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Objectives: To investigate the optimal duration of venoarterial extracorporeal membrane oxygenation (ECMO) for cardiogenic shock refractory to medical therapies after cardiac surgery and whether its prolonged use is justified., Data Sources: Previously published articles on postcardiotomy venoarterial ECMO., Study Selection: Articles reporting on the early outcome after postcardiotomy venoarterial ECMO in adult patients were identified through a systematic review of the literature., Data Extraction: Data on prespecified patients' characteristics, operative variables, and outcomes were provided by the authors of previous studies on this topic., Data Synthesis: Individual data of 1267 patients treated at 25 hospitals from ten studies were included in this meta-analysis. In-hospital mortality rates were lowest among patients treated 3-6 days with venoarterial ECMO. Multilevel mixed-effects logistic regression considering the cluster effect of the participating hospitals adjusted for individual patient's risk profile and operative variables showed that the risk in-hospital mortality did not significantly increase in patients treated more than 6 days up to 20 days., Conclusions: The present study demonstrated that prolonged venoarterial ECMO support after adult cardiac surgery may be justified. However, the analysis was limited by the knowledge of only those circumstances known at the start of ECMO., Competing Interests: Dr. Biancari’s institution received funding from the Italian Ministry of Health—Ricerca Corrente to Centro Cardiologico Monzino (IRCCS). Drs. Biancari and Polvani received support for article research form the IRCCS. Dr. Cho received support for article research from the National Institutes of Health/National Heart, Lung, and Blood Institute K23HL157610 and Hyperfine for Safe and Feasibility (SAFE) MRI Extracorporeal Membrane Oxygenation study. Dr. Pérez received funding from Abbott and Abiomed. Dr. Kaserer received funding from Bayer AG (Switzerland), CSL Behring GmbH, AstraZeneca AG, and Pharmacosmos. Dr. Bonalumi received funding from the IRCCS. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2025 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Purpose: This review aims to explore the clinical and research applications of artificial intelligence (AI), particularly machine learning (ML) and deep learning (DL), in understanding, predicting, and managing obesity. It assesses the use of AI tools to identify obesity-related risk factors, predict outcomes, personalize treatments, and improve healthcare interventions for obesity. Methods: A comprehensive literature search was conducted using PubMed and Google Scholar, with keywords including "artificial intelligence", "machine learning", "deep learning", "obesity", "obesity management", and related terms. Studies focusing on AI's role in obesity research, management, and therapeutic interventions were reviewed, including observational studies, systematic reviews, and clinical applications. Results: This review identifies numerous AI-driven models, such as ML and DL, used in obesity prediction, patient stratification, and personalized management strategies. Applications of AI in obesity research include risk prediction, early detection, and individualization of treatment plans. AI has facilitated the development of predictive models utilizing various data sources, such as genetic, epigenetic, and clinical data. However, AI models vary in effectiveness, influenced by dataset type, research goals, and model interpretability. Performance metrics such as accuracy, precision, recall, and F1-score were evaluated to optimize model selection. Conclusions: AI offers promising advancements in obesity management, enabling more personalized and efficient care. While technology presents considerable potential, challenges such as data quality, ethical considerations, and technical requirements remain. Addressing these will be essential to fully harness AI's potential in obesity research and treatment, supporting a shift toward precision healthcare.

Assessment of the quality of orthodontic care in a UAE-based orthodontic postgraduate training institution was conducted using multiple indices, including the Peer Assessment Rating (PAR), American Board of Orthodontics Objective Grading System (ABO-OGS), and Index of Complexity Outcome and Need (ICON). Retrospective evaluation of pre- and post-treatment records of patients (n = 201) treated with fixed orthodontic appliances was performed by two examiners Statistical analysis assessed the influence of gender, type of malocclusion, need for extraction, missed appointments and number of treating residents on treatment duration. The average numerical reduction of the PAR and ICON scores at the start and end of the treatment were 17.2 and 30.3, respectively, while the ABO-OGS post-treatment score was 14.8. The average PAR score reduction (84.5%) showed that the majority of the patients showed significant improvement at the end of treatment. Treatment duration correlated positively with ICON case complexity (p = 0.003), number of treating residents (r = 0.572, p < 0.001), and missed appointments (r = 0.671, p < 0.001) and negatively with age at treatment initiation (r = - 0.165, p = 0.019). The study findings indicated favorable outcomes for the quality of orthodontic care delivered by residents in a postgraduate training institution, though there were areas needing improvement. Optimizing the number of treating residents and minimizing missed appointments could further enhance clinical care., Competing Interests: Declarations. Human ethics and consent to participate: This study was approved by the Mohammed Bin Rashid University—Institutional Review Board (MBRU IRB-2022-163). In this retrospective study, data were collected from the records of patients who had provided consent for research purposes and we certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Due to the retrospective nature of the study, the Mohammed Bin Rashid University—Institutional Review Board waived the need of obtaining informed consent. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Dimethyl fumarate (DMF) is increasingly used in treating multiple sclerosis (MS) with controversial results of the safety and efficacy of different DMF doses. We aimed to systematically review the literature to examine the safety and efficacy of DMF for MS patients., Methods: We searched PubMed Medline, Cochrane, Web of Science, Scopus databases and clinicaltrials.gov up to June 2023 for the published trials evaluating the use of DMF for MS in adults. All included studies were screened and abstracted independently by two authors. Efficacy and safety outcome measures were extracted. The meta-analysis was conducted using Review Manager 5.4., Results: 10 studies including eight randomised controlled trials, one open-label and one single-arm before-after study with a total population size of 4278 patients were included. DMF group showed a statistically significant reduction in the proportion of relapses compared with the control group, (OR: 0.47, 95% CI: [0.41, 0.55], p<0.00001) with no statistical differences between 240 mg two times per day and three times a day doses. Furthermore, the DMF group had a significant reduction in Gd-enhanced lesions compared with control (MD=-1.53, 95% CI: [-1.91 to -1.41], p<0.00001). Our results showed a non-significant difference in adverse events that led to discontinuation of the study with an OR of 1.29 (95% CI: [0.98, 1.71], p value=0.07)., Discussion: DMF had significant efficacy and safety compared with the control, with no difference between the DMF doses. More studies with large sample sizes and longer follow-ups are needed to detect long-term safety and efficacy., Competing Interests: No, there are no competing interests., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Risk stratification for patients undergoing coronary artery bypass surgery (CABG) for left main coronary artery (LMCA) disease is essential for informed decision-making. This study explored the potential of machine learning (ML) methods to identify key risk factors associated with mortality in this patient group., Methods: This retrospective cohort study was conducted on 866 patients from the Gulf Left Main Registry who presented between 2015 and 2019. The study outcome was hospital all-cause mortality. Various machine learning models [logistic regression, random forest (RF), k-nearest neighbor, support vector machine, naïve Bayes, multilayer perception, boosting] were used to predict mortality, and their performance was measured using accuracy, precision, recall, F1 score, and area under the receiver operator characteristic curve (AUC)., Results: Nonsurvivors had significantly greater EuroSCORE II values (1.84 (10.08-3.67) vs. 4.75 (2.54-9.53) %, P <0.001 for survivors and nonsurvivors, respectively). The EuroSCORE II score significantly predicted hospital mortality (OR: 1.13 (95% CI: 1.09-1.18), P <0.001), with an AUC of 0.736. RF achieved the best ML performance (accuracy=98, precision=100, recall=97, and F1 score=98). Explainable artificial intelligence using SHAP demonstrated the most important features as follows: preoperative lactate level, emergency surgery, chronic kidney disease (CKD), NSTEMI, nonsmoking status, and sex. QLattice identified lactate and CKD as the most important factors for predicting hospital mortality this patient group., Conclusion: This study demonstrates the potential of ML, particularly the Random Forest, to accurately predict hospital mortality in patients undergoing CABG for LMCA disease and its superiority over traditional methods. The key risk factors identified, including preoperative lactate levels, emergency surgery, chronic kidney disease, NSTEMI, nonsmoking status, and sex, provide valuable insights for risk stratification and informed decision-making in this high-risk patient population. Additionally, incorporating newly identified risk factors into future risk-scoring systems can further improve mortality prediction accuracy., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Background: There is a paucity of data regarding acute myocardial infarction (MI) complicated by cardiogenic shock (AMI-CS) in the Gulf region. This study addressed this knowledge gap by examining patients experiencing AMI-CS in the Gulf region and analyzing hospital and short-term follow-up mortality. Methods: The Gulf-Cardiogenic Shock registry included 1,513 patients with AMI-CS diagnosed between January 2020 and December 2022. Results: The incidence of AMI-CS was 4.1% (1,513/37,379). The median age was 60 years. The most common presentation was ST-elevation MI (73.83%). In-hospital mortality was 45.5%. Majority of patients were in SCAI (Society for Cardiovascular Angiography and Interventions shock classification) stage D and E (68.94%). Factors associated with hospital mortality were previous coronary artery bypass graft (odds ratio [OR]: 2.49; 95% confidence interval [CI]: 1.321-4.693), cerebrovascular accident (OR: 1.621; 95% CI: 1.032-2.547), chronic kidney disease (OR: 1.572; 95% CI: 1.158-2.136), non-ST-elevation MI (OR: 1.744; 95% CI: 1.058-2.873), cardiac arrest (OR: 5.702; 95% CI: 3.640-8.933), SCAI stage D and E (OR: 19.146; 95% CI: 9.902-37.017), prolonged QRS (OR: 10.012; 95% CI: 1.006-1.019), right ventricular dysfunction (OR: 1.679; 95% CI: 1.267-2.226), and ventricular septal rupture (OR: 6.008; 95% CI: 2.256-15.998). Forty percent had invasive hemodynamic monitoring, 90.02% underwent revascularization, and 45.80% received mechanical circulatory support (41.31% had intra-aortic balloon pump and 14.21% had extracorporeal membrane oxygenation/Impella devices). Survival at 12 months was 51.49% (95% CI: 46.44%-56.29%). Conclusions: The study highlighted the significant burden of AMI-CS in this region, with high in-hospital mortality. The study identified several key risk factors associated with increased hospital mortality. Despite the utilization of invasive hemodynamic monitoring, revascularization, and mechanical circulatory support in a substantial proportion of patients, the 12-month survival rate remained relatively low., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by the Shock Society.)

Background: Postcardiotomy extracorporeal membrane oxygenation (ECMO) in pediatric patients can be affected by the place of initiation, either in the operating room (OR) or the pediatric cardiac intensive care unit (PCICU). This study aimed to characterize and compare patients who had postcardiotomy ECMO initiation in the OR or PCICU and evaluate risk factors for hospital mortality., Methods: This retrospective study included 103 patients who required postcardiotomy ECMO support after the repair of congenital cardiac lesions from 2010 to 2022. Patients were grouped according to the place of ECMO insertion into two groups. Group 1 ( n = 69) had ECMO insertion in the OR, and Group 2 ( n = 34) had ECMO insertion in the PCICU., Results: Cardiac arrest occurred significantly more often in patients with ECMO insertion in the PCICU (21 (61.76%) vs. 13 (18.84%); p < 0.001). Pre-ECMO lactate levels, pH, VIS, base deficit, and PaO 2 did not differ between the groups. Re-exploration for bleeding was significantly higher in Group 1 (32 (46.38%) vs. 8 (23.53%); p = 0.03). Cannula repositioning (4 (11.76%) v. 2 (2.90%); p = 0.09) and mechanical ventilation time were nonsignificantly higher in Group 2 (19.5 (10-31) vs. 11 (5-25) days; p = 0.07). No difference in mortality was found between groups (42 (60.87%) vs. 23 (67.65%), p = 0.50). By multivariable analysis, elevated lactate on ECMO and low pH before ECMO were associated with mortality., Conclusions: ECMO insertion in the OR has a comparable mortality rate to PCICU insertion. Pre-ECMO low pH and high lactate during ECMO could predict mortality., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: It is controversial whether pulmonary function testing should be performed routinely in cardiac surgery patients. The aim of our study was to focus on patients who have congestive heart failure, caused by left ventricular dysfunction or left-sided heart valve disease, and study the prognostic value of performing preoperative pulmonary function testing on their postoperative outcomes., Methods: This is a retrospective propensity score matched study that included 366 patients with congestive heart failure who underwent cardiac surgery and had preoperative pulmonary function test. The patients were divided into two groups: Group 1 who had a normal or mild reduction in pulmonary function tests and group 2 who had moderate to severe reduction in pulmonary function tests. The postoperative outcomes, including pulmonary complications, were compared between the two groups., Results: Pulmonary function tests were normal or mildly reduced in 190 patients (group 1) and moderately to severely reduced in 176 patients (group 2). Propensity matching identified 111 matched pairs in each group with balanced preoperative and operative characteristics. Compared to group 1, Group 2 had longer duration of mechanical ventilation [12 (7.5-16) vs. 9 (6.5-13) hours, p < 0.001], higher postoperative Creatinine [111 (90-142) vs. 105 (81-128) µmol/dl, p = 0.02] and higher hospital mortality (6.31% vs. 0%, p = 0.02)., Conclusion: Routine Pulmonary Function Testing should be performed in patients with Left ventricular dysfunction and/or congestive heart failure undergoing cardiac surgery since moderate to severe reduction in those patients was associated with longer duration of mechanical ventilation and higher hospital mortality., (© 2024. The Author(s).)

Background: The choice of prosthesis for aortic valve replacement (AVR) remains challenging. The risk of anticoagulation complications vs. the risk of aortic valve reintervention should be weighed. This study compared the outcomes of bioprosthetic vs. mechanical AVR in patients older and younger than 50., Methods: This retrospective study was conducted from 2009 to 2019 and involved 292 adult patients who underwent isolated AVR. The patients were divided according to their age (above 50 years or 50 years and younger) and the type of valves used in each age group. The outcomes of bioprosthetic valves (Groups 1a (>50 years) and 1b (≤50 years)) were compared with those of mechanical valves (Groups 2a (>50 years) and 2b (≤50 years)) in each age group., Results: The groups had nearly equal rates of preexisting comorbidities except for Group 1b, in which the rate of hypertension was greater (32.6% vs. 14.7%; p = 0.025). This group also had higher rates of old stroke (8.7% vs. 0%, p = 0.011) and higher creatinine clearance (127.62 (108.82-150.23) vs. 110.02 (84.87-144.49) mL/min; p = 0.026) than Group 1b. Patients in Group 1a were significantly older than Group 2a (64 (58-71) vs. 58 (54-67) years; p = 0.002). There was no significant difference in the NYHA class between the groups. The preoperative ejection fraction and other echocardiographic parameters did not differ significantly between the groups. Re-exploration for bleeding was more common in patients older than 50 years who underwent mechanical valve replacement ( p = 0.021). There was no difference in other postoperative complications between the groups. The groups had no differences in survival, stroke, or bleeding rates. Aortic valve reintervention was significantly greater in patients ≤ 50 years old with bioprosthetic valves. There were no differences between groups in the changes in left ventricular mass, ejection fraction, or peak aortic valve pressure during the 5-year follow-up., Conclusions: The outcomes of mechanical and bioprosthetic valve replacement were comparable in patients older than 50 years. Using bioprosthetic valves in patients younger than 50 years was associated with a greater rate of valve reintervention, with no beneficial effect on the risk of bleeding or stroke.

Introduction: Postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) is associated with significant mortality. Identification of patients at very high risk for death is elusive and the decision to initiate V-A-ECMO is based on clinical judgment. The prognostic impact of pre-V-A-ECMO arterial lactate level in these critically ill patients has been herein evaluated., Methods: A systematic review was conducted to identify studies on postcardiotomy VA-ECMO for the present individual patient data meta-analysis., Results: Overall, 1269 patients selected from 10 studies were included in this analysis. Arterial lactate level at V-A-ECMO initiation was increased in patients who died during the index hospitalization compared to those who survived (9.3 vs 6.6 mmol/L, p < 0.0001). Accordingly, in hospital mortality increased along quintiles of pre-V-A-ECMO arterial lactate level (quintiles: 1, 54.9%; 2, 54.9%; 3, 67.3%; 4, 74.2%; 5, 82.2%, p < 0.0001). The best cut-off for arterial lactate was 6.8 mmol/L (in-hospital mortality, 76.7% vs. 55.7%, p < 0.0001). Multivariable multilevel mixed-effect logistic regression model including arterial lactate level significantly increased the area under the receiver operating characteristics curve (0.731, 95% CI 0.702-0.760 vs 0.679, 95% CI 0.648-0.711, DeLong test p < 0.0001). Classification and regression tree analysis showed the in-hospital mortality was 85.2% in patients aged more than 70 years with pre-V-A-ECMO arterial lactate level ≥6.8 mmol/L., Conclusions: Among patients requiring postcardiotomy V-A-ECMO, hyperlactatemia was associated with a marked increase of in-hospital mortality. Arterial lactate may be useful in guiding the decision-making process and the timing of initiation of postcardiotomy V-A-ECMO., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Preoperative intra-aortic balloon pump (IABP) before coronary artery bypass grafting (CABG) could improve operative outcomes by augmenting the diastolic coronary blood flow. Data on preoperative IABP use in patients with left-main coronary artery (LMCA) disease are limited. This study aimed to characterize patients who received preoperative IABP before CABG for LMCA and evaluate its effect on postoperative outcomes., Methods: This multicenter retrospective cohort study that included consecutive 914 patients who underwent CABG for unprotected LMCA disease from January 2015 to December 2019 in 14 tertiary referral centers. Patients were grouped according to the preoperative IABP insertion into patients with IABP (n=101) and without IABP (n=813). Propensity score matching adjusting for preoperative variables, with 1:1 match and a caliber of 0.03 identified 80 matched pairs. The primary outcomes used in propensity score matching were cardiac mortality and major adverse cardiac and cerebrovascular events (MACCE)., Results: IABP was commonly inserted in patients with previous myocardial infarction (MI), chronic kidney disease, peripheral arterial disease, and congestive heart failure. IABP patients had higher EuroSCORE [ES >8%: 95 (11.86%) vs. 40 (39.60%), P<0.001] and SYNTAX {29 [interquartile range (IQR) 25-35] vs. 33 (IQR 26-36); P=0.02} scores. Preoperative cardiogenic shock and arrhythmia were more prevalent in patients with IABP, while acute coronary syndrome was more prevalent in patients without IABP. After matching, there was no difference in vasoactive inotropic score between groups [3.5 (IQR 1-7.5) vs. 6 (IQR 1-13.5), P=0.06], and lactate levels were nonsignificantly higher in patients with IABP [2.4 (IQR 1.4-4.5) vs. 3.1 (IQR 1.05-7.75), P=0.05]. There were no differences between groups in acute kidney injury [20 (25%) vs. 26 (32.5%), P=0.34], cerebrovascular accidents [3 (3.75%) vs. 4 (5%), P>0.99], heart failure [5 (6.25%) vs. 7 (8.75%), P=0.75], MI [7 (8.75%) vs. 8 (10%), P>0.99], major adverse cardiac and cerebrovascular events [10 (12.5%) vs. 17 (21.25%), P=0.21], and cardiac mortality [6 (7.50%) vs. 14 (17.50%), P=0.09]. Patients who received IABP had longer ventilation times [8.5 (IQR 6-23) vs. 15.5 (IQR 5-50.5) h, P=0.03] and intensive care unit (ICU) stays [3 (IQR 2-5) vs. 4 (IQR 2-7.5) days, P=0.01]., Conclusions: Preoperative IABP in patients with LMCA might not be associated with reduced cardiac mortality or hospital complications. IABP could increase the duration of mechanical ventilation and ICU stay, and its use should be individualized for each patient., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-23-418/coif). The authors have no conflicts of interest to declare., (2024 Cardiovascular Diagnosis and Therapy. All rights reserved.)

There is no consensus regarding mitral valve management during surgical ventricular restoration (SVR) for ischemic cardiomyopathy. We compared the impact of SVR with mitral valve repair (MVr) vs replacement (MVR) on postoperative outcomes and long-term survival in ischemic cardiomyopathy and mitral regurgitation patients. This study included 112 patients who underwent SVR from 2009 to 2018 with MVr (n = 75) or MVR (n = 37). Patients who had MVR had higher Euro SCORE II, dyspnea class, a lower ejection fraction, higher pulmonary artery systolic pressure, higher grade of preoperative mitral and tricuspid regurgitation, and higher end-diastolic and end-systolic diameters. Intra-aortic balloon pump was more commonly used in patients with MVR. Hospital mortality occurred in 7 (9.33%) patients in the MVr group vs 3 (8.11%) in the MVR group (P > .99). Freedom from rehospitalization at 1, 5, and 7 years was 87%, 76%, and 70% in the MVr group and 83%, 61%, and 52% in the MVR group (P = .191). Survival at 1, 5, and 7 years was 88%, 78%, and 74% in the MVr group and 88%, 56%, and 56% in the MVR group (P = .027). Adjusted survival did not differ between groups.MVr or MVR are valid options in patients undergoing SVR, with good long-term outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Limited data evaluated the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with prosthetic valves. This study aimed to compare the outcomes of ECMO support for postcardiotomy cardiogenic shock in patients with mechanical versus bioprosthetic valves., Methods: This retrospective study included patients with ECMO support for postcardiotomy cardiogenic shock after valve replacement. Patients were grouped into bioprosthetic ( n = 49) and mechanical valve ( n = 22) groups., Results: There were no differences in ECMO duration, inotropic support, intra-aortic balloon pump (IABP), stroke, duration of ICU, and hospital stay between groups. Postoperative thrombosis occurred in 2 patients with bioprosthetic valves (5.41%) and 2 with mechanical valves (14.29%), p = .30. All patients with thrombosis had central ECMO cannulation, concomitant IABP, and inotropic support during ECMO. All thrombi were related to the mitral valve. Three patients with thrombi had hospital mortality.Survival at 6, 12, and 36 months for bioprosthetic valve patients was 30.88%, 28.55%, and 25.34% and for mechanical valves was 36.36% for all time intervals (Log-rank p = .93). One patient had bioprosthetic aortic valve endocarditis after 1 year. Three patients with bioprosthetic valves had structural valve degeneration after 1, 2, and 5 years., Conclusions: Outcomes of ECMO in patients with prosthetic valves are comparable between bioprosthetic and mechanical valves. Thrombosis might occur in both valve types and was associated with high mortality. ECMO could affect the long-term durability of the bioprosthetic valves., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Reliable stratification of the risk of early mortality after postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) remains elusive. In this study, we externally validated the PC-ECMO score, a specific risk scoring method for prediction of in-hospital mortality after postcardiotomy V-A-ECMO. Overall, 614 patients who required V-A-ECMO after adult cardiac surgery were gathered from an individual patient data meta-analysis of nine studies on this topic. The AUC of the logistic PC-ECMO score in predicting in-hospital mortality was 0.678 (95%CI 0.630-0.726; p  < 0.0001). The AUC of the logistic PC-ECMO score in predicting on V-A-ECMO mortality was 0.652 (95%CI 0.609-0.695; p  < 0.0001). The Brier score of the logistic PC-ECMO score for in-hospital mortality was 0.193, the slope 0.909, the calibration-in-the-large 0.074 and the expected/observed mortality ratio 0.979. 95%CIs of the calibration belt of fit relationship between observed and predicted in-hospital mortality were never above or below the bisector ( p  = 0.072). The present findings suggest that the PC-ECMO score may be a valuable tool in clinical research for stratification of the risk of patients requiring postcardiotomy V-A-ECMO., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The use of dual antiplatelet therapy (DAPT) after coronary revascularization for left-main disease is still debated. The study aimed to characterize patients who received dual versus single antiplatelet therapy (SAPT) after coronary artery bypass grafting (CABG) for unprotected left-main disease and compare the outcomes of those patients., Results: This multicenter retrospective cohort study included 551 patients who were grouped into 2 groups: patients who received SAPT (n = 150) and those who received DAPT (n = 401). There were no differences in age ( P = 0.451), gender ( P = 0.063), smoking ( P = 0.941), diabetes mellitus ( P = 0.773), history of myocardial infarction ( P = 0.709), chronic kidney disease ( P = 0.615), atrial fibrillation ( P = 0.306), or cerebrovascular accident ( P = 0.550) between patients who received SAPT versus DAPT. DAPTs were more commonly used in patients with acute coronary syndrome [87 (58%) vs. 273 (68.08%); P = 0.027], after off-pump CABG [12 (8%) vs. 73 (18.2%); P = 0.003] and in patients with radial artery grafts [1 (0.67%) vs. 32 (7.98%); P < 0.001]. While SAPTs were more commonly used in patients with low ejection fraction [55 (36.67%) vs. 61 (15.21%); P < 0.001] and in patients with postoperative acute kidney injury [27 (18%) vs. 37 (9.23%); P = 0.004]. The attributed treatment effect of DAPT for follow-up major adverse cerebrovascular and cardiac events was not significantly different from that of SAPT [β, -2.08 (95% confidence interval (CI), -20.8-16.7); P = 0.828]. The attributed treatment effect of DAPT on follow-up all-cause mortality was not significantly different from that of SAPT [β, 4.12 (CI, -11.1-19.32); P = 0.595]. There was no difference in bleeding between groups ( P = 0.666)., Conclusions: DAPTs were more commonly used in patients with acute coronary syndrome, after off-pump CABG, and with radial artery grafts. SAPTs were more commonly used in patients with low ejection fraction and acute kidney injury. Patients on DAPT after CABG for left-main disease had comparable major adverse cerebrovascular and cardiac events and survival to patients on SAPT, with no difference in bleeding events., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Atrial fibrillation after cardiac surgery (POAF) is associated with increased morbidity and mortality. Several scores were used to predict POAF, with variable results. Thus, this study assessed the performance of several scoring systems to predict POAF after mitral valve surgery. Additionally, we identified the risk factors for POAF in those patients., Methods: This retrospective cohort included 1381 recruited from 2009 to 2021. The patients underwent mitral valve surgery, and POAF occurred in 233 (16.87%) patients. The performance of CHADS2, CHA2DS2-VASc, POAF, EuroSCORE II, and HATCH scores was evaluated., Results: The median age was higher in patients who developed POAF (60 vs. 54 years; p  < .001). CHA2-DS2-VASc, POAF, EuroSCORE II, and HATCH scores significantly predicted POAF, with areas under the curve of the receiver operator curve (AUCROC) of 0.56, 0.61, 0.58, and 0.54, respectively. We identified age > 58 years, body mass index > 28 kg/m 2 , creatinine clearance < 90 mL/min, reoperative surgery, and preoperative inotropic and intra-aortic balloon pump use as predictors of POAF. We constructed a score from these variables (PSCC-AF). A score > 2 significantly predicted POAF ( p  < .001). The AUCROC of this score was 0.67, which was significantly higher than the AUCROC of the POAF score ( p  = .009)., Conclusion: POAF after mitral valve surgery can be predicted based on preoperative patient characteristics. The new PSCC-AF score significantly predicted POAF after mitral valve surgery and can serve as a bedside diagnostic tool for POAF risk screening. Further studies are needed to validate the PSCC-AF-mitral score externally., Competing Interests: Authors declare no conflict of interests for this article., (© 2024 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of Japanese Heart Rhythm Society.)

Currently, gender is not considered in the choice of the revascularization strategy for patients with unprotected left main coronary artery (ULMCA) disease. This study analyzed the effect of gender on the outcomes of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) in patients with ULMCA disease. Females who had PCI (n = 328) were compared with females who had CABG (n = 132) and PCI in males (n = 894) was compared with CABG (n = 784). Females with CABG had higher overall hospital mortality and major adverse cardiovascular events (MACE) than females with PCI. Male patients with CABG had higher MACE; however, mortality did not differ between males with CABG vs PCI. In female patients, follow-up mortality was significantly higher in CABG patients, and target lesion revascularization was higher in patients with PCI. Male patients had no difference in mortality and MACE between groups; however, MI was higher with CABG, and congestive heart failure was higher with PCI. In conclusion, women with ULMCA disease treated with PCI could have better survival with lower MACE compared with CABG. These differences were not evident in males treated with either CABG or PCI. PCI could be the preferred revascularization strategy in women with ULMCA disease., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Female gender is a risk factor in several cardiac surgery risk stratification systems. This study explored the differences in the outcomes following triple heart valve surgery in men vs women. The study included 250 patients (males n = 101; females n = 149) who underwent triple valve surgery from 2009 to 2020. BMI (body mass index) was higher in females (29.6 vs 26.5 kg/m 2 , P < .001), and diabetes was more common in males (44 vs 42%, P = .012). The ejection fraction was higher in females (55 vs 50%, P < .001). The severity of mitral valve stenosis and tricuspid valve regurgitation was significantly greater in females (33.11 vs 27.72%, P = .003 and 44.30 vs 19.8%, P < .001, respectively). Mitral valve replacement was more common in females ( P < .001), and they had lower concomitant coronary artery bypass grafting ( P = .001). Bleeding and renal failure were lower in females ( P = .021 and <0.001, respectively). Hospital mortality, readmission, and reintervention were not significantly different between genders. By multivariable analysis, male gender was a risk factor for lower survival [HR (hazard ratio): 2.18; P = .024]. Triple valve surgery can be performed safely in both genders, with better long-term survival in females. Female gender was not a risk factor in patients undergoing triple valve surgery., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Patients requiring postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) have a high risk of early mortality. In this analysis, we evaluated whether any interinstitutional difference exists in the results of postcardiotomy V-A-ECMO., Methods: Studies on postcardiotomy V-A-ECMO were identified through a systematic review for individual patient data (IPD) meta-analysis. Analysis of interinstitutional results was performed using direct standardization, estimation of observed/expected in-hospital mortality ratio and propensity score matching., Results: Systematic review of the literature yielded 31 studies. Data from 10 studies on 1269 patients treated at 25 hospitals were available for the present analysis. In-hospital mortality was 66.7%. The relative risk of in-hospital mortality was significantly higher in six hospitals. Observed versus expected in-hospital mortality ratio showed that four hospitals were outliers with significantly increased mortality rates, and one hospital had significantly lower in-hospital mortality rate. Participating hospitals were classified as underperforming and overperforming hospitals if their observed/expected in-hospital mortality was higher or lower than 1.0, respectively. Among 395 propensity score matched pairs, the overperforming hospitals had significantly lower in-hospital mortality (60.3% vs 71.4%, p  = 0.001) than underperforming hospitals. Low annual volume of postcardiotomy V-A-ECMO tended to be predictive of poor outcome only when adjusted for patients' risk profile., Conclusions: In-hospital mortality after postcardiotomy V-A-ECMO differed significantly between participating hospitals. These findings suggest that in many centers there is room for improvement of the results of postcardiotomy V-A-ECMO., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Blood-based cardioplegia is the standard myocardial protection strategy in pediatric cardiac surgery. Custadiol (histidine-tryptophan-ketoglutarate), an alternative, may have some advantages but is potentially less effective at myocardial protection. This study aimed to test whether custadiol is not inferior to blood-based cardioplegia in pediatric cardiac surgery., Methods: The study was designed as a randomized controlled trial with a blinded outcome assessment. All pediatric patients undergoing cardiac surgery with cardiopulmonary bypass and cardioplegia, including neonates, were eligible. Emergency surgery was excluded. The primary outcome was a composite of death within 30 days, an ICU stay longer than 5 days, or arrhythmia requiring intervention. Secondary endpoints included total hospital stay, inotropic score, cardiac troponin levels, ventricular function, and extended survival postdischarge. The sample size was determined a priori for a noninferiority design with an expected primary outcome of 40% and a clinical significance difference of 20%., Results: Between January 2018 and January 2021, 226 patients, divided into the Custodiol cardioplegia (CC) group (n = 107) and the blood cardioplegia (BC) group (n = 119), completed the study protocol. There was no difference in the composite endpoint between the CC and BC groups, 65 (60.75%) vs. 71 (59.66%), respectively (P = 0.87). The total length of stay in the hospital was 14 (Q2-Q3: 10-19) days in the CC group vs. 13 (10-21) days in the BC group (P = 0.85). The inotropic score was not significantly different between the CC and BC groups, 5 (2.6-7.45) vs. 5 (2.6-7.5), respectively (P = 0.82). The cardiac troponin level and ventricular function did not differ significantly between the two groups (P = 0.34 and P = 0.85, respectively). The median duration of follow-up was 32.75 (Q2-Q3: 18.73-41.53) months, and there was no difference in survival between the two groups (log-rank P = 0.55)., Conclusions: Custodial cardioplegia is not inferior to blood cardioplegia for myocardial protection in pediatric patients. Trial registration The trial was registered in Clinicaltrials.gov, and the ClinicalTrials.gov Identifier number is NCT03082716 Date: 17/03/2017., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: The optimal venoarterial extracorporeal membrane oxygenation (VA ECMO) cannulation strategy in patients with postcardiotomy cardiogenic shock is still debatable. Studies evaluating the effect of cannulation strategy on long-term survival are scarce., Objectives: We investigated the impact of central versus peripheral cannulation strategy for ECMO insertion on hospital outcomes and survival in postcardiotomy cardiogenic shock patients., Methods: This retrospective study involved 101 patients who had either central or peripheral ECMO due to postcardiotomy shock between June 2009 and December 2020. Study endpoints were limb ischemia, bleeding, blood transfusion, wound infection, and overall survival., Results: Eighty-four patients received central (c) ECMO, and 17 patients had peripheral (p) ECMO. In the group of pECMO, limb ischemia was significantly higher (5 [29.41%] vs 6 [7.14%]; p = .01). Other endpoints were similar in both groups. Thirty-day mortality was nonsignificantly different between both cohorts (cECMO 34 [41.67%] vs pECMO 10 [58.82%]; p = .29). However, overall survival was better with cECMO (Log-rank p = .02). Patients' age [HR: 1.04 (95% CI: 1.02-1.06); p = .001], pECMO [HR: 1.98 (95% CI: 1.11-3.55), p = .002] and presence of infective endocarditis [HR: 3.54 (95% CI: 1.52-8.24), p = .03] were significant predictors of overall mortality., Conclusions: Peripheral ECMO was associated with an increased risk of limb ischemia; however, bleeding, blood transfusion, infection, and 30-day mortality were comparable to central ECMO. Central cannulation was associated with a better 1-year survival rate. Therefore, central cannulation might be the preferred strategy for patients with postcardiotomy cardiogenic shock., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: We studied the effect of tricuspid valve (TV) surgery combined with surgical ventricular restoration (SVR) on operative outcomes, rehospitalization, recurrent tricuspid regurgitation, and survival of patients with ischemic cardiomyopathy. Additionally, surgery was compared to conservative management in patients with mild or moderate tricuspid regurgitation. To the best of our knowledge, the advantage of combining TV surgery with SVR in patients with ischemic cardiomyopathy had not been investigated before., Methods: This retrospective cohort study included 137 SVR patients who were recruited from 2009 to 2020. Patients were divided into two groups - those with no concomitant TV surgery (n=74) and those with concomitant TV repair or replacement (n=63)., Results: Extracorporeal membrane oxygenation use was higher in SVR patients without TV surgery (P=0.015). Re-exploration and blood transfusion were significantly higher in those with TV surgery (P=0.048 and P=0.037, respectively). Hospital mortality occurred in eight (10.81%) patients with no TV surgery vs. five (7.94%) in the TV surgery group (P=0.771). Neither rehospitalization (log-rank P=0.749) nor survival (log-rank P=0.515) differed in patients with mild and moderate tricuspid regurgitation in both groups. Freedom from recurrent tricuspid regurgitation was non-significantly higher in mild and moderate tricuspid regurgitation patients with no TV surgery (P=0.059). Conservative management predicted the recurrence of tricuspid regurgitation., Conclusion: TV surgery concomitant with SVR could reduce the recurrence of tricuspid regurgitation; however, its effect on the clinical outcomes of rehospitalization and survival was not evident. The same effects were observed in patients with mild and moderate tricuspid regurgitation.

Currently, there is no preference for surgical (SAVR) vs transcatheter (TAVR) aortic valve replacement in patients with low ejection fraction (EF). The present study retrospectively compared the outcomes of SAVR vs TAVR in patients with EF ≤40% (70 SAVR and 117 TAVR patients). Study outcomes were survival and the composite endpoint of stroke, aortic valve reintervention, and heart failure readmission. The patients who had TAVR were older (median: 75 (25-75th percentiles: 69-81) vs 51 (39-66) years old; P < .001) with higher EuroSCORE II (4.95 (2.99-9.85) vs 2 (1.5-3.25); P < .001). Postoperative renal impairment was more common with SAVR (8 (12.5%) vs 4 (3.42%); P = .03), and they had longer hospital stay [9 (7-15) vs 4 (2-8) days; P < .001). There was no difference between groups in stroke, reintervention, and readmission (Sub-distributional Hazard ratio: .95 (.37-2.45); P = .92). Survival at 1 and 5 years was 95% and 91% with SAVR and 89% and 63% with TAVR. Adjusted survival was comparable between groups. EF improved significantly (β: .28 (.23-.33); P < 0.001) with no difference between groups ( P = .85). In conclusion, TAVR could be as safe as SAVR in patients with low EF.

Background: New-onset postoperative atrial fibrillation (PoAF) is one of the most frequent yet serious complications following cardiac surgery. Long-term consequences have not been thoroughly investigated, and studies have included different cardiac operations. The objectives were to report the incidence and short- and long-term outcomes in patients with PoAF after mitral valve surgery., Methods: This is a retrospective cohort study of 1401 patients who underwent mitral valve surgery from 2009 to 2020. Patients were grouped according to the occurrence of PoAF ( n = 236) and the nonoccurrence of PoAF ( n = 1165). Long-term outcomes included mortality, heart failure rehospitalization, stroke, and mitral valve reinterventions., Results: The overall incidence of PoAF was 16.8%. PoAF was associated with higher rates of operative mortality (8.9% vs. 3.3%, p < 0.001), stroke (6.9% vs. 1.5%, p < 0.001), and dialysis (13.6% vs. 3.5%, p < 0.001). ICU and hospital stays were significantly longer in patients with PoAF ( p < 0.001 for both). PoAF was significantly associated with an increased risk of mortality [HR: 1.613 (95% CI: 1.048-2.483); p = 0.03], heart failure rehospitalization [HR: 2.156 (95% CI: 1.276-3.642); p = 0.004], and stroke [HR: 2.722 (95% CI: 1.321-5.607); p = 0.007]. However, PoAF was not associated with increased mitral valve reinterventions [HR: 0.938 (95% CI: 0.422-2.087); p = 0.875]., Conclusions: Atrial fibrillation after mitral valve surgery is a common complication, with an increased risk of operative mortality. PoAF was associated with lower long-term survival, increased heart failure rehospitalization, and stroke risk. Future studies are needed to evaluate strategies that can be implemented to improve the outcomes of these patients.

Background: The use of rivaroxaban in patients with atrial fibrillation (AF) and chronic kidney disease (CKD) poses the risk of over- or underdosing. We aimed to compare rivaroxaban and warfarin in AF patients with moderate and severe renal impairment., Methods: This retrospective study was conducted between 2015 and 2016 to compare the use of warfarin ( n = 164) and rivaroxaban ( n = 149) in patients with AF and moderate or severe CKD. The study outcomes were survival, stroke, and major bleeding events. The median follow-up was 50 months (interquartile range: 23-60)., Results: Thirty-six patients had major bleeding: 24 with rivaroxaban and 12 with warfarin ( P = 0.01). The rivaroxaban group had major bleeding in 3 patients with moderate CKD, 4 with severe CKD, and 17 on dialysis. Multivariable analysis of factors affecting major bleeding revealed that warfarin use lowered the risk of bleeding (hazard ratio: 0.34; P = 0.004). Stroke occurred in 14 patients: 6 in the rivaroxaban group and 8 in the warfarin group ( P = 0.44). Survival at 1, 3, and 5 years was 89%, 77%, and 71% with warfarin and 99%, 94%, and 88% with rivaroxaban, respectively ( P < 0.001). Multivariable analysis showed higher mortality in patients with lower creatinine clearance and those on warfarin., Conclusions: The safety of warfarin could be better than rivaroxaban in patients with CKD with fewer bleeding complications but similar stroke rates. Further studies on rivaroxaban dosing in patients on dialysis are required., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Heart Views.)

Background: The optimal revascularization strategy in patients with left main coronary artery (LMCA) disease in the emergency setting is still controversial. Thus, we aimed to compare the outcomes of percutaneous coronary interventions (PCI) vs. coronary artery bypass grafting (CABG) in patients with and without emergent LMCA disease., Methods: This retrospective cohort study included 2138 patients recruited from 14 centers between 2015 and 2019. We compared patients with emergent LMCA revascularization who underwent PCI (n = 264) to patients who underwent CABG (n = 196) and patients with non-emergent LMCA revascularization with PCI (n = 958) to those who underwent CABG (n = 720). The study outcomes were in-hospital and follow-up all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE)., Results: Emergency PCI patients were older and had a significantly higher prevalence of chronic kidney disease, lower ejection fraction, and higher EuroSCORE than CABG patients. CABG patients had significantly higher SYNTAX scores, multivessel disease, and ostial lesions. In patients presenting with arrest, PCI had significantly lower MACCE (P = 0.017) and in-hospital mortality (P = 0.016) than CABG. In non-emergent revascularization, PCI was associated with lower MACCE in patients with low (P = 0.015) and intermediate (P < 0.001) EuroSCORE. PCI was associated with lower MACCE in patients with low (P = 0.002) and intermediate (P = 0.008) SYNTAX scores. In non-emergent revascularization, PCI was associated with reduced hospital mortality in patients with intermediate (P = 0.001) and high (P = 0.002) EuroSCORE compared to CABG. PCI was associated with lower hospital mortality in patients with low (P = 0.031) and intermediate (P = 0.001) SYNTAX scores. At a median follow-up time of 20 months (IQR: 10-37), emergency PCI had lower MACCE compared to CABG [HR: 0.30 (95% CI 0.14-0.66), P < 0.003], with no significant difference in all-cause mortality between emergency PCI and CABG [HR: 1.18 (95% CI 0.23-6.08), P = 0.845]., Conclusions: PCI could be advantageous over CABG in revascularizing LMCA disease in emergencies. PCI could be preferred for revascularization of non-emergent LMCA in patients with intermediate EuroSCORE and low and intermediate SYNTAX scores., (© 2023. The Author(s).)

Background: Tricuspid valve repair (TVr) is the recommended approach for managing tricuspid regurgitation; however, there is a concern about the long-term durability of the repair. Therefore, this study aimed to compare the long-term outcomes of TVr versus tricuspid valve replacement (TVR) in a matched cohort of patients., Methods: This study included 1161 patients who underwent tricuspid valve (TV) surgery from 2009 to 2020. Patients were grouped according to the procedure into two groups: patients who underwent TVr ( n  = 1020) and patients who underwent TVR (n = 159). The propensity score identified 135 matched pairs., Results: Renal replacement therapy and bleeding were significantly higher in the TVR group compared to the TVr group both before and after matching. Thirty-day mortality occurred in 38 (3.79%) patients in TVr group versus 3 (1.89%) in the TVR group ( P  ≤ 0.001) but was not significant after matching. After matching, TV reintervention (hazard ratio (HR): 21.44 (95% CI: 2.17-211.95); P   =  0.009) and heart failure rehospitalization (HR: 1.89 (95% CI: 1.13-3.16); P   =  0.015) were significantly higher in the TVR group. There was no difference in mortality in the matched cohort (HR: 1.63 (95% CI: 0.72-3.70); P   =  0.25)., Conclusions: TVr was associated with lower renal impairment, reintervention, and heart failure rehospitalization than replacement. TVr remains the preferred approach whenever feasible.

We aimed to compare the outcomes of ECMO with and without IABP for postcardiotomy cardiogenic shock. The study included 103 patients who needed ECMO for postcardiotomy cardiogenic shock. Patients were grouped according to the use of IABP into ECMO without IABP ( n  = 43) and ECMO with IABP ( n  = 60). The study endpoints were hospital complications, successful weaning, and survival. Patients with IABP had lower preoperative ejection fraction ( p  = 0.002). There was no difference in stroke ( p  = 0.97), limb ischemic ( p  = 0.32), and duration of ICU stay ( p  = 0.11) between groups. Successful weaning was non-significantly higher with IABP (36 (60%) vs 19 (44.19%); p  = 0.11). Predictors of successful weaning were inversely related to the high pre-ECMO lactate levels (OR: 0.89; p  = 0.01), active endocarditis (OR: 0.06; p  = 0.02), older age (OR: 0.95; p  = 0.02), and aortic valve replacement (OR: 0.26; p  = 0.04). There was no difference in survival between groups ( p  = 0.80). Our study did not support the routine use of IABP during ECMO support.

Purpose: We compared the composite outcome of tricuspid valve (TV) reintervention or heart failure (HF) admission in patients who underwent tricuspid valve replacement (TVR) with tissue vs. mechanical valves., Patients and Methods: The study included 159 patients who underwent TVR from 2009 to 2019. We grouped the patients according to the valve's type into tissue valve group (n = 139) and mechanical valve group (n = 20)., Results: The mean age of patients was 52.4 ± 12.8 years, and 117 patients were females (73.6%). Hospital mortality occurred in 20 patients (12.6%); all of them were in the tissue valve group. The composite outcome of reintervention and HF readmission occurred in 8 patients with mechanical valves (40%) vs. 24 patients with tissue valves (17.3%), (P = 0.018). Predictors of reintervention and HF admission were female (subdistributional hazard ratio [SHR]: 1.38-34.3, P = 0.019), stroke (SHR: 1.25-8.76, P = 0.016), hypertension (SHR: 1.13-5.36, P = 0.024), and mechanical valves (SHR: 1.6-10.7, P = 0.003). In post hoc analysis, the difference in the composite outcome was derived from the difference in the reintervention rate that was higher in mechanical valves. Survival did not differ significantly between groups (P = 0.12)., Conclusion: Mechanical TVs have a higher rate of composite outcome of reintervention or HF readmission than tissue TVs that are related mainly to higher rate of reintervention.

Background: Stroke is one of the most feared complications post coronary artery bypass with aortic calcifications being the commonest source of embolic stroke. The aim of our study was to determine the clinical impact and usefulness of routine use of plain chest computerised tomography to screen for aortic calcification on incidence of postoperative stroke in coronary artery bypass grafting (CABG) patients., Methods: This is a retrospective case-control study that included four hundred and five patients who underwent primary isolated CABG and had preoperative plain chest computerised tomography as a screening for aortic calcification. Aortic calcification was classified according to the area involved (ascending, arch, arch vessels and descending aorta) and the pattern of calcification. Patients were divided into two groups according to the incidence of postoperative stroke and the aortic calcification distribution was compared between the two groups. Stroke predictors were studies using univariate and multivariate regression analysis., Results: Fourteen patients (3.5%) developed postoperative stroke. There was no difference in preoperative and operative characteristics between patients who developed postoperative stroke and those who did not, except for the history of preoperative stroke or transient ischemic attack (TIA) that was higher in the group who developed postoperative stroke (50.00% vs. 6.19%, P<0.001). Patients who developed postoperative stroke had higher percentage of aortic root calcification (78.57% vs. 64.18%), ascending aortic calcification (28.57% vs. 19.07%) and descending aortic calcification (85.71% vs. 73.71%) but none of them reached statistical significance. History of preoperative stroke or TIA was the only significant predictor of postoperative stroke using both univariate and multivariate regression models., Conclusions: Our study showed the importance of preoperative computed tomography (CT) scan of the chest as a screening tool as it detected a high prevalence of aortic calcification in our patients. However, its impact on prevention of postoperative stroke needs to be investigated further in future prospective studies., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-22-1047/coif). The authors have no conflicts of interest to declare., (2023 Quantitative Imaging in Medicine and Surgery. All rights reserved.)

Background: Sepsis could affect the outcomes of patients with postcardiotomy cardiogenic shock supported with extracorporeal membrane oxygenation (ECMO). Our objectives were to characterize sepsis patients with ECMO support for postcardiotomy cardiogenic shock and assess its predictors and effect on patients' outcomes., Methods: This retrospective study included 103 patients with ECMO for postcardiotomy cardiogenic shock from 2009 to 2020. Patients were divided according to the occurrence and timing of sepsis into three groups. Group 1 included patients with no sepsis ( n  = 67), Group 2 included patients with ECMO-related sepsis ( n  = 10), and Group 3 included patients with non-ECMO-related sepsis ( n  = 26)., Results: Lactate level before ECMO was highest in the ECMO-associated sepsis group (Group 1 and 2 p  = 0.003 and Group 2 and 3 p  = 0.003). Dialysis and gastrointestinal bleeding were highest in ECMO-associated sepsis ( p  = 0.03 and 0.04, respectively). Blood transfusion was higher in ECMO-associated sepsis than in patients with no sepsis ( p  = 0.01). Mortality was nonsignificantly higher in patients with ECMO-associated sepsis. High BMI (OR: 1.11; p  = 0.004), preoperative dialysis (OR: 7.35; p  = 0.02), preoperative IABP (OR: 9.9.61; p  = 0.01) and CABG (OR: 6.29; p  = 0.01) were significantly associated with sepsis. Older age (OR: 1.08; p = 0.004), lower BSA (OR: 0.004; p  = 0.003), peripheral cannulation (OR: 29.82; p  = 0.03), and high pre ECMO lactate level (OR: 1.24; p  = 0.001) were associated with increased mortality. Sepsis did not predict mortality (OR: 1.83; p  = 0.21)., Conclusions: Sepsis is a dreaded complication in patients with postcardiotomy cardiogenic shock, especially ECMO-associated sepsis. Preoperative risk factors could predict postoperative sepsis in ECMO patients.

Background: The efficacy and safety of non-vitamin K-dependent anticoagulants (NOAC) are not well investigated in the obese population, and fixed dosing could lead to under-anticoagulation. Our objective was to evaluate the effect of obesity on anticoagulation outcomes and survival in non-valvular atrial fibrillation (AF) patients., Methods: We enrolled 755 patients who required anticoagulation for AF from 2015 to 2016. We grouped the patients into four groups. Group 1 (n = 297) included patients with BMI< 40 kg/m2 treated with NOACs, Group 2 (n = 358) included patients on warfarin with BMI< 40 kg/m2, Group 3 (n = 57) had patients on NOACs with BMI≥ 40 kg/m2 and Group 4 (n = 43) included patients on warfarin and BMI≥ 40 kg/m2. Study outcomes were the composite endpoint of stroke, bleeding, and survival., Results: Competing risk regression showed that stroke and bleeding were not affected by obesity or treatment (SHR: 1.09 (95% CI: 0.79-1.51); P = 0.62). Older age was the predictor of stroke/bleeding (HR:1.03 (95% CI:1.01-1.06); P = 0.02). Predictors of mortality were heart failure (HR:2.23 (95% CI:1.25-3.97); P = 0.007), lower creatinine clearance (HR: 0.98 (95% CI:0.97-0.98): P < 0.001), non-obese patients on warfarin (HR:3.51 (95%CI:1.6-7.7): P = 0.002) and obese patients on warfarin (HR: 6.7 (95% CI:2.51-17.92); P < 0.001)., Conclusion: NOACs could have a similar risk profile to warfarin in obese and non-obese patients with non-valvular AF but could have better survival. Larger randomized trials are recommended., Competing Interests: Conflict of interest and Funding None declared., (© 2023 Saudi Heart Association.)

Introduction: Bleeding after transcatheter aortic valve replacement (TAVR) is associated with increased mortality. The predictive value of the HAS-BLED score in TAVR patients is still to be evaluated. We assessed the value of the HAS-BLED score to predict in-hospital bleeding and mortality after TAVR and the impact of diferent renal impairment definitions on the predictive value of the score system., Methods: We retrospectively included 574 patients who underwent TAVR at a single center. Study outcomes were 30-day mortality and the composite endpoint of major and life-threatening bleeding as defined by The Valve Academic Research Consortium-2. The predictive value of the HAS-BLED score was calculated and compared to a modified model. The performance of the score was compared using two definitions of renal impairment. Model discrimination was tested using C-statistic and the Net Reclassification Index., Results: Bleeding occurred in 78 patients (13.59%). HAS-BLED category 3 was a significant predictor of bleeding (OR: 1.99 ]1.18- 3.37], C-index: 0.56, P=0.01). C-index increased to 0.64 after adding body surface area and extracardiac arteriopathy to the model. The Net Reclassification Index showed an increase in the predic tive value of the model by 11.4% (P=0.002). The C-index increased to 0.61 using renal impairment definition based on creatinine clearance. Operative mortality was significantly associated with the HAS-BLED score (OR: 7.54 [95% CI: 2.73- 20.82], C-index: 0.73, P<0.001)., Conclusion: The HAS-BLED score could be a good predictor of in-hospital mortality after TAVR. Its predictive value for bleeding was poor but improved by adding procedure-specific factors and using creatinine clearance to define renal impairment.

Introduction: Repeat transcatheter mitral valve replacement (rTMVR) has emerged as a new option for the management of high-risk patients unsuitable for repeat surgical mitral valve replacement (rSMVR). The aim of this study was to compare hospital outcomes, survival, and reoperations after rTMVR versus surgical mitral valve replacement., Methods: We compared patients who underwent rTMVR (n=22) from 2017 to 2019 (Group 1) to patients who underwent rSMVR (n=98) with or without tricuspid valve surgery from 2009 to 2019 (Group 2). We excluded patients who underwent a concomitant transcatheter aortic valve replacement or other concomitant surgery., Results: Patients in Group 1 were significantly older (72.5 [67-78] vs. 57 [52-64] years, P<0.001). There was no diference in EuroSCORE II between groups (6.56 [5.47-8.04] vs. 6.74 [4.28-11.84], P=0.86). Implanted valve size was 26 (26-29) mm in Group 1 and 25 (25-27) mm in Group 2 (P=0.106). There was no diference in operative mortality between groups (P=0.46). However, intensive care unit (ICU) and hospital stays were shorter in Group 1 (P=0.03 and <0.001, respectively). NYHA class improved significantly in both groups at one year (P<0.001 for both groups). There was no group effect on survival (P=0.84) or cardiac readmission (P=0.26). However, reoperations were more frequent in Group 1 (P=0.01)., Conclusion: Transcatheter mitral valve-in-valve could shorten ICU and hospital stay compared to rSMVR with a comparable mortality rate. rTMVR is a safe procedure; however, it has a higher risk of reoperation. rTMVR can be an option in selected high-risk patients.

Background: There is conflicting evidence regarding the success of the Maze procedure to restore sinus rhythm in patients with rheumatic heart disease. Hence, the aim of our study was to describe the results of surgical ablation for atrial fibrillation in patients with rheumatic heart disease undergoing cardiac surgery., Methods: This is a retrospective study that included adult patients with rheumatic heart disease who underwent surgical ablation for atrial fibrillation. The ablation lesions were performed using monopolar radiofrequency ablation in all patients., Results: Fifty-seven consecutive patients were included in the study. Cox Maze IV was performed in 44 patients (77%), while left-sided surgical ablation was performed in 10 patients (17%) and pulmonary vein isolation in 3 patients (5%). The percentage of patients who were in sinus rhythm on discharge, at 1-month, at 3-months, 6-months and 12-months follow up were 56%, 54%, 52%, 56% and 46% respectively. Complete heart block occurred in 21 patients (44%), but only 15 of them (26%) required permanent pacemaker insertion. Freedom from composite endpoint of death, stroke, and readmission for heart failure was 78% at one-year follow up., Conclusion: Despite the suboptimal rates of sinus rhythm at the intermediate and long term follow up, surgical ablation of atrial fibrillation in patients with rheumatic heart disease should continue to be performed. Continuation of Class III antiarrhythmic medications and early intervention for recurrent atrial fibrillation is crucial to the success of this procedure and for maintenance of higher rates of sinus rhythm at intermediate and long-term follow up., Competing Interests: Conflict of interest None., (© 2022 Saudi Heart Association.)

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in revascularization of left main coronary artery (LMCA) disease has been evaluated in previous studies. However, there has been minimal study of the relationship between co-existing non-coronary atherosclerosis (NCA) and LMCA disease revascularization. We aim to examine this relationship. The Gulf-LM study is a retrospective analysis of unprotected LMCA revascularization cases undergoing PCI with second generation drug-eluting stent vs CABG across 14 centers within 3 Gulf countries between January 2015 and December 2019. A total of 2138 patients were included, 381 with coexisting NCA and 1757 without. Outcomes examined included major adverse cardiovascular and cerebrovascular events (MACCE), cardiac and non-cardiac death, and all bleeding. In patients with NCA, preexisting myocardial infarction and congestive heart failure were more common, with PCI being the most common revascularization strategy. A statistically significant reduction in in-hospital MACCE and all bleeding was noted in patients with NCA undergoing PCI as compared to CABG. At a median follow-up of 15 months, MACCE and major bleeding outcomes continued to favor the PCI group, though no such difference was identified between revascularization strategies in patients without NCA.In this multicenter retrospective study of patients with and without NCA who require revascularization (PCI and CABG) for unprotected LMCA disease, PCI demonstrated a better clinical outcome in MACCE both in-hospital and during the short-term follow-up in patients with NCA. However, no such difference was observed in patients without NCA., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: The evidence about the optimal revascularization strategy in patients with left main coronary artery (LMCA) disease and impaired renal function is limited. Thus, we aimed to compare the outcomes of LMCA disease revascularization (percutaneous coronary intervention [PCI] vs. coronary artery bypass grafting [CABG]) in patients with and without impaired renal function., Methods: This retrospective cohort study included 2,138 patients recruited from 14 centers between 2015 and 2,019. We compared patients with impaired renal function who had PCI (n= 316) to those who had CABG (n = 121) and compared patients with normal renal function who had PCI (n = 906) to those who had CABG (n = 795). The study outcomes were in-hospital and follow-up major adverse cardiovascular and cerebrovascular events (MACCE)., Results: Multivariable logistic regression analysis showed that the risk of in-hospital MACCE was significantly higher in CABG compared to PCI in patients with impaired renal function (odds ratio [OR]: 8.13 [95% CI: 4.19-15.76], p &lt; 0.001) and normal renal function (OR: 2.59 [95% CI: 1.79-3.73]; p &lt; 0.001). There were no differences in follow-up MACCE between CABG and PCI in patients with impaired renal function (HR: 1.14 [95% CI: 0.71-1.81], p = 0.585) and normal renal function (HR: 1.12 [0.90-1.39], p = 0.312)., Conclusions: PCI could have an advantage over CABG in revascularization of LMCA disease in patients with impaired renal function regarding in-hospital MACCE. The follow-up MACCE was comparable between PCI and CABG in patients with impaired and normal renal function., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Introduction: The aim of this study was to evaluate the effects of baseline anemia and anemia following revascularization on outcomes in patients with unprotected left main coronary artery (ULMCA) disease., Methods: This was a retrospective, multicenter, observational study conducted between January 2015 and December 2019. The data on patients with ULMCA who underwent revascularization through percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) were stratified by the hemoglobin level at baseline into anemic and non-anemic groups to compare in-hospital events. The pre-discharge hemoglobin following revascularization was categorized into very low (&lt;80 g/L for men and women), low (≥80 and ≤119 g/L for women and ≤129 g/L for men), and normal (≥130 g/L for men and ≥120 g/L for women) to assess impact on follow-up outcomes., Results: A total of 2,138 patients were included, 796 (37.2%) of whom had anemia at baseline. A total of 319 developed anemia after revascularization and moved from being non-anemic at baseline to anemic at discharge. There was no difference in hospital major adverse cardiac and cerebrovascular event (MACCE) and mortality between CABG and PCI in anemic patients. At a median follow-up time of 20 months (interquartile range [IQR]: 27), patients with pre-discharge anemia who underwent PCI had a higher incidence of congestive heart failure (CHF) (p &lt; 0.0001), and those who underwent CABG had significantly higher follow-up mortality (HR: 9.85 (95% CI: 2.53-38.43), p = 0.001)., Conclusion: In this Gulf LM study, baseline anemia had no impact upon in-hospital MACCE and total mortality following revascularization (PCI or CABG). However, pre-discharge anemia is associated with worse outcomes after ULMCA disease revascularization, with significantly higher all-cause mortality in patients who had CABG, and a higher incidence of CHF in PCI patients, at a median follow-up time of 20 months (IQR: 27)., (© 2023 S. Karger AG, Basel.)

Background: It is unclear whether peripheral arterial cannulation is superior to central arterial cannulation for postcardiotomy veno-arterial extracorporeal membrane oxygenation (VA-ECMO)., Methods: A systematic review was conducted using PubMed, Scopus, and Google Scholar to identify studies on postcardiotomy VA-ECMO for the present individual patient data (IPD) meta-analysis. Analysis was performed according to the intention-to-treat principle., Results: The investigators of 10 studies agreed to participate in the present IPD meta-analysis. Overall, 1269 patients were included in the analysis. Crude rates of in-hospital mortality after central versus peripheral arterial cannulation for VA-ECMO were 70.7% vs. 63.7%, respectively (adjusted OR 1.38, 95% CI 1.08-1.75). Propensity score matching yielded 538 pairs of patients with balanced baseline characteristics and operative variables. Among these matched cohorts, central arterial cannulation VA-ECMO was associated with significantly higher in-hospital mortality compared to peripheral arterial cannulation VA-ECMO (64.5% vs. 70.8%, p = 0.027). These findings were confirmed by aggregate data meta-analysis, which showed that central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation (OR 1.35, 95% CI 1.04-1.76, I 2 21%)., Conclusions: Among patients requiring postcardiotomy VA-ECMO, central arterial cannulation was associated with an increased risk of in-hospital mortality compared to peripheral arterial cannulation. This increased risk is of limited magnitude, and further studies are needed to confirm the present findings and to identify the mechanisms underlying the potential beneficial effects of peripheral VA-ECMO.

Background: The debate about the optimal mitral valve prosthesis continues. We aimed to compare the early and late outcomes, including stroke, bleeding, survival, and reoperation after isolated mitral valve replacement (MVR) using tissue versus mechanical valves., Methods: This retrospective cohort study included 291 patients who had isolated MVR from 2005 to 2015. Patients were grouped into the tissue valve group (n = 140) and the mechanical valve group (n = 151)., Results: There were no differences in duration of mechanical ventilation, hospital stay, and hospital mortality between groups. Fifteen patients required cardiac rehospitalization, nine in the tissue valve group, and six in the mechanical valve group (p = .44). Stroke occurred in nine patients, five with tissue valves, and four with mechanical valves (p = .66). Bleeding occurred in 22 patients, seven patients with tissue valves, and 15 patients with mechanical valves (p = .09). Freedom from reoperation was 95%, 93%, 84%, 67% at 3, 5, 7, and 10 years for tissue valve and 97%, 96%, 96%, and 93% for mechanical valves, respectively (p˂ .001). The median follow-up was 84 months (Q1: Q3: 38-139). Survival at 3, 5, 7, and 10 years was 94%, 91%, 89%, 86% in tissue valves and 96%, 93%, 91%, 91% in mechanical valves, respectively (p = .49)., Conclusions: Tissue valve degeneration is still an issue even in the new generations of mitral tissue valves. The significant risk of reoperation in patients with mitral tissue valves should be considered when using those valves in younger patients. Mechanical valves remain a valid option for all age groups., (© 2022 Wiley Periodicals LLC.)

Introduction: Bleeding after transcatheter aortic valve replacement (TAVR) has a negative impact on the outcome of the procedure. Risk factors for bleeding vary widely in the literature, and the impact of preoperative antithrombotic agents has not been fully established. The objectives of our study were to assess bleeding after TAVR as defined by the Valve Academic Research Consortium-2 (VARC-2), identify its risk factors, and correlate with antithrombotic treatment in addition to its effect on procedural mortality., Methods: The study included 374 patients who underwent TAVR from 2009 to 2018. We grouped the patients into four groups according to the VARC-2 definition of bleeding. Group 1 included patients without bleeding (n=265), group 2 with minor bleeding (n=22), group 3 with major bleeding (n=61), and group 4 with life-threatening bleeding (n=26). The median age was 78 (25th-75th percentiles: 71-82), and 226 (60.4%) were male. The median EuroSCORE was 3.4 (2-6.3), and there was no difference among groups (P=0.886). The TAVR approach was transfemoral (90.9%), transapical (5.6%), and trans-subclavian (1.9%). Results: Predictors of bleeding were stroke (OR: 2.465; P=0.024) and kidney failure (OR: 2.060; P=0.046). Preoperative single and dual antiplatelet therapy did not increase the risk of bleeding (P=0.163 and 0.1, respectively). Thirty-day mortality occurred in 14 patients (3.7%), and was significantly higher in patients with life-threatening bleeding (n=8 [30.8%]; P<0.001). Conclusion: Bleeding after TAVR is common and can be predicted based on preprocedural comorbidities. Preprocedural antithrombotic therapy did not affect bleeding after TAVR in our population.

Current classifications of cor triatriatum sinister (CTS) do not address the associated heart defects or single ventricle pathology. Therefore, these classifications are not prognostic classifications and only describe the anatomy and the pulmonary venous drainage. The proposed classification considered the associated congenital cardiac lesions and the single ventricle pathology, therefore, it could have prognostic value. Future multicenter studies are required to measure the performance of this classification and its prognostic value in patients with CTS., (© 2022 Wiley Periodicals LLC.)

Management of patients with end-stage heart failure is still challenging. We report a case of idiopathic dilated cardiomyopathy who went through a challenging course. The case was presented as acute heart failure syndrome, which rapidly declined into cardiogenic shock and cardiac arrest that required an extracorporeal membrane oxygenator, then biventricular assist device implantation for circulatory support. The course was complicated with severe gastrointestinal bleeding and multiorgan failure until achieving full cardiac and organ recovery. The left ventricle ejection fraction improved from 10% to 50% at discharge., (© 2022 Wiley Periodicals LLC.)

Background: COVID-19 infection affects the quality of the medical services globally. The pandemic required changes to medical services in several institutions. We established a virtual clinic for anticoagulation management during the pandemic using the Whatsapp application., Objectives: Compare anticoagulation management quality in virtual versus in-person clinics., Design: A retrospective crossover study SETTINGS: Specialized cardiac care center PATIENTS AND METHODS: The study included patients who presented to Prince Sultan Cardiac Center in Riyadh for anticoagulation management during the pandemic from March 2020 to January 2021. We compared time in therapeutic range (TTR) in the same patients during virtual and in-person clinics. All international normalized ratio (INR) measures during the virtual clinic visits and prior ten INR measures from the in-person clinic were recorded. Patients who had no prior follow-up in the in-person clinic were excluded., Main Outcome Measure: TTR calculated using the Rosendaal method., Sample Size: 192 patients RESULTS: The mean age was 58.6 (16.6) years and 116 (60.4%) were males. Patients were diagnosed with atrial fibrillation (n=101, 52.6%), mechanical mitral valve (n=88, 45.8%), mechanical aortic valve (n=79, 41%), left ventricular thrombus (n=5, 2.6%) and venous thromboembolism (n=8, 4.2%). Riyadh residents represented 56.7% of the study population (n=93). The median (IQR) percent TTR was 54.6 (27.3) in the in-person clinic versus 50.0 (33.3) ( P =.07)., Conclusion: Virtual clinic results were comparable to in-person clinics for anticoagulation management during the COVID-19 pandemic., Limitations: Number of INR measures during the virtual clinic visits, retrospective nature and single-center experience., Conflict of Interest: None.

Objective: A primary cavopulmonary shunt as a component of the initial Norwood palliation could be an option in patients with hypoplastic left heart syndrome and single-ventricle lesions. We present our initial experience with this approach in carefully selected patients with unrestricted pulmonary blood flow and low pulmonary vascular resistance., Methods: The study included 16 patients; the mean age was 137.9 ± 84.2 days. All patients underwent a Norwood palliation consisting of atrial septectomy, Damus-Kaye-Stansel connection, and arch augmentation in addition to the cavopulmonary shunt as the initial palliation., Results: The mean preoperative pulmonary to systemic blood flow (Qp/Qs) ratio on room air (n = 9) and with 100% oxygen (n = 8) was 5.3 ± 3.2 and 8.6 ± 4.3, respectively. The mean pulmonary vascular resistance on room air (n = 10) and 100% oxygen (n = 9) was 4.8 ± 3.1 and 1.7 ± 0.97 WU/m 2 , respectively. Delayed chest closure was needed in 12 patients, and 6 patients required postoperative inhaled nitric oxide. One patient underwent takedown of the cavopulmonary shunt and construction of the right ventricle to pulmonary artery conduit after 1 month. The mean intensive care unit stay was 18.9 ± 15.4 days. There were 2 in-hospital deaths (48 hours and 8 days after surgery) and 2 postdischarge deaths (6 months and 2 years after hospital discharge). Seven patients have undergone the Fontan completion successfully, and 5 patients await further surgery., Conclusions: First-stage Norwood palliation with cavopulmonary shunt for patients with hypoplastic left heart syndrome or single-ventricle lesions is feasible in late presenters with low pulmonary vascular resistance., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The influence of the etiology of mitral valve (MV) lesion on outcomes of concomitant repair for functional tricuspid regurgitation (TR) is not well studied. Our objectives were to compare long-term survival and TR recurrence after tricuspid valve (TV) repair concomitant with surgery for rheumatic versus degenerative MV disease., Methods: We included 480 patients who had concomitant MV and TV surgery from 2009 to 2019. We grouped the patients into Group 1 (n = 345; rheumatic MV) and Group 2 (n = 135; degenerative MV). Propensity score matching identified 104 matched pairs., Results: There was no significant difference in survival between groups before (p = .46) or after matching (p = .09). There was no difference in the recurrence of moderate TR (subdistributional hazard ratio [SHR]: 1.22 [0.77-1.95], p = .40). Recurrent TR was significantly associated with the preoperative TR grade (SHR: 1.8 [1.5-2.16], p < .001); body mass index (SHR: 1.05 [1.03-1.08], p < .001), and the use of flexible versus rigid TV prosthesis (SHR: 0.64 [0.41-0.99], p = .042). Recurrence of TR was higher with MV replacement compared with repair (SHR: 1.69 [1.03-2.78], p = .038). The change in the degree of TR did not differ between groups before matching (OR: 0.77 [0.56-1.04], p = .09) or after matching (OR: 0.98 [0.67-1.44]; p = .93)., Conclusion: Outcomes of concomitant TR repair were comparable in rheumatic and degenerative mitral pathology. Type of the TV prosthesis and TR grade affected TR recurrence. MV repair could be associated with a lower recurrence of TR compared with replacement., (© 2022 Wiley Periodicals LLC.)

Background: The ideal tricuspid valve annuloplasty (TVA) prosthesis is controversial. This study aimed to compare the effect of rigid versus flexible TVA prostheses on long-term outcomes after repair of functional tricuspid regurgitation (FTR)., Methods: We included 713 patients who had repair of FTR from 2009 to 2017. Patients were divided into 2 groups according to the type of TVA prosthesis. Group 1 (n = 104) included patients who had repair using rigid rings; group 2 (n = 609) included patients with flexible bands. Median age was 53.5 years (25th through 75th percentiles; range, 42.5-62 years) in group 1 versus 56 years (range, 45-65 years) in group 2 (P = .11). Propensity score matching identified 91 matched pairs for comparison., Results: In the matched pairs, operative mortality was identical (4 in both groups [4.4%]; P ˃ .99). Median follow-up was 55 months (range, 28-83 months). The cumulative incidence of moderate or higher tricuspid regurgitation (TR) in the presence of death as a competing risk was higher in group 2 (subdistribution hazard ratio = 1.63, P = .019; and subdistribution hazard ratio = 1.6, P = .099 before and after matching, respectively). There was a trend of higher pacemaker insertion in group 1 (7 [7.69%] versus 3 [3.3%]; P = .34), which did not reach statistical significance after matching. There was no significant change in the degree of TR over time between groups (odds ratio = 1.21, P = .53; and odds ratio = 1.75, P = .21 before and after matching, respectively)., Conclusions: Both types of TVA prostheses had comparable efficacy in managing FTR; however, freedom from moderate or more TR was higher in the rigid ring group., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Data on mitral valve replacement (MVR) in young children is still limited. Our objective was to evaluate MVR in children below 5 years and identify factors affecting the outcomes. This retrospective study included 29 patients who had MVR from 2002 to 2020. We grouped the patients into two groups according to their age: age ≤ 24 months (n = 18) and > 24 months (n = 11). Primary cardiac diagnoses were Shone complex (n = 7; 24%), isolated congenital mitral valve abnormality (n = 11; 38%), and complete atrioventricular septal defect (n = 3; 10%). The median age was 19 month (25th-75th percentile: 11-32) and 59% were females (n = 17). The hemodynamic lesions were mitral regurgitation in 66%, mitral stenosis in 10%, and combined mitral stenosis and regurgitation in 24% of the patients. St. Jude mitral valve was the most common valve implanted (n = 19, 66%), followed by CarboMedics in 21% of the patients (n = 6). The mitral valve was implanted in the supra-annular position in 6 cases (21%). Preoperative and operative data were comparable between both groups. There was no association between valve size and position with postoperative heart block (P > 0.99, for both). The median follow-up duration was 19.4 months (8.6-102.5). Nine patients had mitral valve reoperation, six had MVR, and three had clot removal from the mitral valve. There was no effect for age group on reoperation (SHR 0.89 (95% CI 0.27-2.87), P = 0.84). Valve size significantly affected reoperation (SHR 0.39 (95% CI 0.18-0.87), P = 0.02). The supra-annular position was associated with an increased risk of reoperation (SHR 3.1 (95% CI 1.003-9.4), P = 0.049). There was no difference in survival according to the age (Log-rank P = 0.57) or valve size (Log-rank P = 0.66). Mitral valve replacement in children is associated with low morbidity and mortality. The risk of reoperation could be affected by the valve size and position rather than the age., (© 2021. The Author(s).)

Background: The number of MtraClip procedures is increasing, and consequently, the number of patients with residual or recurrent mitral regurgitation (MR). We aimed to characterize patients who had residual versus recurrent MR after MitraClip and report the outcomes of different treatment strategies., Methods: From 2012 to 2020, 167 patients had MitraClip. Out of them, 16 patients (9.5%) had residual mitral regurgitation (MR), and 27 patients (16.2%) had recurrent MR., Results: The median age in patients with residual MR was 67.5 (59-73) years versus 69 (61-78) years in patients with recurrent MR (p = .87). The etiology of mitral valve disease was functional in 13 patients (81.3%) and 22 patients (84.6%) in residual versus recurrent MR patients (p > .99). Cardiac resynchronization therapy-defibrillator implantation was higher in patients with residual MR (p = .02). Survival was 93.7% at 1 year, 76.4% at 3 years versus 92.5% at 1 year, and 84.5% at 3 years in residual versus recurrent MR (p = .69). Two patients in the residual MR group had re-clip, and three had surgery, and in the recurrent MR group, one patient had re-clip, and two patients had surgery (p = .23). Patients who had re-clip were older (p = .09). Surgery was associated with 100% survival at 5 years, 63% after medical therapy and the worst survival was reported in re-clip patients (p = .007)., Conclusion: The outcomes of patients with residual versus recurrent mitral regurgitation after MitraClip were comparable. Survival could be improved with surgery compared with medical therapy and re-clip., (© 2021 Wiley Periodicals LLC.)

Background: Rivaroxaban has been recently introduced for the management of non-valvular intra-cardiac thrombosis with variable results. We aimed to compare the results of the off-label use of rivaroxaban versus warfarin in the management of patients with left ventricle (LV) thrombus. This research is a retrospective study conducted on 63 patients who had LV thrombus from January to December 2016. We compared patients treated with warfarin (n=35) to patients who had rivaroxaban (n=28), and study outcomes were time to thrombus resolution, bleeding, stroke, and mortality., Results: The median duration of treatment was 9.5 (25th-75th percentiles: 6-32.5) months for rivaroxaban and 14 (3-41) months for warfarin. Thrombus resolution occurred in 24 patients in the warfarin group (68.6%) and 20 patients in the rivaroxaban group (71.4%). The median time to resolution in the warfarin group was 9 (4-20) months and 3 (2-11.5) months in the rivaroxaban group. Thrombus resolution was significantly faster in patients on rivaroxaban (p= 0.019). Predictors of thrombus resolution were thrombus surface area (HR: 1.21; CI 95% (1.0-1.46); p= .048) and the use of rivaroxaban (HR: 1.92; CI 95% (1.01-3.65); p= 0.048). There was no difference in stroke, bleeding, and mortality between both groups., Conclusion: Rivaroxaban was as effective and safe as warfarin in managing patients with left ventricle thrombus. Larger randomized clinical trials are recommended to confirm our findings.