A study of size-selective renal elimination using a novel human model

The recently discovered selective glomerular hypofiltration syndromes have increased interest in the actual elimination of molecules in the human kidney. In the present study, a novel human model was introduced to directly measure the single-pass renal elimination of molecules of increasing size. Plasma concentrations of urea, creatinine, C-peptide, insulin, pro-BNP, β2-microglobulin, cystatin C, troponin-T, orosomucoid, albumin, and IgG were analysed in arterial and renal venous blood from 45 patients undergoing Transcatheter Aortic Valve Implantation (TAVI). The renal elimination ratio (RER) was calculated as the arteriovenous concentration difference divided by the arterial concentration. Estimated glomerular filtration rate (eGFR) was calculated by the CKD-EPI equations for both creatinine and cystatin C. Creatinine (0.11 kDa) showed the highest RER (21.0 ± 6.3%). With increasing molecular size, the RER gradually decreased, where the RER of cystatin C (13 kDa) was 14.4 ± 5.3% and troponin-T (36 kDa) was 11.3 ± 4.6%. The renal elimination threshold was found between 36 and 44 kDa as the RER of orosomucoid (44 kDa) was -0.2 ± 4.7%. The RER of creatinine and cystatin C showed a significant and moderate positive linear relationship with eGFR (r = 0.48 and 0.40). In conclusion, a novel human model was employed to demonstrate a decline in renal elimination with increasing molecular size. Moreover, RERs of creatinine and cystatin C were found to correlate with eGFR, suggesting the potential of this model to study selective glomerular hypofiltration syndromes.

ACURATE neo2 Transcatheter aortic valve implantation without balloon aortic valvuloplasty - direct ACURATE neo2

BACKGROUND

ACURATE neo2 (Neo2) implantation is performed after systematic Balloon Aortic Valvuloplasty (BAV) in most patients. No reports exist about the feasibility and safety of direct Neo2 transcatheter aortic valve implantation (TAVI) in comparison to the standard practice.

AIM

We aimed to identify the patients' baseline anatomical characteristics, procedural, and early post-procedural outcomes in patients treated using Neo2 with and without BAV.

METHODOLOGY

This is a retrospective multicentre analysis of 499 patients with severe aortic stenosis who underwent TAVI using Neo2. The comparison was done according to the performance or omission of BAV. Echocardiography and computed tomography were analysed by an independent Core Lab. Propensity score matching (PSM) was performed based on the annular diameter and AV calcium volume, which identified 84 matched pairs.

RESULTS

Among the cohort included, 391 (78%) patients received BAV (BAV-yes) and 108 (22%) were not attempted (BAV-no or Direct TAVI). Patients in BAV-no cohort had smaller annular diameter (22.6 vs 23.4 mm; p < 0.001) and lower calcium volume (163 vs 581 mm3; p < 0.001) compared to BAV-yes cohort. In the matched cohort, VARC-3 device technical success was similar (95%) and all other outcome measures were statistically comparable between cohorts.

CONCLUSION

Direct TAVI using ACURATEneo2 without pre-TAVI balloon aortic valvuloplasty in patients with mild or less valve calcifications might be feasible and associated with comparable early outcomes compared to patients with similar anatomical features undergoing systematic balloon valvuloplasty.

Regional assessment of availability for transcatheter aortic valve implantation in Sweden: a long-term observational study

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is an increasingly important treatment option for patients with severe aortic stenosis. Its best implementation is debated, as few centres with high volumes are associated with better outcomes, while centralisation might lead to an inferior availability of treatment for patients living far away. The aim of this study was to investigate the implementation of TAVI in Sweden with a focus on regional differences in terms of availability, short-term mortality and waiting times.

METHODS

All patients undergoing TAVI between 2008 and 2020 from the Swedish Transcatheter Cardiac Intervention Registry (SWENTRY) were included. SWENTRY was linked to the National Cause of Death Registry and to publicly available geospatial data from Statistics Sweden.

RESULTS

A total of 7280 patients were included. Over time, TAVI interventions increased markedly, while surgical aortic valve replacement (SAVR) remained constant. There were no statistically significant regional differences in incidence between counties with or without a local TAVI centre (p = 0.7) and no clustering tendencies around regions with a local TAVI centre (p = 0.99). Thirty-day mortality improved over time without evidence of regional differences. No regional differences in waiting time from decision to intervention were found for TAVI centre regions and non-TAVI centre regions (p = 0.7).

CONCLUSION

This nationwide study indicated no regional differences in terms of availability, short-term mortality or waiting times. An organisation with a few specialised centres was found to be sufficient to provide national coverage of TAVI interventions.

Interleukin-10: A Potential Pre-Cannulation Marker for Development of Acute Kidney Injury in Patients Receiving Veno-Arterial Extracorporeal Membrane Oxygenation

INTRODUCTION

Acute kidney injury (AKI) in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is associated with high mortality. The objective of this study was to investigate whether cytokine levels before the initiation of ECMO treatment could predict AKI. We also aimed to investigate the impact of AKI on 30-day and 1-year mortality.

METHODS

Serum cytokine levels were analyzed in 100 consecutive VA-ECMO-treated patients at pre-cannulation, at 48 h post-cannulation, and at 8 days. Clinical data to establish the incidence and outcome of AKI after the start of ECMO was retrieved from the local ECMO registry.

SETTING

The study was conducted at tertiary care, university hospital. Participants included 100 patients treated with VA-ECMO.

INTERVENTIONS

The blood samples for cytokine analysis were collected before VA-ECMO treatment, at 48 h after VA-ECMO treatment was started, and at 8 days.

RESULTS

Pre-cannulation serum IL-10 levels were significantly higher in patients who developed AKI (212 [38.9, 620.7]) versus those who did not (49.0 [11.9, 102.2]; p = 0.007), and the development of AKI can be predicted by pre-cannulation IL-10 levels (p = 0.025, OR = 1.2 [1.02-1.32]). The development of AKI during ECMO treatment is associated with increased 30-day mortality (p = 0.049) compared to patients who did not develop AKI and had a pre-cannulation estimated glomerular filtration rate ≥ 45 mL/min. The 1-year survival rate for patients with AKI who survived the first 30 days of ECMO treatment is comparable to that of patients without AKI.

CONCLUSION

Increased pre-cannulation IL-10 levels are associated with the development of AKI during VA-ECMO support. AKI is associated with increased 30-day mortality compared to patients with no AKI and better renal function. However, patients with AKI who survive the first 30 days have a 1-year survival rate similar to those without AKI.

The Early neo2 Registry: Transcatheter Aortic Valve Implantation With ACURATE neo2 in a European Population

Background ACURATE neo2 is a transcatheter aortic valve implantation system consisting of a self-expanding bioprosthetic valve with supra-annular leaflet position and featuring innovations to facilitate placement accuracy and reduce paravalvular regurgitation. Methods and Results The goal of the Early neo2 (Early neo2 Registry of the ACURATE neo2 TAVI Prosthesis) was to gather real-life data on safety and efficacy in a European transcatheter aortic valve implantation population treated with ACURATE neo2. Data were collected from 554 consecutive patients treated with ACURATE neo2 at 12 European sites (mean age, 82 years; 66% women; mean European System for Cardiac Operative Risk Evaluation II, 4.5%±3.8%) between September 2020 and March 2021. The composite primary end point was the occurrence of any of the following: postoperative (in-hospital) paravalvular regurgitation grade ≥2, in-hospital acute kidney injury stage 3, postoperative pacemaker implantation, 30-day death, and 30-day stroke. The primary end point occurred in 12.6% of patients. The 30-day rates for all-cause death and all stroke were 1.3% and 2.7%, respectively, and 1.5% of patients exhibited stage 3 acute kidney injury. A total of 34 patients (6.2%) received a postoperative permanent pacemaker. Per core laboratory-adjudicated echocardiographic analysis, mean postoperative aortic valve gradient was 7.6±3.3 mm Hg, and 2.8% of patients exhibited paravalvular regurgitation grade ≥2. Conclusions In this report of postmarket use of the ACURATE neo2 valve in a real-world transcatheter aortic valve implantation population, patients exhibited favorable postoperative hemodynamics and clinical outcomes and a low rate of postoperative pacemaker implantation.

Carbon dioxide flooding to reduce postoperative neurological injury following surgery for acute type A aortic dissection: a prospective, randomised, blinded, controlled clinical trial, CARTA study protocol - objectives and design

INTRODUCTION

Neurological complications after surgery for acute type A aortic dissection (ATAAD) increase patient morbidity and mortality. Carbon dioxide flooding is commonly used in open-heart surgery to reduce the risk of air embolism and neurological impairment, but it has not been evaluated in the setting of ATAAD surgery. This report describes the objectives and design of the CARTA trial, investigating whether carbon dioxide flooding reduces neurological injury following surgery for ATAAD.

METHODS AND ANALYSIS

The CARTA trial is a single-centre, prospective, randomised, blinded, controlled clinical trial of ATAAD surgery with carbon dioxide flooding of the surgical field. Eighty consecutive patients undergoing repair of ATAAD, and who do not have previous neurological injuries or ongoing neurological symptoms, will be randomised (1:1) to either receive carbon dioxide flooding of the surgical field or not. Routine repair will be performed regardless of the intervention. The primary endpoints are size and number of ischaemic lesions on brain MRI performed after surgery. Secondary endpoints are clinical neurological deficit according to the National Institutes of Health Stroke Scale, level of consciousness using the Glasgow Coma Scale motor score, brain injury markers in blood after surgery, neurological function according to the modified Rankin Scale and postoperative recovery 3 months after surgery.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Swedish Ethical Review Agency for this study. Results will be disseminated through peer-reviewed media.

TRIAL REGISTRATION NUMBER

NCT04962646.

Treatment refractory arthritis and stroke - A case of infective endocarditis caused by Tropheryma whipplei

Whipple´s disease is a rare multisystem condition affecting < 1/1.000.000 per year. The condition often presents with polyarthritis, diarrhea, and intestinal malabsorption. Endocarditis is seen in a minority of these patients, and is typically culture negative, as the causative agent Tropheryma whipplei does not grow in ordinary culture media. We present the case of a 78-year-old man with a history of seronegative polyarthritis that was refractory to treatment with several biological agents for a duration of 5 years prior to presentation to the emergency department with stroke. Echocardiography revealed aortic valve endocarditis with a 3.6 cm vegetation and multiple smaller vegetations. The patient underwent surgery with aortic valve replacement followed by prolonged antibiotic treatment. 16 S rDNA PCR analysis of the resected valve revealed T. whipplei as the causative agent. Two years after surgery and treatment with antibiotics, the patient's previously longstanding arthritis had totally disappeared and all rheumatological treatment had been discontinued.

The complexity of kidney disease and diagnosing it - cystatin C, selective glomerular hypofiltration syndromes and proteome regulation

Estimation of kidney function is often part of daily clinical practice, mostly done by using the endogenous glomerular filtration rate (GFR)-markers creatinine or cystatin C. A recommendation to use both markers in parallel in 2010 has resulted in new knowledge concerning the pathophysiology of kidney disorders by the identification of a new set of kidney disorders, selective glomerular hypofiltration syndromes. These syndromes, connected to strong increases in mortality and morbidity, are characterized by a selective reduction in the glomerular filtration of 5-30 kDa molecules, such as cystatin C, compared to the filtration of small molecules <1 kDa dominating the glomerular filtrate, for example water, urea and creatinine. At least two types of such disorders, shrunken or elongated pore syndrome, are possible according to the pore model for glomerular filtration. Selective glomerular hypofiltration syndromes are prevalent in investigated populations, and patients with these syndromes often display normal measured GFR or creatinine-based GFR-estimates. The syndromes are characterized by proteomic changes promoting the development of atherosclerosis, indicating antibodies and specific receptor-blocking substances as possible new treatment modalities. Presently, the KDIGO guidelines for diagnosing kidney disorders do not recommend cystatin C as a general marker of kidney function and will therefore not allow the identification of a considerable number of patients with selective glomerular hypofiltration syndromes. Furthermore, as cystatin C is uninfluenced by muscle mass, diet or variations in tubular secretion and cystatin C-based GFR-estimation equations do not require controversial race or sex terms, it is obvious that cystatin C should be a part of future KDIGO guidelines.

S100B predicts neurological injury and 30-day mortality following surgery for acute type A aortic dissection: an observational cohort study

BACKGROUND

Neurological injuries are frequent following Acute Type A Aortic Dissection (ATAAD) repair occurring in 4-30% of all patients. Our objective was to study whether S100B can predict neurological injury following ATAAD repair.

METHODS

This was a single-center, retrospective, observational study. The study included all patients that underwent ATAAD repair at our institution between Jan 1998 and Dec 2021 and had recorded S100B-values. The primary outcome measure was neurological injury, defined as focal neurological deficit or coma diagnosed by clinical assessment with or without radiological confirmation and with a symptom duration of more than 24 h. Secondary outcome measure was 30-day mortality.

RESULTS

538 patients underwent surgery during the study period and 393 patients, had recorded S100B-values. The patients had a mean age of 64.4 ± 11.1 years and 34% were female. Receiver operating characteristic curve for S100B 24 h postoperatively yielded area under the curve 0.687 (95% CI 0.615-0.759) and best Youden's index corresponded to S100B 0.225 which gave a sensitivity of 60% and specificity of 75%. Multivariable logistic regression identified S100B ≥ 0.23 μg/l at 24 h as an independent predictor for neurological injury (OR 4.71, 95% CI 2.59-8.57; p < 0.01) along with preoperative cerebral malperfusion (OR 4.23, 95% CI 2.03-8.84; p < 0.01) as well as an independent predictor for 30-day mortality (OR 4.57, 95% CI 1.18-11.70; p < 0.01).

CONCLUSIONS

We demonstrated that S100B, 24 h after surgery is a strong independent predictor for neurological injury and 30-day mortality after ATAAD repair.

TRIAL REGISTRATION

As this was a retrospective observational study it was not registered.

Temperature effects on incidence of surgery for acute type A aortic dissection in the Nordics

We aimed to investigate a hypothesised association between daily mean temperature and the risk of surgery for acute type A aortic dissection (ATAAD). For the period of 1 January 2005 until 31 December 2019, we collected daily data on mean temperatures and date of 2995 operations for ATAAD at 10 Nordic cities included in the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) collaboration. Using a two-stage time-series approach, we investigated the association between hot and cold temperatures relative to the optimal temperature and the rate of ATAAD repair in the selected cities. The relative risks (RRs) of cold temperatures (≤-5°C) and hot temperatures (≥21°C) compared to optimal temperature were 1.47 (95% CI: 0.72-2.99) and 1.43 (95% CI: 0.67-3.08), respectively. In line with previous studies, we observed increased risk at cold and hot temperatures. However, the observed associations were not statistically significant, thus only providing weak evidence of an association.

Impact of national holidays and weekends on incidence of acute type A aortic dissection repair

Previous studies have demonstrated that environmental and temporal factors may affect the incidence of acute type A aortic dissection (ATAAD). Here, we aimed to investigate the hypothesis that national holidays and weekends influence the incidence of surgery for ATAAD. For the period 1st of January 2005 until 31st of December 2019, we investigated a hypothesised effect of (country-specific) national holidays and weekends on the frequency of 2995 surgical repairs for ATAAD at 10 Nordic cities included in the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) collaboration. Compared to other days, the number of ATAAD repairs were 29% (RR 0.71; 95% CI 0.54-0.94) lower on national holidays and 26% (RR 0.74; 95% CI 0.68-0.82) lower on weekends. As day of week patterns of symptom duration were assessed and the primary analyses were adjusted for period of year, our findings suggest that the reduced surgical incidence on national holidays and weekends does not seem to correspond to seasonal effects or surgery being delayed and performed on regular working days.

Reduced renal elimination of larger molecules is a strong predictor for mortality

Renal dysfunction is a major risk factor for premature death and has been studied extensively. A new renal syndrome, shrunken pore syndrome (SPS), confers higher mortality in all studied populations. SPS is a condition in which cystatin C-based estimation of glomerular filtration rate (eGFR_{cystatin C}) is ≥ 60% than creatinine-based estimation of glomerular filtration rate (eGFR_creatinine). We aimed to study the impact of SPS on mortality in a cohort of patients with follow up of up to 10 years. This was a retrospective single centre cohort study. We enrolled 3993 consecutive patients undergoing elective cardiac surgery. Outcome was evaluated using Kaplan Meier analysis and multivariable Cox regression. 1-, 5- and 10-year survival for patients with SPS was 90%, 59% and 45%, and without SPS 98%, 88% and 80% (p < 0.001). SPS was found to be an independent predictor for mortality with an HR of 1.96 (95% CI 1.63-2.36). SPS negatively affected survival regardless of pre-operative renal function. SPS is an independent predictor for mortality after elective cardiac surgery, equal to or greater than risk factors such as diabetes, impaired left ventricular function or renal dysfunction. SPS affected mortality even in patients with normal eGFR.Clinical registration number: ClinicalTrials.gov, ID NCT04141072.

Long-term Outcomes of Transcatheter Aortic Valve Replacement With the Lotus Valve vs CoreValve/EvolutR: A Secondary Analysis of the REPRISE III Randomized Clinical Trial

IMPORTANCE

Long-term follow-up after transcatheter aortic valve replacement (TAVR) is of interest given that longitudinal data on mortality and durability of transcatheter heart valves are limited. The REPRISE III (Repositionable Percutaneous Replacement of Stenotic Aortic Valve Through Implantation of Lotus Valve System-Randomized Clinical Evaluation) randomized clinical trial compared the mechanically expanded Lotus valve with the self-expanding CoreValve/EvolutR TAVR platforms.

OBJECTIVE

To describe the final 5-year outcomes of the REPRISE III trial.

DESIGN, SETTING, AND PARTICIPANTS

This prespecified secondary analysis assessed the final 5-year clinical, functional, and echocardiographic outcomes of 912 patients from the REPRISE III trial, which was conducted at 55 centers in North America, Europe, and Australia between September 22, 2014, and December 24, 2015. Patients had high risk for aortic stenosis or severe or symptomatic aortic stenosis. Data were analyzed from September 22, 2014, to May 21, 2021.

INTERVENTION

Lotus valve or CoreValve/EvolutR TAVR platforms.

MAIN OUTCOMES AND MEASURES

Valve Academic Research Consortium-2 end points, hemodynamic measures, functional status, and health status were examined through the 5-year follow-up.

RESULTS

A total of 912 patients (mean [SD] age, 82.8 [7.3] years; 463 women [50.8%]) were randomized to either the Lotus valve group (n = 607) or CoreValve/EvolutR group (n = 305), with a baseline Society of Thoracic Surgeons risk score of 6.8%. Clinical follow-up data from the REPRISE III trial were available for 581 patients (95.7%) in the Lotus valve group and 285 patients (93.4%) in the CoreValve/EvolutR group. At 5 years, the cumulative event rate for all-cause mortality was 50.9% in the Lotus valve group vs 52.8% in the CoreValve/EvolutR group (P = .59). Disabling stroke was less frequent with the Lotus valve vs CoreValve/EvolutR (cumulative event rates, 8.3% vs 12.2%; P = .04), whereas the cumulative event rates for overall stroke were similar in both groups (14.1% vs 15.3%; P = .38). Insertion of a new permanent pacemaker (38.9% vs 27.3%; P < .001) and detection of prosthetic aortic valve thrombosis (5.8% vs 1.8%; P = .007) were more common in the Lotus valve group than in the CoreValve/EvolutR group. A smaller proportion of patients who received the Lotus valve experienced valve malpositioning (0% vs 2.6%; P < .001) and required the use of a second valve (1.0% vs 3.8%; P < .001) during the procedure compared with those who received the CoreValve/EvolutR. Compared with the Lotus valve group, the CoreValve/EvolutR group had a significantly lower mean (SD) aortic gradient (7.8 [4.2] mm Hg vs 12.6 [6.7] mm Hg; P < .001) and larger valve areas (1.57 [0.56] cm2 vs 1.42 [0.42] cm2; P = .10). After 5 years, the proportion of patients with moderate or greater paravalvular leak was not significantly higher with the CoreValve/EvolutR than with the Lotus valve (1.9% vs 0%; P = .31); however, the proportion of patients with mild paravalvular leak was higher in the CoreValve/EvolutR group compared with the Lotus valve group (23.1% vs 7.8%; P = .006). Long-term, similar improvements in New York Heart Association class and Kansas City Cardiomyopathy Questionnaire score were observed in both groups.

CONCLUSIONS AND RELEVANCE

The REPRISE III trial found that, at 5 years, the clinical outcomes of the Lotus valve were comparable to those of the CoreValve/EvolutR and that the Lotus valve was safe and effective.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02202434.

Calcium Load in the Aortic Valve, Aortic Root, and Left Ventricular Outflow Tract and the Risk for a Periprocedural Stroke

Background

Periprocedural stroke during transcatheter aortic valve implantation is a rare but devastating complication. The calcified aortic valve is the most likely source of the emboli in a periprocedural stroke. The total load and distribution of calcium in the leaflets, aortic root, and left ventricular outflow tract varies from patient to patient. Consequently, there could be patterns of calcification that are associated with a higher risk of stroke. This study aimed to explore whether the pattern of calcification in the left ventricular outflow tract, annulus, aortic valve, and ascending aorta can be used to predict a periprocedural stroke.

Methods

Among the 3282 consecutive patients who received a transcatheter aortic valve implantation in the native valve in Sweden from 2014 to 2018, we identified 52 who had a periprocedural stroke. From the same cohort, a control group of 52 patients was constructed by propensity score matching. Both groups had one missing cardiac computed tomography, and 51 stroke and 51 control patients were blindly reviewed by an experienced radiologist.

Results

The groups were well balanced in terms of demographics and procedural data. Of the 39 metrics created to describe calcium pattern, only one differed between the groups. The length of calcium protruding above the annulus was 10.6 mm (interquartile range 7-13.6) for patients without stroke and 8 mm (interquartile range 3-10) for stroke patients.

Conclusions

This study could not find any pattern of calcification that predisposes for a periprocedural stroke.

Once after a full moon: acute type A aortic dissection and lunar phases

OBJECTIVES

Acute type A aortic dissection (ATAAD) is a rare but severe condition, routinely treated with emergent cardiac surgery. Many surgeons have the notion that patients with ATAAD tend to come in clusters, but no studies have examined these observations. This investigation was undertaken to study the potential association between the lunar cycle and the incidence of ATAAD.

METHODS

We collected information on 2995 patients who underwent ATAAD surgery at centres from the Nordic Consortium for Acute Type A Aortic Dissection collaboration. We cross-referenced the time of surgery with lunar phase using a case-crossover design with 2 different definitions of full moon (>99% illumination and the 7-day full moon period).

RESULTS

The period when the moon was illuminated the most (99% definition) did not show any significant increase in incidence for ATAAD surgery. However, when the full moon period was compared with all other moon phases, it yielded a relative risk of 1.08 [95% confidence interval (CI) 1.00-1.17, P = 0.057] and, compared to waxing moon, only the relative risk was 1.11 (95% CI 1.01-1.23, P = 0.027). The peak incidence came 4-6 days after the moon was fully illuminated.

CONCLUSIONS

This study found an overrepresentation of surgery for ATAAD during the full moon phase. The explanation for this is not known, but we speculate that sleep deprivation during full moon leads to a temporary increase in blood pressure, which in turn could trigger rupture of the aortic wall. While this finding is interesting, it needs to be corroborated and the clinical implications are debateable.

Effect of Cyclosporine on Cytokine Production in Elective Coronary Artery Bypass Grafting: A Sub-Analysis of the CiPRICS (Cyclosporine to Protect Renal Function in Cardiac Surgery) Study

OBJECTIVES

The augmented inflammatory response to cardiac surgery is a recognized cause of postoperative acute kidney injury. The present study aimed to investigate the effects of preoperative cyclosporine treatment on cytokine production and delineate factors associated with postoperative kidney impairment.

DESIGN

A randomized, double-blind, placebo-controlled, single-center study.

SETTING

At a tertiary care, university hospital.

PARTICIPANTS

Patients eligible for elective coronary artery bypass grafting surgery; 67 patients were enrolled.

INTERVENTIONS

Patients were randomized to receive 2.5 mg/kg cyclosporine or placebo before surgery. Cytokine levels were measured after the induction of anesthesia and 4 hours after the end of cardiopulmonary bypass.

MEASUREMENTS AND MAIN RESULTS

Tissue-aggressive (interleukin [IL]-1β, macrophage inflammatory protein [MIP]-1β, granulocyte colony-stimulating factor [G-CSF], IL-6, IL-8, IL-17, MCP-1), as well tissue-lenient (IL-4) cytokines, were significantly elevated in response to surgery. Changes in cytokine levels were not affected by cyclosporine pretreatment.

CONCLUSIONS

Elective coronary artery bypass grafting surgery with cardiopulmonary bypass triggers cytokine activation. This activation was not impacted by preoperative cyclosporine treatment.

Late stroke after transcatheter aortic valve replacement: a nationwide study

Transcatheter aortic valve replacement (TAVR) is a rapidly growing field. Short-term safety and efficacy of these procedures have been studied extensively. However, little is known about the safety of these devices over time. Stroke is one feared long-term complication, and an increased stroke rate could affect guidelines for treating both the aortic stenosis and choosing antithrombotic therapy after TAVR. The primary objective was to study the incidence of stroke up to 8 years after TAVR implantation, comparing it with the risk of stroke in the general population. Secondary objectives were to study risk factors for late stroke and to study outcomes after stroke. A nationwide, all-comers study of patients who underwent TAVR in Sweden 2008–2018 was performed. The study was based on data from three national registries: a TAVR registry, a stroke registry, and a diagnosis registry. The main outcome was stroke incidence 30-days or more after TAVR implantation and was compared to a standardized incidence. The annual risk for stroke varied between 2.0% and 3.1% as compared to 1.5% and 1.9% in an age- and sex-matched cohort. Risk factors for developing stroke were reduced renal function, diabetes, history of stroke, age, and male sex. The 1-year mortality after stroke was 44%. This study demonstrated an increased rate of stroke after TAVR, but the findings suggest that this can in part be attributed to the group’s higher frequency of pre-disposing risk factors.

Transcatheter Aortic Valve Replacement With the LOTUS Edge System: Early European Experience

OBJECTIVES

The aim of this study was to evaluate the short-term safety and efficacy of transcatheter aortic valve replacement (TAVR) with the LOTUS Edge system.

BACKGROUND

The LOTUS Edge system was commercially re-released in April 2019. The authors report the first European experience with this device.

METHODS

A multicenter, single-arm, retrospective registry was initiated to evaluate short-term clinical outcomes. Included cases are the first experience with this device and new implantation technique in Europe. Clinical, echocardiographic, and computed tomographic data were analyzed. Endpoints were defined according to Valve Academic Research Consortium-2 and were site reported.

RESULTS

Between April and November 2019, 286 consecutive patients undergoing TAVR with the LOTUS Edge system at 18 European centers were included. The mean age and Society of Thoracic Surgeons score were 81.2 ± 6.9 years and 5.2 ± 5.4%, respectively. Nearly one-half of all patients (47.9%) were considered to have complex anatomy. Thirty-day major adverse events included death (2.4% [n = 7]) and stroke (3.5% [n = 10]). After TAVR, the mean aortic valve area was 1.9 ± 0.9 cm², and the mean transvalvular gradient was 11.9 ± 5.7 mm Hg. None or trace paravalvular leak (PVL) occurred in 84.4% and moderate PVL in 2.0%. There were no cases of severe PVL. New permanent pacemaker (PPM) implantation was required in 25.9% among all patients and 30.8% among PPM-naive patients.

CONCLUSIONS

Early experience with the LOTUS Edge system demonstrated satisfactory short-term safety and efficacy, favorable hemodynamic data, and very low rates of PVL in an anatomically complex cohort. New PPM implantation remained high. Further study will evaluate if increasing operator experience with the device and new implantation technique can reduce the incidence of PPM implantation.

Exercise Echocardiography following Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy

OBJECTIVES

 To investigate outcome after septal myectomy and to evaluate long-term hemodynamics with exercise echocardiography.

METHODS

 This study included 40 consecutive patients operated with septal myectomy for hypertrophic obstructive cardiomyopathy from January 1998 to August 2017 at Skane University Hospital, Lund, Sweden. Perioperative clinical data and echocardiography measurements were reviewed retrospectively. Patients (n = 36) who were alive and living in Sweden were invited for exercise echocardiography to evaluate exercise capacity and hemodynamics, of whom 19 patients performed exercise echocardiography.

RESULTS

 Overall survival was 100% at 1 year and 96% at 5 years following surgery. Preoperative median resting peak LVOT (left ventricular outflow tract) gradient was 80 mm Hg. Septum thickness was reduced from 22 ± 4 mm preoperatively to 16 ± 3 mm postoperatively (p < 0.001). During exercise echocardiography, the peak LVOT gradient was 8 mm Hg at rest, and increased to 13 mm Hg during exercise echocardiography (p = 0.002). None of the patients had dynamic LVOT obstruction during exercise echocardiography, and there was no clinically significant systolic anterior motion or severe mitral insufficiency during exercise.

CONCLUSIONS

 Long-term survival following septal myectomy is very good. At long-term follow-up, LVOT gradients were low and exercise echocardiography demonstrated good hemodynamics.

Infective endocarditis after transcatheter aortic valve implantation: a nationwide study

Aims 

Transcatheter aortic valve implantation (TAVI), now a common procedure to treat high-risk patients with severe aortic stenosis, has rapidly been expanding into younger and lower-risk populations, creating a need to better understand long-term outcome after TAVI. The aim of the present investigation was to determine the incidence, risk factors for, clinical presentation of, and outcome after prosthetic valve endocarditis (PVE) in patients treated with TAVI in a nationwide study.

Methods and results 

Three registries were used: a national TAVI registry, a national diagnosis registry, and a national infective endocarditis registry. Combining these registries made it possible to perform a nationwide, all-comers study with independent and validated reporting of PVE in 4336 patients between 2008 and mid-2018. The risk for PVE after TAVI was 1.4% (95% confidence interval 1.0–1.8%) the first year and 0.8% (0.6–1.1%) per year thereafter. One-year survival after PVE diagnosis was 58% (49–68%), and 5-year survival was 29% (17–41%). Body surface area, estimated glomerular filtration rate <30 mL/min/1.73 m², critical pre-operative state, mean pre-procedural valve gradient, amount of contrast dye used, transapical access, and atrial fibrillation were identified as independent risk factors for PVE. Staphylococcus aureus was more common in early (<1 year) PVE. Infection with S. aureus, root abscess, late PVE, and non-community acquisition was associated with higher 6-month mortality.

Conclusion 

The incidence of PVE was similar to that of surgical bioprostheses. Compromised renal function was a strong risk factor for developing PVE. In the context of PVE, TAVI seems to be a safe option for patients.

Clinical Trial Registration

NCT03768180 (http://clinicaltrials.gov/).

Single-center evaluation of a next generation fully repositionable and retrievable transcatheter aortic valve replacement

BACKGROUND

The mechanically expandable Lotus Valve System is a fully repositionable and retrievable valve with an adaptive seal to minimize paravalvular leak (PVL). The aim of this study was to evaluate the short- and long-term safety and efficacy of the new device with focus on a new implantation technique to reduce the need for a permanent pacemaker (PPM) post procedure.

METHODS

We performed a prospective single-center, non-randomized evaluation of the Lotus Valve System. The first 100 consecutive Lotus Valve implantations were included in the analysis. Outcome was assessed according to VARC2-criteria. Postoperative pacemaker rates were assessed using the national pacemaker registry and electronic medical records. Mortality at 30 days and 12 months were acquired from the national population registry.

RESULTS

Mean age was 82.7 ± 5.6 years, mean Euroscore I was 25.3 ± 14.5%, mean STS-score was 6.5 ± 4.1% and mean aortic valve area was 0.6 ± 0.1 cm². There were no cases of valve embolization, ectopic valve deployment or additional valve implantation. Device success according to the VARC2-criteria was 97%. The 30-day mortality rate was 3%. Two deaths occurred due to stroke and one due to a ventricular rupture. Major stroke rate was 2% and major vascular complication rate was 2%. The 12-month mortality rate was 14%. At discharge 87% of patients had no/trace PVL, 12% had mild PVL and one patient had a moderate PVL. A total of 13% received a new PPM post valve implantation. Among patients who did not have a PPM before the procedure, the PPM rate was 15.3%.

CONCLUSIONS

This single-center evaluation of the Lotus Valve System demonstrated a good clinical outcome with a low mortality, in a high-risk population. Introduction of a new implantation technique resulted in lower PPM rates than previously reported without negatively affecting PVL.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14952278 , retrospectively registered 06/11/2017.

Perioperative Hyperlactemia Is a Poor Predictor of Outcome in Patients Undergoing Surgery for Acute Type-A Aortic Dissection

OBJECTIVE

In patients presenting with acute type-A aortic dissection (aTAAD), lactic acid measurement is a frequently used analysis for diagnosis of acute ischemia, which may have a dismal prognosis. The aim of the current study was to determine the performance of perioperative arterial lactic acid measurements in predicting outcome in aTAAD patients.

DESIGN

Retrospective, observational study.

SETTING

Cardiothoracic surgery unit at a tertiary-level hospital.

PARTICIPANTS

The study involved 285 consecutive patients undergoing surgery for aTAAD.

INTERVENTIONS

Preoperative and postoperative lactic acid levels were measured and evaluated together with clinical data related to outcome, including in-hospital and 1-year mortality.

MEASUREMENTS AND MAIN RESULTS

Altogether, 37 patients (13%) died during the index hospital admission, and survival was 84.4 ± 2.2 at 1 year. Preoperative cardiac malperfusion (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.3-7.3) and cerebral malperfusion (OR 2.6; 95% CI 1.2-5.6) were associated significantly with poorer 1-year survival. The area under the curve (AUC) for in-hospital and 1-year mortality in relation to preoperative lactic acid levels was 0.684 and 0.673, respectively, corresponding to a lactic acid cut-off for in-hospital mortality of 2.75 mmol/L (sensitivity 56%; specificity 72%) and a cut-off for 1-year mortality of 2.85 mmol/L (sensitivity 48%; specificity 74%). The AUC for in-hospital and 1-year mortality in relation to lactic acid levels measured postoperatively on arrival at the intensive care unit was 0.582 and 0.498, respectively.

CONCLUSION

Although hyperlactemia in aTAAD indicates an increased risk of postoperative mortality, the sole use of lactic acid levels as a tool for accurate assessment of postoperative mortality is inadvisable due to its poor discriminatory performance.

Effect of Mechanically Expanded vs Self-Expanding Transcatheter Aortic Valve Replacement on Mortality and Major Adverse Clinical Events in High-Risk Patients With Aortic Stenosis: The REPRISE III Randomized Clinical Trial

IMPORTANCE

Transcatheter aortic valve replacement (TAVR) is established for selected patients with severe aortic stenosis. However, limitations such as suboptimal deployment, conduction disturbances, and paravalvular leak occur.

OBJECTIVE

To evaluate if a mechanically expanded valve (MEV) is noninferior to an approved self-expanding valve (SEV) in high-risk patients with aortic stenosis undergoing TAVR.

DESIGN, SETTING, AND PARTICIPANTS

The REPRISE III trial was conducted in 912 patients with high or extreme risk and severe, symptomatic aortic stenosis at 55 centers in North America, Europe, and Australia between September 22, 2014, and December 24, 2015, with final follow-up on March 8, 2017.

INTERVENTIONS

Participants were randomized in a 2:1 ratio to receive either an MEV (n = 607) or an SEV (n = 305).

MAIN OUTCOMES AND MEASURES

The primary safety end point was the 30-day composite of all-cause mortality, stroke, life-threatening or major bleeding, stage 2/3 acute kidney injury, and major vascular complications tested for noninferiority (margin, 10.5%). The primary effectiveness end point was the 1-year composite of all-cause mortality, disabling stroke, and moderate or greater paravalvular leak tested for noninferiority (margin, 9.5%). If noninferiority criteria were met, the secondary end point of 1-year moderate or greater paravalvular leak was tested for superiority in the full analysis data set.

RESULTS

Among 912 randomized patients (mean age, 82.8 [SD, 7.3] years; 463 [51%] women; predicted risk of mortality, 6.8%), 874 (96%) were evaluable at 1 year. The primary safety composite end point at 30 days occurred in 20.3% of MEV patients and 17.2% of SEV patients (difference, 3.1%; Farrington-Manning 97.5% CI, -∞ to 8.3%; P = .003 for noninferiority). At 1 year, the primary effectiveness composite end point occurred in 15.4% with the MEV and 25.5% with the SEV (difference, -10.1%; Farrington-Manning 97.5% CI, -∞ to -4.4%; P<.001 for noninferiority). The 1-year rates of moderate or severe paravalvular leak were 0.9% for the MEV and 6.8% for the SEV (difference, -6.1%; 95% CI, -9.6% to -2.6%; P < .001). The superiority analysis for primary effectiveness was statistically significant (difference, -10.2%; 95% CI, -16.3% to -4.0%; P < .001). The MEV had higher rates of new pacemaker implants (35.5% vs 19.6%; P < .001) and valve thrombosis (1.5% vs 0%) but lower rates of repeat procedures (0.2% vs 2.0%), valve-in-valve deployments (0% vs 3.7%), and valve malpositioning (0% vs 2.7%).

CONCLUSIONS AND RELEVANCE

Among high-risk patients with aortic stenosis, use of the MEV compared with the SEV did not result in inferior outcomes for the primary safety end point or the primary effectiveness end point. These findings suggest that the MEV may be a useful addition for TAVR in high-risk patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02202434.

Predictors and impact of massive bleeding in acute type A aortic dissection

Objectives

Bleeding complications associated with acute type A aortic dissection (aTAAD) are a well-known clinical problem. Here, we evaluated predictors of massive bleeding related to aTAAD and associated surgery and assessed the impact of massive bleeding on complications and survival.

Methods

This retrospective study of 256 patients used Blood Conservation Using Antifibrinolytics in a Randomized Trial (BART) criteria to define massive bleeding, which was met by 66 individuals (Group I) who were compared to the remaining patients (Group II). Multivariable logistic regression was used to identify independent predictors of massive bleeding and in-hospital mortality, Kaplan-Meier estimates for analysis of late survival, and Cox regression analysis to evaluate independent predictors of late mortality.

Results

Independent predictors of massive bleeding included symptom duration (odds ratio [OR], 0.974 per hour increment; 95% confidence interval [CI], 0.950-0.999; P  =   0.041) and DeBakey type 1 dissection (OR, 2.652; 95% CI, 1.004-7.008; P  =   0.049). In-hospital mortality was higher in Group I (30.3% vs 8.0%, P  <0.001). Kaplan-Meier estimates of survival indicated poorer survival for Group I at 1, 3 and 5 years (68.8 ± 5.9% vs 92.8 ± 1.9%; 65.2 ± 6.2% vs 85.3 ± 2.7%; 53.9 ± 6.9% vs 82.1 ± 3.3 %, respectively; log rank P  <   0.001). Re-exploration for bleeding was an independent predictor of in-hospital (OR, 3.109; 95% CI, 1.044-9.256; P  =   0.042) and late mortalities (hazard ratio, 3.039; 95% CI, 1.605-5.757; P  =   0.001).

Conclusions

Massive bleeding in patients with aTAAD is prompted by shorter symptom duration and longer extent of dissection and has deleterious effects on outcomes of postoperative complications as well as in-hospital and late mortalities.

The safety of introducing a new generation TAVR device: one departments experience from introducing a second generation repositionable TAVR

Background

In the evolving field of transcatheter aortic valve replacements a new generation of valves have been introduced to clinical practice. With the complexity of the TAVR procedure and the unique aspects of each TAVR device, there is a perceived risk that changing or adding a new valve in a department could lead to a worse outcome for patients, especially during the learning phase. The objective was to study the safety aspect of introducing a second generation repositionable transcatheter valve (Boston Scientific Lotus valve besides Edwards Sapien valve) in a department.

Methods

In a retrospective study, 53 patients receiving the Lotus system, and 47 patients receiving the Sapien system over a period of three years were compared for short-term outcome according to VARC-2 definitions and 1-year survival.

Results

Outcome in terms VARC-2 criteria for early safety and clinical efficacy, stroke rate, and survival at 30 days and at 1 year were similar. The Lotus valve had less paravalvular leakage, where 90% had none or trace aortic insufficiency as compared to only 48% for the Sapien system.

Conclusions

Introduction of a new generation valve can be done with early device success and safety, and without jeopardizing the outcome for patients up to one year. We found no adverse effects by changing valve type and observed improved outcome in terms of lower PVL-rates. Both existing and new centers starting a TAVR program can benefit from the use of a new generation device.

Ciclosporin to Protect Renal function In Cardiac Surgery (CiPRICS): a study protocol for a double-blind, randomised, placebo-controlled, proof-of-concept study

INTRODUCTION

Acute kidney injury (AKI) after cardiac surgery is common and results in increased morbidity and mortality. One possible mechanism for AKI is ischaemia-reperfusion injury caused by the extracorporeal circulation (ECC), resulting in an opening of the mitochondrial permeability transition pore (mPTP) in the kidneys, which can lead to cell injury or cell death. Ciclosporin may block the opening of mPTP if administered before the ischaemia-reperfusion injury. We hypothesised that ciclosporin given before the start of ECC in cardiac surgery can decrease the degree of AKI.

METHODS AND ANALYSIS

Ciclosporin to Protect Renal function In Cardiac Surgery (CiPRICS) study is an investigator-initiated double-blind, randomised, placebo-controlled, parallel design, single-centre study performed at a tertiary university hospital. The primary objective is to assess the safety and efficacy of ciclosporin to limit the degree of AKI in patients undergoing coronary artery bypass grafting surgery. We aim to evaluate 150 patients with a preoperative estimated glomerular filtration rate of 15-90 mL/min/1.73 m². Study patients are randomised in a 1:1 ratio to receive study drug 2.5 mg/kg ciclosporin or placebo as an intravenous injection after anaesthesia induction but before start of surgery. The primary end point consists of relative P-cystatin C changes from the preoperative day to postoperative day 3. The primary variable will be tested using an analysis of covariance method. Secondary end points include evaluation of P-creatinine and biomarkers of kidney, heart and brain injury.

ETHICS AND DISSEMINATION

The trial is conducted in compliance with the current version of the Declaration of Helsinki and the International Council for Harmonisation (ICH) Good Clinical Practice guidelines E6 (R1) and was approved by the Regional Ethical Review Board, Lund and the Swedish Medical Products Agency (MPA). Written and oral informed consent is obtained before enrolment into the study.

TRIAL REGISTRATION NUMBER

NCT02397213; Pre-results.

Shrunken Pore Syndrome is associated with a sharp rise in mortality in patients undergoing elective coronary artery bypass grafting

Shrunken Pore Syndrome was recently suggested for the pathophysiologic state in patients characterized by an estimation of their glomerular filtration rate (GFR) based upon cystatin  C, which is lower or equal to 60% of their estimated GFR based upon creatinine, i.e. when eGFR_{cystatin  C} ≤ 60% of eGFR_creatinine. Not only the cystatin  C level, but also the levels of other low molecular mass proteins are increased in this condition. The preoperative plasma levels of cystatin  C and creatinine were measured in 1638 patients undergoing elective coronary artery bypass grafting. eGFR_{cystatin  C} and eGFR_creatinine were calculated using two pairs of estimating equations, CAPA and LMrev, and CKD-EPI_{cystatin  C} and CKD-EPI_creatinine, respectively. The Shrunken Pore Syndrome was present in 2.1% of the patients as defined by the CAPA and LMrev equations and in 5.7% of the patients as defined by the CKD-EPI_{cystatin  C} and CKD-EPI_creatinine equations. The patients were studied over a median follow-up time of 3.5 years (2.0–5.0 years) and the mortality determined. Shrunken Pore Syndrome defined by both pairs of equations was a strong, independent, predictor of long-term mortality as evaluated by Cox analysis and as illustrated by Kaplan-Meier curves. Increased mortality was observed also for the subgroups of patients with GFR above or below 60 mL/min/1.73 m². Changing the cut-off level from 60 to 70% for the CAPA and LMrev equations increased the number of patients with Shrunken Pore Syndrome to 6.5%, still displaying increased mortality.

The predictive value of s-cystatin C for mortality after coronary artery bypass surgery

OBJECTIVES

To evaluate serum creatinine (s-creatinine) and serum cystatin C (s-cystatin C) levels and estimated glomerular filtration rate (eGFR) at different time points as predictors for mortality in patients undergoing coronary artery bypass grafting (CABG).

METHODS

A total of 1638 patients undergoing elective CABG were studied prospectively over a median follow-up of 3.5 years (range, 2.0-5.0 years). Renal function was assessed by a comparison of s-creatinine, s-cystatin C values measured preoperatively and at the lowest postoperative level of renal function. The eGFR was estimated by different formulas: Modification of Diet in Renal Disease, the 2009 Chronic Kidney Disease Epidemiology (CDK-EPI) for s-creatinine, the 2012 CKD-EPI formula for s-cystatin C, the 2012 CKD-EPI formula for s-cystatin C and s-creatinine in combination, and the Caucasian Asian, Pediatric, and Adult subjects formula for s-cystatin C. Cox proportional hazards model analysis and C-statistics were used to evaluate independent predictors of mortality and to assess the predictive ability of the different renal function measures.

RESULTS

The 30-day mortality was 0.8%. Overall survival was 96.1% ± 0.4% at 2 years and 90.0% ± 1.2% at 5 years. Preoperative s-cystatin C showed greater predictive power than s-creatinine for overall mortality (area under the curve, 0.794 vs 0.653). Preoperative s-cystatin C (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.36-1.99) and eGFR based on s-cystatin C (HR, 0.96; 95% CI, 0.95-0.98), were both independent predictors of mortality. The unadjusted HR for mortality comparing the lowest preoperative cystatin C quintile (Q1) with Q4-Q5 were as follows: Q1 versus Q5, HR, 2.0; 95% CI, 1.6-2.5 (P < .001); Q1 versus Q4, HR, 1.6; 95% CI, 1.2-2.2 (P = .005).

CONCLUSIONS

The s-cystatin C level and s-cystatin C-based eGFR measured preoperatively are strong predictors for mortality after elective CABG.

Late survival and heart failure after transcatheter aortic valve implantation

BACKGROUND

Short-term survival in patients undergoing transcatheter aortic valve implantation is favorable. Our aim was to evaluate late survival and composite clinical endpoints specified by the Valve Academic Research Consortium-2, including rehospitalization for congestive heart failure.

METHODS

Between January 2008 and April 2014, 166 consecutive patients with severe symptomatic aortic stenosis underwent 168 transcatheter aortic valve implantation procedures at our facility. This cohort was compared with propensity score-matched aortic valve replacement patients. Event rates were estimated by the Kaplan-Meier method and compared using the log-rank test. Cox regression analysis was performed to determine predictors of outcome.

RESULTS

Although 30-day mortality rates following both procedures were similar (4.2% and 4.8%; p = 0.81), significant differences were seen in corresponding rates of survival (51.7% ± 5.8% vs. 72.3% ± 4.3%; p < 0.001) and cumulative rehospitalization for congestive heart failure (41.3% ± 7.2% vs. 23% ± 4.3%; p = 0.006). New York Heart Association functional class IV preoperative status was an independent risk factor for rehospitalization due to congestive heart failure (p = 0.015).

CONCLUSIONS

This study confirms the merit of transcatheter aortic valve implantation in high-risk patients with aortic stenosis, although late survival proved inferior to that of aortic valve replacement in propensity score-matched subjects. Early safety was excellent for both treatment groups, however, patients undergoing transcatheter aortic valve implantation had a higher incidence of rehospitalization for congestive heart failure and myocardial infarction during follow-up. Patients with severe congestive heart failure should be carefully monitored and aggressively treated to improve outcomes.

Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study

Aims

Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients.

Methods and results

All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012–13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued <24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72–120 or >120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53–1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72–120 vs. >120 h before surgery (OR 1.71 (95% CI 1.04–2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56–0.92), P = 0.012].

Conclusion

The incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued <24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel.

Safety, Feasibility, and Hemodynamic Effects of Mild Hypothermia in Transcatheter Aortic Valve Replacement: The TAVR-CHILL Trial

The safety, feasibility, and hemodynamic effects of mild hypothermia (MH) induced by transnasal cooling were studied in transcatheter aortic valve replacement (TAVR). MH is a common therapy following cardiac arrest and seems to have favorable effects in myocardial infarction and on hemodynamic stability. In TAVR, hemodynamic instability is common during rapid pacing. Twenty subjects undergoing TAVR were randomized 1:1 to hypothermia or normothermia. Hemodynamic endpoints were mean arterial blood pressure and required dosage of vasoactive and inotropic drugs. Patients were followed up at 6 months. All patients in the MH group (n=10) reached the target temperature of 34°C before first rapid pacing. Tympanic and urinary bladder temperature remained significantly lower in the MH group during the procedure. No adverse effects of cooling were observed. Mean arterial pressure was higher in the MH group (90±20 mm Hg) than in the control group (71±13 mm Hg) at the start of the procedure, at first rapid pacing (94±19 vs. 80±16 mm Hg), and at balloon aortic valvuloplasty (90±17 vs. 73±14 mm Hg). Less norepinephrine was administered to the hypothermia group. Transnasal cooling during TAVR was safe and well tolerated. We observed a more stable hemodynamic profile in the MH group, indicated by higher blood pressure and lower levels of vasoactive drugs required. A larger study of patients with severe ventricular dysfunction is required to more comprehensively investigate the hemodynamic effects of transnasal cooling in TAVR.

Generalized ischaemia in type A aortic dissections predicts early surgical outcomes only

OBJECTIVES

In patients with acute type A aortic dissection (aTAAD), early post-surgical outcomes are largely influenced by preoperative conditions, specifically localized or generalized ischaemia. Such states are reflected in the recent Penn classification. Our aim was to determine the impact of preoperative ischaemia (by Penn class) on in-hospital and long-term mortality.

METHODS

All consecutive patients (n = 341) surgically treated for aTAAD between 1998 and 2014 were recruited for a retrospective observational study. Parameters impacting in-hospital and long-term mortality were identified through univariable and multivariable analyses.

RESULTS

In-hospital mortality rates by Penn class were as follows: Class Aa, 11%; Class Ab, 14%; Class Ac, 42% and Class Abc, 29%. Both Ac [odds ratio (OR) = 4.4; 95% confidence interval (CI), 1.92-9.80] and Abc (OR = 3.72; 95% CI, 1.26-10.99) classifications independently predicted in-hospital mortality, as did cardiopulmonary bypass time (OR = 1.01; 95% CI, 1.00-1.01). Relative to Class Aa patients, survival did not differ significantly in Class Ac and Abc subsets (log-rank P = 0.365 and P = 0.716, respectively), once 30-day postoperative deaths were excluded. The leading cause of late mortality was cardiac failure or myocardial infarction (29%), followed by aortic rupture (25%). Independent predictors of long-term mortality after aTAAD were age [hazard ratio (HR) = 1.08; 95% CI, 1.05-1.10] and supracoronary replacement graft (HR = 2.27; 95% CI, 1.1-4.75).

CONCLUSIONS

Penn classes Ac and Abc were identified as an independent risk factor for in-hospital mortality, whereas neither Penn class nor organ-specific ischaemia significantly impacted long-term survival. Regardless of ischaemic manifestations at presentation, the prognosis of patients surviving both surgery and early postoperative period proved acceptable.

Acute kidney injury assessed by cystatin C after transcatheter aortic valve implantation and late renal dysfunction

OBJECTIVE

The aim of the present study was to evaluate acute kidney injury (AKI) with cystatin C following transcatheter aortic valve implantation (TAVI) and to assess the impact of postoperative AKI on outcome and late renal function.

DESIGN

A prospective study.

SETTING

Single, tertiary referral center.

PARTICIPANTS

Sixty-eight consecutive patients with severe aortic stenosis and advanced comorbidity.

INTERVENTIONS

Blood samples were collected on 4 occasions pre- and postoperatively to determine levels of s-creatinine and cystatin C. Additionally, a sample was collected at followup 12 months postoperatively for the determination of s-creatinine.

MEASUREMENTS AND MAIN RESULTS

The mean preoperative eGFR (s-creatinine) was 67±24 mL/min/1.73 m² compared to 45±21 mL/min/1.73 m² with eGFR (cystatin C) (p<0.001). Postoperative AKI was diagnosed in 25 patients (39%) with eGFR (cystatin C), compared to 21 patients (33%) with GFR (s-creatinine) and the RIFLE criteria. The 90-day mortality was 14.3% for the AKI+group and 2.3% for the AKI-group (p = 0.099). At 12 months followup, renal function remained impaired in patients with postoperative AKI and deteriorated in patients without.

CONCLUSIONS

The risk of postoperative AKI is considerable following TAVI, with an increased risk of early mortality for AKI+patients. Cystatin C may be a valuable adjunct to the established biomarker s-creatinine for preoperative risk assessment and for early postoperative diagnosis of AKI. The acute postoperative renal impairment in patients with AKI does not fully recover in the long term. There is a progressive renal impairment in both groups postoperatively, the etiology probably being multifactorial.

Incidence, dynamics, and prognostic value of acute kidney injury for death after cardiac surgery

OBJECTIVE

This study relates long-term mortality after cardiac surgery to different methods of measuring postoperative renal function, classified according to the Risk, Injury, Failure, Loss, and End-stage (RIFLE) criteria. The dynamics of acute kidney injury during hospital stay were studied by comparing renal function preoperatively, at its poorest measurement, and at discharge.

METHODS

A total of 5746 patients undergoing coronary artery bypass grafting were studied in a Cox analysis, over a median follow-up time of 6.0 years (range, 2.5-9.5 years). Renal function was determined using the highest and discharge levels of plasma creatinine by Cockroft-Gault and Modification of Diet in Renal Disease formulae. Acute kidney injury was classified according to the RIFLE criteria. Renal recovery was studied in a 2-dimensional matrix, and the impact of renal function at different time points was related to survival.

RESULTS

Although the p-creatinine classified most patients in the nonacute kidney injury and Risk class; the Cockroft-Gault and Modification of Diet in Renal Disease formulae classified more patients in Injury and Failure classes; and higher Risk, Injury, and Failure classes were associated with increased long-term mortality. The effect of renal recovery on long-term survival was only in part associated with improved outcome. In addition, the poorest renal function was a stronger predictor of mortality compared with preoperative and discharge levels.

CONCLUSIONS

Classification using RIFLE criteria seems to be useful because it detects patients with renal impairment that affects long-term survival. The Modification of Diet in Renal Disease method seems to be the most robust method when predicting outcome, and the poorest renal function was the best predictor of outcome. Renal recovery was generally associated with better outcome.

Risks associated with the transfusion of various blood products in aortic valve replacement

BACKGROUND

Patients undergoing cardiac operations often require transfusions of red blood cells, plasma, and platelets. From a statistical point of view, there is a significant collinearity between the components, but they differ in indications for use and composition. This study explores the relationship between the transfusion of different blood components and long-term mortality in patients undergoing aortic valve replacement alone or combined with revascularization.

METHODS

A retrospective single-center study was performed including 1,311 patients undergoing aortic valve replacement. Patients who received more than 7 units of red blood cells, those who died early (7 days), and emergency cases were excluded. Patients were monitored for up to 9.5 years. A broad selection of potential risk factors were analyzed using Cox proportional hazards regression, where transfusion of red blood cells, plasma, and platelets were forced to remain in the model.

RESULTS

The transfusion of red blood cells was not associated with decreased long-term survival (hazard ratio [HR], 1.01; p = 0.520) nor was the transfusion of platelets (HR, 0.946; p = 0.124); however, the transfusion of plasma was (HR, 1.041; p < 0.001). All HRs are per unit of blood product transfused. No increased risk was found for patients undergoing a combined procedure.

CONCLUSIONS

No significant risk for long-term mortality was associated with transfusion of red blood cells during the study period. However, the transfusion of plasma was associated with increased mortality.

Successful transcatheter valve-in-valve implantation in a small deteriorated aortic valve bioprosthesis

Increased life expectancy and improvement in clinical outcome following surgery has led to an increasing number of elderly patients with a history of prior aortic valve replacement (AVR). As a consequence, a considerable number of patients may require reintervention due to a dysfunctional bioprosthesis with structural valve deterioration (SVD). Transcatheter aortic valve implantation (TAVI) has become an established surgical alternative in patients with aortic stenosis and severe comorbidities. For those patients requiring reoperation, the 'valve-in-valve' concept has been described. Here, the case is reported of a patient with a very small Sorin Soprano 18 bioprosthesis with SVD who underwent a reintervention with the transapical valve-in-valve technique. The implantation was uneventful, with no residual paravalvular leakage and a low mean transprosthetic gradient. The valve-in-valve procedure may represent a feasible alternative for redo AVR in patients with a very small, structurally deteriorated bioprosthesis.

Giant aneurysm in the sinus of Valsalva presenting as an acute coronary symptom

We describe an 85-year old male who was admitted to the hospital with acute coronary symptoms. Bedside echocardiography revealed a structure in the aortic root, and a computed tomography scan verified the diagnosis of an aneurysm in the sinus of Valsalva below the left coronary ostium. A coronary angiography also depicted the aneurysm clearly and clearly showed how the aneurysm compressed and dislocated the left main coronary artery, explaining his initial symptoms. The patient was operated on with an aortic root replacement procedure, and recovered quickly.

A randomized study of coronary artery bypass surgery performed with the Resting Heart™ System utilizing a low vs a standard dosage of heparin

OBJECTIVES

Allogeneic blood transfusion and reoperation for postoperative bleeding after the coronary artery bypass grafting have a negative impact on the patient outcome. This study aimed at evaluating the effects of reduced doses of heparin and protamine on the patient outcome, using a heparin-coated mini-cardiopulmonary bypass (CPB) system.

METHODS

Sixty patients undergoing elective first-time CPB were prospectively randomized either to have a reduced systemic heparinization [activated clotting time (ACT) = 250 s] or to a control group perfused with a full heparin dose (ACT = 420 s). Blood transfusions, ventilation time, early postoperative bleeding, ICU stay, reoperations for bleeding, postoperative cognitive status and the level of mobilization were registered.

RESULTS

Twenty-nine patients were randomized to the control group, 27 patients to the low-dose group and 4 patients were excluded because of protocol violations. Four patients in the control group received a total of 10 units of packed red blood cells, and in the low-dose group, no transfusions were given, P = 0.046. No patient was reoperated because of bleeding. The ICU stay was significantly shorter in the low-dose group (8.4 vs 13.7 h, P = 0.020), less dependent on oxygen on the first postoperative day (78 vs 97%, P = 0.034), better mobilized (89 vs 59%, P = 0.006) and had less pain (visual analogue scale 2.0 vs 3.5, P = 0.019) compared with the control group.

CONCLUSIONS

The use of a mini-CPB system combined with a low dose of heparin reduced the need for blood transfusions and may facilitate the faster mobilization of the patients.

Lipid emboli distribution in cardiac surgery is dependent on the state of emulsification

OBJECTIVE

Lipid embolizations from retransfused shed blood during cardiac surgery have been shown to enter the circulation and end up in different organs. The purpose of this investigation was to evaluate differences in the kinetics and deposition between emulsified and non-emulsified lipid emboli in a porcine model.

DESIGN

Twelve animals were anesthetized and put on cardiopulmonary bypass. A shed-blood phantom (6 animals given emulsified and 6 given non-emulsified lipids) was produced from arterial blood, saline, and tritium-labeled triolein. The phantom was infused into the cardiopulmonary bypass circuit. Arterial and venous blood samples were taken at short intervals. Tissue samples were taken post-mortem from examined organs and prepared for scintillation counting. Levels of radioactivity were used to measure lipid emboli content in blood and tissue.

RESULTS

Emulsified lipid emboli generated a 5-fold higher embolic load in the arterial and a 12-fold higher in the venous circulation, compared with non-emulsified lipid emboli. Emulsified lipid micro emboli resulted in a 2-15-fold higher tissue deposition in investigated organs compared with non-emulsified lipid micro emboli.

CONCLUSIONS

This study shows that the state of emulsion significantly alter the kinetics and tissue deposition of lipid emboli. Emulsified lipid emboli give higher embolic load in the arterial and venous circulation, and higher tissue deposition versus non-emulsified lipid emboli. In both groups, the embolic load was higher in the arterial circulation than on the venous side.

Blood transfusion after cardiac surgery: is it the patient or the transfusion that carries the risk?

BACKGROUND

The transfusion of red blood cells (RBCs) after cardiac surgery has been associated with increased long-term mortality. This study reexamines this hypothesis by including pre-operative hemoglobin (Hb) levels and renal function in the analysis.

METHODS

A retrospective single-center study was performed including 5261 coronary artery bypass grafting (CABG) patients in a Cox proportional hazard survival analysis. Patients with more than eight RBC transfusions, early death (7 days), and emergent cases were excluded. Patients were followed for 7.5 years. Previously known risk factors were entered into the analysis together with pre-operative Hb and estimated glomerular filtration rate (eGFR). In addition, subgroups were formed based on the patients' pre-operative renal function and Hb levels.

RESULTS

When classical risk factors were entered into the analysis, transfusion of RBCs was associated with reduced long-term survival. When pre-operative eGFR and Hb was entered into the analysis, however, transfusion of RBCs did not affect survival significantly. In the subgroups, transfusion of RBCs did not have any effect on long-term survival.

CONCLUSIONS

When pre-operative Hb levels and renal function are taken into account, moderate transfusions of RBC after CABG surgery do not seem to be associated with reduced long-term survival.