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Mitral annular abscesses are rare and can be caused by infective endocarditis. We present the case of a patient with an infected mitral prosthesis, with multiple suspected periprosthetic abscesses. However, perioperative inspection showed a supra-annular implanted prosthesis., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Transcatheter aortic valve replacement (TAVR) is the standard of care in aortic stenosis with results comparable to surgical aortic valve replacement. However, paravalvular regurgitation (PVR) is more common after TAVR. With the alteration of devices and implantation techniques, the incidence of moderate or more PVR has declined. Mild PVR is still common in around 30% of TAVR patients in low-risk trials. Progression of AS causes myocardial hypertrophy and varying degrees of diastolic dysfunction which may cause heart failure even in combination with small volumes of PVR. Any degree of PVR is associated with an increased risk of overall and cardiovascular mortality. Predictors of PVR are annular eccentricity, severe calcification of the aortic valve, bicuspid aortic valves, and type of prosthesis where balloon-expandable devices are associated with less PVR. PVR is diagnosed using echocardiography, aortic angiogram with or without videodensitometry, haemodynamic parameters, or cardiac magnetic resonance. PVR can be treated using post-dilation, interventional treatment using a vascular plug, or implantation of a second device. Successful post-dilation depends on balloon size which should at least be equal to or >95% of the mean annulus diameter. Implantation of a second device to reduce PVR is successful in ∼90% of cases, either through lengthening of the sealing skirt in case of inadequate position or through further expansion of the index device. Implantation of a vascular plug can successfully reduce PVR and reduce mortality., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Patients with severe aortic stenosis (AS) frequently present with concomitant obstructive coronary artery disease (CAD). In those, current guidelines recommend combined coronary artery bypass grafting (CABG) and surgical aortic valve replacement (SAVR) as the preferred treatment option, although this surgical approach is associated with a high rate of clinical events. Combined transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) with or without FFR have evolved as a valid alternative for cardiac surgery in patients with AS and multivessel or advanced CAD. To date, no dedicated trial has prospectively evaluated the outcomes of a percutaneous versus surgical treatment for patients with both severe AS and CAD., Aims: To investigate whether fractional-flow reserve (FFR)-guided PCI and TAVI is noninferior to combined CABG and SAVR for the treatment of severe AS and multivessel or advanced CAD., Methods: The Transcatheter Valve and Vessels (TCW) trial (clinicaltrial.gov: NCT03424941) is a prospective, randomized, controlled, open label, international trial. Patients ≥ 70 years with severe AS and multivessel (≥ 2 vessels) or advanced CAD, deemed feasible by the heart team for both; a full percutaneous or surgical treatment, will be randomised in a 1:1 fashion to either FFR-guided PCI followed by TAVI (intervention arm) vs. CABG and SAVR (control arm). The primary endpoint is a patient-oriented composite of all-cause mortality, myocardial infarction, disabling stroke, unscheduled clinically-driven target vessel revascularization, valve reintervention, and life threatening or disabling bleeding at 1 year. The TCW trial is powered for noninferiority, and if met, superiority will be tested. Assuming a primary endpoint rate of 30% in the CABG-SAVR arm, with a significance level α of 5%, a noninferiority limit delta of 15% and a loss to follow-up of 2%, a total of 328 patients are needed to obtain a power of 90%. The primary endpoint analysis is performed on an intention-to-treat basis., Summary: The TCW Trial is the first prospective randomized trial that will study if a less invasive percutaneous treatment for severe AS and concomitant advanced CAD (i.e., FFR-guided PCI-TAVI) is noninferior to the guidelines recommended approach (CABG-SAVR)., Competing Interests: Conflict of interest E.K. reports institutional research grants support from Abbott Vascular Laboratories and Medtronic as well as proctor/lecture fees from Abbott Vascular. R.H. reports lecture fees from Abbott Vascular, Amgen, Novartis. M.H. reports proctor for Meril Life. I.A.S. reports proctor for Boston Scientific, Medtronic and Meril Life. M.A. reports proctor/speaker/consultant fees from Edwards, Abbott, Medtronic, Boston, Zoll, Abbvie and received institutional research grants Edwards, Abbott, Medtronic, LSI. L.C: Advisory Board member for Abbott, Medtronic and JenaValve, consultant for Edwards Lifesciences, Boston Scientific, PiCardia, MicroPort, MicroInterventions. W. Wojakowski: Medtronic advisory board, lecture fees from Edwards Lifesciences, Abbott, Medtronic; E.L.Institutional Research from Abbott Medical Netherlands. All other authors don't report any conflict of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Transfemoral (TF) access is default in transcatheter aortic valve implantation (TAVI). Transaxillary (TAx) access has been shown to be a safe alternative in case of prohibitive iliofemoral anatomy, but whether TAx as preferred access has similar safety and efficacy as TF access is unknown. The aim of this study was to compare outcomes between patients treated with self-expanding devices using TF or TAx route as preferred access in TAVI., Methods: A single center cohort of 354 patients treated using TAx as preferred access and a multi-center cohort of 5980 patients treated using TF access were compared. Propensity score matching was used to reduce selection bias and potential confounding. After propensity score matching, each group consisted of 322 patients. Clinical outcomes according to VARC-2 were compared using chi-square test., Results: In 6334 patients undergoing TAVI, mean age was 81.4 ± 7.0 years, 57% was female and median logistic EuroSCORE was 14.7% (IQR 9.5-22.6). In the matched population (age 79.3 ± 7.0, 50% female, logistic EuroSCORE 13.4%, IQR 9.0-21.5), primary outcomes 30-day and one-year all-cause mortality were similar between Tax and TF groups (30 days: 5% versus 6%, p = 0.90; 1 year: 20% versus 16%, p = 0.17). Myocardial infarction was more frequent in patients undergoing Tax TAVI compared with TF (4% versus 1%, p = 0.05), but new permanent pacemakers were less frequently implanted (12% versus 21%, p = 0.001)., Conclusion: TAx as preferred access is feasible and safe with outcomes that are comparable to TF access., Competing Interests: Conflict of interest statement Dr. van Wely is a proctor for Abbott Vascular. Dr. van Nieuwkerk has no relevant disclosures. Dr. Rooijakkers has no relevant disclosures. Dr. van der Wulp has no relevant disclosures. Dr. Gehlmann is a proctor for Abbott Vascular and Medtronic. Dr. van Garsse is a proctor for Edwards Lifesciences. Dr. de Brito Jr. is a proctor for Edwards Lifesciences and Medtronic. Dr. Geuzebroek has no relevant dislclosures. Dr. Baz has no relevant disclosures. Dr. Tchétché has no relevant disclosures. Dr. De Brito Jr. has no relevant disclosures. Dr. Barbanti is consultant for Edwards Lifesciences and received speaker honoraria from Medtronic and Biotronik. Dr. Kornowski has no relevant disclosures. Dr. Latib is a consultant for Medtronic and has received honoraria from Abbott Vascular. Dr. D'Onofrio is a proctor for Edwards Lifesciences and for Symetis. Dr. Ribichini has no relevant disclosures. Dr. Dangas has no relevant disclosures. Dr. Mehran has no relevant disclosures. Dr. Delewi has no relevant disclosures. Dr. van Royen received research grants from Abbott Vascular, Philips, and Biotronik, speaker honoraria from Abbott Vascular and is consultant for Medtronic, Rainmed and Castor., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Grading paravalvular leak (PVL) at the time of transcatheter aortic valve implantation (TAVI) deployment is challenging. Per-procedural invasive hemodynamic measurements could serve to optimize PVL grading and predict outcome after TAVI. The aim of this study was to compare hemodynamic measures of paravalvular leak and their prognostic relevance in self-expanding TAVI devices. Between December 2008 and December 2017 consecutive patients treated for severe symptomatic aortic valve stenosis with self-expanding devices were prospectively studied. Peri-procedural hemodynamic measurements, echocardiographic data as well as clinical follow-up according to VARC-2 criteria were prospectively collected. Diastolic delta (DD), heart rate adjusted DD, aortic regurgitation index (ARI) and ARI ratio were calculated and assessed for their association with 1-year mortality. A total of 651 patients were studied. Moderate or severe paravalvular leakage was found in 4.8% of patients. ARI ratio < 0.6 (hazard ratio 1.96 [1.23-3.12], P = 0.005) was the best independent predictor of 1-year mortality. This study confirms the value of hemodynamic measures, specifically ARI ratio, for prognostication, potentially supporting procedural decision-making with regard to PVL., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Extracorporeal circulation is accompanied by changes in red blood cell morphology and structural integrity that affect cell function and survival, and thereby may contribute to the various side effects of heart-lung machine-assisted surgery. Our main objectives were to determine the effect of circulation of red blood cells in a stand-alone extracorporeal circuit on several parameters that are known to be affected by, as well as contribute to red blood cell aging. As a source of RBCs, we employed blood bank storage units of different ages. In order to assess the relevance of our in vitro observations for the characterization of extracorporal circulation technology, we compared these changes in those of patients undergoing extracorporeal circulation-assisted cardiac surgery. Our results show that circulation in a heart-lung machine is accompanied by changes in red blood cell volume, an increase in osmotic fragility, changes in deformability and aggregation behavior, and alterations in the exposure of phosphatidylserine and in microvesicle generation. RBCs from 1-week-old concentrates showed the highest similarities with the in vivo situation. These changes in key characteristics of the red blood cell aging process likely increase the susceptibility of red blood cells to the various mechanical, osmotic, and immunological stress conditions encountered during and after surgery in the patient's circulation, and thereby contribute to the side effects of surgery. Thus, aging-related parameters in red blood cell structure and function provide a foundation for the validation and improvement of extracorporeal circulation technology., (© 2020 The Authors. Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Aims: Vascular complications are among the most commonly observed complications after TAVI. Iliofemoral vascular outcome has been described extensively. Little is known about vascular complications in transaxillary TAVI. The aim of the current study was to describe the incidence and predictors of axillary artery complications incorporating computed tomography angiography (CTA) measurements., Methods and Results: CT analysis was performed in two hundred patients treated with transaxillary TAVI in our centre between January 2014 and December 2017. Vascular complications occurred in 37 (18.5%) patients. Patient characteristics predicting this outcome were female gender (aOR 3.88 [1.48-10.14], p=0.006) and age (aOR 1.08 [1.01-1.16], p=0.034). The CTA measurement predicting vascular complications was a sheath to artery area ratio (SAAR) equal to or larger than 1.63 (OR 3.95 [1.29-12.12], p=0.016)., Conclusions: The present study describes the incidence of axillary artery complications and identifies patient characteristics associated with this outcome. CTA analysis was shown to be an important screening tool in the assessment of patient (access) eligibility. Axillary artery dimensional screening should be based on vascular luminal area assessment rather than diameter measurement alone.

Background/objectives: Prospectively collected data on postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) are scarce. The aim of this study was to report the incidence and risk factors of delirium after TAVI under general anesthesia and to assess the association of POD with clinical outcome and short- and long-term survival., Design: Prospective cohort study., Setting: Academic medical center., Participants: A total of 703 subsequent patients undergoing TAVI under general anesthesia between 2008 and 2017., Measurements: Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria. Outcomes were postprocedural clinical outcome and short- and long-term survival (30 days and 5 years, respectively)., Results: POD was observed in 16.5% (116/703), was the strongest independent predictor of long-term mortality (hazard ratio = 1.91; 95% confidence interval [CI] = 1.36-2.70), and was associated with impaired 30-day and 5-year survival (92.2% vs 96.8% [P = .025] and 40.0% vs 50.0% [P = .007], respectively). Stroke and new onset of atrial fibrillation were more often observed in delirious patients (6.9% vs 1.9% and 12.1% vs 5.1%, respectively). Strongest independent predictors of POD were prior delirium (odds ratio [OR] = 2.56; 95% CI = 1.52-4.31) and aortic valve area less than 0.75 cm 2 (OR = 2.39; 95% CI = 1.53-3.74)., Conclusion: One in six patients experienced POD after TAVI under general anesthesia. POD was the strongest predictor of long-term mortality and was associated with impaired short- and long-term survival. Prior delirium and a more calcified aortic valve were the strongest independent predictors of POD. J Am Geriatr Soc 67:2325-2330, 2019., (© 2019 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.)

Bone cement leakage is a common complication after percutaneous kyphoplasty. In rare cases, leakage into the venous system occurs, which can be life-threatening, especially when it embolizes the heart. Here, we present a case of cement embolization of the right ventricle with tricuspid valve involvement. A 69-year-old woman with an asymptomatic severe tricuspid valve regurgitation was referred to our department. She had a history of balloon kyphoplasty because of osteoporotic collapsed vertebrae in 2010. Echocardiography showed a foreign body attached to the right ventricle, prolapsing into the right atrium and causing a severe tricuspid valve regurgitation. The foreign body was surgically removed, and the tricuspid valve was replaced with a biological valve. The foreign body was analysed by scanning electron microscopy and element analysis. Zirconium was identified within the foreign body, which is an additive in bone cement used in orthopaedic surgery. Intracardiac cement embolism following percutaneous kyphoplasty is a rare but life-threatening complication. Here, we present a case of tricuspid valve destruction caused by the long-term presence of an intracardiac foreign body, specifically a cement embolus.

Background: Patients with severe aortic stenosis present frequently (∼50%) with concomitant obstructive coronary artery disease. Current guidelines recommend combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) as the preferred treatment. Transcatheter aortic valve implantation (TAVI) and fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) represent a valid treatment alternative. We aimed to test the non-inferiority of FFR-guided PCI plus TAVI versus SAVR plus CABG in patients with severe aortic stenosis and complex coronary artery disease., Methods: This international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial was conducted at 18 tertiary medical centres across Europe. Patients (aged ≥70 years) with severe aortic stenosis and complex coronary artery disease, deemed feasible for percutaneous or surgical treatment according to the on-site Heart Team, were randomly assigned (1:1) to FFR-guided PCI plus TAVI or SAVR plus CABG according to a computer-generated sequence with random permuted blocks sizes stratified by site. The primary endpoint was a composite of all-cause mortality, myocardial infarction, disabling stroke, clinically driven target-vessel revascularisation, valve reintervention, and life-threatening or disabling bleeding at 1 year post-treatment. The trial was powered for non-inferiority (with a margin of 15%) and if met, for superiority. The primary and safety analyses were done per an intention-to-treat principle. This trial is registered with ClinicalTrials.gov (NCT03424941) and is closed., Findings: Between May 31, 2018, and June 30, 2023, 172 patients were enrolled, of whom 91 were assigned to the FFR-guided PCI plus TAVI group and 81 to the SAVR plus CABG group. The mean age of patients was 76·5 years (SD 3·9). 118 (69%) of 172 patients were male and 54 (31%) patients were female. FFR-guided PCI plus TAVI resulted in favourable outcomes for the primary endpoint (four [4%] of 91 patients) versus SAVR plus CABG (17 [23%] of 77 patients; risk difference -18·5 [90% CI -27·8 to -9·7]), which was below the 15% prespecified non-inferiority margin (p non-inferiority <0·001). FFR-guided PCI plus TAVI was superior to SAVR plus CABG (hazard ratio 0·17 [95% CI 0·06-0·51]; p superiority <0·001), which was driven mainly by all-cause mortality (none [0%] of 91 patients vs seven (10%) of 77 patients; p=0·0025) and life-threatening bleeding (two [2%] vs nine [12%]; p=0·010)., Interpretation: The TCW trial is the first trial to compare percutaneous treatment versus surgical treatment in patients with severe aortic stenosis and complex coronary artery disease, showing favourable primary endpoint and mortality outcomes with percutaneous treatment., Funding: Isala Heart Centre and Medtronic., Competing Interests: Declaration of interests EKe reports institutional research grants from Abbott Vascular Laboratories and Medtronic and proctor or lecture fees from Abbott Vascular. RSH reports lecture fees from Abbott Vascular, Amgen, Novartis, Edwards Lifesciences, and Meril. DvG reports lecture fees from Cardiovasculair Onderwijs Instituut. GA reports lecture fees from Medtronic, Abbott, and Meril Life, patents planned for Tdaflo, and being a data and safety monitoring board member for Vivasure. IJA-S reports proctor, lecture, and consultant fees from Medtronic, Boston Scientific, Meril Life, and Products&Features. MA reports institutional research grants from Edwards, Abbott, Medtronic, and LSI, and proctor, lecture, and consultant fees from Edwards Lifesciences, Abbott, Medtronic, Boston, Zoll, and BBraun. GB reports a consulting grant from Medtronic. LC reports consulting fees from Medtronic, Abbott, JenaValve, Edwards Lifesciences, BostonScientific, PiCardia, MicroPort, VenusMedtech, 4C Medical, Smartcanula, MicroInterventions, and Neovasc, support for attending meetings or travel (or both) from Medtronic, Abbott, JenaValve, Edwards Lifesciences, and BostonScientific, and being a data and safety monitoring board member for Medtronic, Abbott, and JenaValve. LvG reports proctor fees from Edwards Lifesciences and support for attending meetings or travel (or both) from Edwards Lifesciences, Corcym, and Atricure. WW reports lecture fees from Medtronic and is a data safety monitoring board member for Medtronic. VV reports consulting fees from Medtronic. JS reports lecture fees from Abiomed. EL reports institutional research grants from Abbott. LN-F reports consulting fees from Abbot, Edwards Lifesciences, and Boston, and proctor, lecture, and consultant fees from Abbott, Edwards Lifesciences, Medtronic, and Boston. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Myasthenia gravis (MG) with antibodies against the acetylcholine receptor (AChR-MG) is considered as a prototypic autoimmune disease. The thymus is important in the pathophysiology of the disease since thymus hyperplasia is a characteristic of early-onset AChR-MG and patients often improve after thymectomy. We hypothesized that thymic B cell and antibody repertoires of AChR-MG patients differ intrinsically from those of control individuals. Using immortalization with Epstein-Barr Virus and Toll-like receptor 9 activation, we isolated and characterized monoclonal B cell lines from 5 MG patients and 8 controls. Only 2 of 570 immortalized B cell clones from MG patients produced antibodies against the AChR (both clones were from the same patient), suggesting that AChR-specific B cells are not enriched in the thymus. Surprisingly, many B cell lines from both AChR-MG and control thymus samples displayed reactivity against striated muscle proteins. Striational antibodies were produced by 15% of B cell clones from AChR-MG versus 6% in control thymus. The IgVH gene sequence analysis showed remarkable similarities, concerning VH family gene distribution, mutation frequency and CDR3 composition, between B cells of AChR-MG patients and controls. MG patients showed clear evidence of clonal B cell expansion in contrast to controls. In this latter aspect, MG resembles multiple sclerosis and clinically isolated syndrome, but differs from systemic lupus erythematosus. Our results support an antigen driven immune response in the MG thymus, but the paucity of AChR-specific B cells, in combination with the observed polyclonal expansions suggest a more diverse immune response than expected., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: The accuracy of a three-dimensional robotic-assisted videothoracoscopic approach may favor a radical resection of thymomas. The aim of this study was to demonstrate the feasibility of the robotic approach by reporting 8 years experience in a single referral center of surgical treatment of thymomas., Methods: We retrospectively analyzed all consecutive patients who underwent a thymectomy from April 2004 to April 2012. We analyzed the procedure time, morbidity, mortality, conversions, hospitalization, freedom from recurrence, time to progression, and overall survival., Results: From 2004 until 2012, a total of 138 robotic procedures for mediastinal tumors were performed in our center, of which 37 patients with a mean age of 57.3 years underwent a thymectomy for a thymoma. Histological analysis revealed four type A thymomas (10.8 %), seven type AB thymomas (18.9 %), seven type B1 thymomas (18.9 %), fourteen type B2 thymomas (37.8 %), four type B3 thymomas (10.8 %), and one thymus carcinoma (2.7 %). The Masaoka–Koga stages were as follows: stage I in twenty patients (54 %), stage IIA in five patients (13.5 %), stage IIB in eight patients (21.6 %), stage III in three patients (8.1 %), and stage IVa in one patient (2.7 %). The mean overall procedure time was 149 min (range 88–353). No surgical mortality was reported, and there were no peri-operative complications. No conversions were needed for surgical complications. In three cases, a conversion to sternotomy was preferred by the surgeon because tumor invasion in greater vessels was suspected. Two patients (5.4 %) suffered from a myasthenic crisis postoperatively and required prolonged mechanical ventilation. One patient (2.7 %) underwent a procedure for a thoracic herniation 6 months following thymectomy. The median hospitalization was 3 days. The follow-up analysis showed an overall survival of 100 % and tumor recurrence in one patient (2.7 %)., Conclusions: Robotic thymectomies are safe in patients with early-stage thymomas. Robotic surgery may also be feasible for some selected advanced thymomas.

Background: There is scant information on the prevalence and factors associated with preoperative anemia in patients undergoing transcatheter aortic valve implantation (TAVI) and whether it is associated with mortality. We sought to determine the prevalence and factors associated with preoperative anemia in addition to the prognostic effects of the various levels of preoperative hemoglobin level on mortality in patients undergoing TAVI., Methods and Results: Ten-center observational study encompassing 1696 patients with aortic stenosis who underwent TAVI was conducted. Anemia was defined by the World Health Organization criteria (hemoglobin <12.0 g/dL in women and <13.0 g/dL in men). The prevalence of preoperative anemia was 57%. Patient-related factors associated with preoperative anemia were (descending order of odds ratio [95% confidence interval]) as follows: anemia-related medication (4.90 [3.08-7.80]), history of heart failure (1.77 [1.43-2.20]), male sex (1.69 [1.32-2.16]), mitral regurgitation grade ≥III (1.61 [1.15-2.25]), history of malignancy (1.44 [1.03-2.09]), and peripheral vascular disease (1.33 [1.04-1.70]). The creatinine clearance was inversely associated with preoperative anemia (odds ratio, 0.92 [0.87-0.97]). In multivariable analyses, preoperative anemia was not associated with 30-day mortality (1.72 [0.96-3.12]; P=0.073) but showed the strongest association with 1-year mortality with a hazard ratio (95% confidence interval) of 2.78 (1.60-4.82) in patients with hemoglobin <10 g/dL. Patients with anemia received ≥1 blood transfusion 2× more often, but the indication of transfusion was unrelated to overt bleeding in 60%. Blood transfusion was associated with mortality at 30 days (odds ratio, 1.25 [95% confidence interval, 1.08-3.67]) and during follow-up (hazard ratio, 1.09 [95% confidence interval, 1.03-1.14])., Conclusions: Preoperative anemia is prevalent in >50% of patients undergoing TAVI. Various baseline factors were related to anemia, which in turn was associated with 1-year mortality. Patients with anemia received more transfusions but mostly for indications unrelated to overt bleeding, whereas transfusion was independently associated with both early and 1-year mortality. These findings indicate that optimization of baseline factors related to preoperative anemia, in addition to more strict criteria of the use of blood products, may improve outcome after TAVI.

Background: In our study, we investigated the impact of papillary muscle systolic dyssynchrony (DYS-PAP) obtained by 2D speckle-tracking echocardiography (2D-STE) in the prediction of recurrent ischemic mitral regurgitation (MR) after restrictive annuloplasty., Methods: The study population consisted of 524 consecutive patients who survived coronary artery bypass grafting (CABG) and restrictive annuloplasty, performed between 2001 and 2010 at 3 different Institutions and who met inclusion criteria. The assessment of DYS-PAP was performed preoperatively and at follow-up (median 45.3 months [IQR 26-67]) by 2D-STE in the apical four-chamber view for the anterolateral papillary muscle (ALPM) and apical long-axis view for the posteromedial papillary muscle (PMPM)., Results: Recurrence of MR (≥ 2+ in patients with no/trivial MR at discharge) was found in 112 patients (21.3%) at follow-up. Compared to patients without recurrence of MR, these patients had higher DYS-PAP values at baseline (60.6 ± 4.4 ms vs. 47.2 ± 2.9 ms, p<0.001) which significantly worsened at follow-up (74.4 ± 5.2 ms, p=0.002 vs. baseline). In contrast, in patients with no MR recurrence, DYS-PAP was significantly reduced (25.3 ± 4.4 ms, p=0.002 vs. baseline). At logistic regression analysis DYS-PAP (odds ratio [OR]: 4.8, 95% Confidence Interval [CI]: 3.4-8.2, p<0.001), was the strongest predictor of recurrent MR with a cutoff ≥ 58 ms (95%CI 51-66 ms). The model showed an area under the Receiver Operating Characteristic (ROC) curve of 0.97 (CI 0.94-0.99 [optimism-corrected 0.94; CI 0.89-0.95]) with 98% sensitivity (CI 96-100% [optimism-corrected 95%; CI 91-96%]) and 90% specificity (CI 85-94% [optimism-corrected 87%; CI 82-90%])., Conclusions: DYS-PAP represents a reliable tool to identify patients with ischemic MR who can benefit from restrictive annuloplasty., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Aims: We retrospectively evaluated left atrial (LA) strain and strain rate (SR) before and after undersized mitral ring annuloplasty (UMRA) for chronic ischaemic mitral regurgitation (CIMR) with two-dimensional speckle-tracking echocardiography., Methods and Results: Left atrial volumes, LA reservoir, LA conduit, LA contractile phases, and LA ejection fraction (LAEF) were measured in 95 CIMR patients who underwent coronary bypass grafting and UMRA. Left atrial peak global strain (ε), LA reservoir (SRp), LA conduit (SRE), and LA contractile phase (SRA) strain rates were obtained at the baseline and at the follow-up (median 41.5 months, interquartile range 23-61). Based on the recurrence of mitral regurgitation (MR) at the follow-up, the patients were divided into two groups: patients with (group MR+, n = 30) or without (group MR-, n = 65) recurrent MR. Twenty age-and gender-matched healthy adults were controls. In the MR- group, baseline ε (P < 0.001), SRP (P < 0.001), SRE (P < 0.001), and SRA (P < 0.001) were enhanced, while in MR+ group, ε (P < 0.001), SRP (P = 0.03), SRE (P = 0.03), and SRA (P = 0.003) were worse than controls. At the follow-up, none of these indices changed in the MR+ group while all returned to normal values in patients belonging to the MR- group. Left atrial deformation correlated with corresponding volumetric parameters. Furthermore, we found a direct correlation between SRE and early peak diastolic velocity (E) (ρ = 0.52, P = 0.02) and E-wave deceleration time (ρ = 0.50, P = 0.02). Finally, there was a strong correlation between ε, SRP, and SRA (ρ = 0.72, P < 0.001 and ρ = 0.79, P < 0.001, respectively) and SRE (ρ = 0.69, P < 0.001 and ρ = 0.71, P < 0.001, respectively). Finally, ε, SRP, and SRE (all, P < 0.001) were co-factors associated to recurrent MR., Conclusion: Left atrial peak global strain, peak systolic SR, and peak early diastolic SR were cofactors associated to recurrent MR. The assessment of LA strain and SR, in addition to other echocardiographic parameters, can be helpful in detecting patients undergoing UMRA who are unlikely to benefit from annuloplasty.

Background: The aim of this retrospective study was to explore whether different tethering patterns in chronic ischemic mitral regurgitation have different distributions of left ventricular (LV) systolic longitudinal, circumferential, and radial strain before and after mitral valve repair., Methods: Sixty-one patients with chronic ischemic mitral regurgitation who underwent mitral repair were divided on the basis of the preoperative anterior/posterior tethering angle ratio (cutoff value, 0.76). There were 29 patients with symmetric (group 1) and 32 with asymmetric (group 2) preoperative tethering patterns. Assessment of longitudinal peak systolic strain was performed offline by applying speckle-tracking imaging to the apical two-chamber, three-chamber, and four-chamber views of the left ventricle. Peak systolic radial and circumferential strain was obtained from short-axis views at the basal, middle, and apical levels. Twenty healthy subjects served as controls., Results: In group 1, baseline LV strain was impaired in all LV segments, with the worst values in the anterolateral, anterior, and inferolateral segments at the midventricular and basal levels. In contrast, asymmetric patients showed higher values in the inferior and inferoseptal walls and values closer to normal in the other segments. After surgery, all strain measurements showed significant improvements in all LV segments in group 2, whereas in Group 1, strain worsened in the inferoseptal, inferior, and anteroseptal walls and did not change in the other segments., Conclusions: Patients with baseline symmetric tethering patterns showed more extensive abnormal strain, which was observed in all LV segments and was not reverted by surgery. These findings require confirmation in additional larger studies., (Copyright © 2013 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

The "hybrid" approach to multivessel coronary artery disease combines surgical left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) bypass grafting and percutaneous coronary intervention of the remaining lesions. Ideally, the LITA to LAD bypass graft is performed in a minimally invasive fashion. This review aims to clarify the place of hybrid coronary revascularization (HCR) in the current therapeutic armamentarium against multivessel coronary artery disease. Eighteen studies including 970 patients were included for analysis. The postoperative LITA patency varied between 93.0% and 100.0%. The mean overall survival rate in hybrid treated patients was 98.1%. Hybrid treated patients showed statistically significant shorter hospital length of stay (LOS), intensive care unit (ICU) LOS, and intubation time, less packed red blood cell (PRBC) transfusion requirements, and lower in-hospital major adverse cardiac and cerebrovascular event (MACCE) rates compared with patients treated by on-pump and off-pump coronary artery bypass grafting (CABG). This resulted in a significant reduction in costs for hybrid treated patients in the postoperative period. In studies completed to date, HCR appears to be a promising and cost-effective alternative for CABG in the treatment of multivessel coronary artery disease in a selected patient population.

In the recent years minimally invasive mitral valve surgery (MIMVS) has become a well-established and increasingly used option for managing patients with a mitral valve pathology. Nonetheless, whether the purported benefits of MIMVS translate into clinically important outcomes remains controversial. Therefore, in this paper we provide an overview of MIMVS and discuss results, morbidity, mortality, and quality of life following mitral minimally invasive procedures. MIMVS has been proven to be a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality. Reported benefits of MIMVS include also decreased postoperative pain, improved postoperative respiratory function, reduced surgical trauma, and greater patient satisfaction. Finally, compared to standard surgery, MIMVS demonstrated comparable efficacy across a range of long-term efficacy measures such as freedom from reoperation and long-term survival.

Background: We evaluated the papillary muscle systolic dyssynchrony (DYS-PAP) using two-dimensional speckle tracking echocardiography (2D-STE) in patients with chronic ischemic mitral regurgitation (CIMR) showing different preoperative leaflet pattern and investigated the impact of baseline tethering pattern in the prediction of significant post-repair desynchronized papillary muscle contraction., Methods: We recruited 152 CIMR consecutive patients (64.4% male, mean age 65.9 ± 7.1 years) who survived coronary artery bypass grafting (CABG) and (undersized mitral ring annuloplasty, performed between 2001and 2010. The assessment of DYS-PAP was performed preoperatively and at follow-up (median 41.5 months [IQR 23-61]) by 2D-STE in the apical 4-chamber view for anterolateral papillary muscle and apical long-axis view for posteromedial papillary muscle). Based on the cutoff value (anterior-posterior tethering angle ratio α/β ≥ 0.76) patients were classified in 2 groups; symmetrical (group 1, n = 73, mean α/β = 0.81 ± 0.6) and asymmetrical preoperative tethering pattern (group 2, n = 79, mean α/β = 0.66 ± 0.4)., Results: Recurrent MR occurred in 67.1% (n = 49) in group 1 versus 3.8% (n = 3) in group 2 (p < 0.001). Comparing both groups at baseline, patients in group 1 had higher DYS-PAP (57.7 ± 5.3 vs 29.8 ± 2.4 ms in group 2, p < 0.001) that significantly worsened at follow-up (78.1 ± 8.8 ms, p < 0.001 versus baseline), whereas in group 2 it improved (26.6 ± 6.0 ms, p < 0.001 versus baseline). Tethering symmetry significantly correlated with DYS-PAP (r = 0.90, p < 0.001) and it was a strong multivariable predictor of significant postoperative DYS-PAP (odds ratio 4.2; 95% confidence level 3.4 to 5.2, p < 0.001)., Conclusions: Tethering symmetry is an easy and immediate tool to identify CIMR patients with advanced DYS-PAP who are unlikely to benefit from mitral repair with undersized mitral ring annuloplasty., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: We investigated the impact of papillary muscle dyssynchrony (DYS-PAP) in predicting recurrent mitral regurgitation (MR) in patients with ischemic cardiomyopathy (ICM) undergoing undersized mitral ring annuloplasty (UMRA)., Methods: One hundred forty-four ICM patients (left ventricular ejection fraction <35%) in sinus rhythm undergoing UMRA between January 2001 and December 2010 at three Institutions (University Hospital, Maastricht, The Netherlands; Careggi Hospital, Florence, Italy; Civic Hospital, Brescia, Italy) were recruited. The primary endpoint was the recurrence of MR at the latest echocardiographic study defined as insufficiency ≥2+ in patients with no/trivial MR at discharge. The assessment of DYS-PAP was performed by applying two-dimensional (2D) speckle-tracking imaging., Results: In patients with MR recurrence, DYS-PAP significantly worsened (84.1 ± 8.8 msec vs.65.4 ± 8.8 msec at baseline, P < 0.001) whereas in patients with no MR recurrence, DYS-PAP did not vary (22.3 ± 5.3 msec vs. 25.9 ± 7.2 msec at baseline, P = 0.8). Recurrent MR was positively correlated with preoperative DYS-PAP (P < 0.001), baseline anterior mitral leaflet tethering angle α (P < 0.001) and tethering symmetry index α/β before surgery (P < 0.001). There was no significant correlation between MR recurrence and other echocardiographic parameters. Logistic regression analysis revealed that baseline values of DYS-PAP (OR: 5.4 [95% CI: 3.1-7.7], P < 0.001), α (OR: 5.0 [2.6-6.7], P < 0.001), and α/β (OR: 3.9 [2.5-5.7], p < 0.001) were predictors of recurrent MR. A DYS-PAP value ≥ 58 msec predicted recurrence of MR with 100% sensitivity and 83% specificity (area under the curve [AUC]: 0.92 [0.7-1], P < 0.001)., Conclusions: A DYS-PAP cutoff value of 58 msec is useful to identify patients in whom UMRA is likely to fail. That way decision making in ischemic functional MR might be facilitated., (© 2012, Wiley Periodicals, Inc.)

Background: Blood transfusion is associated with acute kidney injury (AKI) after transcatheter aortic valve implantation (TAVI). We sought to elucidate in more detail the relation between blood transfusion and AKI and its effects on short- and long-term mortality., Methods and Results: Nine hundred ninety-five patients with aortic stenosis underwent TAVI with the Medtronic CoreValve or the Edwards Valve in 7 centers. AKI was defined by the Valve Academic Research Consortium (absolute increase in serum creatinine ≥0.3 mg/dL [≥26.4 μmol/L] or ≥50% increase ≤72 hours). Logistic and Cox regression was used for predictor and survival analysis. AKI occurred in 20.7% (n=206). The number of units of blood transfusion ≤24 hours was the strongest predictor of AKI (≥5 units, OR, 4.81 [1.45-15.95], 3-4 units, OR, 3.05 [1.24-7.53], 1-2 units, OR, 1.47 [0.98-2.22]) followed by peripheral vascular disease (OR, 1.48 [1.05-2.10]), history of heart failure (OR, 1.43 [1.01-2.03]), leucocyte count ≤72 hours after TAVI (OR, 1.05 [1.02-1.09]) and European System for Cardiac Operative Risk Evaluation (EuroSCORE; OR, 1.02 [1.00-1.03]). Potential triggers of blood transfusion such as baseline anemia, bleeding-vascular complications, and perioperative blood loss were not identified as predictors. AKI and life-threatening bleeding were independent predictors of 30-day mortality (OR, 3.15 [1.56-6.38], OR, 6.65 [2.28-19.44], respectively), whereas transfusion (≥3 units), baseline anemia, and AKI predicted mortality beyond 30 days., Conclusions: AKI occurred in 21% of the patients after TAVI. The number of blood transfusions but not the indication of transfusion predicted AKI. AKI was a predictor of both short- and long-term mortality, whereas blood transfusion predicted long-term mortality. These findings indicate that outcome of TAVI may be improved by more restrictive use of blood transfusions.