IMPORTANCE Ventricular septal rupture (VSR) is a rare but life-threatening mechanical complication of acute myocardial infarction associated with high mortality despite prompt treatment. Surgery represents the standard of care; however, only small single-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic. OBJECTIVESTo assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality. DESIGN, SETTING, AND PARTICIPANTS The Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort (CAUTION) Study is a retrospective multicenter international cohort study that includes patients who were treated surgically for mechanical complications of acute myocardial infarction. The study was conducted from January 2001 to December 2019 at 26 different centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR. EXPOSURES Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting). MAIN OUTCOMES AND MEASURESThe primary outcome was early mortality; secondary outcomes were postoperative complications. RESULTSOf the 475 patients included in the study, 290 (61.1%) were men, with a mean (SD) age of 68.5 (10.1) years. Cardiogenic shock was present in 213 patients (44.8%). Emergent or salvage surgery was performed in 212 cases (44.6%). The early mortality rate was 40.4% (192 patients), and it did not improve during the nearly 20 years considered for the study (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P < .001) and early surgery (time to surgery Ն7 days, survived: 105 [57.4%]; died, 47 [35.1%]; P < .001) were associated with lower survival. At multivariate analysis, older age (odds ratio [

OBJECTIVES Papillary muscle rupture (PMR) is a rare but potentially fatal complication of acute myocardial infarction. The aim of this study was to analyse the patient characteristics and early outcomes of the surgical management of post-infarction PMR from an international multicentre registry. METHODS Patients underwent surgery for post-infarction PMR between 2001 through 2019 were retrieved from database of the CAUTION study. The primary end point was in-hospital mortality. RESULTS A total of 214 patients were included with a mean age of 66.9 (standard deviation: 10.5) years. The posteromedial papillary muscle was the most frequent rupture location (71.9%); the rupture was complete in 67.3% of patients. Mitral valve replacement was performed in 82.7% of cases. One hundred twenty-two patients (57%) had concomitant coronary artery bypass grafting. In-hospital mortality was 24.8%. Temporal trends revealed no apparent improvement in in-hospital mortality during the study period. Multivariable analysis showed that preoperative chronic kidney disfunction [odds ratio (OR): 2.62, 95% confidence interval (CI): 1.07–6.45, P = 0.036], cardiac arrest (OR: 3.99, 95% CI: 1.02–15.61, P = 0.046) and cardiopulmonary bypass duration (OR: 1.01, 95% CI: 1.00–1.02, P = 0.04) were independently associated with an increased risk of in-hospital death, whereas concomitant coronary artery bypass grafting was identified as an independent predictor of early survival (OR: 0.38, 95% CI: 0.16–0.92, P = 0.031). CONCLUSIONS Surgical treatment for post-infarction PMR carries a high in-hospital mortality rate, which did not improve during the study period. Because concomitant coronary artery bypass grafting confers a survival benefit, this additional procedure should be performed, whenever possible, in an attempt to improve the outcome. Clinical trial registration clinicaltrials.gov: NCT03848429.

No abstract

on behalf of the GIROC Investigators Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. A multicenter retrospective study was designed to assess pacemaker dependency (PMD) and longterm mortality after cardiac surgery procedures. Between 2004 and 2016, PPI-patients from 18 centers were followed. Time-to-event data were evaluated with semiparametric regression Cox models and semiparametric Fine and Gray model for competing risk framework. Of 859 (0.90%) PPI-patients, 30% were pacemaker independent (PMI) at 6 months. PMD showed higher mortality compared with PMI (10-year survival 80.1% § 2.6% and 92.2% +2.4%, respectively, log-rank p-value < 0.001) with an unadjusted hazard ratio for death of 0.36 (95% CI 0.20 to 0.65, p< 0.001 favoring PMI) and an adjusted hazard ratio of 0.19 (95% CI 0.08 to 0.45, p< 0.001 with PMD as reference). Crude cumulative incidence function of restored PMI rhythm at follow-up at 6 months, 1 year and 12 years were 30.5% (95% CI 27.3% to 33.7%), 33.7% (95% CI 30.4% to 36.9%) and 37.2% (95% CI 33.8% to 40.6%) respectively. PMI was favored by preoperative sinus rhythm with normal conduction (SR) (HR 2.37, 95% CI 1.65 to 3.40, p< 0.001), whereas coronary artery bypass grafting and aortic valve replacement were independently associated with PMD (HR 0.63, 95% CI 0.45 to 0.88, p = 0.006 and HR 0.807, 95% CI 0.65 to 0.99, p = 0.047 respectively). Time-to-implantation was not associated with increased rate of PMI.

No abstract

Introduction: Permanent pacemaker (PPM) implantation represents a potential event after cardiac surgery. However, comprehensive investigation of robust patient cohorts in this respect is unavailable. Hypothesis: A multicenter retrospective study was undertaken to assess in-hospital and long-term postoperative outcome of a large patient population undergoing PPM soon after cardiac surgery procedures. Methods: Among 94.693 patients submitted to cardiac surgery procedures in 16 centers from 2000 to 2013, there were 1.156 patients (1.2 %) with PPM implantation during hospitalization postoperatively. Preoperative, in-hospital, and follow-up data were collected with a common dataset and analyzed. Follow-up was performed by direct visit, and PPM dependency was assessed by electrocardiogram and pacemaker check during periodic examinations. The identification of potential predictors of PPM dependency at follow-up was evaluated with a multivariate logistic regression. Results: Patient mean age was 69 years (range 17-92 years) and 53.4% were male. Preoperative electrocardiogram showed first degree atrio/ventricular block in 11.0% of patients, left bundle branch block in 11.1%, right bundle branch block in 11.0%, and atrial fibrillation in 22.8%, respectively. Most of the patients had had isolated aortic valve replacement (25.8%). Pacemakers were implanted after a median of 11 days after surgery. At follow-up, 43.6% of the patients did not show a PPM dependency with restoration of sinus rhythm. The multivariate logistic regression demonstrated that only preoperative right bundle branch block (p-value 0.031) and mitral valve repair (p-value 0.032) were independent risk factor for PPM dependency at follow-up. Conclusions: More than 40% of patients with PPM implantation shortly after cardiac surgery show recovery of sinus rhythm at follow-up. Wide variability of strategies and PM implant timing are currently applied in routine practice. Refinement of current guidelines in this setting based also on predictors of permanent conduction defects postoperatively are warranted.

Background and Aim: Right-sided infective endocarditis (RSIE) is less common than left-sided infective endocarditis (IE), encompassing only 5–10% of cases, 90% of RSIE involves the tricuspid valve (TV). We sought to evaluate early and late mortality of patients with isolated TVIE. Methods: The National Registry for Surgical Treatment of Valve and Prosthesis Infective Endocarditis included 4084 patients from February 1999 to January 2018. From 1983 to 2018, isolated TVIE was surgically treated in 157 (3.8%). Mean age was 47 ± 16 (15–86 years); 25% were females 142 (90%) native tricuspid regurgitation; 7 (5%) native stenosis-insufficiency and 8 (5%) tricuspid prosthesis endocarditis (TPIE). 38% due to IVDU; 21% due to PMK/ICD leads; 1% due to vascular access for dialysis; in the remaining cases, the cause was unknown Staphilococcus aureus was the most common germ (45%); The primary end-point was long-term survival freedom from recurrence; Results: 77 (49%) underwent TV repair, 72 (46%) TV replacement and 8 (5%) TV prosthesis replacement. Early mortality was 11% (17 patients); Expected mortality according to EndoSCORE was 12%; age (OR 1.06) and redo (OR 6.64) were risk factors. Median follow up was 229 months (172–286) Late deaths were 31;Recurrences were 4 (all dead). Survival at 10, 20 and 25-year were 66%, 60% and 44%, respectively. Risk factors were age (HR 1.06), fungine TVIE (HR 4.2), IVDU HR 4.90), redo (HR 4.4) and presence of leads (HR 3.0). No difference was found between repair and replacement (Figure) Conclusions: Patients with isolated TVIE undergoing surgical treatment show good early and late outcome.

OBJECTIVES Endocarditis after the Bentall procedure is a severe disease often complicated by a pseudoaneurysm or mediastinitis. Reoperation is challenging but conservative therapy is not effective. The aim of this study was to assess short- and midterm outcomes of patients reoperated on for Bentall-related endocarditis. METHODS Seventy-three patients with Bentall procedure-related endocarditis were recorded in the Italian registry. The mean age was 57 ± 14 years and 92% were men; preoperative comorbidities included hypertension (45%), diabetes (12%) and renal failure (11%). The logistic EuroSCORE was 25%; the EuroSCORE II was 8%. RESULTS Preoperatively, 12% of the patients were in septic shock; left ventricular-aortic discontinuity was present in 63% and mitral valve involvement occurred in 12%. The most common pathogens were Staphylococcus aureus (22%) and Streptococci (14%). Reoperations after a median interval of 30 months (1–221 months) included a repeat Bentall with a bioconduit (41%), a composite mechanical (33%) or biological valved conduit (19%) and a homograft (6%). In 1 patient, a heart transplant was required (1%); in 12%, a mitral valve procedure was needed. The hospital mortality rate was 15%. The postoperative course was complicated by renal failure (19%), major bleeding (14%), pulmonary failure (14%), sepsis (11%) and multiorgan failure (8%). At multivariate analysis, urgent surgery was a risk factor for early death [hazard ratio 20.5 (1.9–219)]. Survival at 5 and 8 years was 75 ± 6% and 71 ± 7%, with 3 cases of endocarditis relapse. CONCLUSIONS Surgery is effective in treating endocarditis following the Bentall procedure although it is associated with high perioperative mortality and morbidity rates. Endocarditis relapse seems to be uncommon.