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Background Aortic valve infective endocarditis (IE) is associated with significant morbidity and mortality. We aimed to describe the clinical profile, risk factors and predictors of short- and long-term mortality in patients with aortic valve IE treated with aortic valve replacement (AVR) compared with a control group undergoing AVR for non-infectious valvular heart disease. Methods Between January 2008 and December 2013, a total of 170 cases with IE treated with AVR (exposed cohort) and 677 randomly selected non-infectious AVR-treated patients with degenerative aortic valve disease (controls) were recruited from three tertiary hospitals with cardiothoracic facilities across Scandinavia. Crude and adjusted hazard ratios (HR) were estimated using Cox regression models. Results The mean age of the IE cohort was 58.5 ± 15.1 years (80.0% men). During a mean follow-up of 7.8 years (IQR 5.1-10.8 years), 373 (44.0%) deaths occurred: 81 (47.6%) in the IE group and 292 (43.1%) among controls. Independent risk factors associated with IE were male gender, previous heart surgery, underweight, positive hepatitis C serology, renal failure, previous wound infection and dental treatment (all p  < 0.05). IE was associated with an increased risk of both short-term (≤ 30 days) (HR 2.86, [1.36–5.98], p  = 0.005) and long-term mortality (HR 2.03, [1.43–2.88], p  < 0.001). In patients with IE, chronic obstructive pulmonary disease (HR 2.13), underweight (HR 4.47), renal failure (HR 2.05), concomitant mitral valve involvement (HR 2.37) and mediastinitis (HR 3.98) were independent predictors of long-term mortality. Staphylococcus aureus was the most prevalent microbe (21.8%) and associated with a 5.2-fold increased risk of early mortality, while enterococci were associated with the risk of long-term mortality (HR 1.78). Conclusions In this multicenter case-control study, IE was associated with an increased risk of both short- and long-term mortality compared to controls. Efforts should be made to identify, and timely treat modifiable risk factors associated with contracting IE, and mitigate the predictors of poor survival in IE.

Background Observational studies have shown reduced perioperative bleeding in patients undergoing minimally invasive, compared with full sternotomy, aortic valve replacement. Data from randomized trials are conflicting. Methods This was a Swedish single center study where adult patients with aortic stenosis, 100 patients were randomly assigned in a 1:1 ratio to undergo either minimally invasive (ministernotomy) or full sternotomy aortic valve replacement. The primary outcome was severe or massive bleeding defined by the Universal Definition of Perioperative Bleeding in adult cardiac surgery (UDPB). Secondary outcomes included blood product transfusions, chest tube output, re-exploration for bleeding, and several other clinically relevant events. Results Out of 100 patients, three patients randomized to ministernotomy were intraoperatively converted to full sternotomy (none was bleeding-related). Three patients (6%) in the full sternotomy group and 3 patients (6%) in the ministernotomy group suffered severe or massive postoperative bleeding according to the UDPB definition ( p  = 1.00). Mean chest tube output during the first 12 postoperative hours was 350 (standard deviation (SD) 220) ml in the full sternotomy group and 270 (SD 190) ml in the ministernotomy group ( p  = 0.08). 28% of patients in the full sternotomy group and 36% of patients in the ministernotomy group received at least one packed red blood cells transfusion ( p  = 0.39). Two patients in each group (4%) underwent re-exploration for bleeding. Conclusions Minimally invasive aortic valve replacement did not result in less bleeding-related outcomes compared to full sternotomy. Clinical Trial Registration http://www.clinicaltrials.gov . Unique identifier: NCT02272621.

Background Clinical evidence in coronary surgery is usually derived from retrospective, single institutional series. This may introduce significant biases in the analysis of critical issues in the treatment of these patients. In order to avoid such methodological limitations, we planned a European multicenter, prospective study on coronary artery bypass grafting, the E-CABG registry. Design The E-CABG registry is a multicenter study and its data are prospectively collected from 13 centers of cardiac surgery in university and community hospitals located in six European countries (England, Italy, Finland, France, Germany, Sweden). Data on major and minor immediate postoperative adverse events will be collected. Data on late all-cause mortality, stroke, myocardial infarction and repeat revascularization will be collected during a 10-year follow-up period. These investigators provided a score from 0 to 10 for any major postoperative adverse events and their rounded medians were used to stratify the severity of these complications in four grades. The sum of these scores for each complication/intervention occurring after coronary artery bypass grafting will be used as an additive score for further stratification of the prognostic importance of these events. Discussion The E-CABG registry is expected to provide valuable data for identification of risk factors and treatment strategies associated with suboptimal outcome. These information may improve the safety and durability of coronary artery bypass grafting. The proposed classification of postoperative complications may become a valuable research tool to stratify the impact of such complications on the outcome of these patients and evaluate the burden of resources needed for their treatment. Clinical Trials number NCT02319083

Background Arterial air embolism during open heart surgery may cause postoperative complications including cerebral injury, myocardial dysfunction, and dysrhythmias. Despite standard de-airing techniques during surgery large amounts of arterial air emboli may still occur, especially during weaning from cardiopulmonary bypass. To prevent this insufflation of carbon dioxide in the wound cavity has been used since the 1950s. The aim of this study was to assess a new mini-diffuser for efficient carbon dioxide de-airing of a minimal invasive cardiothoracic wound cavity model. Up until now no device has been evaluated for this purpose. Methods A new insufflation device, a mini-diffuser, was tested. A thin plastic tube was used as control. The end of the mini-diffuser or the control, respectively, was positioned in a minimal invasive thoracic wound model. Remaining air content was measured during steady state and during intermittent suction with a rough suction device at different carbon dioxide flow rates. Measurements were also carried out in the open surgical wound during minimal invasive aortic surgery in six patients. Results T he air content was below 1% 4 cm below the surface of the open wound model during continuous carbon dioxide inflow of 2–10 L/min with the mini diffuser. In comparison, carbon dioxide insufflation via the open-ended tube resulted in a mean air content between 10 and 75%. The mean air content of the wound model remained below 1% at a carbon dioxide flow rate of 3–5 L/min during intermittent application of a suction device with a suction rate of 15 L/min. In 6 patients undergoing minimal invasive aortic valve replacement air content in the open surgical wound remained below 1% at a continuous carbon dioxide flow rate of 5 and 8 L/min via the mini-diffuser, respectively. Conclusions The mini diffuser was effective for carbon dioxide de-airing, i.e. < 1% remaining air, of a minimal invasive cardiothoracic wound cavity model with and without intermittent rough suction as well as in patients undergoing minimal invasive aortic valve surgery.

Salvage coronary artery bypass grafting (CABG) is often performed for cardiogenic shock on compassionate basis without clinical data justifying this aggressive approach. The aim of this study was to analyze early and intermediate outcomes after salvage CABG. We retrospectively reviewed the data of 85 patients who underwent salvage CABG at 11 European cardiac surgery centers. Salvage CABG was defined according to the EuroSCORE criteria, that is, a procedure performed in patients requiring cardiopulmonary resuscitation (external cardiac massage) en route to the operating theater or before induction of anesthesia. A percutaneous coronary intervention procedure preceded salvage CABG in 55 patients (64.7%). Thirty patients (35.3%) died during the inhospital stay. The mean EuroSCORE II was 32.0% and the observed-to-expected ratio was 1.08. Salvage CABG was associated with high rates of postoperative stroke (9.4%), resternotomy for bleeding (23.5%), resternotomy for hemodynamic instability (15.3%), dialysis (18.8%), severe gastrointestinal complications (12.9%), and deep sternal wound infection (10.6%). Survival at 1, 3, and 5 years was 58.6%, 49.8%, and 40.9%, respectively. Twenty patients (23.5%) were postoperatively treated with extracorporeal membrane oxygenation (ECMO). The rates of adverse events after ECMO were particularly high (stroke 40%, resternotomy for bleeding 60%, dialysis 35%, gastrointestinal complications 30%, and deep sternal wound infection 30%). Of patients treated with ECMO, 8 (40%) survived to discharge, and 1-year survival was 29.2%. Salvage CABG is associated with high risk of immediate mortality and severe adverse events. However, the observed immediate and intermediate outcome justify coronary surgery in these critically ill patients. A number of these patients are currently treated by ECMO, and its results are encouraging.

OBJECTIVES Myocardial recovery allows for left ventricular assist device (LVAD) explantations after long-term support. Several surgical approaches, including interventional decommissioning, off-pump explantation using a custom-made plug and complete LVAD removal through redo sternotomy, have been described. We present the results from an evaluation of the long-term follow-up of patients who received a titanium sintered plug after LVAD explantation. METHODS We performed a retrospective, European, multicentre analysis of patients who received a titanium sintered plug to seal the apical fixation ring after LVAD explantation. Data were collected from a questionnaire that included demographics, procedural details and follow-up information. RESULTS Out of 54 contacted centres in 12 countries (n = 179 patients), a total of 68 patients were successfully included in the study. The median follow-up was 34 months (interquartile range: 17–58.5 months); 57 (84%) patients had >1-year follow-up. At the time of the last follow-up, 55 (81%) patients were alive, with a Kaplan–Meier 1-year survival of 90.1% (95% confidence interval: 84.0–98.1%) and a 5-year survival of 80.0% (95% confidence interval: 68.4–92.9%). One patient (1.5%) developed a plug infection originating from an infected part of the incorporated driveline and, after complete removal, is currently in good condition. No postoperative stroke has been reported after plug implantation. CONCLUSIONS In this European multicentre study, the use of a custom-made titanium plug to close the apical fixation ring after LVAD explantation resulted in a low incidence of plug-related complications. With the volume of patients undergoing LVAD explantations after myocardial recovery increasing, the plug has evolved as a simple alternative to more invasive device explantation procedures or decommissioning with a high risk for infection of the remaining system or stroke.

Aims Ramp testing in the postoperative period can be used to optimize left ventricular assist device (LVAD) speed for optimal left ventricular (LV) unloading. We tested the hypothesis that a non‐invasive echocardiographic ramp test post‐HeartMate 3 implantation improves LV unloading immediately after and 1–3 months after as compared with before the test. We also tested a secondary hypothesis that speed adjustments during echocardiography‐guided ramp testing do not worsen right ventricular (RV) function immediately after and 1–3 months after. Methods and results We retrospectively reviewed data from patients who underwent an echocardiographic ramp test. A total of 14 out of 19 patients were clinically stable and were enrolled. Adequate LV unloading was defined as no more than mild mitral regurgitation, and intermittent aortic valve (AV) opening or closed AV, and reduction of left ventricular end‐diastolic diameter (LVEDD); and for the follow‐up measurement, decreased NT‐proBNP. Median (interquartile range) time from implantation to ramp test was 27 (16; 56) days, and median time from ramp test to follow‐up echocardiography was 55 (47; 102) days. Median LVAD speed achieved during ramp testing was 5550 (5375; 6025) revolutions per minute (rpm), and median final LVAD speed was 5200 (5000; 5425) rpm. Ramp testing resulted in final LVAD speed increase in 11 (79%) patients and a median net change of 200 (200; 300) rpm. Speed adjustments after ramp testing resulted in improved LVAD unloading that was achieved in additional 3 (21%) patients who were not originally optimized. RV function did not worsen significantly during ramp testing or at final LVAD speed. Conclusions The echocardiographic ramp test allowed LVAD speed adjustment and optimization and improved LV unloading during ramp testing and at final speed with no evidence of worsening of RV function.

The aim of this study was to compare the immediate outcome of patients undergoing transcatheter (TAVI) versus surgical aortic valve replacement with the sutureless Perceval bioprosthesis (SU-AVR). This is a retrospective multicenter analysis of 773 patients who underwent either TAVI (394 patients, mean age, 80.8 ± 5.5 years, mean EuroSCORE II 5.6 ± 4.9 %) or SU-AVR (379 patients, 77.4 ± 5.4 years, mean EuroSCORE II 4.0 ± 3.9 %) with or without concomitant myocardial revascularization. Data on SU-AVRs were provided by six European institutions (Belgium, Finland, Germany, Italy and Sweden) and data on TAVIs were provided by a single institution (Catania, Italy). In-hospital mortality was 2.6 % after SU-AVR and 5.3 % after TAVI ( p  = 0.057). TAVI was associated with a significantly high rate of mild (44.0 vs. 2.1 %) and moderate–severe paravalvular regurgitation (14.1 vs. 0.3 %, p  < 0.0001) as well as the need for permanent pacemaker implantation (17.3 vs. 9.8 %, p  = 0.003) compared with SU-AVR. The analysis of patients within the 25th and 75th percentiles interval of EuroSCORE II, i.e., 2.1–5.8 %, confirmed the findings of the overall series. One-to-one propensity score-matched analysis resulted in 144 pairs with similar baseline characteristics and operative risk. Among these matched pairs, in-hospital mortality (6.9 vs. 1.4 %, p  = 0.035) was significantly higher after TAVI. SU-AVR with the Perceval prosthesis in intermediate-risk patients is associated with excellent immediate survival and is a valid alternative to TAVI in these patients.

Background The open surgical wound is exposed to cold dry ambient air, resulting in substantial heat loss through radiation, evaporation, and convection. At the same time, anesthesia decreases the patient’s core temperature. Despite preventive measures, mild intraoperative hypothermia has been associated with postoperative morbidity. We hypothesized that local insufflation of warmed humidified carbon dioxide (CO 2 ) would maintain wound and core temperature. Methods Eighty patients undergoing open colon surgery were randomized to standard warming measures, or to additional local wound insufflation of warmed (30 °C) humidified (93 % rH) CO 2 via a gas diffuser. Surface temperature of the open abdominal wound was measured with a heat-sensitive infrared camera, and core temperature was measured with an ear thermometer. Results Mean operative time was 219 ± 104 and 205 ± 85 min in the CO 2 group and the control group, respectively ( p  = 0.550). Clinical variables did not differ significantly between the groups. The median wound area and wound edge temperatures were 1.2 °C ( p  < 0.001) and 1.0 °C ( p  = 0.002) higher in the CO 2 group, respectively, than in the control group. The mean core temperature after intubation was the same (35.9 °C) in both groups, but at end of surgery core temperature in the two groups differed, with a mean of 36.2 ± 0.5 °C in the CO 2 group and a mean of 35.8 ± 0.5 °C in the control group ( p  = 0.003). Conclusions Insufflation of warmed, humidified CO 2 in an open surgical wound cavity prevents intraoperative decrease in surgical wound temperature as well as core temperature.

Background The use of left ventricular assist devices (LVADs) has increased in the last decade. Major complications have been well described, but there is no data on device alarms and actual or threatening malfunction which impair quality of life and may impair outcomes. This study describes the technical problems related to the use of the HVAD® left ventricular assist device in a single center. Methods We retrospectively reviewed device malfunctions and outcomes in 22 patients with HVAD ® left ventricular assist device followed at Karolinska University Hospital between 2011 and 2016. Device malfunction was defined by INTERMACS as a failure of one or more of the components of the LVAD system. The primary outcome was defined as death or hospitalization or unplanned urgent clinic visit due to device alarm of unknown significance or actual or threatening malfunction. Separate secondary outcomes were malfunction resulting in controller exchange and malfunction resulting in battery change. Exploratory outcomes were death, transplantation, or explantation because of recovery. Results Median age was 59 years and 19% were women. Over a mean follow-up time of 1.7 years (37 patient-years), the primary outcome occurred 30 times (0.8 events per patient-year; 0 deaths, 2 hospitalizations and 28 un-planned clinic visits). Secondary outcomes were 41 device malfunctions for 14 patients requiring 45 controller exchanges in 12 patients (1.1 events per patient-year) and 128 battery changes in 12 patients (3.5 events per patient-year). Exploratory outcomes were 8 deaths (36.4%), 7 transplantations (31.8%) and 2 explants due to recovery (9.1%). Conclusion The use of HVAD® was associated with technical problems requiring frequent un-planned clinic visits and changes of controller and/or batteries. There were no deaths due to device malfunction. Further studies are warranted to evaluate the risk of device malfunction and associated reductions in quality of life and cost.