Introduction Vasoplegia is a common complication after cardiac surgery and is associated with poor prognosis. It is characterised by refractory hypotension despite normal or even increased cardiac... Show moreIntroduction Vasoplegia is a common complication after cardiac surgery and is associated with poor prognosis. It is characterised by refractory hypotension despite normal or even increased cardiac output. The pathophysiology is complex and includes the systemic inflammatory response caused by cardiopulmonary bypass (CPB) and surgical trauma. Patients with end-stage heart failure (HF) are at increased risk for developing vasoplegia. The CytoSorb adsorber is a relatively new haemoadsorption device which can remove circulating inflammatory mediators in a concentration based manner. The CytoSorb-HF trial aims to evaluate the efficacy of CytoSorb haemoadsorption in limiting the systemic inflammatory response and preventing postoperative vasoplegia in HF patients undergoing cardiac surgery with CPB. Methods and analysis This is an investigator-initiated, single-centre, randomised, controlled clinical trial. In total 36 HF patients undergoing elective cardiac surgery with an expected CPB duration of more than 120 min will be randomised to receive CytoSorb haemoadsorption along with standard surgical treatment or standard surgical treatment alone. The primary endpoint is the change in systemic vascular resistance index with phenylephrine challenge after CPB. Secondary endpoints include inflammatory markers, sublingual microcirculation parameters and 30-day clinical indices. In addition, we will assess the cost-effectiveness of using the CytoSorb adsorber. Vascular reactivity in response to phenylephrine challenge will be assessed after induction, after CPB and on postoperative day 1. At the same time points, and before induction and on postoperative day 4 (5 time points in total), blood samples will be collected and the sublingual microcirculation will be recorded. Study participants will be followed up until day 30.Ethics and dissemination The trial protocol was approved by the Medical Ethical Committee of Leiden The Hague Delft (METC LDD, registration number P20.039). The results of the trial will be published in peer-reviewed medical journals and through scientific conferences. Show less
Background With the increase of highly portable, wireless, and low-cost ultrasound devices and automatic ultrasound acquisition techniques, an automated interpretation method requiring only a... Show moreBackground With the increase of highly portable, wireless, and low-cost ultrasound devices and automatic ultrasound acquisition techniques, an automated interpretation method requiring only a limited set of views as input could make preliminary cardiovascular disease diagnoses more accessible. In this study, we developed a deep learning method for automated detection of impaired left ventricular (LV) function and aortic valve (AV) regurgitation from apical 4-chamber ultrasound cineloops and investigated which anatomical structures or temporal frames provided the most relevant information for the deep learning model to enable disease classification. Methods and Results Apical 4-chamber ultrasounds were extracted from 3554 echocardiograms of patients with impaired LV function (n=928), AV regurgitation (n=738), or no significant abnormalities (n=1888). Two convolutional neural networks were trained separately to classify the respective disease cases against normal cases. The overall classification accuracy of the impaired LV function detection model was 86%, and that of the AV regurgitation detection model was 83%. Feature importance analyses demonstrated that the LV myocardium and mitral valve were important for detecting impaired LV function, whereas the tip of the mitral valve anterior leaflet, during opening, was considered important for detecting AV regurgitation. Conclusions The proposed method demonstrated the feasibility of a 3-dimensional convolutional neural network approach in detection of impaired LV function and AV regurgitation using apical 4-chamber ultrasound cineloops. The current study shows that deep learning methods can exploit large training data to detect diseases in a different way than conventionally agreed on methods, and potentially reveal unforeseen diagnostic image features. Show less
Schneider, A.W.; Hazekamp, M.G.; Versteegh, M.I.M.; Weger, A. de; Holman, E.R.; Klautz, R.J.M.; ... ; Braun, J. 2019
OBJECTIVES: Repeat aortic valve interventions after previous stentless aortic valve replacement (AVR) are considered technically challenging with an increased perioperative risk, especially after... Show moreOBJECTIVES: Repeat aortic valve interventions after previous stentless aortic valve replacement (AVR) are considered technically challenging with an increased perioperative risk, especially after full-root replacement. We analysed our experience with reinterventions after stentless AVR.METHODS: A total of 75 patients with previous AVR using a Freestyle stentless bioprosthesis (31 subcoronary, 15 root-inclusion and 29 full-root replacement) underwent reintervention in our centre from 1993 until December 2018. Periprocedural data were retrospectively collected from the department database and follow-up data were prospectively collected.RESULTS: Median age was 62 years (interquartile range 47-72 years). Indications for reintervention were structural valve deterioration (SVD) in 47, non-SVD in 13 and endocarditis in 15 patients. Urgent surgery was required in 24 (32%) patients. Reinterventions were surgical AVR in 16 (21%), root replacement in 51 (68%) and transcatheter AVR in 8 (11%) patients. Early mortality was 9.3% (n = 7), but decreased to zero in the past decade in 28 patients undergoing elective reoperation. Per indication, early mortality was 9% for SVD, 8% for non-SVD and 13% for endocarditis. Aortic root replacement had the lowest early mortality rate (6%), followed by surgical AVR (13%) and transcatheter AVR (25%, 2 patients with coronary artery obstruction). Pacemaker implantation rate was 7%. Overall survival rate at 10 years was 69% (95% confidence interval 53-81%).CONCLUSIONS: Repeat aortic valve interventions after stentless AVR carry an increased, but acceptable, early mortality risk. Transcatheter valve-in-valve procedures after stentless AVR require careful consideration of prosthesis leaflet position to prevent obstruction of the coronary arteries. Show less
Introduction: Gaseous microemboli that originate from the cardiopulmonary bypass circuit may contribute to adverse outcome after cardiac surgery. We prospectively evaluated the influence of gaseous... Show moreIntroduction: Gaseous microemboli that originate from the cardiopulmonary bypass circuit may contribute to adverse outcome after cardiac surgery. We prospectively evaluated the influence of gaseous microemboli on the release of various biomarkers after use of a minimally invasive extracorporeal technology system. Methods: In 70 patients undergoing coronary artery bypass grafting with minimized cardiopulmonary bypass, gaseous microemboli were measured intraoperatively with a bubble counter. Intra- and postoperative biomarker levels for inflammatory response (interleukin-6, C5b-9), endothelial damage (von Willebrand factor, soluble vascular cell adhesion molecule-1), oxidative stress (malondialdehyde, 8-isoprostane, neuroketal), and neurological injury (neuron-specific enolase, brain-type fatty acid-binding protein) were analyzed using immune assay techniques. The relationship between gaseous microemboli number or volume and the incremental area under the curve (iAUC(24h)) or peak change for the biomarkers was calculated. Results: All biomarkers except for malondialdehyde increased at least temporarily after coronary artery bypass grafting with a minimally invasive extracorporeal technology system. The median total gaseous microemboli number was 6,174 (interquartile range: 3,507-10,531) and the median total gaseous microemboli volume was 4.31 mu L (interquartile range: 2.71-8.50). There were no significant correlations between total gaseous microemboli number or volume and iAUC(24h) or peak change for any of the biomarkers. After controlling for the variance of possible other predictor variables, multiple linear regression analysis showed no association between gaseous microemboli parameters and release of biomarkers. Conclusion: This study showed no evidence that gaseous microemboli contribute to increased biomarker levels after coronary artery bypass grafting with cardiopulmonary bypass. A reason for the absence of damage by gaseous microemboli may be the relative and considerably small amount of gaseous microemboli entering the patients in this study. Show less
OBJECTIVES The purpose of this study was to randomly compare the incidence of asymptomatic cerebral embolism (ACE) between the second-generation pulmonary vein ablation catheter (PVAC Gold) and the... Show moreOBJECTIVES The purpose of this study was to randomly compare the incidence of asymptomatic cerebral embolism (ACE) between the second-generation pulmonary vein ablation catheter (PVAC Gold) and the irrigated Thermocool catheter.BACKGROUND Pulmonary vein isolation (PVI) with the PVAC is associated with ACE. The PVAC Gold was designed to avoid this complication.METHODS Patients with paroxysmal atrial fibrillation were randomized 1:1 to PVI with the PVAC Gold or Thermocool catheter. Cerebral magnetic resonance imaging was performed in the days before and after ablation and repeated after 3 months in case of a new lesion. Monitoring for microembolic signals (MES) was performed by using transcranial Doppler ultrasonography. Parameters of coagulation were determined before, during, and after ablation. Neuropsychological tests and questionnaires were applied 10 days before and 3 months after ablation.RESULTS Seventy patients were included in the study (mean age 61 +/- 9 years; 43 male subjects; CHA(2)DS(2)-VASc [congestive heart failure, hypertension, age >= 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score 1.6 +/- 1.2; international normalized ratio 2.7 +/- 0.5; activated clotting time 374 +/- 24 s; p > 0.05 for all parameters). Procedural duration was shorter in the PVAC Gold group (140 +/- 34 vs. 207 +/- 44 min; p < 0.001). Eight (23%; 7 infarcts) patients in the PVAC Gold group exhibited a new ACE, compared with 2 (6%; no infarcts) patients in the Thermocool group (p = 0.042). Median number of MES was higher in the PVAC Gold group (1,111 [interquartile range, 715-2,234] vs. 787 [interquartile range, 532-1,053]; p < 0.001). There were no differences between groups regarding coagulation and neuropsychological outcomes.CONCLUSIONS PVI with the new PVAC Gold was associated with a higher incidence of ACE/cerebral infarcts and number of MES. Both catheters induced a comparable procoagulant state. Because there were no measurable differences in neuropsychological status, the clinical significance of ACE remains unclear. (Cerebral Embolism [CE] in Catheter Ablation of Atrial Fibrillation [AF] [CE-AF]; NCT01361295) (C) 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. Show less
The Ross-Konno procedure is a durable solution for multilevel LVOTO in a highly complex patient population with high incidence of previous procedures. High early mortality rates in patients with... Show moreThe Ross-Konno procedure is a durable solution for multilevel LVOTO in a highly complex patient population with high incidence of previous procedures. High early mortality rates in patients with impaired left ventricular function emphasize the importance of patient selection. Freedom from reoperation shows a continuous attrition rate. Reoperation for autograft failure may occur late after the Ross-Konno procedure. Show less
The Freestyle stentless bioprosthesis is a valuable option to reconstruct the LVOT after debridement in extensive aortic valve endocarditis. It is readily available with a versatility and clinical... Show moreThe Freestyle stentless bioprosthesis is a valuable option to reconstruct the LVOT after debridement in extensive aortic valve endocarditis. It is readily available with a versatility and clinical outcome comparable with that of homografts. Although early mortality remains considerable in this high-risk group of patients, late survival is good with low rates of recurrence of endocarditis, immediate local control and good haemodynamic performance on echocardiography. Show less
