BackgroundLeft ventricular (LV) remodelling in mitral valve prolapse (MVP) is usually induced by chronic mitral regurgitation (MR), however it can also be disproportionate to the volume load, generating the hypothesis of MVP cardiomyopathy. Changes in the sarcomeric protein titin could contribute to its underlying pathophysiology.ObjectivesTo investigate the role of titin modulation as a mechanism of disproportionate LV remodelling in MVP patients.MethodsMyocardial biopsies from 16 patients with MVP and severe MR were compared with 6 controls. All patients underwent pre-operative transthoracic echocardiography and cardiac magnetic resonance imaging. Titin modifications were analyzed by gel electrophoresis and western blotting.ResultsFive patients had disproportionate LV remodelling. Compared to controls, the larger N2BA isoform was significantly upregulated in MVP patients, displaying a significantly higher N2BA/N2B isoform ratio (0.589 ± 0.055 vs. 0.479 ± 0.024, p < 0.001). The proportion of total N2B-phosphorylated titin was significantly lower in MVP patients with normal vs. disproportionate LV remodelling (0.709 ± 0.142 vs. 0.971 ± 0.084, p = 0.008) and controls (1.246 ± 0.147, p < 0.001). Furthermore, titin oxidation was significantly higher in MVP patients vs. controls (0.635 ± 0.104 vs. 0.481 ± 0.105, p = 0.006). Finally, there was less N2B-titin ubiquitination in MVP compared to controls (0.607 ± 0.138 vs. 0.989 ± 0.102, p < 0.001). Univariate linear regression showed that corrected LV end-diastolic volume index was correlated with total N2B-titin phosphorylation (R2 = 0.362, p = 0.014), suggesting lower passive stiffness in disproportionate LV remodelling.ConclusionsMVP patients with severe MR demonstrate significant changes in titin isoform ratio, phosphorylation, oxidation and ubiquitination compared to controls. Disproportionate LV remodelling was correlated with increased phosphorylation and showed a trend towards increased N2BA titin, both markers of decreased myocardial stiffness.

Ovarian vein coil embolization is a well-established treatment for pelvic congestion syndrome. Although regarded as a safe and effective procedure, complications related to coil migration to the heart remain exceedingly rare but require a multidisciplinary approach to weigh the risks and benefits of conservative management against surgical intervention. Our case describes an asymptomatic delayed coil migration to the right ventricle attached to the subvalvular apparatus observed on echocardiography. Considering the risk of an endovascular retrieval and to mitigate further risks of complications, the coil was successfully removed via a minimally invasive right mini-thoracotomy.

Background: The Perceval device is a sutureless, rapid-deployment valve designed to shorten aortic cross-clamp (ACC) and cardiopulmonary bypass (CPB) times, with the aim of improving postoperative outcomes in older, high-risk patients. Methods: A systematic review was conducted for full articles published between 2020 and 2024, comparing the Perceval valve with conventionally sutured valves, with a focus on preoperative and operative data, as well as postoperative outcomes. Single-arm series were retained for the same purpose. Articles with at least 100 valves were included. Results: A total of six propensity score-matched series and four randomized controlled trials were identified after removing articles with data from the same patient population. Consequently, age and risk scores were comparable. The use of a minimally invasive approach and the association of other procedures, such as coronary artery bypass grafting (CABG), varied depending on the research design. Adverse postoperative events were comparable for both valve types, except for the development of conduction defects, which required the implantation of a permanent pacemaker (PPM). The initial PPM implantation rate was higher for the Perceval valve, as shown in 5 of the 14 comparative series; however, this rate decreased after the adaptation of surgical techniques. A meta-analysis showed that the CPB and ACC times were significantly shorter using the Perceval valve, at 14.9 (8.2–21.5) minutes and 16.6 (12.1–21.2) minutes, respectively. Platelet counts after implantation were lower with no clinical consequences, and the hemodynamic performance of the Perceval device was acceptable and stable over time. The survival and durability of the Perceval valve were also acceptable, with a reoperation rate of 1% at the 5-year follow-up. Conclusions: The Perceval valve appears to be a suitable alternative for older, high-risk patients undergoing aortic valve replacement. Notably, the Perceval valve is associated with shorter surgical times and could facilitate the advantage of minimally invasive surgery. The need for postoperative PPM implantation remains an issue.

Lung ischemia–reperfusion injury (LIRI) remains a major contributor to perioperative morbidity and mortality in thoracic surgery, especially for lung transplantations, where it is one of the principal drivers of primary graft dysfunction (PGD). Although substantial advances have been made in surgical technique, donor management, and perioperative care, LIRI continues to pose a significant clinical challenge. Mechanistically, LIRI reflects a combined pathology of oxidative stress, endothelial and glycocalyx disruption, innate immune activation, mitochondrial dysfunction, and regulated cell death, resulting in loss of alveolar–capillary barrier integrity and gas exchange failure. Current management is phase-specific and multimodal, spanning donor care and preservation, controlled reperfusion and lung-protective ventilation, and pharmacological treatments. Treatment candidates that target oxidative stress and inflammatory cascades (e.g., antioxidants, complement and adenosine pathways, mesenchymal stromal cell products, and dipeptidyl-peptidase-4 inhibition) show promise, yet translation into a clinical scenario remains difficult. Increasing evidence supports endothelial-preserving and mitochondria-sparing strategies, rigorous perioperative bundles, and biomarker-guided trials to move from pathophysiology to practice. Ultimately, addressing LIRI requires an integrated, multidisciplinary approach that spans surgical, anesthetic, and pharmacologic domains, with the goal of improving both early outcomes and long-term graft survival in lung transplant patients.

BACKGROUND:Preprocedural virtual planning of transcatheter aortic valve implantation (TAVI) using FEops HEARTguideTM may reduce major TAVI complications. AIMS:(1) To compare morphometric aortic root measurements by FEops HEARTguideTM and GE software; (2) to validate the accuracy of FEops HEARTguideTM in predicting post-TAVI paravalvular aortic regurgitation (AR) and new conduction abnormalities. METHODS:In 106 consecutive TAVI patients, aortic root dimensions essential for prosthesis sizing were measured using both GE software and FEops HEARTguideTM. FEops HEARTguideTM predictions were compared with the severity of post-TAVI AR assessed by echocardiography, angiography, invasive hemodynamics, and the development of conduction abnormalities assessed by serial electrocardiography. RESULTS:Bland-Altman analysis revealed smaller annulus perimeter, area and coronary artery ostia heights with FEops HEARTguideTM compared with GE software, leading to differences in prosthesis sizing in 23% of cases. Predicted AR was significantly higher in patients with moderate versus none/trace AR on echocardiography (14.3 vs. 2.8 mL/s, p = 0.006) and angiography (23.6 vs. 4.0 mL/s, p = 0.009), though overlap between adjacent AR grades was observed. Predicted AR did not significantly differ between patients with AR index < 25 and ≥ 25 (10.2 vs. 5.7 mL/s, p = 0.079). Contact pressure index was significantly higher in patients with new conduction abnormalities (17.5 vs. 10.0%, p = 0.006), despite overlap at patient level. CONCLUSIONS:FEops HEARTguideTM generally underestimates aortic root dimensions compared with GE software, affecting prosthesis sizing in a substantial proportion of patients. While predictive at a population level, overlap in parameters predicted by FEops HEARTguideTM is encountered at an individual patient level.

Aims Atrial fibrillation (AF) and atrial flutter (AFL) after cardiac surgery are common and associated with adverse outcomes. The increased risk related to AF or AFL may extend beyond discharge. This study aims to determine whether photoplethysmography (PPG)-based smartphone monitoring to detect AF or AFL after hospital discharge following cardiac surgery improves AF management. Methods and results The intervention group performed 1 min rhythm checks three times daily using a smartphone-based PPG application during 6 weeks after hospitalization for cardiac surgery. The primary outcome involved AF management interventions by independent physicians, including initiation of oral anticoagulation (OAC), direct cardioversion, and up-titration or initiation of antiarrhythmic drugs. The study included 450 patients [mean (SD) age, 64.1 (9.2) years; 96 women (21.3%); 130 patients with AF history (28.9%); median (IQR) CHA2DS2-VASc score, 2 (1-3)], of whom 238 were randomized to PPG-based monitoring and 212 to usual care. AF/AFL was detected with PPG or electrocardiography in 44 patients (18.5%) in the monitoring group and 4 patients (1.9%) in the usual care group (OR 11.8; 95% CI, 4.2-33.3; P < 0.001); these were new detections in, respectively, 22 patients (9.2%) and 1 patient (0.5%) (OR 21.3; 95% CI, 2.9-166.7; P = 0.003). AF management interventions occurred in 24 patients (10.1%) in the monitoring group compared to 5 patients (2.4%) in the usual care group [odds ratio (OR), 5.1; 95% CI, 1.8-14.4; P = 0.002]. Conclusion In unselected patients discharged home following cardiac surgery, PPG-based smartphone monitoring revealed significantly more AF/AFL which led to significantly more optimization of AF management.

Introduction The primary aim was to describe the outcome, the compliance with inclusion criteria and the characteristics of patients who underwent extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). The secondary aim was to calculate the cost of ECPR for the patients and the public Belgian healthcare system. Methods Single-centre retrospective cohort study in Antwerp University Hospital. We included all patients who underwent ECPR for OHCA from 2018 to 2020. Medical records were assessed to determine the clinical outcome and invoices were assessed to calculate the charged fees. We collected all relevant cost components at the most detailed level (micro costing technique). Results Sixty-five patients who received ECPR for OHCA were included. Thirty-eight patients (58%) died within one week after ECPR initiation. After one year, twelve patients (18.5%) were still alive of which ten (15.4%) had a good neurological outcome (Cerebral Performance Category (CPC) 1 or 2). Forty-nine patients (75.4%) met the ECPR inclusion criteria. A total of 2,552,498.34 euro was charged. The patients and the public Belgian healthcare system contributed to a 255,250 euro cost for each survivor after one year with good neurological outcome. Conclusion Our analysis highlights the complex interplay between clinical efficacy and financial implications in the utilization of ECPR. While ECPR demonstrates potential in improving survival rates and neurological outcomes among cardiac arrest patients, its adoption presents substantial economic challenges. Inappropriate patient selection may lead to significant increases in resource utilisation without improved outcome.

Tropic fever can have several causes. It is important to investigate thoroughly and consider less obvious explanations. This paper presents the case of a biologist in close contact with chimpanzees, who developed fever in the tropics. Despite treatment for some tropical diagnosis, the fever persisted. On arrival in Belgium, further diagnostics revealed an unexpected diagnosis: Citrobacter koseri endocarditis of the native aortic valve. He was treated with ceftriaxone and amikacin and underwent aortic valve replacement. C koseri is a commensal in humans and animals. It is likely that the patient was infected with this bacterium through his close contact with chimpanzees. Only a few cases of C koseri endocarditis have been published worldwide, with most patients being immunocompromised. Patients with tropical fever may have unsuspected underlying causes, like endocarditis.

BACKGROUND:While barbed sutures have been extensively utilized in other disciplines, they have not been widely adopted in cardiac surgery. The lack of safety and feasibility data has limited its use within the field. To aide in the further understanding of how cardiac surgeons can use barbed sutures, we sought to develop a high-pressure in vitro simulation model. We compared knotless barbed sutures in a highly pressurized anastomosis to conventional sutures. METHODS:Ten specimens in total were utilized in prosthesis anastomosis, using 34 mm Gelweave Plexus (Terumo Aortic, Sunrise, FL 33325, USA) and 34 mm Hemabridge (Intergard Woven Hemabridge, Getinge, Göteborg, Sweden). Five models of size 3-0 barbed suture anastomoses using non-absorbable, barbed, self-retaining, monofilament polypropylene sutures (Filbloc® 3-0, Assut Europe, Rome, Italy) were compared against five conventional anastomoses using size 4-0 polypropylene monofilament (Ethicon, USA). The systems were connected using a novel-designed extracorporeal circulation system. Pressure was rapidly increased in the specimen to a mean pressure of 300-350 mmHg, running then for a minimum of 48 hours to assess anastomosis strength and endurance. RESULTS:No anastomotic dehiscence or rupture was recorded. Complex, angular anastomosis required extra stitch leakage sutures in both conventional and barbed suture specimens. CONCLUSION:Using knotless barbed sutures with an additional self-locking maneuver for prosthesis-prosthesis anastomosis in cardiac surgery is feasible in an in vitro model under long term, high-mean pressure when compared to conventional sutures. In vivo trials should be performed to further validate the in vitro findings.

Background Postoperative cardio-surgical haemostatic management is centre-specific and experience-based, which leads to a variability in patient care. This study aimed to identify which postoperative haemostatic interventions may reduce the need for reoperation after cardiac surgery in adults. Methods A retrospective case-control study in a tertiary centre. Adult, elective, primary cardiac surgical patients were selected (n = 2098); cases (n = 42) were patients who underwent reoperation within 72 h after the initial surgery. Interventions administered to control surgical bleeding were compared for the need to re-operate using multiple logistic regression. Results Rate of cardiac surgical reoperation was 2% in the study population. Three variables were found to be associated with cardiac reoperation: preoperative administration of fresh frozen plasma (OR 5.45, CI 2.34-12.35), cumulative volume of chest tube drainage and cumulative count of packed red blood cells transfusion on ICU (OR 1.98, CI 1.56-2.51). Conclusion No significant difference among specific types of postoperative haemostatic interventions was found between patients who needed reoperation and those who did not. Perioperative transfusion of fresh frozen plasma, postoperative transfusion of packed cells and cumulative volume of chest tube drainage were associated with reoperation after cardiac surgery. These variables could help predict the need for reoperation.

BACKGROUND:The importance of genetic testing for cardiomyopathies has increased in the last decade. However, in heart transplant patients with former cardiomyopathy, genetic testing in retrospect is not routinely performed. We hypothesize that the yield of genetic testing in this population is considerable, and will have a major impact for both patients and relatives. METHODS:Patients that underwent heart transplantation (HTx) between 1995 and 2020 and were still in follow-up, were offered genetic testing if the primary etiology was non-ischemic cardiomyopathy. Next generation sequencing (NGS) of known cardiomyopathy genes was performed and variants were classified as variant of unknown significance (class 3), likely pathogenic (class 4) or pathogenic (class 5) variant. RESULTS:Of the 99 HTx patients in active follow-up, only 6 patients had a genetic diagnosis at the time of HTx. In this study, 31 selected patients with prior non-ischemic cardiomyopathy underwent genetic testing post HTx. 23/31 patients (74.2%) carried a variant that was classified as class 3 or higher. In 12/31 patients a class 4/5 variant (38.7%) was identified, and in 11/31 patients (35.5%) a class 3 variant. Class 5 Variants in TTN were the most prevalent (7/31), followed by class 5 variants in MYBPC3 (2/31). A positive family history was present in 21/31 (67.7%) and a second precipitating factor (e.g., alcohol abuse, pregnancy) was present in 17/31 patients (54.8%). Diagnostic yield of genetic testing was similar between patients with or without familial history and/or second hit. Through cascade screening 48 family members were screened for presence of a class 4/5 variant, of whom 19 (39.6%) were genotype positive, of whom 10 (52.6%) showed a cardiac phenotype. Appropriate follow-up was offered. CONCLUSIONS:Genetic testing for cardiomyopathy genes established a molecular diagnosis in 38.7% of patients post HTx. These results highlight the importance of genetic testing in this population as it is still often overlooked in patients that already underwent HTx in the past. Genetic testing is highly recommended, independent of family history or second precipitating factors, as it might identify relatives at risk.

Supplemental Digital Content is available in the text Aims The aim of this study was to determine if computed tomography (CT) psoas muscular attenuation measurements may predict all-cause mortality in patients undergoing TAVI. Methods Ninety-four consecutive patients undergoing TAVI were analysed. The CT axial slice at the level of the fourth lumbar vertebra was selected. The psoas muscle areas were manually contoured. The circumferential surface area (CSA) of both psoas muscles was determined by selecting the voxels with attenuation values, ranging from 0 to 100 Hounsfield Units (HU). The mean CT attenuation coefficient of the psoas muscle (Psoas mean HU) was measured. The muscle was subdivided into a low-density muscle (LDM) (0–29 HU) and high-density muscle (HDM) (30–100 HU) portion. The HDM/LDM ratio was calculated. We searched for a correlation between HDM/LDM, CSA LDM (%), Psoas mean HU and all-cause mortality. Results The mean age was 81.2 ± 7.5 years. Thirty patients had adverse outcome (all-cause mortality). Compared with patients with the lowest CSA LDM (%), patients in the third and second tertiles had an increased hazard ratio for mortality (2.871; 95% confidence interval 0.880–9.371 and 5.044; 95% confidence interval 1.641–15.795, respectively) in a multivariable model with EuroSCORE II, Barthel frailty index and CSA LDM (%) (P = 0.231, 0.097 and 0.019, respectively). HDM/LDM and Psoas mean HU (as continuous variable) were also independent predictors of all-cause mortality (P = 0.019, P = 0.013, respectively) Conclusion CSA LDM (%), Psoas mean HU and HDM/LDM are independent and incremental predictors of all-cause mortality in patients undergoing TAVI.

Background Quantifiable biomarkers may be useful for a better risk and frailty assessment of patients referred for transcatheter aortic valve implantation (TAVI). Hypothesis To determine if adiponectin serum concentration predicts all-cause mortality in patients undergoing TAVI. Methods 77 consecutive patients, undergoing TAVI, were analyzed. The CT axial slices at the level of the fourth lumbar vertebra were used to measure the psoas muscle area, and its low-density muscle fraction (LDM (%)). To assess the operative risk, the STS (Society of Thoracic Surgeons Predicted Risk of Mortality) score, Log. Euroscore, and Euroscore II were determined. A clinical frailty assessment was performed. ELISA kits were used to measure adiponectin serum levels. We searched for a correlation between serum adiponectin concentration and all-cause mortality after TAVI. Results The mean age was 80.8 +/- 7.4 years. All-cause mortality occurred in 22 patients. The mean follow-up was 1779 days (range: 1572-1825 days). Compared with patients with the lowest adiponectin level, patients in the third tertile had a hazards ratio of all-cause mortality after TAVI of 4.155 (95% CI: 1.364-12.655) (p = .004). In the multivariable model, including STS score, vascular access of TAVI procedure, LDM (%), and adiponectin serum concentration, serum adiponectin level, and LDM(%) were independent predictors of all-cause mortality after TAVI (p = .178, .303, .042, and .017, respectively). Adiponectin level was a predictor of all-cause mortality in females and males (p = .012 and 0.024, respectively). Conclusion Adiponectin serum level is an independent and incremental predictor of all-cause mortality in patients undergoing TAVI.

Aims Smoking is linked to disease and survival in the general and transplant population. We studied the smoking history, disease and survival of patients after heart transplantation. Methods A total of 130 patients who underwent heart transplantation between 1995 and 2019 received a questionnaire to document their smoking history. We assessed patient characteristics, comorbidities and survival. Results Sixty-five per cent of patients were active or former smokers prior to heart transplantation. All patients stopped smoking; 26% of the former smokers resumed smoking after transplantation. Patients who resumed smoking were younger at the time of transplantation, used fewer statins and were more likely to be treated with azathioprine after transplantation. The mean follow-up for all patients was 11 +/- 5.5 years. Patients who resumed smoking were more likely to develop solid organ cancers (45%) compared to those who remained abstinent (23%) and those who never smoked (13%) (p 0.014). A Cox proportional hazards regression analysis identified smoking resumption, with a RR of 2.31 (1.14-4.68, p 0.02), and age at transplantation, with a RR of 1.03 (1-1.06, p 0.034), as significant for survival. Patients resuming smoking after transplantation had a significantly higher risk of dying from solid organ cancer, with a RR of 2.54 (1.03, 6.28; p 0.04) with a short median survival time (25th-75th percentile) of (1 (0-5) months, p 0.007). Conclusion Patients who resume smoking after heart transplantation have worse survival and are at higher risk of dying from solid organ cancer. Implementing a smoking cessation plan throughout the post-transplant period is important.

A 50-year-old woman was hospitalised because of a high fever. Her medical history revealed chronic pain after failed back surgery. Emboli were seen in the brain and left kidney. Transoesophageal echocardiography showed large mobile vegetation on the atrial side of the posterior mitral leaflet and perforation of P1 causing mitral regurgitation (Figure 1). Blood cultures were positive for methicillin-susceptible Staphylococcus aureus. Thorough anamnesis and clinical examination did not reveal any clue for drug abuse. Shortly after the initiation of 6 2 g intravenous flucloxacillin/day, mitral valve replacement was performed given the persistence of positive blood cultures, the size of the vegetation and embolic phenomena. In the search for cardiac emboli and an entry port, an 18-fluorodeoxyglucose–positron emission tomography/computed tomography (FDG-PET/CT) was done postoperatively which displayed extensive panniculitis in the glutaeal region (Figure 2). The patient admitted self-administration of subcutaneous morphine. We hypothesised this being the port of entry for the staphylococcus aureus sepsis. Panniculitis and cutaneous granulomas can be seen due to extravascular injections. The use of FDG-PET/CT is well estab-