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Background and Objectives: Increasing reluctance to perform surgical mitral valve repair or replacement particularly in high-risk patients with poor left-ventricular function is trending. These patients are increasingly treated interventionally, e.g., by MitraClip, but often show only low to moderate improvement. The primary objective of the study was to investigate whether left ventricular ejection fraction (LVEF) influences postoperative mortality. Materials and Methods: The study included 903 patients undergoing mitral valve repair or replacement between 2009 and 2021. Statistical comparison was performed between patients with LVEF ≤ 30% and LVEF > 30%. Finally, statistical analysis was performed according to propensity score matching (1:3 PS matching). Results: No significant difference in in-hospital mortality was found before and after matching regarding LVEF ≤ 30% and LVEF > 30% (Pre: 10.8% vs. 15.1%, p = 0.241, after: 11.6% vs. 18.1%, p = 0.142). After PS matching, the 112 patients with LVEF ≤ 30% compared with 336 patients with LVEF > 30% showed a significantly higher preoperative NT-proBNP (p < 0.001), larger diameters at preoperative left ventricle and atrium (p < 0.001), lower preoperative TAPSE (p = 0.003) and PAP (p = 0.003), and more dilated cardiomyopathy and chronic kidney disease (p < 0.001, p = 0.045). Conclusions: The results of this study demonstrate that poor preoperative LVEF alone does not play a significant role in postoperative outcome and long-term mortality. Prognosis appears to be multifactorial. Poor preoperative LVEF is not a contraindication for surgery and does not justify primary interventional treatment accepting inferior hemodynamic results impeding outcome.

Background and Objectives: Friable or infected tissue remains a challenge in surgical aortic valve replacement. We recently described the “Caput medusae” method, in which circumferential tourniquets temporarily secure the prosthesis and are then gently knotted. Tourniquets have been shown to develop significantly less force than knots. The current study investigates the critical threshold forces for tissue damage to the aortic annulus. Materials and Methods: In 14 fresh porcine hearts, the aortic valve leaflets were removed and several pledgeted sutures were placed along the annulus at defined locations. The hearts were mounted in a self-constructed device. Incremental traction force was applied to every suture and continuously recorded. The movement of each Teflon pledget was filmed with a high-speed camera. Forces at the moment of pledget “cut-in” as well as complete “tear-out” were determined from the recordings. Results: The average threshold force was determined 9.31 ± 6.04 N for cut-in and 20.41 ± 10.02 N for tear-out. Detailed analysis showed that the right coronary region had lower threshold forces than the other regions (4.77 ± 3.28 N (range, 1.67–12.75 N) vs. 10.67 ± 6.04 N (1.62–26.00 N) for cut-in and 10.67 ± 4.04 N (5.40–18.64 N) vs. 23.33 ± 9.42 N (9.22–51.23 N) for tear-out). The findings are discussed in conjunction with the knot and tourniquet forces from our previous study. Conclusions: Even in healthy tissue, moderate forces can reach a critical level at which a Teflon pledget will cut into the annulus, while a complete tear-out is unlikely. The right coronary portion is more susceptible to damage than the remaining regions. When compared to previous data, forces during manual knotting may exceed the critical cut-in level, while rubber tourniquets may provide a higher safety margin against tissue rupture.

The study aimed to establish a long-term 3D cell culture model using luteinized follicular cells to investigate the functionality and life cycle of the CL in felids. A mixture of cell types from antral follicles was luteinized in vitro and cultured for up to 23 days. The method, initially applied to the domestic cat, was later extended to Persian and Clouded leopards. Antral follicles were isolated and digested with enzymes; then, the cells were subjected to culture. Experimental subsets were treated with/without 1 µg/mL cloprostenol to validate the cell culture model’s suitability for functional studies. In domestic cat samples, microscopic evaluation indicated luteinization, which was confirmed by increased progestagen concentrations and IHC staining for HSD3B and CYP11A1. The gene expression of selected steroidogenic factors (HSD3B1, STAR, CYP11A1) and hormone receptors (LHCGR, PTGFR, PRLR) significantly increased, while CYP17A1 expression decreased. Cloprostenol treatment resulted in reduction of steroidogenic activity, proving its suitability for functional studies. Persian and Clouded leopards’ cell cultures exhibited similar patterns in progestagen secretion and gene expression, compared to domestic cats. This model, with its defined luteinization, as well as high and stable progestagen production, allows future investigation of factors regulating CL life cycle and function.

(1) Background: Polymeric heart valves are prostheses constructed out of flexible, synthetic materials to combine the advantageous hemodynamics of biological valves with the longevity of mechanical valves. This idea from the early days of heart valve prosthetics has experienced a renaissance in recent years due to advances in polymer science. Here, we present progress on a novel, 3D-printable aortic valve prosthesis, the TIPI valve, removing the foldable metal leaflet restrictor structure in its center. Our aim is to create a competitive alternative to current valve prostheses made from flexible polymers. (2) Methods: Three-dimensional (3D) prototypes were designed and subsequently printed in silicone. Hemodynamic performance was measured with an HKP 2.0 hemodynamic testing device using an aortic valve bioprosthesis (BP), a mechanical prosthesis (MP), and the previously published prototype (TIPI 2.2) as benchmarks. (3) Results: The latest prototype (TIPI 3.4) showed improved performance in terms of regurgitation fraction (TIPI 3.4: 15.2 ± 3.7%, TIPI 2.2: 36.6 ± 5.0%, BP: 8.8 ± 0.3%, MP: 13.2 ± 0.7%), systolic pressure gradient (TIPI 3.4: 11.0 ± 2.7 mmHg, TIPI 2.2: 12.8 ± 2.2 mmHg, BP: 8.2 ± 0.9 mmHg, MP: 10.5 ± 0.6 mmHg), and effective orifice area (EOA, TIPI 3.4: 1.39 cm2, TIPI 2.2: 1.28 cm2, BP: 1.58 cm2, MP: 1.38 cm2), which was equivalent to currently used aortic valve prostheses. (4) Conclusions: Removal of the central restrictor structure alleviated previous concerns about its potential thrombogenicity and significantly increased the area of unobstructed opening. The prototypes showed unidirectional leaflet movement and very promising performance characteristics within our testing setup. The resulting simplicity of the shape compared to other approaches for polymeric heart valves could be suitable not only for 3D printing, but also for fast and easy mass production using molds and modern, highly biocompatible polymers.

Objective: Cardiosurgical mitral valve repair (MVR) cannot be easily replaced by other interventional procedures due to the complexity of mitral valve regurgitation as well as physiologic and anatomic repair techniques. A wide variety of techniques have been adopted for proper reconstruction of posterior leaflet prolapse. We investigated the long-term results of quadrangular resections and compared them with a simplified reconstruction maneuver, the inverse plication. Methods: We retrospectively collected data from 1977 patients after mitral valve repair between 2004 and 2022. After considering inclusion and exclusion criteria, we analyzed data from 180 patients after MVR with and without concomitant procedures such as CABG and/or aortic valve replacement (AVR). All MVRs were performed with a semi-rigid annuloplasty ring. A total of 180 patients received quadrangular resection (QuadRes, N = 120)) or inverse plication (InvPlic, N = 60) of the posterior leaflet, among other measures. Demographic data, risk factors, procedure times, hospitalization time, early and long-term mortality as well as Kaplan–Meier survival were analyzed. Results: Age (65.3 vs. 63.1 years) and sex (28.8% female vs. 337.5% female) did not differ significantly, and the EuroSCORE was significantly higher in the InvPlic group (6.46 ± 2.75) than in the QuadRes group (5.68 ± 3.1). Procedural times did not differ for cardiopulmonary bypass, and were as follows: InvPlic 136 ± 44 min; QuadRes 140 ± 48 min; X-Clamp: InvPlic 91 ± 31 min; QuadRes 90 ± 32 min. Hospitalization time was slightly but insignificantly lower in the InvPlic group (15.5 days) than in the QuadRes group (16.1 days). Early mortality (5.08% vs. 8.33%) and re-do procedures (1.69% InvPlic; 6.67% QuadRes) did not differ significantly. However, long-term mortality was significantly lower in the InvPlic group (15.25% vs. 32.32%, p = 0.029). Conclusions: Among the surgical measures for the posterior leaflet, inverse plication appears to be non-inferior to quadrangular resection in unselected all-comer patients. Long-term results and absence of re-do procedures indicate very good stability. Thus, inverse plication not only allows correction of PML, but is also completely safe in the long term and can replace quadrangular resection, especially in patients where a reduction in technical challenges and procedure duration is desired.

Background and Objectives: Developing a prosthetic heart valve that combines the advantageous hemodynamic properties of its biological counterpart with the longevity of mechanical prostheses has been a major challenge for heart valve development. Anatomically inspired artificial polymeric heart valves have the potential to combine these beneficial properties, and innovations in 3D printing have given us the opportunity to rapidly test silicone prototypes of new designs to further the understanding of biophysical properties of artificial heart valves. TRISKELION is a promising prototype that we have developed, tested, and further improved in our institution. Materials and Methods: STL files of our prototypes were designed with FreeCad 0.19.2 and 3D printed with an Agilista 3200W (Keyence, Osaka, Japan) using silicones of Shore hardness 35 or 65. Depending on the valve type, the support structures were printed in AR-M2 plastics. The prototypes were then tested using a hemodynamic pulse duplicator (HKP 2.0) simulating an aortic valve cycle at 70 bpm with 70 mL stroke volume (cardiac output 4.9 L/min). Valve opening cycles were visualized with a high-speed camera (Phantom Miro C320). The resulting values led to further improvements of the prototype (TRISKELION) and were compared to a standard bioprosthesis (Edwards Perimount 23 mm) and a mechanical valve (Bileaflet valve, St. Jude Medical). Results: We improved the silicone prototype with currently used biological and mechanical valves measured in our setup as benchmarks. The regurgitation fractions were 22.26% ± 4.34% (TRISKELION) compared to 8.55% ± 0.22% (biological) and 13.23% ± 0.79% (mechanical). The mean systolic pressure gradient was 9.93 ± 3.22 mmHg (TRISKELION), 8.18 ± 0.65 mmHg (biological), and 10.15 ± 0.16 mmHg (mechanical). The cardiac output per minute was at 3.80 ± 0.21 L/min (TRISKELION), 4.46 ± 0.01 L/min (biological), and 4.21 ± 0.05 L/min (mechanical). Conclusions: The development of a heart valve with a central structure proves to be a promising concept. It offers another principle to address the problem of longevity in currently used heart valves. Using 3D printing to develop new prototypes provides a fast, effective, and accurate way to deepen understanding of its physical properties and requirements. This opens the door for translating and combining results into modern prototypes using highly biocompatible polymers, internal structures, and advanced valve layouts.

Background: While the relationship between recent dental treatment and the development of endocarditis is largely undisputed, the relationship between poor dental status and the development of infective endocarditis has not yet been proven beyond doubt. We have therefore analyzed this hypothetical connection using our established endocarditis register (B.E.R.). Patients and Methods: A total of 72 patients who underwent dental treatment (TREAT) and 55 patients with a desolate dental status (DESOLATE) were found in our database of 530 patients subsequently developing infective endocarditis necessitating valve surgery. A propensity score analysis was performed comparing TREAT as well as DESOLATE with matched patients without these conditions as CONTROL. Results: TREAT showed significantly more often Strept. mitis (26.9%) as well as other Streptococci (36.54%, p = 0.001) compared to CONTROL (3.51% and 10.53%, respectively), whereas Staphylococci and E. faecalis were found more often in CONTROL than in TREAT (S. aureus: 22.81% vs. 15.38%, n.s.; other Staphylococci 14.04% vs. 1.92%, p = 0.033; E. faec.: 26.32% vs. 9.62%, p = 0.045). DESOLATE showed significantly more Strept. mitis compared to CONTROL (27.91% vs. 4.88%, p = 0.007). Early mortality was 23.7% in the TREAT group, while it was 15.25% in the CONTROL group and 17.02% in the DESOLATE group vs. 20.83% in the CONTROL patients. Conclusions: The current results suggest that adequate endocarditis prophylaxis to prevent bacteremia may not be carried out in patients undergoing dental treatment and may occur spontaneously in patients with poor dental care. Both situations require new strategies to avoid such severe consequences.

Objective: Age has an undeniable impact on perioperative mortality. However, it is not necessarily a predictor of frailty per se, as older patients have different outcomes. To verify specific conditions underlying frailty, we examined demographics, comorbidities, frequency, and distribution of postoperative complications influencing outcomes in a challenging cohort of patients undergoing mitral valve surgery. Methods: The study enrolled 1627 patients who underwent mitral valve surgery. Patients younger than 40 years who had been diagnosed with endocarditis were excluded. Patients were divided into three groups with ages ranging from 40–59 (n = 319), 60–74 (n = 795), and >75 years (n = 513). Baseline, comorbidities, postoperative complications, and mortality were recorded. Results: The older the patients were, the more frequently they suffered from pre- and postoperative renal insufficiency (p < 0.001). The likelihood of postoperative renal failure requiring dialysis was significantly higher with pre-existing renal failure. There was a significant association between postoperative renal insufficiency and the development of postoperative pleural or pericardial effusion (p < 0.001, p = 0.016). A significant decrease in BMI was observed in patients >75 years of age compared to the 60–74 years group (27.3 vs. 28.2 kg/m2, p = 0.007). The development of critical illnesses such as myopathy and neuropathy (CIP/CIM) was age-dependent and increased significantly with age (p = 0.04). Hospitalization duration and mortality also increased significantly with age (p = 0.013, p < 0.001). Conclusions: It appears that elderly patients with advanced renal failure have a significantly higher risk of mortality, postoperative renal failure, need for dialysis, and possibly the development of pleural and pericardial effusions in mitral valve surgery. In addition, more frequent CIP/CIM with concomitant decrease in BMI in the most advanced age group indicate sarcopenia and thus an additional feature of frailty besides renal failure.

Background: Demographic changes have led to an increase in the proportion of older patients undergoing heart surgery. The number of endocarditis cases is also steadily increasing. Given the sharp increase in patients who have received valve prostheses or electrophysiological implants, who are on chronic dialysis or taking immunosuppressants, the interdependence of these two developments is quite obvious. We have studied the situation of older patients suffering from endocarditis compared to younger ones. Are they more susceptible, and are there differences in outcomes? Patients and Methods: A total of 162 patients was studied from our database, enrolled from 2020 to 2022. Fifty-four of them were older than 75 years of age (mean age 79.9 ± 3.8 years). The remaining 108 patients had a mean age of 61.6 ± 10.1 years. EuroSCORE II (ES II) was higher in the older patients (19.3 ± 19.7) than in the younger ones (13.2 ± 16.84). The BMI was almost identical. The preoperative NYHA proportions did not differ. A statistical analysis was performed using R. Results: Older patients had a lower left ventricular ejection fraction (LVEF), a higher proportion of coronary heart disease (CHD), a higher amount of N-terminal probrain natriuretic peptides (NT-proBNPs), worse coagulation function, worse renal function than younger patients, and were more often valve prosthesis carriers compared to the younger patients. The diagnostic interval was 66.85 ± 49.53 days in the younger cohort, whereas it was only 50.98 ± 30.55 in the elderly (p = 0.081). Significantly fewer septic emboli were observed in the older patients than in the younger patients, but postoperative delirium and critical illness polyneuropathy and critical illness myopathy (CIP/CIM) were observed significantly more frequently compared to younger patients. In-hospital mortality was higher in older patients than in younger patients, but did not reach statistical significance (29.91% vs. 40.38%; p = 0.256). The postoperative clinical status was worse in older patients than in the younger ones (NYHA-stage, p = 0.022). Conclusions: Age did have an impact on the outcome, probably due to causing a higher number of cumulative preoperative risk factors. However, an interesting phenomenon was that older patients had fewer septic emboli than younger patients. It can only be speculated whether this was due to a shorter diagnostic interval or lower mobility, i.e., physical exertion. Older patients suffered more frequently than younger ones from typical age-related postoperative complications, such as delirium and CIP/CIM. In-hospital mortality was high, but not significantly higher compared to the younger patients. Considering the acceptable mortality risks, and in light of the lack of alternatives, older patients should not be denied surgery. However, individual consideration is necessary.

Jehovah's Witnesses (JW) reject the transfusion of blood components based on their religious beliefs, even if they are in danger of harm or death. In cardiac surgery, this significantly reduces the margin of safety and leads to ethical conflicts. Informed consent should be carefully documented and the patient's family should be involved. This study aims to compare the postoperative course of JW who underwent major cardiac surgery with a similar population of non-Witnesses (NW). Demographic, procedural, and postoperative data of all consecutive JW who underwent cardiac surgery at our institution were obtained from the records. They were compared with a propensity-score-matched group of NW. Anemic JW were treated with erythropoietin and/or iron as needed. Cardiac surgery was performed by experienced surgeons using median sternotomy and cardiopulmonary bypass. Common blood-sparing techniques were routinely used. Periprocedural morbidity and mortality were statistically evaluated for both groups. A total of 32 JW and 64 NW were part of the matched dataset, showing no demographic or procedural differences. EPO was used preoperatively in 34.4% and postoperatively in 15.6% of JW but not in NW. Preoperative hemoglobin levels were similar (JW, 8.09 ± 0.99 mmol/L; NW, 8.18 ± 1.06; = 0.683). JW did not receive any transfusions except for one who revoked, while NW transfusion rates were 2.5 ± 3.1 units for red cells ( < 0.001) and 0.3 ± 0.8 for platelets ( = 0.018). Postoperative levels differed significantly for hemoglobin (JW, 6.05 ± 1.00 mmol/L; NW, 6.88 ± 0.87; < 0.001), and hematocrit (JW, 0.29 ± 0.04; NW, 0.33 ± 0.04; < 0.001) but not for creatinine. Early mortality was similar (JW, 6.3%; NW, 4.7%; = 0.745). There were more pacemakers and pneumonias in JW, while all other postoperative conditions were not different. Real-world data indicate that Jehovah's Witnesses can safely undergo cardiac surgery provided that patients are preconditioned and treated by experienced surgeons who use blood-saving strategies. Postoperative anemia is observed but does not translate into a worse clinical outcome. This is consistent with other studies. Finally, the results of this study suggest that all patients should benefit from optimal pretreatment and blood-sparing strategies in cardiac surgery, not just Jehovah's Witnesses.