Johannes Petersen

Objectives: Enhanced recovery after surgery (ERAS) protocols are patient-centred, interprofessional perioperative care models aimed at reducing hospital stays, complications, healthcare costs, and improving patient satisfaction. Evidence for ERAS in cardiac surgery is scarce; therefore, we aimed to assess its efficacy and safety in minimally invasive heart valve surgery (MIHS). Methods: Interdisciplinary Perioperative Care in Minimally Invasive Heart Valve Surgery (INCREASE) is a randomized-controlled trial that compares ERAS with standard care in MIHS. The intervention group (IG) received ERAS-based treatment; the control group (CG) standard care. Co-primary end-points were in-hospital stay for cardiovascular reasons within 1 year postoperatively (superiority hypothesis) and physical performance (6-minute walk test [6MWT]) at discharge (non-inferiority hypothesis). Superiority hypothesis was tested primarily in surgically treated patients (modified intention to treat population), while non-inferiority hypothesis was tested in per protocol population. Results: In total, 201 patients scheduled for MIHS were randomized (IG: 101; CG: 100). Total weighted in-hospital stay within 1 year was non-significantly shorter in the IG (adjusted mean difference −2.7 days, 95% confidence interval (CI) (−6.3, 0.9), 1-sided P = .07). Sensitivity analyses favoured the IG (adjusted ratio 0.71, 95% CI, 0.6, 0.85). For 6MWT, adjusted mean difference was −14%, 95% CI (−43%, 15%) exceeding the non-inferiority margin of −15% (1-sided P = .48). Without baseline adjustment, 6MWT values revealed a mean difference between groups of −1%, 95% CI (−10%, 8%), reaching non-inferiority of the IG. Safety outcomes were comparable with the exception of an unexpected higher rate of post-operative atrial fibrillation in patients randomized to ERAS. Conclusions: ERAS is feasible and safe in MIHS. The trial did not demonstrate a reduction in length of hospital stay during the first postoperative year in the population studied. Exploratory analyses suggest that further evaluation of ERAS concepts is justified.

Aims: Optimal outcomes for patients with cardiac arrhythmias can be achieved through multimodal therapy including lifestyle support, medication, and interventions. Planning of these therapy concepts requires a detailed understanding of phenotypes, responses to therapies, and outcomes. Objective: The prospective Long-term Outcome and Predictors for Recurrence after Medical and Interventional Treatment of Arrhythmias at the University Heart Center Hamburg (TRUST) combines deep phenotypic, procedural, and follow-up information in a contemporary cohort of patients with cardiac arrhythmias. Methods and results: TRUST is an investigator-initiated, prospective, cohort study enrolling consecutive patients at the UHZ Hamburg. Comprehensive baseline work-up, imaging, and biobanking at baseline is combined with follow-up using a combination of in-person visits, online questionnaires, and remote rhythm-monitoring. Enrolment started in March 2021 and is ongoing. This paper describes the design and the clinical characteristics of the first 1500 enrolled patients with verified baseline datasets (562 women (37%), median age 64 (IQR 55, 74) years). Overall, 1077/1500 patients (71%) were seen for atrial fibrillation, 161/1500 (11%) for ventricular tachycardia and premature ventricular complexes, 239/1500 (16%) for supraventricular tachycardia, and 23/1500 (2%) patients for other reasons. Ablations, rhythm surgery, or invasive procedures were performed in 1363/1500 (91%) within 1 month after inclusion. Conclusion: This snapshot of the first 1500 patients enrolled in TRUST illustrates current characteristics and comorbidity burden in patients undergoing arrhythmia treatment. This rich data set will provide information on treatment patterns, detailed phenotypes, and follow-up, offering insights into the natural progression and treatment responses of arrhythmias in routine care.

Objectives: Aortic valve repair is an evolving and still underused strategy in young bicuspid aortic valve (BAV) patients with aortic regurgitation (AR). The lack of standardization remains the main limitation of current repair techniques, resulting in an increased risk of AR recurrence and reoperation. The most controversial issue is the stabilization of the BAV annulus. Methods: The CONTOUR trial is a multicentre RCT designed to compare 2 aortic valve annuloplasty concepts in 100 consecutive BAV patients. BAV AR patients with an asymmetric configuration and without aortopathy will be randomized 1:1 to undergo aortic valve repair using an internal HAART 200 annuloplasty device (INTERNAL group) or double external annuloplasty using Extra Aortic ring (EXTERNAL group). 4 D flow magnetic resonance imaging (MRI) will be performed preoperatively (t1), postoperatively at discharge (t2), and at 1-year follow-up (t3) for rater-blinded assessment of haemodynamic profiles (ie, flow eccentricity) and regurgitation fraction at the MRI core-lab. Two hierarchically ordered primary end-points will be considered: (1) postoperative reduction of flow eccentricity at hospital discharge and (2) regurgitation fraction (%) at 1-year follow-up. Results: The CONTOUR trial is the first RCT designed to compare 2 different annuloplasty techniques in their effectivity to create a completely symmetric post-repair BAV geometry and to achieve superior aortic valve repair outcomes. Conclusions: The study findings are expected to significantly influence aortic valve repair practice and contribute to the refinement of guideline recommendations in the management of BAV patients with AR. Trial Registration: NCT06869954.

The 2017 and 2021 ESC/EACTS guidelines for the management of valvular heart disease recommend transcatheter aortic valve implantation (TAVI) as a treatment option for severe symptomatic aortic valve stenosis (AS) in patients ≥75 years of age. However, surgical aortic valve replacement (SAVR) remains a viable option for elderly patients, particularly in specific anatomical or clinical subsets. The objective of this study was to analyze indications for SAVR and postoperative outcomes in patients ≥75 years of age. Heart team protocols were reviewed to determine indications for SAVR. The adjudication of acute procedural and early clinical outcomes was conducted in accordance with the standardized VARC-3 definitions. Furthermore, cardiovascular mortality and rate of aortic valve re-intervention were assessed at latest follow-up with a median duration of 5.5 years (1.9–7.1 years). A total of 43 patients ≥75 years of age (51% male) underwent isolated SAVR at our center between 2017 and 2022. STS/EuroSCORE II was 1.7 ± 0.6%/1.7 ± 0.4%. The age distribution of patients was as follows: 75 to 76 years in 32.5% (14/43), 77 to 79 years in 46.5% (20/43), and 80 to 83 years in 21% (9/43) of patients. Indications for SAVR included low operative risk according to STS (1.6 ± 0.3%) and EuroSCORE II (1.4 ± 0.3%) in 51.2% (22/43), unicuspid/bicuspid aortic valve in 21% (9/43), patient preference in 13.9% (6/43), large aortic annulus in 9.3% (4/43), and massive calcification of the left ventricular outflow tract in 4.6% (2/43) of patients. Mean aortic cross clamp and cardiopulmonary bypass times were 67.1 ± 18.2 minutes and 98.6 ± 25.1 minutes. All-cause 30-day mortality was 0% (0/43). Technical success, device success, and early safety were 100% (43/43), 100% (43/43), and 81.4% (35/43). Bleeding complications and the need for permanent pacemaker implantation (PPM) were observed in 9.3% (4/43) and 4.6% (2/43) of patients. Mean ICU and hospital stay were 2.9 ± 2.1 days and 12.5 ± 3.6 days. Post-procedural echocardiography demonstrated absence of paravalvular leakage (PVL) in all but one patient, who exhibited moderate PVL. The mean transvalvular pressure gradient was 11.4 ± 4.5 mmHg. Latest follow-up was at median 5.5 years (1.9–7.1 years). Aortic valve re-intervention at follow-up was 2.3% (1/43) and cardiovascular mortality was 4.6% (2/43). In the current era, SAVR is rarely performed in patients ≥75 years of age. Despite the highly selective nature of the patient cohort studied, the results are excellent, with a 30-day mortality of 0% and a low cardiovascular mortality at 5 years. SAVR should still be considered a valid option in elderly patients, evaluated by a heart team, which considers each patient's unique clinical, anatomic, and procedural characteristics.

Objectives: Concomitant atrial fibrillation ablation is a well-established procedure in patients undergoing mitral valve (MV) surgery. However, data concerning the long-term outcomes of cryoablation performed during totally endoscopic MV surgery remain limited. Furthermore, different lesion sets and energy sources used in endoscopic approach may result in varying outcomes. We therefore, analysed rhythm outcome in patients undergoing left-sided cryoablation during totally endoscopic MV surgery. Methods: Patients, who underwent totally endoscopic MV surgery with concomitant left-sided cryoablation between 2016 and 2023 at our centre were included in the study. The retrospective data analysis was based on 24-h Holter monitor follow-up data. Results: A total of 123 patients were included in the study. No complications related to the ablation procedure were observed. The median follow-up period was 36.0 (interquartile range: 17-60) months. During this period, 34 episodes of atrial fibrillation recurrence were documented, corresponding to a recurrence rate of 8.43 per 100 patient-years (95% confidence interval: 5.90-11.73). The estimated freedom from AF at 1, 3, and 5 years were 96.6%, 86.3%, and 69.4% respectively. Type of atrial fibrillation (P = .004; hazard ratio [HR]: 2.521; 95% confidence interval [CI]: 1.347-4.716) and left atrial volume (P = .003; HR: 1.010; 95% CI: 1.003-1.016) were identified as predictors for atrial fibrillation recurrence. Conclusions: Concomitant left-sided cryoablation during totally endoscopic MV surgery is a safe and effective procedure for atrial fibrillation treatment. The encouraging long-term outcomes support the consideration of this approach in totally endoscopic mitral surgery.

OBJECTIVES: To define morphologic risk constellations during valve-sparing aortic root replacement (VSARR) for aortic valves with paracommissural fenestrations. METHODS: Patients from the multicentre prospective intention-to-treat VSARR-registry German Aortic Root Repair Registry (GEARR) were screened for paracommissural cusp fenestrations. We studied a combined end-point of residual aortic regurgitation (rAR) on post-cardiopulmonary bypass (CPB) transesophageal echocardiography (TEE), mid-term progress of rAR (transthoracic echocardiography) and aortic valve replacement for AR. RESULTS: Of a total of 762 registry patients (operated 2016–2024), 145 were identified with ≥1 paracommissural cusp fenestration. Eighteen patients (12%) were not treated as planned but underwent composite valved graft (CVG) implantation. Mean follow-up time was 3 years. Upon post-CPB TEE, rAR grade 1 or 2 were present in 44 (33%) and 3 (2%) patients. 50% of patients with fenestrations in more than one cusp showed early progression of rAR. At 3 years, freedom from the combined end-point was 78% (99% CI 74–79%) for the complete study cohort. Patients with a maximum free margin length difference of 5 mm (30% vs 70%, P = 0.018). CONCLUSIONS: Fenestrations in more than one cusp, inhomogeneities of cusp-free margin lengths, and additional prolapse are associated with inferior outcome after VSARR for valves with paracommissural fenestrations. Clinical trial registration number: DRKS00007872

Background: Marfan syndrome (MFS) guidelines recommend optimal pharmacological therapy (OPT) and replacement of the ascending aorta (RAA) at 5.0cm diameters to prevent acute type A aortic dissection (ATAAD) and death. The effect of early MFS diagnosis and initiation of therapy on outcomes is not known. Objective: To evaluate the effect of age at MFS diagnosis and therapy initiation on delayed RAA and death. Methods: This retrospective observational cohort study with long-term follow-up included consecutive patients with MFS, pathogenic FBN1 variant, and regular visits to a European Reference Network Center. We considered MFS diagnosis at age ≥21 years late, and OPT initiation at age 5.0cm or ATAAD, and death from all causes. We used landmark design starting at age 21 years to determine associations with outcomes. Results: The study group consisted of 288 patients (45.1% male), including 169 patients with late MFS diagnosis (58.7%) and 63 with early OPT (21.9%). During mean follow-up of 25±14.7 years, 78 patients had delayed RAA, with 42 operations for ATAAD and 36 for aneurysms ≥5.0cm. There were 33 deaths, including 11 deaths late after ATAAD. All deaths were cardiovascular. Late diagnosis, but not early OPT, showed univariate association with delayed RAA (P<0.001) and death (P=0.025). Multivariate Cox regression analysis confirmed late diagnosis as predictor of delayed RAA (hazard ratio (HR)=8.01; 95% confidence interval (95%CI) 2.52-25.45; P<0.001) and death (HR=4.68; 95%CI 1.17-18.80; P=0.029). Conclusions: Late diagnosis of Marfan syndrome is associated with delayed surgery and death.

Background Alterations in left ventricular (LV) diastolic function following native tissue-preserving aortic valve (AV) procedures have not been systematically investigated. Furthermore, no comparisons have been made between these changes and those observed after prosthetic AV replacement. Methods From October 2017 to August 2020, 74 patients aged <65 years were referred to our institution for elective AV surgery. Preoperative and postoperative (i.e., discharge, 3-month and 1-year follow-up) transthoracic echocardiography was analyzed. Results Native tissue-preserving surgery was performed in 55 patients (AV repair: n = 42, Ross procedure: n = 13). The remaining 19 patients underwent prosthetic AV replacement. Preoperatively and at discharge, transvalvular hemodynamics and LV diastolic function were comparable in both groups. At 1-year follow-up, native valve (NV) patients showed significantly lower mean transvalvular gradient (7 ± 5 vs. 9 ± 3 mmHg, p = 0.046) and peak velocity (1.74 ± 0.51 vs. 2.26 ± 0.96 m/s, p = 0.004), and significantly better septal e′ (9.1 ± 2.7 vs. 7.7 ± 2.5 cm/s, p = 0.043) and lateral e′ (14.7 ± 3.1 vs. 11.7 ± 3.7 cm/s, p = 0.001). From preoperatively to 1-year postoperatively, septal and lateral e′ and E/e′ improved markedly after NV preservation (septal e′: +0.7 cm/s, p = 0.075; lateral e′: +2.3 cm/s, p < 0.001; E/e′: −1.5, p = 0.001) but not after AV replacement (septal e′: +0.2 cm/s, p = 0.809; lateral e′: +0.8 cm/s, p = 0.574; E/e′: −1.2, p = 0.347). Significant negative linear correlations between postoperative transvalvular gradients and absolute changes in lateral e′ and E/e′ were detected during follow-up. Conclusion Preservation of native tissue in AV surgery results in superior transvalvular hemodynamics compared with prosthetic AV replacement. This may induce faster LV reverse remodeling and may explain more pronounced improvement in LV diastolic function.