Background The optimal strategy in prosthetic heart valve thrombosis (PVT) remains controversial, with no randomized trials and conflicting observational data. We performed a systematic review and meta‐analysis of evidence comparing systemic thrombolysis and cardiac surgery in PVT. Methods and Results We searched PubMed, the Cochrane Library, and Embase for studies on treatment strategies in patients with left‐sided PVT since 2000. The primary outcome was death, and the secondary outcomes were major bleeding and thromboembolism during follow‐up (International Prospective Register of Systematic Reviews No. CRD42022384092). We identified 2298 studies, of which 16 were included, comprising 1389 patients with PVT (mean age, 50.4±9.3 years; 60.0% women). Among them, 67.2% were New York Heart Association stage III/IV at admission. Overall, 48.1% were treated with systemic thrombolysis and 51.9% with cardiac surgery. The mortality rate was 10.8% in the thrombolysis group and 15.3% in the surgery group. The pooled risk difference for death with systemic thrombolysis was 1.13 (exact CI, 0.74–1.79; ζ 2 =0.89; P <0.001) versus cardiac surgery. Rates of both transient ischemic attack and non–central nervous system embolism were higher in the thrombolysis group ( P =0.002 and P =0.02, respectively). Treatment success, major bleeding, and stroke were similar between groups. Sensitivity analysis including studies that used low‐dose or slow‐infusion thrombolysis showed that the mortality rate was lower, and treatment success was higher, in patients referred to systemic thrombolysis, with similar rates of other secondary outcomes. Conclusions There is evidence to suggest that thrombolysis might be the preferred option for the management of PVT without cardiogenic shock, pending future randomized controlled trials or larger observational studies.

Background: The risk for acute aortic dissection (AAD) increases with ascending aortic diameter especially above a cut-off of 60 mm. Therefore, ESC/EACTS guidelines recommend prophylactic replacement of the ascending aorta from a diameter of 55 mm. However, 60% of AAD occur at small aortic diameters (defined as maximum diameter of ascending aorta / aortic root < 55 mm). To identify patients at risk, we sought to evaluate predictors for AAD in patients with aortic diameters < 55 mm.

Background: Acute type A aortic dissection (TAAD) is a life-threatening condition which requires immediate surgical intervention at any time of day or night. We hypothesize that during nighttime, these procedures often are performed by surgeons less experienced in aortic surgery. Therefore, our aim was to investigate whether nighttime surgical procedures for TAAD are associated with adverse acute outcome.

Background: Postoperative acute kidney injury (AKI) is known to be a driving factor for prolonged hospital stay and mortality. Thus, identification of risk factors that can predict the risk of postoperative occurrence of AKI is of utmost importance.

Objectives: In patients who receive coronary artery bypass grafting (CABG), preoperative renal dysfunction is a strong predictor for postoperative acute kidney injury (AKI) and mortality. However, it remains controversial, whether waiving cardiopulmonary bypass (CPB) could reduce the risk for postoperative AKI. We therefore compared postoperative renal function in patients with preoperative renal dysfunction undergoing On- versus Off-pump CABG.

Objectives: With the occurrence of the COVID-19 pandemic in the year of 2020 the number of patients in need ofintensive care medicine increased dramatically in many countries Several of them developed an acute respiratory distresssyndrome (ARDS) linked to the COVID-19 infection and many required the use of extracorporeal membrane oxygenation(ECMO) Methods: We are retrospectively reviewing 141 patients who underwent ECMO for severe COVID-19-related ARDS in amulticenter study at 10 European ECMO centers Result: A total of 141 patients (67 4% male, median age was 55 4 years (interquartile range [IQR]: 44-67 5) were treatedwith ECMO for confirmed (132) or suspected (9) severe COVID-19-related ARDS Before ECMO, the median SequentialOrgan Failure Assessment (SOFA) score was 9 0 (IQR: 7 0-11 5), median pH was 7 25 (IQR: 7 20-7 30), and medianPaO /FiO ratio was 70 mm Hg (IQR: 60-77) Venovenous ECMO was provided in 130 patients (92%) and venoarterial ECMO in 11 patients (8%) The median duration ofECMO treatment by now was 11 days, IQR: 7-17) At the time of reporting, 71 confirmed COVID-19 patients (53 8%) arealive, of whom 33 (43 4%) are still in the intensive care unit (9 on ECMO, 24 weaned from ECMO and extubated) Overallmortality so far occurred in 62 patients (46 2%) By now advanced age, low arterial pH, and low platelet count before ECMO were independent risk factors for increasedmortality during the intensive care treatment Conclusion: Despite a substantial overall mortality of over 40%, approximately half of the patients with severe COVID-19-related ARDS, refractory to conventional treatment, may be successfully managed with ECMO therapy

OBJECTIVES This study aims to investigate the incidence and determinants of major early adverse events in low-risk patients undergoing isolated coronary artery bypass grafting (CABG). METHODS The multicentre E-CABG registry included 7352 consecutive patients who underwent isolated CABG from January 2015 to December 2016. Patients with an European System for Cardiac Operative Risk Evaluation (EuroSCORE) II of <2% and without any major comorbidity were the subjects of the present analysis. RESULTS Out of 2397 low-risk patients, 11 (0.46%) died during the index hospitalization or within 30 days from surgery. Five deaths were cardiac related, 4 of which were secondary to technical failures. We estimated that 8 out of 11 deaths were potentially preventable. Logistic regression model identified porcelain aorta [odds ratio (OR) 34.3, 95% confidence interval (CI) 1.3-346.3] and E-CABG bleeding grades 2-3 (OR 30.2, 95% CI 8.3-112.9) as independent predictors of hospital death. CONCLUSIONS Mortality and major complications, although infrequently, do occur even in low-risk patients undergoing CABG. Identification of modifiable causes of postoperative adverse events may be useful to develop preventative strategies to improve the quality of care of patients undergoing cardiac surgery. CLINICAL TRIAL REGISTRATION NCT02319083 (https://clinicaltrials.gov/ct2/show/NCT02319083).

OBJECTIVE:To develop a risk score for surgical site infections (SSIs) after coronary artery bypass grafting (CABG).DESIGN:Retrospective study.SETTING:University hospital.PATIENTS:A derivation sample of 7,090 consecutive isolated or combined CABG patients and 2 validation samples (2,660 total patients).METHODS:Predictors of SSIs were identified by multivariable analyses from the derivation sample, and a risk stratification tool (additive and logistic) for all SSIs after CABG (acronym, ASSIST) was created. Accuracy of prediction was evaluated with C-statistic and compared 1:1 (using the Hanley-McNeil method) with most relevant risk scores for SSIs after CABG. Both internal (1,000 bootstrap replications) and external validation were performed.RESULTS:SSIs occurred in 724 (10.2%) cases and 2 models of ASSIST were created, including either baseline patient characteristics alone or combined with other perioperative factors. Female gender, body mass index >29.3 kg/m2, diabetes, chronic obstructive pulmonary disease, extracardiac arteriopathy, angina at rest, and nonelective surgical priority were predictors of SSIs common to both models, which outperformed (P < .0001) 6 specific risk scores (10 models) for SSIs after CABG. Although ASSIST performed differently in the 2 validation samples, in both, as well as in the derivation data set, the combined model outweighed (albeit not always significantly) the preoperative-only model, both for additive and logistic ASSIST.CONCLUSIONS:In the derivation data set, ASSIST outperformed specific risk scores in predicting SSIs after CABG. The combined model had a higher accuracy of prediction than the preoperative-only model both in the derivation and validation samples. Additive and logistic ASSIST showed equivalent performance.

Objectives: Although CABG has a beneficial effect on CV mortality in patients with heart failure,1 little data exist on the characteristics of this patient cohort. The aim of this study was to identify prevalence and outcome of patients with severely reduced ejection fraction undergoing isolated CABG.

Background and aim: The aim of this study was to evaluate the prognostic impact of asymptomatic carotid artery stenosis(CAS) in patients undergoing isolated coronary artery bypass grafting(CABG). Methods: Patients from the multicenter, prospective E-CABG registry without history of stroke or transient ischemic attack and screened by duplex ultrasound for CAS before isolated CABG were included in this analysis. Results: Among 2813 patients screened by duplex ultrasound for asymptomatic CAS, 11.1% had a CAS of 50–59%, 6.0% of 60–69%, 3.1% of 70–79%, 1.4% of 80–89%, 0.5% of 90–99%, and 1.1% had carotid occlusion. Postoperative stroke occurred in 25 patients (0.9%). Lesions were bilateral in five patients (25%) and ipsilateral to a CAS ≥50% in six patients (30%). In univariate analysis, the severity of CAS was associated with a significantly increased risk of stroke (p < 0.0001). In multivariate analysis, a CAS of 90–99%(OR 12.03, 95%CI 1.34–108.23) and the presence of an occluded internal carotid artery (OR 8.783, 95%CI 1.820–42.40) were independent predictors of stroke along with urgency of the procedure, severe-massive bleeding according to the E-CABG classification and the presence of a porcelain ascending aorta. Conclusions: Among patients with asymptomatic CAS, the risk of stroke is significant only in patients with a stenosis ≥90%. Since this condition has a low prevalence and when left untreated is associated with a relatively low rate of stroke, preoperative screening of asymptomatic CAS before CABG may not be justified. Instead, avoiding manipulation of diseased ascending aorta and prevention of excessive bleeding may be more effective measures to prevent stroke after CABG.

Background and Aim: Redo mitral surgery is an high risk procedure. Several preoperative conditions identify patients at unusual surgical risk. Few studies clarify technical issues and perioperative complications affecting early survival. The aim of this multicentre study is to determine predictors of adverse outcome among intraoperative factors and postoperative events. Methods: Operative mortality and major morbidity events from 832 redo mitral procedures, from January 2005 to December 2014 at eight European centres, were analysed. Statistical analysis was performed by the SPSS 13.0 program for Windows (SPSS, Inc., Chicago, IL, USA). Normally distributed continuous variables were compared using the unpaired t-test, not-normally distributed variables using the Mann–Whitney U-test and categorical variables using the χ 2 test. Only variables with a P < 0.10 at univariable analysis were included into the regression models. Results: Injury of a previous patent left internal mammary artery graft (LIMA) [odds ratio (OR) 4.2, 95% confidence interval (CI): 1.6–11.5; P = 0.005], major cardiovascular iatrogenic lesions at re-entry (OR 19.2, 95% CI: 9.2–39.9; P < 0.001), extracellular crystalloid cardioplegia (OR 7.3, 95% CI: 1.4–37.8; P = 0.018) and incremental cardiopulmonary bypass time (OR 1.1, 95% CI: 1.0–1.2; P = 0.001) independently predicted operative mortality. Conclusion: Operative mortality in redo mitral surgery is still significant. Injury of a previous LIMA graft identifies patients at higher. Prolonged cross-clamp times, extracellular crystalloid cardioplegia, massive transfusions, perioperative myocardial infarction, prolonged intubation also predict adverse early outcome. Combined antegrade + retrograde cardioplegia seems to be the only protective factor these high-risk patients.

Background and Aim: Recent studies suggested that prothrombin complex concentrate (PCC) might be more effective than fresh frozen plasma (FFP) to reduce red blood cell (RBC) transfusion requirement after cardiac surgery. The benefits and risks associated with the use of PCC over FFP have been investigated in this study including patients undergoing isolated coronary artery bypass grafting(CABG) from a prospective, multicenter registry. Methods: This is a comparative analysis of 416 patients who received postoperatively FFP and 119 patients who received PCC with or without FFP after isolated CABG. Results: Mixed-effects regression analyses adjusted for multiple covariates and participating centers showed that PCC significantly decreased RBC transfusion (67.2% vs. 87.5%, adjusted OR 0.319, 95%CI 0.136–0.752) and platelet transfusion requirements (11.8% vs. 45.2%, adjusted OR 0.238, 95%CI 0.097–0.566) compared with FFP. The PCC cohort received a mean of 2.7 ± 3.7 (median, 2.0, IQR 4) units of RBC and the FFP cohort received a mean of 4.9 ± 6.3 (median, 3.0, IQR 4) units of RBC (adjusted coefficient, -1.926, 95%CI -3.357–0.494). The use of PCC increased the risk of KDIGO acute kidney injury (41.4% vs. 28.2%, adjusted OR 2.300, 1.203–4.400), but not of KDIGO acute kidney injury stage 3 (6.0% vs. 8.0%, OR 0.850, 95%CI 0.258–2.796) when compared with the FFP cohort. Conclusions: These results suggest that the use of PCC compared with FFP may reduce the need of blood transfusion after CABG. In view of the observational nature of this study, these results should be considered hypothesis generating and need to be confirmed in randomized trials.

Abstract Objectives: The aim of this study was to assess the impact of frailty on the outcome after coronary artery bypass grafting (CABG) and whether it mayimprove the predictive ability of EuroSCORE II. Methods: The Clinical Frailty Scale (CFS) was assessed preoperatively in patients undergoing isolated CABG from the multicenter E-CABG registry and patients were stratified in three classes: scores 1–2, scores 3–4 and scores 5–7. Results: Of 6156 patients enrolled, 39.2% had CFS scores 1–2, 57.6% scores 3–4, and 3.2% scores 5–7. Logistic regression adjusted for multiple covariates showed that the CFS was an independent predictor of hospital/30-day mortality (CFS scores 3–4, OR 3.95, 95%CI 2.19–7.14; CFS scores 5–7, OR 5.90, 95%CI 2.67–13.05) and resulted in an Integrated Improvement Index of 1.3 (p < 0.001) and a Net Reclassification Index of 55.6 (p < 0.001) for prediction of hospital/30-day mortality. Adding the CFS classes to EuroSCORE II resulted in an Integrated Improvement Index of 0.9 (p < p < 0.001) and Net Reclassification Index of 59.6 (p < p < 0.001) for prediction of hospital/30-day mortality, with a significantly larger area under the receiver operating characteristics curve (0.809 vs. 0.781, p = 0.028). The CFS was an independent predictor of mid-term mortality (CFS scores 3–4, HR 2.05, 95%CI 1.43–2.85; CFS scores 5–7, HR 3.05, 95%CI 1.83–5.06). Conclusions: The CFS predicted early and mid-term mortality in patients undergoing isolated CABG. Further studies are needed to evaluate whether frailty may improve the estimation of the operative risk of patients undergoing adult cardiac surgery.

Pressure sores are a major complication in the bed-ridden older patient. In this report, we present the case of platelet rich plasma (PRP) application for the treatment of a pressure sore in an 88-year-old female affected by transfusion-dependent chronic inflammatory disease anemia associated with the congenital and inherited condition of thalassemic trait carrier. A weekly application schedule was planned athome, given the patient's debilitation and her decreased performance status as well as personal and family difficulties to go as outpatients at our treatment center. After 9 PRP applications, a remarkable sore improvement was achieved so that PRP was discontinued; nevertheless, sore rapidly improved until the full resolution and the complete closing after 4 months from the start of PRP treatment. Noteworthy, transfusion support was interrupted and a significant recovery and a sustained stabilization of hemoglobin (Hb) level at 1 year after ulcer healing were observed. The present case suggests that PRP application, performed athome in our case, is a feasible and effective treatment for pressure sores and related complications.

We have read with great interest the paper by Trifilio and colleagues, 1 Trifilio S. Welles C. Seeger K. et al. Olanzapine reduces chemotherapy-induced nausea and vomiting compared with aprepitant in myeloma patients receiving high-dose melphalan before stem cell transplantation: a retrospective study. Clin Lymphoma Myeloma Leuk. 2017; 17: 584-589 Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar entitled “Olanzapine Reduces Chemotherapy-induced Nausea and Vomiting Compared With Aprepitant in Myeloma Patients Receiving High-dose Melphalan Before Stem Cell Transplantation: A Retrospective Study.” The authors illustrated the result of a retrospective comparative clinical trial of an olanzapine-containing regimen versus an aprepitant- or fosaprepitant-containing regimen for the prevention of chemotherapy-induced nausea and vomiting (CINV) among patients affected by multiple myeloma undergoing autologous stem cell transplantation (ASCT) with high-dose melphalan (HDMel). The results cautiously suggest the superiority of an olanzapine-containing regimen in prevention of CINV in this setting, similarly to what has been demonstrated in conventional-dose chemotherapy. 2 Navari R.M. Gray S.E. Kerr A.C. Olanzapine versus aprepitant for the prevention of chemotherapy-induced nausea and vomiting: a randomized phase III trial. J Support Oncol. 2011; 9: 188-195 Crossref PubMed Scopus (251) Google Scholar Moreover, the authors reported original data about the neglected issue of protracted CINV. The knowledge of nausea and vomiting in the setting of ASCT is lacking, and the management of CINV is still controversial and suboptimal. 3 Tendas A. Niscola P. Perrotti A. Dentamaro T. de Fabritiis P. Arcese W. Rome Transplant Network (RTN) Quality of Life Working PartyChemotherapy induced nausea and vomiting in bone marrow transplant: the unmet need. Support Care Cancer. 2015; 23: 2211 Crossref PubMed Scopus (4) Google Scholar , 4 Tendas A. Sollazzo F. Niscola P. et al. Rome Transplant Network Quality of Life Working PartyAdherence to recommendation for chemotherapy-induced nausea and vomiting prophylaxis: the proposal of a score. Support Care Cancer. 2013; 21: 5-6 Crossref PubMed Scopus (6) Google Scholar , 5 Tendas A. Sollazzo F. Bruno A. et al. Obstacles to managing chemotherapy-induced nausea and vomiting in high-dose chemotherapy with stem cell transplant. Support Care Cancer. 2012; 20: 891-892 Crossref PubMed Scopus (9) Google Scholar Therefore, the data reported by the authors are undoubtedly of great interest.