Publications by authors named "Martin Misfeld"

228 Publications

Commentary: More insights into the resect versus respect debate: Will we ever have a winner?

J Thorac Cardiovasc Surg 2021 Mar 24. Epub 2021 Mar 24.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.068DOI Listing
March 2021

Mid-term results after isolated tricuspid valve surgery in the presence of right ventricular leads.

J Cardiovasc Surg (Torino) 2021 Apr 8. Epub 2021 Apr 8.

University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Background: Patients with tricuspid valve (TV) disease and indication for TV surgery frequently have permanent pacemaker (PM) or defibrillator (AICD) leads, placed in the right ventricle (RV). The aim of this study was to analyse postoperative results and mid-term outcomes after isolated TV surgery (with no further concomitant cardiac procedures) in the presence of permanent RV leads.

Methods: From January 2005 to January 2019 a total of 80 patients (mean age: 67.7±10.3 yrs; 56.3% male) with isolated TV disease and presence of at least one permanent RV lead in place were referred to our institution for isolated TV repair / replacement; patients with concomitant procedures were excluded for this analysis. All data were retrospectively analysed. The follow-up was 98% complete.

Results: Mean follow-up time was 4.3±3.9 years. Mean preoperative clinical NYHA status was 3.0±0.8, left ventricular ejection fraction 50.7±12.9%, mean pulmonary artery pressure 23.8±9.3mmHg, creatinine 125.7±57.5μmol/l, mean MELD-XI Score (Model of Endstage-Liver Disease excluding INR) was 14.6±5.0 μmol/l. Thirty-day mortality was 6.3% with a 5-years survival of 58.2±6.0%. Cox regression analysis revealed the MELD-XIScore as the only highly significant predictor for postoperative mortality (p=0.002).

Conclusions: In conclusion, Hepatorenal dysfunction-possibly indicating long lasting TV failure- could be a factor for limited postoperative survival in our patient cohort. This finding could unterline our hypothesis, that early TV surgery may achieve better postoperative survival, even in patients with TV disease caused by RV leads. Further investigations are needed.
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http://dx.doi.org/10.23736/S0021-9509.21.11803-8DOI Listing
April 2021

Proximal aortic aneurysms: correlation of maximum aortic diameter and aortic wall thickness.

Eur J Cardiothorac Surg 2021 Apr 5. Epub 2021 Apr 5.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objectives: The goal of therapy of proximal aortic aneurysms is to prevent an aortic catastrophe, e.g. acute dissection or rupture. The decision to intervene is currently based on maximum aortic diameter complemented by known risk factors like bicuspid aortic valve, positive family history or rapid growth rate. When applying Laplace's law, wall tension is determined by pressure × radius divided by aortic wall thickness. Because current imaging modalities lack precision, wall thickness is currently neglected. The purpose of our study was therefore to correlate maximum aortic diameter with aortic wall thickness and known indices for adverse aortic events.

Methods: Aortic samples from 292 patients were collected during cardiac surgery, of whom 158 presented with a bicuspid aortic valve and 134, with a tricuspid aortic valve. Aortic specimens were obtained during the operation and stored in 4% formaldehyde. Histological staining and analysis were performed to determine the thickness of the aortic wall.

Results: Patients were 62 ± 13 years old at the time of the operation; 77% were men. The mean aortic dimensions were 44 mm, 41 mm and 51 mm at the aortic root, sinotubular junction and ascending aorta, respectively. Aortic valve stenosis was the most frequent (49%) valvular dysfunction, followed by aortic valve regurgitation (33%) and combined dysfunction (10%). The maximum aortic diameter at the ascending level did not correlate with the thickness of the media (R = 0.07) or the intima (R = 0.28) at the convex sample site. There was also no correlation of the ascending aortic diameter with age (R = -0.18) or body surface area (R = 0.07). The thickness of the intima (r = 0.31) and the media (R = 0.035) did not correlate with the Svensson index of aortic risk. Similarly, there was a low (R = 0.29) or absent (R = -0.04) correlation between the aortic size index and the intima or media thickness, respectively. There was a similar relationship of median thickness of the intima in the 4 aortic height index risk categories (P < 0.001).

Conclusions: Aortic diameter and conventional indices of aortic risk do not correlate with aortic wall thickness. Other indices may be required in order to identify patients at high risk for aortic complications.
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http://dx.doi.org/10.1093/ejcts/ezab147DOI Listing
April 2021

Cytoreductive surgical resection of a rare pulmonary artery intimal sarcoma involving the pulmonary valve and right ventricle: a case report.

J Surg Case Rep 2021 Mar 29;2021(3):rjab051. Epub 2021 Mar 29.

Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.

Pulmonary artery intimal sarcoma (PAIS) is an extremely rare malignant tumour. It is often misdiagnosed as chronic pulmonary thromboembolism. We describe a complex case in a 70-year-old man with PAIS extending into his right ventricle undergoing salvage cytoreductive surgical resection utilizing bivalirudin for cardiopulmonary bypass anticoagulation due to heparin-induced thrombocytopenia and thrombosis syndrome. The prognosis for PAIS is extremely poor, with a median survival of 1.5 months without surgical resection. Cytoreductive surgical debulking can improve the median survival time to 17 months. The main aim of palliative surgical resection is to improve ventilation-perfusion mismatch and prevent haemodynamic collapse.
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http://dx.doi.org/10.1093/jscr/rjab051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007161PMC
March 2021

German Aortic Root Repair Registry - Insights from the First 400 Consecutive Patients.

Ann Thorac Surg 2021 Mar 31. Epub 2021 Mar 31.

Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany.

Background: The objective was to provide initial data from our prospective valve-sparing aortic root replacement (V-SARR) registry and reasons for conversion to prosthetic replacement (AVR).

Methods: Six centers established an intention-to-treat-design V-SARR-registry (German Aortic Root Repair Registry, GEARR, first-patient-in 10/2016) with main inclusion criterion "scheduled for V-SARR as Plan A". Clinical information, operative details, intraoperative valve/root measurements and clinical/TTE follow-up-data are documented.

Results: Of a total of n=449, we report data on n=401 patients (81% male, mean age 51±14y). N=350 underwent V-SARR as scheduled (Group A, "David"-variants I 55%, III 2%, IV 13%, V 24%, V- Stanford 2%, Yacoub-Remodeling 2%), n=51 were converted to AVR (Group B). Median follow-up was 11 months (0-2.6y), cumulative follow-up 279 patient-years. In Group B there were less connective tissue disorders (6vs16%), fewer patients had LVEF>50% (60%vs90%), more had bicuspid aortic valves (BAV,45%vs28%), fewer patients had preoperative non/trace AR (2%vs20%). Fewer individuals in Group B had rare types of BAV (fused N/L, R/N, 10%vs30%) and more had unbalanced roots (56%vs40%). Immediate-postoperative AR was none/trace in 79%, and mild in 20%. At 30 days the dpmean was 7±5mmHg. None of the patients died in hospital, two strokes occurred. One patient needed early AVR as re-do surgery.

Conclusions: Main factors causing surgeons to convert a planned V-SARR to AVR include asymmetry of aortic valve/root, severity of AR, safety-reasons (LVEF), and BAV, but not rare types of BAV. GEARR will help us identify the impact on long-term outcomes of pre- and postoperative valvular anatomy and various V-SARR types.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.060DOI Listing
March 2021

Postoperative outcome after reoperative isolated tricuspid valve surgery-is there a predictor for survival?

Eur J Cardiothorac Surg 2021 Mar 26. Epub 2021 Mar 26.

University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objectives: Reoperative tricuspid valve (TV) surgery is considered high risk even in the absence of additional concomitant cardiac procedures. The purpose of this study was to evaluate preoperative clinical parameters as predictors for survival after isolated reoperative TV surgery.

Methods: From January 2005 to January 2019, 85 patients (mean age: 66.7 ± 10.3 years, 34 male) with severe isolated TV regurgitation and prior cardiac surgery were referred to our centre for elective or urgent TV repair/replacement; patients with endocarditis were excluded. We retrospectively analysed preoperative hepatorenal function [reflected by widely used clinical and laboratory parameters and the Model of End-stage-Liver Disease excluding International Normalized Ratio (MELD-XI) score] as a predictor for postoperative survival.

Results: At hospital admission, the patients' average preoperative New York Heart Association class was 2.9 ± 0.6, left ventricular ejection fraction 52.5 ± 10.6%, mean pulmonary artery pressure 24.7 ± 8.0 mmHg, creatinine 115.4 ± 66.6 μmol/l, bilirubin 20.0 ± 19.6 μmol/l and the mean MELD-XI score was 13.3 ± 4.0 μmol/l. The mean follow-up was 5.4 ± 4.2 years. Thirty-day mortality was 5%, 5-year survival was 60.6 ± 5.4% and 10-year survival was 42.9 ± 6.5%. The multivariable Cox regression analysis evaluated the MELD-XI score [hazard ratio (HR 1.144, confidence interval 95% 1.0-1.3, P = 0.005] and diabetes mellitus (HR 2.27, confidence interval 95% 1.0-5.0, P = 0.04) as significant predictors for excess mortality while age and mean pulmonary artery pressure did not reliably predict clinical outcome.

Conclusions: Hepatorenal dysfunction was one main factor accounting for limited postoperative survival in our patient cohort. The MELD-XI score is easy to calculate and seems to reliably predict the perioperative risk in patients with prior cardiac surgery and indication for TV surgery.
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http://dx.doi.org/10.1093/ejcts/ezab134DOI Listing
March 2021

Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: The Leipzig experience.

J Thorac Cardiovasc Surg 2021 Feb 17. Epub 2021 Feb 17.

Leipzig Heart Center, University Department for Cardiac Surgery, Leipzig, Germany.

Objective: Minimally invasive direct coronary artery bypass (MIDCAB) surgery involving left anterior descending coronary artery grafting with the left internal thoracic artery through a left anterior small thoracotomy is being routinely performed in some specified centers for patients with isolated complex left anterior descending coronary artery disease, but very few reports regarding long-term outcomes exist in literature. Our study was aimed at assessing and analyzing the early and long-term outcomes of a large cohort of patients who underwent MIDCAB procedures and identifying the effects of changing trends in patient characteristics on early mortality.

Methods: A total of 2667 patients, who underwent MIDCAB procedures between 1996 and 2018, were divided into 3 groups on the basis of the year of surgery: group A, 1996-2003 (n = 1333); group B, 2004-2010 (n = 627) and group C, 2011-2018 (n = 707). Groupwise characteristics and early postoperative outcomes were compared. Long-term survival for all patients was analyzed and predictors for late mortality were identified using Cox proportional hazards methods.

Results: The mean age was 64.5 ± 10.9 years and 691 (25.9%) patients were female. Group C patients (log EuroSCORE I = 4.9 ± 6.9) were older with more cardiac risk factors and comorbidities than groups A (log EuroSCORE I = 3.1 ± 4.5) and B (log EuroSCORE I = 3.5 ± 4.7). Overall and groupwise in-hospital mortality was 0.9%, 1.0%, 0.6%, and 1.0% (P = .7), respectively. Overall 10-, 15-, and 20-year survival estimates for all patients were 77.7 ± 0.9%, 66.1 ± 1.2%, and 55.6 ± 1.6%, respectively.

Conclusions: MIDCAB can be safely performed with very good early and long-term outcomes. In-hospital mortality remained constant over the 22-year period of the study despite worsening demographic profile of patients.
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http://dx.doi.org/10.1016/j.jtcvs.2020.12.149DOI Listing
February 2021

Midterm outcomes with a sutureless aortic bioprosthesis in a prospective multicenter cohort study.

J Thorac Cardiovasc Surg 2021 Jan 13. Epub 2021 Jan 13.

Cardio-thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.

Objective: The objective of this study was to report midterm clinical outcomes with a self-expandable sutureless aortic valve.

Methods: Between 2010 and 2013, 658 patients at 25 European institutions received the Perceval sutureless valve (LivaNova Plc, London, United Kingdom). Mean follow-up was 3.8 years; late cumulative follow-up was 2325.2 patient-years.

Results: The mean age of the population was 78.3 ± 5.6 years and 40.0% (n = 263) were 80 years of age or older; mean Society of Thoracic Surgeons-Predicted Risk of Mortality score was 7.2 ± 7.4. Concomitant procedures were performed in 31.5% (n = 207) of patients. Overall duration of cardiopulmonary bypass time was 64.8 ± 25.2 minutes and aortic cross-clamping time was 40.7 ± 18.1 minutes. Thirty-day all-cause mortality was 3.7% (23 patients), with an observed:expected ratio of 0.51. Overall survival was 91.6% at 1 year, 88.5% at 2 years, and 72.7% at 5 years. Peak and mean gradients remained stable during follow-up, and were 17.8 ± 11.3 mm Hg and 9.0 ± 6.3 mm Hg, respectively, at 5 years. Preoperatively, 33.4% of those who received the Perceval valve (n = 210) were in New York Heart Association functional class I or II versus 93.1% (n = 242) at 5 years.

Conclusions: This series, representing, to our knowledge, the longest follow-up with sutureless technology in a prospective, multicenter study, shows that aortic replacement using sutureless valves is associated with low mortality and morbidity and good hemodynamic performance.
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http://dx.doi.org/10.1016/j.jtcvs.2020.12.109DOI Listing
January 2021

Spinal cord protection in thoracoabdominal aortic aneurysm surgery: a multimodal approach.

J Cardiovasc Surg (Torino) 2021 Jan 26. Epub 2021 Jan 26.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany -

Spinal cord injury is one major complication of open and endovascular thoracic and thoracacoabdominal aortic aneurysm repair. Despite numerous neuroprotective adjuncts, the incidence of SCI remains high. This review article discusses established and novel adjuncts for spinal cord protection, including priming and preconditioning of the paraspinal collateral network, intraoperative systemic hypothermia, distal aortic perfusion, motor- and somatosensory evoked potentials and non-invasive cnNIRS monitoring as well as peri- and postoperative drainage of cerebrospinal fluid. Regardless of the positive influence of many of these strategies on neurologic outcome, to date no strategy assures definitive preservation of spinal cord integrity during and after aortic aneurysm repair.
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http://dx.doi.org/10.23736/S0021-9509.21.11783-5DOI Listing
January 2021

Resection of a tumor with thymic-like differentiation and reconstruction of the innominate artery.

Ann Thorac Surg 2021 Jan 11. Epub 2021 Jan 11.

Department of General- and Visceral Surgery, Helios Clinic Schkeuditz, Schkeuditz, Germany.

Carcinomas showing thymic-like differentiation (CASTLE-tumors) are a very rare entity requiring an individualized therapeutic plan. Herein we present a case of reconstruction of the innominate artery following radical resection of the tumor in which a custom-made cerebral shunt was used for continuous cerebral perfusion.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.037DOI Listing
January 2021

Management of aortic root in type A dissection: Bentall approach.

J Card Surg 2021 May 20;36(5):1779-1785. Epub 2020 Dec 20.

Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany.

Background: We analyzed the results of the modified Bentall procedure in a high-risk group of patients presenting with acute type A aortic dissection (ATAAD).

Methods: ATAAD patients undergoing a modified Bentall between 1996 and 2018 (n = 314) were analyzed. Mechanical composite conduits were used in 45%, and biological ones using either a bioprosthesis implanted into an aortic graft (33%) or xeno-/homograft root conduits (22%) in the rest. Preoperative malperfusion was present in 34% of patients and cardiopulmonary resuscitation required in 9%.

Results: Concomitant arch procedures consisted of hemiarch in 56% and total arch/elephant trunk in 34%, while concomitant coronary artery surgery was required in 20%. The average cross-clamp and cardiopulmonary bypass times were 126 ± 43 and 210 ± 76 min, respectively, while the average circulatory arrest times were 29 ± 17 min. A total of 69 patients (22%) suffered permanent neurologic deficit, while myocardial infarction occurred in 18 cases (6%) and low cardiac output syndrome in 47 (15%). The in-hospital mortality rate was 17% due to intractable low cardiac output syndrome (n = 29), major brain injury (n = 16), multiorgan failure (n = 6), and sepsis (n = 2). The independent predictors of in-hospital mortality were critical preoperative state (odds ratio [OR], 5.6; p < .001), coronary malperfusion (OR, 3.6; p = .002), coronary artery disease (OR, 2.6; p = .033), and prior cerebrovascular accident (OR, 5.6; p = .002).

Conclusions: The modified Bentall operation, along with necessary concomitant procedures, can be performed with good early results in high-risk ATAAD patients presenting.
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http://dx.doi.org/10.1111/jocs.15271DOI Listing
May 2021

Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis.

Ann Cardiothorac Surg 2020 Sep;9(5):347-363

Ospedale del Cuore Fondazione Toscana "G. Monasterio", Massa, Italy.

Background: New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed.

Methods: Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis.

Results: Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups.

Conclusions: Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.
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http://dx.doi.org/10.21037/acs-2020-surd-17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7548209PMC
September 2020

David aortic valve-sparing reimplantation versus biological aortic root replacement: a retrospective analysis of 411 patients.

Indian J Thorac Cardiovasc Surg 2020 Jan 14;36(Suppl 1):97-103. Epub 2019 Oct 14.

Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany.

Objectives: This study aimed to compare short- and long-term results for patients undergoing either aortic valve-sparing reimplantation (David) procedure (AVr-D) or biological aortic root replacement (Bentall) procedure (ARr-B-bio) for aortic root pathology.

Methods: We compared outcomes for patients who underwent AVr-D ( = 261) or ARr-B-bio ( = 150) between 2000 and 2015 at our institution. The mean age of patients was 55 ± 13 years and 21.7% ( = 89) were female. ARr-B-bio patients were significantly older than AVr-D patients (58 ± 10 vs 53 ± 15 years,  < 0.001) and had a significantly lower incidence of connective tissue disorders (2.0% vs 16.9%,  < 0.001). Follow-up was complete in 88% of patients.

Results: Mortality at 30 days was 1.2% ( = 5) overall, at 0.4% ( = 1) significantly lower in the AVr-D group compared with 2.7% ( = 4) in the ARr-B-bio group ( = 0.04). Postoperative low cardiac output was more common in ARr-B-bio patients ( = 4) versus AVr-D patients ( = 0;  = 0.008). The occurrence of postoperative strokes was 2.2% ( = 9) in both groups, without significant differences ( = 0.84). Five- and ten-year survival was 93.7 ± 1.8% and 84.4 ± 4.7% in patients who received AVr-D and 90.9 ± 2.6% and 84.6 ± 5.4% for ARr-B-bio patients (log-rank  = 0.37). Using Cox regression analysis, age (HR 1.06; 95% CI 1.02-1.10,  = 0.002), smoking (HR 2.74; 95% CI 1.28-5.86,  = 0.01), and emergency surgery (HR 6.58; 95% CI 1.69-25.54,  = 0.007) were found to be independent predictors of long-term mortality.There was no difference in freedom from reoperation between AVr-D (89.4 ± 3.4% at 10 years) and ARr-B-bio (80.4 ± 7.5% at 10 years, log-rank  = 0.66) patients, nor for freedom from stroke, bleeding, myocardial infarction, or endocarditis during follow-up.

Conclusions: Short-term outcomes for both AVr-D and ARr-B-bio are excellent in patients with aortic root pathology. The long-term outcomes were associated with comparable survival and freedom from reoperation. AVr-D may be preferable to ARr-B-bio in patients with suitable pathoanatomy.
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http://dx.doi.org/10.1007/s12055-019-00873-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525841PMC
January 2020

Propensity score matched comparison of isolated, elective aortic valve replacement with and without concomitant septal myectomy: is it worth it?

J Cardiovasc Surg (Torino) 2021 Jun 4;62(3):258-267. Epub 2020 Sep 4.

Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany -

Background: Septal myectomy during open aortic valve replacement (AVR) is an effective surgical treatment for asymmetric secondary basal septal hypertrophy. Concerns regarding higher rates of complications associated with this procedure have been raised - such as permanent pacemaker implantation. The aim of this study was to compare outcomes and complications of patients with and without concomitant septal myectomy using propensity score matching applied to a large, consecutive single center cohort.

Methods: A total of 2199 consecutive patients undergoing either AVR with concomitant myectomy (AVR-M, N.=212) or AVR alone (N.=1987) were analyzed (2009-2015). Patients with previous cardiac or emergency surgery, concomitant cardiac procedures and endocarditis were excluded. As reference to previously published data, patient characteristics and outcomes of the overall cohort were examined and for comparison between groups propensity score matching utilized.

Results: In the unmatched cohort, AVR-M patients were older (71.2±8 vs. 67.6±10 years, P<0.001) and more often female (68% vs. 37%, P<0.001) in comparison to patients receiving only AVR. After matching (N.=374) no significant difference in baseline features was evident. No significant difference in hospital mortality (2.1% vs. 1.6%, P=1.000) and pacemaker-implantation rate (5.3% vs. 3.7%, P=0.621) was observed. Mid-term survival was comparable between the two groups (86.1±5% vs. 84.4±5% after 6 years, P=0.957). The overall patient cohort showed a survival comparable to that of an adjusted regional normal population (P=0.178).

Conclusions: This study demonstrates that concomitant myectomy in patients undergoing AVR is a safe surgical technique resulting in comparable hospital mortality and mid-term survival. Concomitant septal myectomy seems not to be associated with an increased pacemaker implantation rate.
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http://dx.doi.org/10.23736/S0021-9509.20.11443-5DOI Listing
June 2021

Sutureless and rapid deployment implantation in bicuspid aortic valve: results from the sutureless and rapid-deployment aortic valve replacement international registry.

Ann Cardiothorac Surg 2020 Jul;9(4):298-304

Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ospedali Riuniti, Ancona, Italy.

Background: Benefits of sutureless and rapid deployment (SURD) bioprostheses in bicuspid aortic valves (BAV) are controversial. The aim of this study is to report the outcomes of patients undergoing aortic valve replacement (AVR) for BAV from the Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry (SURD-IR).

Methods: Of the 4,636 patients who received primary isolated SURD-AVR between 2007 and 2018, 191 (4.1%) BAV patients underwent AVR with SURD valve.

Results: Overall 30-day mortality was 1.6%. The Intuity valve was implanted in 53.9% of cases, whereas the Perceval was implanted in 46.1%. Rate of stroke for isolated AVR was 4.2%. No case of endocarditis, thromboembolism, myocardial infarction, valve dislocation or structural valve deterioration was reported in the early phase. Rate of pacemaker implantation and moderate-severe aortic regurgitation (AR) were 7.9% and 3.7%, respectively.

Conclusions: BAV is not considered a contraindication for the implantation of SURD valves. However, detailed information of aortic root geometry as well as the knowledge of some technical considerations are mandatory for a good outcome.
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http://dx.doi.org/10.21037/acs-2020-surd-33DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415698PMC
July 2020

A series of four transcatheter aortic valve replacement in failed Perceval valves.

Ann Cardiothorac Surg 2020 Jul;9(4):280-288

University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

In recent years, sutureless valves (SV) and rapid deployment valves (RDVs) have become interesting aortic valve substitutes, especially in minimally invasive aortic valve surgery, as they reduce cardio-pulmonary bypass and cross-clamp times. There are two valve types available, the sutureless Perceval and the rapid deployment Intuity valve prosthesis. When these valves fail, besides surgical re-replacement, the valve-in-valve concept has been reported in a small series of case reports. Our own experience includes four cases of failed Perceval valves, in which a balloon-expandable transcatheter valve was implanted in three patients, and a self-expanding transcatheter valve was implanted in a fourth patient. Here, we present these four cases with a focus on the specific valve design of the Perceval valve, as well as on important technical aspects. All cases were performed successfully with clinical improvement. Transcatheter aortic valve replacement (TAVR) as a valve-in-valve concept seems to be a valuable option in selected patients with failed sutureless or RDVs.
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http://dx.doi.org/10.21037/acs-2020-surd-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415688PMC
July 2020

Loop neochord versus leaflet resection techniques for minimally invasive mitral valve repair: long-term results.

Eur J Cardiothorac Surg 2021 Jan;59(1):180-186

University Clinic of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objectives: Non-leaflet resection techniques including loop chordal replacement are being used with increasing frequency, but the long-term results of these techniques are still unknown. The aim of this study was to compare the long-term results of loop neochord replacement with leaflet resection techniques in patients undergoing minimally invasive mitral valve (MV) repair for MV prolapse.

Methods: Between 1999 and 2014, 2134 consecutive MV prolapse patients underwent minimally invasive MV repair with isolated loop (n = 1751; 82.1%) or resection techniques (n = 383, 17.9%) at our institution. Follow-up data were available for 86% of patients with a mean follow-up time of 6.1 ± 4.3 years.

Results: The 30-day mortality was 0.8% for all patients (loop: 0.7%, resection: 1.6%; P = 0.09). Leaflet resection was associated with more moderate or more mitral regurgitation on predischarge echocardiography (P = 0.003). The 1-, 5- and 10-year survival rates were 98 ± 1%, 95 ± 1% and 86 ± 2% for the loop technique versus 97 ± 1%, 92 ± 1% and 81 ± 2% for resection patients, respectively (P = 0.003). Significant predictors for late mortality were MV repair technique (P = 0.004), left ventricular ejection fraction (P < 0.001), age (P < 0.001) and myocardial infarction (P < 0.001). Freedom from MV reoperation at 1, 5 and 10 years was 98 ± 1%, 97 ± 1%, 97 ± 1% and 97 ± 1%, 97 ± 1%, 96 ± 1% for patients operated on with the loop technique and leaflet resection (P = 0.4).

Conclusions: In our patient cohort, MV repair with loop chordal replacement is associated with less early recurrent mitral regurgitation and very good long-term results when compared to classical leaflet resection techniques for MV prolapse and is therefore an excellent option for such patients.
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http://dx.doi.org/10.1093/ejcts/ezaa255DOI Listing
January 2021

"Possum, sed nolo" (I could, but I don't want to).

J Thorac Cardiovasc Surg 2020 Aug 3. Epub 2020 Aug 3.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

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http://dx.doi.org/10.1016/j.jtcvs.2020.06.135DOI Listing
August 2020

Midterm results after St Jude Medical Epic porcine xenograft for aortic, mitral, and double valve replacement.

J Card Surg 2020 Aug 29;35(8):1769-1777. Epub 2020 Jun 29.

Department of Cardiac Surgery, Heart Center, Leipzig University, Leipzig, Germany.

Background: The aim of this study was to evaluate the results after stented porcine xenograft implantation (Epic, SJM, St Paul, MN) with Linx anticalcification treatment in elderly patients at our high-volume tertiary care center.

Methods: A total of 3825 patients undergoing aortic (AVR = 2441), mitral (MVR = 892), or double valve (DVR = 492) replacement between 11/2001 and 12/2017 with Epic xenografts were evaluated. Outcomes were assessed by reviewing the prospectively acquired hospital database results, and regular annual follow-up information was acquired from questionnaires or telephone interviews.

Results: For patients undergoing AVR, MVR, DVR, age at surgery were 76.4 ± 6, 71.2 ± 9, 72.9 ± 8 years; active endocarditis was an indication for valve surgery in 4.5%, 20.7%, 19.7%; and the predicted median (interquartile range [IQR]) mortality risk (EuroSCORE II) was 5.2% (3.1%-9.4%), 7.5% (3.9%-16.2%), 9.9% (6.0%-19.6%), respectively. Median follow-up was 3.04 (IQR: 0.18-5.21). Thirty-day survival was 91.2% ± 0.6%, 87.6% ± 0.1.1%, 84.7% ± 1.6%; and 10-year survival was 56.7% ± 1.0%, 59.4% ± 2.5%, 50.45% ± 3.1%, respectively. Patients who underwent MVR versus AVR were at significant increased risk for reoperation for endocarditis (adjusted odds ratio; 2.2, 95% confidence interval; 1.29-3.7; P = .003). There was no significant difference in all-cause mortality at midterm in AVR vs MVR in the matched cohort (P = .85).

Conclusions: Implantation of the Epic stented porcine xenograft is associated with acceptable survival and freedom from valve-related complications or reoperation due to structural valve disease at midterm follow-up.
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http://dx.doi.org/10.1111/jocs.14554DOI Listing
August 2020

Minimally invasive access type related to outcomes of sutureless and rapid deployment valves.

Eur J Cardiothorac Surg 2020 11;58(5):1063-1071

Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ospedali Riuniti, Ancona, Italy.

Objectives: Minimally invasive surgical techniques with optimal outcomes are of paramount importance. Sutureless and rapid deployment aortic valves are increasingly implanted via minimally invasive approaches. We aimed to analyse the procedural outcomes of a full sternotomy (FS) compared with those of minimally invasive cardiac surgery (MICS) and further assess MICS, namely ministernotomy (MS) and anterior right thoracotomy (ART).

Methods: We selected all isolated aortic valve replacements in the Sutureless and Rapid Deployment Aortic Valve Replacement International Registry (SURD-IR, n = 2257) and performed propensity score matching to compare aortic valve replacement through FS or MICS (n = 508/group) as well as through MS and ART accesses (n = 569/group).

Results: Postoperative mortality was 1.6% in FS and MICS patients who had a mean logistic EuroSCORE of 11%. Cross-clamp and cardiopulmonary bypass (CPB) times were shorter in the FS group than in the MICS group (mean difference 3.2 and 9.2 min; P < 0.001). Patients undergoing FS had a higher rate of acute kidney injury (5.6% vs 2.8%; P = 0.012). Direct comparison of MS and ART revealed longer mean cross-clamp and CPB times (12 and 16.7 min) in the ART group (P < 0.001). The postoperative outcome revealed a higher stroke rate (3.2% vs 1.2%; P = 0.043) as well as a longer postoperative intensive care unit [2 (1-3) vs 1 (1-3) days; P = 0.009] and hospital stay [11 (8-16) vs 8 (7-12) days; P < 0.001] in the MS group than in the ART group.

Conclusions: According to this non-randomized international registry, FS resulted in a higher rate of acute kidney injury. The ART access showed a lower stroke rate than MS and a shorter hospital stay than all other accesses. All these findings may be related to underlying patient risk factors.
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http://dx.doi.org/10.1093/ejcts/ezaa154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577292PMC
November 2020

Pneumorrhachis After Thoracoabdominal Aortic Repair.

Ann Thorac Surg 2020 10 6;110(4):e349. Epub 2020 Jun 6.

University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

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http://dx.doi.org/10.1016/j.athoracsur.2020.04.078DOI Listing
October 2020

Minimally invasive coronary bypass surgery with bilateral internal thoracic arteries: Early outcomes and angiographic patency.

J Thorac Cardiovasc Surg 2020 Apr 8. Epub 2020 Apr 8.

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objective: Multivessel minimally invasive coronary artery bypass grafting, performed chiefly with left internal thoracic artery and saphenous vein grafts through a left anterolateral thoracotomy, has recently emerged as an alternative to conventional coronary artery bypass grafting. The present study involves our initial experience with respect to early postoperative and angiographic outcomes after total arterial multivessel off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries.

Methods: A total of 88 consecutive patients undergoing total arterial off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries without ascending aortic manipulation were included in this study. Bilateral internal thoracic arteries were harvested under direct vision through a left anterolateral thoracotomy and used as Y or in situ grafts. Multivessel grafting was performed off pump. Postoperative graft assessment was performed in 51 patients.

Results: The mean age of patients was 67.1 ± 7.2 years, and 79 patients (89.8%) were male. The mean body mass index and ejection fraction were 26.7 ± 2.7 kg/m and 57.6% ± 6.6%, respectively, and 40 patients (45.5%) had left main disease. No intraoperative conversions to cardiopulmonary bypass or sternotomy occurred. A total of 209 distal anastomoses (mean 2.4 ± 0.5) were performed, with 57 patients undergoing double, 29 patients undergoing triple, and 2 patients undergoing quadruple coronary artery bypass grafting. There was no in-hospital mortality, and 5 patients underwent reexploration for bleeding. No patient had stroke or chest wound infections. Predischarge coronary angiography revealed an overall graft patency rate of 96.8%.

Conclusions: Off-pump minimally invasive coronary artery bypass grafting using total arterial revascularization with bilateral internal thoracic arteries is a feasible and safe operation that is associated with excellent short-term outcomes and early graft patency. Future studies should focus on improving the generalizability and reproducibility of this technique.
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http://dx.doi.org/10.1016/j.jtcvs.2019.12.136DOI Listing
April 2020

Five-year outcomes following complex reconstructive surgery for infective endocarditis involving the intervalvular fibrous body.

Eur J Cardiothorac Surg 2020 11;58(5):1080-1087

Department of Cardiothoracic Surgery, Helios Klinikum Siegburg, Siegburg, Germany.

Objectives: Destruction of the intervalvular fibrous body (IFB) due to infective endocarditis (IE) warrants a complex operation involving radical debridement of all infected tissue, followed by double valve replacement (aortic and mitral valve replacement) with patch reconstruction of the IFB. This study assesses the 5-year outcomes in patients undergoing this complex procedure for treatment of double valve IE with IFB involvement.

Methods: A total of 127 consecutive patients underwent double valve replacement with reconstruction of the IFB for active complex IE between January 1999 and December 2018. Primary outcomes were 3-year and 5-year survival, as well as 5-year freedom from reoperation.

Results: Patients' mean age was 65.3 ± 12.9 years. Preoperative cardiogenic shock and sepsis were present in 17.3% and 18.9%, respectively. The majority of patients (81.3%) had undergone previous cardiac surgery. Overall, 30-day and 90-day mortality rates were 28.3% and 37.0%, respectively. The 3- and 5-year survival rates for all patients were 45.3 ± 5.1% and 41.8 ± 5.8%, and for those who survived the first 90 postoperative days 75.8 ± 6.1% and 70.0 ± 8.0%, respectively. The overall 5-year freedom from reoperation was 85.1 ± 5.7%. Preoperative predictors for 30-day mortality were Staphylococcus aureus [odds ratio (OR) 1.65; P = 0.04] and left ventricular ejection fraction (LVEF) <35% (OR 12.06; P = 0.03), for 90-day mortality acute kidney injury requiring dialysis (OR 6.2; P = 0.02) and LVEF <35% (OR 9.66; P = 0.03) and for long-term mortality cardiogenic shock (hazard ratio 2.46; P = 0.01).

Conclusions: Double valve replacement with reconstruction of the IFB in patients with complex IE is a challenging operation associated with high morbidity and mortality, particularly in the first 90 days after surgery. Survival and freedom from reoperation rates are acceptable thereafter, particularly considering the severity of disease and complex surgery.
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http://dx.doi.org/10.1093/ejcts/ezaa146DOI Listing
November 2020

Current trends of sutureless and rapid deployment valves: an 11-year experience from the Sutureless and Rapid Deployment International Registry.

Eur J Cardiothorac Surg 2020 11;58(5):1054-1062

Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ospedali Riuniti, Ancona, Italy.

Objectives: Current evidence on sutureless and rapid deployment aortic valve replacement (SURD-AVR) is limited and does not allow for the assessment of the clinical impact and the evolution of procedural and clinical outcomes of this new valve technology. The Sutureless and Rapid Deployment International Registry (SURD-IR) represents a unique opportunity to evaluate the current trends and outcomes of SURD-AVR interventions.

Methods: Data from 3682 patients enrolled between 2007 and 2018 were analysed. Patients were divided according to the date of surgery into 6 equal groups and by the type of intervention: isolated SURD-AVR (n = 2472) and combined SURD-AVR (n = 1086).

Results: Across the 11-year study period, significant changes occurred in patient characteristics including a decrease in age and in estimated surgical risk. Less invasive approaches for isolated SURD-AVR increased considerably from 49.4% to 85.5%. The overall in-hospital mortality rate was 1.6% and 3.9% in isolated and combined procedures, respectively, with no change over time. The rate of perioperative stroke decreased significantly (from 4% to 0.5%), as did the rates of postoperative pacemaker implantation (from 12.8% to 5.9%) and aortic regurgitation (from 17.8% to 2.7%).

Conclusions: The present study provides a comprehensive analysis of the current trends and results of SURD-AVR interventions. The most notable changes over time were the increasing implantation of SURD valves in a younger population, with more frequent utilization of less invasive techniques. SURD-AVR demonstrated remarkable improvements in clinical outcomes with a significant reduction in the rates of stroke, pacemaker implantation and postoperative aortic regurgitation.
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http://dx.doi.org/10.1093/ejcts/ezaa144DOI Listing
November 2020

Prevalence of permanent pacemaker implantation after conventional aortic valve replacement-a propensity-matched analysis in patients with a bicuspid or tricuspid aortic valve: a benchmark for transcatheter aortic valve replacement.

Eur J Cardiothorac Surg 2020 07;58(1):130-137

University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.

Objectives: Elective treatment of aortic valve disease by transcatheter aortic valve replacement (TAVR) is becoming increasingly popular, even in patients with low risk and intermediate risk. Even patients with a bicuspid aortic valve (BAV) are increasingly considered eligible for TAVR. Permanent pacemaker implantation (PMI) is a known-frequently understated-complication of TAVR affecting 9-15% of TAVR patients with a potentially significant impact on longevity and quality of life. BAV patients are affected by the highest PMI rates, although they are frequently younger compared to their tricuspid peers. The aim of the study is to report benchmark data-from a high-volume centre (with a competitive TAVR programme) on PMI after isolated surgical aortic valve replacement (SAVR) in patients with BAV and tricuspid aortic valve (TAV).

Methods: We performed a retrospective single-centre analysis on 4154 patients receiving isolated SAVRs (w/o concomitant procedures), between 2000 and 2019, of whom 1108 had BAV (27%). PMI rate and early- and long-term outcomes were analysed. For better comparability of these demographically unequal cohorts, 1:1 nearest neighbour matching was performed.

Results: At the time of SAVR, BAV patients were on average 10 years younger than their TAV peers (59.7 ± 12 vs 69.3 ± 9; P < 0.001) and had less comorbidities; all relevant characteristics were equally balanced after statistical matching. Overall PMI rate was significantly higher in BAV patients (5.4% vs 3.8%; P = 0.03). BAV required PMI exclusively (100%) and TAV required predominately (96%) for persistent postoperative high-degree atrioventricular block. After matching, the PMI rate was similar (5.1% vs 4.4%, P = 0.5). In-hospital mortality in the matched cohort was 1% in both groups. Long-term survival was more favourable in BAV patients (94% vs 90% in TAV at 5 years; 89% vs 82% in TAV at 9 years; P = 0.013).

Conclusions: With SAVR, the overall incidence of PMI among BAV patients seems significantly higher; however, after propensity matching, no difference in PMI rates between BAV and TAV is evident. The PMI rate was remarkably lower among BAV patients after SAVR compared to the reported incidence after TAVR.
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http://dx.doi.org/10.1093/ejcts/ezaa053DOI Listing
July 2020

Minimally Invasive Redo Aortic Valve Replacement: Results From a Multicentric Registry (SURD-IR).

Ann Thorac Surg 2020 08 16;110(2):553-557. Epub 2020 Jan 16.

Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ospedali Riuniti, Ancona, Italy; The Collaborative Research (CORE) Group.

Background: Reoperation for aortic valve replacement can be challenging and is usually associated with an increased risk for complications and mortality. The study aim was to report the results of a multicenter cohort of patients who underwent minimally invasive reoperative aortic valve replacement with a sutureless or rapid-deployment prosthesis.

Methods: From 2007 to 2018 data from 3651 patients were retrospectively collected from the Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry. Of them, 63 patients who had previously undergone cardiac surgery represented the study population. In-hospital clinical and echocardiographic outcomes were recorded.

Results: Mean age of the selected 63 patients was 75.3 ± 7.8 years and logistic EuroSCORE 10.1. Surgery was performed by ministernotomy in 43 patients (68.3%) and by anterior right thoracotomy in 20 (31.7%); 31 patients (49.2%) received the Perceval valve (Livanova PLC, London, UK) and 32 (50.8%) the Intuity valve (Edwards Lifesciences, Irvine, CA). Mean cross-clamp time was 57.8 ± 23.2 minutes and cardiopulmonary bypass time 95.0 ± 34.3 minutes. Neither conversion to full sternotomy nor in-hospital deaths occurred. Postoperative events were ischemic cerebral events in 3 patients (4.8%), need for pacemaker implantation in 2 (3.6%), bleeding requiring reoperation in 5 (8.9%), and dialysis in 1 (1.6%). Median intensive care unit stay was 1 day, and median length of hospital stay was 10 days. On echocardiographic evaluation 1 patient showed a significant postoperative aortic regurgitation.

Conclusions: Minimally invasive reoperative aortic valve replacement with a sutureless or rapid-deployment prosthesis is a safe and feasible treatment strategy, resulting in fast recovery and improved postoperative outcome with no mortality and an acceptable complication rate.
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http://dx.doi.org/10.1016/j.athoracsur.2019.11.033DOI Listing
August 2020

Concomitant Tricuspid Valve Repair during Minimally Invasive Mitral Valve Repair.

Thorac Cardiovasc Surg 2020 09 31;68(6):486-491. Epub 2019 Dec 31.

Department of Heart Surgery, Leipzig Heart Centre, Leipzig University Hospital, Leipzig, Germany.

Background: Concomitant use of tricuspid valve (TV) surgery and minimally invasive mitral valve (MV) repair is debatable due to a prolonged time of surgery with presumably elevated operative risk. Herein, we examined cardiopulmonary bypass times and 30-day mortality in patients who underwent MV repair with and without concomitant TV surgery.

Methods: We retrospectively evaluated 3,962 patients with MV regurgitation who underwent minimally invasive MV repair without ( = 3,463; MVr group) and with ( = 499; MVr + TVr group) concomitant TV surgery between 1999 and 2014. Preoperative parameters between the groups were significantly different; therefore, propensity score matching was performed.

Results: Mean cardiopulmonary bypass time for all patients was 125.5 ± 55.8 minutes in MVr and 162.0 ± 58.0 minutes in MVr + TVr ( < 0.001). Overall 30-day mortality was significantly different between these groups (4.8 vs. 2.1%;  < 0.001); however, after adjustment, there was no significant difference (3.3 vs. 1.2%;  = 0.07). Backward logistic regression revealed that cardiopulmonary bypass time was not a significant predictor for early mortality within the MVr + TVr cohort.

Conclusion: Concomitant TV repair using prosthetic rings through a minimally invasive approach is safe and does not lead to elevated early mortality in our patient cohort. Therefore, prolonged cardiopulmonary bypass time should not be the sole reason to rule out MV repair with concomitant TV repair and to prefer the use of suture techniques, which saves only a few minutes compared with prosthetic ring implantation.
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http://dx.doi.org/10.1055/s-0039-1700506DOI Listing
September 2020

Antithrombotic therapy and bleeding events after aortic valve replacement with a novel bioprosthesis.

J Thorac Cardiovasc Surg 2019 Nov 2. Epub 2019 Nov 2.

Department of Surgery, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Objective: Several recent-generation surgical tissue valves have been found to have bleeding rates exceeding rates recommended by regulatory bodies. We explored bleeding events using data from the Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial for the Avalus valve (Medtronic, Minneapolis, Minn) to examine whether this end point remains relevant for the evaluation of bioprostheses.

Methods: Patients (n = 1115) underwent aortic valve replacement. Bleeding and thromboembolic event episodes in patients within 3 years postimplant were analyzed for frequency, timing, and severity, focusing on patients taking antiplatelet/anticoagulant medications at the time of the event. Clinical and hemodynamic outcomes are also reported.

Results: At 3 years, the Kaplan-Meier cumulative probability estimate of all-cause death was 7.2% (cardiac, 3.6%; valve-related, 1.1%). The Kaplan-Meier cumulative probability estimates of all and major hemorrhage were 8.7% and 5.2%, respectively. Ninety-nine bleeding events occurred in 86 patients: most occurred >30 days postsurgery. Among the 51 late major bleeds, in 5 cases the patients were taking anticoagulant/antiplatelet medication for prophylaxis after surgical aortic valve replacement at the time of the event, whereas the remaining patients were taking medications for other reasons. Age (hazard ratio, 1.035; 95% confidence interval, 1.004-1.068), peripheral vascular disease (hazard ratio, 2.135; 95% confidence interval, 1.106-4.122), renal dysfunction (hazard ratio, 1.920; 95% confidence interval, 1.055-3.494), and antithrombotic medication use at the time of the event (hazard ratio, 1.417; 95% confidence interval, 1.048-1.915) were associated with late bleeds (major and minor).

Conclusions: Overall clinical outcomes demonstrated low mortality and few complications except for major bleeding. Most bleeding events occurred >30 days after surgery and in patients taking antiplatelet and/or anticoagulation for indications other than postimplant prophylaxis.
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http://dx.doi.org/10.1016/j.jtcvs.2019.10.095DOI Listing
November 2019

Tricuspid valve endocarditis.

Ann Cardiothorac Surg 2019 Nov;8(6):708-710

Leipzig Heart Center, University Department for Cardiac Surgery, Leipzig, Germany.

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http://dx.doi.org/10.21037/acs.2019.10.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892727PMC
November 2019

The "UFO" procedure.

Ann Cardiothorac Surg 2019 Nov;8(6):691-698

Department for Cardiac and Thoracic Surgery, Helios Clinic Siegburg, Siegburg, Germany.

The term "UFO" is not a medical term, but helps emphasize the extremely high degree of complexity of a surgical repair that is akin to someone observing an unidentified flying object. It involves replacement of the mitral and aortic valves with reconstruction of the intervalvular fibrous body (IVFB). Specific pathologies that render this operation necessary usually involve the IVFB, which is located between the aortic and mitral valves and constitutes a major portion of the fibrous skeleton of the heart. Patients that most often require such an operation are those with extensive aortic and mitral valve endocarditis with perivalvular extension into the IVFB. Other infrequent situations such as severe aortic and mitral annular calcification involving the IVFB, double valve replacement in patients with extremely small aortic and mitral annuli or double valve reoperations in which no IVFB is available following excision of both valves, necessitating the UFO procedure. The basic surgical principle has been first described as early as 1980. Depending on the extent of excised tissue due to the underlying disease, modifications and additional complex repair techniques have to be adopted. It is of utmost importance to have adequate visibility and exposure. There are certain important structures, which are at a risk of either injury or neglect, that can result in development of life-threatening complications during this operation, which a surgeon should be aware of. A step by step description of the "UFO" procedure can help guide the surgeon to perform this operation safely and efficiently. Although clinical complications are high, they are often related to the underlying disease and not specifically to the procedure itself, if performed perfectly.
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http://dx.doi.org/10.21037/acs.2019.11.05DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6892712PMC
November 2019