OBJECTIVES:Minimally invasive mitral valve repair (MIMVR) is the preferred approach to treat mitral regurgitation in specialized centres. Custodiol and Del Nido cardioplegia are widely used, yet direct comparative data on their efficacy and safety in this setting remain limited. This study investigated their efficacy and impact on early outcomes in a propensity-matched cohort. METHODS:We performed a single-centre, retrospective matched cohort study of 2490 patients undergoing minimally invasive mitral valve surgery between October 2014 and January 2025. After exclusions, 960 patients entered 1:1 propensity score matching based on risk factors, baseline characteristics and procedural parameters, yielding 778 matched cases treated with Custodiol or Del Nido cardioplegia. Perioperative dynamics of cardiac enzymes were evaluated as the primary outcome measure, along with an exploratory analysis on clinical outcomes. RESULTS:Del Nido cardioplegia was associated with lower postoperative creatine kinase and creatine kinase‑MB levels, most pronounced in the first 24 hours (P < .001). Del Nido yielded a lower inotrope score at 6 hours, higher perioperative sodium and fewer cardioversions for ventricular arrhythmia after declamping with fewer shocks required (all P < .001). Rates of major complications were similar between groups, and 30‑day mortality was 0% in both groups. CONCLUSIONS:Del Nido cardioplegia provided superior myocardial protection based on biomarker dynamics and a lower incidence of post-cross-clamp ventricular arrhythmia, while overall clinical outcomes remained comparable. It may therefore be considered the preferred single-dose cardioplegic solution for MIMVR.

BACKGROUND:Embolization of atrial septal defect (ASD) occluders is uncommon but potentially life-threatening, often requiring urgent intervention. Transcatheter retrieval is typically attempted first, but success depends on achieving slenderizing of the device-which may be limited by anatomy or device position, frequently necessitating surgical removal. CASE SUMMARY:A 25-year-old woman presented with hemodynamic compromise after embolization of an ASD occluder into the main pulmonary artery. A tailored hybrid strategy was undertaken: controlled snare-guided mobilization of the device into the right ventricle created a surgically accessible position, enabling minimally invasive 3D-endoscopic extraction and definitive ASD repair, avoiding sternotomy and pulmonary arteriotomy. DISCUSSION:This case represents the first reported hybrid combination of transcatheter approach with minimally invasive endoscopic cardiac surgery for pulmonary artery-embolized ASD occluder retrieval, highlighting the importance of interdisciplinary, cross-subspecialty procedural planning. TAKE-HOME MESSAGE:Hybrid transcatheter-endoscopic approaches may be a feasible, least-invasive retrieval and repair strategy when standalone transcatheter retrieval is unsuccessful.

OBJECTIVES:The growing elderly population contributes to an increasing prevalence of severe degenerative native aortic valve (AV) or mitral valve (MV) disease in combination with bio-prosthetic valve failure of prior implanted (aortic or mitral) bio-prostheses, as well as concomitant failure of both aortic and mitral bio-prosthetic valves. A combined surgical AV and MV replacement carries a markedly higher risk, especially in the redo setting. Transcatheter double-valve implantation (TDVI) is emerging as a promising alternative that may mitigate the risks of redo surgery. The evidence for TDVI is very limited. This study aims to address the current gap in the literature by analysing a large institutional series of single-stage TDVI. METHODS:Single-centre retrospective analysis of all patients (n = 13) undergoing simultaneous transcatheter aortic valve implantation (TAVI) and transcatheter mitral valve implantation (TMVI) from October 2018 until April 2024. Primary end-points were Valve Academic Research Consortium-3 (VARC-3) and Mitral Valve Academic Research Consortium (MVARC) technical success, 30-day device success and early safety (MVARC procedural success). Secondary end-points included echocardiographic TDVI performance, adverse events, symptom change and survival. RESULTS:The median age of patients was 77 years, with 7/13 (53.8%) females. Median EuroSCORE II was 16.9%. All patients presented with structural valve degeneration with severe haemodynamic valve deterioration according to the VARC-3 definition. Procedural outcomes showed 100% technical success. There was absence of 30-day mortality (0%). Thirty-day device success and early safety/MVARC procedural success were 100%. No major adverse events occurred. After TDVI, the median New York Heart Association functional class improved from III to II. CONCLUSIONS:TDVI appears to be a safe and effective alternative to surgical redo double-valve replacement for selected patients. Our findings support the feasibility of TDVI with excellent early outcomes. Further prospective multicentre studies with larger cohorts are needed to validate the long-term effects and to establish TDVI as a guideline consideration.

BACKGROUND:Transcatheter double valve replacement is an evolving strategy for managing combined mitral and aortic valve disease, particularly in patients with bioprosthetic valve degeneration. CASE SUMMARY:We report the case of an octogenarian with severe native mitral regurgitation and stenosis of a degenerated transcatheter aortic valve. Comorbid conditions, including extensive peripheral and coronary artery disease, limited conventional surgical and transcatheter access options. A tailored approach involving single-stage transapical implantation of a balloon-expandable aortic prosthesis and a dedicated mitral system resulted in favorable hemodynamic and clinical outcome. DISCUSSION:This case represents the first published use of dedicated transcatheter mitral device in combination with transcatheter-valve-in-transcatheter-valve replacement. It underscores the potential of fully catheter-based double valve therapy in challenging scenarios. TAKE-HOME MESSAGES:Transapical transcatheter double valve replacement offers a viable alternative to redo surgery in select patients. Procedural success hinges on imaging-guided planning and individualized device strategy.

Objectives: Second cross-clamping (2nd XCL) is infrequently required in patients undergoing mitral valve repair (MVr), mostly due to unsatisfactory initial repair results. This study investigated risk factors for 2nd XCL and compared early and mid-term outcomes in a propensity-matched cohort undergoing minimally invasive MVr (MI-MVr). Methods: A retrospective review of patients undergoing MI-MVr for degenerative mitral regurgitation (DMR) or functional mitral regurgitation (FMR) between October 2014 and March 2024 was performed. Patients with a single vs 2nd XCL were matched 1:1 based on age, gender, MR aetiology, and other baseline characteristics. Echocardiographic assessments, surgical techniques, and postoperative outcomes were analysed. Logistic regression identified predictors for 2nd XCL, and Kaplan-Meier survival analysis compared mid-term outcomes. Results: Out of 1732 patients, 76 (4.4%) required 2nd XCL. The primary reason for 2nd XCL was residual MR. Complex valve pathology in DMR (odds ratio 3.386, P = .005) and leaflet restriction in FMR (odds ratio 8.00, P = .014) were identified as predictors for 2nd XCL but were not confirmed as independent predictors in multivariable regression analysis. The 2nd XCL group had longer cardiopulmonary bypass and aortic cross-clamp times (149.5 vs 99.5 min and 96.0 vs 60.0 min, respectively; P < .001). No differences were observed in midterm outcomes between the 2nd XCL and control groups (74.4% vs 84.6%, log-rank P = .07), except for prolonged length of ventilation time and intensive care unit stay (17.0 vs 12.5 hours and 32.0 vs 24.0 hours, P < .001, respectively). Conclusions: 2nd XCL can be performed safely without impairing early and mid-term postoperative outcomes. Patients with complex valve pathology in DMR and leaflet restriction in FMR are at a higher risk for 2nd XCL.

Minimally invasive surgery is the state-of-the-art approach for repairing the mitral valve, which controls the blood flow into the left heart chamber. The surgeons rely on camera and sensor technologies to support visualization, navigation, and measurement. As patients are connected to a cardio-pulmonary bypass, the anatomy is severely deformed by the altered pressure conditions. We developed a technique that combines stereo-endoscopic video with three-dimensional transesophageal echocardiography (3D TEE) to improve anatomic visualization and measurement accuracy during mitral valve repairs. Our methodology includes stereo camera calibration, image segmentation, and 3D model reconstruction. Anatomical landmarks are used to align the imaging modalities. This approach allows the visualization of pre-operatively determined mitral valve properties, e.g., overlaying heat maps in stereo endoscopic data. Our validation results showed high precision and accuracy within an error range of 0.5 +/- 0.1 mm. The effectiveness of the heatmap visualization in complex prolapse cases varied. In the future, this approach can also be used to visualize local tissue properties or the optimal positions of implants.

Solid organ transplantation (SOT) is a life-saving intervention for pediatric patients with end-stage organ failure. Due to the limited availability of pediatric donor organs, organs from older donors are frequently utilized, increasing the risk of age-mismatched transplants. Older donor organs are linked to heightened immunogenicity, rejection rates, and impaired long-term outcomes. Emerging evidence suggests that aged donor organs may transfer senescence to pediatric recipients, accelerating aging-like processes such as frailty, cognitive decline, and organ dysfunction. Additionally, the induction of senescence could alter pediatric conditions like chronic kidney disease (CKD), juvenile idiopathic arthritis (JIA), and pediatric brain tumors which have been linked to augmented senescence. Animal models have shown that older donor organs induce senescence-associated changes in young recipients, including immune dysfunction and physical and cognitive impairments. This review highlights the role of cellular senescence in pediatric organ transplantation and discusses strategies to mitigate its impact. Therapies targeting senescence, such as senolytics, offer a potential approach to improve outcomes in pediatric recipients. Further research is needed to validate these findings in human studies and guide clinical strategies that expand the donor pool while prioritizing age-matched transplantation for pediatric patients.

Minimally invasive mitral valve repair (MI-MVr) is the preferred treatment approach in experienced centers for mitral valve disease (MVD), offering reduced surgical trauma and fast recovery. However, limited operative exposure and increased procedural complexity can represent a challenge in complex MVD. This narrative review provides an overview of current literature on clinical outcomes of MI-MVr in challenging MVD scenarios, such as mitral valve (MV) endocarditis, annulus calcification, and mitral annular disjunction, in the context of myxomatous MVD. Despite the complex anatomy and MVD, MI-MVr is non-inferior in long-term outcomes in treating MV endocarditis, MV calcification, and myxomatous MVD with mitral annular disjunction. Nonetheless, careful patient selection and referral to high-volume centers, where surgeons with expertise in MI-MVr operate, are key elements for achieving a durable, patient-tailored repair with an optimal long-term outcome in treating complex MVD.

This report describes a hybrid intervention addressing left circumflex artery occlusion during minimally invasive mitral valve repair. By using a radiopaque Cor-Knot device (LSI Solutions), targeted removal of occluding sutures was achieved, circumventing sternotomy and coronary artery bypass. Real-time coronary angiography provided assessment of procedural success during surgical revision in a hybrid operating room.

OBJECTIVES:The study aimed to analyse outcomes of surgery for blood culture-negative infective endocarditis (BCNIE) and to evaluate the role of molecular biological imaging. METHODS:Patients undergoing surgery for native or prosthetic valve endocarditis from 2013 to 2022 were analysed regarding blood culture-positive infective endocarditis (BCPIE) and BCNIE. For laboratory diagnostics in BCNIE, excised valves or prostheses underwent conventional microbiological culture and fluorescence in situ hybridization combined with 16S rRNA-gene polymerase chain reaction and sequencing (FISHseq). RESULTS:Of 521 patients overall, we identified 473 patients (342 males, mean age 63 ± 14.4 years) with preoperative blood cultures: 396 with BCPIE (83.7%) and 77 with BCNIE (16.3%). Preoperative characteristics and operative procedures were comparable between groups and the calculated perioperative risk (EuroSCORE II) was identical (BCNIE: 12.2 ± 8.8%, BCPIE: 12.9 ± 11.9%, P = 0.788). At surgery, signs of infective endocarditis were present in 71%, missing in 18% and inconclusive in 10% of patients with BCNIE. While valve cultures alone identified pathogens in 32% of BCNIE patients, the combination with FISHseq confirmed the infective aetiology in 98% and identified causative pathogens in 52%. Overall, early mortality was similar in BCNIE (16.9%) and BCPIE (18.2%, P = 0.620), but increased in 37 BCNIE patients without pathogen identification compared to 40 patients with pathogen identification (27.0% vs 7.5%, P = 0.032). CONCLUSIONS:Integrating FISHseq as molecular biological imaging technique into valve analysis algorithms in patients undergoing surgery for BCNIE increases diagnostic gain and potentially improves outcome.

Minimally invasive surgery is the state-of-the-art approach for repairing the mitral valve, which controls the blood flow into the left heart chamber. The surgeons rely on camera and sensor technologies to support visualization, navigation, and measurement. As patients are connected to the cardio-pulmonary bypass, the anatomy is severely deformed by the altered pressure conditions. We developed a technique that combines stereo-endoscopic video with three-dimensional transesophageal echocardiography (3D TEE) to improve anatomic visualization and measurement accuracy during mitral valve repairs. Our methodology includes stereo camera calibration, image segmentation, and 3D model reconstruction. Anatomical landmarks are used to align the imaging modalities. This approach allows the visualization of pre-operatively determined mitral valve properties, e.g., overlaying heat maps in stereo endoscopic data. Our validation results showed high precision and accuracy within an error range of 0.5 +/- 0.1 mm. The effectiveness of the heatmap visualization in complex prolapse cases varied. Integrating stereoscopic and 3D TEE promises greater precision in mitral valve repairs. In the future, this approach can also be used to visualize local tissue properties or the optimal locations of implants.

(1) Background: The successful treatment of infective endocarditis (IE) relies on detecting causative pathogens to administer targeted antibiotic therapy. In addition to standard microbiological cultivation of pathogens from tissue obtained during heart valve surgery, the potential of molecular biological methods was evaluated. (2) Methods: A retrospective study was performed on heart valve tissue from 207 patients who underwent heart valve surgery for IE. FISHseq (fluorescence in situ hybridization combined with 16S rRNA gene PCR and sequencing) was performed in addition to conventional culture-based microbiological diagnostics. The diagnostic performance of FISHseq was compared with the conventional methods and evaluated in the clinical context. (3) Results: Overall, FISHseq provided a significantly higher rate of specific pathogen detection than conventional valve culture (68.1% vs. 33.3%, p < 0.001). By complementing the findings from blood culture and valve culture, FISHseq was able to provide a new microbiological diagnosis in 10% of cases, confirm the cultural findings in 24.2% of cases and provide greater diagnostic accuracy in 27.5% of cases. FISHseq could identify a pathogen in blood-culture-negative IE in 46.2% of cases, while valve culture provided only 13.5% positive results (p < 0.001). (4) Conclusions: This study demonstrates that using FISHseq as an additional molecular biological technique for diagnostics in IE adds substantial diagnostic value, with potential implications for the treatment of IE. It provides pathogen detection, especially in cases where conventional microbiological cultivation is negative or inconclusive.

BACKGROUND:Rothia sp. are Gram-positive bacteria in the class of Actinobacteria that are part of the physiological oral flora. In rare cases, Rothia aeria and Rothia dentocariosa can cause infective endocarditis (IE). The biofilm potential of Rothia in endocarditis is unknown.METHODS:Specimen from two cases of Rothia endocarditis were obtained during cardiac surgery. One of the patients suffered mitral valve IE from Rothia aeria. In the other case, IE of a prosthetic pulmonary valve was caused by Rothia dentocariosa. Fluorescence in situ hybridization (FISH) was used for visualization of microorganisms within heart valve tissues in combination with PCR and sequencing (FISHseq).RESULTS:The two heart valve specimens featured mature biofilms of bacteria that were identified by FISHseq as Rothia aeria and Rothia dentocariosa, respectively. FISH showed in situ biofilms of both microorganisms that feature distinct phenotypes for the first time ex vivo. Both of our reported cases were treated successfully by heart valve surgery and antibiotic therapy using beta-lactam antibiotics.CONCLUSION:The biofilm potential of Rothia sp. must be taken into account. The awareness of Rothia aeria and Rothia dentocariosa as rare but relevant pathogens for infective endocarditis must be raised. Use of biofilm-effective antibiotics in Rothia IE should be discussed.

Introduction: Cocaine use is known to be associated with an increased risk for vascular diseases. It is likely to trigger or increase the risk for an aortic dissection. We conducted an analysis of 45 cases of cocaine-related aortic dissection to further characterize the clinical features and outcomes of this patient cohort.Methods: Our study cohort of 45 patients consisted of 11 cases from our institutional database and 34 published case reports.Results: The observed cases of acute aortic dissection related to cocaine use showed a high proportion of young (41.3 +/- 8.67 years) and male (88.9%) patients. Most of the cases (75%) were classified as Stanford type A. Also, in 75% of the cases, cocaine use was prevalent for more than one year. Median time from last cocaine use to onset of symptoms was one hour. In-hospital mortality was 21.4%, while additional 11.9% of the cases died before arriving at the hospital.Conclusion: Acute aortic dissection related to cocaine use occurs in predominantly young male patients and has a dismal outcome when compared to all comer series.

BACKGROUNDThe aim of this study was to evaluate the impact of transcatheter aortic valve implantation (TAVI) on mitral valve geometry and function.METHODSEighty-four patients underwent TAVI. Forty-four (52%) patients received a balloon-expandable valve and 40 (48%) were implanted with a self-expandable valve. All patients underwent three-dimensional-volumetric transesophageal echocardiography of the mitral valve before and immediately after TAVI. A dedicated software was used for assisted semiautomatic measurement of mitral annular geometry.RESULTSDuring systole, the anterior to posterior (AP) diameter was significantly reduced after the procedure (3.4 ± 0.5 cm vs 3.2 ± 0.5 cm; P < .05). The mitral annular area (10.8 ± 2.8cm2 vs 9.9 ± 2.6cm2 ; P < .05) as well as the tenting area (1.6 ± 0.7 cm2 vs 1.2 ± 0.6 cm2 ; P < .001) measured at mid-systole were reduced after TAVI. Diastolic measures were similar. Patients treated with balloon-expandable valves showed a significantly larger reduction in the AP diameter compared to self-expandable valves (-0.25 cm vs -0.11 cm; P < .05). The reduction of the annular area was higher in the balloon-expandable group (-1.2 ± 1.59 vs -0.22 ± 1.41; P < .05). Grade of mitral regurgitation did improve or remained stable after TAVI.CONCLUSIONTAVI significantly impacts the mitral valve and mitral annular geometry and morphology. The choice of the prosthesis (balloon- vs self-expandable) may be relevant for those changes.