This review investigates that atrial fibrillation (AFIB) is affecting a large and increasing number of patients. The underlying pathophysiological process is not yet fully understood. Minimal invasive surgical ablation offered to some patients has a high success rate, long durability, and minimal risk. In patients with concomitant heart surgery, the benefit also has a prognostic effect and is recommended in cardiac surgery guidelines. Referral to a thoracic surgical centre should be considered for patients with symptomatic AF not responding to conventional therapy.

This review investigates that atrial fibrillation (AFIB) is affecting a large and increasing number of patients. The underlying pathophysiological process is not yet fully understood. Minimal invasive surgical ablation offered to some patients has a high success rate, long durability, and minimal risk. In patients with concomitant heart surgery, the benefit also has a prognostic effect and is recommended in cardiac surgery guidelines. Referral to a thoracic surgical centre should be considered for patients with symptomatic AF not responding to conventional therapy.

OBJECTIVES:Chronic kidney disease can develop as a long-term complication after cardiac surgery-a condition associated with increased risk of new cardiovascular events, readmissions and mortality. Diagnosis is often delayed, as the condition is asymptomatic in early stages and post-discharge kidney follow-up is not routinely performed. We aimed to evaluate the occurrence and timing of chronic kidney disease after cardiac surgery in patients with normal preoperative kidney function and describe associated temporal trends in risk factors and mortality. METHODS:Patients undergoing cardiac surgery at Odense University Hospital, Denmark, between January 2000 and May 2022 were identified from the Western Denmark Heart Registry. Clinical data were extracted and merged with biochemical data from regional laboratory systems. Only the most recent operation was included in the analysis. Patients with pre-existing kidney disease and endovascular procedures were excluded. RESULTS:A total of 13 299 patients were included. Median follow-up time was 88 months (42-141 months). Competing risk analysis revealed that 13.8% developed chronic kidney disease within 3 years after surgery and 18.8% within 5 years. Overall 90-day mortality was 3.6%, and 1-year mortality was 5.1%, with variations over time. During the observation period, patients became older and more comorbid, while preoperative kidney function improved. Postoperative acute kidney injury occurred in 25-30% of patients, with increasing severity over time. CONCLUSIONS:Chronic kidney disease is a common and serious complication following cardiac surgery. Identification of patients in high risk of chronic kidney disease is important to develop post-discharge follow-up programs and improve patient outcomes.

Background Guidelines recommend preoperative dental screening (PDS) prior to surgical valve replacement (SVR) to reduce risk of prosthetic valve infective endocarditis (IE). Nonetheless, limited data support these recommendations. Objectives The objective of this study was to investigate the impact of mandatory preoperative dental screening (MPDS) on risk of IE in patients undergoing SVR. Methods Patients undergoing SVR in Western Denmark from 2020 to 2022 were included in this observational study. Patients were considered based on 2 applied PDS practices: MPDS, and no routine referral to preoperative dental screening (NPDS). Data were retrieved from Danish registries and adjudicated using medical records. The primary endpoint was incidence of IE. Secondary endpoints were all-cause mortality, and the composite endpoint of IE and all-cause mortality. Results A total of 1,207 patients undergoing SVR were included. Of 805 patients in the MPDS, 93% (n = 751) underwent subsequent PDS, compared to 5% (n = 21) among 402 patients in the NPDS. Patients in the MPDS were older with higher rates of coexisting comorbidities. During a median follow-up of 2.6 years, 3.3% (n = 40) developed IE. The IE incidence rate for MPDS and NPDS was 16.0 (95% CI: 11.3-22.6) and 8.0 (95% CI: 4.0-16.0) per 1,000 person-years, respectively. Mortality rate was higher in MPDS (2-year mortality: 6.2% (95% CI: 4.7-8.1) vs 2.8% (95% CI: 1.6-5.0). Differences in IE rates, all-cause mortality but not composite endpoint were abolished in 370 propensity score-matched patients. Conclusions Risk of IE was low regardless of PDS practice. MPDS prior to surgery did not alter the risk of IE or all-cause mortality in patients undergoing SVR in Denmark.

BACKGROUND:Patients benefit from antiplatelet therapy after coronary-artery bypass grafting (CABG) for an acute coronary syndrome. Whether the addition of ticagrelor to aspirin, as compared with aspirin alone, further reduces the risk of adverse cardiovascular outcomes is unclear. METHODS:In this open-label, registry-based, clinical trial conducted at 22 Nordic cardiothoracic surgery centers, we randomly assigned patients in a 1:1 ratio to receive either ticagrelor plus aspirin or aspirin alone for 1 year after CABG for an acute coronary syndrome. The primary outcome was a composite of death, myocardial infarction, stroke, or repeat revascularization, evaluated at 1 year. A key secondary outcome was net adverse clinical events, defined as a primary-outcome event or major bleeding. RESULTS:A total of 2201 patients were randomly assigned to receive ticagrelor plus aspirin (1104 patients) or aspirin alone (1097 patients). The mean age of the patients was 66 years, and 14.4% were women. A primary-outcome event occurred in 53 patients (4.8%) in the ticagrelor-plus-aspirin group and 50 (4.6%) in the aspirin-alone group (hazard ratio, 1.06; 95% confidence interval [CI], 0.72 to 1.56; P = 0.77). Net adverse clinical events occurred in 9.1% of patients in the ticagrelor-plus-aspirin group and 6.4% in the aspirin-alone group (hazard ratio, 1.45; 95% CI, 1.07 to 1.97). Major bleeding occurred in 4.9% of patients in the ticagrelor-plus-aspirin group and 2.0% in the aspirin-alone group (hazard ratio, 2.50; 95% CI, 1.52 to 4.11). CONCLUSIONS:Among patients who underwent CABG for an acute coronary syndrome, ticagrelor plus aspirin did not result in a lower incidence of death, myocardial infarction, stroke, or repeat coronary revascularization than aspirin alone at 1 year. (Funded by the Swedish Research Council and others; TACSI ClinicalTrials.gov number, NCT03560310; EudraCT number, 2017-001499-43; EU Clinical Trials number, 2023-508551-40-00.).

OBJECTIVES It is uncertain whether Thunderbeat has a place in harvesting the left internal mammary artery (LIMA) and whether skeletonization is superior to pedicle-harvested LIMA. Some investigations have shown improved flowrates in the skeletonized graft. The aim of this study was to compare 3 groups of harvesting techniques: Pedicled, surgical skeletonized and skeletonized with Thunderbeat in terms of flow rates in the LIMA and postoperative in-hospital outcomes. METHODS Patients undergoing coronary artery bypass grafting with the LIMA to the anterior descending artery were randomized to pedicled (n = 56), surgical skeletonized (n = 55) and skeletonized with Thunderbeat (n = 54). Main outcomes were blood flow and pulsatility index in the graft. RESULTS No statistical difference between groups regarding flow in LIMA or pulsatility index. Similarly, no difference in postoperative bleeding or days of hospitalization. The duration of harvesting was faster for the pedicled technique compared with surgical skeletonized and skeletonized with Thunderbeat [mean total min: pedicled 20.2 min standard deviation (SD) +/- 5.4; surgical skeletonized 28.6 min SD +/- 8.7; skeletonized with Thunderbeat 28.3 min SD +/- 9.11, P < 0.001]. No grafts discarded due to faulty harvesting and there was no graft failure within hospital stay. CONCLUSIONS We found no difference between the harvesting methods except for a significantly faster harvesting time with the pedicled technique. However, non-touch skeletonized LIMA harvesting with Thunderbeat seems to be an effective alternative to traditional surgical skeletonized LIMA. The future will reveal whether patency is harvesting dependent. Clinical trial registration ClinicalTrials.gov Identifier: NCT05562908.

Data-dependent liquid chromatography tandem mass spectrometry is challenged by the large concentration range of proteins in plasma and related fluids. We adapted the SCoPE method from single-cell proteomics to pericardial fluid, where a myocardial tissue carrier was used to aid protein quantification. The carrier proteome and patient samples were labeled with distinct isobaric labels, which allowed separate quantification. Undepleted pericardial fluid from patients with type 2 diabetes mellitus and/or heart failure undergoing heart surgery was analyzed with either a traditional liquid chromatography tandem mass spectrometry method or with the carrier proteome. In total, 1398 proteins were quantified with a carrier, compared to 265 without, and a higher proportion of these proteins were of myocardial origin. The number of differentially expressed proteins also increased nearly four-fold. For patients with both heart failure and type 2 diabetes mellitus, pathway analysis of upregulated proteins demonstrated the enrichment of immune activation, blood coagulation, and stress pathways. Overall, our work demonstrates the applicability of a carrier for enhanced protein quantification in challenging biological matrices such as pericardial fluid, with potential applications for biomarker discovery. Mass spectrometry data are available via ProteomeXchange with identifier PXD053450.

Due to degeneration, homografts were since the 1950s only used strictly for replacement of complex arterial segments and lesions incl. the aortic valve, replacement of infected arterial prostheses, and vascular access for patients on haemodialysis. During the 1990s, rate-differentiated freezing methods and anti-crystallization agents proved to prevent crystallisation, and more widespread use with expanded indications incl. coronary and lower limb bypasses began justified by promising midterm results. In 2021, the first Scandinavian homograft biobank was founded in Odense in Denmark. This review summarises the history and the experiences from this biobank.

Objectives: The American College of Cardiology (ACC) guidelines recommend the same imaging frequency for all bioprosthetic valves, but some have demonstrated poor durability. We aimed to assess mortality differences between small (19-21 mm) and large (23-29 mm) in Mitroflow and Carpentier-Edwards Perimount aortic valves.Methods: A retrospective observational study was conducted by all patients undergoing isolated surgical aortic valve replacement with Mitroflow or Perimount in Western Denmark between 1999 and 2014 and followed until January 2024. The primary endpoint was all-cause mortality. Secondary endpoints were cardiovascular mortality and sudden cardiac death. A propensity score-matched analysis was performed.Results: A total of 1150 patients were analyzed, with 496 (43%) receiving Mitroflow valves and 654 (57%) receiving Perimount valves. In the Mitroflow group, 108 (22%) had a valve size of 19-21 mm, and 388 (78%) in the size range of 23-29 mm. In the Perimount group, the distribution was 99 (15%) and 555 (85%), respectively. The compromised survival of Mitroflow valves was attributed to the valve type, regardless of the valve sizes. Larger Mitroflow valves exhibited the same compromised late mortality as smaller valves, 66.7% vs 61.5%, respectively (p = 0.95). The same pattern of mortality was observed in the matched population, with Perimount demonstrating significant lower risk of mortality.Conclusion: Mitroflow valves were associated with a poorer prognosis compared to Perimount valves. Additionally, larger Mitroflow valves were not associated with an improved prognosis compared to smaller valve sizes. EuroSCORE2 had a significant impact on patient survival.

Aims This systematic review and meta-analysis sought (i) to provide an overview of the incidence of delirium following open cardiac surgery and (ii) to investigate how incidences of delirium are associated with different assessment tools.Methods and results A systematic search of studies investigating delirium following open cardiac surgery was conducted in Medline (Ovid), EMBASE, PsycINFO, CiNAHL, and the Cochrane Database. Only studies with patients diagnosed or screened with a validated tool were included. Studies published from 2005-2021 were included in the meta-analysis. Of 7126 individual studies retrieved, 106 met the inclusion criteria for the meta-analysis, hereof 31% of high quality. The weighted pooled incidence of delirium following open cardiac surgery across all studies was 23% (95% CI 20-26%), however we found a considerable heterogeneity (I2 = 99%), which could not be explained by subgroups or further sensitivity analyses. The most commonly applied screening tool for delirium is CAM/CAM-ICU. The lowest estimates of delirium were found by applying the Delirium Observation Scale (incidence 14%, 95% CI 8-20%), and the highest estimates in studies using 'other' screening tools (Organic Brain Symptom Scale, Delirium Symptom Interview) with a pooled incidence of 43% (95% CI 19-66%), however, only two studies applied these.Conclusion Delirium following open cardiac surgery remains a complication with a high incidence of overall 23%, when applying a validated tool for screening or diagnosis. Nevertheless, this systematic review and meta-analyses highlight the significant inconsistency in current evidence regarding assessment tools and regimens.Registration Prospero CRD42020215519. Graphical Abstract

Odense University Hospital is a major tertiary vascular hospital in Scandinavia, performing approx. 200 aortic repairs annually. This article presents the rationale behind this endeavor and the early outcomes of the initial implantation of locally processed homografts. All patients receiving a homograft were identified from the established homograft biobank database and their medical records were reviewed after obtaining consent. All surgeons in charge of homograft implantations were semi structured interviewed regarding the harvesting procedure, the tools for detecting available homografts, their quality and delivery. The National board of Health approved the biobank fulling the EU Directive of Tissues and Cells after 18 months of preparation. From May 6, 2021, to March 1, 2023, 26 patients had a homograft implantation, with 7 for mycotic aneurysms, 10 for aorto-iliac graft infection, 6 for infra-inguinal graft infection, and 3 for graft infection in thoracic aorta. Six (23%) were emergently performed. Two (7.7%) died within 30 days postoperatively, both following in situ replacement of an infected aortoiliac graft, corresponding to a 20% mortality in this subgroup. The incidence of reinfections was 19.2%; one each in the mycotic aneurysm group, the aortoiliac graft infection group, and the thoracic graft infection group. After 90 days, two patients were diagnosed with aorto-enteric fistula. All involved surgeons could easily identify available suitable homografts, and within 2 h have homografts of acceptable quality and requested dimensions. The establishment of the Danish Cardiovascular Homograft Biobank was straightforward and effectively serves cardiovascular procedures performed 24/7. Additionally, the initial experiences seem comparable to others experiences.

OBJECTIVES The healthcare registries in Denmark present a unique opportunity to gain novel insights into the outcomes associated with both transcatheter and surgical approaches to aortic valve replacement. Our objective is to enhance shared decision-making by comparing long-term mortality and clinical outcomes between treatments. METHODS This observational study included all patients with severe aortic stenosis undergoing elective isolated transfemoral transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) in Western Denmark between January 2016 and April 2022. Patient population and clinical data were identified from the Western Danish Heart Registry and the National Danish Patient Registry, respectively. A propensity score-matched population was generated. Outcomes were investigated according to Valve Academic Research Consortium-3. RESULTS A total of 2269 TAVI patients and 1094 SAVR patients where identified. The propensity score-matched population consisted of 468 TAVI patients (mean[SD]age, 75.0[5.3] years) and 468 SAVR patients (mean[SD] age, 75.1[4.6]years). The Kaplan-Meier estimate for the 5-year all-cause mortality was 29.8% in the TAVI group and 16.9% for in the SAVR group (P = 0.019). The risk of all stroke or transient ischaemic attack after five year was 15.1% in the TAVI group and 11.0% in the SAVR group (P = 0.047). CONCLUSIONS This study underscores the importance of evaluating all patient factors when choosing an aortic valve replacement method. Surgical aortic valve replacement was an excellent choice, especially for patients with New York Heart Association class I/II, >= 75 age, left ventricular ejection fraction >= 50%, or longer life expectancy.

Background Cardiopulmonary bypass induces a systemic inflammatory response and alterations in fluid homeostasis, resulting in generalized tissue edema. Additionally, ischemia-reperfusion injury following cardioplegic arrest presumably prompts organ-specific myocardial edema.Case presentation The case report presents a 75-year-old Caucasian male diagnosed with aortic dissection, Stanford type A, who underwent complicated open-heart surgery. Postoperatively, the patient developed excessive myocardial edema, particularly affecting the right ventricle myocardium to an extent where the right ventricle surpassed the sternal rim, making it impossible to close the sternum. Ischemia was ruled out by performing coronary angiography, demonstrating well-calibrated coronary arteries. Transoesophageal echocardiography showed a restrictive right ventricle with free-wall thickness of 30 mm, severely reduced right ventricle systolic function and a volume-depleted left ventricle consistent with right ventricular heart failure due to right ventricular edema. The patient presented with unstable haemodynamics despite use of inotropes and continuation of open sternotomy. In an attempt to reduce myocardial edema, the patient was started on corticosteroid treatment despite of ongoing mediastinitis. Corticosteroid treatment reduced myocardial edema and enabled the closure of sternum on the 44th postoperative day.Conclusions The case report addresses the clinical relevance of corticosteroid treatment in selective cases of intractable haemodynamically significant postoperative myocardial edema.

Objective: To resolve an exceptional clustering of Cutibacterium avidum prosthetic valve infective endocarditis (IE) at a single heart center. Methods: During a period of 21 months, three patients experienced C. avidum bacteremia 24-128 days after aortic valve replacement. Operative procedures and electronic prescriptions of antimicrobials were surveyed, and bacterial isolates were genome sequenced. Results: The prosthetic valves were inserted by separate surgical teams. In one case, echocardiographic confirmation of IE was not achieved until 4 months after the first positive blood culture, but the causative agents were irrefutably documented in all cases by culture, or amplification of bacterial deoxyribonucleic acid, from removed prosthetic material. Whole-genome sequencing clustered isolates to a distinctive subgroup of the species but did not suggest inter-patient transmission of isolates. Conclusions: Despite vigorous sampling of blood and tissue, detection of C. avidum was not unconditional, neither by culture nor polymerase chain reaction test. The causative agent is likely underreported and should be meticulously searched for in culture-negative prosthetic valve endocarditis.

BackgroundArteriovenous (AV) grafts often develop severe complications of stenosis due to neointimal proliferation that occurs either at the venous anastomosis site or at the outflow receiving vein. This study compares primary patency during 12 months of follow up for a new experimental Biomodics© interpenetrating polymer network (IPN) drug-eluting graft prototype with state-of-the-art GORE® ACUSEAL (ACUSEAL) in an AV graft model in sheep.Methods and resultsAn end-to-end bypass from the common carotid artery to the jugularis vein was performed bilaterally in 12 sheep. The usage of ACUSEAL or the IPN, both 6.0 mm in diameter, was determined via randomization. The sheep were followed up every 4 weeks with ultrasonic duplex scanning to determine patency; the experienced observer was blinded to the randomization. One sheep died after 11 days, and the final sample accordingly consisted of 11 animals. When comparing neointimal hyperplasia after 12 months in the two grafts, Fisher's exact test showed a significant difference with none out of 11 in the IPN grafts and 9 out of 11 in the ACUSEAL graft (p < 0.001). However, the Biomodics© IPN exhibited severe deterioration over time.ConclusionsAlmost all of the grafts occluded during the 12 months of follow up. Although the zwitterion-bounded interpenetrating drug eluting polymer network showed signs to impair neointimal hyperplasia and thrombosis, age-related degeneration hindered demonstrating a potential improvement in patency.

Objectives: To evaluate the impact of acute kidney injury on transition to chronic kidney disease (CKD) after cardiac surgery and to determine frequency of incident CKD in these patients. Design: A systematic review and meta-analysis of observational studies. Setting: Electronic databases Medline and Embase were systematically searched from 1974 to February 6, 2023. Participants: Eligible studies were original observational studies on adult cardiac surgery patients, written in the English language, and with clear kidney disease definitions. Exclusion criteria were studies with previously transplanted populations, populations with preoperative kidney impairment, ventricular assist device procedures, endovascular procedures, a kidney follow-up period of <90 days, and studies not presenting necessary data for effect size calculations. Interventions: Patients developing postoperative acute kidney injury after cardiac surgery were compared with patients who did not develop acute kidney injury. Measurements and Main Results: The search identified 4,329 unique studies, 87 underwent full-text review, and 12 were included for analysis. Mean acute kidney injury occurrence across studies was 16% (minimum-maximum: 8-50), while mean occurrence of CKD was 24% (minimum-maximum: 3-35), with high variability depending on definitions and follow-up time. Acute kidney injury was associated with increased odds of CKD in all individual studies. The pooled odds ratio across studies was 5.67 (95% confidence interval, 3.34-9.64; p < 0.0001). Conclusions: Acute kidney injury after cardiac surgery was associated with a more than 5-fold increased odds of developing CKD. New-onset CKD occurred in almost 1 in 4 patients in the years after surgery.

Aortic root aneurysm is a frequent condition, which is associated with increased mortality and morbidity compared to other aortic aneurysms. The treatment relies on surgery, most often with the Bentall procedure or aortic valve-sparing root replacement (AVSRR). AVSRR is a highly specialised treatment associated with increased survival and low incidences of valve-related complications compared to the Bentall procedure. The purpose of this review is to highlight the diagnosing and surgical treatments of AAR with a focus on the newest international experiences with AVSRR.

Abstract Background Heart failure due to myocardial infarction (MI) involves fibrosis driven by epicardium‐derived cells (EPDCs) and cardiac fibroblasts, but strategies to inhibit and provide cardio‐protection remains poor. The imprinted gene, non‐canonical NOTCH ligand 1 (Dlk1), has previously been shown to mediate fibrosis in the skin, lung and liver, but very little is known on its effect in the heart. Methods Herein, human pericardial fluid/plasma and tissue biopsies were assessed for DLK1, whereas the spatiotemporal expression of Dlk1 was determined in mouse hearts. The Dlk1 heart phenotype in normal and MI hearts was assessed in transgenic mice either lacking or overexpressing Dlk1. Finally, in/ex vivo cell studies provided knowledge on the molecular mechanism. Results Dlk1 was demonstrated in non‐myocytes of the developing human myocardium but exhibited a restricted pericardial expression in adulthood. Soluble DLK1 was twofold higher in pericardial fluid (median 45.7 [34.7 (IQR)) μg/L] from cardiovascular patients (n = 127) than in plasma (median 26.1 μg/L [11.1 (IQR)]. The spatial and temporal expression pattern of Dlk1 was recapitulated in mouse and rat hearts. Similar to humans lacking Dlk1, adult Dlk1−/− mice exhibited a relatively mild developmental, although consistent cardiac phenotype with some abnormalities in heart size, shape, thorax orientation and non‐myocyte number, but were functionally normal. However, after MI, scar size was substantially reduced in Dlk1−/− hearts as compared with Dlk1+/+ littermates. In line, high levels of Dlk1 in transgenic mice Dlk1fl/flxWT1GFPCre and Dlk1fl/flxαMHCCre/+Tam increased scar size following MI. Further mechanistic and cellular insight demonstrated that pericardial Dlk1 mediates cardiac fibrosis through epithelial to mesenchymal transition (EMT) of the EPDC lineage by maintaining Integrin β8 (Itgb8), a major activator of transforming growth factor β and EMT. Conclusions Our results suggest that pericardial Dlk1 embraces a, so far, unnoticed role in the heart augmenting cardiac fibrosis through EMT. Monitoring DLK1 levels as well as targeting pericardial DLK1 may thus offer new venues for cardio‐protection.