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BACKGROUND/OBJECTIVES To assess the course and prediction of basic activities of daily living (ADL) function in patients after transcatheter aortic valve implantation (TAVI). DESIGN This was a prospective cohort study. SETTING The setting was a single academic center in Switzerland. PARTICIPANTS Participants included individuals aged ≥70 years (n = 330) undergoing TAVI. MEASUREMENTS A frailty index (based on geriatric assessment) and cardiac risk scores (EuroSCORE, Society of Thoracic Surgeons [STS] score) were determined in patients before TAVI. Basic ADL function was measured with patient or proxy interviews at baseline and 1-year follow up. We used logistic regression models to investigate the association between baseline factors and functional decline. RESULTS At 1-year follow up, 229 (69.4%) of the 330 patients had stable or improved basic ADL function, 49 (14.8%) experienced a decline in basic ADL function, and 52 (15.8%) died. The frailty index, but not cardiac risk scores, significantly predicted decline in basic ADL function. Among the 34 surviving very frail patients, 12 (35.3%) experienced a functional status decline, and the remaining 22 (64.7%) had stable or improved functional status at 1-year follow up. CONCLUSION This study confirms that a frailty index, and not cardiac risk scores, identifies patients at an increased risk of functional status decline after TAVI. Identifying patients with a high frailty index before TAVI is clinically relevant as these patients might benefit from targeted geriatric management and rehabilitation after TAVI. However, based on current data, it is not justified to use information on frailty status as the criterion for identifying patients in whom TAVI might be futile. Although the probability of poor outcome is high, very frail patients also have a high probability of favorable long-term functional outcome.

OBJECTIVE We sought to evaluate the feasibility and safety of carotid access transcatheter aortic valve replacement (TAVR) by performing a meta-analysis of published cases. BACKGROUND Several case series and regional data have provided initial basis for carotid access TAVR in patients with prohibitive femoral approach. We performed this meta-analysis to provide further evidence of feasibility and safety of carotid TAVR. METHODS We searched PubMed, EMBASE, CINAHL, and Cochrane CENTRAL for any study on carotid access TAVR involving ⩾5 patients since inception till March 1, 2020. Random-effects model was used to compute overall effects. The outcomes analyzed were all-cause mortality, Transient ischemic attack (TIA)/stroke, need for permanent pacemaker (PPM) implantation, pericardial tamponade, access site complications, major bleeding, and length of stay. RESULTS There was a total of 17 retrospective studies (n = 2082) with a median follow-up of 1 month. Mean age of the patient was 80 years. Mean Euroscore and STS scores were 15 ± 6.2 and 7.9 ± 3.3, respectively. The procedural success rate was 99%. The rate of all-cause mortality was 6.7% (range 4.6-9.7%, p

Objectives To investigate 4-year, post-transcatheter aortic valve implantation (TAVI) survival and predictors of survival by sex, in a real-world cohort that underwent transfemoral TAVI with SAPIEN 3 transcatheter heart valve. Background Previous TAVI investigations of first-generation devices demonstrated an early- to mid-term survival advantage in women compared with men. Methods SOURCE 3 (SAPIEN 3 Aortic Bioprosthesis European Outcome) is a post-approval, multicentre, observational registry. Patients (N = 1,694, 49.2% women, age 81.7 ± 6.7 years) with severe aortic stenosis and high surgical risk (logistic EuroSCORE 17.8%) underwent TAVI between 2014 and 2015. Kaplan-Meier event estimates were used to determine mortality by sex. Predictors of overall mortality were identified using a cox multivariate proportional hazard model. Results At 4 years, women had lower all-cause mortality than men (36.0 vs 39.7%; p = .0911; HR: 0.87 [95% CI: 0.75-1.02]). No difference was observed for cardiac mortality between women 24.2% and men 24.7% (p = .76; HR: 0.97 [95% CI: 0.79-1.19]). When adjusted for baseline characteristics (age, height, weight, NYHA functional class, renal insufficiency, EuroScore, and tricuspid regurgitation), sex had no impact on mortality. Conclusions In this large, real-world cohort, all-cause mortality trended lower in women than men at 4 years post TAVI; however, several baseline factors, but not sex, were predictors of mortality. No difference between sexes was observed for cardiovascular mortality.

Background Interventional closure of the left atrial appendage (LAA) is an alternative option to stroke prophylaxis, particularly in multimorbid patients with a high risk of bleeding under oral anticoagulation. Due to the multiple comorbidities, the prognosis of patients is reduced, and the clinical benefit of the procedure is therefore questionable in the individual patient. Hypothesis The present study aims to identify independent preprocedural risk factors to improve risk stratification in these highly selected patients. Methods This study consecutively included 128 patients who received an interventional LAA occlusion with Amplatzer device (St Jude Medical, St Paul, Minnesota). The preinterventional risk assessment was performed with the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) II. The primary endpoint was all‐cause mortality. Secondary endpoints were thromboembolic events and severe bleeding. Results During a follow‐up of 781 ± 498 days the primary endpoint (all‐cause mortality) was reached in 35 patients (27%). The only independent predictor of mid‐term mortality was a logistic EuroSCORE II > 2% (Hazard risk [HR] 4.55, confidence interval [CI] 1.599‐12.966, P = .005). In our study, 33 patients (26%) suffered from end‐stage renal disease which was not associated with increased mortality (P = .371), increased thromboembolic events (P = .475), or severe bleeding (P = .613). Conclusions In patients undergoing interventional LAA occlusion, preprocedural assessment of logistic EuroSCORE II provide independent prognostic information. This parameter might help to improve risk stratification in these highly selected patients. In contrast, terminal renal failure was not associated with a significantly worse outcome.

Background Both coronavirus disease (COVID-19) and cardiac surgery have a negative impact on pulmonary function. This study aimed to determine the postoperative respiratory outcomes of patients with COVID-19 who underwent cardiac surgery. Methods In this retrospective study, we reviewed and analyzed the patient characteristics and clinical data of 25 asymptomatic patients with COVID-19 who underwent urgent or emergency cardiac surgery at Tehran Heart Center Hospital, Iran, between 29 February and 10 April 2020. Results The mean age, EuroSCORE, and body mass index were 57.3 ± 15.1 years, 6.65 ± 1.29, and 25.7 ± 3.7 kg/m2 , respectively. Four patients underwent off-pump cardiac surgery and 21 underwent on-pump cardiac surgery with a median cardiopulmonary bypass time of 85 minutes (interquartile range (IQR, 50-147). The overall mortality rate and the length of stay in the intensive care unit (ICU) were higher compared to those of a propensity-matched group of patients who underwent cardiac surgery in the pre-COVID era. The median intubation time was 13 hours (IQR, 9.5-18), which was comparable to that of pre-COVID cardiac surgery patients. The readmission rate to the ICU was 16%. In this ICU readmitted group, the mean oxygen index, FiO2 , and mortality rate were higher and the PaO2 /FiO2 ratio was lower than those of the nonreadmitted patients. Conclusions Although early respiratory outcomes of asymptomatic COVID-19 patients who underwent early cardiac surgery appeared to be satisfactory, compared to the propensity-scored matched non-COVID group, the postoperative outcomes were worse, especially in the ICU readmitted patients. We suggest postponing cardiac operations unless the patient requires emergency surgery.

BACKGROUND Handgrip strength (HGS) is a potential method to approximate perioperative risk in cardiothoracic surgery patients and correlates well with European System for Cardiac Operative Risk Evaluation (EuroSCORE) values. This study aimed to characterize the functional capacity in preoperative cardiac surgery patients through HGS. METHODS This cross-sectional study investigated patients aged 18 years or older. The collected data included surgical risk (EuroSCORE), body mass index (BMI), body composition (electrical bioimpedance), and HGS. RESULTS The mean age of the 278 participants was 62.1 ± 11.2 years, of whom 61.5% were male, 43.2% were overweight, and 26.3% were obese. The main types of surgery were myocardial revascularization (50%) and valve replacement (40.6%). HGS values differed between genders in all age groups (P < 0.05) and were approximately 40% lower than reference values for healthy individuals. The values differed with respect to operative risk (P = 0.003) and had a moderate positive correlation with fat-free mass (rs = 0.435, P < 0.001), a moderate negative correlation with fat mass (rs = -0.447, P < 0.001), and weak negative correlations with age (rs = -0.270, P < 0.01) and EuroSCORE (rs = -0.316, P < 0.01). CONCLUSIONS The HGS values of preoperative elective cardiac surgery patients were below reference values for healthy individuals, were lower in male patients, were positively correlated with fat-free mass, and were negatively correlated with fat mass, age, and operative risk. Its preoperative use in these patients is an attractive complementary method of risk assessment in clinical practice.

Journal of parenteral and enteral nutrition : JPEN 43(6), 768-779 (2019). doi:10.1002/jpen.1486, Published by Wiley, Hoboken, NJ

OBJECTIVES To evaluate the impact of baseline left ventricular ejection fraction (LVEF) and its interaction with low-gradient aortic stenosis (LGAS) on all-cause mortality after transfemoral aortic valve implantation (TF-TAVI). METHODS We reviewed mortality data of 624 consecutive single center TF-TAVI patients and categorized LVEF according to current ASE/EACVI recommendations (normal, mildly-, moderately-, and severely abnormal). RESULTS Baseline LVEF was normal in 336 (53.8%), mildly abnormal in 160 (25.6%), moderately abnormal in 91 (14.6%), and severely abnormal in 37 (5.9%) patients, and 1-year mortality was 19%, 17%, 23%, and 43% (P = 0.002), respectively. Patients with LGAS had a similar 1-year mortality compared to those without LGAS in groups with normal (19% vs 19%, P = 0.899) and mildly abnormal LVEF (16% vs 17%, P = 0.898). One-year mortality of patients with LGAS was significantly greater than in those without LGAS in presence of moderately abnormal LVEF (31% vs 11%, P = 0.022), and it was numerically greater than in those without LGAS in presence of severely abnormal LVEF (48% vs 25%, P = 0.219). In multivariate analysis, only the combination of moderately/severely abnormal LVEF and LGAS predicted increased 1-year mortality (HR: 2.12, 95% CI: 1.4-3.2, P

Objectives The ability of the Society of Thoracic Surgeons (STS) and European System for Cardiac Operative Risk Evaluation (EuroSCORE)-2 scores to predict outcomes after transcatheter aortic valve replacement (TAVR) is insufficient. Frailty and serum albumin as a frailty marker were shown to correlate with prognosis after TAVR. We sought to evaluate the additive value of serum albumin to STS and EuroSCORE-2 scores to predict mortality in individuals undergoing TAVR. Design Retrospective analysis. Setting Tertiary-care hospital prospective registry. Participants Individuals who underwent TAVR (N = 426). Measurements We compared survival rates according to median baseline albumin levels (4 g/dL), STS score (4.5%), and EuroSCORE-2 (3.45%). Participants were divided into four groups according to median serum albumin and median STS and EuroSCORE-2 scores (high vs low), and 1-year survival rates were compared. A category-free net reclassification index (NRI) was calculated to compare the ability of a model of STS or EuroSCORE-2 alone to classify mortality risk with and without the addition of baseline serum albumin. Results Participants with low albumin levels had higher mortality (hazard ratio (HR) = 3.03, 95% confidence interval (CI) = 1.66–5.26, P < .001). Participants with low serum albumin and a high STS (HR = 4.55, 95% CI = 2.21–9.38, P < .001) or EuroSCORE-2 (HR = 2.72, 95% CI = 1.48–5.06, P = .001) score had higher mortality. Using NRI analysis, a model that included albumin in addition to STS correctly reclassified 42% of events (NRI = 0.58) and a model that included albumin in addition to EuroSCORE-2 correctly reclassified 44% of events (NRI = 0.64). Conclusion Serum albumin, as a marker of frailty, can significantly improve the ability of STS and EuroSCORE-2 scores to predict TAVR-related mortality.

Background Risk prediction in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) is challenging. Development of novel markers for patient risk assessment is of great clinical value. Deceleration capacity (DC) of heart rate is a strong risk predictor in post-infarction patients. Hypothesis DC provides prognostic information in patients undergoing TAVI. Methods We enrolled 374 consecutive patients with severe AS undergoing TAVI. All patients received 24-hour Holter recording or continuous heart-rate monitoring to assess DC before intervention. Primary endpoint was all-cause mortality after 1 year. Results Forty-nine patients (13.1%) died within 1 year. DC was significantly lower in nonsurvivors than in survivors (1.2 ± 4.8 ms vs 3.3 ± 2.9 ms; P < 0.001), whereas the logistic EuroSCORE and EuroSCORE II were comparable between groups (logistic EuroSCORE: 27.3% ± 17.0% vs 22.9% ± 14.2%; P = 0.122; EuroSCORE II: 8.0% ± 6.9% vs 6.7% ± 4.8%, P = 0.673). One-year mortality in the 116 patients with impaired DC (

Background: Selection of valve and procedural anticoagulant type may impact bleeding and vascular complications in transfemoral transcatheter aortic valve replacement (TAVR). We sought to compare outcomes by valve [balloon expandable (BE) or non-BE] and anticoagulant [bivalirudin vs. unfractionated heparin (UFH)] type from the BRAVO-3 trial. Methods: BRAVO-3 was a randomized multicenter trial included 500 BE-TAVR and 282 non-BE TAVR patients, randomized to bivalirudin vs. UFH. Selection of valve type was at the discretion of the operator and randomization was stratified according to device type. Total follow up was to 30 days. We examined the incidence of Bleeding Academic Research Consortium (BARC) type ≥3b bleeding, major vascular complications and all ischemic outcomes at 30-days. Outcomes were adjusted using logistic regression analysis. Results: Of the trial cohort treated, 63.9% were treated with BE valves (n=251 bivalirudin vs. n=249 UFH) and 36.1% with non-BE valves (n=140 bivalirudin vs. n=142 UFH). Patients treated with non-BE valves were older, with higher euroSCORE I. At 30 days, there were non-significant differences between the two valve types with a trend for higher adjusted risk of all-cause mortality (HR 2.07, 95% CI 0.91-4.70, p = 0.084) and major vascular complications (HR 1.78, 95% CI 0.97-3.26, p = 0.062) with non-BE compared to BE valves. A significant interaction was observed between valve and anticoagulant type, with lower risk of major vascular complications with bivalirudin compared to UFH in non-BE TAVR (p-interaction = 0.039). Conclusions: Majority of patients in the BRAVO 3 trial received BE valves. At 30-days, there were non-significant differences with a tendency for greater death and major vascular complications with non-BE vs. BE valves. A significant interaction was observed between valve type and procedural anticoagulant for lower risk of major vascular complications with bivalirudin versus UFH in non-BE TAVR. This article is protected by copyright. All rights reserved.

Background: Prior studies have suggested that patients with atrial fibrillation (AF) undergoing transcatheter aortic valve replacement (TAVR) are at higher risk for adverse cardiovascular events. Whether procedural bivalirudin compared to unfractionated heparin (UFH) has a beneficial effect on early outcomes in these patients is unknown. We examined for the effect of baseline or new-onset AF within 30 days of TAVR and explored for the effect of bivalirudin vs. UFH by AF status, on 30-day outcomes from the BRAVO 3 trial. Methods: The BRAVO-3 trial multicenter randomized trial included 802 patients undergoing transfemoral TAVR randomized to bivalirudin or UFH. We compared AF and no-AF groups and examined for 30-day Bleeding Academic Research Consortium (BARC) type ≥3b bleeding, major vascular complications and all ischemic endpoints. Adjusted outcomes were analyzed using logistic regression methods. Results: Of the study population, 41.4% (n=332) patients had baseline or new-onset AF within 30 days of TAVR, whereas 58.6% (n= 470) had no AF. Patients with AF had greater prevalence of renal dysfunction, lower left ventricular ejection fraction and higher euroSCORE I compared to their counterparts without AF. Among AF and no-AF patients, there were no significant baseline differences between bivalirudin and UFH groups. At 30 days the incidence of death (6.0% vs. 4.5%, p = 0.324) and stroke (3.9% vs. 2.6%, p = 0.274) was similar in AF vs. no-AF patients. However, new-onset AF (n=38) was associated with significantly greater crude risk of 30-day stroke compared to no AF (HR 4.49, 95% CI 1.37-14.67). Regardless of AF status, there were no differences in 30-day death (p-int = 0.652) or stroke (p-int= 0.066) by anticoagulation type. Conclusions: Prior or new-onset AF within 30 days of transfemoral TAVR is noted in more than one-third of patients. Despite greater baseline comorbidities than non-AF patients, AF was not associated with greater risk of adjusted 30-day outcomes. In the BRAVO 3 trial, early outcomes were similar regardless of anticoagulant strategy in each group. This article is protected by copyright. All rights reserved.

Introduction Soluble ST2 (sST2) has been introduced as a novel biomarker in patients suffering from heart failure for risk stratification. In this study we sought to investigate whether sST2 is useful for risk stratification and prediction of mortality in patients undergoing transcatheter aortic valve implantation (TAVI). Materials and Methods 274 patients undergoing TAVI were included in this study (149 female; age 80.50±0.51 years; EUROSCORE 25±1; STS Score 3.8±0.2). Plasma samples were obtained pre-interventional and analyzed for sST2. Patients were followed-up one month and one year after TAVI. Results In a Cox regression analysis, sST2 plasma concentration was associated with increased mortality (changes per pg/ml sST2 concentration; HR 1.00006 95% (1.00004-1.00009); p

Although transcatheter aortic valve implantation (TAVI) has been indicated for patients with high surgical risk, indications for or against the procedure become more difficult as vascular access becomes more proximal and/or invasive in order to accommodate patients with even higher risks. We compared preoperative factors including the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Society of Thoracic Surgeons Predicted Risk of Mortality (STS) score with postoperative survival in 195 patients undergoing TAVI during 2.5 years (January 2010 to June 2012), when vascular access routes were developed from iliofemoral (IL/Fm access, n = 149), axillo-clavicular, apical, and direct aortic approaches (alternative access, n = 46). Logistic regression analyses showed that alternative access was associated with reduced 30-day survival (P = 0.024), while high surgical risk (>15% in both EuroSCORE and STS score) was associated with reduced 1-year survival (P = 0.046). Thus, patients treated via IL/Fm access had acceptable outcome regardless of preoperative risk levels while patients with low surgical risk ( 15%) requiring alternative access, had a prohibitive risk in our experience, they might have been considered untreatable or not amenable even to TAVI and offered medical or alternative managements.

Background Women comprise almost 50% of patients undergoing transcatheter aortic valve replacement (TAVR) and previous studies have indicated higher rates of procedural complications and bleeding in women compared to men. It is unknown whether men and women demonstrate a differential response to bivalirudin versus unfractionated heparin (UFH) in TAVR. We sought to evaluate outcomes by sex and type of anticoagulant from the Bivalirudin Versus Heparin Anticoagulation in Transcatheter Aortic Valve Replacement (BRAVO-3) trial of transfemoral TAVR. Methods BRAVO-3 was a randomized multicenter trial comparing transfemoral TAVR with bivalirudin versus UFH (31 centers, n = 802). The primary endpoint was 48 h major bleeding defined as Bleeding Academic Research Consortium (BARC) type ≥3b. Major adverse cardiovascular events (MACE) were a composite of 30-day death, myocardial infarction, or stroke. Net adverse cardiovascular events (NACE) were a composite of BARC ≥3b bleeding or 30-day MACE. We examined the outcomes in men and women. Results The total cohort included 49% women (n = 391, 195 received bivalirudin and 196 UFH) and 51% men (n = 411, 209 received bivalirudin and 202 UFH). Women were older than men with fewer comorbidities including coronary artery disease, atrial fibrillation, diabetes but similar EuroSCORE I. Women received smaller sheath and device sizes compared with men without differences in the use of vascular closure devices. At 48-hr post-TAVR there was no difference in bleeding or vascular complications in women compared to men. The use of bivalirudin did not result in significantly lower bleeding at 48 hr or 30-days compared to UFH. Conclusions There was no difference in early outcomes with bivalirudin versus UFH in men or women undergoing contemporary TAVR. © 2016 Wiley Periodicals, Inc.

OBJECTIVES To evaluate the long-term prognostic value of risk scores in the setting of drug-eluting stent (DES) implantation for uLMCA. BACKGROUND Data on the prognostic value of novel risk scores developed to select the most appropriate revascularization strategy in patients undergoing DES implantation for uLMCA disease are relatively limited. METHODS The study represents a patient-level pooled analysis of the ISAR-LEFT-MAIN (607 patients randomized to paclitaxel-eluting or sirolimus-eluting stents) and the ISAR-LEFT-MAIN-2 (650 patients randomized to everolimus-eluting or zotarolimus-eluting stents) randomized trials. The Syntax Score (SxScore) as well the Syntax Score II (SS-II), the EuroSCORE and the Global Risk Classification (GRC) were calculated. The primary outcome was all-cause mortality. RESULTS At a mean follow-up of 3 years there were 160 deaths (12.7%). The death-incidence was significantly higher in the upper tertiles than in the intermediate or lower ones for all risk scores (log-rank test P

Background Acute kidney injury (AKI) is a relatively common complication following CABG and is associated with adverse outcomes. Nonetheless, we hypothesized that the majority of patients make a good long-term recovery of their renal function. We studied the incidence and risk factors of AKI together with renal recovery and long-term survival in patients who developed AKI following CABG. Methods This nationwide study examined AKI among 1754 consecutive patients undergoing CABG in 2001–2013. AKI was defined according to the KDIGO criteria. Results Postoperatively 184 (11%) patients developed AKI; 121 (7%), 27 (2%), and 36 (2%) at stages 1, 2, and 3, respectively. AKI was an independent risk factor for chronic kidney disease (CKD) and AKI patients had worse post-operative outcomes. Lower pre-operative glomerular filtration rate, higher EuroSCORE and BMI, diabetes, reoperation, and units of red blood cells transfused were independent risk factors of AKI. At post-operative day 10, renal recovery rates, defined as serum creatinine ratio

Objectives To evaluate the feasibility and safety of direct transcatheter aortic valve implantation (TAVI) by the transfemoral approach without balloon pre-dilatation using the Edwards SapienXT valve. Background TAVI is established in selected high-risk patients with severe aortic stenosis. Balloon aortic valvuloplasty (BAV) is recommended prior to valve implantation, but may contribute to procedural risk. It is unknown whether this is necessary for successful passage and deployment of the device. Methods 81 patients (mean age 84 [95%CI:82–85.8], 62% male, median EuroScore 22.8% [95%CI:20.5–27]) undergoing transfemoral TAVI (35 by direct implantation [direct group]; 46 with balloon pre-dilatation [balloon group]) between 2010 and 2013 were analyzed for efficacy and safety endpoints. Results Procedural success was 100%. Pre and post-procedural peak gradients in the direct group were 66mmHg (95%CI:59–72.8) and 14mmHg (95%CI:12–17.8)(P

BACKGROUND Recent animal studies suggest that transfusion of plasma from young donors reverses age-related neurologic and cardiac changes in older recipients. Associations between age of blood product donors and corresponding outcomes in recipients have not been studied in humans. Therefore, our primary objective was to examine this relationship between donor age and recipient outcomes among patients that received plasma during and after coronary artery bypass grafting (CABG) surgery. STUDY DESIGN AND METHODS This retrospective cohort included patients undergoing CABG surgery who received plasma during or after surgery. All plasma units transfused were evenly divided into tertiles based on the plasma donor age (17-37, 38-50, and 51-86 years), and CABG patients receiving all perioperative plasma within a single donor tertile were studied. Patient demographics and outcomes including mortality, length of stay (LOS), and acute kidney injury (AKI) were measured. RESULTS Overall, 1306 patients (24% of 5339) received American Red Cross plasma perioperatively, with a median dose of 2 units. In a multivariate model of 1-year mortality, transfusion of a greater number of plasma units (p = 0.0007) and EuroSCORE (p

Summary It is widely accepted that the performance of the operating surgeon affects outcomes, and this has led to the publication of surgical results in the public domain. However, the effect of other members of the multidisciplinary team is unknown. We studied the effect of the anaesthetist on mortality after cardiac surgery by analysing data collected prospectively over ten years of consecutive cardiac surgical cases from ten UK centres. Casemix‐adjusted outcomes were analysed in models that included random‐effects for centre, surgeon and anaesthetist. All cardiac surgical operations for which the EuroSCORE model is appropriate were included, and the primary outcome was in‐hospital death up to three months postoperatively. A total of 110 769 cardiac surgical procedures conducted between April 2002 and March 2012 were studied, which included 127 consultant surgeons and 190 consultant anaesthetists. The overwhelming factor associated with outcome was patient risk, accounting for 95.75% of the variation for in‐hospital mortality. The impact of the surgeon was moderate (intra‐class correlation coefficient 4.00% for mortality), and the impact of the anaesthetist was negligible (0.25%). There was no significant effect of anaesthetist volume above ten cases per year. We conclude that mortality after cardiac surgery is primarily determined by the patient, with small but significant differences between surgeons. Anaesthetists did not appear to affect mortality. These findings do not support public disclosure of cardiac anaesthetists' results, but substantially validate current UK cardiac anaesthetic training and practice. Further research is required to establish the potential effects of very low anaesthetic caseloads and the effect of cardiac anaesthetists on patient morbidity.

Introduction Implantation of transcatheter heart valves (THV) into degenerated surgical valves is an emerging therapy for selected high-risk patients. Although, CE mark of most THV is limited for native aortic valvular stenosis, transcatheter valve implantation into degenerated bioprostheses, even in mitral position is very intriguing. Methods and Results After placement of a cerebral protection device (Claret Sentinel®), three consecutive patients (age, 79.0 ± 6.1; log EuroSCORE I: 33.3 ± 9.2%) with a degenerated mitral bioprosthesis were treated by transapical implantation of the Lotus® valve (Boston Scientific Inc.). In addition, a SwanGanz catheter was introduced in the pulmonary artery for hemodynamic assessments all patients. Procedural success was 100%. Valve implantation was performed without rapid ventricular pacing. Resheating was performed in two patients due to suboptimal initial positioning. Invasive online hemodynamics revealed stable blood pressure in all patients. After Lotus® valve implantation, valvular mitral regurgitation was completely eliminated in all patients. One patient had a mild paravalvular leak of the surgical bioprosthesis, which was present before implantation. Invasive right and left heart hemodynamics showed an immediate improvement after Lotus® valve implantation. Mean mitral surface area (2.1 ± 0.2 cm2) and mean gradient (3.7 ± 2.1 mm Hg) demonstrated satisfactory results. All patients were immediately extubated and discharged from the hospital without any adverse event. Conclusions This study demonstrates for the first time the feasibility of transapical Lotus® Valve implantation in degenerated mitral bioprostheses. The controlled mechanical Lotus® valve expansion with remarkably stable hemodynamics throughout the procedure offers a new and valuable treatment option. © 2015 Wiley Periodicals, Inc.

BACKGROUND Although numerous studies have demonstrated the feasibility of cardiac surgery for blood refusal patients, few studies match to controls, and fewer examine cost. This historical cohort study aims to compare costs and outcomes after cardiac surgery in Jehovah's Witness patients who refuse blood transfusion with a group of matched patients accepting transfusion. STUDY DESIGN AND METHODS A retrospective database review was performed to find all patients having cardiac surgery who refused blood products from January 2005 to July 2012 at Duke University Medical Center. These 45 patients were closely matched 1:2 with controls who accepted transfusion based on characteristics likely to influence transfusion. Cost from day of surgery to hospital discharge and other outcome data (length of stay [LOS], discharge hemoglobin [Hb], acute kidney injury) were analyzed retrospectively. RESULTS Forty-five Witnesses having cardiac surgery were temporally matched to two controls having the same surgery. Median euroSCORE was the same in both groups (6.0, p = 0.9981). In the matched-pairs comparison of cost, there was no significant difference in total cost for Witnesses and controls. There was no difference in intensive care unit LOS (median, 1 day, both groups) or total LOS (median, 9 days for Witnesses vs. 7 days for controls). Mean Hb at discharge was higher in Witnesses than in controls (11.7 g/dL vs. 9.8 g/dL, p

Objective: To assess midterm (3 years) clinical outcomes of transcatheter aortic valve implantation (TAVI) in Belgium using the Edwards SAPIEN valve or the Medtronic CoreValve transcatheter heart valve (THV). Background: Medium and long term follow-up data of both THVs are still relatively scarce, although of great clinical relevance for a relatively new but rapidly expanding treatment modality. Therefore, reporting mid- and long term clinical outcome data, coming from large “real world” national registries, remains contributive. Methods: Between December 2007 and March 2012, 861 “real world” patients who were not candidates for surgical aortic valve replacement as decided by the local heart teams, underwent TAVI at 23 sites. Eleven sites exclusively used SAPIEN THV (n 5460), while 12 exclusively used CoreValve THV (n 5401). Differences in clinical outcomes by valve system were assessed, according to access route and baseline EuroSCORE risk profile ( 20%: high risk). Results: Overall cumulative survival at 3 years was 51% for SAPIEN vs. 60% for CoreValve (P 50.021). In transfemorally treated patients, SAPIEN and CoreValve had similar survival at 3 years for each of the baseline EuroSCORE cohorts (low risk: 72% vs. 76%, P 50.45; intermediate risk: 62% vs. 59%, P 50.94; high risk: 48% vs. 53%, P 50.65). Conclusion: Cumulative midterm 3 year survival after transfemoral TAVI in “real world” patients refused for surgery with similar baseline EuroSCORE risk profile is not different between SAPIEN or CoreValve. V C 2015 Wiley Periodicals, Inc.

Objectives To assess outcomes for patients undergoing transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement but with less than high risk. Background While there is abundant data for high risk patients there is insufficient data for reduced risk. Methods Patients undergoing TAVI or SAVR between 2007 and 2012 in Karlsruhe were considered. They were assessed by cardiac computed tomography, transoesophageal echocardiogram, and logistic EuroSCORE I (ES) and groups compared using Propensity Score Matching. Results The mean ES was 10.1±2.8 in the TAVI group (n = 419) and 5.7 ± 3.2 in the SAVR group (n = 722; P

Objectives To describe the feasibility and safety of transcatheter aortic valve implantation (TAVI) with a visiting on-site cardiac surgery program for surgical back-up. Background Both European and American guidelines recommend institutional cardiac surgery back-up for TAVI. However, the conversion to cardiac surgery is very rare, many complications of TAVI can be managed by catheter techniques and a visiting team can also provide surgical stand-by. Therefore, the need for institutional cardiac surgery (by a surgeon who routinely performs conventional surgical valve replacement at the institution performing TAVI) has been questioned. Methods A retrospective review of consecutive TAVI cases with visiting on-site cardiac surgery was performed. Key demographic, echocardiographic, and procedural data were collected prospectively. Results A total of 97 patients (81.9 ± 6.3 years) with high-risk criteria (log Euroscore 21.6 ± 14.4, chronic renal failure 39.2%, severe systolic dysfunction 24.7%) underwent TAVI with visiting on-site cardiac surgery at our institution. Local anesthesia with or without conscious sedation was used in 94.8% of patients. Procedural technical success was 100%, with 2 episodes of tamponade (both treated with pericardiocentesis) and a 16.5% vascular complication rate (all treated conservatively or percutaneously). Thirty-day mortality was 3.1%, with 5.2% rate of stroke and 8.2% rate of major bleeding. There were no conversions to surgery. Conclusions TAVI can be done safely in the setting of a hospital with visiting on-site cardiac surgery. This requires careful patient selection, experienced operators and surgeons in experienced centers with well-established criteria and processes of care. In this setting, it may be an option for hospitals without institutional cardiac surgery. (J Interven Cardiol 2015;28:76–81)

Background Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and predicts increased morbidity and mortality. Identification of patients at high risk of POAF with the help of circulating biomarkers may enable early preventive treatment but data are limited, especially in contemporary surgical patients. Methods Plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) were measured at enrolment, on the morning of cardiac surgery, at end surgery, and 2 days postsurgery in 562 patients undergoing cardiac surgery, randomized to perioperative supplementation with oral fish oil or placebo in the Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation trial (OPERA). The primary endpoint was incident POAF lasting ≥ 30 s, centrally adjudicated and confirmed electrocardiographically. Results Higher levels of NT-proBNP and hs-cTnT before surgery were associated with older age, renal or cardiac dysfunction and EuroSCORE. NT-proBNP peaked on postoperative day 2 (2172 [1238–3758] ng/L, median [Q1–Q3]), while hs-cTnT peaked at the end of surgery (373 [188–660] ng/L). Fish oil supplementation did not alter the time course of the cardiac biomarkers (P > 0·05). Concentrations of NT-proBNP or hs-cTnT, on the morning of surgery, or changes in their level between morning of surgery and postsurgery, were not significantly associated with POAF after adjustment for clinical and surgical characteristics. Conclusion Among patients undergoing cardiac surgery, NT-proBNP and hs-cTnT are related to clinical and surgical characteristics, have different perioperative time courses but are not independently associated with risk of POAF.

Objectives We aimed at identifying predictors of renal impairment and its impact on long-term outcome after transcatheter aortic valve implantation (TAVI). Background Renal impairment is common in mostly elderly, multimorbid patients undergoing TAVI. The risk of periprocedural renal function impairment and its association with outcome is incompletely understood. Methods In 458 consecutive patients (mean age, 80.6 ± 7.0 years, 52.2% women) who underwent routine TAVI procedures, we assessed estimated glomerular filtration rate (eGFR) at baseline, during 72-hr postprocedure and at discharge. Over a median follow-up of 0.96 years, we observed 142 deaths. Results: In multivariable-adjusted models, predictors of renal function deterioration within 72 hr were baseline eGFR (β = 0.83, 95% confidence interval [CI] = 0.76/0.91; P

Objectives Our aim was to analyze the prevalence and predictors of Carotid artery stenosis (CAS) in patients undergoing transcatheter aortic valve implantation (TAVI). Background CAS is associated with the risk of periprocedural stroke in patients undergoing cardiac surgery. However, little is known about the prevalence of and clinical significance of CAS in the setting of TAVI. Methods Consecutive patients undergoing a carotid Doppler study the day before TAVI were followed prospectively. CAS was defined in accordance with current practice guidelines. Logistic regression models were used to identify independent correlates of CAS. Results The study included 171 patients (age 82 ± 6, male gender 47%). Carotid atherosclerosis (CA, defined as any carotid plaque) was present in 164 (96%) of patients, and CAS (peak systolic velocity [PSV] ≥ 125 cm/sec; ≥50% diameter stenosis) in 57 (33%) patients. Severe CAS (PSV ≥ 230 cm/sec; ≥70% stenosis, or near occlusion) was found in 15 (9%) patients. By multivariate analysis, smoking and a higher Euroscore independently predicted the presence of CAS. Patients in the present TAVI cohort had a significantly higher prevalence of both unilateral and bilateral CAS ≥ 50% than those in a previously reported cohort (n = 494 patients, age ≥ 70) undergoing clinically driven coronary angiography (33% vs. 20%, OR = 1.9, P = 0.001; and, 13% vs. 6%, OR = 2.3, P = 0.003, respectively). CAS was not independently associated with 30-day mortality or stroke rates. Conclusions The prevalence of CAS in patients undergoing TAVI is high, exceeding that observed in patients undergoing catheterization for coronary indications. The impact of CAS on clinical outcomes following TAVI merits further research. © 2014 Wiley Periodicals, Inc.

Objective The aim is to find predictors for a prolonged LOHS after MitraClip® implantation. Background Due to its less invasive nature, average length of hospital stay (LOHS) after the MitraClip® procedure is shorter compared to mitral valve surgery. However, some patients have a prolonged LOHS. Methods Records of consecutive patients who underwent MitraClip® procedure were reviewed. A total of 41 consecutive patients with MitraClip® implantation (76 ± 9 years, 59% men) were included. Median hospital stay was 7 days. Hospitalization lasting longer than 7 days was considered prolonged. Results Procedural success was achieved in 88% of the cases. In-hospital death occurred in 4 of 41 patients (10%). Patients with a prolonged hospital stay (46%) had a higher EuroSCORE I (22.7% [IQR 10.3–28.3] vs. 6.7% [IQR 3.5–18.3], P = 0.017), a higher STS mortality score (6.1%[(IQR 3.7–7.5] vs. 2.6% [IQR 1.4–4.8]; P = 0.043) and a higher STS long-length-of-stay score (18.9% [IQR 11.3–22.5] vs. 9.6% [IQR 6.2–16.1]; P = 0.039) as well as a lower estimated glomerular filtration rate (eGFR) (41 ml/min/1.73 m2 [IQR 19–52] vs. 56 ml/min/1.73 m2 [IQR 49–62]; P = 0.008) than those whose did not. In the multivariate model, lower eGFR was identified as predictor for a prolonged hospitalization. Conclusion Lower pre-procedure eGFR is independently associated with a longer hospitalization. © 2014 Wiley Periodicals, Inc.

The study aims to verify quality of life of elderly patients submitted to cardiac surgery, and correlating surgical risk to health-related quality of life instrument domains. Prospective cohort study, performed at a cardiology hospital. It included elderly patients who had undergone elective cardiac surgery. Pre- and postoperative quality of life was evaluated by applying the World Health Organization Quality of Life-Old (WHOQOL-OLD) scale and the Short-Form Health Survey (SF-36) questionnaire. Surgical risk was stratified using the European System for Cardiac Operative Risk Evaluation (EuroSCORE). Fifty-four patients, mostly men (64.8%), were included, with a mean age of 69.3 ± 5.7 years. The eight domains of the SF-36 questionnaire, and the four facets presented for the WHOQOL-OLD scale showed improved quality of life 6 months after surgery (P

Aims In low-flow, low-gradient aortic stenosis (LF/LG AS), the assessment of contractile reserve (CR) by dobutamine stress echocardiography (DSE) is recommended for risk stratification and treatment strategy. However, DSE may show limitations in cases of left ventricular dyssynchrony (LVD). The impact of LVD in LF/LG AS, and the feasibility of CRT in this setting have never been evaluated. We aimed to assess: (i) the proportion of LF/LG AS patients with LVD; (ii) the influence of LVD on CR at DSE; and (iii) the effects of CRT in these patients. Methods and results Thirty consecutive patients with LF/LG AS underwent DSE with study of CR. The operative risk for aortic valve replacement (AVR) was assessed using the logistic EuroSCORE. Twenty-one of the 30 patients had LVD. They were significantly older, more symptomatic, had a higher EuroSCORE, and a lower prevalence of CR than those with a narrow QRS (47% vs. 100%, P = 0.009). A CRT pacemaker was implanted in 19 of the 21 patients with LVD. All 19 (except for one patient who died suddenly) experienced significant clinical and echocardiographic improvement. Fourteen CRT patients underwent subsequent AVR with a low event rate. Four CRT patients refused AVR; two of them worsened again 1–2 years post-CRT. Conclusion LVD is common in LF/LG AS patients and may be a major mechanism of afterload mismatch, as well as a cause of underdetection of CR. CRT in this population is feasible and may be proposed as a bridge to surgery.

Objectives: The purpose of this study was to compare outcomes using standard clipping (SC) (one to two clips) or multiple clipping (MC) (more than two clips). Background: MitraClip® implantation using MC has been proposed to treat severe mitral regurgitation (MR) in high-risk patients. Methods and Results: A tailored strategy was used implanting as many clips as required to eliminate MR. A total of 85 consecutive patients [78 ± 6 years, 48 men (56.5%) ] with MR (grade 3+ or 4+) were included. EuroSCORE was 24 ± 12 (2.5–56.3) and STS-score 12 ± 7 (1.2–31.2). SC was used in 61 (71.8%) and MC in 24 (28.2%) patients. Patients in MC group had larger mitral valve (MV) annuli (P = 0.025), MV orifice areas (MVOA) (P = 0.01), and MR degree (P = 0.005). Successful clip placement was achieved in 82 patients (96.5%). At discharge, no patient had grade 4+ MR. MR 3+ presented in 4 patients (7.0%) in the SC group and in 1 (4.5%) in the MC group (P = 0.72). There were 3 (3.5%) in-hospital deaths. Follow up (211 ± 173 days, range 4–652) echocardiography confirmed similar MVOA (P = 0.83) and MV gradients (P = 0.54) in the both groups. At linear regression there was no independent correlation between clips number and postoperative MVOA/gradient. One-year survival was 71.1% without difference between groups (P = 0.74). Conclusion: Although the hemodynamic and anatomical basis of MR may differ, every procedure should aim at eliminating MR. In some patients this goal can be achieved using MC with minimized risk of MV stenosis if preoperative anatomy/mechanism of MV regurgitation are adequately assessed. © 2012 Wiley Periodicals, Inc.

Objectives We undertook this study to investigate the mid-term clinical results after MitraClip® implantation and the impact of post-repair mitral valve (MV) function and anatomy on survival and outcome composite endpoint in high-risk patients. Background Percutaneous MV repair is a potential treatment option for high-risk patients with severe mitral regurgitation (MR). Methods MitraClip® was implanted in patients with symptomatic MR rejected to conventional surgery. Differences between patients that survived at follow-up and patients deceased were tested. A stepwise Cox multivariate analysis was performed to identify independent predictors for composite endpoint of mortality, cardiac re-hospitalization, re-intervention, and major cerebro-vascular and cardiac events. Results A total of 85 consecutive patients [78 ± 6 years, 48 (56.5%) men] with severe MR were included. There was no operative mortality while in-hospital mortality was 3.5% (n = 3) and 30-day mortality 4.7% (n = 4). Follow-up was 211 ± 173 days. Survival and composite endpoint-free survival at one year were 71% and 55%. Multivariate analysis revealed that residual MR immediately after MitraClip® placement (OR 7.4; 95% CI 2.3–23.7) and preoperative MV gradient (OR 2.7; 95% CI 1.5–5.0) were predictors for composite endpoint. Chronic obstructive pulmonary disease (OR 8.3; 95% CI 1.9–37.1) was an additional predictor for composite endpoint. Conclusion MitraClip® is a valid tool with favorable outcomes in high-risk patients. The degree of residual MR seems to impact on follow-up composite endpoint outcome. An optimal correction of MR after MitraClip placement could be advocated to optimize the benefits of the procedure and minimize the risk of adverse outcomes. © 2012 Wiley Periodicals, Inc.

Objectives The purpose of this study was to examine the performance of the European system for cardiac operative risk evaluation II (ESII) in patients undergoing transcatheter aortic valve implantation (TAVI). Background The ESII was developed recently to improve the predictive value of the original logistic EuroSCORE (LES). Methods Between October 2006 and November 2011, 453 consecutive patients with severe aortic stenosis undergoing TAVI with either the Edwards valve or the Corevalve were included in the current analysis. The performance of the ESII, LES, and society of thoracic surgeons predicted risk of mortality score (STS) was evaluated. Results Mean age was 83.1 ± 6.4 years. The Edwards valve was used in 382 patients (84.3%) of the cohort, transfemoral approach (TF) in 55.0%, transapical approach (TA) in 25.2%, transaortic approach (TAo) 17.8%, transsubclabian approach (SC) 2.0%. The observed 30-day mortality was 12.6% (11.2, 18.4, 7.4, and 22.2% for TF, TA, TAo, SC, respectively). The mean LES, STS, and ESII were 22.4 ± 12.1, 8.1 ± 6.0, and 8.1 ± 5.2, respectively. The Hosmer–Lemeshow test showed ESII was inadequately calibrated for 30-day mortality compared with other risk scores (ESII P = 0.09, LES P = 0.84, STS P = 0.34). By using the area under the receiver operating characteristic curve (AUC), ESII better predicted 30-day mortality, albeit poorly, compared to LES and STS (AUC = 0.68, 0.65, and 0.60, respectively). In the TF cohort, ESII was better in predicting 30-day mortality compared to LES and STS (AUC = 0.74, 0.61, 0.60, respectively). Conclusions Although the ESII demonstrated better predictive performance especially in the TF cohort, ESII is still inadequate in predicting mortality after TAVI as are LES and STS. © 2013 Wiley Periodicals, Inc.

Background and Objectives Transcatheter aortic valve replacement (TAVR) via femoral access is a new option for patients with severe aortic valve stenosis considered to be at high risk for conventional open-heart surgery. This procedure requires peripheral arteries that are able to accommodate the large sheaths required for valve delivery. We present a series of patients with suboptimal vascular conditions, who received a self-expandable vascular sheath. Methods and Results From January 2009 to September 2011, a total of 96 patients (43% male) were treated with the 18F Medtronic CoreValve (Medtronic, Minneapolis, MN, USA). The patients' average age was 82.5 ± 4.6 years, and the mean EuroSCORE was 29%. In eight cases, vascular conditions were inadequate either due to advanced atherosclerotic disease (n = 5, 62.5%), or an arterial diameter ≤7 mm (n = 3, 37.5%). Instead of the standard 18F sheath, a balloon-expandable transfemoral introducer (SoloPath™-Introducer, Onset Medical Corporation, Irvine, CA, USA) was delivered and removed without complications in all but one (87.5%) patient. In the last case, rupture of the right femoral artery occurred after removal of the sheath with the need of vascular surgery. Conclusion The SoloPath sheath is a feasible alternative to conventional sheaths for transfemoral TAVR patients with difficult femoral vascular access.

Background EuroSCORE and completeness of revascularization predicts long-term survival after multivessel PCI (MV-PCI). The SYNTAX-Score has also been proposed to predict clinical outcome. The prognostic impact of these scores to predict long-term survival after PCI has not yet been compared. Methods and Results Long-term survival was assessed in 740 patients undergoing MV-PCI. We calculated EuroSCORE, SYNTAX-Score, STS-Score, the clinical SYNTAX-Score (CSS), and the “post-PCI residual SYNTAX-Score.” Mean follow-up time was 4.5 ± 2.5 years. 341 patients (46%) were treated for ACS (STEMI N = 191; NSTEMI N = 150). 113 patients (15%) underwent PCI of left main coronary artery. The EuroSCORE was significantly lower for stable patients compared to patients with ACS (stable 4.1 ± 4.5, NSTEMI 13.9 ± 13.3, STEMI 18.1 ± 18.7, p

Objective To identify clinical and electrical factors predicting delayed high-degree atrio-ventricular block (AVB) after transcatheter aortic valve implantation (TAVI). Background TAVI is a new technique for treating severe aortic valve stenosis in patients at high surgical risk but can be followed by high-grade AVB requiring permanent pacing (PP). Methods and Results The study included 79 patients (82 ± 17 years, Euroscore = 23% ± 10%) free of PP need before and immediately after TAVI procedure. Delayed high-degree AVB was defined by types 2 or 3 AVB diagnosed at least 24 hr after the index procedure. Permanent pacemaker implantation was performed for all these patients. We compared clinical and electrical variables before and after TAVI in patients with delayed AVB or not. TAVI was performed successfully in all patients. The 21 (26%) patients who exhibited delayed high-grade AVB had significantly deeper prosthesis implantation (12 ± 4 mm vs. 9 ± 5 mm, P = 0.03) and wider post-TAVI QRS duration (155 ± 17 msec vs. 131 ± 25 msec, P = 0.0004), with no difference in baseline QRS duration. Post-TAVI QRS duration was the only independent predictor of post-TAVI permanent for delayed high-degree AVB (P = 0.02). After a mean follow-up of 10 ± 8 months, all 21 patients with post-TAVI QRS ≤128 msec were free of high-grade AVB, whereas 21/55 (38%) patients with post-TAVI QRS >128 msec had PP (P = 0.0016). Conclusion Delayed (>24 hr after the procedure) high-grade AVB necessitating PP is common after TAVI. QRS duration measured immediately after TAVI was the best independent predictor of PP in this population. Patients with QRS ≤128 msec immediately after TAVI had no risk of requiring PP. © 2012 Wiley, Periodicals, Inc.

Background: This prospective study examines the impact of EuroSCORE and transfemoral (TF) or transapical (TA) delivery approach on mortality at 30 days and 1 year in patients with severe aortic stenosis implanted with either the Edwards SAPIEN Transcatheter Heart Valve (THV) or Medtronic CoreValve. Methods and Results: TAVI was successfully performed in 293 (97.7%) of 300 patients (TF: 174, TA: 126, mean EuroSCORE 24.0). The mortality at 30 days and after 1 year was 6.0% and 17.3%. Mortality depends significantly on the logistic EuroSCORE with a 30-day odds ratio (OR) of 1.92 (95% CI 1.41 to 2.62, P < 0.001) and after 1 year of 1.67 (95% CI 1.34 to 2.08, P < 0.001). Mortality in patients with a logistic EuroSCORE

Eur J Clin Invest 2012 Abstract Background This study tested the hypothesis that surgical stress and the host response to this trauma trigger an inflammatory cascade in which the neutrophil plays a central role. We hypothesised that pre-operative neutrophil migratory responses will correlate with post-operative clinical outcome in our shock model of open-heart surgery patients. We also tested the hypothesis that surface expression of adhesion molecules involved in the migratory process – CD11b, CD47 and CD99 – could be used to predict outcome. We believe that combining neutrophil migratory response, CD11b, CD47 and CD99 with the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) will strengthen the power of the EuroSCORE not only in predicting post-operative mortality but also other clinical endpoints. Materials and methods Neutrophils were isolated pre-operatively from n = 31 patients undergoing open-heart surgery and allowed to migrate across endothelial monolayers in response to N-formyl-methionine-leucine-phenylalanine (fMLP). Isolated neutrophils were also assessed for surface expression of CD11b, CD47 and CD99 in response to fMLP by flow cytometry. Post-operative clinical parameters collected included days 1–5 white cell count and creatinine levels as well as intensive care unit (ICU) and post-operative hospital stay. Results Pre-operative surface expression of CD99 and CD47 correlates with post-operative creatinine levels (P

Background: Transcatheter aortic valve insertion (TAVI) is an emerging therapy in patients at high risk for open heart surgery. The long-term durability of the bioprosthesis is unknown. This is the first report of a severely degeneratively stenosed 2nd generation 26 mm CoreValve® aortic bioprosthesis which occurred five and a half years after TAVI. Methods and Results: A 92-year-old patient presented with decompensated heart failure NYHA class IV, pulmonary edema, and severe pulmonary hypertension. Echocardiography revealed critical AV-stenosis due to heavily calcified bioprosthetic valve leaflets. Due to high surgical risk with an EuroSCORE of 64.97% and a STS-mortality score of 27.0%, we decided to attempt a valve-in-valve insertion of a 3rd generation CoreValve® prosthesis of the same size. Following the delicate retrograde passage of the calcified valve with a preformed stiff wire, balloon valvuloplasty of the severely stenosed CoreValve® prosthesis under rapid right ventricular pacing was complicated by two balloon catheter ruptures. Insertion of the 3rd generation CoreValve® prosthesis of the same size was quite complex but finally it was successfully completed. There was mild periprosthetic regurgitation and significant decrease in transaortic pressure without residual transvalvular gradient immediately after TAVI. Echocardiography and clinical follow-up at 72 hr after TAVI confirmed excellent valve function with a decrease in systolic pulmonary artery pressure from 70 mm Hg to 35 mm Hg, increase in LV-EF from 35% to 45%, and improvement of functional status from NYHA IV to NYHA II. The patient was discharged in good medical conditions at day eight. Conclusion: Degenerative stenosis of a CoreValve® bioprothesis may be observed during long-term follow-up after successful TAVI for the treatment of severe aortic valve stenosis. A second valve-in-valve insertion appears feasible but may require particular interventional approaches. © 2011 Wiley Periodicals, Inc.

Background: Rheumatic heart disease constitutes a significant disease burden in under-resourced communities. Recognition of the devastating impact of rheumatic heart disease has resulted in volunteer cardiac teams from Australasia providing surgical services to regions of need. The primary objective of this study was to compare New Zealand hospitals' volunteer cardiac surgical operative results in Samoa and Fiji with the accepted surgical mortality and morbidity rates for Australasia. Methods: A retrospective review from seven volunteer cardiac surgical trips to Samoa and Fiji from 2003 to 2009 was conducted. Patient data were retrospectively and prospectively collected. Preoperative morbidity and mortality risk were calculated using the European System for Cardiac Operative Risk Evaluation (euroSCORE). Audit data were collated in line with the Australasian Society of Cardiac and Thoracic Surgeons guidelines. Results: One hundred and three operations were performed over 6 years. EuroSCORE predicted an operative mortality of 3.32%. In-hospital mortality was 0.97% and post-discharge mortality was 2.91%, resulting in a 30-day mortality of 3.88%. Conclusion: This study demonstrated that performing cardiac surgery in Fiji and Samoa is viable and safe. However, the mortality was slightly higher than predicted by euroSCORE. Difficulties exist in predicting mortality rates in patients with rheumatic heart disease from Pacific Island nations as known risk scoring models fail to be disease, ethnically or culturally inclusive. Audit processes and risk model development and assessment are an essential part of this complex surgical charity work and will result in improved patient selection and outcomes.

Background Prolonged ventilation is a serious complication after cardiac surgery, but few risk prediction models exist. Our objectives were to develop a specific risk prediction model based on pre-operative variables, to identify whether selected intraoperative variables could improve prediction, and to compare our model with the EuroSCORE. Methods Data from 5027 patients undergoing open-heart surgery in 2000–2007 were used for logistic regression model development. Internal validation was performed by bootstrapping. Discrimination and calibration were assessed with areas under the receiver operating characteristic curve (AUC) and the Hosmer–Lemeshow test. Our pre-operative model was compared with predictions based on the additive and logistic EuroSCORE. Results Age, previous cardiac surgery, peripheral arterial disease, left ventricular hypertrophy, chronic pulmonary disease, renal insufficiency, pre-operative hemoglobin concentration, urgent or emergency operation, and operation other than isolated coronary artery bypass grafting were identified as pre-operative predictors for prolonged ventilation (model I). Discrimination and accuracy were excellent (AUC: 0.848 and shrinkage factor: 94%). Calibration was good (Hosmer–Lemeshow test: P = 0.43). Inclusion of a few intraoperative variables somewhat improved the model, increasing shrinkage factors (96%) and discrimination ability (AUC model II = 0.870 and model III = 0.875 for two alternative such models). Our pre-operative model showed better performance than the logistic or additive EuroSCORE. Conclusions The pre-operative risk prediction model for prolonged ventilation with easily obtainable variables in routine clinical work performed well and was only slightly improved by inclusion of intraoperative variables. Performance was better than with the EuroSCORE.

Aims: To define the impact of transcutaneous aortic valve implantation (TAVI) using the CoreValve prosthesis on myocardial deformation in a serial echocardiographic study with analysis of strain and strain rate. Methods: In 36 patients (83 ± 6 years; EuroScore: 26 ± 13%) with severe aortic stenosis scheduled for CoreValve implantation serial echocardiographic studies pre- and postintervention (within 1 month) were performed. Midparasternal short-axis and three apical views were acquired. Using customized computer software which allows automatic frame-by-frame tracking of acoustic markers during the heart cycle circumferential, radial, and longitudinal strain (CS, RS, and LS) and strain rate (CSR, RSR, and LSR) were calculated for each segment in a 16 segment model of the left ventricle. Results: Longitudinal strain, systolic, and early diastolic longitudinal strain rate increased significantly within 1 month after TAVI (LS from –15.8 ± 3.6% to –17.6 ± 3.1%; P < 0.001; LSR(S) from –1.03 ± 0.21 s−1 to –1.21 ± 0.19 s−1; P < 0.001 and LSR (E) from –1.15 ± 0.42 s−1 to 1.51 ± 0.44 s−1; P < 0.001). Circumferential strain and strain rate values remained unchanged after CoreValve implantation. RS (29.1 ± 17.1 to 34.0 ± 15.8%; ns), RSR (S) (1.56 ± 0.69 to 1.91 ± 0.87 s−1; ns) and RSR(E) (–1.56 ± 0.78 to –1.81 ± 0.82 s−1; ns) increased only nonsignificantly after TAVI. Analysis of covariance showed only chronic kidney disease to have a relevant impact on early diastolic LSR (P = 0.01). Conclusions: Mainly longitudinal mechanics respond to unloading of the left ventricle after TAVI for severe aortic stenosis while radial and circumferential deformation is substantially unchanged. Pacemaker implantation or onset of left bundle brunch block after TAVI do not influence early myocardial deformation parameters. (Echocardiography 2011;28:397-401)

Objectives: We seek to identify predictors of 30-day mortality after balloon aortic valvuloplasty (BAV). Background: To date, there is no validated method of predicting patient outcomes after percutaneous aortic valve interventions. Methods: Data for consecutive patients with severe aortic stenosis who underwent BAV at the Mount Sinai Medical Center from January 2001 to July 2007 were retrospectively reviewed. Cox-proportional hazards regression was used to identify significant predictors of 30-day mortality, and the resultant model was compared to the EuroSCORE using Akaike's Information Criterion and area under the receiver-operating curve (AUC). Results: The analysis included 281 patients (age 83 ± 9 years, 61% women, aortic valve area: 0.64 ± 0.2 cm2) and 36 (12.8%) of whom died within 30 days of BAV. With identified risk factors for 30-day mortality, critical status, renal dysfunction, right atrial pressure, and cardiac output, we constructed the CRRAC the AV risk score. Thirty-day survival was 72% in the highest tertile versus 94% in the lower two tertiles of the score. Compared to the additive and logistic EuroSCORE, the risk score demonstrated superior discrimination (AUC = 0.75 vs. 0.60 and 0.63, respectively). Conclusions: We derived a risk score, the CRRAC the AV score that identifies patients at high-risk of 30-day mortality after BAV. Validation of the developed risk prediction score, the CRRAC the AV score, is needed in other cohorts of post-BAV patients and potentially in patients undergoing other catheter-based valve interventions. © 2010 Wiley-Liss, Inc.

Background: Several models for prediction of early mortality after open-heart surgery have been developed. Our objectives were to develop a local mortality risk prediction model, compare it with the European System for Cardiac Operative Risk Evaluation (EuroSCORE), and investigate whether the addition of intra-operative variables could enhance the accuracy of risk prediction. Methods: All 5029 patients undergoing open-heart surgery in 2000–2007 were included in the study. Logistic regression with bootstrap methods was used to develop a pre-operative risk prediction model for in-hospital mortality. Next, several intra-operative variables were added to the pre-operative model. Calibration and discrimination were assessed, and the model was internally validated for prediction in future datasets. We thereafter compared the pre-operative model with the additive and logistic EuroSCOREs. Results: Our pre-operative model included eight risk factors that are routinely registered in our department: age, gender, degree of urgency, operation type, previous cardiac surgery, and renal, cardiac, and pulmonary dysfunction. The model estimated mortality accurately throughout the dataset except in the 1% of patients at extremely high risk, in which mortality was somewhat overestimated. The estimated shrinkage factor was 0.930. The areas under the receiver operating characteristic curve for our pre-operative model and the logistic EuroSCORE were 0.857(0.823–0.891) and 0.821(0.785–0.857) (P=0.02). There was no significant difference in performance between the pre-operative and the intra-operative model (P>0.10). Conclusion: Our pre-operative model was simple and easy to use, and showed good predictive ability in our population. Internal validation indicated that it would accurately predict mortality in a future dataset.

Several genetic polymorphisms have been identified to play a role in the occurrence and progression of renal dysfunction after cardiac surgery with cardiopulmonary bypass (CPB). Recently, it was demonstrated that the T allele of SNP rs1617640 in the promoter of the erythropoetin (EPO) gene is significantly associated with proliferative diabetic retinopathy (PDR) and end-stage renal disease (ESRD) due to increased EPO expression. This disease risk-associated gene and its potential pathway mediating severe microvascular complications in T-allele carriers could also play a role on renal dysfunction in patients who underwent cardiac surgery with CPB. We hypothesized that the patients' ability to produce increased EPO concentrations will affect morbidity and mortality after CPB. We conducted a prospective single center study between April 2006 and May 2007. In 481 patients who underwent cardiac surgery with CPB we prospectively examined the SNP rs1617640 in the promoter of the EPO gene by DNA sequencing. The patients were grouped according to their genotype (GG, GT, and TT). The genotype distribution of SNP rs1617640 in the promoter of the EPO gene was 36% (TT), 49% (TG), and 15% (GG). There was no difference in age, body mass index, gender, CPB time, or length of stay in intensive care unit. The hospitalization was irrespective of the patients' genotypes. The baseline creatinine in the TT group was 0.2 points higher than in the other groups; however this was without statistical significance in the multivariate analysis. No significant difference was shown in Euroscore, the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation Score II, Acute Renal Failure Score, or the Risk, Injury, Failure, Loss of Kidney Function Score. The mortality was equal across the genotypes. However, an association between the TT genotype and acute renal replacement therapy (P=0.03), intra-aortic balloon pump usage (P=0.02), and serum creatine phosphokinase-MB increase (P=0.03) were observed after cardiac surgery. Our analysis suggests that the risk allele (T) of rs1617640 plays a role in the development of renal dysfunction after cardiac surgery with CPB. Patients with the TT risk allele required more frequent acute renal replacement therapy. Since our result is close to the border of significance, this hypothesis should be investigated in larger prospective studies with long-term follow-up to emphasize this polymorphism as a potential risk factor.

Objectives: We report our experience with transcatheter valve-in-valve implantations in patients with degenerated bioprostheses in aortic and mitral position. Background: Xenograft degeneration is a potential problem after biological valve replacement. Reoperation remains the gold standard with very good short- and long-term results. In selected patients not suitable for surgery however, interventional techniques for valve implantation and repair may be valuable alternative treatment options with regard to the good results of transcatheter valve implantation for native aortic valve stenosis. Methods: Five patients presented with significant xenograft degeneration 15.4 ± 5.2 years after aortic (n = 4) and mitral (n = 1) valve replacement. Mean patient age was 82.0 ± 6.5 years and predicted operative mortality was 55.8% ± 18.9% (logistic EuroSCORE). Transcatheter valve-in-valve implantation was performed successfully through a transapical access in all patients. A 23-mm Edwards Sapien valve was deployed into the degenerated valve prosthesis. Results: Mean transvalvular gradients were reduced from 31.2 ± 17.4 to 19.0 ± 12.4 mm Hg in aortic and from 9 to 3 mm Hg in mitral position without significant regurgitation in any of these patients. Two patients died within 30 days due to low cardiac output and acute hemorrhage, respectively, one of whom presented with a EuroSCORE of 88.9%. Conclusions: With growing need for reoperative valve replacement in elderly patients with disproportional operative risks, transcatheter valve-in-valve implantation in aortic and mitral position offers an alternative treatment option. Although valve function after transcatheter implantation was good in all patients, two high risk patients died in the postoperative period due to their significant comorbidities, underscoring the bail-out character of this procedure. © 2010 Wiley-Liss, Inc.

Aims/Methods: The long-term outcome of patients (pts) undergoing percutaneous coronary intervention (PCI) of unprotected left main coronary artery (LMCA) is unclear so far. We prospectively investigated the outcome of 102 consecutive patients who underwent stent PCI of unprotected LMCA. Patients were divided according to clinical indication for PCI: stable coronary artery disease (CAD) (N = 60), NSTEMI (N = 18), STEMI (N = 24). Expected in-hospital mortality of coronary artery bypass grafting (CABG) was calculated using the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and compared to the observed survival rate during long-term follow-up (mean 1.8 ± 1.2 years). Results: The observed 30-day mortality was 1.7% (1/60 pts) in patients with stable CAD, 11% (2/18 pts) in NSTEMI patients, and 13% (3/24 pts) in STEMI patients. The observed mortality was lower than the predicted mortality of CABG as calculated by the logistic EuroSCORE. Using receiver-operator characteristics curves (ROC), EuroSCORE demonstrated a high predictive value for both 30-day mortality as well as 1-year mortality (AUC > 0.8; P < 0.01). Prognostically relevant patient related factors (P < 0.01) included severely reduced left ventricular ejection fraction (HR 3.24), ACS (HR 3.18), STEMI (HR: 3.01), Killip class IV (HR 7.69), occurrence of neoplastic disease (HR 3.97), and elevated CRP (HR 3.86). Conclusions: LMCA-PCI was associated with lower long-term mortality rates compared to the estimated mortality of CABG. This prospective observational study suggests that DES-PCI of unprotected LMCA in “all-comers” can be carried out with reasonable risk.