2) years, 15% (n = 169) patients died. We observed a strong and independent inverse association between 6mWT distance and mortality, with every 10 m increase in distance associated to a 4% reduction in mortality (HR: 0.96, 95% CI 0.94–0.98, P < 0.001). Those in the top tertile for predicted 6mWT performance had a 49% reduced risk of mortality (HR: 0.51, 95% CI 0.33–0.79) compared to those in the bottom tertile. Patients who met or exceeded the minimum normal 6mWT distance had 36% lower mortality risk (HR: 0.64, 95% CI 0.45–0.92) compared to those who did not meet this benchmark. Subgroup analysis showed that combined CABG and valve surgery patients walked less in the 6mWT compared to those undergoing isolated CABG or valve surgeries, with a significant association between 6mWT and mortality observed in the isolated procedure groups only. In conclusion, the longer the distance covered in the 6mWT before leaving the hospital, the lower the risk of mortality.

Outcome following acute and recurrent rheumatic fever

ABSTRACT Background Rheumatic carditis is the leading cause of permanent disability caused by damage of the cardiac valve. This study aimed to determine the outcome and predictors of valve surgery in patients with acute rheumatic fever (ARF) and recurrent rheumatic fever (RRF). Methods This was a retrospective study of patients diagnosed with ARF and RRF between 2006 and 2021. The predictors of valve surgery were analysed using multivariable Cox proportional regression. Results The median age of patients with ARF and RRF (n=92) was 11 years (range 5–18). Seventeen patients (18%) were diagnosed with RRF. The most common presenting symptoms included clinical carditis (87%), heart failure (HF) (63%), fever (49%) and polyarthralgia (24%). Patients with moderate-to-severe rheumatic carditis (88%) were given prednisolone. After treatment, the severity of valvular regurgitation was reduced in 52 patients (59%). Twenty-three patients (25%) underwent valve surgery. The incidence of HF, RRF, severe mitral regurgitation on presentation, left ventricular enlargement and pulmonary hypertension was greater in the surgical group than in the non-surgical group. Recurrent rheumatic fever (hazard ratio 7.9, 95% CI 1.9–33.1), tricuspid regurgitation (TR) gradient ≥ 42 mmHg (HR 6.3, 95%CI 1.1–38.7) and left ventricular end-diastolic dimension (LVEDD) ≥6 cm (HR 8.7, 95% CI 2.1–35.9) were predictors of valve surgery (multivariable Cox proportional regression analysis). Conclusion Clinical carditis was the most common presenting symptom in patients with ARF and RRF. The majority of patients responded positively to prednisolone. These findings highlight the predictors of valve surgery following ARF, including RRF, TR gradient ≥ 42 mmHg and LVEDD ≥ 6 cm. Abbreviations: ARF: acute rheumatic fever; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; GAS: group A beta-haemolytic Streptococcus; HF: heart failure; HR: hazard ratio; LVEDD: left ventricular end-diastolic dimension; MR: mitral regurgitation; RHD: rheumatic heart disease; RRF: recurrent rheumatic fever; TR: tricuspid regurgitation.

Efficacy of automated fasteners versus hand-tied knots in cardiac surgery: a systematic review and meta-analysis.

Valve surgery is common in cardiac procedures, with fasteners like COR-KNOT® and hand-tied knots used for knot securing. This study compares their efficacy in valve surgery patients. We searched PubMed, SCOPUS, and Cochrane Central until August 2023. Outcomes assessed included aortic cross-clamp time (AXT), cardiopulmonary bypass (CPB) time, valvular regurgitation, mortality, prolonged ventilatory support, atrial fibrillation, postoperative left ventricular ejection fraction (LVEF), and renal failure. Subgroup analysis was performed for minimally invasive and open cardiac surgery. We used a random effects model for analysis. We included eight observational studies and two randomized controlled trials (RCTs) with a total of 1.411 participants. COR-KNOT significantly reduced AXT [MD -15.14, 95 % CI (-18.57, -11.70), P<0.00001] and CPB time [MD -12.38, 95 % CI (-14.99, -9.77), P<0.00001]. Valvular regurgitation [RR 0.40, 95 % CI (0.26, 0.61), P<0.0001] and need for prolonged ventilatory support [RR 0.29, 95 % CI (0.13, 0.65), P=0.003] were significantly lower with COR-KNOT. There were no significant differences in mortality [RR 0.39, 95 % CI (0.09, 1.69), P=0.44], atrial fibrillation [RR 1.03, 95 % CI (0.83, 1.27), P=0.81], LVEF changes [MD 0.05, 95 % CI (-1.37, 1.47), P = 0.95], or renal failure [RR 0.87, 95 % CI (0.16, 4.80), P = 0.87]. COR-KNOT devices reduce operative time and valvular regurgitation without increasing mortality or adverse outcomes. This supports their use in enhancing surgical efficiency and patient outcomes. However, ongoing discussions about suturing techniques, especially in minimally invasive procedures, highlight the need for further research and consensus among practitioners. See also the graphical abstract(Fig. 1).