Publications by authors named "Roberto Lorusso"

391 Publications

Outcome of percutaneous HeartMate3 decommissioning: A single-centre experience.

Artif Organs 2022 May 12. Epub 2022 May 12.

Heart & Vascular Centre, Maastricht University Medical Centre (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.

Objectives: To highlight the role of percutaneous left ventricular assist device (LVAD) decommissioning as a safe procedure after myocardial recovery in patients with advanced heart failure.

Background: The HeartMate3 LVAD (Abbott, Chicago, IL, USA) is designed to provide circulatory support with enhanced hemocompatibility for patients with advanced heart failure. Most VADs are used as a bridge to heart transplantation; however, in certain cases, myocardial function recovers, and VADs can be explanted after the patient is weaned. Although surgical explantation remains the gold standard, minimally invasive percutaneous decommissioning has been described as a successful alternative. In this study, we present our experience, one-year outcomes, and adverse events associated with percutaneous LVAD decommissioning.

Methods: We conducted a retrospective review of data from six consecutive patients who underwent percutaneous LVAD decommissioning.

Results: Six patients were enrolled in the study. For all six patients, HM3 decommissioning was completed at least 6 months ago. No technical complications were documented. No strokes were observed within the study period, and the ejection fraction improved. The mean follow-up duration was 18 ± 8.5 months, and the survival rate was 100%.

Conclusion: Percutaneous HeartMate3 decommissioning appears to be safe. In particular, the survival after the procedure was 100%, and no events, especially thromboembolic ones, occurred.
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http://dx.doi.org/10.1111/aor.14279DOI Listing
May 2022

Temporary mechanical circulatory support for COVID-19 patients: A systematic review of literature.

Artif Organs 2022 May 1. Epub 2022 May 1.

Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.

Objective: Myocardial damage occurs in up to 25% of coronavirus disease 2019 (COVID-19) cases. While veno-venous extracorporeal life support (V-V ECLS) is used as respiratory support, mechanical circulatory support (MCS) may be required for severe cardiac dysfunction. This systematic review summarizes the available literature regarding MCS use rates, disease drivers for MCS initiation, and MCS outcomes in COVID-19 patients.

Methods: PubMed/EMBASE were searched until October 14, 2021. Articles including adults receiving ECLS for COVID-19 were included. The primary outcome was the rate of MCS use. Secondary outcomes included mortality at follow-up, ECLS conversion rate, intubation-to-cannulation time, time on ECLS, cardiac diseases, use of inotropes, and vasopressors.

Results: Twenty-eight observational studies (comprising both ECLS-only populations and ECLS patients as part of larger populations) included 4218 COVID-19 patients (females: 28.8%; median age: 54.3 years, 95%CI: 50.7-57.8) of whom 2774 (65.8%) required ECLS with the majority (92.7%) on V-V ECLS, 4.7% on veno-arterial ECLS and/or Impella, and 2.6% on other ECLS. Acute heart failure, cardiogenic shock, and cardiac arrest were reported in 7.8%, 9.7%, and 6.6% of patients, respectively. Vasopressors were used in 37.2%. Overall, 3.1% of patients required an ECLS change from V-V ECLS to MCS for heart failure, myocarditis, or myocardial infarction. The median ECLS duration was 15.9 days (95%CI: 13.9-16.3), with an overall survival of 54.6% and 28.1% in V-V ECLS and MCS patients. One study reported 61.1% survival with oxy-right ventricular assist device.

Conclusion: MCS use for cardiocirculatory compromise has been reported in 7.3% of COVID-19 patients requiring ECLS, which is a lower percentage compared to the incidence of any severe cardiocirculatory complication. Based on the poor survival rates, further investigations are warranted to establish the most appropriated indications and timing for MCS in COVID-19.
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http://dx.doi.org/10.1111/aor.14261DOI Listing
May 2022

Patterns of oxygen debt repayment in cardiogenic shock patients sustained with extracorporeal life support: A retrospective study.

J Crit Care 2022 Apr 21;71:154044. Epub 2022 Apr 21.

Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands.

Cardiogenic shock is the most frequent kind of shock in cardiac intensive care, and cardiac dysfunction and hypoxia are often seen in critically ill patients. Inadequate organ and tissue perfusion and hypoxia result in anaerobic metabolism with hyperlactatemia and oxygen debt accumulation. However, the role of accumulated oxygen debt in the course of cardiogenic shock and hypoxia has not been clearly described. Here, we first described the existence of several patterns of oxygen debt repayment in cardiogenic shock patients maintained by an extracorporeal life support system. Oxygen debt was computed from the lactate concentration at five time points, covering the first 26 h of ECLS. Patterns representing basic pathophysiological processes were independent of the cause of the primary insult. Groups of patients classified into specific patterns differed in terms of survival rate from 51.5% to only 4.6%. It is very important that the initial group not predetermine the fate of the patient and may change in the course of treatment due to 'between-cluster migration'. We believe that our finding of different patterns of oxygen debt repayment in cardiogenic shock patients may offer new insights for a more rational, goal-directed treatment of highly morbid conditions such as hypoxia and cardiogenic shock.
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http://dx.doi.org/10.1016/j.jcrc.2022.154044DOI Listing
April 2022

Permanent pacemaker implantation after valve and arrhythmia surgery in patients with preoperative atrial fibrillation.

Heart Rhythm 2022 Apr 13. Epub 2022 Apr 13.

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

Background: Among patients referred for cardiac surgery, atrial fibrillation (AF) is a common comorbidity and a risk factor for postoperative arrhythmias (eg, sinus node dysfunction, atrioventricular heart block), including those requiring permanent pacemaker (PPM) implantation.

Objective: The purpose of this study was to evaluate the prevalence and long-term survival of postoperative PPM implantation in patients with preoperative AF who underwent valve surgery with or without concomitant procedures.

Methods: Presented analysis pertains to the HEIST (HEart surgery In atrial fibrillation and Supraventricular Tachycardia) registry. During the study period, 11,949 patients underwent valvular (aortic, mitral, or tricuspid valve replacement or repair) surgery and/or surgical ablation (SA) and were stratified according to postoperative PPM status.

Results: PPM implantation after surgery was necessary in 2.5% of patients, with significant variation depending on the type of surgery (from 1.1% in mitral valve repair to 3.3% in combined mitral and tricuspid valve surgery). In a multivariate logistic regression model, tricuspid intervention (P <.001), cardiopulmonary bypass time (P = .024), and endocarditis (P = .014) were shown to be risk factors for PPM. Over long-term follow-up, PPM was not associated with increased mortality compared to no PPM (hazard ratio 0.96; 95% confidence interval 0.77-1.19; P = .679). SA was not associated with PPM implantation. However, SA improved survival regardless of PPM status (log rank P <.001).

Conclusion: In patients with preoperative AF, the need for PPM implantation after valve surgery or SA is not an infrequent outcome, with SA not affecting its prevalence but actually improving long-term survival.
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http://dx.doi.org/10.1016/j.hrthm.2022.04.007DOI Listing
April 2022

Contemporary outcomes of cardiac surgery patients supported by the intra-aortic balloon pump.

Interact Cardiovasc Thorac Surg 2022 Apr 5. Epub 2022 Apr 5.

Department of Cardiac Surgery, Ospedale Universitario, Catanzaro, Italy.

Objectives: Although the intra-aortic balloon pump (IABP) has been the most widely adopted temporary mechanical support device in cardiac surgical patients, its use has declined. The current study aimed to evaluate the occurrence and predictors of early mortality and complication rates in contemporary cardiac surgery patients supported by an IABP.

Methods: A multicentre, retrospective analysis was performed of all consecutive cardiac surgical patients receiving perioperative balloon pump support in 8 centres between January 2010 to December 2019. The primary outcome was early mortality, and secondary outcomes were balloon-associated complications. A multivariable binary logistic regression model was applied to evaluate predictors of the primary outcome.

Results: The study cohort consisted of 2615 consecutive patients. The median age was 68 years [25th percentile 61, 75th percentile 75 years], with the majority being male (76.9%), and a mean calculated 30-day mortality risk of 10.0%. Early mortality was 12.7% (n = 333), due to cardiac causes (n = 266), neurological causes (=22), balloon-related causes (n = 5) and other causes (n = 40). A composite end point of all vascular complications occurred in 7.2% of patients, and leg ischaemia was observed in 1.3% of patients. The most important predictors of early mortality were peripheral vascular disease [odds ratio (OR) 1.63], postoperative dialysis requirement (OR 10.40) and vascular complications (OR 2.57).

Conclusions: The use of the perioperative IABP proved to be safe and demonstrated relatively low complication rates, particularly for leg ischaemia. As such, we believe that specialists should not be held back to use this widely available treatment in high-risk cardiac surgical patients when indicated.
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http://dx.doi.org/10.1093/icvts/ivac091DOI Listing
April 2022

Editor's Choice - Extending Aortic Replacement Beyond the Proximal Arch in Acute Type A Aortic Dissection: A Meta-Analysis of Short Term Outcomes and Long Term Actuarial Survival.

Eur J Vasc Endovasc Surg 2022 May 2;63(5):674-687. Epub 2022 Apr 2.

Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.

Objective: The extent of aortic replacement during surgery for acute type A aortic dissection (ATAAD) is an important matter of debate. This meta-analysis aimed to evaluate the short and long term outcomes of a proximal aortic repair (PAR) vs. total arch replacement (TAR) in the treatment of ATAAD.

Data Sources: A systematic search of PubMed and Embase was performed. Studies comparing PAR to TAR for ATAAD were included.

Review Methods: The primary outcomes were early death and long term actuarial survival at one, five, and 10 years. Random effects models in conjunction with relative risks (RRs) were used for meta-analyses.

Results: Nineteen studies were included, comprising 5 744 patients (proximal: n = 4 208; total arch: n = 1 536). PAR was associated with reduced early mortality (10.8% [95% confidence interval (CI) 8.4 - 13.7] vs. 14.0% [95% CI 10.4 - 18.7]; RR 0.73 [95% CI 0.63 - 0.85]) and reduced post-operative renal failure (10.4% [95% CI 7.2 - 14.8] vs. 11.1% [95% CI 6.7 - 17.5]; RR 0.77 [95% CI 0.66 - 0.90]), but there was no difference in stroke (8.0% [95% CI 5.9 - 10.7] vs. 7.3% [95% CI 4.6 - 11.3]; RR 0.87 [95% CI 0.69 - 1.10]). No statistically significant difference was found for survival after one year (83.2% [95% CI 77.5 - 87.7] vs. 78.6% [95% CI 69.7 - 85.5]; RR 1.05 [95% CI 0.99 - 1.11]), which persisted after five years (75.4% [95% CI 71.2 - 79.2] vs. 74.5% [95% CI 64.7 - 82.3]; RR 1.02 [95% CI 0.91 - 1.14]). After 10 years, there was a significant survival benefit for patients who underwent TAR (64.7% [95% CI 61.1 - 68.1] vs. 72.4% [95% CI 67.5 - 76.7]; RR 0.91 [95% CI 0.84 - 0.99]).

Conclusion: PAR appears to lead to an improved early mortality rate and a reduced complication rate. In the current meta-analysis, the suggestion of an improved 10 year survival benefit of TAR was found, which should be interpreted in the context of potential confounders such as age at presentation, comorbidities, and haemodynamic stability. In any case, PAR seems to be intuitive in older patients with limited dissections, and in those presenting in less stable conditions.
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http://dx.doi.org/10.1016/j.ejvs.2021.12.045DOI Listing
May 2022

Mitral valve repair or replacement. How long is this feud to last?

J Card Surg 2022 Jun 1;37(6):1599-1601. Epub 2022 Apr 1.

Division of Cardiac Surgery A, "Henry Dunant" Hospital, Athens, Greece.

Choosing to perform mitral valve (MV) repair or replacement remains a hot and highly debated topic. The current guidelines seem to be conflicting in this specific field and the evidence at our disposal are scarce, only one small randomized trial and few larger retrospective studies. The meta-analysis by Gamal and coworkers tries to summarize the current evidence, concluding that MV replacement for the treatment of ischemic mitral regurgitation (MR) is at least as safe as repair and certainly offers a more stable result over time than the latter. Obviously, the implantation of a prosthesis, especially a mechanical one, brings with it a series of problems, such as anticoagulation and, above all, a possible lack of ventricular remodeling, especially if a chordal sparing replacement is not performed. It must be said, on the other hand, that isolated annuloplasty cannot act as a counterpart to replacement, because ischemic MR cannot be considered only an annular disease. Therefore, wanting to mimic the nature that, after an infarction, enacts a series of changes involving also the mitral leaflets and chordae, the surgeons are called to act also on these two entities and not only to downsize the annulus. In a nutshell, a procedure should not be opposed in a fundamentalist way to another one, but we must accept the concept of armamentarium where both procedures are present and tail on the single patient, and also on the surgeon's expertize, the technique guaranteeing the best possible result.
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http://dx.doi.org/10.1111/jocs.16479DOI Listing
June 2022

[Mechanical complications of acute myocardial infarction: from diagnosis to treatment].

G Ital Cardiol (Rome) 2022 Mar;23(3):190-199

Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Olanda - Cardiovascular Research Institute Maastricht, Maastricht, Olanda.

Post-infarction mechanical complications include left ventricular free-wall rupture, ventricular septal rupture, and papillary muscle rupture. With the advent of early reperfusion strategies, including thrombolysis and percutaneous coronary intervention, these events now occur in fewer than 0.3% of patients following acute myocardial infarction. However, unfortunately, there has been no parallel decrease in associated mortality rates over the past two decades. Moreover, during the ongoing COVID-19 pandemic the incidence of mechanical complications resulting from ST-elevation myocardial infarction has possibly risen. Early diagnosis and prompt management are crucial to improving outcomes. Although some percutaneous device repair approaches are available, surgical treatment remains the gold standard for these catastrophic post-infarction complications. The timing of surgery, also related to the type of complication and patient's clinical conditions, and the possible role of mechanical circulatory supports before and after surgery, represent main topics of debate that still need to be fully addressed.
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http://dx.doi.org/10.1714/3751.37338DOI Listing
March 2022

Perioperative incidence of ECMO and IABP on 5901 mitral valve surgery procedures.

J Cardiothorac Surg 2022 Mar 17;17(1):38. Epub 2022 Mar 17.

Department of Cardiac Surgery, Perfusion Service, Anthea Hospital, GVM Care and Research, Via Camillo Rosalba 35/37, 70124, Bari, Italy.

Background: Report the incidence and results of peri-operative extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) of patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) and conventional full sternotomy (FS) for a period of 6 years from eleven tertiary Cardiac Surgery Institutes of GVM Care & Research Italia.

Methods: From January 2016 to November 2021, a total of 5901 consecutive patients underwent MVS through RT and FS. The primary outcome of the study was the mortality and incidence of low cardiac output syndrome (LCOS) treated with intra-aortic balloon pump (IABP) with or without inotropic support and the incidence of Postcardiotomy Cardiogenic Shock (PCS) treated with Veno-arterial (VA) Extracorporeal Membrane Oxygenation (ECMO) on patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) versus conventional full sternotomy (FS).

Results: The mean age was 66 ± 15 years, 3389 patients underwent in RT approach 2512 in FS, 3081 (52%) patients were male and 2.3% had previous cardiac operations. Cardiopulmonary bypass time was 93 min for RT and 81 min for FS and cross clamp time 75 min for RT and 63 min for FS for mitral valve repair. Incidence of perioperative IABP for the treatment of low cardiac output was reported on 99 patients (1.6%), 51 for RT (1.5%), 35% used inotropic support (adrenaline and milrinone) and 48 in FS (1.9), 28% use inotropic support, 21 patients died after IABP (3 RT and 18 FS). Incidence of perioperative VA-ECMO for the PCS treatment was 13 and 4 with IABP, 9 RT (0.2%) and 4 FS approach (0.15%), 12 patients died after VA-ECMO.

Conclusion: Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity. ECMO and IABP incidence for the treatment of PCS was 0.2% and for Low cardiac output syndrome (LCOS) was 1.6% in elective mitral valve surgery is very low. The patients that use the perioperative IABP in minimally invasive mitral valve surgery (MIMVS) trough RT reported a reduced mortality compared to FS in relation to the operative risk and surgical technique. Low incidence of VA-ECMO was found in RT and FS approach, only one patient survived after VA-ECMO after minimally invasive mitral valve surgery.
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http://dx.doi.org/10.1186/s13019-022-01790-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8928683PMC
March 2022

Pacemaker implantation after sutureless or stented valve: results from a controlled randomized trial.

Eur J Cardiothorac Surg 2022 Mar 15. Epub 2022 Mar 15.

Department of Cardiac Surgery, Cardiovascular Center, Paracelsus Medical University-Klinikum Nürnberg, Nuremberg, Germany.

Objectives: Sutureless aortic valves demonstrated non-inferiority to standard stented valves for major cardiovascular and cerebral events at 1 year after aortic valve replacement. We aim to assess the factors correlating with permanent pacemaker implantation (PPI) in both cohorts.

Methods: PERSIST-AVR is a prospective, randomized, open-label trial. Patients undergoing aortic valve replacement were randomized to receive a sutureless aortic valve replacement (Su-AVR) or stented sutured bioprosthesis (SAVR). Multivariable analysis was performed to identify possible independent risk factors associated with PPI. A logistic regression analysis was performed to estimate the risk of PPI associated to different valve size.

Results: The 2 groups (Su-AVR; n = 450, SAVR n = 446) were well balanced in terms of preoperative risk factors. Early PPI rates were 10.4% in the Su-AVR group and 3.1% in the SAVR. PPI prevalence correlated with valve size XL (P = 0.0119) and preoperative conduction disturbances (P = 0.0079) in the Su-AVR group. No predictors were found in the SAVR cohort. Logistic regression analysis showed a significantly higher risk for PPI with size XL compared to each individual sutureless valve sizes [odds ratio (OR) 0.272 vs size S (95%confidence interval 0.07-0.95), 0.334 vs size M (95% CI 0,16-0; 68), 0.408 vs size L (95% CI 0,21-0.81)] but equivalent risk of PPI rates for all other combination of valve sizes.

Conclusions: Su-AVR is associated with higher PPI rate as compared to SAVR. However, the increased PPI rate appears to be size-dependent with significant higher rate only for size XL. The combination of preoperative conduction disorder and a size XL can lead to a higher probability of early PPI in Su-AVR.

Clinical Trial Registration Number: NCT02673697.
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http://dx.doi.org/10.1093/ejcts/ezac164DOI Listing
March 2022

Early paravalvular leak after conventional mitral valve replacement: A single-center analysis.

J Card Surg 2022 Jun 15;37(6):1559-1566. Epub 2022 Mar 15.

Department of Medicine and Surgery, Cardiac Surgery Unit, Circolo Hospital, University of Insubria, Varese, Italy.

Introduction: Paravalvular leak (PVL) is a well-recognized complication after mitral valve replacement (MVR). However, there are only a few studies analyzing leak occurrence and postoperative results after surgical MVR. The aim of this study was to assess the rate and determinants of early mitral PVL and to evaluate the impact on survival.

Methods: We performed a retrospective analysis involving patients who underwent MVR from January 2012 to December 2019 at our Institution. Postoperative transthoracic echocardiography evaluation was done for all subjects before hospital discharge. Multivariable analysis was carried out by constructing a logistic regression model to identify predictors for PVL occurrence.

Results: Four hundred ninety-four patients were enrolled. Operative mortality was 4.9%. Early mitral PVL was found in 16 patients (3.2%); the majority were mild (75%). Leaks occurred more frequently along the posterior segment of the mitral valve annulus (62.5%). Only one individual with moderate-to-severe PVL underwent reoperation during the same hospital admission. Multivariable analysis revealed that preoperative diagnosis of infective endocarditis was the only factor associated with early leak after MVR (odds ratio: 4.96; 95% confidence interval: 1.45-16.99; p = .011). Overall mortality at follow-up (mean follow-up time: 4.7 [SD: 2.5] years) was 19.6% and favored patients without early mitral PVL.

Conclusion: The incidence of early PVL after MVR is low. PVL is usually mild and develop more frequently along the posterior segment of the mitral valve annulus. Preoperative diagnosis of infective endocarditis increases the risk of PVL formation.
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http://dx.doi.org/10.1111/jocs.16422DOI Listing
June 2022

Commissural closure to treat severe mitral regurgitation: standing the test of time.

Eur J Cardiothorac Surg 2022 Mar 12. Epub 2022 Mar 12.

Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy.

Objectives: Mitral regurgitation (MR) due to commissural prolapse or flail represents a pattern of valve dysfunction that can be treated, among other techniques, by suturing the margins of the anterior and posterior leaflets in the commissural area (commissural closure). The very long-term results of this technique have not been reported so far and represent the objective of this study.

Methods: A retrospective review of our institutional database was carried on querying for patients who underwent commissural closure and ring annuloplasty within the time frame 1997-2007 to provide a robust long-term assessment. Cumulative incidence function (CIF) using death as a competitive outcome was used to estimate cardiac death and reoperation for mitral valve replacement. To describe the time course of MR, we performed a longitudinal analysis using generalized estimating equations with a random intercept for correlated data.

Results: A total of 125 patients were included. At 15 years, the CIF for cardiac death, with non-cardiac death as a competitive event, was 8.0 ± 2.57% (95% confidence interval [3.88-13.93]). At 15 years, the CIF for reintervention for a mitral valve replacement with death as a competitive event was 5.0 ± 1.98%, 95% confidence interval [2.04-9.89]. No significant predictors of reintervention for mitral valve replacement were identified. At 5 years, the predicted rate of MR ≥3+ recurrence was 2.53% while it was 8.22% at 15 years. In no case a more than mild mitral stenosis was detected.

Conclusions: Severe MR due to commissural prolapse/flail can be effectively treated with commissural closure and ring annuloplasty. In our series, the rate of reoperation in the very long term was extremely low. Similarly, longitudinal analysis demonstrated a very low rate of MR ≥3+ recurrence.
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http://dx.doi.org/10.1093/ejcts/ezac135DOI Listing
March 2022

Mid-term outcomes of isolated tricuspid valve surgery according to preoperative clinical and functional staging.

Eur J Cardiothorac Surg 2022 Mar 10. Epub 2022 Mar 10.

Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.

Objectives: This study aimed at assessing mid-term outcomes of patients undergoing isolated tricuspid valve (TV) surgery based on a preoperative baseline clinical and functional classification.

Methods: All patients treated with isolated TV repair or replacement from March 1997 to May 2020 at a single institution were retrospectively reviewed and assessed for mid-term postoperative outcome according to a novel classification [stages 1-5 related to the absence or presence and extent of right heart failure (RHF)]. Kaplan-Meier survival curves were used to estimate mid-term survival. Competing risk analysis for time to cardiac death and hospitalizations for RHF were also carried out.

Results: Among the 172 patients included, 129 (75%) underwent TV replacement and 43 (25%) TV repair. At follow-up (median 4.2 years [2.1-7.5]), there were 23 late deaths. At 5 years, overall survival was 100% in stage 2, 88 ± 4% in stage 3 and 60 ± 8% in stages 4-5 (P = 0.298 and P = 0.001, respectively). Cumulative incidence function of cardiac death at 5 years was 0%, 8.6 ± 3.76% and 13.2 ± 5% for stages 2, 3 and 4 and 5, respectively. At follow-up, cumulative incidence function of re-hospitalizations for RHF was 0% for stage 2, 20 ± 5% for stage 3 and 20 ± 6.7% for stages 4 and 5 (P = 0.118 and P = 0.039, respectively).

Conclusions: Both short- and mid-term outcomes support early referral for surgery in isolated TV disease, with excellent survival at 5 years and no further hospitalizations for RHF.
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http://dx.doi.org/10.1093/ejcts/ezac172DOI Listing
March 2022

Hemodynamic Performance of Sutureless vs. Conventional Bioprostheses for Aortic Valve Replacement: The 1-Year Core-Lab Results of the Randomized PERSIST-AVR Trial.

Front Cardiovasc Med 2022 18;9:844876. Epub 2022 Feb 18.

Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC+), Maastricht, Netherlands.

Objective: Sutureless aortic valves are an effective option for aortic valve replacement (AVR) showing non-inferiority to standard stented aortic valves for major cardiovascular and cerebral events at 1-year. We report the 1-year hemodynamic performance of the sutureless prostheses compared with standard aortic valves, assessed by a dedicated echocardiographic core lab.

Methods: Perceval Sutureless Implant vs. Standard Aortic Valve Replacement (PERSIST-AVR) is a prospective, randomized, adaptive, open-label trial. Patients undergoing AVR, as an isolated or combined procedure, were randomized to receive a sutureless [sutureless aortic valve replacement (Su-AVR)] ( = 407) or a stented sutured [surgical AVR (SAVR)] ( = 412) bioprostheses. Site-reported echocardiographic examinations were collected at 1 year. In addition, a subgroup of the trial population (Su-AVR = 71, SAVR = 82) had a complete echocardiographic examination independently assessed by a Core Lab (MedStar Health Research Institute, Washington D.C., USA) for the evaluation of the hemodynamic performance.

Results: The site-reported hemodynamic data of stented valves and sutureless valves are stable and comparable during follow-up, showing stable reduction of mean and peak pressure gradients through one-year follow-up (mean: 12.1 ± 6.2 vs. 11.5 ± 4.6 mmHg; peak: 21.3 ± 11.4 vs. 22.0 ± 8.9 mmHg). These results at 1-year are confirmed in the subgroup by the core-lab assessed echocardiogram with an average mean and peak gradient of 12.8 ± 5.7 and 21.5 ± 9.1 mmHg for Su-AVR, and 13.4 ± 7.7 and 23.0 ± 13.0 mmHg for SAVR. The valve effective orifice area was 1.3 ± 0.4 and 1.4 ± 0.4 cm at 1-year for Su-AVR and SAVR. These improvements are observed across all valve sizes. At 1-year evaluation, 91.3% ( = 42) of patients in Su-AVR and 82.3% in SAVR ( = 51) groups were free from paravalvular leak (PVL). The rate of mild PVL was 4.3% ( = 2) in Su-AVR and 12.9% ( = 8) in the SAVR group. A similar trend is observed for central leak occurrence in both core-lab assessed echo groups.

Conclusion: At 1-year of follow-up of a PERSIST-AVR patient sub-group, the study showed comparable hemodynamic performance in the sutureless and the stented-valve groups, confirmed by independent echo core lab. Perceval sutureless prosthesis provides optimal sealing at the annulus with equivalent PVL and central regurgitation extent rates compared to sutured valves. Sutureless valves are therefore a reliable and essential technology within the modern therapeutic possibilities to treat aortic valve disease.
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http://dx.doi.org/10.3389/fcvm.2022.844876DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8894864PMC
February 2022

Extracorporeal membrane oxygenation in children with COVID-19 and PIMS-TS during the second and third wave.

Lancet Child Adolesc Health 2022 04 4;6(4):e14-e15. Epub 2022 Mar 4.

Cardio-thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands; Cardiovascular Research Institute, Maastricht, Netherlands.

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http://dx.doi.org/10.1016/S2352-4642(22)00065-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8896737PMC
April 2022

Isolated tricuspid valve surgery: beyond the idea of a high-mortality surgery.

Eur J Cardiothorac Surg 2022 Mar 4. Epub 2022 Mar 4.

Vita-Salute San Raffaele University, Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Milan, Italy.

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http://dx.doi.org/10.1093/ejcts/ezac151DOI Listing
March 2022

Nutrition during extracorporeal life support: A review of pathophysiological bases and application of guidelines.

Artif Organs 2022 Mar 1. Epub 2022 Mar 1.

Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.

Background: Patients on extracorporeal life support (ECLS), either for respiratory or cardiac support, are at high risk of malnutrition; guidelines on nutrition in critical care have not incorporated solid evidence regarding these settings. The aim of this narrative review is to gather the available evidence in the existing literature and transpose general principles to the ECLS population.

Methods: A literature review of observational and interventional studies on nutrition during ECLS, and evaluation of nutrition guidelines in this perspective.

Results: Nutrition is paramount for improving outcomes in ECLS, as well as in critically ill patients. The caloric needs during ECLS can vary according to the severity of the clinical state, sedation, paralysis, and temperature stability. Precise evaluation of energy expenditure by indirect calorimetry is difficult because ECLS is a system dedicated to removing carbon dioxide; however, modified equations composed of carbon dioxide values taken from the membrane lung are available. Guidelines suggest starting early enteral nutrition (EN) with a hypocaloric (70%-80% of the needs) strategy, also in acute states such as septic or cardiogenic shock. Moreover, EN, despite previous concerns, is feasible in prone position, an increasingly adopted strategy during mechanical ventilation. The catabolic state is maximal in these patients, causing a protein and muscular reduction. Therefore, adequate protein delivery should be guaranteed by administering a high protein intake of up to 2 g/kg/day.

Conclusions: Studies on nutrition tailored to ECLS patients are warranted. Early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.
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http://dx.doi.org/10.1111/aor.14215DOI Listing
March 2022

Sex differences in primary malignant cardiac tumors: A multi-institutional cohort study from National Cancer Database.

J Card Surg 2022 May 28;37(5):1275-1286. Epub 2022 Feb 28.

Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht University, Maastricht, The Netherlands.

Introduction: Despite the significant clinical importance of sex among factors affecting cancer progression and survival, it remains one of the least studied factors. Therefore, we sought to examine these differences in relation to primary malignant cardiac tumors (PMCTs) using a national data set.

Methods: The 2004-2017 National Cancer Database was queried for patients with PMCTs. Annual trend of females' percent was assessed. Overall survival predictors were evaluated with Kaplan-Meier and Cox-regression. Subgroup analysis was done based on histology, comorbidity index, race, insurance, and surgical treatment.

Results: PMCTs were identified in 736 patients (median age 52, female [47.8%]). Most of them were high-grade (49.2%). About 60% underwent surgery. Angiosarcoma (43%), fibrosarcoma (5.2%), and leiomyosarcoma (5.2%) were the most common pathologies. Based on multivariate Cox-regression, higher income, higher comorbidity index, angiosarcoma, and Stage III/IV were associated with higher late mortality, while year of diagnosis and use of surgery or chemotherapy were associated with lower mortality. Among the surgical group, age, higher income, higher comorbidity index, angiosarcoma, and Stage III/IV were independent predictors of higher late mortality, while private insurance and year of diagnosis were associated with lower late mortality. No difference was seen between males and females in 30-day and late mortality (p = .71). Subgroup analysis based on Cox-regression showed no differences in late mortality between males and females.

Conclusion: PMCTs have poor overall survival. Surgery and chemotherapy were associated with longer survival benefits. On the contrary, the associated risk factors for mortality were advanced age, higher comorbidity index, angiosarcoma histology, and Stage III/IV.
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http://dx.doi.org/10.1111/jocs.16359DOI Listing
May 2022

A retrospective analysis of the hemolysis occurrence during extracorporeal membrane oxygenation in a single center.

Perfusion 2022 Feb 26:2676591211073768. Epub 2022 Feb 26.

Cardio-Thoracic Surgery Department, Heart & Vascular Centre, 199236Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.

Introduction: Extracorporeal membrane oxygenation (ECMO)-associated hemolysis still represents a serious complication. The present study aimed to investigate those predictive factors, such as flow rates, the use of anticoagulants, and circuit connected dialysis, that might play a pivotal role in hemolysis in adult patients.

Methods: This is a retrospective single-center case series of 35 consecutive adult patients undergoing veno-venous ECMO support at our center between April 2014 and February 2020. Daily plasma-free hemoglobin (pfHb) and haptoglobin (Hpt) levels were chosen as hemolysis markers and they were analyzed along with patients' characteristics, daily laboratory findings, and corresponding ECMO system variables, as well as continuous renal replacement therapy (CRRT) when administered, looking for factors influencing their trends over time.

Results: Among the many settings related to the ECMO support, the presence of CRRT connected to the ECMO circuit has been found associated with both higher daily pfHb levels and lower Hpt levels. After correction for potential confounders, hemolysis was ascribable to circuit-related variables, in particular the membrane oxygenation dead space was associated with an Hpt reduction (B = -215.307, = 0.004). Moreover, a reduction of ECMO blood flow by 1 L/min has been associated with a daily Hpt consumption of 93.371 mg/dL ( = 0.001).

Conclusions: Technical-induced hemolysis during ECMO should be monitored not only when suspected but also during quotidian management and check-ups. While considering the clinical complexity of patients on ECMO support, clinicians should not only be aware of and anticipate possible circuitry malfunctions or inadequate flow settings, but they should also take into account the effects of an ECMO circuit-connected CRRT, as an equally important key factor triggering hemolysis.
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http://dx.doi.org/10.1177/02676591211073768DOI Listing
February 2022

Right Ventricular Failure and Lateral Thoracotomy: the Monster Medusa and the Holy Grail.

Ann Thorac Surg 2022 Feb 14. Epub 2022 Feb 14.

Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.

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http://dx.doi.org/10.1016/j.athoracsur.2022.01.036DOI Listing
February 2022

Longitudinal Trends in Bleeding Complications on Extracorporeal Life Support Over the Past Two Decades-Extracorporeal Life Support Organization Registry Analysis.

Crit Care Med 2022 Jun 3;50(6):e569-e580. Epub 2022 Feb 3.

Division of Cardiothoracic Surgery, University of Utah Health, Salt Lake City, UT.

Objectives: Data about inhospital outcomes in bleeding complications during extracorporeal life support (ECLS) have been poorly investigated.

Design: Retrospective observational study.

Setting: Patients reported in Extracorporeal Life Support Organization Registry.

Patients: Data of 53.644 adult patients (greater than or equal to 18 yr old) mean age 51.4 ± 15.9 years, 33.859 (64.5%) male supported with single ECLS run between 01.01.2000 and 31.03.2020, and 19.748 cannulated for venovenous (V-V) ECLS and 30.696 for venoarterial (V-A) ECLS.

Interventions: Trends in bleeding complications, bleeding risk factors, and mortality.

Measurement And Main Results: Bleeding complications were reported in 14.786 patients (27.6%), more often in V-A ECLS compared with V-V (30.0% vs 21.9%; p < 0.001). Hospital survival in those who developed bleeding complications was lower in both V-V ECLS (49.6% vs 66.6%; p < 0.001) and V-A ECLS (33.9 vs 44.9%; p < 0.001). Steady decrease in bleeding complications in V-V and V-A ECLS was observed over the past 20 years (coef., -1.124; p < 0.001 and -1.661; p < 0.001). No change in mortality rates was reported over time in V-V or V-A ECLS (coef., -0.147; p = 0.442 and coef., -0.195; p = 0.139).Multivariate regression revealed advanced age, ecls duration, surgical cannulation, renal replacement therapy, prone positioning as independent bleeding predictors in v-v ecls and female gender, ecls duration, pre-ecls arrest or bridge to transplant, therapeutic hypothermia, and surgical cannulation in v-a ecls.

Conclusions: A steady decrease in bleeding over the last 20 years, mostly attributable to surgical and cannula-site-related bleeding has been found in this large cohort of patients receiving ECLS support. However, there is not enough data to attribute the decreasing trends in bleeding to technological refinements alone. Especially reduction in cannulation site bleeding is also due to changes in timing, patient selection, and ultrasound guided percutaneous cannulation. Other types of bleeding, such as CNS, have remained stable, and overall bleeding remains associated with a persistent increase in mortality.
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http://dx.doi.org/10.1097/CCM.0000000000005466DOI Listing
June 2022

After the storm comes a calm: the (rather good) post-discharge survival of adults undergoing post-cardiotomy extracorporeal life support.

Eur J Cardiothorac Surg 2022 05;61(5):1186-1187

Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands.

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http://dx.doi.org/10.1093/ejcts/ezac094DOI Listing
May 2022

Incidence and Predictors of Permanent Pacemaker Implantation after Transcatheter Aortic Valve Procedures: Data of The Netherlands Heart Registration (NHR).

J Clin Med 2022 Jan 23;11(3). Epub 2022 Jan 23.

Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), 6202 AZ Maastricht, The Netherlands.

Atrioventricular conduction disturbance leading to permanent pacemaker (PM) implantation is a frequent and relevant complication after transcatheter aortic valve implantation (TAVI). We aimed to evaluate the rate of post-TAVI permanent PM implantation over time and to identify the predictive factors for post-TAVI PM. The data were retrospectively collected by the Netherlands Heart Registration (NHR). In total, 7489 isolated TAVI patients between 2013 and 2019 were included in the final analysis. The primary endpoint was a permanent PM implantation within 30 days following TAVI. The incidence of the primary endpoint was 12%. Post-TAVI PM showed a stable rate over time. Using multivariable logistic regression analysis, age (OR 1.01, 95% CI 1.00-1.02), weight (OR 1.00, 95% CI 1.00-1.01), creatinine serum level (OR 1.15, 95% CI 1.01-1.31), transfemoral TAVI approach (OR 1.34, 95% CI 1.11-1.61), and TAVI post-dilatation (OR 1.58, 95% CI 1.33-1.89) were shown to be independent predictors of PM. Male sex (OR 0.80, 95% CI 0.68-0.93) and previous aortic valve surgery (OR 0.42, 95% CI 0.26-0.69) had a protective effect on post-TAVI PM. From a large national TAVI registry, some clinical and procedural factors have been identified as promoting or preventing post-TAVI PM. Further efforts are required to identify high-risk patients for post-TAVI PM and to reduce the incidence of this important issue.
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http://dx.doi.org/10.3390/jcm11030560DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8836997PMC
January 2022

Apical versus subclavian transcatheter aortic valve implantation: An 8-year United Kingdom analysis.

J Card Surg 2022 Apr 11;37(4):978-984. Epub 2022 Feb 11.

Cardiac Surgery, Cardiac Center, Brighton and Sussex University Hospital, Royal Sussex County Hospital, Brighton and Hove, UK.

Objectives: Subclavian (SC) and transapical (TA) approaches are the main alternatives to the default femoral delivery for transcatheter aortic valve implantation (TAVI). The aim of this study was to compare complications and morbidity/mortality associated with SC and TA in a long-term time frame.

Methods: From January 2007 to July 2015, 1506 patients underwent TAVI surgery in 36 United Kingdom TAVI centers. Primary outcomes were complications according to VARC-2 criteria. The secondary outcome was long-term survival.

Results: The enrolled patients were distributed as follows: 1216 in the TA group and 290 in the SC group. There were no differences in the rates of acute myocardial infarction, emergency valve-in-valve, paravalvular leak, balloon post dilatation, cardiac tamponade, stroke, renal replacement therapy, vascular injuries, and 30-day mortality among the groups. Conversely, the rate of permanent pacemaker implantation (p = .02), the procedural time duration (p = .04), and the 12-month mortality (p = .03) was higher in SC than in TA, while in-hospital length of stay was reduced in SC than in TA (p = .01). Up to 8 years, the long-term mortality was not different among groups (p = .77), and no difference in long-term survival between self- versus balloon-expandable devices was found (p = .26).

Conclusions: According to our results, TA provided the best 12-month survival compared to SC, while the long-term survival up to 2900 days is not significantly different between groups, so SC and TA may both represent a safe non-femoral access if femoral is precluded.
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http://dx.doi.org/10.1111/jocs.16298DOI Listing
April 2022

COVID-19 and Extracorporeal Membrane Oxygenation.

Adv Exp Med Biol 2021 ;1353:173-195

Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, the Netherlands.

Introduction: Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has recently and rapidly emerged and developed into a global pandemic. In SARS-CoV-2 patients with refractory respiratory failure, there may be a role for veno-venous extracorporeal membrane oxygenation (V-V ECMO) as a life-saving rescue intervention.

Methods: This review summarizes the evidence gathered until June 12, 2020; electronic databases were screened for pertinent reports on coronavirus and V-V ECMO. Search was conducted by two independent investigators; keywords used were SARS-CoV-2, COVID-19, ECMO, and extracorporeal life support (ECLS).

Results: Many patients with COVID-19 experience moderate symptoms and a relatively quick recovery, but others must be admitted into the intensive care unit due to severe respiratory failure and often must be mechanically ventilated. Further deterioration may require institution of extracorporeal oxygenation. Infection mechanisms may trigger "cytokine storm," an inflammatory disorder notable for multi-organ system failure; together with other metabolic and hematological changes, these amplify the changes pertinent to ECMO therapy, often exaggerating blood coagulation disorders. Thirty-two studies were found describing experiences with ECMO in the treatment of COVID-19. Of 4,912 COVID-19 patients, 2,119 (43%) developed ARDS and 2,086 (42%) were transferred to the ICU; 1,015 patients (21%) were treated with ECMO. While in an overall cohort, observed mortality was 640 (13%), the mortality within ECMO subgroups reached up to 34.6% (range 0-100%).

Conclusion: The efficacy of ECMO treatment for COVID-19 is largely dependent on the expertise of the center in ECLS due to the interplay between the changes in hematological and inflammatory modulators associated with both COVID-19 and ECMO. In order to support gas exchange during early infection with SARS-CoV-2, ECMO has a strong rationale for the treatment of the most critically ill patients. Due to the limited resources during a global pandemic, ECMO should be reserved for only the most severe cases of COVID-19.
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http://dx.doi.org/10.1007/978-3-030-85113-2_10DOI Listing
February 2022

Immunological and Hematological Response in COVID-19.

Adv Exp Med Biol 2021 ;1352:73-86

Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.

Introduction: Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has recently and rapidly emerged and developed into a global pandemic. Through the renin-angiotensin system, the virus may impact the lung circulation, but the expression on endothelium may conduct to its activation and further systemic damage. While precise mechanisms underlying these phenomena remain to be further clarified, the understanding of the disease, its clinical course, as well as its immunological and hematological implications is of paramount importance in this phase of the pandemic.

Methods: This review summarizes the evidence gathered until 12 June; electronic databases were screened for pertinent reports on coronavirus and inflammatory and hematological changes. Search was conducted by two independent investigators; keywords used were "SARS-CoV-2," "COVID-19," "inflammation," "immunological," and "therapy."

Results: The viral infection is able to trigger an excessive immune response in predisposed individuals, which can result in a "cytokine storm" that presents an hyperinflammation state able to determine tissue damage and vascular damage. An explosive production of proinflammatory cytokines such as TNF-α IL-1β and others occurs, greatly exaggerating the generation of molecule-damaging reactive oxygen species. These changes are often followed by alterations in hematological parameters. Elucidating those changes in SARS-CoV-2-infected patients could help to understand the pathophysiology of disease and may provide early clues to diagnosis. Several studies have shown that hematological parameters are markers of disease severity and suggest that they mediate disease progression. According to the available literature, the primary hematological symptoms-associated COVID-19, and which distinguish patients with severe disease from patients with nonsevere disease, are lymphocytopenia, thrombocytopenia, and a significant increase in D-dimer levels.

Conclusions: SARS-CoV-2 infection triggers a complex response altering inflammatory, hematological, and coagulation parameters. Measuring these alterations at certain time points may help identify patients at high risk of disease progression and monitor the disease severity.
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http://dx.doi.org/10.1007/978-3-030-85109-5_5DOI Listing
February 2022

Percutaneous versus surgical cannulation for femoro-femoral VA-ECMO in patients with cardiogenic shock: Results from the Extracorporeal Life Support Organization Registry.

J Heart Lung Transplant 2022 Apr 10;41(4):470-481. Epub 2022 Jan 10.

Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China. Electronic address:

Purpose: Percutaneous cannulation is increasingly used for veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, there is limited evidence about the benefit of this approach compared with conventional surgical cannulation. By using a large international database, this study was designed to compare in-hospital outcomes in cardiac shock patients who received femoro-femoral VA-ECMO with percutaneous versus surgical cannulation.

Methods: Adults with refractory cardiogenic shock treated with percutaneous (percutaneous group) or surgical (surgical group) femoro-femoral VA-ECMO between January 2008 and December 2019 were extracted from the international Extracorporeal Life Support Organization registry. The primary outcome was in-hospital mortality. Multivariable logistic regression analyses were performed to assess the association between percutaneous cannulation and in-hospital outcomes.

Results: Among 12,592 patients meeting study inclusion, 9,249 (73%) underwent percutaneous cannulation. The proportion of patients undergoing percutaneous cannulation increased from 32% to 84% over the study period (p < 0.01 for trend). In-hospital mortality (53% vs 58%; p < 0.01), cannulation site bleeding (19% vs 22%; p < 0.01), and systemic infection (8% vs 15%; p < 0.01) occurred less frequently in the percutaneous group compared to the surgical group. In adjusted analyses, percutaneous cannulation was independently associated with lower rates of in-hospital mortality (odds ratio [OR] 0.76; 95% CI 0.70-0.84; p < 0.01), cannulation site bleeding (OR 0.70; 95% CI 0.60-0.80; p < 0.01) and systemic infection (OR, 0.63; 95% CI 0.54-0.74; p < 0.01). Severe limb ischemia was more frequently observed in the percutaneous group (5% vs 3%; p < 0.01). However, this association was not significant in adjusted analysis (OR 1.28; 95% CI 0.93-1.62; p = 0.15).

Conclusions: Compared with surgical cannulation, percutaneous cannulation was independently associated with lower in-hospital mortality and fewer complications.
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http://dx.doi.org/10.1016/j.healun.2022.01.009DOI Listing
April 2022

Isolated tricuspid regurgitation: A plea for early correction.

Int J Cardiol 2022 04 4;353:80-85. Epub 2022 Feb 4.

Vita-Salute San Raffaele University, Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Milan, Italy.

Isolated tricuspid regurgitation (TR) is gaining increasing recognition. Left untreated, isolated TR significantly worsens survival. Management of patients with severe isolated TR remains controversial and stand-alone surgery is rarely performed due to reported high in-hospital mortality. However, recent data has underlined how early referral and surgical correction result in excellent both short-and long-term results, with no in-hospital mortality, 100% 5-year survival and no further hospitalizations for right heart failure. These results should prompt a drastic change in attitude in the treatment, management and referral of patients with severe isolated TR, especially since surgery remains the only effective therapy.
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http://dx.doi.org/10.1016/j.ijcard.2022.01.069DOI Listing
April 2022

Acute infective endocarditis during COVID-19 pandemic time: The dark side of the moon.

J Card Surg 2022 May 1;37(5):1168-1170. Epub 2022 Feb 1.

Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.

The COVID-19 pandemic has remarkably impacted the hospital management and the profile of patients suffering from acute cardiovascular syndromes. Among them, acute infective endocarditis (AIE) represented a rather frequent part of these urgent/emergent procedures. The paper by Liu et al. has clearly shown the higher risk features which patients with a diagnosis of AIE presented at hospital admission during the first part (first and second waves) of the outbreak, often requiring challenging operations, but fortunately not associated with the worse outcome if compared to results obtained before the SARS-2 pandemic. The report discussed herein presents several other aspects worth discussion and comments, particularly in relation to hospital management and postdischarge outcome which certainly deserve to be highlighted, but also further investigations.
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http://dx.doi.org/10.1111/jocs.16281DOI Listing
May 2022

RBC Transfusion in Venovenous Extracorporeal Membrane Oxygenation: A Multicenter Cohort Study.

Crit Care Med 2022 02;50(2):224-234

Department of Critical Care, Royal Adelaide Hospital, Adelaide, SA, Australia.

Objectives: In the general critical care patient population, restrictive transfusion regimen of RBCs has been shown to be safe and is yet implemented worldwide. However, in patients on venovenous extracorporeal membrane oxygenation, guidelines suggest liberal thresholds, and a clear overview of RBC transfusion practice is lacking. This study aims to create an overview of RBC transfusion in venovenous extracorporeal membrane oxygenation.

Design: Mixed method approach combining multicenter retrospective study and survey.

Setting: Sixteen ICUs worldwide.

Patients: Patients receiving venovenous extracorporeal membrane oxygenation between January 2018 and July 2019.

Interventions: None.

Measurements And Main Results: The primary outcome was the proportion receiving RBC, the amount of RBC units given daily and in total. Furthermore, the course of hemoglobin over time during extracorporeal membrane oxygenation was assessed. Demographics, extracorporeal membrane oxygenation characteristics, and patient outcome were collected. Two-hundred eight patients received venovenous extracorporeal membrane oxygenation, 63% male, with an age of 55 years (45-62 yr), mainly for acute respiratory distress syndrome. Extracorporeal membrane oxygenation duration was 9 days (5-14 d). Prior to extracorporeal membrane oxygenation, hemoglobin was 10.8 g/dL (8.9-13.0 g/dL), decreasing to 8.7 g/dL (7.7-9.8 g/dL) during extracorporeal membrane oxygenation. Nadir hemoglobin was lower on days when a transfusion was administered (8.1 g/dL [7.4-9.3 g/dL]). A vast majority of 88% patients received greater than or equal to 1 RBC transfusion, consisting of 1.6 U (1.3-2.3 U) on transfusion days. This high transfusion occurrence rate was also found in nonbleeding patients (81%). Patients with a liberal transfusion threshold (hemoglobin > 9 g/dL) received more RBC in total per transfusion day and extracorporeal membrane oxygenation day. No differences in survival, hemorrhagic and thrombotic complication rates were found between different transfusion thresholds. Also, 28-day mortality was equal in transfused and nontransfused patients.

Conclusions: Transfusion of RBC has a high occurrence rate in patients on venovenous extracorporeal membrane oxygenation, even in nonbleeding patients. There is a need for future studies to find optimal transfusion thresholds and triggers in patients on extracorporeal membrane oxygenation.
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http://dx.doi.org/10.1097/CCM.0000000000005398DOI Listing
February 2022
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