BACKGROUND:The Medtronic Freestyle is widely used for full-root aortic valve replacement, offering excellent hemodynamics. However, structural valve deterioration, including pseudoaneurysm formation, raises concerns. METHODS:Our single-center retrospective and prospective cohort study of adult patients who underwent modified Bentall procedures with the Medtronic Freestyle between September 2015 and November 2023 analyzed early and late complications, echocardiographic results, and survival. A cross-sectional computed tomographic angiography (CTA) evaluation assessed postoperative structural abnormalities. RESULTS:Included were 153 patients (median European System for Cardiac Operative Risk Evaluation 2011 revision, 3.4%). The 1- and 5-year actuarial survival rates were 96.7% and 87.2%, respectively. Postoperative mean and maximal transvalvular gradients were 5.8 mm Hg (interquartile range, 4.3-7.6 mm Hg) and 11.1 mm Hg (interquartile range, 8.2-14.9 mm Hg). Of the 98 patients (77.8% of eligible patients) who underwent CTA imaging, 23.5% had structural abnormalities. Pseudoaneurysms were the most common (15.3%) and warranted reintervention in 3 cases. Routine echocardiography failed to detect the pseudoaneurysms. Multivariate analysis identified previous cardiac surgery as an independent predictor of pseudoaneurysm development (odds ratio, 4.32; P = .046). The cumulative risk of CTA-detectable structural abnormalities may reach 22.7% at 5 years. CONCLUSIONS:The Medtronic Freestyle displays excellent hemodynamic performance. However, silent structural deterioration is not rare. Routine echocardiography may miss these lesions, supporting the role of systematic postoperative CTA imaging, especially for redo patients. Further studies are needed to guide optimal imaging surveillance protocols.

Revascularization of the circumflex artery territory is challenging due to its anatomical position and technical complexity. We present a novel approach using the proximal circumflex trunk for arterial bypass, ensuring natural antegrade blood flow and avoiding multiple distal anastomoses. This streamlined technique minimizes grafting complications and achieves efficient revascularization in complex left main disease.

Abstract Background Postoperative pulmonary complications (PPCs) remain the most frequent adverse events after cardiac surgery. Enhanced Recovery After Surgery (ERAS) programs aim to reduce postoperative morbidity, and data describing the incidence, patterns, and protective factors associated with PPCs within cardiac ERAS pathways remain limited. Methods We analyzed 500 consecutive adult patients undergoing cardiac surgery within a standardized ERAS program at a tertiary center. PPCs included respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, or aspiration pneumonitis. Results PPCs occurred in 130 of 500 patients (26%). The most frequent events were atelectasis (28.5%), respiratory failure (23.8%), and pneumonia (20%). Independent preoperative and intraoperative factors included age ≥ 70 years (OR 1.86, 95% CI 1.14–3.03), BMI ≥ 35 kg/m2 (OR 2.37, 95% CI 1.18–4.76), active smoking (OR 1.95, 95% CI 1.13–3.37), frailty (OR 2.21, 95% CI 1.12–4.33), and redo surgery (OR 3.09, 95% CI 1.52–6.26). Patients with PPCs had longer ICU and hospital length of stay, higher ICU readmission rates, and increased postoperative complications, without a significant difference in 30-day mortality. Exploratory analyses identified early extubation and shorter chest drain duration as variables associated with a lower incidence of PPCs, whereas postoperative delirium and transfusion were associated with an increased risk of PPCs. Conclusion PPCs affected one in four patients in this ERAS cardiac surgery cohort and were associated with significant morbidity. Preoperative factors including age, obesity, frailty, and redo surgery were the main associated factors. Among these, frailty and active smoking emerged as key modifiable associated factors that remain incompletely addressed and represent important targets for optimization. Several postoperative factors, including early extubation, delirium, transfusion, and chest drain management, were potential targets for optimization. Further studies are needed to better clarify their causal role and to guide targeted interventions.

Extrinsic coronary compression is rare, difficult to diagnose, and can have serious consequences. A patient who had surgery for aortic valve endocarditis with patch closure of a septal abscess was readmitted for myocardial infarction. CT scan revealed compression of the left main stem due to pseudoaneurysm formation under the patch. Positron emission tomography confirmed acute hypoperfusion of the left ventricle, making immediate high-risk reoperation unavoidable. Imaging of the patient at one-year follow-up showed complete thrombosis of the former abscess cavity. Extrinsic coronary compression due to an abscess/pseudoaneurysm is associated with a high mortality rate and surgery appears to be the only possible life-saving treatment. In cases of unclear cardiac symptoms occurring under these circumstances (and thus suggesting extrinsic coronary compression), early imaging for quantitative myocardial perfusion should be considered to assess severity of myocardial ischaemia and thus urgency of surgery.

BACKGROUND:An aorto-right ventricular fistula (ARVF) secondary to membranous septum rupture is an exceptionally rare complication after surgical aortic valve replacement (SAVR). While sutureless prostheses such as the Perceval valve have gained wide acceptance due to reduced cross-clamp times and procedural simplification, the reported adverse events predominantly include conduction disturbances and paravalvular leaks. Structural septal disruption remains sparsely described. We report a case of an early ARVF after Perceval implantation and review the pathophysiological and procedural mechanisms implicated in septal injury following sutureless and transcatheter aortic valve interventions. CASE DESCRIPTION:A 66-year-old woman with severe bicuspid aortic valve stenosis underwent SAVR via a median sternotomy using a Perceval XL prosthesis after meticulous annular decalcification and sizing. Immediate intraoperative transesophageal echocardiography (TEE) confirmed optimal seating without any paravalvular regurgitation. Within 24 h, the patient developed a complete atrioventricular block followed by cardiogenic shock. A repeat TEE revealed a large ARVF with significant left-to-right shunt. Emergent re-exploration identified a membranous septum tear. The Perceval prosthesis was explanted, the defect was closed with a reinforced patch repair, and a 27 mm Inspiris Resilia bioprosthesis was implanted. Peripheral veno-arterial ECMO support was required temporarily. The patient recovered and remained free of prosthetic dysfunction at the two-year follow-up. DISCUSSION:Membranous septum rupture after AVR has an estimated incidence of 0.4-1.5% in TAVR cohorts but is virtually unreported with Perceval valves. The mechanisms are thought to be chronic radial stress from oversized or malpositioned prostheses. Case reports with TAVR devices emphasize oversizing as a risk factor. Predictive factors for septal injury in sutureless AVR mirror those for conduction disturbances: valve oversizing, shallow infra-annular septal length, heavy calcification, and prior valve surgery. Preventive measures, such as strict sizing protocols, the avoidance of balloon dilation, and optimized implantation depth, have reduced conduction complications and may mitigate septal trauma. The treatment choice, whether percutaneous or surgical closure, depends on hemodynamic stability, defect size and anatomy, and operative risk. CONCLUSIONS:Early ARVF after Perceval implantation is exceedingly rare but potentially catastrophic. Strict adherence to sizing principles, awareness of septal anatomy, and prompt management, percutaneous in selected stable cases or surgical in acute large defects, are essential to optimize outcomes in sutureless AVR.

Background:Embolic events (EEs) are frequent and clinically important complications of infective endocarditis (IE). Three scores have been developed to predict EEs: the Embolic Risk French Calculator (for EEs occurring after treatment initiation), and the Italian Endocarditis Study and University of Campania "L. Vanvitelli" Napoli Score (for EEs occurring before or after antimicrobial initiation). This study aimed to externally validate and compare the predictive performance of these scores. Methods:This is a multicenter retrospective study including adult patients diagnosed with IE between 2014 and 2024 at Lausanne University Hospital and University Hospital Zurich. Embolic events and IE were defined according to the 2023 International Society of Cardiovascular Infectious Diseases (ISCVID) Duke criteria. Scores were applied according to their respective populations, and performance was evaluated using sensitivity, specificity, and accuracy. Results:Among 1331 IE episodes, 674 (51%) experienced EEs, with 474 (36%) before and 348 (26%) after antimicrobial initiation. The Embolic Risk French Calculator, applied to 1201 valve-related IE episodes, identified 358 (30%) as high risk. Accuracy for predicting postantibiotic EEs was 66% (95% CI 64%-69%). The Italian Endocarditis Study score, applied to 1073 episodes with left-side IE, classified 563 (53%) as intermediate/high risk, with an overall accuracy of 60% (56%-62%). The University of Campania score, applied to 701 valve-related IE episodes, identified 341 (49%) as intermediate/high risk, with an accuracy of 63% (60%-67%). Conclusions:All 3 scores demonstrated limited predictive accuracy and frequently misclassified patients. More robust tools are needed to guide embolic risk stratification in clinical practice.

BACKGROUND:Valve leaflet thickening was recently incorporated into the 2023 version of the Duke criteria by the European Society of Cardiology (ESC) as a potential imaging marker of infective endocarditis (IE). The study aimed to assess the impact of valve leaflet thickening on the diagnosis of IE among patients investigated for suspected IE. METHODS:This retrospective study included adults with suspected IE at Lausanne University Hospital (2014-2025). IE was diagnosed by the 2023 Duke-ISCVID based on the clinical, pathological, and rejection criteria. Reclassification of IE status was assessed according to the 2023 Duke-ESC clinical criteria with and without inclusion of leaflet thickening. RESULTS:Among 3,747 episodes of suspected IE, valve leaflet thickening was identified in 288 (8%). IE was diagnosed in 193/288 (67%) episodes. Among the 193 IE episodes, 62 (32%) showed no additional intracardiac lesion typically associated with IE. When leaflet thickening was excluded from imaging criteria, 144 episodes (50%) still fulfilled a major imaging criterion according to the 2023 Duke-ESC clinical criteria. Incorporation of leaflet thickening into the 2023 Duke-ESC clinical criteria increased sensitivity from 59% (95% CI: 52-66%) to 79% (95% CI: 73-85%), while specificity decreased from 98% (95% CI: 93-100%) to 46% (95% CI: 36-57%). CONCLUSIONS:Valve leaflet thickening is a frequent but non-specific imaging finding that substantially reduces diagnostic specificity when incorporated into the 2023 Duke-ESC clinical criteria. Its use as a major imaging criterion risks overdiagnosis and overtreatment, underscoring the need for cautious interpretation within a multidisciplinary diagnostic framework.

Whether longer cold ischemic time (CIT) increases early hemodynamic support after heart transplantation (HTx) with histidine-tryptophan-ketoglutarate (HTK) preservation is unclear. We examined the association between CIT and the vasoactive-inotropic score (VIS), a marker of circulatory support. We studied consecutive adults transplanted with HTK-preserved grafts at Lausanne University Hospital (January 2016-March 2025). VIS was calculated hourly for 48 h after ICU admission, and its association with CIT modeled using restricted cubic splines. Among 130 recipients (75% male, aged 52±12 years), mean CIT was 152±50 min. Longer CIT was associated with higher 24-hour VIS (Poverall=0.048), rising steeply beyond ≈200 min. Patients with CIT ≥200 min (n=14) had higher VIS (difference at 48 h 10.2 points, p=0.024), more post-transplant ECMO (43% vs 9%, p<0.001), and longer ICU stay (11.0 vs 6.1 days, p=0.014). The CIT-VIS relationship was non-linear, supporting CIT as a potentially modifiable determinant of early hemodynamic status after HTx.

Background and Clinical Significance: The Ozaki procedure offers excellent hemodynamics and mid-term durability, but infective endocarditis (IE), although rare, remains its most serious complication and frequently requires complex redo surgery. Sutureless valve technology, particularly the Perceval bioprosthesis, has shown value in high-risk endocarditis due to reduced annular manipulation and rapid deployment. Case Presentation: We describe the first reported case of Perceval sutureless valve implantation as a bail-out strategy for IE after a prior Ozaki procedure. A 68-year-old male previously treated with Ozaki reconstruction and LIMA-LAD bypass presented with septic and cardiogenic shock caused by Streptococcus bovis endocarditis, two years after the first surgery. TOE revealed torrential aortic regurgitation from destruction of the anterior neocuspid and large vegetations. Despite a EuroSCORE II of 89.5%, emergent redo surgery was undertaken. Redo sternotomy revealed extensive leaflet destruction and a sub-annular abscess involving two sinuses. Following radical debridement and annular reconstruction, a medium Perceval valve was implanted due to severe tissue fragility. The prosthesis seated securely with no paravalvular leakage. Conclusions: This case demonstrates that the Perceval sutureless valve can be an effective bailout option for post-Ozaki infective endocarditis, particularly when annular integrity is compromised, and conventional sutured prostheses are high risk. The combination of rapid deployment and minimal annular stress may expand therapeutic possibilities in complex redo aortic surgery.

Abstract Background Extracorporeal cardiopulmonary resuscitation (ECPR) can improve survival in patients with refractory cardiac arrest (CA). However, defining optimal selection criteria for ECPR remains a major challenge. Methods We retrospectively analyzed all ECPR treatments for refractory in-hospital CA (IHCA) and out-of-hospital CA (OHCA) in adult patients from January 1, 2010 through December 31, 2024 at our tertiary 35-bed Intensive Care Unit. Before July 2017 (Period 1), ECPR was implemented at physician discretion. From July 2017 (Period 2), a dedicated protocol recommended physicians to implement ECPR based on four criteria: age < 70 years, shockable rhythm, no-flow duration < 5 min, and total low-flow duration < 80 min. The primary outcome was hospital mortality. The secondary outcome was good neurological outcome at 3 months, defined by a cerebral performance category (CPC) score of 1 or 2. Results A total of 166 patients (45 in period 1, 121 in period 2), including 80 IHCAs and 86 OHCAs, were included. The proportion of patients fulfilling the 4 criteria was low yet significantly greater in period 2 than in period 1 (35.0 vs. 17.8%, p = 0.027). Hospital survival was improved in period 2 (26.5% vs. 8.9%, p = 0.015), whereas good neurological outcome was not (14.9 vs. 6.7%, p = 0.157). When evaluating the impact of the 4 criteria over the whole study period, patients with 4 criteria vs. those with < 4 criteria displayed marked improvements in survival (48.0 vs. 9.6%, p < 0.001) and good neurological outcome (30.0 vs. 5.2%, p < 0.001). In multivariable analysis, only the simultaneous presence of the 4 criteria was independently associated with a decreased risk of death (OR = 0.11, 95% CI 0.01–0.87, p = 0.037), whereas no single criterion alone was significantly predictive. Conclusion Implementing a clinical ECPR protocol in our institutional practice improved meaningful survival in patients with refractory IHCA and OHCA fulfilling four predefined criteria including an age < 70 years, a shockable rhythm, a no-flow < 5 min, and a low-flow < 80 min.

BACKGROUND:The clinical significance and impact of valve strands, also known as Lambl's excrescences, on management in patients with suspected infective endocarditis (IE) remain unclear. The study aimed to assess the impact of the diagnosis of valve strands on the outcomes of patients investigated for suspected IE. METHODS:We conducted a retrospective study at Lausanne University Hospital (2014-2024) including adult patients with a valve strand identified on cardiac imaging. Episodes were classified as IE or non-IE by a multidisciplinary Endocarditis Team (2018-2024) or by expert clinicians (2014-2017). One-year outcomes included recurrence of bacteremia/candidemia or IE by the same microorganism. RESULTS:Among 305 episodes with valve strands, 101 (33%) were diagnosed as IE by the Endocarditis Team or expert clinicians. Among the 204 episodes without IE, 165 (81%) had bacteremia/candidemia. Valve strands were identified by transthoracic echocardiography in 141 (50%) out of 282 episodes, and by transesophageal echocardiography in 191 (79%) out of 244 episodes. Among the 257 episodes with bacteremia/candidemia, recurrence of bacteremia/candidemia caused by the same microorganism within one year occurred in 7/92 (8%) among those with IE and 11/165 (7%) among those without (P=0.971). Recurrence of IE due to the same microorganism within one year was significantly more frequent among episodes with IE compared to those without (6/92; 7% versus 2/165; 1%; P=0.029). CONCLUSIONS:Most valve strands detected in patients with suspected IE do not represent infectious lesions. Careful evaluation by expert cardiologists and multidisciplinary discussion can safely differentiate valve strands from vegetations, reducing unnecessary treatment.

Background and Clinical Significance: Revascularization of the circumflex territory remains technically challenging because of its anatomical position and the frequent need for distal branch grafting. Case presentation: We report the case of a 76-year-old man in whom the proximal circumflex trunk was used as the target for an in situ right internal thoracic artery routed through the transverse sinus during combined coronary and ascending aortic surgery. This approach allowed antegrade perfusion of the circumflex territory while avoiding multiple distal anastomoses. In this selected anatomical setting, the technique proved feasible and was associated with excellent intraoperative flow and 1-year radiological patency. Conclusions: Direct grafting of the circumflex trunk is not a new concept, but this case revisits it using a contemporary total arterial revascularization strategy. This approach may represent a useful adjunctive option in carefully selected patients with favorable circumflex anatomy.

Background Echocardiography is central to the diagnosis of infective endocarditis (IE). Although guidelines recommend repeating echocardiography when clinical suspicion persists despite negative or inconclusive findings, the diagnostic value of repeating transthoracic echocardiography (TTE) remains uncertain. The aim was to evaluate the diagnostic performance of repeat TTE in the diagnosis of IE among patients with suspected IE. Methods This retrospective study conducted at Lausanne University Hospital (2015–2024) including adult patients with suspected IE who underwent 2 TTEs within 21 days. IE was classified according to the 2023 Duke‐International Society for Cardiovascular Infectious Diseases criteria. Results A total of 503 episodes were included, of which 254 (50%) were diagnosed as IE. The second TTE was performed within 8 days from first TTE (interquartile range, 5–13 days). The second TTE identified new vegetations in 34 (7%) episodes and new paravalvular complications in 17 (3%) episodes. Sensitivity for detecting vegetations increased from 47% (95% CI, 39%–56%) for the first TTE to 57% (95% CI, 48%–65%) for the second. By excluding the results of cardiac imaging modalities other than TTE, the sensitivity of the second TTE for diagnosing IE was higher (45% [95% CI, 38%–51%]), compared with 34% (95% CI, 28%–41%) for the first TTE; the second TTE led to reclassification from possible to definite IE in 7 (1%) of cases. Conclusions Repeat TTE modestly improved typical IE lesion detection; however, within a multimodality imaging strategy, its incremental diagnostic contribution was limited. These results suggest that repeated TTE alone is unlikely to substantially alter diagnosis in most patients, supporting the use of complementary imaging when suspicion of IE remains high.

Abstract Background Complications at the saphenous vein harvest site, including surgical site infection, wound dehiscence and prolonged drainage, remain underexplored in cardiac surgery despite their impact on recovery, length of hospital stay and healthcare costs. Up to 24% of patients undergoing coronary artery bypass grafting (CABG) experience such complications. Skin closure of vein harvest sites is traditionally performed using skin staples. Alternative closure systems such as PRINEO combine an adhesive layer with a reinforcing mesh designed to support wound edge approximation and protection. Aims To compare postoperative outcomes of saphenous vein harvest site closure using traditional skin staples versus the PRINEO adhesive mesh system in patients undergoing CABG. Methods This retrospective single centre cohort study included adult patients undergoing CABG with saphenous vein grafts between January 2018 and October 2024. Patients receiving exclusively arterial grafts were excluded. Patients were grouped according to harvest site closure technique: staples or PRINEO. Primary outcomes were local complications including surgical site infection, wound dehiscence and prolonged drainage. Secondary outcomes included length of hospital stay, need for reintervention and 30 day mortality. Results A total of 747 patients were included. Mean age was 62.4 years and 83.4% were male. Preoperative risk factors and operative variables were comparable between groups. Surgical site infection occurred in 3.58% of patients in the PRINEO group and 12% in the staple group (P<0.01). Wound dehiscence or prolonged drainage occurred in 5% versus 20%, respectively (P<0.01). Thirty day mortality did not differ. Length of hospital stay was shorter in the PRINEO group. Conclusion In this cohort, PRINEO was associated with fewer local wound complications and shorter hospital stay compared with staple closure. Prospective studies are warranted to confirm these findings.

Among 598 infective endocarditis (IE) episodes, follow-up blood cultures within 14 days of antimicrobial treatment completion were performed in 135 (23%) cases and detected only 2 (1.5%) recurrences. This strategy failed to identify 8 (6%) additional IE recurrences diagnosed between days 15 and 120, underscoring its limited utility.

In a retrospective cohort of 549 Enterococcus faecalis bacteremia episodes, the MEFIER score showed poor rule-out performance (negative likelihood ratio of 0.69), misclassifying 60% of IE episodes as low-risk. In contrast, DENOVi score achieved a low negative likelihood ratio (0.07), misclassifying only 5% while limiting unnecessary echocardiography.

Background Postoperative care with ERAS programs resulted in a reduction in the incidence of postoperative delirium (POD). This study aims to evaluate the incidence of POD, describe the postoperative course of patients managed exclusively within an ERAS pathway after cardiac surgery, and explore potential factors associated with the occurrence of delirium. Methods We enrolled patients managed within an ERAS program in cardiac surgery. The primary outcome was the incidence of delirium. Secondary outcomes included the impact of POD on the postoperative course and perioperative factors associated with its occurrence. Results Among 500 patients included POD occurred in 30 patients (6%). Patients with POD were older (70 vs. 64years, p = 0.006), had a lower BMI. Patients with POD experienced significantly more postoperative complications, longer ICU (3 vs. 1 days, p < 0.001) and hospital stays. In multivariable analysis, older age, lower BMI and ICU readmission were associated with POD, whereas early extubation and opioid discontinuation before postoperative day 3 were associated with lower odds of POD. Conclusion POD remains a persistent complication despite implementation of a mature ERAS pathway and is associated with a more complex postoperative recovery. Exploratory analyses identified early extubation and shorter postoperative opioid exposure as potentially modifiable perioperative factors.

BACKGROUND:Fever is common in infective endocarditis (IE), yet little is known about fever duration in such patients. We aim to identify predictors of persistent fever in patients with suspected IE. METHODS:This study was conducted at the Lausanne University Hospital, Switzerland, from January 2014 to June 2023. All patients with suspected IE being febrile upon presentation were included. Fever (>38°C) was considered persistent if it continued for at least 96 hours from antimicrobial treatment initiation. A case was classified as IE by the Endocarditis Team. RESULTS:Among 1399 episodes with suspected IE, persistent fever was observed in 260 (19%) episodes. IE was diagnosed in 536 (41%) episodes, of which 82 (15%) had persistent fever. Among episodes with suspected IE, persistent bacteremia/candidemia for 96 hours (P < .001), spondylodiscitis (P = .039), intrabdominal infection (P = .001) were associated with persistent fever. Conversely, bacteremia by streptococci (P = .049), or enterococci (P = .001), source control performed withing 96 hours (P = .015) and appropriate antimicrobial treatment within 48 hours (P = .018) were associated with early defervescence. No association between persistent fever and infective endocarditis was found (P = .207). Among 536 IE episodes, persistent bacteremia/candidemia for 96 hours (P < .001), and native bone and joint infection (P = .020) were associated with persistent fever. Conversely, bacteremia by streptococci or enterococci (P = .001; adjusted odds ratio [aOR] 0.25, 95% confidence interval [CI] .11-.58) were associated with early defervescence. CONCLUSIONS:In episodes with suspected IE, persistent fever was associated with spondylodiscitis, inappropriate antimicrobial treatment and absence of source control interventions. Among IE patients, persistent fever was associated with native bone and joint infections.