BACKGROUND:Mitral annular calcification (MAC) can be complicated by mitral regurgitation (MR). However, data on outcomes of severe MR caused by MAC are limited. This study evaluated outcomes of severe MR due to MAC and the prognostic significance of frailty and comorbidities in guiding management. METHODS:In this single-center, retrospective cohort study, we reviewed our echocardiographic database to identify patients with isolated severe MR due to severe MAC. The primary endpoint was all-cause mortality. The Society of Thoracic Surgeons (STS) risk score, Charlson Comorbidity Index (CCI), and a 3-point frailty index (hemoglobin, albumin, inactivity) were calculated. Echocardiographic parameters were recorded. RESULTS:Between January 2010 and August 2023, out of 10,061 patients with severe MAC on echocardiography, 128 patients with severe MR due to severe MAC were identified, and followed for a median of 134 days (IQR: 33-1812). Median age was 81 years; 72.7% were female. Forty-five patients (35.2%) underwent mitral valve (MV) intervention, and 83 (64.8%) received conservative management. During follow-up, 63 patients (49.2%) died. MV intervention improved survival, even after propensity score matching (p < 0.001). Higher frailty scores predicted poorer outcomes in the entire cohort (p = 0.004) and the conservative subgroup (p = 0.014) but not the surgical group (p = 0.406). CCI did not influence mortality when stratified by treatment. CONCLUSION:Patients with severe MR due to MAC were frail with multiple comorbidities and often managed conservatively. Frailty is associated with all-cause mortality, and MV intervention improves survival regardless of frailty status.

Objective: Secondary aortoesophageal fistula (AEF) after thoracic endovascular aortic repair (TEVAR) is a rare but life-threatening complication. Definitive treatment guidelines are lacking, and surgical management has traditionally relied on staged procedures. Reports of successful single-stage repair with long-term follow-up remain scarce. This case report aims to describe the workup, surgical strategy, and long-term outcomes of a single-stage multidisciplinary repair of secondary AEF after TEVAR. Methods: We report the case of a 75-year-old man who presented with recurrent infectious episodes 9 years after TEVAR. A secondary AEF was diagnosed in May 2022. After the failure of conservative treatment (ie, antibiotic therapy) over approximately 1 year, a multidisciplinary team recommended definitive surgery. In April 2023, a single-stage repair was performed, comprising complete resection of the infected stent graft, in situ replacement with an antibiotic-soaked prosthesis, primary esophageal repair, and interposition of a pedicled latissimus dorsi muscle flap. Results: The patient was discharged on postoperative day 30. Three-year follow-up demonstrated sustained remission with normalized inflammatory markers and no evidence of graft reinfection. Conclusions: In this case report, a single-stage multidisciplinary surgical repair of secondary AEF after TEVAR yielded durable infection control and favorable long-term outcomes. Careful patient selection within a multidisciplinary team, meticulous surgical planning, and close postoperative infectious disease follow-up are essential. Three-year follow-up demonstrated sustained remission with normalized inflammatory markers and no evidence of graft reinfection.

Infective endocarditis (IE) is most often caused by alpha-hemolytic streptococci or Staphylococcus aureus and is characterized by the presence of vegetations on the heart valves. Here we present a case of IE caused by Streptococcus pyogenes, a distinctly uncommon IE-pathogen, where no vegetations could be visualized on repeated echocardiography. Diagnosis was instead evident from septic embolizations and progressive aortic insufficiency and IE was verified upon heart valve surgery. The patient was a 69-year-old man who presented with a two-day-history of fever and confusion. Several lesions on the skin and in the brain were suggestive of septic embolization and blood cultures grew S. pyogenes of sequence type 39, emm4. The patient developed progressive aortic insufficiency and was subjected to surgery at day seven after admittance. The aortic cusp showed signs of destructive IE and analysis of the valve demonstrated the presence of DNA from S. pyogenes ultimately confirming the diagnosis. The patient received a biological heart valve prosthesis and needed medical treatment for atrial fibrillation and heart failure post operatively. There was no relapse at six months post-surgery.

Surgical myectomy (SM), performed to relieve dynamic left ventricular outflow tract obstruction in symptomatic obstructive hypertrophic cardiomyopathy (oHCM) patients, provides improved quality of life and symptoms and excellent long-term survival. Guidelines recommend SM in symptomatic oHCM patients refractory to optimal medical therapy. We sought to assess whether SM in patients with fewer symptoms at initial referral is associated with improved long-term outcomes in oHCM. Baseline symptom burden at the time of referral emerged as a powerful prognostic discriminator among 3546 HCM patients undergoing SM. Our findings suggest that earlier surgical referral before advanced decompensation may be associated with more favourable long-term outcomes. Women were more likely to present with advanced symptoms and had higher adjusted risk. These results underscore the need to determine whether a proactive therapeutic strategy, including an earlier intervention, can modify long-term survival in oHCM.

Background: In asymptomatic patients with hypertrophic cardiomyopathy (HCM), treadmill stress echocardiography (TSE) is performed to assess for functional capacity, ischemia, arrhythmias and dynamic left ventricular outflow tract obstruction (LVOTO). Objective: We sought to assess if TSE provides incremental diagnostic and prognostic value in asymptomatic HCM. Methods: Between 1/2002 and 12/2018, out of 7954 HCM patients, 1126 underwent resting and symptom limited TSE after being deemed to be in New York Heart Association (NYHA) Class I following a thorough evaluation at a tertiary referral center. Peak-exercise LVOT gradient and metabolic equivalents (METs) were recorded. %Age-gender predicted METs (%AGP-METs) were calculated. Need for myectomy was recorded. Primary outcome was a composite of mortality, appropriate internal cardioverter defibrillator (ICD) discharge or cardiac transplantation. Results: Baseline characteristics of obstructive (oHCM, n=656) vs. nonobstructive (nHCM, n=470) patients, separated on basis of (LVOT gradient ≥30 mm Hg) are shown in Figure 1. Despite being asymptomatic, 413 (37%) did not achieve 85%AGP-METs. Obstructive HCM patients were on higher proportion of background HCM therapy and had higher LV wall thickness and degree of mitral regurgitation at baseline with lower METs and %AGP-METs achieved (Figure 1). During a mean follow-up of 12.9±5 years, there were 200 (18%) composite events (173 deaths, 23 appropriate ICD discharges and 7 transplants). After 988±1271 days, 190 patients underwent myectomy. On survival analyses, patients achieving ≥85%AGP METs had better long-term survival vs. those who did not (81/413 [20%] vs. 111/713 [16%], p=0.004, Figure 2). Similarly, nHCM patients and oHCM patients undergoing myectomy had significantly better long-term freedom from composite events vs. oHCM without myectomy (67/470 [14%] vs. 27/190 [14%] vs. 106/466 [23%], p=0.004, Figure 3). Conclusions: In HCM patients undergoing TSE, despite being asymptomatic, only 63% achieved ≥85% of AGP-METs, and %AGP-METs <85% was associated with worse long-term event-free survival. Similarly, oHCM patients without a myectomy had worse long-term event-free survival vs. nHCM patients and those oHCM patients who eventually underwent a myectomy. TSE provides incremental diagnostic and prognostic value by delineating obstructive HCM physiology and ascertaining true asymptomatic status while aiding optimal timing of therapeutic interventions.

OBJECTIVES:Patients with acute type A aortic dissection (ATAAD) presenting with cerebral malperfusion have significantly poorer postoperative outcomes, making the decision whether to perform acute surgery difficult. The aim of this study was to investigate types of neurological symptoms and radiological findings and their association with permanent neurological injury and mortality following ATAAD repair. METHODS:This was a single-center, retrospective, observational study. A total of 629 patients underwent ATAAD surgery between January 1998 and December 2023 at Skåne University Hospital, Lund, Sweden. Of these, 93 (14.7%) presented with cerebral malperfusion and constituted the study population. The primary endpoints were clinical neurological injury and 30-day mortality. RESULTS:Overall 30-day mortality was 25.0%. Fifty-two patients (57.1%) had persisting neurological deficit. Patients with postoperative neurological deficit had significantly higher 30-day mortality than patients without postoperative neurological deficit (37.3% vs 5.1%, p > 0.001). Common carotid artery dissection and carotid artery occlusion were significantly more frequent in patients who developed postoperative neurological injury. Preoperative hemiparesis/hemiplegia was associated with a significant increase of persisting neurological deficits, and unconsciousness was associated with a significant increase in 30-day mortality or persisting neurological deficits. After repair, 52.2% of patients showed an improvement in their clinical neurological status. CONCLUSION:In ATAAD patients who present with cerebral malperfusion, the risk of permanent neurological deficit and 30-day mortality is high, but a significant proportion of patients survive and more than half demonstrate an improved neurological state postoperatively.

Background: Surgical myectomy (SM) is recommended to relieve left ventricular outflow tract obstruction (LVOTO) in symptomatic obstructive hypertrophic cardiomyopathy (oHCM) patients who are intolerant to maximal background medical therapy. However, outcomes of such patients, if operated earlier at the onset of symptoms, remains uncertain. Objective: We sought to assess whether an earlier SM is associated with improved longer-term outcomes in oHCM. Methods: Between 1/2002 and 12/2018, out of 7954 HCM patients, 2904 with oHCM underwent SM following a thorough clinical evaluation at a large tertiary referral center. Clinical and imaging characteristics were recorded. Time to SM, cardiac transplantation, appropriate defibrillator discharge during follow-up were recorded. Primary outcome was a composite of mortality, appropriate internal cardioverter defibrillator (ICD) discharge or cardiac transplantation. Results: Baseline characteristics, divided based on New York Heart Association (NYHA) class I (n=328), II (n=1062) and III (n=1514) are shown in Figure 1. Patients undergoing SM after progressing to NYHA Class III/IV were older, more likely to be women, had significantly higher proportion of comorbidities and background HCM therapy, poorer functional capacity, along with a higher proportion of concomitant mitral regurgitation vs. those who were in NYHA Class I/II. Overall, in-hospital mortality was observed in 9 (0.3%) patients. At a mean follow-up of 12±5 years, there were 672 composite events (635 deaths, 9 cardiac transplants and 47 appropriate ICD discharges). Despite a much longer time from initial evaluation to SM, patients in NYHA Class III/IV at initial presentation had significantly higher proportion (similar to age-gender matched normal US population) of adjusted longer-term composite events vs. NYHA Class II and I, respectively (387 [26%] vs. 216 [20%] vs. 69 [21%], p<0.001, Figure 2). Conclusions: In a large sample of oHCM patients, evaluated at a high-volume tertiary care center, SM performed earlier closer to the time of symptom onset have significantly better long-term freedom from composite events vs. those who underwent SM after developing advanced symptoms. Better strategies for earlier symptom recognition, especially in women with oHCM, need to be developed. This would potentially enable early institution of appropriate therapies to relieve LVOTO.

Aims:The high mortality in untreated acute type A aortic dissection (ATAAD) stresses the need for prompt diagnosis and immediate surgical treatment. Our aim was to evaluate the frequency and clinical impact of misdiagnosis and delayed diagnosis of ATAAD. Methods and results:This was a single-centre, retrospective, observational study including all ATAAD patients with available admission charts between 2001 and 2021 in an area of 1.9 million inhabitants in southern Sweden. The primary endpoints were initial misdiagnosis, delayed diagnosis, and 30-day mortality. Surgical treatment was a secondary endpoint. Independent predictors of misdiagnosis and 30-day mortality were identified by multivariable logistic regression and subgroup analyses by severity of clinical presentation were performed. There were 556 patients included in the study (418 surgically treated and 138 non-surgically treated), and 45.3% were initially misdiagnosed. Misdiagnosed patients were more often female (47.6 vs. 35.9%; P = 0.005) and demonstrated significantly lower rates of syncope, hypotensive shock, and malperfusion. Patients without signs of malperfusion subjected to diagnostic delay were less likely offered surgical treatment (74.0 vs. 91.5%; P < 0.001) and had higher 30-day mortality (21.3 vs. 10.8%; P = 0.040). Female sex was an independent predictor of misdiagnosis (OR: 1.748; 95% CI 1.145-2.668; P = 0.010), but neither misdiagnosis nor delayed diagnosis were independent predictors of 30-day mortality. Conclusion:Although misdiagnosis and delayed diagnosis did not influence overall 30-day mortality, delayed diagnosis led to significantly higher 30-day mortality in the large group of patients presenting without signs of malperfusion, likely caused by the observed higher risk of being denied surgical treatment.

PURPOSE OF REVIEW:National databases reveal increased application of the surgical robot to facilitate mitral valve repair. Single-center and multiinstitutional studies confirm that excellent results are achievable with robotic mitral valve repair. However, not all patients with degenerative mitral valve disease are appropriate candidates for robotic mitral valve repair. RECENT FINDINGS:With increased experience, surgeons have successfully applied the surgical robot to perform mitral valve repair in conjunction with concomitant procedures. Concurrently, selection criteria have expanded, enabling more patients to enjoy the benefits of a less invasive approach. A small group of patient-related and anatomic factors are best managed via a standard sternal approach. SUMMARY:Approaching 15% of all mitral valve repairs for degenerative disease, robotic mitral valve repair has reached an inflection point in its growth. Well tolerated application of this technology requires understanding of both its advantages and its limitations.