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Background: Total arterial revascularization is associated with superior outcomes to conventional coronary artery bypass graft (CABG) surgery performed with the left internal thoracic artery (ITA) and veins. It is often performed with bilateral ITAs that increase risk of sternal wound infection. Minimally invasive multivessel CABG through a left anterior minithoracotomy eliminates sternal wound complications. However, being performed only in a few specialized centers, there is a paucity in follow-up outcome data. We, therefore, describe our 5-year single-center experience with such operations., Methods: Between 2015 and 2021, 186 patients underwent elective, total arterial minimally invasive CABG in our institution. Patient data were prospectively collected in the institutional database and retrospectively analyzed. Primary end points were in-hospital mortality and 5-year survival. The secondary end points included freedom from major adverse cerebrovascular and cardiac events., Results: Patients were a mean age of 66 ± 9 years, and 23 (12%) were women. The mean number of bypass grafts performed was 2.4 ± 0.5 (range, 2-4 grafts). Bilateral ITAs were used in 163 patients (88%) and left ITA and radial arteries in 22 (12%). The mean procedure time was 277 ± 58 minutes. There was 1 hospital death. Perioperative myocardial infarction, repeat thoracotomy, and conversion to sternotomy was observed in 6 (3%), 12 (6.5%), and 2 patients (1.1%), respectively. The mean 5-year survival was 93.3% ± 2.2%, and freedom from major adverse cardiac and cerebrovascular events was 83.8% ± 4.1%., Conclusions: Total arterial minimally invasive CABG is a feasible surgical approach yielding excellent short- and midterm results when performed in selected patients in specialized high-volume cardiac centers., Competing Interests: Disclosures Piroze Minoo Davierwala reports a relationship with Medtronic Inc that includes: speaking and lecture fees and travel reimbursement. The other authors have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Guidelines on the management of aortic aneurysm disease do not account for sex differences regarding surgical procedures on the proximal aorta, although faster aneurysm growth, increased rupture risk, and higher postoperative mortality have been found in women. We therefore analyzed outcome differences between men and women receiving operations on the proximal aorta., Methods: A total of 1773 patients underwent nonemergency surgical procedures on the aortic valve (AV) and proximal aorta at our institution between 2000 and 2018. Of these, 772 patients (21.8% women) received a Bentall procedure, 349 (20.3% women) had AV-sparing root replacement, and 652 (31.1% women) underwent AV and supracommissural ascending aorta replacement. Primary outcomes were in-hospital mortality and midterm survival., Results: When assessing sex-related differences within the entire group of patients that received an operation on the proximal aorta, women were found to be older, had a lower body mass index, and were smokers less often. Despite shorter procedural times, median ventilation times and intensive care unit length of stay were longer in women. In-house mortality was also higher in women (3.6% vs 0.9%, P < .001). Multivariable logistic regression revealed age (odds ratio [OR], 1.8; 95% CI, 1.4-2.3 per 5 years added; P < .001), female sex (OR, 2.6; 95% CI, 1.2-5.8; P = .02), and urgent surgery (OR, 3.1; 95% CI, 1.2-7.3; P = .01) as independent risk factors for in-house death. Midterm survival was lower for women in the entire cohort (P = .02) and particularly within the Bentall subgroup (P = .004)., Conclusions: Female sex is an independent risk factor for operative mortality in patients undergoing proximal aortic surgery but is currently not addressed in guidelines. More research should focus on etiology and prevention of these worse outcomes in female patients., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Partial intraluminal thrombosis of the frozen elephant trunk (FET) stent graft is a poorly described but not infrequent complication after aortic arch surgery. This study aims to describe and analyze the occurrence of early FET stent graft thrombosis., Methods: Retrospective single-center analysis including patients who underwent aortic arch replacement with FET technique between 2006 and 2020. Stent graft thrombosis was diagnosed through computed tomography scan. Several computed tomography scan parameters and clinical variables were analyzed as predictors of this event., Results: A total of 125 patients were included for analysis. Among these, 21 (16.8%) patients developed early postoperative FET stent graft thrombosis. Mean volumetric size of the aorta was 12.2 ± 2.0 mL in patients with FET stent graft thrombosis and 10.1 ± 2.8 mL in patients without thrombosis (P < .01). Thrombosis occurred more frequently among patients requiring thoracic endovascular aortic repair completion (15 of 21 [71.4%] patients) than in patients with completely excluded aneurysms (6 of 21 [28.6%] patients) (P = .01). Mean stent-to-aneurysm diameter ratio was 0.8 ± 0.2 among patients with thrombosis and 1.0 ± 0.2 among patients without thrombosis (P < .01). Thrombosis was more frequently observed among patients with conservative management of postoperative bleeding (P = .04). Patients with early FET thrombosis had a nonsignificantly higher in-hospital all-cause mortality than patients without thrombosis (19.0% vs 8.7%; P = .3)., Conclusions: Early postoperative intraluminal thrombosis is a frequent complication post FET surgery. Smaller stent graft sizes, larger or partially covered aneurysms, and major bleeding are associated with early thrombosis. Slight FET oversizing, prompt thoracic endovascular aortic repair completion, and early reintervention for major bleeding may prevent early thrombosis., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In 2009, updated European Society of Cardiology guidelines on the prevention, diagnosis, and treatment of infective endocarditis (IE) were released and restricted the use of antibiotic prophylaxis to high-risk patients only. The aim of this study was to analyze the effect of the restrictive antibiotic regimen on the incidence and manifestations of surgically treated IE before and after the guideline change., Methods: This study retrospectively analyzed data of 4917 patients who underwent valve surgical procedures for IE between 1994 and 2018 in 6 German cardiac surgery centers. Potential risk factors for 30-day mortality were assessed using logistic regression. Interrupted time series regression was used to evaluate the effect of the guideline change on the manifestation of IE., Results: A total of 2014 patients (41%) underwent surgical procedures before the guideline change, and 2903 patients (59%) underwent surgical procedures after the change. After 2009, patients were older (67.0 years [interquartile range, 56.0-74.0 years] vs 64.0 years [interquartile range, 52.0-71.0 years]; P < .001), and they presented with more comorbidities, such as hypertension (56.9% vs 41.7%; P < .001), diabetes (27.4% vs 24.4%; P = .020), peripheral artery disease (8.5% vs 6.5%; P = .011), and preoperative acute kidney injury (42.8% vs 31.9%; P < .001). Patients had worse clinical outcomes with respect to 30-day mortality (18.1% vs 14.3%; P = .001) and 1-year mortality (37.1% vs 29.1%; P < .001). An increase in Streptococcus-related IE (P = .002) and an increase in mitral valve IE (P = .035) were observed after the guideline change., Conclusions: Since 2009, there has been a significant increase in the incidence of mitral valve IE and Streptococcus-related IE. Patients undergoing surgical procedures for IE present with more comorbidities, which contribute to high mortality rates., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study compared clinical and hemodynamic in-hospital outcomes of patients undergoing sutureless vs rapid deployment aortic valve replacement (SURD-AVR) in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR)., Methods: We examined 4695 patients who underwent isolated or combined SURD-AVR. The "sutureless" Perceval valve (LivaNova PLC, London, United Kingdom) was used in 3133 patients and the "rapid deployment" Intuity (Edwards Lifesciences, Irvine, CA) in 1562. Potential confounding factors were addressed by the use of propensity score matching. After matching, 2 well-balanced cohorts of 823 pairs (isolated SURD-AVR) and 467 pairs (combined SURD-AVR) were created., Results: Patients who received Perceval and Intuity valves showed similar in-hospital mortality and rate of major postoperative complications. Perceval was associated shorter cross-clamp and cardiopulmonary bypass times. In the isolated SURD-AVR group, patients receiving Perceval were more likely to undergo anterior right thoracotomy incision. Postoperative transvalvular gradients were significantly lower for the Intuity valve compared with those of the Perceval valve, either in isolated and combined SURD-AVR. The Intuity valve was associated with a lower rate of postoperative mild aortic regurgitation., Conclusions: Our results confirm the safety and efficacy of SURD-AVR regardless of the valve type. The Perceval valve was associated with reduced operative times and increased anterior right thoracotomy incision. The Intuity valve showed superior hemodynamic outcomes and a lower incidence of postoperative mild aortic regurgitation., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The objective was to provide initial data from our prospective valve-sparing aortic root replacement (V-SARR) registry and reasons for conversion to prosthetic aortic valve replacement., Methods: Six centers established an intention-to-treat-design V-SARR-registry (the German Aortic Root Repair Registry; first patient in October 2016); the main inclusion criterion was being scheduled for V-SARR as plan A. Clinical information, operative details, intraoperative valve/root measurements, and clinical and transthoracic echocardiography follow-up-data are documented., Results: Of a total of 449 patients, we report data for 401 (81% male; mean age 51 ± 14 years). Overall, 350 patients underwent V-SARR as scheduled, group A (David variants I 55%, III 2%, IV 13%, V 24%, V-Stanford 2%, and Yacoub remodeling 2%); and 51 were converted to aortic valve replacement (group B). Median follow-up was 11 months (range, 0 to 2.6 years), cumulative follow-up was 279 patient-years. In group B, there were fewer connective tissue disorders (6% vs 16%), fewer patients had left ventricular ejection fraction greater than 50% (60% vs 90%), more had bicuspid aortic valves (45% vs 28%), and fewer patients had preoperative none/trace aortic regurgitation (2% vs 20%). Fewer patients in group B had rare types of bicuspid aortic valve (fused N/L, R/N, 10% vs 30%) and more had unbalanced roots (56% vs 40%). Immediate postoperative aortic regurgitation was none/trace in 79% and mild in 20%. At 30 days, the mean transvalvular pressure gradient was 7 ± 5 mm Hg. None of the patients died in hospital; two strokes occurred. One patient needed early aortic valve replacement as redo surgery., Conclusions: The main factors causing surgeons to convert a planned V-SARR to aortic valve replacement include asymmetry of aortic valve/root, severity of aortic regurgitation, safety reasons (left ventricular ejection fraction), and bicuspid aortic valves (but not rare types). The German Aortic Root Repair Registry will help us identify the impact on long-term outcomes of preoperative and postoperative valvular anatomy and various V-SARR types., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Carcinomas showing thymic-like differentiation (CASTLE tumors) are very rare entities requiring an individualized therapeutic plan. This report describes a case of reconstruction of the innominate artery after radical resection of the tumor in a patient in whom a custom-made cerebral shunt was used for continuous cerebral perfusion., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Reoperation for aortic valve replacement can be challenging and is usually associated with an increased risk for complications and mortality. The study aim was to report the results of a multicenter cohort of patients who underwent minimally invasive reoperative aortic valve replacement with a sutureless or rapid-deployment prosthesis., Methods: From 2007 to 2018 data from 3651 patients were retrospectively collected from the Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry. Of them, 63 patients who had previously undergone cardiac surgery represented the study population. In-hospital clinical and echocardiographic outcomes were recorded., Results: Mean age of the selected 63 patients was 75.3 ± 7.8 years and logistic EuroSCORE 10.1. Surgery was performed by ministernotomy in 43 patients (68.3%) and by anterior right thoracotomy in 20 (31.7%); 31 patients (49.2%) received the Perceval valve (Livanova PLC, London, UK) and 32 (50.8%) the Intuity valve (Edwards Lifesciences, Irvine, CA). Mean cross-clamp time was 57.8 ± 23.2 minutes and cardiopulmonary bypass time 95.0 ± 34.3 minutes. Neither conversion to full sternotomy nor in-hospital deaths occurred. Postoperative events were ischemic cerebral events in 3 patients (4.8%), need for pacemaker implantation in 2 (3.6%), bleeding requiring reoperation in 5 (8.9%), and dialysis in 1 (1.6%). Median intensive care unit stay was 1 day, and median length of hospital stay was 10 days. On echocardiographic evaluation 1 patient showed a significant postoperative aortic regurgitation., Conclusions: Minimally invasive reoperative aortic valve replacement with a sutureless or rapid-deployment prosthesis is a safe and feasible treatment strategy, resulting in fast recovery and improved postoperative outcome with no mortality and an acceptable complication rate., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to compare the short- and long-term outcomes of patients who underwent aortic valve-sparing reimplantation (David) vs aortic root replacement (Bentall) operations in a propensity-matched analysis., Methods: The study compared the data of propensity-matched patients who underwent David (n = 261) or Bentall (n = 262) procedures from 2000 to 2015. The mean age at surgery in the entire cohort was 53 ± 13 years, and 19.7% (n = 103) of the study patients were female. Connective tissue disease was present in 9.4% (n = 49) of patients, whereas 37.1% (n = 194) presented with a bicuspid aortic valve., Results: The overall 30-day mortality was 1.1% (n = 6) and was not significantly different in patients with the David compared with the Bentall operation (0.4% [n = 1] vs 1.9% [n = 5]; P = .1). The 5- and 10-year survival rates were 93.7 ± 1.8% vs 93.8 ± 1.6% and 84.4 ± 4.7% vs 89.5 ± 3.2% for David vs Bentall, respectively (log-rank P = .98). Cox regression analysis identified age, smoking and previous cardiac surgery as independent predictors of long-term mortality. Freedom from reoperation did not significantly differ between patient groups (89.5 ± 3.4% vs 87.8 ± 4.1% 10 years postoperatively; log-rank P = .71). Bentall-treated patients had a higher rate of serious bleeding during follow-up (P = .025)., Conclusions: Both the David and Bentall operations are associated with excellent early and long-term results in patients with aortic root aneurysmal disease. The David operation is associated with less bleeding than the Bentall operation, without an increased risk of reoperation. Because of avoidance of bleeding and other long-term complications associated with prosthetic heart valves, the David operation is preferable to the Bentall operation in patients with appropriate pathoanatomy., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Injury of the circumflex artery (Cx) during mitral valve surgery is a rare and underrecognized life-threatening complication. A retrospective analysis of patients undergoing mitral valve operations at 2 centers was conducted. Five mitral valve operations are described. After diagnosis of Cx injury, 2 patients were treated by stent implantation, 1 by coronary bypass to the Cx, and 1 by repositioning the responsible annular stitches. In another patient, the Cx injury was not treated and was diagnosed at autopsy. There were no deaths in patients whose Cx injury was promptly treated. Cx injury can be successfully managed when it is treated on time., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A 66-year-old patient presented to the Leipzig Heart Center in Leipzig, Germany with therapy-refractory hypotension with a history of postural presyncope 7 years after supraaortic debranching and thoracic endovascular aortic repair of the transverse arch. Arterial angiography with invasive blood pressure measurement revealed pronounced hypertension of the lower body (blood pressure, 270/120 mm Hg) and subtotal prosthetic graft stenosis of the bypasses to the innominate artery and to the left common carotid artery. Open reoperation for removal of the stenosed Y-limb prosthesis and extraanatomic supraaortic revascularization was successfully performed. Subtotal prosthetic graft stenosis with need for reoperation may occur as a long-term complication after supraaortic debranching and thoracic endovascular aortic repair., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Trifecta valve (St. Jude Medical, St. Paul, MN) is a stented bovine pericardial bioprosthesis for aortic valve replacement (AVR). Implantation experience and midterm follow-up of this valve have not yet been reported from a large single-center cohort., Methods: We retrospectively analyzed data from 918 patients (73.2 ± 6.5 years; logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE], 13.2 ± 14.3) who underwent AVR. Analyses addressed implantation safety, short- and long-term survival, and hemodynamic valve performance., Results: Concomitant procedures were performed in 54.9% of the patients. Low cardiac output syndrome, postoperative bleeding requiring transfusion or reoperation, and acute renal failure requiring temporary hemodialysis occurred at rates of 4.3%, 7.0%, and 11.7%, respectively. At discharge, 44 patients (4.8%) were identified with moderate prosthesis-patient mismatch (PPM) and none was identified with severe PPM. Mean follow-up was 2.7 ± 1.6 years (maximum, 7.4 years). Survival at 30 days was 88.7% and 92.0% for all patients and patients with isolated AVR, respectively; 5-year overall survival for these groups was 73.4% and 82.2%, respectively. Myocardial infarction (odds ratio [OR], 78; 95% confidence interval [CI], 20.8-294) and inotropic medication (OR, 6.8; 95% CI, 3.2-14.5) were the strongest independent predictors for long-term mortality. Five-year freedom from structural valve deterioration (SVD) was 97.9% ± 1.5%. Left ventricular ejection fraction (LVEF) after implantation was similar to baseline and was stable over time (range, 58.9%-62.3%). The mean gradient improved substantially (39.3 mm Hg at baseline versus 9.4 mm Hg at 6 months)., Conclusions: This large single-center cohort shows the easy and safe implantation, adequate hemodynamic performance, and satisfactory durability of the Trifecta valve at midterm follow-up., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to determine the preoperative predictors of in-hospital and medium-term mortality in patients with dialysis-dependent chronic renal failure (DD CRF) undergoing cardiac operations., Methods: Between January 1996 and June 2014, 483 consecutive patients with DD CRF underwent cardiac surgical procedures. The mean age was 65 ± 11 years, and 32. 3% were women. Isolated coronary artery bypass grafting (CABG) or isolated valve operations were performed in 39.8% and 32.3%, of patients, respectively. Combined surgical procedures (CABG with valve operations) were necessary in 20.3% of patients. Endocarditis was an indication for surgical intervention in 11% of patients. Urgent or emergent operations were performed in 49.3% of patients., Results: The in-hospital mortality was 15.3%. Postoperative respiratory failure, gastrointestinal complications, low cardiac output, stroke, and sepsis occurred in 25.7%, 12.4%, 11.8%, 5.6%, and 5.2% of patients, respectively. The independent predictors of in-hospital mortality were combined mitral and aortic valve pathologic conditions (odds ratio [OR], 3.7, 95% CI, 1. 5-9; p = 0.003), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.1-5.9; p = 0. 03), peripheral vascular disease (OR, 2.3; 95% CI, 1.04-4; p = 0.003), left ventricular ejection fraction (LVEF) <30% (OR, 2.9; 95% CI, 1.3-6. 4; p = 0.008), and active endocarditis (OR, 2.2; 95% CI, 1.04-4.6; p = 0.04). The estimated 2-, 4-, and 6-year survival was 50.1% ± 2%, 34.3% ± 2%, and 20.3% ± 2%, respectively. Previous cerebrovascular accident, active endocarditis, previous cardiac operations, and combined aortic/mitral valve pathologic conditions were independent predictors of medium-term mortality., Conclusions: Patients with DD CRF undergoing cardiac operations have high perioperative and medium-term mortality, particularly in the presence of combined aortic and mitral valve pathologic conditions, active endocarditis, and poor left ventricular function., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Bicuspid aortic valve (BAV), the most frequent congenital cardiac abnormality, is associated with a higher risk for ascending aortic aneurysms and aorta-related complications (ie, dissection and rupture). The aim of this study was to quantify granular media calcinosis (GMC) in the ascending aortic wall of patients with BAV., Methods: We analyzed samples of the ascending aorta from patients with BAV (n = 54) and patients with tricuspid aortic valve (TAV) (n = 33) who underwent aortic repair, regarding medial thickness and diameter expansion. Additionally, the convexity and concavity of the samples were stained for GMC and elastin fragmentation., Results: The quantitative analysis revealed a significantly higher extent of GMC in patients with BAV at the aortic convexity and concavity compared with patients with TAV, independent of aortic diameter. Additionally, GMC increased with enlargement of the aortic diameter in patients with BAV. Furthermore, we found a significantly reduced total medial thickness in patients with BAV compared with patients with TAV., Conclusions: Our findings highlight GMC as a prominent feature of bicuspid aortopathy., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Barlow's mitral valve (MV) disease remains a surgical challenge. We compared short- and medium-term outcomes of neochordal ("loop") versus edge-to-edge ("Alfieri") minimally invasive MV repair in patients with Barlow's disease., Methods: From January 2009 to April 2014, 123 consecutive patients with Barlow's disease (defined as bileaflet billowing or prolapse [or both], excessive leaflet tissue, and annular dilatation with or without calcification) underwent minimally invasive MV operations for severe mitral regurgitation (MR) at our institution. Three patients (2.4%) underwent MV replacement during the study period and were excluded from subsequent analysis. The loop MV repair technique was used in 68 patients (55.3%) and an edge-to-edge repair was performed in 44 patients (35.8%). Patients who underwent a combination of these 2 techniques (n = 8 [6.5%]) were excluded. The median age was 48 years, and 62.5% of patients were men. Concomitant procedures included closure of a patent foramen ovale or atrial septal defect (n = 19), tricuspid valve repair (n = 5), and atrial fibrillation ablation (n = 15). Follow-up was performed 24.7 ± 17 months postoperatively and was 98% complete., Results: No deaths occurred perioperatively or during follow-up. Aortic cross-clamp time (64.1 ± 17.6 minutes versus 95.9 ± 29.5 minutes) and cardiopulmonary bypass (CPB) time (110.0 ± 24.2 minutes versus 146.4 ± 39.1 minutes) were significantly shorter (p < 0.001) in patients who received edge-to-edge repair. Although patients who underwent edge-to-edge repair received a larger annuloplasty ring (38.6 ± 1.5 mm versus 35.8 ± 2.7 mm; p < 0.001), the early postoperative resting mean gradients were higher (3.3 ± 1.2 mm Hg versus 2.6 ± 1.2 mm Hg; p = 0.007) and the mitral orifice area tended to be smaller in this group (2.8 ± 0.7 cm(2) versus 3.0 ± 0.7 cm(2); p = 0.06). The amount of residual MR was similar between groups (0.3 ± 0.6 versus 0.6 ± 1.0 for edge-to-edge versus loop procedures, respectively; p = 0.08). More than mild MR requiring early MV reoperation was present in 3 patients who underwent loop procedures (4.4%) and in no patients who had edge-to-edge procedures (p = 0.51). During follow-up, 2 patients (1 in each group) required MV replacement for severe MR. The 4-year freedom from MV reoperation was 92.8% ± 5.0% in the Alfieri group compared with 90.9% ± 4.6% in the loop group (p = 0.94)., Conclusions: Minimally invasive MV repair can be accomplished with excellent early and medium-term outcomes in patients with Barlow's disease. The edge-to-edge (Alfieri) repair can be performed with reduced operative times when compared with the loop technique, but it results in mildly increased transvalvular gradients and mildly decreased valve opening areas without any difference in residual MR., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The high risk of morbidity and mortality for patients on hemodialysis who are undergoing cardiac surgery is increased for those with active infective endocarditis (AIE). This retrospective observational single-center study evaluated the impact of chronic hemodialysis on the outcome of aortic valve replacement in patients with aortic AIE., Methods: Data were retrospectively collected for consecutive patients undergoing aortic valve surgery for AIE diagnosed according to modified Duke criteria between October 1994 and January 2011. Characteristics and outcomes of patients receiving preoperative chronic hemodialysis were analyzed., Results: Aortic valve AIE was present in 992 patients. Forty-five (4.5%) of the aortic valve AIE patients were receiving long-term hemodialysis preoperatively, 19 of whom (42.2%) had diabetes mellitus. Mean logistic EuroSCORE was 64.2% ± 32.2%. Twenty-four preoperative septic emboli were found in 15 patients. Results of microbiologic cultures were positive in 36 patients, with the major causative organisms identified as Staphylococcus aureus (n = 17) and Enterococcus faecalis (n = 10). Isolated aortic valve replacement was performed in 19 patients (42.2%), and 26 patients (57.8%) underwent concomitant procedures. The mean follow-up was 5.3 ± 5.2 years (range, 0.1 to 17.1 years). Postoperative complications occurred in 30 patients (66.7%). Nineteen patients (42.2%) died within 30 days of surgery, which in 8 patients was attributable to a cardiac cause., Conclusions: In patients receiving chronic hemodialysis who undergo aortic valve replacement for acute AIE, postoperative mortality is high, especially in patients undergoing aortic root replacement or culture-negative AIE., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The impact of antegrade versus retrograde perfusion during cardiopulmonary bypass on short- and long-term outcome after repair for acute type A aortic dissection is controversial., Methods: We reviewed 401 consecutive patients (age, 59.2 ± 14 years) with acute type A aortic dissection who underwent aggressive resection of the intimal tear and aortic replacement (March 1995 through July 2011). Arterial perfusion was antegrade in 78% (n = 311), either by means of the right axillary artery (n = 297) or through direct aortic cannulation (n = 15). Retrograde perfusion through the femoral artery was used in 22% (n = 90)., Results: Of the 401 patients with acute type A aortic dissection, 16% (n = 64) presented in critical condition and 10% (n = 39) entered the operating room under cardiopulmonary resuscitation. In 14% (n = 54) the dissection did not extend beyond the ascending aorta (DeBakey II); 82% of dissections did involve at least the aortic arch (n = 326, DeBakey I+III). Mean age was not significantly different between patients undergoing antegrade (59.4 ± 14 years) versus retrograde (59.2 ± 13 years; p = 0.489) perfusion. Operative mortality was 20% and did not differ significantly between the groups (p = 0.766); postoperative stroke occurred also with a similar prevalence (antegrade, 15% versus retrograde, 18%; p = 0.623). Patients undergoing antegrade perfusion had a better long-term survival. Survival at 10 years after discharge was 71% versus 51% (p = 0.025) in favor of antegrade perfusion. Retrograde perfusion was identified to be an independent risk factor for late mortality in multivariate analysis (hazard ratio = 2; p = 0.009)., Conclusions: Survival during the initial perioperative period was equivalent comparing antegrade and retrograde perfusion. Antegrade perfusion to the true lumen, however, appears to be associated with superior long-term survival after hospital discharge., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Severe mitral regurgitation secondary to papillary muscle rupture is an infrequent but catastrophic complication after myocardial infarction. Without surgical treatment, mortality can reach 80%, but surgical treatment also carries substantial perioperative morbidity and mortality., Methods: We retrospectively analyzed 28 patients who underwent mitral valve surgery for ischemic papillary muscle rupture., Results: The 30-day mortality rate was 39.3% (11 of 28). There were no significant differences in the baseline characteristics, and concomitant coronary artery bypass (CABG) was performed in 66.7% of the survivor group and in 61.5% of the nonsurvivor group (p = 0.245). Mortality predictors included low cardiac output (p = 0.05), renal failure (p = 0.005), and implementation of extracorporeal membrane oxygenation therapy (p = 0.005). The time between myocardial infarction and surgery showed no significant effects on survival., Conclusions: Papillary muscle rupture with severe mitral regurgitation carries a high operative mortality. Additional CABG does not influence the acute postoperative course. Postoperative development of low cardiac output with a need for extracorporeal membrane oxygenation therapy and renal failure with hemodialysis substantially reduces survival., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Off-pump coronary artery bypass (OPCAB) operations with bilateral internal thoracic artery (BITA) or left internal thoracic artery (LITA) and radial artery (RA) in a Y-graft configuration achieves adequate myocardial revascularization while avoiding manipulation of the ascending aorta. The purpose of our study was to determine if saphenous veins can be used as composite grafts with the LITA as a last resort., Methods: Multivessel OPCAB without aortic manipulation was performed in 564 patients between February 2002 and October 2010. Patients receiving a LITA-vein composite graft (n = 62) were older and had more emergency procedures, renal insufficiency, peripheral vascular disease and therefore a higher logistic EuroSCORE predicted risk of mortality (all p < 0.001) than did patients who underwent BITA and LITA-RA grafts., Results: Overall 30-day mortality was 1.1%: 6.5% in patients who received LITA-vein grafts and 0.5% in both total arterial groups (p = 0.001). Neurologic events occurred in 3.2%, 0.7%, and 0.5% of patients, respectively (p = 0.3). No patient who received a LITA-vein graft experienced perioperative myocardial infarction (MI). Patients in the total arterial graft groups had better 5-year survival (> 90%) and freedom from major adverse cardiovascular and cerebrovascular events (≥ 80%) than did patients who received LITA-vein grafts (74 ± 7.8% and 62.5 ± 8.1%, respectively). However there was no difference in the 3 groups with respect to freedom from MI and repeat revascularization., Conclusions: LITA-vein composite graft use is associated with a lower survival and higher complication rate, probably because of the higher patient risk profile. LITA-vein composite grafts may be used as a last resort in selected patients undergoing OPCAB operations without manipulation of the aorta when arterial grafts are not available or recommended., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Mitral valve (MV) surgical procedures in the elderly are associated with profound operative and long-term mortality. We report our experience and results for MV surgical procedures in the elderly, especially with regard to the influence of comorbidities., Methods: Our hospital database was assessed to identify all patients who underwent MV surgical procedures at the age of 70 years and older between 1999 and 2009. The data were retrospectively analyzed., Results: A total of 2,503 patients operated on during this 10-year period were identified. In 97% of patients, mitral regurgitation (MR) was the primary indication for operation, followed by coronary artery disease in 41.6% and aortic valve stenosis in 21.3%. The 30-day mortality rate was 3.1%, and the long-term survival at 5 years was 55.2% (95% confidence interval, 52.3% to 57.5%). Coronary artery bypass grafting was identified to be associated with inferior short-term and long-term survival. Numerous comorbidities significantly influenced long-term survival. The observed mortality was significantly lower than predicted by EuroSCORE (17.2%)., Conclusions: MV operations in the elderly can be performed with a low early mortality and promising long-term survival. However, our large series demonstrates that comorbidities are to be attributed as the real burden for successful treatment of elderly patients undergoing MV procedures., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Tricuspid valve (TV) regurgitation has recently been identified as a major risk factor for long-term mortality. Isolated reoperative tricuspid valve repair/replacement (TVR/r) carries an excessively high operative risk. Currently, isolated TVR/r with minimally invasive access through a right lateral thoracotomy is being used increasingly in our institution to treat progressive TV pathologic processes after previous cardiac operations. We analyzed our early and midterm results with reoperative TVR/r in this unique patient cohort., Methods: Forty-eight consecutive patients underwent isolated TV operations after previous cardiac operations with minimally invasive access through a right lateral thoracotomy at our institution between September 2000 and December 2011. Previous cardiac operations included 26 patients (54.2%) with mitral valve replacement/repair, 18 patients (37.5%) with an aortic valve replacement, 10 patients (20.4%) with a TVR/r, and 8 patients (16.7%) with coronary artery bypass grafting. Operations were performed electively in 79% of patients (n=38). Mean patient age was 63.8±13.4 years, with an average log EuroSCORE of 13.9%±11.3%; 67% of patients were women. Follow-up was 94% complete, with a mean duration of 2.8±2.3 years., Results: Thirty-day mortality for patients undergoing elective surgery was zero. For all patients early mortality was 4.2%. Five-year survival for patients after elective reoperative TVR/r through minimally invasive access was 72.2%±10.0%, and 5-year freedom from TV-related reoperations was 88.1%±6.7%, respectively., Conclusions: Minimally invasive access through a right thoracotomy provides a safe option for reoperative TVR and offers excellent early outcome, particularly in elective cases. Surgical intervention should be performed earlier rather than later., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Tricuspid valve (TV) operations can be done with either a beating-heart or arrested-heart technique. We herein report the postoperative outcome of patients with isolated TV operations performed with a beating heart or arrested heart, having a closer look at echocardiographic results after TV repair, postoperative incidence of pacemaker implantations, neurologic complications, survival, and freedom from TV-related reoperation., Methods: We present a retrospective analysis of 105 patients who underwent isolated TV operations with a beating-heart (n=63) or arrested-heart technique (n=42). Mean patient age was 61.2±15.1 years. Male patients were 41.9% of the total, and the average log EuroSCORE was 12.4%±11.4%. Redo operations made up 51.4% of the total. Follow-up was 95% complete, with a mean duration of 32.0±32.6 months., Results: Overall operative mortality was 8.6%. Five-year survival was 68.8%±7.1% versus 66.3%±9.1% for patients with beating-heart versus arrested-heart operations (p=0.9). During follow-up, 7 patients underwent TV reoperations, resulting in a 5-year event-free survival rate of 90.1%±5.9% for patients with beating-heart and 84.0%±6.7% for patients with arrested-heart operations. There was no significant difference regarding postoperative echocardiographic results after TV repair, postoperative pacemaker implantations, or neurologic outcome., Conclusions: Although both cohorts were very heterogeneous and difficult to compare, our results show that both surgical strategies for TV repair have good results regarding postoperative survival, neurologic complications, and postoperative indications for a pacemaker. TV repair with the beating-heart technique has excellent results and can be safely accomplished in a minimally invasive manner., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The optimal management of the dissected aortic root remains unclear. The purpose of this study was to determine whether aortic valve-sparing root replacement (VSRR) compromises survival in aortic dissection repair and to evaluate the comparative efficacy of 2 types of VSRR procedures., Methods: The Heart Center database (Leipzig, Germany) was reviewed to identify patients who underwent a VSRR for acute type A aortic dissection (AAAD) repair. Patients were classified into 3 groups: Bentall (biological or mechanical valved conduit), Yacoub VSRR, and David VSRR. Intergroup comparisons were performed using the t test and analysis of variance as appropriate., Results: From March 1995 to April 2010, 208/374 patients (56%) undergoing AAAD repair received an aortic root procedure. Group 1 (n=130) underwent a Bentall operation, group 2 (n=51) underwent a modified Yacoub procedure, and group 3 (n=27) underwent a modified David procedure. Age and logistic European system for cardiac operative risk evaluation (EuroSCORE) as well as cross-clamp, cardiopulmonary bypass, and circulatory arrest times were similar among the groups. Hospital mortality among all 3 groups was similar (group 1, 27%; group 2, 16%; group 3, 15%). At a mean follow-up of 44 months for group 2 and 27 months for group 3, there was no difference in the need for aortic valve replacement for moderate to severe aortic insufficiency (AI) (2/37 survivors in group 2 versus 1/23 survivors in group 3; z score=-0.279; p>0.05). Five-year survival estimates were 66% for group 1, 65% for group 2, and 80% for group 3 (log rank p=0.2)., Conclusions: Both the David and Yacoub techniques have similar midterm durability in AAAD repair. When compared with the Bentall procedure, neither technique compromises short-term or midterm survival after AAAD repair., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Cerebral protection during aortic arch surgery can be performed using various surgical strategies. We retrospectively analyzed our results of different brain protection modalities during aortic arch surgery., Methods: Between January 2003 and November 2009, 636 consecutive patients underwent aortic arch replacement surgery using unilateral antegrade cerebral perfusion (UACP [n=123]), bilateral antegrade cerebral perfusion (BACP [n=242]), retrograde cerebral perfusion (RCP [n=51]), or deep hypothermia and circulatory arrest (DHCA [n=220]). Mean age of patients was 62±14 years, 64% were male, 15% were reoperations, and 37% were performed for acute type A dissections. Mean follow-up was 4.9±0.1 years and was 97% complete., Results: Circulatory arrest time was 22±17 minutes UACP, 23±21 minutes BACP, 18±12 minutes RCP, and 15±13 minutes DHCA; p<0.001). Early mortality was 11% (n=72) and was not different between the surgical groups. Stroke rate was 9% for ACP patients (n=33) versus 15% (n=39) for patients who did not receive ACP (p=0.035). Independent predictors of stroke were type A aortic dissection (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 3.2; p<0.001), age (OR, 1.04; 95% CI, 1.01 to 1.06; p=0.001), duration of circulatory arrest (OR, 1.01, 95% CI, 1.002 to 1.03; p=0.02), and total aortic arch replacement (OR, 2.7; 95% CI, 1.3 to 5.7; p=0.005). Five year survival was 68%±4% and was not significantly different between groups., Conclusions: Antegrade cerebral perfusion is associated with significantly less neurologic complications than RCP and DHCA, despite longer circulatory arrest times. Medium-term survival is worse for patients with postoperative permanent neurologic deficit and preoperative type A aortic dissection., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Prosthetic replacement of the ascending aorta with nonelastic vascular grafts impairs the local Windkessel function. Whether this increases wall tension in the remaining aorta is still a not completely investigated hypothesis but is of clinical relevance with respect to postprocedural development of aneurysms and dissections, especially in the proximal descending aorta., Methods: Fresh porcine thoracic aortas, including the root, were set up in a mock circulation before and after prosthetic replacement of the ascending aorta. Cyclic changes in aortic dimensions were measured by ultrasonic micrometers at defined positions at the proximal part of the descending aorta. At the same positions, aortic pressures were recorded simultaneously using Millar tip manometers. Wall thickness was measured after pulsatile testing, and the resulting wall tension was calculated from the Laplace law., Results: After prosthetic replacement of the ascending aorta, peak systolic pressure in the proximal descending aorta increased from 117.6 +/- 6.1 mm Hg to 129.2 +/- 6.3 mm Hg, resulting in a rise of wall tension by 12.4% +/- 4.2% (p = 0.001). The maximum rate of pressure rise (dp/dt(max)) increased by 42.6% +/- 16.4% (p < 0.001)., Conclusions: Replacement of the ascending aorta with noncompliant prosthetic material significantly increases wall tension and rate of pressure rise in the residual aorta. This may have clinical impact with respect to a sudden and sustained rise of mechanical load, especially at the vulnerable proximal descending aorta.

Background: Valve-sparing operations are gaining increasing acceptance; however, there is an ongoing discussion about the technique-specific indications. We present our experience with a follow-up of 123 months., Methods: Between July 1993 and July 2005, 164 consecutive patients were operated on using the remodeling (group A, n = 96) or reimplantation technique (group B, n = 68). Fifty-seven patients presented with acute type A dissection. Aortic regurgitation was present in 84%. Follow-up was 54.7 +/- 28 in group A and 48.4 +/- 37.3 months in group B., Results: After urgent operations, 4 patients died in each group, but none died after elective surgery. Late mortality was 8% in group A and 4% in group B. Seven patients of group A and 1 in group B required reoperation. Echocardiographic follow-up of reoperation-free survivors showed that 3 patients (all group A, 1.3%) had aortic regurgitation of more than grade II. Root diameter, valve pressure gradient, and valve orifice area were comparable. No gross thromboembolic or bleeding events occurred., Conclusions: Aortic valve-sparing operations can provide acceptable long-term results in both techniques. Particular care to the annulus in the remodeling technique and different prosthesis designs in the reimplantation technique may overcome the intrinsic problems of each procedure.

A quadricuspid aortic valve is a rare congenital cardiovascular abnormality, and when present, it is associated with aortic valve regurgitation. If aortic valve replacement is required, mechanical or biological prostheses are used. We report the case of a patient with a severely regurgitant quadricuspid aortic valve in whom a Ross procedure was performed.

Background: There is still a considerable controversy regarding optimal treatment for patients with acute type B aortic dissection. Patients with complicated disease are particularly challenging for cardiovascular treatment. Early surgery for acute dissections of the descending aorta with life-threatening complications is known to carry a high mortality. Endovascular stent grafting is developing as an alternative treatment mainly for chronic stages of type B aortic dissection. It is not clear whether endovascular stent grafting is safe and effective in emergency treatment of acute type B aortic dissection., Methods: In 10 patients (7 men, 3 women; mean age, 59.2 years; range, 46 to 65 years), endovascular stent grafting was performed within 11.0 +/- 5.9 hours (range, 4 to 24 hours) of diagnosis of complications. Indications for acute intervention included contained rupture, hematothorax, life-threatening malperfusion, and refractory pain. Using a retrograde endovascular route after surgical exposure of the femoral artery, self-expanding stent prostheses consisting of polyester-covered Nitinol (Talent, World Medical; mean diameter, 40 +/- 4 mm; length, 10 cm) were placed into the descending aorta distal to the subclavian artery. Before discharge and on follow-up visits, imaging of the aorta was performed using computed tomography., Results: In 9 of 10 patients (90%), the primary entry could be completely occluded with the endovascular stent. Early mortality was 20% (2 of 10): 1 patient died after disruption of the intimal layer distal to the stent, and 1 patient died in hemorrhagic shock after surgical fenestration of the abdominal aorta for persistent malperfusion. Three patients (30%) required consecutive surgical treatment: indications included acute development of retrograde type A aortic dissection, acute stent dislocation by fractured wires and secondary leakage, and late formation of an aneurysm of the descending aorta 6 months after endovascular stent grafting. There were no surgical or late deaths., Conclusions: Our experience provides some evidence that early mortality of life-threatening acute type B aortic dissection may be reduced by emergency endovascular stent grafting and that this form of treatment is a promising therapeutic option. Refinements, especially in stent design and application, may further improve the prognosis of patients in the life-threatening situation of complicated acute type B aortic dissection.

Purpose: Current replacement of the thoracic aorta performed with straight vascular prostheses may cause kinking, potentially affecting hemodynamics and promoting vortices and thrombus formation. A novel vascular prosthesis, resistant to pressure-related shape deformation, was designed to imitate the curved anatomy of the thoracic aorta., Description: A woven velour prosthesis was trimmed with cross-sutures along a marked line, resulting in a curved-shaped anatomic form, and was compared with conventional straight and thermally fixed curved grafts. The vascular prostheses were fixed at both ends at various base distances (8, 10, 12, 14, and 16 cm) and pressurized. To imitate the neck vessels an abutment was fixed at the upper convexity of the grafts. Radius of curvature or depth of kinking was measured at different pressures (100, 125, and 150 mm Hg). Pressure gradients and flow profiles were further analyzed in an aortic arch glass model., Evaluation: When pressurized the straight and the thermally fixed protheses showed double kinking before and behind the abutment at all pressures and distances. Kinking depth increased with increasing pressure and less base distance. Transkinking pressure gradients increased with the degree of kinking. In a glass model flow profiles showed postkinking turbulences and vortex formation. The newly designed vascular prosthesis showed no kinking and remained form stable at all test conditions., Conclusions: This novel curved vascular prosthesis for replacement of the thoracic aorta demonstrates form stability compared with conventional straight and thermally fixed vascular prostheses in an aortic arch model, with smaller pressure gradients and flow disturbances.

The short left main trunk with early bifurcation is a common variation of the left coronary anatomy and is easily overlooked during antegrade selective cardioplegia resulting in the risk of single branch perfusion. We describe an obvious characteristic sign to detect this pitfall during blood cardioplegia.

Background: Transmyocardial laser revascularization for severe diffuse coronary artery disease reduces angina significantly. The effect on survival, however, is questionable, and risk factors are not adequately addressed. Considering that transmyocardial laser revascularization channels do not remain patent for improving direct myocardial blood supply, other variables such as perfusion through open native or grafted vessels in remote non-transmyocardial laser revascularization areas are probably more important for survival. This hypothesis is the subject of the study., Methods: Transmyocardial laser revascularization was performed with a CO2 laser system in 63 patients between October 1995 and December 1997. Patients received transmyocardial laser revascularization alone or in combination with coronary artery bypass grafting. The heart was divided into three perfusion zones as determined by the three major coronary arteries. Patients were divided into three groups according to the number of zones that were perfused by either a native coronary artery or a patent bypass graft: group 1 (n = 9), none; group 2 (n = 24), one; and group 3 (n = 30), two. Follow-up was performed at 3, 6, 12, 24, and 36 months and was 100% complete. Mean latest follow-up was 26.2 months, minimal follow-up of survivors was at least 12 months., Results: Overall mortality was remarkably higher in group 1 (77.8%) compared with group 2 (20.8%, p = 0.005) and group 3 (13.3%, p = 0.001). Hospital mortality was 22.2% in group 1, 0% in group 2, and 3.3% in group 3. Late mortality was also higher in group 1 (55.5% versus 20.8%, and versus 9.9%, respectively). Cardiac deaths were more frequent in group 1 (55.5% versus 12.5% in group 2, p = 0.02, and versus 9.9% in group 3, p = 0.009). The number of perfused myocardial zones showed a significant influence for survival (p = 0.002)., Conclusions: These data give some directional evidence that survival seems to be beneficially affected by the number of nonlasered perfused myocardial zones through native vessels or grafts in patients undergoing transmyocardial laser revascularization.

Although the aortic outflow and root (AoR) constitute a short channel connecting the left ventricle to the aorta, its different components have been shown to be highly specialized structures, interacting with each other as well as with surrounding structures, thus providing a "tale of dynamism and crosstalk." Thorough knowledge of the AoR and morphological and structural changes, that occur during pathological processes, can have important implications in evolving and executing surgical procedures designed to preserve and restore the "dynamism and crosstalk." The crown-shaped annulus, fibrous trigones, aortic cusps components, aortic sinuses, and the sinotubular junction share a dynamic coordinated behavior, which can be partially or completely restored in various repair or replacement procedures of the AoR. The interaction and the specific operations are presented with evidence supporting the notion that the dynamic behavior of the root does influence the pattern of instantaneous movements of the aortic cusps after different types of operations. Further studies are required to evaluate the influence of adopting these ideas on the long-term results of operative procedures.

Background: Postoperative bleeding still remains a serious problem in bypass surgery. This study evaluated fibrinolysis and perioperative low-dose antifibrinolytic regimens adjusted to the time course of fibrinolysis., Methods: In a prospective, randomized study of 42 patients undergoing bypass grafting, patients received low-dose aprotinin (group A; n = 14) or low-dose tranexamic acid (group TA; n = 14) intraoperatively and postoperatively, respectively, with no antifibrinolytics for comparison (group C; n = 14). Parameters of procoagulation, fibrinolysis, and activated factor VII were measured preoperatively, intraoperatively, and postoperatively. Blood loss was determined up to 24 hours., Results: The level of thrombin-antithrombin III complex was significantly decreased postoperatively in the treatment groups (group A and TA versus C: 25 +/- 14 and 19 +/- 10 microg/L, respectively, versus 40 +/- 21 microg/L; p < 0.05). Levels of plasmin-antiplasmin complexes were significantly decreased postoperatively in group A (607 +/- 231 microg/L) versus group C (825 +/- 225 microg/L) (p < 0.05) but were increased in group TA (1,145 +/- 394 microg/L) versus group C (p < 0.05). At all times intraoperatively and postoperatively, levels of D-dimers were significantly decreased in group A and group TA versus control (p < 0.001), indicating that fibrinolysis persists after the operation. Intraoperatively, the factor VIIa level decreased significantly in group A (20 +/- 8 mU/mL) versus group C (31 +/- 15 mU/mL) (p < 0.05), but not in group TA (32 +/- 15 mU/mL). Blood loss was significantly lower in group A (135 +/- 37 mL) and group TA (155 +/- 71 mL) versus group C (354 +/- 170 mL) (p < 0.001)., Conclusions: This low-dose aprotinin regimen adjusted to perioperative fibrinolysis reduces blood loss significantly in coronary bypass grafting. For further progress in this subject, clinical investigations of individual fibrinolysis-adjusted antifibrinolytic treatment seems warranted.