Search Results (957)

Balloon valvuloplasty is a commonly performed catheter-based procedure in dogs with congenital pulmonic stenosis. Worldwide, veterinary cardiologists often administer peri- and postoperative prophylactic antimicrobials to prevent infectious complications, like bacterial endocarditis. Infective endocarditis of the pulmonary valve is, however, extremely rare in dogs, and it has never been reported after balloon valvuloplasty. The objective of this retrospective case series was to investigate the incidence of infective endocarditis, if balloon dilatation of pulmonic stenosis was performed without antimicrobial prophylaxis. Medical records of dogs operated at a university teaching hospital in a 20-year period from 2006 to 2025 were reviewed for clinical signs and echocardiographic changes that could be caused by infective endocarditis. Of the 83 dogs that were operated without peri- or postoperative antimicrobial prophylaxis, survived the surgery, and had at least three weeks of follow-up, none developed infective endocarditis. Follow-up in 68 dogs was based on medical history, physical examination and echocardiography during rechecks at the authors’ institution. Follow-up information from the remaining 15 dogs was gained from the owners and/or the referring veterinarians. Our study demonstrated zero event rate in dogs that underwent balloon dilatation of congenital pulmonic stenosis without antimicrobial prophylaxis. Full article

Infective endocarditis (IE) continues to represent a major challenge for global health systems. In 2019, its annual incidence was estimated at 13.8 cases per 100,000 individuals, contributing to approximately 66,300 deaths worldwide. Due to its high morbidity and mortality rates, enhancing preventive measures has become a priority in both clinical practice and ongoing research efforts. Since the publication of the 2015 ESC Guidelines for the management of IE, several pivotal studies have emerged, prompting a re-evaluation and potential update of the existing recommendations. One growing concern is the increasing antibiotic resistance among oral streptococci, particularly to macrolides such as azithromycin and clarithromycin, which now show higher resistance levels than penicillin. Changes in national antibiotic stewardship programs may have inadvertently contributed to a rise in IE incidence, in part due to altered prophylactic practices. At the same time, advances in diagnostic modalities—including more widespread and targeted use of echocardiography in patients with positive blood cultures for organisms like Enterococcus faecalis, Staphylococcus aureus, and various streptococci—have likely improved detection rates. Additionally, innovations in imaging, particularly computed tomography (CT) and nuclear medicine techniques, have enhanced the diagnosis of IE, especially among patients with prosthetic heart valves or implantable cardiac devices. This has allowed for better characterization of patient populations, aiding in the refinement of diagnostic criteria and therapeutic approaches. Furthermore, updated antibiotic treatment protocols, informed by EUCAST’s antimicrobial susceptibility data, have helped tailor antimicrobial regimens to current resistance trends. The combination of improved diagnostic sensitivity and evolving microbial resistance patterns has also led to an increased number of patients being considered for cardiac surgery as part of their treatment pathway. This review seeks to synthesize the latest findings and guideline revisions, offering an integrated overview of recent progress in the diagnosis, medical treatment, and surgical management of infective endocarditis. It will also explore current therapeutic strategies and operative indications in light of the most recent evidence. Full article

Background: Acute kidney injury (AKI) is a common complication following cardiac surgery and is associated with increased morbidity and mortality. Contemporary national estimates of its clinical and economic burden in the United States remain limited. Methods: We conducted a retrospective cross-sectional study using the Nationwide Inpatient Sample (NIS) for 2022–2023. Adult hospitalizations undergoing coronary artery bypass grafting (CABG), valve surgery, or combined CABG and valve surgery were identified using ICD-10-PCS codes. Hospitalizations with end-stage kidney disease were excluded. The primary exposure was AKI. Outcomes included in-hospital mortality, length of stay (LOS), non-home discharge, and hospitalization cost. Survey-weighted multivariable regression models were used to evaluate the independent association between AKI and study outcomes. Results: The final cohort included 133,801 hospitalizations, representing an estimated 669,005 cardiac surgery hospitalizations nationally. AKI occurred in 123,240 weighted hospitalizations (18.4%). Compared with hospitalizations without AKI, those with AKI had higher unadjusted mortality (7.21% vs. 0.71%), longer LOS (14.4 vs. 6.3 days), greater rates of non-home discharge (68.1% vs. 41.2%), and higher hospitalization costs ($97,452 vs. $56,253). After adjustment for demographic, socioeconomic, clinical, and procedural characteristics, AKI remained independently associated with in-hospital mortality (adjusted odds ratio [aOR] 9.91, 95% confidence interval [CI] 8.95–11.00), non-home discharge (aOR 2.52, 95% CI 2.42–2.63), prolonged LOS (adjusted rate ratio [aRR] 1.88, 95% CI 1.85–1.91), and increased hospitalization costs (cost ratio 1.59, 95% CI 1.56–1.61). AKI was associated with an adjusted incremental cost of $33,497 per hospitalization, corresponding to an estimated national attributable cost burden of $4.13 billion during the study period. Conclusions: AKI complicates nearly one in five cardiac surgery hospitalizations in the United States and is associated with substantially increased mortality, healthcare utilization, and hospitalization costs. These findings highlight the significant clinical and economic burden of cardiac surgery–associated AKI and support continued efforts to improve prevention, risk stratification, and perioperative management. Full article

Systolic anterior motion (SAM) of the mitral valve can occur either in association with or in the absence of hypertrophic obstructive cardiomyopathy (HOCM). SAM induces dynamic left ventricular outflow tract obstruction (LVOTO) and, in the majority of cases, is associated with a substantial degree of mitral regurgitation (MR) that significantly impacts patient morbidity and mortality. This narrative review explores the contemporary understanding of the pathophysiology, diagnosis, and management of SAM, focusing particularly on surgical strategies and the novel therapeutic class of cardiac myosin inhibitors. Extended septal myectomy remains the gold-standard treatment for HOCM-related SAM, yielding superior long-term outcomes compared to alcohol septal ablation (ASA). Advanced imaging modalities, including three-dimensional transesophageal echocardiography (3D-TEE), enable precise pre-operative characterization of the mitral valve apparatus. Some patients may benefit from septal reduction strategies while concomitant mitral valve interventions are generally reserved for highly selected cases with intrinsic valve pathology or persistent residual SAM, thereby avoiding unnecessary valvular manipulation and its potential hemodynamic risks. Mavacamten, a selective cardiac myosin inhibitor, represents an important advance in pharmacological management, achieving a mean LVOT gradient reduction of 37.2 mmHg in symptomatic patients. Furthermore, data from the MARVEL registry confirm the real-world clinical efficacy of mavacamten in obstructive hypertrophic cardiomyopathy, with 86% of patients successfully down-staged to NYHA functional class I–II. Although ASA serves as a viable alternative to surgery, it entails a higher risk of conduction abnormalities requiring permanent pacemaker implantation and subsequent re-intervention. Beyond classical hypertrophic SAM, this review addresses the diagnosis and management of post-mitral repair complications and non-hypertrophic variants. Optimal management and risk stratification remain an evolving field requiring a multidisciplinary Heart Team approach, leverage of advanced imaging, and adoption of novel medical therapies. Interventional strategies must be carefully tailored to maximize the efficacy-to-safety profile on an individualized patient basis. Full article

Background: Minimally invasive approaches for multivalve surgery have attracted increasing interest; however, data on combined aortic and mitral valve replacement or repair using via right anterior minithoracotomy remain quite limited. This study aimed to evaluate the feasibility, safety, and early outcomes of minimally invasive concomitant aortic and mitral valve replacement or repair using this approach. Methods: This retrospective study included 24 patients who underwent simultaneous aortic and mitral valve procedures via right anterior minithoracotomy. We collected preoperative, intraoperative, and postoperative data, assessing echocardiographic parameters. Early clinical outcomes, complications, and mortality rates were analyzed, with correlations between EuroSCORE II and outcomes explored. Results: The median follow-up was 412 days. All procedures were completed successfully without conversion to sternotomy. Postoperative echocardiography demonstrated a significant reduction in transvalvular gradients, with aortic mean pressure gradient decreasing from 51.3 ± 23.0 mmHg to 6.7 ± 1.7 mmHg (p < 0.001) and mitral mean pressure gradient from 19.3 ± 26.7 mmHg to 4.0 ± 1.4 mmHg (p < 0.001), while left ventricular ejection fraction remained unchanged (p = 0.67). During the study period, one patient died from a non-cardiac cause. EuroSCORE II showed a moderate positive correlation with intensive care unit length of stay (p = 0.011) but not with hospital stay or operative times. Conclusions: Minimally invasive aortic and mitral valve replacement or repair via right anterior minithoracotomy is feasible and was associated with favorable early hemodynamic and clinical outcomes in this single-center cohort. Full article

Objectives: Functional tricuspid regurgitation (TR) recurrence after concomitant mitral–tricuspid surgery remains associated with adverse long-term outcomes, while reintervention on the isolated tricuspid valve carries substantial operative risk. Despite increasing awareness of the prognostic importance of functional TR, concomitant tricuspid valve repair remains inconsistently adopted in contemporary practice, particularly in technically demanding procedures. We sought to identify predictors of recurrent TR and develop an individualized prediction model to support patient-tailored surgical planning. Methods: This single-center ambispective study included 178 consecutive patients undergoing concomitant mitral–tricuspid surgery between January 2012 and June 2019. Baseline clinical, echocardiographic and operative variables were retrospectively collected, whereas long-term clinical and echocardiographic follow-up was prospectively completed after Ethics Committee approval. Clinical, echocardiographic and operative variables were first evaluated by univariable Cox proportional hazards analysis. Based on their univariable association with recurrent TR, biological plausibility and clinical relevance, candidate predictors were subsequently entered into a multivariable Cox proportional hazards model while limiting model complexity according to the number of available outcome events. Internal validation was performed by bootstrap resampling, and regression coefficients were transformed into an exploratory individualized perioperative nomogram estimating 5-year tricuspid regurgitation recurrence-free survival. Results: Univariable analysis identified female sex, dyslipidemia, left ventricular ejection fraction < 45%, severe pre-operative TR, indexed tricuspid annular diameter and suture-based annuloplasty as predictors of recurrent TR. Multivariable analysis identified surgical repair strategy as the only independent predictor associated with recurrent TR, with suture-based annuloplasty showing a significantly higher recurrence risk than prosthetic ring annuloplasty. These variables were integrated into an exploratory individualized prediction model estimating 5-year recurrence-free survival: the FuTURe nomogram. Conclusions: Our findings confirm the association between prosthetic ring annuloplasty and a lower risk of recurrent TR, consistent with current evidence supporting ring implantation as the preferred repair strategy. Beyond identifying predictors of recurrence, the FuTURe study proposes an exploratory perioperative individualized prediction model intended to complement current guideline recommendations. Consistent with its acronym, the FuTURe study shifts the focus from immediate procedural success to the patient’s future clinical trajectory, highlighting the value of individualized recurrence-risk assessment from a lifetime management perspective. Full article

Background: Minimally invasive cardiac valve surgery has emerged as a preferred approach in selected patients, yet optimal postoperative extubation timing remains debated. This systematic review and meta-analysis examined clinical outcomes associated with extubation in the operating room (OR) versus the intensive care unit (ICU) among adult patients undergoing minimally invasive cardiac valve surgery. Methods: The study was conducted according to PRISMA guidelines. A single unit of analysis was applied throughout. Pooled odds ratios were computed with the Mantel–Haenszel random-effects method; where a study reported only a matched or covariate-adjusted estimate, that estimate was reserved for a prespecified sensitivity analysis using the generic inverse-variance method. Results: Five observational studies (2023–2025) including 1101 OR-extubated and 899 ICU-extubated patients from high-volume centers with fast-track or enhanced recovery pathways were included. OR extubation was associated with lower odds of reintubation (OR 0.40; 95% CI 0.24–0.69; I² = 0%), postoperative delirium (OR 0.47; 95% CI 0.31–0.72; I² = 0%), and pneumonia (OR 0.30; 95% CI 0.16–0.53; I² = 0%). No significant differences were observed for new-onset atrial fibrillation, stroke, or reoperation for bleeding. Thirty-day mortality was reported by four of the five studies and comprised few events (5 of 1043 ORE versus 17 of 645 ICE across the four studies reporting this outcome); given the small number of events, the concentration of deaths in the higher-risk ICU-extubated patients, and the reliance of the pooled estimate on two confounded cohorts, this difference is not interpretable as a treatment effect, and no pooled odds ratio is reported here. Length of stay was consistently shorter after OR extubation but was not pooled because of extreme heterogeneity (I² = 96–100%). Sensitivity analyses using adjusted estimates attenuated the associations for reintubation and pneumonia, consistent with substantial confounding by indication. Conclusions: In appropriately selected patients undergoing minimally invasive valve surgery, OR extubation is feasible and is associated with a recovery profile at least comparable to that of ICU extubation. Because extubation location was determined largely by intraoperative and early postoperative stability, these associations should be read as reflecting patient selection rather than a causal benefit of the strategy. The findings support the feasibility of OR extubation in appropriately selected patients at experienced centers and motivate prospective, ideally randomized, evaluation. Full article

Background/Objectives: Reoperative (redo) cardiac surgery carries elevated risk, yet determinants and mechanisms of early death in valve- and endocarditis-predominant cohorts are poorly described. We aimed to identify preoperative determinants of early mortality, derive a clinically usable risk model, examine the mechanisms of death, and evaluate EuroSCORE II. Methods: We analysed all redo cardiac operations through repeat sternotomy at a single tertiary centre (December 2010–December 2025); the cohort comprised 821 patients with verified in-hospital mortality status. Independent preoperative predictors were identified by multivariable logistic regression. Discrimination and calibration of the model and of EuroSCORE II were compared, and procedural complexity, graded low-cardiac-output severity, postoperative morbidity, and failure-to-rescue were examined. Results: The early mortality rate was 22.8% (187/821). The independent preoperative predictors were chronic kidney disease (adjusted odds ratio 2.25), age ≥70 years (2.32), active endocarditis (1.89), advanced functional class (1.78), non-elective status (1.69), and systolic pulmonary artery pressure (1.15 per 10 mmHg); the model discriminated and calibrated well (concordance statistic 0.755). EuroSCORE II discriminated similarly but systematically under-predicted mortality (observed-to-expected ratio 1.46; worst 2.06 at intermediate risk). Mortality rose with procedural complexity (17.3% to 37.3%) and graded haemodynamic support (3.4% to 79.1%). Failure-to-rescue was 38.5%, compared with 5.8% mortality in patients without a major complication. A standard-risk subgroup (n = 209) had 12.4% mortality. Conclusions: Early mortality after redo cardiac surgery is driven by identifiable preoperative comorbidity, procedural complexity, and low-cardiac-output physiology, and is concentrated in failure-to-rescue. A parsimonious preoperative model predicted mortality well; EuroSCORE II, although discriminating, systematically under-predicted risk, supporting redo-specific assessment and recalibration. Full article

In humans, surgical repair is commonly performed for infective endocarditis (IE) associated with mitral valve destruction. However, extensive valve destruction may make repair impossible and require prosthetic valve replacement. In small-breed dogs, appropriately sized prosthetic valves are lacking, and complete surgical mitral valve reconstruction in dogs has not been reported. We encountered a Chihuahua that developed IE after mitral valve repair. During reoperation for progressive mitral regurgitation recurrence, the mitral leaflets were extensively destroyed and torn, and re-repair using native tissue was impossible; the entire valve was therefore reconstructed with fresh autologous pericardium. A graft was harvested and fashioned into a cylindrical valve based on a design previously described in a human study. Intraoperative saline testing and immediate postoperative echocardiography confirmed adequate opening and closure of the reconstructed pericardial valve, with only mild mitral regurgitation and no stenosis. The dog died on the second day after reoperative day of an uncontrolled infection caused by extended-spectrum beta-lactamase-producing Escherichia coli. This case demonstrates that an autologous pericardial valve can provide short-term mechanical function as a mitral valve in a small-breed dog and indicates that infection control is the principal determinant of outcome. Full article

Background: Tricuspid valve surgery is indicated for severe symptomatic tricuspid valve regurgitation (TR) when performed concomitant to another cardiac operation. While percutaneous therapies for TR continue to advance, anatomic constraints may necessitate consideration of surgery in some patients. Methods: Herein, we provide a contemporary review of surgical techniques used to treat TR, which can serve as a complement to existing and emerging tricuspid valve treatment therapies. Results: We performed a literature review on established surgical tricuspid repair techniques. Conclusions: Surgical repair of the tricuspid valve is safe and feasible. While annuloplasty remains the cornerstone operative strategy, leaflet and sub-valvular techniques serve as adjuncts to help successful repair. The therapeutic paradigm for TR continues to evolve. Full article

Background/Objectives: Femoral cannulation is the cornerstone of endoscopic minimally invasive heart valve surgery (MICS). We compared three femoral access strategies—surgical cut-down, suture-based percutaneous closure (ProGlide^®) and plug-based percutaneous closure (MANTA^®)—for access-site outcomes, operative times and 30-day morbidity. Methods: This is a retrospective single-centre analysis of 445 consecutive patients undergoing endoscopic MICS (February 2021–May 2025). Access strategy (cut-down n = 119; ProGlide n = 219; MANTA n = 107) was selected by preoperative CT angiography and the surgeon’s discretion, with hostile anatomy triaged to cut-down. Baseline characteristics, intraoperative timing, primary haemostasis, conversion and 30-day outcomes were compared; a multivariable model within the percutaneous cohort adjusted for arterial cannula size and baseline covariates was used. Results: The mean age was 61.6 ± 11.3 years; 60.8% were male. EuroSCORE II was comparable between the percutaneous and cut-down groups (1.89 ± 2.55 vs. 2.03 ± 2.41; p = 0.594). Primary haemostasis was higher with MANTA than ProGlide (96.2% vs. 83.1%; p = 0.001; adjusted OR 4.79). Conversion to cut-down was similar (3.7% vs. 3.6%; p = 1.000). Intervention-requiring groin complications were fewer with percutaneous access (3.7% vs. 7.5%; p = 0.232). Cross-clamp, bypass and total operative times were shortest with MANTA (all p < 0.001). In-hospital mortality was 2.1% vs. 1.6% (p = 1.000). Conclusions: In appropriately selected patients, percutaneous femoral cannulation in MICS is safe and is associated with fewer groin complications and shorter operative times than cut-down. Within the percutaneous arm, MANTA was associated with a higher rate of primary haemostasis in our institutional experience. Cut-down remains indispensable for hostile femoral anatomy. Full article

Background: Minimally invasive approaches for combined aortic valve and ascending aortic surgery remain challenging. We report a case of utilizing a transaxillary approach (TAX) in combination with the RAM^® system. Methods: A 65-year-old male presented with exertional angina and palpitations. He reported a one-year history of dizziness. Diagnostics revealed severe aortic regurgitation due to a calcified bicuspid aortic valve and an ascending aortic aneurysm measuring 57 × 54 mm. Left ventricular ejection fraction was reduced to 42%. Coronary artery disease was excluded. Surgery was performed via a right transaxillary mini-thoracotomy (3rd intercostal space) using endoscopic visualization. Cardiopulmonary bypass was established through femoral cannulation. After aortic cross-clamping and cardioplegic arrest, the bicuspid valve was excised and replaced with a bioprosthesis. A supracoronary ascending aortic replacement was performed using a Dacron graft. The RAM^® system was used for annular suturing and proximal anastomosis, with automated fastener fixation. Results: The patient was extubated on postoperative day 1 and transferred to intermediate care on day 2. Postoperative recovery was uneventful, with no neurological deficits, bleeding, or other complications. Discharge occurred on postoperative day 9 in stable condition. Conclusions: This case highlights the feasibility and safety of a minimally invasive transaxillary approach for combined aortic valve and ascending aortic replacement using the RAM^® system. This technique may expand the surgical armamentarium for complex aortic pathology while avoiding sternotomy. Further studies are required to evaluate reproducibility, long-term outcomes, and broader applicability. Full article

Patent foramen ovale (PFO) is a condition present in 20–25% of the general population and can rarely be associated with clinical conditions such as stroke, decompression sickness, desaturation, and migraine with aura. Screening for PFO for primary prevention is not recommended. Several trials have been published demonstrating the efficacy of percutaneous PFO closure in patients under 60 years of age with embolic stroke of unknown etiology. Such evidence has not been achieved in other patient groups, such as those with migraine with aura or decompression sickness. There is also a subset of patients, such as pregnant women or patients undergoing laparoscopic non-cardiac surgery, in whom an increased risk of paradoxical embolism requires preoperative stratification. In all cases, it is necessary to characterize the PFO based on the size of the shunt and the anatomy (e.g., the presence of a large tunnel, prominent Eustachian valve, atrial septal aneurysm), all factors that can increase the risk of paradoxical embolism. This review summarizes the current view on diagnostic and therapeutic work-up of PFO in light of the most recent international guidelines. Full article

Coronary artery bypass grafting is frequently performed in combination with valve surgery; however, minimally invasive approaches for such combined procedures remain limited due to challenges in exposure and access. While bilateral minimally invasive strategies have been described in selected cases, standardized access concepts for concomitant procedures are not well defined. This study aimed to assess the anatomical accessibility and procedural workflow of a minimally invasive biaxillary access strategy for combined coronary and valve surgery in a human cadaver model. Combined coronary artery bypass grafting and valve procedures were performed in nine Thiel/ethanol-fixed human cadavers using a biaxillary access approach. Anatomical exposure, conduit length, graft harvesting and anastomosis times, and valve positioning were evaluated by macroscopic inspection and postprocedural three-dimensional computed tomography imaging. All planned procedural steps were completed in all nine cadavers. The mean left and right internal thoracic artery lengths were 18.1 ± 1.8 cm and 18.9 ± 1.9 cm, respectively. The average bilateral internal thoracic artery harvest and anastomosis times were 52.0 ± 17.6 min and 46.6 ± 12.6 min, respectively. Postprocedural three-dimensional computed tomography imaging and macroscopic inspection demonstrated consistent graft positioning and anatomical valve seating across all specimens. This cadaveric study demonstrates that a minimally invasive biaxillary access strategy allows anatomical exposure and supports a conceptual procedural workflow for combined coronary and valve interventions. These findings represent an early-stage technical proof-of-concept and require further validation before clinical application can be considered. Full article

Background and Objectives: The optimal timing for surgical intervention in acute aortic valve infective endocarditis (IE) remains debated. Although European guidelines distinguish emergency, urgent, and delayed indications, some centres postpone surgery, concerned that operating before sufficient antibiotic sterilization could increase IE relapse risk. Materials and Methods: This retrospective, observational, multicenter study included patients with acute aortic valve IE. Patients who were not operated, had non-aortic valve IE, or underwent emergency surgery were excluded. Surgery within 7 days of starting targeted antibiotics was classified as “early”; surgery between 7 and 30 days as “late.” Primary outcomes were in-hospital mortality and 30-day permanent pacemaker implantation. Secondary endpoints included reinfection, reoperation for IE relapse, and mid-term survival. Results: A total of 203 patients included: 104 early and 99 late. In-hospital mortality was comparable (early: 16 patients, 15.4%; late: 16 patients, 16.2%; p = 0.90). Permanent pacemaker implantation was higher in the late group (early: 9 patients, 8.7%; late: 18 patients, 18.2%; p = 0.046). Mid-term survival at four years was similar (early: 67.1 ± 5.8%; late: 59.7 ± 8.1%; p = 0.71). Recurrence of IE (early: 5.7%; late: 4.8%; p > 0.9) and reoperation for recurrent IE (early: 5.7%; late: 4.8%; p > 0.9) did not differ. Conclusions: Delaying surgery for acute aortic valve IE does not improve procedural safety, as in-hospital mortality is similar. Early intervention does not increase reinfection or reoperation risk, and may reduce permanent pacemaker implantation, likely by preventing progressive fibrosis of the cardiac conduction system caused by infection and prolonged antibiotic exposure. Full article