Background: Currently, there are no standardized guidelines for graft allocation in heart transplants (HTxs), particularly when considering organs from marginal donors and donors after cardiocirculatory arrest. This complexity highlights the need for an effective risk analysis tool for primary graft dysfunction (PGD), a severe complication in HTx. Existing score systems for predicting PGD lack superior predictive capability and are often too complex for routine clinical use. This study sought to develop a user-friendly score integrating variables from these systems to enhance the efficacy of the organ allocation process. Methods: Severe PGD was defined as the need for mechanical circulatory support and/or death from an unknown etiology within the first 24 hours following HTx. We used a meta-analytical approach to create a derivation cohort to identify risk factors. We then applied a logistic regression analysis to generate an equation predicting severe PGD risk. We used our previous experience in HTx to create a validation cohort. Subsequently, we implemented the formula in a smartphone application. Results: The meta-analysis comprising six studies revealed a 10.5% ( 95% confidence interval (CI): 5.3–12.4) incidence rate of severe PGD and related 30-day mortality of 38.6%. Eleven risk factors were identified: female donors, female donor to male recipient, undersized donor, donor age, recipient on ventricular assist device support, recipient on amiodarone treatment, recipient with diabetes and renal dysfunction, re-sternotomy, graft ischemic time, and bypass time. An equation to predict the risk, including the 11 parameters (GREF-11), was created using logistic regression models and validated based on our experience involving 116 patients. In our series, 29 recipients (25%) required extracorporeal membrane oxygenation support within 24 hours post-HTx. The overall 30-day mortality was 4.3%, 3.4%, and 6.8% in the non-PGD and severe PGD groups, respectively. The area under the receiver operating characteristic (AU-ROC) curve of the model in the validation cohort was 0.804. Conclusions: The GREF-11 application should offer HTx teams several benefits, including standardized risk assessment and bedside clinical decision support, thereby helping minimize the risk of severe PGD post-HTx.

BACKGROUND:Life-threatening pulmonary arterial hypertension (PAH) still lacks a direct therapeutic approach targeted to the molecular defects associated with the disease. Here, we focus on the impaired regulation of intracellular acidity and sodium/calcium overload by testing the hypothesis that inhibiting NHE-1 (sodium/hydrogen exchanger isoform 1) with rimeporide enables the recovery of pulmonary and right ventricular dysfunctions in the Sugen5416/hypoxia PAH model in rats. METHODS AND RESULTS:Adult Sprague-Dawley male rats (n=44) rats were divided into 2 broad groups: control and Sugen5416/hypoxia. After verifying PAH insurgence in the Sugen5416/hypoxia group by transthoracic echocardiography and pulse-wave Doppler analysis, rats were treated with either 100 mg/kg per day rimeporide or placebo in drinking water for 3 weeks. The functional, morphological (fibrosis and hypertrophy), and biochemical (inflammation, signaling pathways) dysfunctions caused by PAH were partially reverted by rimeporide in both the lungs and myocardium, where the most striking effects were observed in the right ventricle. Rimeporide improved hemodynamics in the pulmonary circulation and in the right ventricle, with decrease in right ventricle hypertrophy, pulmonary vascular remodeling, inflammation, and fibrosis. No effect of rimeporide was detected in control rats. The protective effect of rimeporide was accompanied by decreased p-Akt/Akt (phosphorylated protein kinase B/protein kinase B) ratio and increased autophagy flux mainly in the right ventricle. CONCLUSIONS:By specifically inhibiting NHE-1, rimeporide at the selected dosage revealed remarkable anti-PAH effects by preventing the functional, morphological, and biochemical deleterious effects of PAH on the right ventricle and lungs. Rimeporide should be considered as a potential treatment for PAH.

Among 302 episodes of prosthetic valve endocarditis (PVE), 1-year mortality was 31%. There was no evidence indicating that early-onset PVE within 6 months from valve surgery led to a worse outcome compared to late-onset PVE (21% vs 32%, P = .126), despite similar redo valve surgeries across both categories.

To ascertain the predictors of persistent bacteraemia among patients with suspected infective endocarditis (IE) and those with IE. Retrospective study. This study conducted at a Swiss university hospital (2015–2023) included adult patients with bacteraemia and suspected IE. Persistent bacteraemia was defined as continued positive blood cultures with the same microorganism for at least 48 h from antibiotic treatment initiation. Endocarditis Team classified cases as IE or not IE. Among 2312 episodes of suspected IE, S. aureus was the most common pathogen (1045 episodes; 45

Among 3127 episodes of suspected infective endocarditis, the 2023 Duke-International Society for Cardiovascular Infectious Diseases clinical criteria showed an accuracy of 90% for infective endocarditis diagnosis. A new heart murmur was present in 690 (22%) episodes. Excluding imaging and surgical findings decreased the accuracy to 73%, while using the physical examination criterion slightly improved the accuracy to 78%. Among 3127 episodes of suspected infective endocarditis, the 2023 Duke-International Society for Cardiovascular Infectious Diseases clinical criteria showed low accuracy (78%) when excluding the imaging and surgical findings and when solely using the physical examination criterion.

Objective The definition of coronary artery bypass graft (CABG)-associated myocardial infarction (MI) is controversial because the postoperative increases in cardiac enzyme activities are multifactorial in origin. Methods We performed a retrospective case–control study of patients who experienced perioperative MI (cardiac enzyme release, electrocardiographic changes, dysfunction on echocardiography) and those without ischemia to identify risk factors and enzyme activity thresholds. Results The estimated incidence of CABG-associated MI was 2.8%. The risk factors were a family history of cardiovascular disease (odds ratio (OR) 2.8), tobacco abuse (OR 3.8), recent MI (OR 3.6), and triple-vessel disease (OR 2.8). The MI group showed higher mortality (OR 2.3), prolonged intubation (OR 3.1), and a prolonged stay in intensive care (OR 4.3). The type 5 MI threshold (10 times the upper limit of the reference range (URL)) was exceeded in 88.4% (troponin I) and 96% (high-sensitivity troponin T; hs-cTnT) of patients without ischemia. Conclusions The frequent exceeding of conventional MI-indicating thresholds in patients without ischemia indicates their low specificity. An enzyme activity increase alone is of limited diagnostic value for perioperative MI, which is associated with greater mortality. Finally, the use of a higher threshold for hs-cTnT (>45 × URL) may increase its specificity for graft failure.

Purpose: The Transmedics Organ Care System (OCS) allows both the expansion of a transplant program to long-distance brain death donation (DBD) and the use of hearts from donation after circulatory death (DCD). However, the implementation of such a system is complex, and in the context of a modest-sized transplant program such as Switzerland's, (on average, 39 transplants per year), the expected benefit was unknown.

Background. Streptococci are a common cause of infective endocarditis (IE). We aimed to evaluate the performance of the HANDOC score to identify patients at high risk for IE and the Duke clinical criteria of the European Society of Cardiology (ESC; 2015 and 2023 versions) and the 2023 version from the International Society of Cardiovascular Infectious Diseases (ISCVID) in diagnosing IE among patients with streptococcal bacteremia. Methods. This retrospective study included adult patients with streptococcal bacteremia hospitalized at Lausanne University Hospital. Episodes were classified as IE by the Endocarditis Team. A HANDOC score >2 classified patients as high risk for IE. Results. Among 851 episodes with streptococcal bacteremia, IE was diagnosed in 171 episodes (20%). Among 607 episodes with non-beta-hemolytic streptococci, 213 (35%) had HANDOC scores >2 points; 132 (22%) had IE. The sensitivity of the HANDOC score to identify episodes at high risk for IE was 95% (95% confidence interval [CI], 90%-98%), the specificity 82% (95% CI, 78%-85%), and the negative predictive value (NPV) 98% (95% CI, 96%-99%). 2015 Duke-ESC, 2023 Duke-ISCVID, and 2023 Duke-ESC clinical criteria classified 114 (13%), 145 (17%), and 126 (15%) episodes as definite IE, respectively. Sensitivity (95% CI) for the 2015 Duke-ESC, 2023 Duke-ISCVID, and 2023 Duke-ESC clinical criteria was calculated at 65% (57%-72%), 81% (74%-86%), and 73% (65%-79%), respectively, with specificity (95% CI) at 100% (98%-100%), 99% (98%-100%), and 99% (98%-100%), respectively. Conclusions. The HANDOC score showed an excellent NPV to identify episodes at high risk for IE. Among the different versions of the Duke criteria, the 2023 Duke-ISCVID version fared better for the diagnosis of IE among streptococcal bacteremia.

Objectives: To ascertain whether infective endocarditis (IE) was associated with persistent bacteraemia/candidaemia among patients with suspected IE. Methods: This study included bacteraemic/candidaemic adult patients with echocardiography and followup blood cultures. Persistent bacteraemia/candidaemia was defined as continued positive blood cultures with the same microorganism for 48 h or more after antibiotic treatment initiation. Each case was classified for IE by the Endocarditis Team. Results: Among 1962 episodes of suspected IE, IE (605; 31%) was the most prevalent infection type. Persistent bacteraemia/candidaemia was observed in 426 (22%) episodes. Persistent bacteraemia was more common among episodes with Staphylococcus aureus bacteraemia compared to episodes with positive blood cultures for other pathogens (32%, 298/933 vs 12%, 128/1029; P < 0.001). Multivariable analysis demonstrated that cardiac predisposing factors (aOR 1.84, 95% CI 1.31-2.60), community or nonnosocomial healthcare -associated (2.85, 2.10-3.88), bacteraemia by high -risk bacteria, such as S. aureus , streptococci, enterococci or HACEK (1.84, 1.31-2.60), two or more positive sets of index blood cultures (6.99, 4.60-10.63), persistent bacteraemia/candidaemia for 48 h from antimicrobial treatment initiation (1.43, 1.05-1.93), embolic events within 48h from antimicrobial treatment initiation (12.81, 9.43-17.41), and immunological phenomena (3.87, 1.09-1.78) were associated with infective endocarditis. Conclusions: IE was associated with persistent bacteraemia/candidaemia, along with other commonly associated factors. (c) 2024 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )

Infective Endocarditis (IE) is a complex, life-threatening disease. The aim of the present study was to evaluate the impact of the Endocarditis-Team on management of IE. This observational study conducted at a university hospital (2015‒22), included adult patients with IE. The study period was divided in two periods: before (pre-Endocarditis-Team; pre-ET) and after the establishment of the Endocarditis-Team (post-Endocarditis-Team; post-ET) on January 2018. Among 505 IE episodes (187 in pre-Endocarditis-Team, 318 in post-ET period), 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography was more commonly used in post-ET period (14 % vs. 28 %; p < 0.001). Overall, thirty-day and one-year mortality were 14 % and 27 %, respectively; no difference was observed between the two periods. In post-ET period, the administration of 4-weeks, rather than 6-weeks, of intravenous antimicrobial treatment was higher than in the post-ET period (15 % vs. 45 %; p < 0.001). Indication for surgery was present in 115 (61 %) patients in pre-ET and in 153 (48 %) in the post-ET period. In post-ET period, among patients with indication, valve surgery was more frequently performed (66 % vs. 78 %; p = 0.038). Such difference was due to a higher acceptance of operative indication by the cardiac surgeon (69 % vs. 94 %; p = 0.013). The observed increase in number of patients benefiting from cardiac surgery in the post-ET period led to a decrease of subsequent embolic events, since among patients with operative indication (n = 268), new embolic events after the establishment of the indication were more common in the pre-ET period compared to post-ET (23 % vs. 12 %; p = 0.033). After the implementation of the multidisciplinary Endocarditis-Team we observed several improvements in the general management of IE patients.

Background. Since publication of Duke criteria for infective endocarditis (IE) diagnosis, several modifications have been proposed. We aimed to evaluate the diagnostic performance of the Duke-ISCVID (International Society of Cardiovascular Infectious Diseases) 2023 criteria compared to prior versions from 2000 (Duke-Li 2000) and 2015 (Duke-ESC [European Society for Cardiology] 2015). Methods This study was conducted at 2 university hospitals between 2014 and 2022 among patients with suspected IE. A case was classified as IE (final IE diagnosis) by the Endocarditis Team. Sensitivity for each version of the Duke criteria was calculated among patients with confirmed IE based on pathological, surgical, and microbiological data. Specificity for each version of the Duke criteria was calculated among patients with suspected IE for whom IE diagnosis was ruled out. Results. In total, 2132 episodes with suspected IE were included, of which 1101 (52%) had final IE diagnosis. Definite IE by pathologic criteria was found in 285 (13%), 285 (13%), and 345 (16%) patients using the Duke-Li 2000, Duke-ESC 2015, or the Duke-ISCVID 2023 criteria, respectively. IE was excluded by histopathology in 25 (1%) patients. The Duke-ISCVID 2023 clinical criteria showed a higher sensitivity (84%) compared to previous versions (70%). However, specificity of the new clinical criteria was lower (60%) compared to previous versions (74%). Conclusions. The Duke-ISCVID 2023 criteria led to an increase in sensitivity compared to previous versions. Further studies are needed to evaluate items that could increase sensitivity by reducing the number of IE patients misclassified as possible, but without having detrimental effect on specificity of Duke criteria.

OBJECTIVES The choice of the cardiac preservation solution for myocardial protection at time of heart procurement remains controversial and uncertainties persist regarding its effect on the early and midterm heart transplantation (HTx) outcomes. We retrospectively compared our adult HTx performed with 2 different solutions, in terms of hospital mortality, mid-term survival, inotropic score, primary graft dysfunction and rejection score. METHODS From January 2009 to December 2020, 154 consecutive HTx of adult patients, followed up in pre- and post-transplantation by 2 different tertiary centres, were performed at the University Hospital of Lausanne, Switzerland. From 2009 to 2015, the cardiac preservation solution used was exclusively St-Thomas, whereafter an institutional decision was made to use HTK-Custodiol only. Patients were classified in 2 groups accordingly. RESULTS There were 75 patients in the St-Thomas group and 79 patients in the HTK-Custodiol group. The 2 groups were comparable in terms of preoperative and intraoperative characteristics. Postoperatively, compared to the St-Thomas group, the Custodiol group patients showed significantly lower inotropic scores [median (interquartile range): 35.7 (17.5-60.2) vs 71.8 (31.8-127), P < 0.001], rejection scores [0.08 (0.0-0.25) vs 0.14 (0.05-0.5), P = 0.036] and 30-day mortality rate (2.5% vs 14.7%, P = 0.007) even after adjusting for potential confounders. Microscopic analysis of the endomyocardial biopsies also showed less specific histological features of subendothelial ischaemia (3.8% vs 17.3%, P = 0.006). There was no difference in primary graft dysfunction requiring postoperative extracorporeal membrane oxygenation. The use of HTK-Custodiol solution significantly improved midterm survival (Custodiol versus St-Thomas: hazard ratio = 0.20, 95% confidence interval: 0.069-0.60, P = 0.004). CONCLUSIONS This retrospective study comparing St-Thomas solution and HTK-Custodiol as myocardial protection during heart procurement showed that Custodiol improves outcomes after HTx, including postoperative inotropic score, rejection score, 30-day mortality and midterm survival.

Abstract Cardiac surgery has become more complex in recent years, with increases in patient age, complexity, and associated costs. The use of a multidisciplinary strategy to analyze and standardize patient management offers significant benefits. The development of Enhanced Recovery After Surgery (ERAS) programs has proven useful in various types of surgery, recently including cardiac surgery, yielding good results. One of the primary objectives of ERAS programs is the reduction of the Inpatients' length of stay (LOS), with the subsequent improvement in the patient experience and a reduction in costs. The aim of this study is to analyze preoperative and postoperative factors related to the LOS reduction in a cohort of elective cardiac surgery patients included in the Cardiac ERAS program at our hospital. All patients included in the ERAS program, corresponding to elective cardiac surgery, were included in the analysis. 138 patients were divided into four quartiles based on the inpatient’s LOS. An extensive search was conducted in our quality control database, which contains 470 variables on the factors more strongly associated with LOS. The results were analyzed using Chi-Square test for categorical and the Kruskal-Wallis test for continuous variables, generally of non-normal distribution. The results are summarized in the table. Age, poor mobility, surgery other than coronary bypass, and reoperation were the non-modifiable factors most associated with a prolonged LOS. Lower preoperative hemoglobin and albumin levels were associated with an increase in LOS. A class 3 or 4 NYHA functional class, chronic pulmonary disease, and anticoagulation use were associated with higher LOS. Classic cardiovascular risk factors, such as dyslipidemia, hypertension, and tobacco use, were not associated with differences in hospitalization duration. Postoperative and intraoperative factors associated with higher LOS included extubation in the operating room or within six hours, ICU stay duration, mobilization on postoperative days one and two, time to oral food tolerance and gut motility recovery, hyperglycemia on postoperative day one, the duration of arterial, venous, and urinary catheters, the amount of fluids on postoperative day one and the opioid use in POD 2. The complications most associated with a prolonged duration were any infectious complication, any respiratory complication, reoperation, readmission to intensive care, transfusion after 12 hours or at any time during hospitalization, prolonged postoperative sedation, and any rhythmic complication. Conclusion In our cohort of elective patients for cardiac surgery, factors traditionally addressed by ERAS programs were identified as being associated with a longer inpatient’s length of stay. Pre-operative nutritional and anemia optimization, early extubation and mobilization, and the prevention of respiratory and infectious complications should be targeted to improve hospital stay duration.

In this retrospective/prospective study, we assessed the role of fundoscopy in 711 episodes with suspected infective endocarditis (IE); 238 (33%) had IE. Ocular embolic events (retinal emboli or chorioretinitis/endophthalmitis) and Roth spots were found in 37 (5%) and 34 (5%) episodes, respectively, but had no impact on IE diagnosis. Fundoscopy among patients with suspected infective endocarditis detected ocular embolic events and Roth spots in 5% of episodes each but failed to substantially reclassify patients according to Duke criteria, suggesting that universal fundoscopy for diagnostic purposes is not justified. Graphical Abstract This graphical abstract is also available at Tidbit: https://tidbitapp.io/tidbits/eyes-wide-shut-a-cohort-study-questioning-the-role-of-fundoscopy-in-infective-endocarditis-diagnosis

Objectives: Mitral valve repair is the current standard approach for mitral valve regurgitation. However, patients suffering from functional mitral regurgitation have a significant risk of recurrent regurgitation. Adjustable mitral rings may provide a solution for this adverse event. Methods: A single-center, first-in-man clinical study was performed on patients suffering from mitral valve regurgitation. Patients were implanted with the study ring and followed for six months. A balloon catheter can be inserted into the study ring frame at any time after implantation and inflated independently in the areas P1, P2, or P3, which reduces the anterior-posterior diameter. Results: Five patients (75.4 ± 6.1 years; EuroSCORE II 2.1 ± 0.9%; three female) were successfully implanted. Mechanisms of mitral regurgitation were prolapse of the P2-segment in three patients and annular dilation in two patients. Surgical implantation according to the protocol was feasible and is described herein. Median cardiopulmonary bypass time and cross clamp time were 105 (118; 195) and 94 (90; 151) min, respectively. The median intensive care unit stay was 2 (2; 3) days. No perioperative, 30-day, or 6-month mortality was observed, and the repair was stable without residual or recurrent regurgitation ≥ grade 2. All patients reached the primary endpoint without device-related morbidity. Conclusions: Successful implantation was completed in five patients without device-related adverse events. Ring implantation was safe and feasible for all patients. The opportunity of post-implant adjustment to improve leaflet coaptation is a promising new therapeutic strategy that is assessed in a phase II study.

INTRODUCTION: Real-world outcomes with the HeartMate 3 left ventricular assist device (LVAD) depending on whether it’s a bridge to transplantation (BTT) or destination therapy (DT) are poorly studied. We aimed to compare the profile and clinical outcomes of patients supported with HeartMate 3 according to a BTT or a DT pre-implantation strategy. METHODS: All patients consecutively implanted with HeartMate 3 at our centre (University Hospital of Lausanne, Switzerland) in 2015–2022 were analysed in a retrospective observational study. Indications for HeartMate 3 implantation were advanced heart failure despite optimal medical treatment. Patients were treated with a vitamin K antagonist anticoagulant combined with antiplatelet therapy after HeartMate 3 implantation and were followed up monthly at our institution. RESULTS: Among 71 patients implanted with HeartMate 3 between 2015 and 2022, 51 (71.8%) were implanted as a BTT and 20 (28.2%) as DT. Their median age was 58 (IQR: 52–69) years and 84% of patients were classified as INTERMACS profiles 2–4. The median follow-up duration was 18.3 (IQR: 7.5–33.9) months. Patients in the DT group were older than those in the BTT group (p <0.001) and had more chronic renal failure (p <0.001). They also had a lower 5-year survival rate (mean ± standard error: 87.3 ± 5.6% vs 49.4 ± 15.1%) and more adverse events such as renal dysfunction requiring temporary perioperative dialysis (p = 0.08) or bleeding (p = 0.06). CONCLUSION: Although patients supported with HeartMate 3 have favourable survival, those with LVAD-DT have poorer outcomes. There is a need to better select patients eligible for LVAD-DT in order to limit the burden of adverse events and improve their prognosis.

Background and Objectives: Dexmedetomidine, an alpha-2 agonist, is used as an adjunct to anesthesia in enhanced recovery after surgery (ERAS) programs. One of its advantages is the opioid-sparing effect which can facilitate early extubation and recovery. When the ERAS cardiac society was set in 2017, our facility was already using the ERAS program, in which the “fast-track Anesthesia” was facilitated by the intraoperative infusion of dexmedetomidine. Our objective is to share our experience and investigate the potential impact of intraoperative dexmedetomidine use as a part of the ERAS program on patient outcomes in elective cardiac surgery. Materials and Methods: An observational retrospective cohort study was conducted at a university hospital in Switzerland. The patients who underwent elective cardiac surgery with cardiopulmonary bypass between 1 June 2017 and 31 August 2018 were included in this analysis (n = 327). Regardless of the surgery type, all the patients received a standardized fast-track anesthesia protocol inclusive of dexmedetomidine infusion, reduced opioid dose, and parasternal nerve block. The primary outcome was the postoperative time when the criteria for extubation were met. Three groups were identified: group 0—(extubated in the operating room), group < 6 (extubated in less than 6 h), and group > 6 (extubated in >6 h). The secondary outcomes were adverse events, length of stay in ICU and in hospital, and total hospitalization costs. Results: Dexmedetomidine was well-tolerated, with no significant adverse events reported. Early extubation was performed in 187 patients (57%). Group 3 had a significantly longer length of stay in the ICU (median: 70 h vs. 25 h) and in hospital (17 vs. 12 days), and consequently higher total hospitalization costs (CHF 62,551 vs. 38,433) compared to the net data from the other two groups (p < 0.0001). Conclusions: Our findings suggest that dexmedetomidine can be safely used as part of the opioid-sparing anesthesia protocol in patients undergoing elective cardiac surgery with cardiopulmonary bypass with the potential to facilitate early extubation, shorter ICU and hospital stays, and reduced hospitalization costs.