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• There is no consistent approach to determine the UMN in complex diseases, such as RVD. • Right heart failure is associated with increased morbidity and mortality while no selective therapy exists. • RVD is an UMN in patients with heart failure and thus a relevant therapeutic target. • Learnings might guide decision making in future drug discovery projects. Although 'unmet medical need' (UMN) is an increasingly used term in the healthcare sector instrumental to the approximate value of drug discovery projects relevant to portfolio management, no standardized approach exists for its quantification. Especially in diseases with different comorbidities, high patient heterogeneity, and incomplete epidemiological data, it is difficult to judge the need for new therapies. The approach presented here combines an expert assessment of key UMN indicators related to the individual patient with a literature search to collect epidemiological data describing the corresponding patient population with its underlying heterogeneity. This assessment supports decision-making within the portfolio management process in larger research and development organizations. [ABSTRACT FROM AUTHOR]

Background The David procedure is a well-known technique in selected patients with aortic root pathology. A minimally invasive approach in heart surgery increases open interest. Methods From 1991 to 2015, the David technique was performed in 296 patients in our unit. In 90 cases, operations were performed through partial upper sternotomy. The patient mean age was 57 ± 14 years in the minimally invasive group (n = 90) and 58 ± 14 years in the complete sternotomy group (n = 206; p = 0.2). The neosinus modification was performed in 80 patients (89%) in the minimally invasive group and in 79 patients (38%) in the complete sternotomy group (p < 0.01). Mean follow-up was 3 ± 2 years in the minimally invasive group and 8 ± 4 years in the complete sternotomy group. Results Thirty-day mortality was zero in the minimally invasive group and was 3% (n = 6) in the complete sternotomy group (p = 0.1). The need for packed red blood cells was significantly lower in the minimally invasive group (1.6 ± 3 U) than in the complete sternotomy group (3.7 ± 6 U; p < 0.01). Thirty late deaths (2% per patientyear) were observed in the complete sternotomy group versus zero in the minimally invasive group (p < 0.01). One patient (0.5% per patient-year) in theminimally invasive group and 12 patients (0.8% per patient-year) in the complete sternotomy group required reoperation in the follow-up period (p = 0.05). Conclusions Minimally invasive David technique for patients with ascending aortic aneurysm and aortic valve insufficiency offers a good solution with low perioperative blood transfusion rate. Our midterm results show low valve-related complications and reoperation rate. However, long-term follow-up of the minimally invasive group is necessary. [ABSTRACT FROM AUTHOR]

OBJECTIVES: For adult patients <60 years with aortic valve disease, the Ross procedure is an attractive alternative to a prosthetic aortic valve. The Ross procedure enables surgeons to achieve a haemodynamically ideal aortic valve replacement. A potential drawback may be long-term durability, which varies considerably between series. METHODS: Between 1996 and 2014, 209 patients (mean age, 43 ± 10 years) underwent an elective Ross procedure in our department. In 78% (n = 161) of patients a bicuspid valve was found. Patients were examined clinically and with echocardiography during the follow-up. The mean follow-up was 7.9 ± 5 years and was 98% complete. RESULTS: The 30-day mortality rate was 2.4% (n = 5). The Kaplan–Meier survival rates at 10 and 15 years were 91 and 85%, respectively. In 17 patients (8.3%) the pulmonary autograft had to be reoperated on: 12 of them could be repaired; only 5 patients finally underwent prosthetic valve replacement. The rate of freedom from reoperation for autograft failure was 93% and that from reoperation or moderate autograft regurgitation was 87% at 10 years. Thromboembolic events occurred in 9 patients (0.54%/patient-year) and were mostly related to atrial fibrillation. Endocarditis involving the pulmonary autograft was observed in 6 patients (0.36%/patient-year). CONCLUSIONS: Pulmonary autograft aortic root replacement to treat patients with severe aortic valve dysfunction is a challenging procedure. The reoperation rate is higher compared with mechanical valve replacement; however, in the majority of patients with reoperations in our series the autograft could be saved. Other valve-related complications are rare. [ABSTRACT FROM AUTHOR]

OBJECTIVES Although data from large series indicate the satisfactory performance of bioprosthetic valves in the right ventricular outflow tract (RVOT), replacement of the pulmonary valve in adult patients undergoing the Ross procedure is usually performed with pulmonary allografts. We evaluated the outcomes of homografts vs. bioprosthetic RVOT replacement after the Ross procedure in adults. METHODS Between 1996 and 2011, a total of 186 adult patients (141 male; mean age 44 ± 10 years) underwent aortic root replacement with a pulmonary autograft. The RVOT was replaced with a homograft in 113 patients and with stentless bioprostheses (Medtronic Freestyle®) in 73. Patients were followed for a mean of 6 years (range 1–15 years; 1106 patient years). RESULTS Twelve patients required reintervention owing to dysfunction of the RVOT replacement, which was caused by endocarditis (n = 4), degeneration (n = 2) or stricture at the proximal suture line (n = 6). For homografts, the incidence of reintervention was 1 in 150 patient years, compared with 1 in 36 patient years for stentless bioprostheses (P = 0.007). The median gradient was 15 mmHg for the homograft group and 24 mmHg for bioprosthesis (P < 0.0001). The incidence of gradients >40 mmHg was 10-fold higher in the bioprosthetic group. CONCLUSIONS Patients with bioprostheses in the RVOT position after the Ross procedure showed a significantly higher risk of reintervention or pulmonary valve dysfunction. The main problem, early development of a stricture at the proximal suture line, has to be solved to achieve satisfactory bioprosthetic function in the RVOT. [ABSTRACT FROM AUTHOR]

The development and adoption of minimally invasive techniques has revolutionized various surgical disciplines and has also been introduced into cardiac surgery, offering patients less invasive options with reduced trauma and faster recovery time compared to traditional open-heart procedures with sternotomy. This article provides a comprehensive overview of the anesthesiologic management for minimally invasive cardiac surgery (MICS), focusing on preoperative assessment, intraoperative anesthesia techniques, and postoperative care protocols. Anesthesia induction and airway management strategies are tailored to each patient's needs, with meticulous attention to maintaining hemodynamic stability and ensuring adequate ventilation. Intraoperative monitoring, including transesophageal echocardiography (TEE), processed EEG monitoring, and near-infrared spectroscopy (NIRS), facilitates real-time assessment of cardiac and cerebral perfusion, as well as function, optimizing patient safety and improving outcomes. The peripheral cannulation techniques for cardiopulmonary bypass (CPB) initiation are described, highlighting the importance of cannula placement to minimize tissue as well as vessel trauma and optimize perfusion. This article also discusses specific MICS procedures, detailing anesthetic considerations and surgical techniques. The perioperative care of patients undergoing MICS requires a multidisciplinary approach including surgeons, perfusionists, and anesthesiologists adhering to standardized treatment protocols and pathways. By leveraging advanced monitoring techniques and tailored anesthetic protocols, clinicians can optimize patient outcomes and promote early extubation and enhanced recovery.