Svetozar Putnik

Rationale and design of the Aortic Valve replAcemenT versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR trial): A randomized multicenter controlled event-driven trial

Aortic valve replacement (AVR) therapy is an obvious choice for symptomatic severe aortic stenosis (AS) patients as it improves symptoms, left ventricular function, and survival. The treatment decisions and indication for AVR in asymptomatic patients with severe AS and normal left ventricular ejection fraction are less well established and the subject of ongoing debate. Many efforts have been made to define the best treatment option in asymptomatic AS patients with normal left ventricular ejection fraction. Retrospective and observational data imply that elective AVR for asymptomatic severe AS may lead to improvement in outcomes in comparison to surgery performed after onset of symptoms. The AVATAR trial will aim to assess outcomes among asymptomatic AS patients randomized to either elective early AVR or medical management with vigilant follow-up. In the latter group, AVR would be delayed until either the onset of symptoms or changes in predefined echocardiographic parameters. To the best of the authors knowledge, it will be the first large prospective, randomized, controlled, multicenter clinical trial that will evaluate the safety and efficacy of elective AVR in this specific group of patients.

A novel technique for treatment of mitral valve prolapse/flail

References 1. Leal-Noval SR, Rincon-Ferrari MD, Garcia-Curiel A, et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery. Chest. 2001;119:1461-8. 2. Rogers MA, Blumberg N, Saint SK, et al. Allogenic blood transfusions explain increased mortality in woman after coronary artery bypass graft surgery. Am Heart J. 2006;152:1028-34. 3. Lacroix J, Hebert PC, Hutchinson JS, et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med. 2007;356:1609-19. 4. Boettcher W, Merkle F, Huebler M, et al. Transfusion-free cardiopulmonary bypass in Jehovah’s Witness patients weighing less than 5 kg. J Extra Corpor Technol. 2005;37:282-5. 5. Redlin M, Koster A, Huebler M, et al. Regional differences in tissue oxygenation during cardiopulmonary bypass for correction of congenital heart disease in neonates and small infants: relevance of near-infrared spectroscopy. J Thorac Cardiovasc Surg. 2008;136:962-7. 6. Golab HD, Takkenberg JJM, Gerner-Weelink GL, et al. Effects of cardiopulmonary bypass circuit reduction and residual volume salvage on allogenic transfusion requirements in infants undergoing cardiac surgery. Interact Cardiovasc Thorac Surg. 2007;6:335-9. 7. Kotani O, Honjo O, Nakakura M, et al. Impact of miniaturization of cardiopulmonary bypass on blood transfusion requirements in neonatal open heart surgery. ASAIO J. 2007;53:662-5. Brief Communications

Can we identify risk factors for postoperative delirium in cardiac coronary patients? Our experience.

INTRODUCTIONnDelirium is a temporary mental disorder that frequently occurs among elderly hospitalized patients. Patients who undergo cardiac operations have an increased risk of postoperative delirium, which is associated with higher mortality and morbidity rates, a prolonged hospital stay, and reduced cognitive and functional recovery.nnnPATIENTS AND METHODSnIn our prospective study, we included 370 consecutive adult patients who underwent on-pump coronary artery surgery between January 1, 2011, and July 1, 2011. We selected 21 potential risk factors and divided them into preoperative, intraoperative, and postoperative groups. Delirium was diagnosed with the Confusion Assessment Method.nnnRESULTSnPostoperative delirium was diagnosed in 74 patients (20%). Four predictive factors were associated with postoperative delirium: diabetes mellitus, cerebrovascular disease, peripheral vascular disease, and prolonged intubation (P < .05).nnnCONCLUSIONnThree of the four predictive factors significantly associated with delirium are preoperative. They are relatively easy to measure and can be used to identify patients at higher risk. Fast extubation of these patients and preventive interventions can be taken to prevent negative consequences of this postoperative complication.

A Randomized Trial in Patients With Asymptomatic Severe Aortic Stenosis: A Future Has Begun!

We have carefully, and with great interest, read the CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients with Severe Aortic Stenosis) registry data by Taniguchi etxa0al. [(1)][1], which was published in a previous issue of the Journal , and the editorials written by

Management and Outcome of Periprocedural Cardiac Perforation and Tamponade with Radiofrequency Catheter Ablation of Cardiac Arrhythmias: A Single Medium-Volume Center Experience

IntroductionCardiac tamponade (CT) is a life-threatening complication of radiofrequency ablation (RFA). The course and outcome of CT in low-to-medium volume electrophysiology centers are underreported.MethodsWe analyzed the incidence, management and outcomes of CT in 1500 consecutive RFAs performed in our center during 2011–2016.ResultsOf 1500 RFAs performed in 1352 patients (age 55xa0years, interquartile range: 41–63), 569 were left-sided procedures (nxa0=xa0406 with transseptal access). Conventional RFA or irrigated RFA was performed in 40.9% and 59.1% of procedures, respectively. Ablation was performed mostly for atrioventricular nodal reentrant tachycardia (25.4%), atrial fibrillation (AF; 18.5%), atrial flutter (18.4%), accessory pathway (16.5%) or idiopathic ventricular arrhythmia (VA; 12.3%), and rarely for structural VA (2.1%). CT occurred in 12 procedures (0.8%): 10 AF ablations, 1 idiopathic VA and 1 typical atrial flutter ablation. Factors significantly associated with CT were older age, pre-procedural oral anticoagulation, left-sided procedures, transseptal access, AF ablation, irrigated RFA and longer fluoroscopy time (on univariate analysis), and AF ablation (on multivariable analysis). The perforation site was located in the left atrium (nxa0=xa07), right atrium (nxa0=xa03), or in the left ventricle or coronary sinus (nxa0=xa01 each). Upon pericardiocentesis, two patients underwent urgent cardiac surgery because of continued bleeding. There was no fatal outcome. During the follow-up of 19xa0±xa014xa0months, eight patients were arrhythmia free.ConclusionIncidence of RFA-related CT in our medium-volume center was low and significantly associated with AF ablation. The outcome of CT was mostly favorable after pericardiocentesis, but readily accessible cardiothoracic surgery back-up should be mandatory in RFA centers.

The impact of the metabolic syndrome on the outcome after aortic valve replacement.

Objectives The aim of this study was to examine the influence of the metabolic syndrome on the left ventricular geometry as well as on the early and mid-time outcome in patients with aortic stenosis who underwent aortic valve replacement. Methodology The study included 182 patients who underwent aortic valve replacement due to aortic stenosis. The metabolic syndrome was defined by the presence of at least three AHA-NHLB (American Heart Association/National Heart, Lung and Blood Institute) criteria. All the patients were followed for at least 2 years after the surgery. Results The metabolic syndrome did not influence the severity of aortic stenosis (mean gradient and aortic valve area). However, the metabolic syndrome was associated with the reduced prevalence of the normal left ventricular geometry and the increased risk of concentric left ventricular hypertrophy in patients with aortic stenosis. Among the metabolic syndrome criteria, only increased blood pressure was simultaneously associated with the short-term and mid-term outcome, independently of other risk factors. Increased fasting glucose level was an independent predictor of the only 30-day outcome after the valve replacement. The metabolic syndrome and left ventricular hypertrophy were, independently of hypertension and diabetes, associated with the 30-day outcome, as well as incidence of major cerebrovascular and cardiovascular events in the 2-year postoperative period. Conclusion The metabolic syndrome does not change severity of the aortic stenosis, but significantly impacts the left ventricular remodeling in these patients. The metabolic syndrome and left ventricular hypertrophy, irrespective of hypertension and diabetes, are predictors of the short-term and mid-term outcome of patients with aortic stenosis who underwent aortic valve replacement.

The Aortic Valve replAcemenT versus conservative treatment in Asymptomatic seveRe aortic stenosis ( AVATAR trial ): a protocol update

The Aortic Valve replAcemenT versus conservative treatment in Asymptomatic seveRe aortic stenosis (AVATAR trial): a randomized, multicenter controlled event-driven trial is actively recruiting patients. At a meeting held on September the 21, 2017, the Avatar trial Steering Committee made a decision tomake two small modifications to the existing protocol previously published in theAmerican Heart Journal. Wewould like to inform themedical/cardiovascular community and the readers of American Heart Journal about the modificationswe havemade. The updated flowchart of the trial has been presented in Figure.

Surgical revascularization on the beating heart in patients with low ejection fraction

INTRODUCTIONnThe subset of patients most likely to benefit from off-pump coronary artery bypass grafting (OPCABG) remains a controversial issue, but the technique has been proposed to decrease postoperative mortality and morbidity. Coronary artery bypass grafting (CABG) with a cardiopulmonary bypass carries a significant risk for patients with severe left ventricular (LV) dysfunction.nnnOBJECTIVEnThe objective of this study was to compare off-pump to on-pump CABG in patients with ejection fraction (EF) lower than 30%.nnnMETHODSnProspective randomized study was carried out between June 2004 and March 2006 at the Institute for Cardiovascular Diseases of the Clinical Centre of Serbia. Sixty prospectively randomized high-risk patients divided into two groups to undergo off-pump or on-pump CABG. All recruited patients had left ventricular ejection fraction lower than 30%.nnnRESULTSnThirty patients averaging 59.2 years of age underwent 2.30 grafts on pump, and another 30 averaging 59.6 years of age underwent 2.03 grafts off pump. OPCABG patients exhibited a significantly less release of TnI (average 0.71 micro/L) than on-pump patients (3.00 micro/L). Inotropic requirements were less in the off-pump group. The patients undergoing OPCABG received fewer units of blood and had shorter postoperative length of stay in intensive care unit and hospital stay. There was no significant difference in hospital mortality and complication rate.nnnCONCLUSIONnThe present study suggests that off-pump CABG in patients with poor LV function when compared with conventional CABG achieved similar number of grafts per patient, similar in-hospital outcomes, shorter length of stay, reduced transfusion requirement, and less myocardial injury.

Aortic Dissection in the Second Trimester of Pregnancy: Is It Possible to Save Both Lives?

Aortic dissection during pregnancy is a potentially catastrophic clinical condition and can be lethal to both mother and fetus. The treatment of aortic dissection in pregnancy is based on location, severity, and gestational age. We report a case of acute aortic dissection in a 30-year-old female patient in her 26th week of gestation. Ascending aorta resection and interposition of a 26-mm Dacron graft was carried out without circulatory arrest by means of a double-felt sandwich technique on both anastomoses. The patient was discharged from the hospital 10 days after her initial admission. At the 34th week of gestation, the patient delivered a healthy baby by cesarean section. Because our patient was hemodynamically unstable, our aim at the 26th week of gestation was to perform a simplified surgical procedure, to avoid circulatory arrest, and to maintain a high perfusion pressure, in order to save the patients life and to decrease the potential risk of damage to the fetus.

Successful establishment of a left ventricular assist device program in an emerging country: one year experience

BackgroundnThe primary goal of this study was to evaluate the outcomes of patients with end-stage heart failure (HF) who underwent continuous flow left ventricular assist device (CF-LVAD) in a developing country and to compare to those reported by more developed countries. The secondary goal was on determining factors that may be connected to improved survival.nnnMethodsnWe prospectively analyzed 47 consecutive patients who underwent CF-LVAD at our institution. After one year the survival and adverse event profiles of patients were evaluated. At 3, 6 and 12 months, the cardiac, renal and liver function outcomes were assessed.nnnResultsnThe 30-day, 6-month and 1-year survival rates were 89%, 85% and 80%, respectively. A significant improvement in dimensions and ejection fraction of left ventricle, BNP, functional capacity, blood urea nitrogen (BUN) and total bilirubin (P<0.05 for all) were noticed 3 months post-CF-LVAD implantation, and patients were stable throughout the entire first year follow up. In the group of patients with baseline renal dysfunction (RD) there were significant improvements of renal function (P=0.004), with no changes on follow up. 57% of patients exhibited some kind of adverse event, commonly in the form of bleeding. In multivariate Cox regression analysis renal failure was found to be as an independent risk factor for the overall survival (HR =13.1, P<0.001).nnnConclusionsnIn conclusion, our data extends previous findings from centers of developed countries, that CF-LVAD is an adequate treatment option for patients suffering from end-stage HF, and encourages expansion of CF-LVAD implantation in developing countries with nascent HT program.