The latest medical research on Cardiothoracic Intensive Care

Repair of the bicuspid aortic valve has evolved in the past 25 years. The aim of this study was to review and analyze the long-term durability of isolated BAV repair with particular focus on commissural orientation (CO).

All patients who underwent bicuspid aortic valve repair for severe aortic regurgitation between 10/1998 and 12/2022 were included. The study group consists of all patients operated after 2009 ie, since CO modification. The control group includes patients who were operated before 2009. Commissural orientation was classified as symmetric, asymmetric, and very asymmetric.

Overall, 594 adult patients (93% male; mean age 42 years) were included. At 15 years, survival was 94.8% (SD : 2.2); freedom from reoperation was 86.8% (SD : 2.3). Freedom from AI≥II was 70.8% (SD : 4.7) at 15 years. Modification of commissural orientation by sinus plication was performed in 200 (33.7%) instances. Using competing risks analysis, the absence of eH measurement (P = 0.018), very asymmetric CO (P = 0.028), the presence of calcification (P < 0.001), the use of pericardial patch (P < 0.001), the use of subcommissural sutures (P < 0.001), and preoperative endocarditis (P = 0.005) were identified as independent predictors for reoperation. Follow-up was 97% complete (4228 patient-years); mean follow-up was 7 years (SD : 5).

Isolated bicuspid aortic valve repair leads to good survival and durability in all morphologic types if cusp repair is guided by effective height, suture annuloplasty is performed, and CO is modified using sinus plication in asymmetrical valves. Very asymmetrical valves may should be treated with a lower threshold for replacement.

Several studies have demonstrated that females have a higher risk of arrhythmia recurrence after pulmonary vein (PV) isolation for atrial fibrillation (AF). There are limited data on sex-based differences in PV reconnection rates at repeat ablation. We aimed to investigate sex-based differences in electrophysiological findings and atrial arrhythmia recurrence after repeat AF ablation METHODS: We conducted a retrospective study of 161 consecutive patients (32% female, age 65 ± 10 years) who underwent repeat AF ablation after index PV isolation between 2010 and 2022. Demographics, procedural characteristics and follow-up data were collected. Recurrent atrial tachycardia (AT)/AF was defined as any atrial arrhythmia ≥30 s in duration.

Compared to males, females tended to be older and had a significantly higher prevalence of prior valve surgery (10 vs. 2%; P = .03). At repeat ablation, PV reconnection was found in 119 (74%) patients. Males were more likely to have PV reconnection at repeat ablation compared to females (81 vs. 59%; P = .004). Excluding repeat PV isolation, there were no significant differences in adjunctive ablation strategies performed at repeat ablation between females and males. During follow-up, there were no significant differences in freedom from AT/AF recurrence between females and males after repeat ablation (63 vs. 59% at 2 years, respectively; P = .48).

After initial PV isolation, significantly fewer females have evidence of PV reconnection at the time of repeat ablation for recurrent AF. Despite this difference, long-term freedom from AT/AF was similar between females and males after repeat ablation.

Recurrence of tricuspid regurgitation after tricuspid annuloplasty can occur in cases where a dilated right ventricle exists and subsequent leaflet tethering follows. We previously reported a new technique of the right ventricular papillary muscle approximation for functional tricuspid regurgitation associated with leaflet tethering. The objective of this study is to elucidate the mid-term outcomes and evaluate the durability of right ventricular papillary muscle approximation.

Between January 2014 and March 2023, we applied right ventricular papillary muscle approximation in 20 patients of advanced functional tricuspid regurgitation with severe leaflet tethering. The indication of the technique was severe TR with leaflet tethering height >8mm, and/or a right ventricular end-diastolic diameter >45mm. The patients were followed up with echocardiography before discharge and at annual interval thereafter.

There was no perioperative mortality. In the echocardiography performed before discharge, tricuspid regurgitation was decreased to mild or less in 85%, and a significant improvement in right ventricular end-diastolic diameter and tethering height were achieved (53 mm to 45 mm, and 11.1 mm to 4.4 mm, respectively). Furthermore, during the median 3-year follow-up period, tricuspid regurgitation was kept controlled mild or less in 80% of the cases.

Right ventricular papillary muscle approximation is considered to be a safe, effective and durable technique as an additional approach for tricuspid annuloplasty.

Patients after the Norwood procedure are prone to postoperative instability. Extracorporeal membrane oxygenation (ECMO) can help to overcome short-term organ failure. This retrospective single-center study examines ECMO weaning, hospital discharge and long-term-survival after ECMO-therapy between Norwood and bidirectional Glenn (BDG) palliation as well as risk factors for mortality.

In our institution over 450 Norwood procedures have been performed. Since the introduction of ECMO-therapy, 306 Norwood operations took place between 2007 and 2022, involving ECMO in 59 cases before BDG. In 48.3% of cases, ECMO was initiated intraoperatively post-Norwood. Patient outcomes were tracked and mortality risk factors were analyzed using uni- and multivariable testing.

ECMO-therapy after Norwood (median duration: 5d; range: 0-17d), saw 31.0% installed under CPR. Weaning was achieved in 46 children (78.0%), with 55.9% discharged home after a median of 45 [36; 66] days. Late-death occurred in 3 patients after 27, 234, and 1541 days. Currently, 30 children are in a median 4.8 year [3.4; 7.7] follow-up. At the time of inquiry, 1 patient awaits BDG, 6 are at stage II palliation, Fontan was completed in 22, and 1 was lost to follow-up post-Norwood. Risk factor analysis revealed dialysis (p < 0.001), cerebral lesions (p = 0.026), longer ECMO duration (p = 0.002), cardiac indication, and lower body weight (p = 0.038) as mortality-increasing factors. The 10-year survival rate after ECMO therapy was 51.1% [95% CI : 37.1-63.5%].

ECMO-therapy in critically ill patients after the Norwood operation may significantly improve survival of a patient cohort otherwise forfeited and give the opportunity for successful future-stage operations.

The indications for use, evidence base and experience with the novel noncovered open hybrid surgical stents for acute type A aortic dissection repair for concurrent stabilization of the "downstream" aorta remains limited. We review the evidence base and the development of these stents.

Data were collected from Pubmed/Medline literature search to develop and review the evidence base for safety and efficacy of non-covered surgical stents. Existing guidelines for use and developments were reviewed.

A single randomized control trial and 4 single center studies were included in the review with a total worldwide experience of 241 patients. The deployment was easy and did not add significantly to the primary operation. The mortality and new stroke ranged from 6.3-18.7%. Safe and complete deployment was accomplished in 92-100%. There was no device related reintervention. There was a significant improvement in malperfusion in over 90% of the cases with varying degrees of remodelling (60-90%) of the downstream aorta.

Open noncovered stent grafts represent a major technical advancement as an adjunct procedure for acute dissection repairs, e.g. hemiarch repair. It has potential for wider use by non-aortic surgeons due to simplicity of technique. Limited safety and efficacy data confirms the device to be safe, feasible and reproducible with potential for wider adoption. However, long term trial and registry data is required before recommendations for standard use outside of high volume experienced aortic centres.