Prosthesis-prosthesis anastomosis using barbed sutures compared to conventional sutures under high, long-term pressure; in vitro extracorporeal circulation setup

BACKGROUND

While barbed sutures have been extensively utilized in other disciplines, they have not been widely adopted in cardiac surgery. The lack of safety and feasibility data has limited its use within the field. To aide in the further understanding of how cardiac surgeons can use barbed sutures, we sought to develop a high-pressure in vitro simulation model. We compared knotless barbed sutures in a highly pressurized anastomosis to conventional sutures.

METHODS

Ten specimens in total were utilized in prosthesis anastomosis, using 34 mm Gelweave Plexus (Terumo Aortic, Sunrise, FL 33325, USA) and 34 mm Hemabridge (Intergard Woven Hemabridge, Getinge, Göteborg, Sweden). Five models of size 3-0 barbed suture anastomoses using non-absorbable, barbed, self-retaining, monofilament polypropylene sutures (Filbloc® 3-0, Assut Europe, Rome, Italy) were compared against five conventional anastomoses using size 4-0 polypropylene monofilament (Ethicon, USA). The systems were connected using a novel-designed extracorporeal circulation system. Pressure was rapidly increased in the specimen to a mean pressure of 300-350 mmHg, running then for a minimum of 48 hours to assess anastomosis strength and endurance.

RESULTS

No anastomotic dehiscence or rupture was recorded. Complex, angular anastomosis required extra stitch leakage sutures in both conventional and barbed suture specimens.

CONCLUSION

Using knotless barbed sutures with an additional self-locking maneuver for prosthesis-prosthesis anastomosis in cardiac surgery is feasible in an in vitro model under long term, high-mean pressure when compared to conventional sutures. In vivo trials should be performed to further validate the in vitro findings.

Tumour necrosis factor-alpha serum level is an independent predictor of medium-term all-cause mortality after transcatheter aortic valve replacement

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a suitable treatment for patients with severe aortic stenosis and severely increased operative risk. There is need for a better preoperative risk assessment for TAVI candidates.

AIM

To determine whether Tumour necrosis factor-alfa (TNFα) is an independent predictor of survival 500 days after TAVI.

METHODS

Sixty patients undergoing TAVI were enrolled in the study. TNFα was determined. The CT measured low-density muscle fraction (LDM%) of the psoas muscle was determined. Operative risk assessment by Logistic EuroSCORE, EuroSCORE II, and STS score was performed. Frailty scores (FRAIL scale and Barthel index) were determined.

RESULTS

Mean age was 81.01 ± 7.54 years. Twenty-six (43.3%) of the patients were males. In the univariable analyses, FRAIL scale and Barthel index were no predictors of survival after TAVI. In the multivariable analysis, including EuroSCORE II, LDM% and TNFα serum concentration, TNFα serum level was an independent predictor of survival 500 days after TAVI (HR: 3.167; 95%: 1.279-7.842; p = 0.013). The multivariable analysis, including TNFα as a categorical variable, showed that compared to patients in the conjugated first and second TNFα serum level tertile, patients in the third tertile had a hazard ratio (HR) of 10.606 (95%CI: 1.203 - 93.467) (p = 0.033).

CONCLUSION

TNFα is an incremental independent predictor of long-term survival after TAVI.

Variable clinical expression of a Belgian TGFB3 founder variant suggests the presence of a genetic modifier

Background: TGFB3 variants cause Loeys-Dietz syndrome type 5, a syndromic form of thoracic aortic aneurysm and dissection. The exact disease phenotype is hard to delineate because of few identified cases and highly variable clinical representation. Methodology: We provide the results of a haplotype analysis and a medical record review of clinical features of 27 individuals from 5 different families, originating from the Campine region in Flanders, carrying the NM_003239.5(TGFB3):c.787G>C p.(Asp263His) likely pathogenic variant, dbSNP:rs796051886, ClinVar:203492. The Asp263 residue is essential for integrin binding to the Arg-Gly-Asp (RGD) motif of the TGFβ3-cytokine. Results: The haplotype analysis revealed a shared haplotype of minimum 1.92 Mb and maximum 4.14 Mb, suggesting a common founder originating >400 years ago. Variable clinical features included connective tissue manifestations, non-aneurysmal cardiovascular problems such as hypertrophic cardiomyopathy, bicuspid aortic valve, mitral valve disease, and septal defects. Remarkably, only in 4 out of the 27 variant-harboring individuals, significant aortic involvement was observed. In one family, a 31-year-old male presented with type A dissection. In another family, the male proband (65 years) underwent a Bentall procedure because of bicuspid aortic valve insufficiency combined with sinus of Valsalva of 50 mm, while an 80-year-old male relative had an aortic diameter of 43 mm. In a third family, the father of the proband (75 years) presented with ascending aortic aneurysm (44 mm). Conclusion: The low penetrance (15%) of aortic aneurysm/dissection suggests that haploinsufficiency alone by the TGFB3 variant may not result in aneurysm development but that additional factors are required to provoke the aneurysm phenotype.

In-hospital and 6-month outcomes in patients with COVID-19 supported with extracorporeal membrane oxygenation (EuroECMO-COVID): a multicentre, prospective observational study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO during the first wave of COVID-19 and to describe the status of patients 6 months after ECMO initiation.

METHODS

EuroECMO-COVID is a prospective, multicentre, observational study developed by the European Extracorporeal Life Support Organization. This study was based on data from patients aged 16 years or older who received ECMO support for refractory COVID-19 during the first wave of the pandemic-from March 1 to Sept 13, 2020-at 133 centres in 21 countries. In-hospital mortality and mortality 6 months after ECMO initiation were the primary outcomes. Mixed-Cox proportional hazards models were used to investigate associations between patient and management-related variables (eg, patient demographics, comorbidities, pre-ECMO status, and ECMO characteristics and complications) and in-hospital deaths. Survival status at 6 months was established through patient contact or institutional charts review. This study is registered with ClinicalTrials.gov, NCT04366921, and is ongoing.

FINDINGS

Between March 1 and Sept 13, 2020, 1215 patients (942 [78%] men and 267 [22%] women; median age 53 years [IQR 46-60]) were included in the study. Median ECMO duration was 15 days (IQR 8-27). 602 (50%) of 1215 patients died in hospital, and 852 (74%) patients had at least one complication. Multiorgan failure was the leading cause of death (192 [36%] of 528 patients who died with available data). In mixed-Cox analyses, age of 60 years or older, use of inotropes and vasopressors before ECMO initiation, chronic renal failure, and time from intubation to ECMO initiation of 4 days or more were associated with higher in-hospital mortality. 613 patients did not die in hospital, and 547 (95%) of 577 patients for whom data were available were alive at 6 months. 102 (24%) of 431 patients had returned to full-time work at 6 months, and 57 (13%) of 428 patients had returned to part-time work. At 6 months, respiratory rehabilitation was required in 88 (17%) of 522 patients with available data, and the most common residual symptoms included dyspnoea (185 [35%] of 523 patients) and cardiac (52 [10%] of 514 patients) or neurocognitive (66 [13%] of 512 patients) symptoms.

INTERPRETATION

Patient's age, timing of cannulation (<4 days vs ≥4 days from intubation), and use of inotropes and vasopressors are essential factors to consider when analysing the outcomes of patients receiving ECMO for COVID-19. Despite post-discharge survival being favourable, persisting long-term symptoms suggest that dedicated post-ECMO follow-up programmes are required.

FUNDING

None.

Adiponectin serum level is an independent and incremental predictor of all-cause mortality after transcatheter aortic valve replacement

Background

Quantifiable biomarkers may be useful for a better risk and frailty assessment of patients referred for transcatheter aortic valve implantation (TAVI).

Hypothesis

To determine if adiponectin serum concentration predicts all‐cause mortality in patients undergoing TAVI.

Methods

77 consecutive patients, undergoing TAVI, were analyzed. The CT axial slices at the level of the fourth lumbar vertebra were used to measure the psoas muscle area, and its low‐density muscle fraction (LDM (%)). To assess the operative risk, the STS (Society of Thoracic Surgeons Predicted Risk of Mortality) score, Log. Euroscore, and Euroscore II were determined. A clinical frailty assessment was performed. ELISA kits were used to measure adiponectin serum levels. We searched for a correlation between serum adiponectin concentration and all‐cause mortality after TAVI.

Results

The mean age was 80.8 ± 7.4 years. All‐cause mortality occurred in 22 patients. The mean follow‐up was 1779 days (range: 1572–1825 days). Compared with patients with the lowest adiponectin level, patients in the third tertile had a hazards ratio of all‐cause mortality after TAVI of 4.155 (95% CI: 1.364–12.655) (p = .004). In the multivariable model, including STS score, vascular access of TAVI procedure, LDM (%), and adiponectin serum concentration, serum adiponectin level, and LDM(%) were independent predictors of all‐cause mortality after TAVI (p = .178, .303, .042, and .017, respectively). Adiponectin level was a predictor of all‐cause mortality in females and males (p = .012 and 0.024, respectively).

Conclusion

Adiponectin serum level is an independent and incremental predictor of all‐cause mortality in patients undergoing TAVI.

Reoperation for bleeding after cardiac surgery

BACKGROUND

Postoperative cardio-surgical haemostatic management is centre-specific and experience-based, which leads to a variability in patient care. This study aimed to identify which postoperative haemostatic interventions may reduce the need for reoperation after cardiac surgery in adults.

METHODS

A retrospective case-control study in a tertiary centre. Adult, elective, primary cardiac surgical patients were selected (n = 2098); cases (n = 42) were patients who underwent reoperation within 72 h after the initial surgery. Interventions administered to control surgical bleeding were compared for the need to re-operate using multiple logistic regression.

RESULTS

Rate of cardiac surgical reoperation was 2% in the study population. Three variables were found to be associated with cardiac reoperation: preoperative administration of fresh frozen plasma (OR 5.45, CI 2.34-12.35), cumulative volume of chest tube drainage and cumulative count of packed red blood cells transfusion on ICU (OR 1.98, CI 1.56-2.51).

CONCLUSION

No significant difference among specific types of postoperative haemostatic interventions was found between patients who needed reoperation and those who did not. Perioperative transfusion of fresh frozen plasma, postoperative transfusion of packed cells and cumulative volume of chest tube drainage were associated with reoperation after cardiac surgery. These variables could help predict the need for reoperation.

Computed tomography measured psoas muscle attenuation predicts mortality after transcatheter aortic valve implantation

AIMS

The aim of this study was to determine if computed tomography (CT) psoas muscular attenuation measurements may predict all-cause mortality in patients undergoing TAVI.

METHODS

Ninety-four consecutive patients undergoing TAVI were analysed. The CT axial slice at the level of the fourth lumbar vertebra was selected. The psoas muscle areas were manually contoured. The circumferential surface area (CSA) of both psoas muscles was determined by selecting the voxels with attenuation values, ranging from 0 to 100 Hounsfield Units (HU). The mean CT attenuation coefficient of the psoas muscle (Psoas mean HU) was measured. The muscle was subdivided into a low-density muscle (LDM) (0-29 HU) and high-density muscle (HDM) (30-100 HU) portion. The HDM/LDM ratio was calculated. We searched for a correlation between HDM/LDM, CSA LDM (%), Psoas mean HU and all-cause mortality.

RESULTS

The mean age was 81.2 ± 7.5 years. Thirty patients had adverse outcome (all-cause mortality). Compared with patients with the lowest CSA LDM (%), patients in the third and second tertiles had an increased hazard ratio for mortality (2.871; 95% confidence interval 0.880-9.371 and 5.044; 95% confidence interval 1.641-15.795, respectively) in a multivariable model with EuroSCORE II, Barthel frailty index and CSA LDM (%) (P = 0.231, 0.097 and 0.019, respectively). HDM/LDM and Psoas mean HU (as continuous variable) were also independent predictors of all-cause mortality (P = 0.019, P = 0.013, respectively).

CONCLUSION

CSA LDM (%), Psoas mean HU and HDM/LDM are independent and incremental predictors of all-cause mortality in patients undergoing TAVI.

Knotless Closure of the Cardiac Venous Cannulation Site Using Barbed Suture: A First Step in Including Barbed Sutures in our Cardiac Surgery Practice

Background: Barbed sutures have rarely been used in cardiac surgery. The reason is the absence of safety and feasibility data. This study was set up to assess the safety and efficacy using barbed sutures for right atrium cannulation-site closure both in short and longer-term follow up. Methods: Ten patients undergoing routine CABG through sternotomy with the use of ECC were included after giving written informed consent. After performing CABG, closure of the venous cannulation site at the right atrium is performed, using Stratafix® 2/0 non-resorbable, spiral polypropylene (SXPL1B400), without knotting. Results: No postoperative bleeding complications or revisions for bleeding or tamponade were noted. No complications or major adverse cardio-cerebrovascular incidents were registered during follow-up. The relevance of this lies in the difficulty in tying timely knots, even in experienced hands, during scopic or minimally invasive procedures. Being able to avoid this cumbersome procedure would largely reduce time spent on tying knots (the single most efficient time reducing step in minimally invasive cardiac surgery). Conclusion: Using knotless barbed sutures with an additional self-locking manoeuvre is feasible for the closure of the right atrium cannulation site in cardiac surgery, with no short-term or long-term complications. This opens up possibilities using knotless barbed sutures safer in minimally invasive cardiac surgery. This study confirms barbed knotless sutures perform adequately when closing a low-pressure cardiac structure, and in such, potentially saving time in minimally invasive surgery. Further investigation in closure of other cardiovascular structures is advisable and are planned by the authors.

The deleterious effects of smoking resumption after heart transplantation

AIMS

Smoking is linked to disease and survival in the general and transplant population. We studied the smoking history, disease and survival of patients after heart transplantation.

METHODS

A total of 130 patients who underwent heart transplantation between 1995 and 2019 received a questionnaire to document their smoking history. We assessed patient characteristics, comorbidities and survival.

RESULTS

Sixty-five per cent of patients were active or former smokers prior to heart transplantation. All patients stopped smoking; 26% of the former smokers resumed smoking after transplantation. Patients who resumed smoking were younger at the time of transplantation, used fewer statins and were more likely to be treated with azathioprine after transplantation. The mean follow-up for all patients was 11 ± 5.5 years. Patients who resumed smoking were more likely to develop solid organ cancers (45%) compared to those who remained abstinent (23%) and those who never smoked (13%) (p 0.014). A Cox proportional hazards regression analysis identified smoking resumption, with a RR of 2.31 (1.14-4.68, p 0.02), and age at transplantation, with a RR of 1.03 (1-1.06, p 0.034), as significant for survival. Patients resuming smoking after transplantation had a significantly higher risk of dying from solid organ cancer, with a RR of 2.54 (1.03, 6.28; p 0.04) with a short median survival time (25th-75th percentile) of (1 (0-5) months, p 0.007).

CONCLUSION

Patients who resume smoking after heart transplantation have worse survival and are at higher risk of dying from solid organ cancer. Implementing a smoking cessation plan throughout the post-transplant period is important.

Study design and rationale of the pAtients pResenTing with cOngenital heaRt dIseAse Register (ARTORIA-R)

Aim

Due to improved therapy in childhood, many patients with congenital heart disease reach adulthood and are termed adults with congenital heart disease (ACHD). ACHD often develop heart failure (HF) as a consequence of initial palliative surgery or complex anatomy and subsequently require advanced HF therapy. ACHD are usually excluded from trials evaluating heart failure therapies, and in this context, more data about heart failure trajectories in ACHD are needed to guide the management of ACHD suffering from HF.

Methods and results

The pAtients pResenTing with cOngenital heaRt dIseAse Register (ARTORIA‐R) will collect data from ACHD evaluated or listed for heart or heart‐combined organ transplantation from 16 countries in Europe and the Asia/Pacific region. We plan retrospective collection of data from 1989–2020 and will include patients prospectively. Additional organizations and hospitals in charge of transplantation of ACHD will be asked in the future to contribute data to the register. The primary outcome is the combined endpoint of delisting due to clinical worsening or death on the waiting list. The secondary outcome is delisting due to clinical improvement while on the waiting list. All‐cause mortality following transplantation will also be assessed. The data will be entered into an electronic database with access to the investigators participating in the register. All variables of the register reflect key components important for listing of the patients or assessing current HF treatment.

Conclusion

The ARTORIA‐R will provide robust information on current management and outcomes of adults with congenital heart disease suffering from advanced heart failure.

Clinical characteristics and outcomes of patients with adult congenital heart disease listed for heart and heart‒lung transplantation in the Eurotransplant region

BACKGROUND

The therapeutic success in patients with congenital heart disease (CHD) leads to a growing number of adults with CHD (adult CHD [ACHD]) who develop end-stage heart failure. We aimed to determine patient characteristics and outcomes of ACHD listed for heart transplantation.

METHODS

Using data from all the patients with ACHD in 20 transplant centers in the Eurotransplant region from 1999 to 2015, we analyzed patient characteristics, waiting list, and post-transplantation outcomes.

RESULTS

A total of 204 patients with ACHD were listed during the study period. The median age was 38 years, and 62.3% of the patients were listed in high urgency (HU), and 37.7% of the patients were in transplantable (T)-listing status. A total of 23.5% of the patients died or were delisted owing to clinical worsening, and 75% of the patients underwent transplantation. Median waiting time for patients with HU-listing status was 4.18 months and with T-listing status 9.07 months. There was no difference in crude mortality or delisting between patients who were HU status listed and T status listed (p = 0.65). In multivariable regression analysis, markers for respiratory failure (mechanical ventilation, hazard ratio [HR]: 1.41, 95% CI: 1.11-1.81, p = 0.006) and arrhythmias (anti-arrhythmic medication, HR: 1.42, 95% CI: 1.01-2.01, p = 0.044) were associated with a higher risk of death or delisting. In the overall cohort, post-transplantation mortality was 26.8% after 1 year and 33.4% after 5 years.

CONCLUSIONS

Listed patients are at high risk of death without differences in the urgency of listing. Respiratory failure requiring invasive ventilation and possibly arrhythmias requiring anti-arrhythmic medication indicate worse outcomes on waiting list.

Cardiogeneticsbank@UZA: A Collection of DNA, Tissues, and Cell Lines as a Translational Tool

Cardiogeneticsbank@UZA is an academic hospital integrated biobank that collects aortic tissue, blood, cell lines (fibroblasts, vascular smooth muscle cells, peripheral blood mononuclear cells, and induced pluripotent stem cells), and DNA from patients with cardiogenetic disorders, for both diagnostic and research purposes. We adhere to a quality management system and have established standard protocols for the sampling and processing of all cardiogenetic patient related materials. Cardiogeneticsbank@UZA is embedded in the Biobanking and Biomolecular Resources Research Infrastructure Belgium (BBMRI.be) and samples from this biobank are available for commercial and academic researchers, through an established access procedure. Currently, the extremely valuable cardiogenetics collection consists of more than 8,700 DNA samples, 380 tissue samples, and 500 cell lines of 7,578 patients, and is linked with extensive clinical data. Some interesting potential research applications are discussed.

De-Differentiated Myxofibrosarcoma Metastasis in the Right Atrium: An Invasive But Diagnostic Approach

Solitary cardiac metastasis remains an uncommon diagnosis. Herein, the authors report describes a rare case of a 53-year-old woman with cardiac metastasis of a peripheral de-differentiated myxofibrosarcoma. This case demonstrates the complexity of pairing multimodality imaging and invasive techniques to achieve tissue characterization and diagnosis. (Level of Difficulty: Beginner.).

Biomarkers and Donor Selection in Heart Transplantation

BACKGROUND

Previously, we showed that B-type natriuretic peptide (BNP) measured in the donor was related to cardiac performance after cardiac transplantation. The present study assesses the value of 3 biomarkers in the selection of donor hearts in a larger cohort.

METHODS

Blood samples were prospectively obtained in 105 brain-dead patients scheduled for heart donation. BNP, soluble suppressor of tumorigenicity 2 (ST2), and troponin of heart donors were correlated with hemodynamic parameters early after transplantation as well as with the mortality of the recipients.

RESULTS

A significant inverse relationship was found between donor BNP measured at the time of donation and recipient cardiac index and cardiac output at day 13 post-transplantation (r = -0.31, P = .005, and r = -0.34, P = .0016, respectively). Logistic regression analysis-including BNP, ST2, and troponin-showed that donor BNP was a predictor of a poor cardiac index (< 2.2 L/min/m²) in the recipient (P = .04). A donor BNP > 132 pg/mL has a sensitivity of 56% (95% confidence interval 21-86) and a specificity of 86% (95% confidence interval 77-93) to predict poor cardiac performance in the recipient. When the donor BNP is ≤ 132 pg/mL, the risk of a poor cardiac function in the recipient is very low (negative predictive value 94%). Mortality at 30 days was also correlated to donor BNP (r = 0.29, P = .0029). Long-term survival of the recipient was not correlated to the biomarkers measured in the donor.

CONCLUSION

Donor BNP, but not donor ST2 or high-sensitivity troponin, provides information on the donor heart and early post-transplant performance, including 1-month mortality.

Thymoma mimicking an aortic aneurysm: always expect the unexpected

Thymic epithelial tumours (TETs) are rare lesions that represent less than 1% of all malignancies in adults. Presentation occurs in three ways: asymptomatic, with local thoracic symptoms or with paraneoplastic symptoms. Heterotopic ossifications are rare histological features in neoplasms and non-neoplastic lesions. Here, we present a 49-year-old male patient with a thymoma type B2 mimicking an aortic aneurysm. Alongside the thymoma, a cholesterol granuloma with unusual ossification features was found as well. This clinical presentation and pathological diagnosis are unusual findings.

Aortic aneurysm/dissection and osteogenesis imperfecta: Four new families and review of the literature

Osteogenesis imperfecta (OI) is the commonest form of heritable bone fragility. It is mainly characterized by fractures, hearing loss and dentinogenesis imperfecta. OI patients are at increased risk of cardiovascular disease of variable severity. Aortic aneurysm/dissection is one of the rarer but potentially serious cardiovascular complications of OI. So far, only six patients with aortic dissection and OI have been reported. As such, present OI diagnostic guidelines do not recommend systematic screening of patients for aortopathy. Here, we report on the clinical and molecular characteristics of three new OI patients and one additional patient with a first degree relative who presented with aortic dissection and/or aneurysm surgery. This observation further opens up the discussion on the need for and extent of cardiovascular screening in adult patients with OI.

For How Long Do We Have to Advise Elastic Support after Varicose Vein Surgery? A Prospective Randomized Study

A prospective randomized study was performed to compare different periods of bandaging after varicose vein surgery. No difference was found from wearing an elastic support for 1, 3 or 6 weeks after surgery.

Preprocedural CT evaluation of transcatheter aortic valve replacement: what the radiologist needs to know

Aortic valve stenosis is the most common valvular heart disease in the Western world. When symptomatic, aortic valve stenosis is a debilitating disease with a dismal short-term prognosis, invariably leading to heart failure and death. Elective surgical valve replacement has traditionally been considered the standard of care for symptomatic aortic valve stenosis. However, several studies have identified various subgroups of patients with a significantly elevated risk for surgery-related complications and death. Thus, not every patient is a suitable candidate for surgery. Recent developments in transcatheter-based therapies have provided an alternative therapeutic strategy for the nonsurgical patient population known as transcatheter aortic valve replacement (TAVR) (also called transcatheter aortic valve implantation or percutaneous aortic valve replacement). In TAVR, the native aortic valve is replaced with a bioprosthetic valve via a nonsurgical endovascular, transaortic, or transapical pathway. Nevertheless, several anatomic and technical criteria must be met to safeguard patient eligibility and procedural success. Therefore, noninvasive imaging plays a crucial role in both patient selection and subsequent matching to a specific transcatheter valve size in an effort to ensure accurate prosthesis deployment and minimize peri- and postprocedural complications. The authors review the relevant anatomy of the aortic root, emphasizing the implications of anatomic pitfalls for correct reporting of imaging-derived measurements and important differences between findings obtained with different imaging modalities. They also discuss the evolving role of computed tomography and the role of the radiologist in patient triage in light of current viewpoints regarding patient selection, device size selection, and the preprocedural evaluation of possible access routes. Online supplemental material is available for this article.

Mutations in a TGF-β ligand, TGFB3, cause syndromic aortic aneurysms and dissections

Background

Aneurysms affecting the aorta are a common condition associated with high mortality as a result of aortic dissection or rupture. Investigations of the pathogenic mechanisms involved in syndromic types of thoracic aortic aneurysms, such as Marfan and Loeys-Dietz syndromes, have revealed an important contribution of disturbed transforming growth factor (TGF)-β signaling.

Objectives

This study sought to discover a novel gene causing syndromic aortic aneurysms in order to unravel the underlying pathogenesis.

Methods

We combined genome-wide linkage analysis, exome sequencing, and candidate gene Sanger sequencing in a total of 470 index cases with thoracic aortic aneurysms. Extensive cardiological examination, including physical examination, electrocardiography, and transthoracic echocardiography was performed. In adults, imaging of the entire aorta using computed tomography or magnetic resonance imaging was done.

Results

Here, we report on 43 patients from 11 families with syndromic presentations of aortic aneurysms caused by TGFB3 mutations. We demonstrate that TGFB3 mutations are associated with significant cardiovascular involvement, including thoracic/abdominal aortic aneurysm and dissection, and mitral valve disease. Other systemic features overlap clinically with Loeys-Dietz, Shprintzen-Goldberg, and Marfan syndromes, including cleft palate, bifid uvula, skeletal overgrowth, cervical spine instability and clubfoot deformity. In line with previous observations in aortic wall tissues of patients with mutations in effectors of TGF-β signaling (TGFBR1/2, SMAD3, and TGFB2), we confirm a paradoxical up-regulation of both canonical and noncanonical TGF-β signaling in association with up-regulation of the expression of TGF-β ligands.

Conclusions

Our findings emphasize the broad clinical variability associated with TGFB3 mutations and highlight the importance of early recognition of the disease because of high cardiovascular risk.

The FORGOTTEN (TRICUSPID) VALVE; THIRD TIME, RIGHT TIME

Tricuspid regurgitation (TR) remains a challenging condition, the indication, timing and type of surgery for which are not yet well established. A 42-year-old woman was referred to the authors' institution with recurrent, symptomatic TR at one year after she had undergone tricuspid valve repair for an Ebstein's anomaly. At 14 months after the first surgery a bioprosthesis was implanted for a detached annuloplasty ring, and she made a complete recovery. However, at 15 months after valve replacement she presented again with right heart failure and massive TR due to rare early pannus formation. A re-redo tricuspid valve replacement was performed. Tricuspid valve replacement with a bioprosthesis is a valid option if repair is unsuccessful. However, there is a need to be aware of concomitant problems such as a requirement for pacemaker implantation, the risk for prosthesis thrombosis or pannus formation, and the importance of anticoagulation therapy. Annual transthoracic echocardiographic follow up is advisable to exclude subclinical TR.

Bone matrix vesicle-bound alkaline phosphatase for the assessment of peripheral blood admixture to human bone marrow aspirates

PURPOSE

Peripheral blood (PB) admixture should be minimized during numerical and functional, as well as cytokinetic analysis of bone marrow (BM) aspirates for research purposes. Therefore, purity assessment of the BM aspirate should be performed in advance. We investigated whether bone matrix vesicle (BMV)-bound bone alkaline phosphatase (ALP) could serve as a marker for the purity of BM aspirates.

RESULTS

Total ALP activity was significantly higher in BM serum (97 (176-124)U/L, median (range)) compared to PB serum (63 (52-73)U/L, p < 0.001). Agarose gel electrophoresis showed a unique bone ALP fraction in BM, which was absent in PB. Native polyacrylamide gel electrophoresis revealed the high molecular weight of this fraction, corresponding with membrane-bound ALP from bone matrix vesicles (BMV), as evidenced by electron microscopy. A serial PB admixture experiment of bone cylinder supernatant samples, rich in BMV-bound ALP, confirmed the sensitivity of this proposed quality assessment method. Furthermore, a BMV ALP fraction of ≥ 15% is suggested as cut-off value for minimal BM quality. Moreover, the BM purity declines rapidly with larger aspirated BM volumes.

CONCLUSION

The exclusive presence of BMV-bound ALP in BM could serve as a novel marker to assess purity of BM aspirates.

Hospitalization costs ofTAVI in one Belgian university hospital

OBJECTIVE

Considering the sizeable cost of transcatheter aortic valve implantation (TAVI) and conflicting cost-effectiveness studies, it is useful to gain more insight into the cost structure of the TAVI hospitalization. This study provides such a cost analysis and starts to evaluate options to soften the hospitalization cost burden in order to make TAVI economically more feasible.

METHODS

Costs forTAVI hospitalization in the University Hospital of Antwerp were analysed uni- and bivariately. Graphical and numerical displays of the data are supplemented with the non-parametric Wilcoxon rank sum statistic and Spearman rank rho correlation.

RESULTS

Overall, 47 percent of the cost could be attributed to the implanted valve and 21 percent was accounted for by the room costs. Further, costs seemed highly insensitive to pre-existing patient characteristics. Only patients with pulmonary hypertension were characterized with systematically higher costs (Wilcoxon rank sum P-value of 0.049). Complications related to TAVI had a significant upward impact on the costs and there was also evidence for a learning effect on total costs.

CONCLUSIONS

In general the analyses showed that only limited options remain for cost reduction of the TAVI hospitalization cost. The most promising option is the reduction of the valve price. Avoidance of complications is hard to achieve given the current state of the art although this would significantly reduce overall costs.

Phase II multicenter clinical trial of isolated lung perfusion (ILuP) with melphalan (MN) in patients (pts) with resectable lung metastases (LM)

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Background: Five-year overall survival (OS) of pts undergoing surgical resection of LM from colorectal cancer (CRC) and sarcoma remains low [20-50%]. Local recurrence rate is high, even after complete surgical resection [48-66%] (Pastorino et al, 1997). Combined modality therapy is currently evaluated. ILuP allows the delivery of high-dose locoregional chemotherapy without systemic exposure. In a previous phase I study maximum tolerated dose of MN was found to be 45mg at a perfusion temperature of 37°C (Grootenboers et al, 2007). Methods: From 2006 to 2011 50 pts, 28 male, median age 57 years [15-76], with LM from CRC [n=30] or sarcoma [n=20] were included in a phase II clinical trial conducted in 4 cardiothoracic surgical centers. In total, 62 ILuP procedures were performed, 12 bilaterally, followed by resection of all palpable LM. Survival was calculated according to the Kaplan-Meier method. Results: Operative mortality was 0%, 90-day morbidity was mainly cardiac [grade 3: 2%] and respiratory [grade 3: 29%, grade 4: 2%]. After a median follow-up of 24 months [3-63 mos] 18 pts died, 2 without recurrence. Seven pts [14%] had their initial recurrence in the perfused lung. Initial progressive disease outside the perfused lung occurred in 23 pts [46%]; contralateral, non-perfused lung 10, liver 3, brain 2, primary site 1 and other location 7. OS and disease-free survival (DFS) are shown in table 1. Lung function data showed a decrease in FEV1 and DLCO of 21.6% and 25.8% after 1 month, and 10.4% and 11.3% after 12 mos, respectively, compared to preoperative values. Long-term quality of life evolution after ILuP and lung metastasectomy was comparable with a standard lung metastasectomy by thoracotomy in one participating center (Balduyck et al, 2012). Conclusions: Compared to historical series of LM resection without ILuP favorable results are obtained in terms of local control without long-term adverse effects. These data support the further investigation of ILuP as additional treatment in pts with resectable LM from CRC or sarcoma. Clinical trial information: 2006-002808-34. [Table: see text]

Intercostal artery pseudoaneurysm: a rare complication of transaortic transcatheter aortic valve implantation

In this case report, we present an 86-year old patient with an intercostal pseudoaneurysm after transaortic transcatheter aortic valve implantation (TAVI). This new technique of a transaortic approach is considered a possible alternative to the more usual transfemoral, trans-subclavian or transapical access site, mainly in patients with extensive peripheral arterial disease. A mini-thoracotomy or mini-sternotomy is needed to access the ascending aorta. The patient presented with a painless but progressive pulsatile mass right parasternally, 3 months after the procedure. An intercostal pseudoaneurysm was diagnosed with duplex examination and chest CT. Successful treatment with an ultrasound-guided injection of thrombin resulted in a complete obliteration of the pseudoaneurysm. Only nine reported cases of intercostal pseudoaneurysms have been reported worldwide, and this is the first case in a patient who underwent a transaortic TAVI. Since the transaortic access is used more frequently, it is important to report on possible complications of this new technique.

Q fever infection: inflammatory aortic root aneurysm in an HIV positive patient

We describe a case of Q fever infection with an inflammated proximal ascending aortic aneurysm in an HIV-infected patient. The patient was treated with aortic root replacement and medication for Q fever, a combination of doxycycline and hydroxychloroquine in addition to highly active antiretroviral therapy. The combination of Q fever and HIV infection has rarely been documented. A case of Q fever infection of a proximal ascending aorta aneurysm in a patient with HIV co-infection has never been described before.

Comparison of magnetic resonance imaging of aortic valve stenosis and aortic root to multimodality imaging for selection of transcatheter aortic valve implantation candidates

The purpose of the present study was to compare the aortic valve area, aortic valve annulus, and aortic root dimensions measured using magnetic resonance imaging (MRI) with catheterization, transthoracic echocardiography (TTE), and transesophageal echocardiography (TEE). An optimal prosthesis--aortic root match is an essential goal when evaluating patients for transcatheter aortic valve implantation. Comparisons between MRI and the other imaging techniques are rare and need validation. In 24 consecutive, high-risk, symptomatic patients with severe aortic stenosis, aortic valve area was prospectively determined using MRI and direct planimetry using three-dimensional TTE and calculated by catheterization using the Gorlin equation and by Doppler echocardiography using the continuity equation. Aortic valve annulus and the aortic root dimensions were prospectively measured using MRI, 2-dimensional TTE, and invasive aortography. In addition, aortic valve annulus was measured using TEE. No differences in aortic valve area were found among MRI, Doppler echocardiography, and 3-dimensional TTE compared with catheterization (p = NS). Invasive angiography underestimated aortic valve annulus compared with MRI (p <0.001), TEE (p <0.001), and 2-dimensional TTE (p <0.001). Two-dimensional TTE tended to underestimate the aortic valve annulus diameters compared to TEE and MRI. In contrast to 2-dimensional TTE, 3 patients had aortic valve annulus beyond the transcatheter aortic valve implantation range using TEE and MRI. In conclusion, MRI planimetry, Doppler, and 3-dimensional TTE provided an accurate estimate of the aortic valve area compared to catheterization. MRI and TEE provided similar and essential assessment of the aortic valve annulus dimensions, especially at the limits of the transcatheter aortic valve implantation range.

Atrial myxomas grow faster than we think

The finding of a cardiac myxoma usually implies immediate consequent surgical excision to prevent embolic events. Reports with documented growth rate are therefore very rare, and the actual growth rate remains a controversial issue. We report the growth of a left atrial myxoma in an asymptomatic 65-year-old patient with several years of follow up for aortic valve disease. A MEDLINE search with the terms "cardiac myxoma and tumor growth" was performed. The calculated growth rate showed an average growth rate of 0.49 cm/month. These reports suggest that the growth rate of myxomas may be faster than is usually thought.

Titanium transverse plate fixation: a new solution for old sternal problems

OBJECTIVE

To evaluate our initial results with the titanium transverse plate fixation system of the sternum in four patients.

METHODS

Two patients with late dehiscence and persistent instability of the sternum after cardiac surgery were treated with refixation by titanium transverse plates and screws. Two patients were treated with the same refixation method after pre-treatment with debridement, antibiotic therapy and vacuum-assisted closure therapy for extensive mediastinitis.

RESULTS

All four patients healed without complications. The mean postoperative length of stay was 17,3 days (range 7-44). The instability and/or pain disappeared in all patients. The postoperative imaging showed good positioning of the osteosynthesis material. There was no re-infection in patients with mediastinitis.

CONCLUSIONS

The titanium transverse plate fixation system is a very promising adjunct to the armamentarium of the cardio-thoracic surgeon for treatment of sternal problems, including dehiscence and fractures, even when mediastinitis is involved. It offers more stability compared to simple rewiring, without the need for extensive retrosternal dissection.

Guidelines for quality improvement in cardiac surgery. The College of Cardiac Surgery : results of the 2007 survey

Optimal delivery of health care is a common goal of individual physicians, professional organizations, hospital structures and governmental authorities. A growing concern has emerged from the public, media and third payer organizations concerning the quality of care and the amount of resources spending. In the United States, large databases, guidelines and performance evaluation have been elaborated by medical societies, particularly in the area of cardiac surgery. These tools are useful for improvement of patients' care, resources distribution, pay for performance and public and practitioners' awareness. The evaluation of quality is based on composite models combining structure, process and outcome indices. However, pitfalls such as patients' selection, and risk avoidance in order to improve results must been prevented by adjustment of the treated populations' risk factors by specific scores. The Belgian Health authorities have built a structure directed at delivery of care improvement based on "Care Programs", monitored by Colleges formed by delegates of professional organizations. The College of Cardiac Surgery has promoted several studies aimed at data collection and evaluation. In 2007, a survey was addressed to all the Belgian Cardiac surgeons to define their opinion as to the best indicators of care in their specialty. These results will serve to define further avenues of research. By maintaining the responsibility of care evaluation in the hands of the involved professionals, this kind of cooperation between governmental and physicians' organizations seems to serve the best interests of the public and the practitioners.

A Patient with Cardiac Fibroma and a Subvalvular Aortic Stenosis Caused by a Subvalvular Membrane

In this report, we describe a patient with two uncommon cardiac abnormalities: a subvalvular membrane in the left ventricular outflow tract and a cardiac fibroma (CF) in the left atrium. This 56-year-old patient presented with a known subaortic stenosis caused by a subvalvular membrane, a large mass attached to the interatrial septum in the immediate proximity of mitral valve, and a cardiac history of infective endocarditis. Initially, the mass was thought to be an old vegetation. However, the histology of this lesion diagnosed a CF. Primary cardiac tumors are rare. Myxoma and papillary fibroelastoma are the most frequently encountered primary cardiac tumors. CF is usually diagnosed during childhood. In this case, the presentation of the CF was atypical for 3 reasons: the tumor was diagnosed in an adult, the fibroma was pedunculated, and not located within the myocardium but originated from the interatrial septum.

Markers of inflammation and oxidative stress in patients undergoing CABG with CPB with and without ventilation of the lungs: a pilot study

Cardiopulmonary bypass triggers systemic inflammation and systemic oxidative stress. Recent reports suggest that continuous ventilation during cardiopulmonary bypass (CPB) can affect the outcome of patients after cardiac surgery. We investigated the influence of lung ventilation on inflammatory and oxidative stress markers during coronary artery bypass graft (CABG) with CPB in 13 patients with (Group 2) or without (Group 1) ventilation of the lungs with small tidal volume (4 ml/kg). IL-10 and elastase in blood were elevated in both groups with a peak at the end of CPB (P<0.05) and returned to the baseline at 24 h after surgery. A significant increase in Trolox Equivalent Antioxidant Capacity (TEAC) was observed in both groups (P<0.05). Glutathione peroxidase (GPx) was significantly elevated 24 h after surgery only in Group 1 (P<0.05). There was a significant decrease in alpha-tocopherol 24 h after surgery in both groups (P<0.05). The inflammatory response observed during CPB is not directly influenced by continuous ventilation of the lungs with small tidal volumes. The modulation of antioxidant defense systems by ventilation needs further investigation.