Background/Objectives: Impella 5.5 provides a higher flow rate than smaller microaxial pumps and has been increasingly adopted for cardiogenic shock (CS). This study aimed to evaluate whether its introduction into our Shock Team program in 2023 improved outcomes compared with a historical cohort supported with other mechanical circulatory support (MCS) devices. Methods: We retrospectively analyzed patients with CS treated with MCS between 2020 and 2024 at a tertiary center. The Impella 5.5 group (n = 17) included patients managed after device implementation, either as stand-alone or sequential therapy. The historical cohort comprised 40 patients treated with ECMO, Impella CP, CentriMag, or IABP prior to 2023. Propensity score matching (age, sex, etiology, lactate, SCAI stage) generated 17 matched pairs. The primary outcome was survival at discharge, 30 days, 3 months, and 6 months. Secondary outcomes included bridging to recovery, heart transplantation (HTx), durable LVAD, and major complications. Results: Impella 5.5 was associated with higher survival at discharge (94.1% vs. 58.8%, p = 0.039), 30 days (94.1% vs. 58.8%, p = 0.039), and 3 months (94.1% vs. 58.8%, p = 0.039). At 6 months, survival remained higher (88.2% vs. 58.8%) but did not reach statistical significance in point analysis (p = 0.118). Bridging occurred more frequently with Impella 5.5 (HTx 64.7% vs. 52.9% (p = 0.464), recovery 17.6% vs. 5.9% (p = 0.292)), while LVAD implantation rates were similar (11.8% vs. 17.6%, p = 1.0). Major bleeding (17.6% vs. 47.1%, p = 0.141), stroke/TIA (5.9% vs. 17.6%, p = 0.601), and the need for renal replacement therapy (5.9% vs. 23.5%, p = 0.335) were numerically lower with Impella 5.5. Conclusions: In this single-center, retrospective analysis, the introduction of Impella 5.5 was associated with higher short-term survival and favorable bridging metrics; estimates are imprecise due to small, heterogeneous samples. These hypothesis-generating findings warrant confirmation in larger, prospective multicenter cohorts

The internal geometric ring provides full three-dimensional annular stability while minimizing the dissection of the aortic root, pulmonary artery and right ventricle and avoids reimplanting the coronaries. The external annuloplasty provides a secondary stabilization of the easily accessed fibrous portion of the annulus using the sutures for the internal annuloplasty device and minimizes the sutures above the leaflets. Together they form a complete remodelling of the ventriculo-aortic junction following its exact course. The junction together with stabilization of the subcommissural triangles defines functional aortic annulus remodelling. External annuloplasty supports the virtual basal ring.

Journal Article Functional aortic annulus remodelling—revisited Marek J Jasinski, Marek J Jasinski Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, PolandDepartment Congenital Cardiac Surgery Children, Memorial Pediatric Health Institute, Warsaw, Poland Corresponding author. Department Cardiac Surgery, Wroclaw Medical University, 213 Borowska, 50556 Wroclaw, Poland. Tel: +48-509911557; e-mail: marekjasinski@yahoo.pl (M.J. Jasinski). https://orcid.org/0000-0002-9989-7748 Search for other works by this author on: Oxford Academic PubMed Google Scholar Rafal Nowicki, Rafal Nowicki Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland https://orcid.org/0000-0002-3256-552X Search for other works by this author on: Oxford Academic PubMed Google Scholar Jakub Jasinski, Jakub Jasinski Department of Cardiac Surgery, Silesian Medical University, Katowice, Poland Search for other works by this author on: Oxford Academic PubMed Google Scholar Grzegorz Bielicki, Grzegorz Bielicki Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland https://orcid.org/0000-0003-0888-4229 Search for other works by this author on: Oxford Academic PubMed Google Scholar Maciej Rachwalik, Maciej Rachwalik Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland Search for other works by this author on: Oxford Academic PubMed Google Scholar Mikolaj Berezowski Mikolaj Berezowski Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland Search for other works by this author on: Oxford Academic PubMed Google Scholar European Journal of Cardio-Thoracic Surgery, Volume 64, Issue 3, September 2023, ezad320, https://doi.org/10.1093/ejcts/ezad320 Published: 22 September 2023 Article history Received: 18 July 2023 Published: 22 September 2023 Corrected and typeset: 27 September 2023

Background and Objectives: The cardioplegic arrest of the heart during cardiosurgical procedures is the crucial element of a cardioprotection strategy. Numerous clinical trials compare different cardioplegic solutions and cardioprotective protocols, but a relatively small number of papers apply to in vitro conditions using cultured cells. This work aimed to analyze whether it is possible to use the rat heart myocardium cells as an in vitro model to study the protective properties of St. Thomas cardioplegia (ST2C). Methods: The rat heart myocardium cells-H9C2 were incubated with cold cardioplegia for up to 24 h. After incubation, we determined: viability, confluency, and cell size, the thiol groups’ level by modifying Ellman’s method, Ki67, and Proliferating Cell Nuclear Antigen expression (PCNA). The impact on cells’ morphology was visualized by the ultrastructural (TEM) study and holotomograpic 3D imaging. Results: The viability and confluency analysis demonstrated that the safest exposure to ST2C, should not exceed 4h. An increased expression of Ki67 antigen and PCNA was observed. TEM and 3D imaging studies revealed vacuolization after the longest period of exposure (24). Conclusions: According to obtained results, we conclude that STC can play a protective role in cardiac surgery during heart arrest.

Background Although cardioplegia is used since the ‘70s of the last century, debate on cardioprotection during cardio-surgical procedures is still actual. The selection of a particular method depends mainly on the preferences and experience of a specific center or even surgeon. Crystalloid cardioplegia is an aqueous ion solution similar to intracellular (Custodiol HTK) or extracellular (Plegisol) fluid. The potensional clinical advantages of relatively new idea of cardioplegia solution based on intracellular composition (Custodiol HTK) justifies futher research, but only a few used cultured cells in laboratory conditions. Methods In this study, the authors sought to compare Custodiol HTK with Plegisol cardioplegia solutions using an in-vitro model simulating cardioplegic arrest. The efficacy of myocardial protection during ischemia was investigated with susceptible indicators like the appearance of the deleterious effect of reactive oxygen species and oxidative stress markers. Immersed human cardiomyocytes and rat cardiomyoblasts H9C2 in cardioplegia for 4 h were examined for expression of oxidative stress markers (MnSOD, iNOS, HSP27), cardioplegic solutions cytotoxicity, and peroxidation damage of the cell’s lipids and proteins. All tests were performed after 0.5 h, 1 h, 2 h, and 4 h of incubation in identical physical and biological conditions, which is difficult to achieve in clinical trials. Results The lower cytotoxicity index performed on matured cells of human cardiomyocytes and highest dehydrogenase level showed after incubation with Custodiol HTK. This did not apply to tests on immature cells H9C2. Custodiol HTK induced significantly stronger iNOS expression. The decrease of HSP27 concentration has been instantaneous and maintained troughout the study only in both cultures incubated with Custodiol HTK. The other tests: lipid peroxidation, carbonyl groups concentration and MnSOD expression show no clear superiority evidence of used cardioplegic solutions. Conclusions Considering proceeded examinations on cultured cardiomyocytes, Custodiol HTK appears to be safer than Plegisol.

OBJECTIVES: This study presents the results of 17 years of experience with bicuspid aortic valve (BAV) repair and the analysis of factors associated with repair failure and early echocardiographic outcome. METHODS: Between 2003 and 2020, a total of 206 patients [mean age: 44.5 ± 15.2 years; 152 males (74%)] with BAV insufficiency with or without aortic dilatation underwent elective aortic valve repair performed by a single surgeon with a mean follow-up of 5 ± 3.5 years. The transthoracic echocardiography examinations were reported. Presented at the 34th Annual Meeting of the European Association for Cardio-Thoracic Surgery, Barcelona, Spain, 8–10 October 2020. C O N V EN TI O N A L A O R TI C

Abstract   OBJECTIVES This study presents the results of 17 years of experience with bicuspid aortic valve (BAV) repair and the analysis of factors associated with repair failure and early echocardiographic outcome. METHODS Between 2003 and 2020, a total of 206 patients [mean age: 44.5 ± 15.2 years; 152 males (74%)] with BAV insufficiency with or without aortic dilatation underwent elective aortic valve repair performed by a single surgeon with a mean follow-up of 5 ± 3.5 years. The transthoracic echocardiography examinations were reported. RESULTS There were no deaths during the hospital stay, and all but 1 patient survived the follow-up period (99.5%). Overall, 10 patients (5%) developed severe insufficiency and 2 (1%) developed aortic dilatation requiring reoperation. Freedom from reoperation at 7 years reached 91.8%. Type 2 BAV configuration [hazard ratio (HR) 3.9; 95% confidence interval (CI): 1.01–60; P = 0.049], no sinotubular junction remodelling (HR 7; 95% CI: 1.7–23; P = 0.005), no circumferential annuloplasty (HR 3.9; 95% CI: 1.01–64; P = 0.047) and leaflet resection (HR 5.7; 95% CI 1.2–13. P = 0.017) have been identified as a risk factor of redo operation. Parameters of the postoperative left ventricle reverse remodelling improved significantly early after the operation and later at 2 years evaluation. CONCLUSIONS The repair of BAV offers good short- and mid-term results providing a significant reverse left ventricular remodelling. Type 0 BAV preoperative configuration, circumferential annuloplasty and sinotubular junction remodelling are associated with better repair durability.

BACKGROUND:Thoracic aortic aneurysm (TAA) formation is accompanied by degradation of extracellular matrix components (EMC). Numerous matrix metalloproteinases (MMPs) have been implicated in the process, but the involvement of MMP-3 remains unclear. Additionally, the changes in proteoglycan (PG) structure can alter the signal transduction pathways in TAA, though the enzymatic systems which originate them are not fully understood.OBJECTIVES:To measure MMP-3 and sulfatase levels in aneurysmal tissue, comparing them with non-aneurysmal vessels, and to investigate possible correlations with patients' serum levels in order to evaluate their potential usefulness in aiding aneurysm detection and monitoring.MATERIAL AND METHODS:The study included 74 patients (TAA: n = 42; control group: n = 32). Sulfatase activity was measured colometrically and MMP-3 levels were measured immunoenzymatically.RESULTS:Sulfatase activities were higher (p = 0.03) and MMP-3 concentrations lower (p = 0.014) in aneurysmal tissue than in normal aortic tissue. Medium-sized dilatations were associated with lower tissue MMP-3 concentrations than small dilatations (p = 0.033). No differences in sulfatase activity or MMP-3 concentration in the serum of TAA patients were observed in comparison with the controls. The serum and tissue levels of MMP-3 were correlated (r = 0.41; p < 0.001). The serum levels of MMP-3 were significantly lower in the female patients than in the male patients (p = 0.006).CONCLUSIONS:Our studies confirmed the lower MMP-3 levels in aneurysmal tissue, but the lack of a statistically confirmed reduction of MMP-3 in the blood serum seems to preclude its usefulness for diagnostic purposes. Our study points to the differences in MMP-3 behavior between TAA and abdominal aortic aneurysms. Significantly higher sulfatase activity in TAA tissue suggests a possible impact of sulfatase on signal transduction pathways involved in aneurysm formation.

Background: Lipomatous hypertrophy of the atrial septum (LHAS) is an anomaly of the heart. It is characterized by an infiltration of adipocytes into myocytes of the interatrial septum, sparing the fossa ovalis, which gives a characteristic hourglass-shaped image. Due to the progress in imaging techniques, it can be recognized more frequently, but it is still often misdiagnosed. Case presentation: We present a case of 65-year-old woman with an incidentally discovered lipomatous hypertrophy of the atrial septum during cardiac surgery, which has caused the technical problems for surgeons with bicaval cannulation and visualization of the operated structures of the heart. Due to the unclear shadow in the lung parenchyma, the patient had preoperative computed tomography (CT) done, but the study report focused only on the lung description, neglecting visible changes in the structure of the heart. Based on the standardly performed intra-operative transesophageal echocardiography (TEE), as well as by analyzing the chest X-ray and CT scans, the diagnosis of LHAS was made. It allowed the surgeon to leave the mass intact, thus not increasing the risk of the baseline surgery. Conclusions: LHAS is a rare but increasingly recognized anomaly of the heart. Contemporary diagnostic methods allow to diagnose and make the right therapeutic decisions. The utility of TEE and analysis of X-ray images, in this case, allowed the surgeon to recognize LHAS, and because of its histologically benign nature and asymptomatic course, to leave this change intact. Surgical treatment should be limited only to cases of patients with life-threatening cardiovascular complications.

BACKGROUND:External wrapping is a surgical technique used in patients with dilated ascending aorta. To date, there is no available data describing the radiographic features of the aorta subjected to external wrapping using a straight corrugated Dacron vascular prosthesis. The aim of this study was to find distinctive radiographic features of an externally constricted aorta.METHODS:Preoperative and early postoperative (7th postoperative day) CT angiography images of ten patients who underwent wrapping procedures were assessed and compared. The images were analyzed in order to find characteristic features of CT angiography images of the ascending aorta subjected to external wrapping.RESULTS:The CT-angiography images showed that the aortic wall deformed significantly (the wall plicated) after the wrapping procedure in one patient, whose aortic diameter was decreased by 47 %. The remaining nine patients did not have significant aortic wall deformations. All patients presented with a periaortic mass. This was a collection of blood clots and pericardial fluid that filled the empty space in the pericardium following a decrease in the diameter of the ascending aorta. A very thin (<1 mm) crescent-shaped uncontrasted layer was noticed between the aorta and the periaortic area in all patients. This, in turn, was an empty space between the aorta and the corrugated vascular prosthesis.CONCLUSIONS:The CT-angiography images of the aorta subjected to external wrapping may have unique features that are not observed after other operations on the ascending aorta. The knowledge about the details of this surgical procedure helps to correctly assess these images.

External wrapping is a surgical technique performed in patients with a dilated ascending aorta. The aim of this study is to present the mid-term results of wrapping of the dilated ascending aorta.

BACKGROUND:Chronic atrial fibrillation may temporarily resolve after cardiac surgery. Prolongation of the ventricular repolarization period may be the electrophysiological background for this phenomenon.OBJECTIVES:The aim of the study was to assess the association between resolution of atrial fibrillation and changes in the duration of the ventricular repolarization period in patients with pre-operative chronic atrial fibrillation who underwent cardiac surgery.MATERIAL AND METHODS:A retrospective analysis of the medical recordings of patients with chronic atrial fibrillation who underwent cardiac surgery was performed. After exclusions the study group comprised 51 patients with chronic atrial fibrillation who underwent surgery in the Cardiac Surgery Department of Wrocław Medical University in 2008 and 2009. The 12-lead EKGs performed before and after the surgery were assessed and the QT and R-R intervals were measured. The patients were divided into Group 1, in whom atrial fibrillation persisted after the cardiac surgery, and Group 2, whose atrial fibrillation resolved after the surgery.RESULTS:In 31 patients (60.8%) atrial fibrillation disappeared during the first 24 hours after cardiac surgery. A significant prolongation of the QT interval after the surgery was found in Group 2 that was not observed in Group 1. Multiple regression analysis revealed that QT interval duration after surgery is related to the resolution of atrial fibrillation independently from the duration of the R-R interval duration and the need for cardiac pacing.CONCLUSIONS:Spontaneous temporary resolution of atrial fibrillation is a common finding after cardiac surgery in patients with chronic atrial fibrillation. This phenomenon is related to a prolonged QT interval, therefore it may have an electrophysiological basis rather than a hemodynamic background. Further studies are required to assess the clinical importance of the prolongation of the QT interval after cardiac surgery.

Application of a high electric field causes an electric shock to the heart. This is utilized in defibrillation to reestablish normal contraction rhythms during dangerous arrhythmias or in cardiac arrest. If shock-induced transmembrane potentials are large enough, they can cause tissue destruction due to irreversible electroporation (EP). Also electrochemotherapy of nearby tissues may have an adverse effect on the heart. Herein, we present experimental data on effects of electroporation in culture of cardiac cells (H9C2). The electric field was applied in short pulses of 25-3250 V/cm, 50 µs each. The viability of cells was tested by MTT assay after 24 hours. For detection of DNA fragmentation, associated with apoptosis, alkaline and neutral comet assays were performed after EP. Additionally phase contrast images of cells obtained directly after EP were analyzed. Although cell images indicated disruption of cell membranes after EP with high intensities, only a few percent of apoptotic cells and no necrotic effects in the cell nucleus could be observed in comet assay tests performed 2 hours post EP. MTT viability test showed that pulse intensities above 375 V/cm are destructive for myocytes viability.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether remote ischaemic preconditioning (RIPC) is of benefit to patients undergoing cardiac surgery. Altogether, more than 264 papers were found using the reported search, 16 of which represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that RIPC is a safe protocol which could potentially be used in cardiac surgery to provide additional cardiac protection against ischaemia reperfusion injury, although it may not be appropriate for patients on K(+) ATPase channel blockers (sulphonylureas) as they seem to eliminate the effect of RIPC. In our study, we found two meta-analyses of cardiac surgery with or without RIPC. Both unequivocally showed 0.81 and 0.74 standardized mean reduction in myocardial necrosis markers in patients receiving RIPC and cardiac or vascular surgery. No difference in perioperative myocardial infarction incidence or 30-day mortality were found. In adult cardiac surgery, we found 11 randomized control trials (RCTs) ranging in size from 45 to 162 patients. Two representative studies reported no difference in postoperative cardiac troponin I concentration in RIPC vs. controls. In one of the studies (CABG ± RIPC) no additional benefit could have been observed for RIPC regarding intra-aortic balloon pump usage (controls 8.5 vs. RIPC 7.5%), inotropic support (39 vs. 50%) or vasoconstrictor usage (66 vs. 64%). On the other hand, in the other study [CABG ± AVR (aortic valve replacement) ± RIPC] significant reduction of troponin I at 8 h postoperatively (controls, 2.90 µg/l vs. RIPC, 2.54 µg/l, P = 0.043) was shown. Marked reduction in cardiac necrosis markers was also found in several smaller RCTs concerning coronary artery bypass grafting (CABG) patients receiving RIPC preoperatively: with cold crystalloid cardioplegia (44.5% reduction), with cross-clamping and fibrillation (43% reduction) and with cold blood cardioplegia (42.4% reduction). The proof of concept trials summarized here give some early evidence that RIPC may potentially provide some reduction in myocardial injury. If confirmed, in future clinical studies this technique may one day lead to a method to reduce reperfusion injury in clinical practice.

Introduction: The internal thoracic artery (ITA) remains the graft of choice for coronary artery bypass grafting (CABG). Harvesting the ITA without pleurotomy may be a desirable approach if the technique is proven to decrease morbidity and mortality and improve the economic result. The aim of the study was to evaluate the impact of different harvesting techniques on postoperative blood loss, transfusion requirements and duration of postoperative therapy.Material and methods: We carried out a prospective study that involved 115 patients who underwent on-pump CABG in our clinic. Patients were divided into two groups: those who underwent pleurotomy due to ITA harvesting (group A; n = 73) and the rest where pleura spearing technique was applied (group B; n = 42). Predicting factors for proposed end-points were assessed by stepwise forward regression.Results: Postoperative chest tube drainage (CTD) at the 12th and the 24th hour as well as the hemoglobin level did not differ statistically. Nonetheless, patients with pleurotomy required significantly more units of packed red blood cells (RBC), fresh frozen plasma (FFP) and packed platelets (PLT) than patients with intact pleural cavity (RBC = 0.94 +/- 1.4 vs. 0.5 +/- 0.9; p < 0.001; FFP = 0.6 +/- 1.5 vs. 0.4 +/- 1.1; p < 0.001; PLT = 0.3 +/- 1.5 vs. 0.1 +/- 0.8; p < 0.001). Regression analysis indicated that opening of the pleural cavity was a prediction factor for higher CTD at the 12th hour (beta = 0.18; p = 0.03) and prolonged postoperative hospitalization (beta = 0.17; p = 0.04). Group A patients were also found to require a longer intensive care unit (ICU) stay than those of group B (A: 1.5 +/- 1.0 vs. B: 1.3 +/- 0.6; p < 0.001).Conclusion: Spearing of pleura in the ITA harvesting procedure decreases morbidity and improves the economic result for patients qualified for on-pump CABG.