Valvular Surgery Research Articles

Streptococcus suis infective endocarditis in patients with Streptococcus suis bacteremia: a retrospective study of prevalence and outcomes

Abstract Background Streptococcus suis (S. suis) is a zoonotic disease that is transmitted to humans via contact or oral route. Although the major clinical presentation of this pathogen is known to be meningitis, S. suis infective endocarditis (IE) has recently emerged as a clinical manifestation of increasing interest. Echocardiography may be an underutilized modality for evaluating patients with S. suis bacteremia. Objective The primary objective was to estimate the prevalence of S. suis IE in patients with S. suis bacteremia. The secondary objective was to investigate the predictors, echocardiographic features, and clinical outcomes of S. suis IE in patients with S. suis bacteremia. Materials and methods This single-center retrospective study was conducted at Siriraj Hospital – Thailand’s largest university-based tertiary referral center. Adult patients (aged > 18 years) who were admitted to our center with confirmed diagnosis of S. suis bacteremia during January 2007 to September 2023 were included. Prevalence is reported as percentage and confidence interval. Baseline characteristics and clinical manifestation were compared between the IE and non-IE groups. Factors found to be statistically significant were further analyzed using binary logistic regression analysis to identify univariate predictors of S. suis IE. Result A total of 71 patients with S. suis bacteremia were included in this study. The prevalence of S. suis IE was 26.8% (95% confidence interval: 17.85–38.05). Perivalvular complications and significant valvular regurgitation were found in 52.6% and 80.0% of patients, respectively. Thirteen of 19 patients (68.4%) required valvular surgery according to standard guidelines. By univariate analysis, dyspnea, new murmur, immunologic phenomenon, and heart failure were predictors of S. suis IE in patients with S. suis bacteremia. Conclusion The results of this study revealed a sizable prevalence of S. suis IE in patients with S. suis bacteremia, and there were high rates of both valvular damage and perivalvular complications. Our results strongly suggest that echocardiography may be indicated to evaluate for S. suis IE in patients diagnosed with S. suis bacteremia. Reclassification of S. suis from an atypical organism to a typical organism should be considered.

Abstract 4138248: Outcomes of Patients with Radiation-Associated Cardiac Disease Undergoing Cardiothoracic Surgery: Development of a Disease Specific Risk Score

Background: Radiation-associated cardiac disease (RACD) has significant long-term mortality and morbidity, often requiring cardiac surgery(CS). Hypothesis: We sought to study factors associated with longer-term survival in RACD patients and develop a specific risk score associated with 5-year survival following CS. Methods: This was an observational cohort study of 351 patients with documented RACD (252 [72%] had mantle radiation for lymphoma at a mean of 18 years prior), who underwent CS at a tertiary care center between 1991-2018. Clinical characteristics were collected, and Society of Thoracic Surgeons (STS) score was calculated. The primary endpoint was mortality. Multivariable analysis for 5-year mortality was performed using age, sex, history of lymphoma, New York Heart Association class, prior cardiac surgery, atrial fibrillation, constriction, chronic pulmonary disease, serum creatinine, left ventricular ejection fraction, right ventricular systolic pressure and valvular surgery(aortic, mitral or tricuspid). Results: Clinical characteristics are shown in Figure 1. Mean follow-up was 6.2±4.6 years&5-year mortality occurred in 123 (35%) patients (7 [2%] in-hospital deaths). Cox 5-year survival analysis results are shown in Figure 2A. A receiver operator curve analysis for 5-year mortality showed an area under curve of 0.70 (95% confidence interval 0.64-76, p<0.001). Subsequently, a 5-year risk score (0-7 points) was generated (Figure 2 A); with an increasing risk of mortality at 5 years, based on increasing risk score (Figure 2C). Cardiac reoperation was not associated with worse outcomes. Conclusion: RACD patients undergoing CTS have a high rate of 5-year mortality, despite a low baseline STS score&perioperative mortality. A novel RACD-specific risk score (incorporating higher age, abnormal renal/pulmonary, constrictive pericarditis&need for concomitant mitral valve surgery) provides good discrimination for 5-year survival&could be used for shared-decision making.

Can Radiological Renal Artery Parameters Predict Acute Kidney Injury in Infective Endocarditis Surgery?—From Imaging to Outcomes

Background: Infective endocarditis (IE) poses significant challenges in cardiovascular medicine, often necessitating valvular surgery to manage severe complications. Postoperative acute kidney injury (AKI) is a notable complication affecting patient outcomes. While clinical and procedural factors have been well studied, the role of radiological renal artery parameters in AKI risk remains underexplored. Methods: This retrospective study analyzed 80 patients with IE who underwent valvular surgery from 2013 to 2021, focusing on postoperative AKI as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Radiological parameters, including renal artery calcification, renal ostial calcification, the presence of renal infarctions, and additional arteries, were assessed using preoperative computed tomography (CT). Statistical analyses included binary logistic and linear regression models, Kaplan–Meier survival curves, and Cox proportional hazard regression to explore associations between these parameters and AKI incidence, creatinine levels, and mortality. Results: Out of 80 patients, 31 (38.8%) developed AKI. No significant differences were found in baseline characteristics or radiological parameters between the AKI+ and AKI− groups. Binary logistic and linear regression analyses revealed no substantial relationship between anatomical factors and AKI risk or creatinine levels. However, Cox regression identified “additional renal artery” as a significant predictor of 1-month mortality (HR: 1.747, 95% CI: 1.024–2.979, p = 0.041) but not for 6- or 12-month mortality. Conclusions: Radiological anatomical factors, including calcifications and additional arteries, did not significantly impact AKI risk in IE patients undergoing valvular surgery. However, the presence of additional arteries was associated with increased short-term mortality. These findings suggest the need for further research to elucidate factors contributing to AKI and mortality in this context.

The incidence of atrial fibrillation and its impact on the length of stay following valvular heart surgery.

There is minimal evidence regarding predictors, preventative measures and treatments of new onset of post-operative atrial fibrillation (POAF) in patients undergoing valvular heart surgery. This study aimed to determine the incidence of new onset atrial fibrillation (AF) and its impact on outcomes and length of stay (LOS) for patients following valvular heart surgery. A single-centre, retrospective study was conducted. New onset AF was observed in 51/120 (42.5%) patients. Baseline and surgical characteristics were similar between patients who did and did not develop AF, although suggestive older age may increase the risk of developing POAF (p=0.06). New onset AF was significantly associated with longer intensive care unit (ICU) LOS-median increase of 2 days (p=0.002)-and overall hospital LOS-median increase of 1.5 days (p=0.006). Patients who received double valve surgery spent 2.5 times longer in the ICU compared to patients who had an aortic valve replacement (AVR) (p=0.033). The incidence of new onset AF following valvular heart surgery was high, with associated prolonged ICU and hospital LOS. Patients undergoing double valve surgery were more likely to have a longer ICU LOS compared with those who received an AVR.

Deferral of left main coronary artery revascularization via IVUS or coronary physiology - Long-term outcomes from the SWEDEHEART registry

BackgroundIntravascular ultrasound (IVUS) guides deferral decision-making regarding the left main coronary artery (LMCA) and improves outcomes. Further studies regarding coronary physiology to guide revascularization in the LMCA are needed. Our aim was to evaluate the outcome of LMCA deferral using IVUS or coronary physiology via instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR). MethodsBetween January 2014 and February 2022, patients undergoing evaluation with either IVUS or coronary physiology in the LMCA were included from the SWEDEHEART registry. Exclusion criteria were a minimum luminal area < 6 mm2, iFR ≤ 0.89, FFR ≤ 0.80, ad hoc percutaneous coronary intervention of lesions in the LMCA, proximal left anterior descending artery, and proximal circumflex artery, planned elective revascularization, and planned valvular surgery. The primary outcome was major adverse cardiac events (MACE), defined as a composite of all-cause death, myocardial infarction, and unplanned revascularization. Kaplan−Meier event rates and multivariable Poisson regression were used for the statistical analyses. ResultsDeferral of revascularization in the LMCA was performed in 1552 patients, 33.6 % with IVUS and 66.4 % with coronary physiology (iFR 11.3 % vs. FFR 55.0 %). The median follow-up time was 2.7 years. No significant difference was seen in MACE (IVUS 40.2 % vs. coronary physiology 35.5 %; adjusted RR: 1.18; 95 %CI: 0.97–1.44; p = 0.09). The results were consistent across all investigated subgroups. The rate of all-cause death was higher in the IVUS group (adjusted RR: 1.38; 95 %CI: 1.03–1.83; p = 0.03). ConclusionsDeferral of coronary revascularization in LMCA lesions using IVUS or coronary physiology did not differ in our combined endpoint. We observed a higher risk of all-cause death using IVUS.

Assessing the Nursing Workload in the Cardiothoracic Intensive Care Unit: Comparative Study.

This study aimed to assess nursing workload in Cardiac Intensive Care Unit (CICU) after three cardiothoracic surgery procedures during first four postoperative days using Nursing Activities Score (NAS) and Nine Equivalents of Nursing Manpower Use Score (NEMS) systems, to compare their performance for that purpose and to investigate association between nursing workload and type of surgery. A comparative study. The research environment includes CICU of the University Hospital for Cardiovascular Diseases in Serbia. A total of 808 patients who underwent coronary, valvular, or combined surgery, resulting in 2282 filled NAS and NEMS pairs chart. Statistical analysis was performed using SPSS-19. The correlation between NAS and NEMS was tested by Spearman's correlation coefficient. Differences were considered statistically significant at p < 0.05. The lowest median of cumulative NAS 176 (175-257) and NEMS 76 (64-91) had coronary surgery patients, the highest NAS 224.5 (178-334.5) and NEMS 83 (69-121) had those with combined surgery; this difference was statistically significant (p < 0.001). The median of both scores decreased after surgery, with the following values from the first to the fourth postoperative day: NAS from 104 (102-105) to 81 (74-85) and NEMS from 46 (42-46) to 30 (30-37). The difference in mean values of both scores between the first and the fourth postoperative day was statistically significant (p < 0.001). NAS and NEMS were in a positive, strong correlation (r = 0.913; p < 0.005). Both scores can be used to measure nursing workload, identify the required number of nurses in CICU, and support task allocation. NAS may have an advantage because it better describes extensive postoperative monitoring and care needed for cardiac surgery patients. Nursing workload is associated with type of surgery, with the highest workload measured in patients who underwent combined surgery procedure and on the first postoperative day.

Association of TRI-SCORE with clinical outcomes after percutaneous tricuspid annuloplasty

Abstract Background Significant tricuspid regurgitation (TR) has been associated with excess mortality and heart failure. Functional TR is associated to progressive right ventricular remodeling and dysfunction, leading to comorbidities which elevate the perioperative mortality of isolated tricuspid regurgitation surgery, with an in-hospital mortality between 6-10% according to series. Transcatheter tricuspid annuloplasty is a promising therapeutic alternative in patients with high surgical risk. Appropriate risk stratification and patient selection is essential to ensure benefits of this intervention. European System for Cardiac Operative Risk Evaluation (EUROSCORE) II and the Society of Thoracic Surgeons (STS) score are widely spread in-hospital mortality risk scores in valvular surgery. TRI-SCORE is focused on isolated TR surgery; nevertheless, application of these scores to transcatheter annuloplasty has not been specifically studied yet. Purpose To analyze the utility of surgical scores (EUROSCORE-II, STS and TRISCORE) to predict all-cause mortality in patients undergoing transcatheter tricuspid annuloplasty. Methods A cohort of 49 patients with significant TR was followed up prospectively after the transcatheter tricuspid annuloplasty with Cardioband between 2019 and January 2024 (mean follow-up 18,43 ± 10,95 months). Every score was evaluated in all patients. According to the TRI-SCORE –– 6 points was the 75-percentile and taken as cutoff value –– we divided the cohort in two groups: a low score group (≤6 points) and a high score group (&amp;gt;6 points). Survival was analyzed in the whole cohort and in both subgroups. The curves are depicted using Kaplan-Meier method and were compared using log rank test. Results The study included 49 patients, with mean age of 77,6 ± 7,67 years, 77,6% being women. All the patients had a secondary etiology of TR and 46,9% massive or torrential TR before the intervention. 49% had previous left heart surgery. The median surgical risk values are represented in Table 1. All-cause mortality during follow-up occurred in 9 patients (18,3%). Survival analysis based on EUROSCORE II and STS did not find statically significant association (Table 1). TRI-SCORE had a hazard ratio (HR) of 1,59, also without statically significant association (CI 0.93 – 2.71; p 0.089). Survival analysis in high score group found an increased risk of all-cause mortality (HR 8.5; p 0.025). According to our findings TRI-SCORE &amp;gt; 6 before the procedure confers significant risk of all-cause death (log rank p = 0.009). Figure 1. Conclusions Transcatheter tricuspid annuloplasty is a promising therapy for patients with significant TR regurgitation who are at high surgical risk. According to our findings, TRI-SCORE is an appropriate scoring model to predict all-cause mortality after percutaneous annuloplasty with band. It is not so for other surgical risk scores. Extended follow-up and broader experienced are needed to corroborate these results.Surgical scores: median and mortalitySurvival curves TRI-SCORE

Prognostic relevance of baseline right ventricular echocardiographic evaluation in patients undergoing valvular surgery with tricuspid intervention

Abstract Background Tricuspid valve (TV) intervention is frequently performed both as part of multivalvular surgery and as an isolated procedure. Tricuspid regurgitation (TR) significantly worsen right ventricular (RV) function, which is a prognostic determinant in many clinical scenarios. Purpose Our aim was to evaluate the relevance of baseline right ventricular (RV) baseline echocardiographic in the prognosis after tricuspid valve surgery (TVS). Methods Retrospective observational study of patients undergoing TVS between 2009 and 2022 in our tertiary centre. Baseline right chambers echocardiographic parameters were evaluated: RV diameters (basal, mid and longitudinal), TAPSE, fractional area change (FAC), Doppler tissue velocity of the tricuspid annulus (RVS´) and free wall- (FW-) and 4 chambers- (4C-) global longitudinal strain (GLS). Likewise, systolic pulmonary artery pressure (sPAP) and left ventricular ejection fraction (LVEF) were collected among other variables. Association of echocardiographic parameters with major clinical events at year was explored. Results Finally 273 consecutive patients (71 ± 10.5 years old, 66.7% female) that underwent valvular surgery with tricuspid intervention were included. Multivalvular procedure was performed in 81.3% (50.6% mitral and tricuspid, 25.6% mitral, aortic and tricuspid and 5.1% aortic and tricuspid) and EuroScore was 5 [3-9]. The most common TV lesion was TR (97.8%), functional in 84.2%. The main surgical technique was tricuspid annuloplasty with prosthetic ring (57.9%). Preoperative echocardiographic parameters are presented in Table. Baseline LVEF was 59 [53-65]%. The most frequent postoperative complication was low output (23.4%) and there was an overall mortality rate of 8.3% during the first year of follow-up. Postsurgical low output state was associated with vena contracta TR (0,78 vs 0,66 cm; p &amp;lt;0.001) and 4C-GLS ((-15.7 vs -17.3%; p= 0.03). None of the baseline echocardiographic variables was associated with early mortality. Conclusions Baseline RV echocardiographic parameters were associated with postoperative low output but not mortality. The relatively preserved RV dimensions and function in our series may explain these findings. Table. Baseline RV echocardiographic variablesTable

Rheumatic heart disease: an ongoing public health concern in vulnerable communities

Abstract Background Acute rheumatic fever (ARF) results from an autoimmune response triggered by group A streptococcus (GAS) infection (1). Severe or recurrent ARF episodes can cause permanent heart valve damage, leading to complications including heart failure, stroke, arrhythmias, carditis, and decompensation during pregnancy (2). Purpose Rheumatic fever (RF) remains a public health concern in Australia, particularly among Indigenous, migrant populations and socioeconomically disadvantaged communities. Europe and various regions worldwide have experienced significant migration from areas with a high prevalence of RHD (3). Amongst the more than 1 million asylum seekers who arrived in Europe in 2015, an estimated 1% could potentially be affected by RHD (3). This migration influx underscores the pressing need for the implementation of strategies in health policy and practice. We aimed to outline the attributes of our RF-RHD cohort to aid in the formulation of a Model of Care (MoC). Methods Cases were identified on a quarterly basis either through the NSW Public Health Rapid, Emergency, Disease, and Syndromic Surveillance (PHREDSS) system or via clinical diagnoses reported to the Public Health Unit (PHU) from January 2015 to June 2023. Demographic profiles, clinical particulars, and patient outcomes were collected from patients in the South Western Sydney Local Health District (SWSLHD), NSW, Australia. Results A total of 45 cases were reported (Table 1). This consisted predominantly of females with an average age at diagnosis of 14 years. A majority were obese (69%). Most were in the Maori and Pacific Islander populations (62%), while a smaller portion of patients were of Aboriginal or Torres Strait Islander descent (9%) (Australian Indigenous community). Notably, 84% of patients diagnosed with ARF subsequently progressed to RHD. Among the reported cases, 16 patients underwent valvular surgery, 2 patients progressed to end-stage heart failure, and there was 1 mortality. 39% (11) of female patients were pregnant during the study period, with 6 (55%) of these patients decompensating during their pregnancy (Table 2). Conclusion Rheumatic fever persists as a public health concern on a global scale. Our findings emphasize the need for a high index of clinical awareness in considering RF/RHD in socioeconomically disadvantaged communities. In our setting, there is a disproportionate burden of disease among the Pacific Islander population. The high occurrence of cardiac decompensation during pregnancy, underscores the need for close monitoring in this demographic. Despite the prevalence of rheumatic fever predominantly affecting young patients in vulnerable groups, we found a significant proportion of individuals lost to follow-up or not connected with Cardiology services. Addressing rheumatic fever requires a comprehensive approach that encompasses improved healthcare accessibility, targeted health education initiatives, and socioeconomic interventions.

Evolution and prognostic relevance of right ventricular morphofunctional parameters in patients undergoing isolated tricuspid valve surgery

Abstract Background Right ventricular (RV) function is key in evolution after isolated tricuspid valve surgery (ITVS). Right ventricular-pulmonary artery coupling (RV-PA coupling), determined with echocardiography as the ratio TAPSE/sPAP, has merged as a relevant functional parameter in many clinical scenarios. Purpose Our aim is to evaluate the prognostic relevance of RV-PA coupling in patients undergoing ITVS. Methods We carried out a retrospective study involving all the patients undergoing ITVS at our tertiary centre. Several RV function measurements were assessed from the baseline echocardiogram (TAPSE, fractional area change (FAC), systolic pulmonary artery pressure (sPAP), tricuspid annulus tissue Doppler velocity (RVS´) and free-wall global longitudinal strain (FW-GLS)) and RV-PA coupling was calculated. Association between RV morphofunctional variables and mortality during one year follow-up was determined. Results 45 patients were included (68 years-old, 51,1% female). The most common TR etiology was functional (51.1%) and 42.2% had previous left-sided valvular surgery. The median Tri-Score was 2 (1-4) points and the most frequent procedure was biological valve replacement (65%). Baseline echocardiographic parameters were as follows: basal 52 (48 – 53.5) mm, mid 40 (36-45.5) mm and longitudinal 73 (68-80) RV diameters, TAPSE 18.1 (15.5-20.7) mm, RVS´ 10.1 (9-12.5) cm/s, FAC 0.5 (0.43-0.57), sPAP 35 (31.5-37.5) mmHg, and FW-GLS - 21.1 (17.2-25) %. During the follow-up 8 (18%) patients died. Solely TAPSE (16 vs 19, p= 0.047) and RV-PA coupling (0.35 vs 0.5; p= 0.035) showed significant differences in mortality among RV echocardiographic parameters. An RV-PA coupling &amp;lt;0.375 mm/mmHg appeared to be the best mortality predictor (RR 1.45; p= 0.04) one year after the intervention (Figure). Conclusions In our series RV-PA coupling has proved to be the best echocardiographic prognostic factor in ITVS, so it could be considered a relevant parameter in risk stratification previous to this surgery. Figure. Kaplan Meier curves of mortality after ITVS by RV-PA coupling.Figure

Machine learning approach for detection of valvular heart disease through digital cardiac auscultation: results from multi-center prospective cross-sectional study

Abstract Background Cardiac auscultation, an essential bedside diagnostic tool, often identifies significant valvular heart disease through murmurs. However, its accuracy is contingent upon the clinician's expertise, leading to a growing dependence on expensive imaging techniques. This study aimed to develop and validate a machine learning model for detecting valvular heart disease from cardiac auscultation. Methods The digital cardiac auscultation and associated echocardiograms were prospectively collected from three sites between May 1, 2022, and Dec 31, 2022. We trained, validated, and externally tested a machine learning based model to classify aortic stenosis, mitral stenosis, aortic regurgitation, mitral regurgitation, tricuspid regurgitation, oveall valvular heart disease from cardiac auscultation, age, sex, and comorbidity. We condcted training, and internal testing using datasets for eXtreme Gradient Boosting (XGBoost) machine learning model from hospital one and hospital two. The dataset from hospital three was employed for external testing. We evaluated the area under the receiver operating characteristic curve (AUROC), area under the precision recall curve (AUPRC), accuracy, sensitivity, specificity. Result We selected the cardiac auscultation and echocardiograms of a total of 4,321 patients, excluding those without valvular heart disease information, congenital heart disease, a history of valvular operation, and cardiac auscultation could not be interpreted. The diagnostic performance of heart murmurs for valvular heart disease across the three datasets generally demonstrated high sensitivity and PPV. Specifically, the sensitivity for aortic stenosis was 89.1%, mitral stenosis 88.8%, aortic regurgitation 88.5%, mitral regurgitation 89.8%, tricuspid regurgitation 90.1%, and for any valvular heart disease, it was 95.0%. However, the NPV was consistently lower, with values of 16.4%, 14.2%, 12.2%, 23.1%, 26.2%, and 65.3% for the respective conditions. In XGBoost machine learning model, the AUROC values for internal testing (N=1,403), along with their 95% confidence intervals, were as follows: aortic stenosis (0.93, 0.88–0.97), mitral stenosis (0.91, 0.81–0.97), aortic regurgitation (0.84, 0.79–0.90), mitral regurgitation (0.94, 0.90–0.98), tricuspid regurgitation (0.81, 0.75–0.87), and overall valvular heart disease (0.86, 0.82–0.89). For external testing (N=814), the AUROC values were: aortic stenosis (0.90, 0.83–0.96), mitral stenosis (0.88, 0.79–0.95), aortic regurgitation (0.94, 0.93–0.96), mitral regurgitation (0.93, 0.92–0.95), tricuspid regurgitation (0.89, 0.87–0.91), and overall valvular heart disease (0.92, 0.90–0.94). Conclusion The machine learning based model can accurately classify valvular heart diseases using information from digital cardiac auscultation.Figure 1.Study FlowFigure 2.AUC curve

Lupus anticoagulant and valvular cardiac surgery.

Despite its name, lupus anticoagulant (LAC) neither exclusively occurs in lupus nor induces anticoagulation. It is an antiphospholipid antibody found in 2%-4% of the population that promotes clot formation by targeting phospholipid-protein complexes in cell membranes. However, in vitro, LAC exhibits paradoxical effects, prolonging clotting times in phospholipid-dependent assays such as Activated Partial Thromboplastin Time (APTT). This unpredictability extends to point-of-care tests like Activated Clotting Time (ACT), which are frequently used to monitor anticoagulation during cardiac surgeries involving cardiopulmonary bypass (CPB). High doses of unfractionated heparin (UFH) are administered in these procedures, but the presence of LAC complicates ACT measurements, creating challenges for both anesthesiologists and surgeons. This case report highlights the clinical implications of LAC in perioperative management, underscoring the difficulties in ensuring adequate anticoagulation during CPB.

Cost-effectiveness analysis of valvular surgery in high- and low- to middle-income countries: A scoping review.

Global disparities in valvular surgery services exist. Cost-effectiveness analysis (CEA) and cost-utility analysis can be used to guide national investment decisions. This scoping review aims to synthesize economic evaluations for valvular surgery by income settings and provide recommendations. A systematic literature review identified primary CEAs or CUAs in English comparing surgical management strategies for valvular heart disease. MEDLINE, Embase, CINAHL, Web of Science, and Business Source Complete were searched using keywords "valvular surgery," "valve disease," "cost-effectiveness," and "cost-benefit analysis". Articles comparing outcomes or costs only were excluded. Search results were uploaded and screened on COVIDENCE. Variables from eligible articles were charted in a spreadsheet. Twenty articles were eligible, six from low- and middle-income countries (LMICs) and 14 from high-income countries (HICs). In HICs, the top conditions were degenerative aortic valve disease (7/14) and mitral valve disease (4/14) compared to congenital (2/6) and rheumatic heart diseases (2/6) in LMICs. HICs evaluated new technologies and techniques, whereas LMICs compared different valve types or surgery versus no intervention. Most articles used published studies (12/20) or databases (7/20) to conduct their CEA and quality-adjusted life years was the most common effectiveness measure (12/20). Comparator interventions were cost-effective in all LMIC articles and in 8/14 for HICs. Economic evaluations are mostly conducted in HICs and for adult conditions. More analyses in LMICs are needed. This can be facilitated by maintaining databases, documenting costs, and implementing quality of life assessments.

Right thoracotomy with central cannulation for valve surgery: 10 years of experience.

The aim of this study is to report the early outcomes of valvular heart surgeries performed via the right thoracotomy approach. While thoracotomy with femoro-femoral bypass is an established method for minimally invasive open-heart surgeries, thoracotomy with conventional cannulation is still being explored. In our center, we conducted 958 valvular heart surgery cases using the right anterolateral thoracotomy approach with central cannulation and data were analyzed. This is a retrospective observational study based on prospectively collected data from patients who underwent valvular heart surgery at our center spanning from April 2013 to April 2023. The data encompass demographics, procedures, operative techniques, post-operative morbidity, mortality, and a 1-month follow-up. Our study revealed no procedure-related mortality. No patient required conversion to median sternotomy. Smooth cannulation and satisfactory exposure were achieved in all patients. The study encompassed a wide age range, from 14 to 68 years, with 618 female patients (64.5%) and 340 male patients (35.5%). The average cross-clamp time ranged from 38 to 90min, the duration of cardio-pulmonary bypass ranged from 45 to 105min, post-operative extubation ranged from 3 to 8h, the average drain volume ranged from 100 to 350ml, and the incision size ranged from 5 to 7cm. Our data demonstrate that conventional cannulation via the right antero-lateral thoracotomy approach for valvular heart disease is a viable alternative to reduce the side effects associated with sternotomy and femoral cannulation. This procedure is safe, reproducible, and provides the same level of treatment quality.

Low Frequency Ventilation During Cardiopulmonary Bypass to Protect Postoperative Lung Function in Cardiac Valvular Surgery: The PROTECTION Phase II Randomized Trial.

Cardiac surgery with cardiopulmonary bypass (CPB) triggers pulmonary injury. In this trial we assessed the feasibility, safety, and efficacy of low frequency ventilation (LFV) during CPB in patients undergoing valvular surgery. Patients with severe mitral or aortic valve disease were randomized to either LFV or usual care. Primary outcomes included release of generic inflammatory and vascular biomarkers and the lung-specific biomarker sRAGE (soluble receptor for advance glycation end products) up to 24 hours postsurgery. Secondary outcomes included pulmonary function tests and 6-minute walking test up to 8 weeks postdischarge. Sixty-three patients were randomized (33 LFV versus 30 usual care). Mean age was 66.8 years and 30% were female. LFV was associated with changes of sRAGE (soluble receptor for advance glycation end products) levels (geometric mean ratio, 3.05; [95% CI, 1.13-8.24] 10 minutes post CPB, and 1.07 [95% CI, 0.64-1.79], 0.84 [95% CI, 0.55-1.27], 0.67 [95% CI, 0.42-1.07], and 0.62 [95% CI, 0.45-0.85] at 2, 6, 12, and 24 hours post CPB respectively). No changes were observed for any of the generic biomarkers. Respiratory index soon after surgery (mean difference, -0.61 [95% CI, -1.24 to 0.015] 10 minutes post end of CPB), forced expiratory volume after 1 second/forced vital capacity ratio (0.050 [95% CI, 0.007-0.093] at 6 to 8 weeks pos-surgery), Forced vital capacity alone (95% CI, -0.191 L [-0.394 to 0.012]) and 6-minute walking test score at discharge (63.2 m [95% CI, 12.9-113.6]) were better preserved in the LFV group. No other differences were noted. The use of LFV during CPB in patients undergoing valvular surgery was feasible and safe and was associated with changes in sRAGE levels along with better preserved lung function and walking performance. These observations warrant further investigation in larger future studies. URL: https://www.isrctn.com; Unique Identifier: ISRCTN75795633.

Incidence of Clinical Outcomes in Minimally Invasive Valvular Surgery at the Ignacio Chávez National Institute of Cardiology.

Minimally invasive cardiac valve replacement surgery (MICS) is a technique that has reported equivalent rates of mortality and reintervention when compared to conventional median sternotomy (CS). Additionally, MICS has inconsistently been reported to be associated with fewer postoperative complications, better cosmetic outcomes, and shorter hospital stays at the expense of longer surgical time, aortic clamp time, and extracorporeal circulation time. When comparing populations undergoing MICS vs CS at the Ignacio Chávez National Institute of Cardiology (INCICh), it was proven that there is a longer surgical, extracorporeal circulation, and aortic clamp durations in the MICS intervention, but no statistically significant difference in global mortality. MICS was also associated with a shorter hospital stay and less surgical discomfort. MICS can be considered an alternative and equivalent approach to CS for patients undergoing aortic and mitral valve replacement surgery in the Mexican population.

Magnesium sulphate to prevent perioperative atrial fibrillation in cardiac surgery: a randomized clinical trial

BackgroundPostoperative atrial fibrillation (POAF) is a common and potentially serious complication post cardiac surgery. Hypomagnesaemia is common after cardiac surgery and recent evidence indicates that supplementation of magnesium may prevent POAF. We aim to investigate the effectiveness of continuous intravenous magnesium sulphate administration in the perioperative period to prevent POAF as compared to placebo.MethodsThe (POMPAE) trial is a phase 2, single-center, double-blinded randomized superiority clinical study. It aims to assess the impact of perioperative continuous intravenous magnesium administration on the occurrence of cardiac surgery-related POAF. A total of 530 patients will be included. Eligible patients will be randomized in 1:1 ratio to the intervention or placebo group with stratification based on the presence of valvular surgery. The objective of the infusion is to maintain ionized magnesium levels between 1.5 and 2.0 mmol/L.DiscussionThe primary outcome measure is the incidence of de novo POAF within the first 7 days following surgery, with censoring at hospital discharge. This trial may generate crucial evidence for the prevention of POAF and reduce clinical adverse events in patients following cardiac surgery.Trial registrationThe POMPAE trial was registered at ClinicalTrials.gov under the following identifier NTC05669417, https://clinicaltrials.gov/ct2/show/NCT05669417. Registered on December 30, 2022.Protocol versionVersion 3.3, dated 13–01-2023.

Aortic Root Enlargement by “Y” Technique – Our Experience

Aortic valve replacement is the commonest valvular surgery done around the world. In Asian population the aortic valve annulus size is smaller. So there is always a chance of patient prosthesis mismatch. There a number of techniques of aortic root enlargement during aortic valve replacement. We have used ‘Y incision technique’ in six of our patients in this case series. This technique is feasible and perioperative outcomes are promising. But it needs more mid and long - term results. Cardiovasc j 2024; 16(2): 98-101

Early administration of ketorolac after cardiac surgery and postoperative complications: Analysis of the MIMIC-IV database.

Inflammation may contribute to postoperative cardiac complications and ketorolac, an anti-inflammatory agent inhibiting cyclooxygenase (COX), shows promise in enhancing cardiac graft patency by suppressing endothelial cell proliferation in animal studies. However, the safety of postoperative ketorolac use remains controversial. This study investigates the association between early ketorolac application and complications following cardiac surgery. Data from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database fueled this retrospective cohort study. The primary outcome is a composite of mortality, pulmonary insufficiency, severe acute kidney injury (AKI), hemorrhage or hematoma, infection, cardiogenic shock, and cerebrovascular infarction postcardiac surgery. Propensity score matching (PSM; 1:1 match, caliper 0.2), multivariate logistic regression, interaction stratification analysis, pairwise algorithmic, and overlap weight model analyses were employed. Following inclusion and exclusion criteria, 7143 patients who underwent valvular surgery or coronary artery bypass grafting (CABG) were included. PSM created a balanced cohort of 3270 individuals (1635 in the ketorolac group). The matched cohort exhibited an 8.1% overall rate of postoperative complications, with a lower composite outcome rate in patients receiving ketorolac within 48 h of surgery compared with those without (PSM, OR 0.70 [95% CI, 0.54-0.90]). Consistent associations were observed in total cohort analyses, sensitivity, and subgroup analyses. Early ketorolac use within 48 h post-CABG or valvular procedures in adults is independently associated with a lower incidence of composite postoperative adverse events. Prospective trials are warranted to assess causality.

Impact of Residential Remoteness on Valvular Heart Surgery Outcomes in Western Australia (WA)

Impact of Residential Remoteness on Valvular Heart Surgery Outcomes in Western Australia (WA)