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The article reports on the clinical statement produced by the European Association for Cardio-Thoracic Surgery (EACTS) which summarizes and updates on modern cardiac surgical treatments and procedures. Topics include the dedicated multidisciplinary heart teams that provide appropriate care for patients considered for cardiac surgery, the cardiac surgical unit which must have dedicated staffs and wards and the intensive care units that should be able to provide all levels of cares for patients.

The authors summarize the 2017 European Association for Cardio-Thoracic Surgery (EACTS) guidelines on perioperative medication in adult cardiac surgery and patient blood management to minimize bleeding. They enumerate the scope of recommendations for perioperative medication subdivided into preoperative, intraoperative and postoperative medications, as well as the steps in the preoperative evaluation of patients and recommended interventions such as use of antifibrinolitic therapy.

Coronary artery bypass grafting, Coronary surgery, Repeat coronary artery bypass surgery, Diseased vein graft. [Extracted from the article]

A correction is presented to the article "Radial artery as a conduit for coronaryartery bypass grafting: a state-of-the-art primer" is presented in the issue.

Background With the advent of bare metal stents and drug-eluting stents, percutaneous coronary intervention has emerged as an alternative to coronary artery bypass grafting surgery for unprotected left main disease. However, whether the evolution of stents technology has translated into better results after percutaneous coronary intervention remains unclear. We aimed to compare coronary artery bypass grafting with stents of different generations for left main disease by performing a Bayesian network meta-analysis of available randomized controlled trials. Methods All randomized controlled trials with at least 1 arm randomized to percutaneous coronary intervention with stents or coronary artery bypass grafting for left main disease were included. Bare metal stents and drug-eluting stents of first- and second-generation were compared with coronary artery bypass grafting. Poisson methods and Bayesian framework were used to compute the head-to-head incidence rate ratio and 95% credible intervals. Primary end points were the composite of death/myocardial infarction/stroke and repeat revascularization. Results Nine randomized controlled trials were included in the final analysis. Six trials compared percutaneous coronary intervention with coronary artery bypass grafting (n = 4654), and 3 trials compared different types of stents (n = 1360). Follow-up ranged from 6 months to 5 years. Second-generation drug-eluting stents (incidence rate ratio, 1.3; 95% credible interval, 1.1-1.6), but not bare metal stents (incidence rate ratio, 0.63; 95% credible interval, 0.27-1.4), and first-generation drug-eluting stents (incidence rate ratio, 0.85; 95% credible interval, 0.65-1.1) were associated with a significantly increased risk of death/myocardial infarction/stroke when compared with coronary artery bypass grafting. When compared with coronary artery bypass grafting, the highest risk of repeat revascularization was observed for bare metal stents (hazard ratio, 5.1; 95% confidence interval, 2.1-14), whereas first-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) and second-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) were comparable. Conclusions The introduction of new-generation drug-eluting stents did not translate into better outcomes for percutaneous coronary intervention when compared with coronary artery bypass grafting. [ABSTRACT FROM AUTHOR]

The article discusses research studies on heart arteries. The studies include "Is the Radial Artery Associated with Improved Survival in Older Patients Undergoing Coronary Artery Bypass Grafting? An Analysis of a Multicentre Experience," by W. Y. Shi at al. and "Equipose Between Radial Artery and Right Internal Thoracic Artery as the Second Arterial Conduit in Left Internal Thoracic Artery-Based Coronary Artery Bypass Graft Surgery: A Multi-Institutional Study," by T. A. Schwann et al.

Open in new tab Download slide Open in new tab Download slide OBJECTIVES The incidence of outcomes in trials comparing transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) is expected to be different in the short and long term. We planned a meta-analysis of reconstructed time-to-event data from trials comparing TAVI and SAVR to evaluate their time-varying effects on outcomes. METHODS We performed a systematic review of the literature from January 2007 through September 2021 on Medline, Embase, the Cochrane Central Register of Controlled Trials and specialistic websites, including randomized trials with allocation to TAVI or SAVR that reported at least 1-year follow-up and that graphed Kaplan–Meier curves of end points. The comparisons were done with grouped frailty Cox models in a landmark framework and fully parametric models. RESULTS Seven trials were included (7770 participants). TAVI showed a lower incidence of the composite of death or stroke in the first 6 months [risk-stratified hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.56–0.77, P -value <0.001], with an HR reversal after 24 months favouring SAVR (risk-stratified HR 1.25; 95% CI 1.08–1.46; P -value 0.003). These outcomes were confirmed for all-cause death (risk-stratified HR after 24 months 1.18; 95% CI 1.03–1.35; P -value 0.01). TAVI was also associated with an increased incidence of rehospitalization after 6 months (risk-stratified HR 1.42; 95% CI 1.06–1.91; P -value 0.018) that got worse after 24 months (risk-stratified HR 1.67; 95% CI 1.24–2.24; P -value <0.001). CONCLUSIONS Although it could appear that there is no difference between TAVI and SAVR in the 5-year cumulative results, TAVI shows a strong protective effect in the short term that runs out after 1 year. TAVI becomes a risk factor for all-cause mortality and the composite end point after 24 months and for rehospitalization after 6 months. [ABSTRACT FROM AUTHOR]

Background: There are several different definitions of complete revascularization on coronary surgery across the literature. Despite the importance of this definition, there is no agreement on which one has the most impact. The aim of this study was to evaluate which definition of complete surgical revascularization correlates with early and late outcomes. Methods: All consecutive patients submitted to isolated CABG from 2012 to 2016 with previous myocardial scintigraphy were evaluated. Exclusion criteria: emergent procedures and previous cardiac surgery procedures. The population of 162 patients, follow‐up complete in 100% patients; median 5.5; IQR: 4.4–6.9 years. Each and all of the 162 patients were classified as complying or not with the four different definitions: numerical, functional, anatomical conditional, and anatomical unconditional. Perioperative outcome: MACCE; long‐term outcomes: survival and repeat revascularization. Univariable and multivariable analyses were developed to detect predictors of outcomes. Results: Complete functional revascularization was a predictor of increased survival (HR: 0.47; CI 95: 0.226–0.969; p =.041). No other definitions showed effect on follow‐up mortality. Age and cardiac dysfunction increased long‐term mortality. The definition of complete revascularization did not have an impact on MACCE or the need for revascularization Conclusions: A uniformly accepted definition of complete coronary revascularization is lacking. This study raises awareness about the importance of viability guidance for CABG. [ABSTRACT FROM AUTHOR]

Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition. [ABSTRACT FROM AUTHOR]

Objectives: Age is an important factor weighing on revascularization decisions. We analysed long-term health outcomes of young patients with low-complexity coronary anatomy suitable for both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), according to revascularization strategy., Methods: Patients 60 years old or less, undergoing invasive coronary angiography between January 2007 and December 2015, presenting with proximal left anterior descending artery involvement, left main or multivessel disease and a SYNTAX Score ≤22 were retrospectively selected. An inverse probability of treatment weight methodology generated a pseudopopulation with well-balanced characteristics, which was used to estimate the average treatment effect between PCI (n = 374) and CABG (n = 173)., Results: Mean age was 53 ± 7 years old, 27% had diabetes mellitus and 48% presented with an acute coronary syndrome. Mean SYNTAX score was 13.6 ± 4.9 and 68% underwent PCI as index revascularization strategy. In the weighed population, the adjusted hazard of the primary end-point of all-cause death at total follow-up (median 9.3 years; interquartile range 6.9-11.7) was 0.40 (95% confidence interval 0.19-0.7) for CABG vs PCI (incidence rate 5.8 vs 14.0 deaths/1000-person-years). Accounting for death as competing risk, the cumulative hazard of new revascularization (sub-distribution hazard ratio 0.72; 95% confidence interval 0.32-1.25) and any cause hospital readmission (sub-distribution hazard ratio 0.70; 95% confidence interval 0.41-1.07) were lower in CABG patients, as opposed to death/stroke rates at 30 days which were higher with CABG (0.3% vs 1.7%; risk ratio = 5.84)., Conclusions: In this quasi-experimental analysis of young patients with coronary artery disease and an equivalent indication for both PCI and CABG, long-term health outcomes were favourably associated with CABG, as compared to PCI. These observations support the need for dedicated randomized trials with longer follow-up in order to better inform lifetime treatment options., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction and Objectives: Oral anticoagulation (OAC) with non-vitamin K antagonist oral anticoagulants (NOACs) after surgical mitral valve repair (MVR) or bioprosthetic valve replacement (BVR) in mitral position remains a controversial topic among the cardiovascular community, in particular in the early postoperative period. This study aimed to evaluate the efficacy and safety of NOACs in the first three months after MVR or mitral BVR compared to vitamin K antagonists (VKAs)., Methods: This was a single-center retrospective study with prospectively collected peri-intervention outcomes between 2020 and 2021. Records were retrieved and all participants were contacted by telephone. Patients were divided into groups according to OAC strategy. The primary outcome was a composite of death, rehospitalization, myocardial infarction, stroke or transient ischemic attack, systemic embolism, mitral thrombosis, or bleeding during the first three months after surgery., Results: A total of 148 patients were enrolled, with a mean age of 65.5±12.2 years, 56.8% male. On discharge, 98 (66.2%) patients were on VKAs and 50 (33.8%) were on DOACs for at least three months. The primary outcome occurred in 22 (22.4%) patients in the VKA group and in three (6%) in the NOAC group (p=0.012), mainly driven by more bleeding events in the former. Independent predictors of the primary outcome were smoking (p=0.028) and OAC with VKAs at discharge, the latter predicting three times more events (p=0.046, OR 3.72, 95% CI 1.02-13.5)., Conclusions: NOACs were associated with fewer events, supporting their efficacy and safety during the first three months after surgical MVR or mitral BVR., (Copyright © 2024 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Cardiac disease is associated with a risk of death, both by the cardiac condition and by comorbidities. The waiting time for surgery begins with the onset of symptoms and includes referral, completion of the diagnosis and surgical waiting list (SWL). This study was conducted during the COVID-19 pandemic, which affected surgical capacity and patients' morbidities., Methods: The cohort includes 1914 consecutive adult patients (36.6% women, mean age 67 ±11 years), prospectively registered in the official SWL from January 2019 to December 2021. We analyzed waiting times ranging from 4 days to one year to exclude urgencies and outliers. Priority was classified by the national criteria for non-oncologic or oncology surgery., Results: During the study period, 74% of patients underwent surgery, 19.2% were still waiting, and 4.3% dropped out. Most cases were valvular (41.2%) or isolated bypass procedures (34.2%). Patients were classified as non-priority in 29.7%, priority in 61.8%, and high priority in 8.6%, with significantly different SWL mean times between groups (p<0.001). The overall mean waiting time was 167 ± 135 days. Mortality on SWL was 2.5%, or 1.1 deaths per patient/weeks. There were two mortality independent predictors: age (HR 1.05) and the year 2021 versus 2019 (HR 2.07) and a trend toward higher mortality in priority patients versus non-priority (p=0.065). The overall risk increased with time with different slopes for each year. Using the time limits for SWL in oncology, there would have been a significant risk reduction (p=0.011)., Conclusion: The increased risk observed in 2021 may be related to the pandemic, either by increasing waiting time or by direct mortality. Since risk stratification is not entirely accurate, waiting time emerges as the most crucial factor influencing mortality, and implementing stricter time limits could have led to lower mortality rates.

Objectives: The aim of this study was to identify methodological variations leading to varied recommendations between the American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) valvular heart disease guidelines and to suggest foundational steps towards standardizing guideline development., Methods: An in-depth analysis was conducted to evaluate the methodologies used in developing the transatlantic guidelines for managing valvular heart disease. The evaluation was benchmarked against the standards proposed by the Institute of Medicine., Results: Substantial discrepancies were noted in the methodologies utilized in development processes, including Writing Committee composition, evidence evaluation, conflict of interest management and voting processes. Furthermore, despite their mutual differences, both methodologies demonstrate notable deviations from the Institute of Medicine standards in several essential areas, including literature review and evidence grading. These dual variances likely influenced divergent treatment recommendations. For example, the ESC/EACTS recommends transcatheter edge-to-edge repair for patients with chronic severe mitral regurgitation ineligible for mitral valve surgery, while the ACC/AHA recommends transcatheter edge-to-edge repair based on anatomy, regardless of surgical risk. ESC/EACTS guidelines recommend a mechanical aortic prosthesis for patients under 60, while ACC/AHA guidelines recommend it for patients under 50. Notably, the ACC/AHA and ESC/EACTS guidelines have differing age cut-offs for surgical over transcatheter aortic valve replacement (<65 and <75 years, respectively)., Conclusions: Variations in methodologies for developing clinical practice guidelines have resulted in different treatment recommendations that may significantly impact global practice patterns. Standardization of essential processes is vital to increase the uniformity and credibility of clinical practice guidelines, ultimately improving healthcare quality, reducing variability and enhancing trust in modern medicine., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Left ventricular (LV) hypertrophy is a common finding in patients with severe aortic stenosis (AS). Cardiac magnetic resonance (CMR) is the gold-standard technique to evaluate LV remodeling. Our aim was to assess the prevalence and describe the patterns of LV adaptation in AS patients before and after surgical aortic valve replacement (AVR). Prospective study of 130 consecutive patients (71y [IQR 68-77y], 48% men) with severe AS, referred for surgical AVR. Patterns of LV remodeling were assessed by CMR. Besides normal LV ventricular structure, four other patterns were considered: concentric remodeling, concentric hypertrophy, eccentric hypertrophy, and adverse remodeling. At baseline CMR study: mean LV indexed mass: 81.8 ± 26.7 g/m 2 ; mean end-diastolic LV indexed volume: 85.7 ± 23.1 mL/m 2 and median geometric remodeling ratio: 0.96 g/mL [IQR 0.82-1.08 g/mL]. LV hypertrophy occurred in 49% of subjects (concentric 44%; eccentric 5%). Both normal LV structure and concentric remodeling had a prevalence of 25% among the cohort; one patient had an adverse remodeling pattern. Asymmetric LV wall thickening was present in 55% of the patients, with predominant septal involvement. AVR was performed in 119 patients. At 3-6 months after AVR, LV remodeling changed to: normal ventricular geometry in 60%, concentric remodeling in 27%, concentric hypertrophy in 10%, eccentric hypertrophy in 3% and adverse remodeling (one patient). Indexes of AS severity, LV systolic and diastolic function and NT-proBNP were significantly different among the distinct patterns of remodeling. Several distinct patterns of LV remodelling beyond concentric hypertrophy occur in patients with classical severe AS. Asymmetric hypertrophy is a common finding and LV response after AVR is diverse., (© 2024. The Author(s).)

In October 2021, the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) jointly agreed to establish a Task Force (TF) to review recommendations of the 2018 ESC/EACTS Guidelines on myocardial revascularization as they apply to patients with left main (LM) disease with low-to-intermediate SYNTAX score (0-32). This followed the withdrawal of support by the EACTS in 2019 for the recommendations about the management of LM disease of the previous guideline. The TF was asked to review all new relevant data since the 2018 guidelines including updated aggregated data from the four randomized trials comparing percutaneous coronary intervention (PCI) with drug-eluting stents vs. coronary artery bypass grafting (CABG) in patients with LM disease. This document represents a summary of the work of the TF; suggested updated recommendations for the choice of revascularization modality in patients undergoing myocardial revascularization for LM disease are included. In stable patients with an indication for revascularization for LM disease, with coronary anatomy suitable for both procedures and a low predicted surgical mortality, the TF concludes that both treatment options are clinically reasonable based on patient preference, available expertise, and local operator volumes. The suggested recommendations for revascularization with CABG are Class I, Level of Evidence A. The recommendations for PCI are Class IIa, Level of Evidence A. The TF recognized several important gaps in knowledge related to revascularization in patients with LM disease and recognizes that aggregated data from the four randomized trials were still only large enough to exclude large differences in mortality., (This article has been co-published with permission in the European Heart Journal and European Journal of Cardio-Thoracic Surgery. © the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery 2023. All rights reserved. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either citation can be used when citing this article.)

Introduction: Infective endocarditis morbidity and mortality remains high. Surgery is performed in about half of endocarditis cases, being the ideal setting to evaluate endocarditis lesions. The aim of this study was to register and describe endocarditis lesions found during surgery; find predictors of morbidity and mortality and correlate lesions found in echocardiogram vs. surgery., Materials and Methods: One hundred consecutive patients with endocarditis lesions seen during surgery were included between June 2014 and August 2018. Pathological lesions were coded prospectively using a coding form published by Pettersson et al. Other data were collected retrospectively., Results: Prosthetic endocarditis accounted for 23% of cases. Embolic events had occurred in 41% of cases, mainly to the brain (22%). The most frequent lesions found in echocardiogram were vegetations (77%). Vegetations and valve integrity anomalies were the main lesions described during surgery (70% and 71% respectively). Invasion was present in 39% of patients. In-hospital mortality was 9%. In univariable analysis, predictors of early mortality included chronic kidney disease (P= .005), prosthetic valve endocarditis (P <.001), EuroSCORE II (P <.001) and valve integrity anomalies (P=.016). Predictors of embolic events included aortic valve vegetations seen during surgery (P= .026). Sensitivity and specificity of echocardiogram findings for identification of vegetations were 84% and 40%, for valve integrity anomalies 42% and 97% and for invasion 54% and 95%, respectively., Conclusions: Diversity of lesions found in endocarditis precludes obtaining significant predictors of morbidity or mortality with small numbers of patients. Echocardiogram lacks sensitivity for valve integrity anomalies and invasion but is highly specific.

Background: 2020 ESC guidelines for non-ST elevation acute coronary syndromes (NSTE-ACS) recommend against the pretreatment with P2Y12 receptor inhibitors (P2Y12i) in patients undergoing early invasive management (<24 h). The rationale is, in part, to prevent bleeding complications and the delay of coronary artery bypass graft surgery (CABG) in patients with suitable coronary anatomy. This study aimed to analyze the theoretical impact of pretreatment with a P2Y12i on delay to CABG surgery in a real-world population with NSTE-ACS., Methods: Single-center retrospective cohort of consecutive patients with NSTE-ACS undergoing invasive evaluation in 2019. Those with previous CABG or nonobstructive coronary disease were excluded., Results: The total cohort included 262 patients (mean age 68±12 years, 69% male, 15% with unstable angina and mean GRACE score 134±35). Median time from FMC to angiography was 2 (1-4) days. Overall, 168 (64%) patients underwent percutaneous coronary intervention, 47 (18%) were proposed for CABG and the remainder received conservative management. All patients considered for CABG received pretreatment with P2Y12i (clopidogrel or ticagrelor). The median time from angiography to CABG was 12 (7-15) days. Six patients experienced recurrent angina (13%) and 2 (4%) died before surgery due to refractory ventricular fibrillation. Those who underwent CABG under P2Y12i effect were more likely to receive blood and platelets transfusions (64.7% vs. 28.6%, P=0.017 and 82.4% vs. 21.4%, P<0.001, respectively), although there were no differences regarding major bleeding., Conclusions: Pretreatment with P2Y12i was a potential but not the sole driver of CABG delay in our cohort. Adopting the new recommendations of withholding pretreatment might decrease this delay, but other factors must be considered.

Introduction and Objective: We performed a collective analysis of a dedicated national post-myocardial infarction ventricular septal defect (VSD) registry to further elucidate controversial areas of this clinical entity's surgical treatment., Methods: A descriptive statistical analysis was carried out and cumulative survival using the Kaplan-Meier method and multivariate logistic regression of risk factors for 30-day mortality are presented., Results: Median survival of the cohort (n=76) was 72 months (95% CI 4-144 months). Better cumulative survival was observed in patients who underwent VSD closure more than 10 days after myocardial infarction (log-rank p=0.036). Concomitant coronary artery bypass grafting (CABG), different closure techniques, location of the VSD, extracorporeal membrane oxygenation as bridge to closure, or intra-aortic balloon pump as bridge to closure showed no statistically significant differences at Kaplan-Meier analysis. Multivariate binary logistic regression for independent factors affecting status at 30 days showed a statistically significant effect of age (OR 1.08; 95% CI 1.01-1.15) and concomitant CABG (OR 0.23; 95% CI 0.06-0.90)., Conclusions: Our results are comparable with previous reports regarding mortality, risk factors and concomitant procedures. Timing of surgery remains a controversial issue. Later closure seems to be advantageous, however, there is significant observational bias., (Copyright © 2023 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)