Elham Bidar

BackgroundRotational thromboelastometry (ROTEM) provides a dynamic assessment of hemostasis in critically ill patients. However, observational studies evaluating ROTEM-guided therapeutic interventions in intensive care units (ICUs) are scarce.ObjectivesTo evaluate the use of ROTEM as routine protocolized care versus indication-based testing and its association with therapeutic interventions in ICU patients.MethodsA single-centre retrospective observational cohort study was conducted at Maastricht University Medical Centre+ between 2013 and 2024. ICU patients who underwent at least one ROTEM measurement were included. ROTEM findings and clinical interventions were compared across four patient groups: elective and emergency cardiothoracic surgery (CTS; routine protocolized ROTEM) and general surgery and non-surgical patients (indication-based ROTEM).ResultsA total of 9141 ICU patients were included: 6739 elective CTS, 489 emergency CTS, 1142 non-surgical, and 771 general surgery patients. Abnormal ROTEM results were more frequent in indication-based groups (39.9-41.9%) compared to routine-based groups (16.3-27.8%; p<0.001). Drug-based interventions and transfusions were also more common in clinically indication-based groups. Actual clinical interventions mirrored this distribution. ConclusionsROTEM abnormalities and associated therapeutic interventions were more frequent when testing was performed based on clinical indication, as compared to routine protocolized care. These findings suggest routine protocolized ROTEM testing in CTS patients is less effective than a strategy based on clinical indication.

Objectives: To assess the long-term effects of teleprehabilitation on modifiable risk factors and quality of life up to 1 year following elective cardiac surgery. Methods: This secondary analysis of the Digital Cardiac Counselling trial, a randomized controlled trial, compared multimodal teleprehabilitation with standard care in patients undergoing elective cardiac surgery. The teleprehabilitation programme targeted physical fitness, inspiratory muscle training, psychological support, nutritional optimization, and smoking cessation. Outcomes included trajectories of modifiable risk factors and quality of life measured preoperatively and at 3, 6, and 12 months postoperatively. Generalized linear mixed models assessed differences over time between groups, with exploratory post hoc analyses for individual timepoints. Results: Both groups showed postoperative reductions in all assessed modifiable risk factors and improvements in quality of life over time (P < .001), except for nutritional optimization (P = .173). Teleprehabilitation was associated with more favourable trajectories for smoking behaviour (P = .045) and nutritional risk (P = .011), with consistently lower incidences throughout follow-up. Smoking prevalence remained significantly lower in the teleprehabilitation group at all timepoints (P < .05), while malnutrition prevalence was lower at 3 months postoperatively (P = .012). Quality-of-life scores were consistently higher in the teleprehabilitation group throughout follow-up (P = .002). Conclusions: Teleprehabilitation in cardiac surgery patients not only reduces postoperative complications, but may also provide additional long-term benefits, particularly in smoking cessation, nutritional optimization, and quality of life. These findings support teleprehabilitation as a valuable addition to standard preoperative care, with possible sustained benefits for long-term lifestyle and quality of life.

Background and Aims: Atrial cardiomyopathy (AtCM) is associated with atrial fibrillation (AF). While histological studies describe underlying mechanisms of AtCM, these insights remain disconnected from clinical AtCM. This study determines the histological basis of non-invasive AtCM markers and assess their prognostic value in patients undergoing cardiac surgery. Methods and results: Left and right (LA/RA) atrial tissue samples were obtained in patients undergoing cardiac surgery (n = 136) in the RACE V Tissue Bank study. Pre-operative rhythm history, digital ECG, transthoracic echocardiography (TTE) and biomarker levels were used to group patients in AtCM stages: AF: history of paroxysmal, persistent or permanent AF, Severe (LAVi>50 mL/m2 or LAEF250 pg/mL), Mild (no AF, LAVi≤34 mL/m2 AND P-terminal Force V1 > 5 mV*ms OR P wave duration > 120 ms), and no AtCM. Tissue was stained (WGA/CD31/Vimentin) to quantify fibrosis, fibroblast density, myocyte diameter and vascularization. Post-operative rhythm was monitored continuously (2.5 years) using implantable loop recorders. Patients with severe AtCM had extended endomysial fibrosis (LA: +0.82µm, pFDR,LA < 0.001; RA: +0.64µm, pFDR,RA = 0.010) and larger left atrial cardiomyocytes (LA: +0.92µm, pFDR,LA = 0.026). Moderate AtCM patients showed LA myocyte hypertrophy (LA: +1.35µm, pFDR,LA = 0.007). Mild AtCM patients had similar histological features to patients without AtCM. Moderate (β = 3.56, pFDR = 0.045) and severe (β = 3.74, pFDR = 0.034) AtCM patients had a higher AF burden late after cardiac surgery. Conclusion: Clinical AtCM markers reflect pro-fibrotic and pro-hypertrophic remodelling in the moderate to severe AtCM stages and are associated with a higher AF burden late after surgery.

Objectives: Aortic arch surgery traditionally relies on hypothermic circulatory and cardioplegic arrest, exposing myocardium and visceral organs to ischaemia-reperfusion injury. We developed a total body perfusion (TBP) strategy providing continuous cerebral, myocardial, and visceral perfusion during arch reconstruction. This study compares outcomes between conventionally and TBP-treated patients. Methods: Analysis included 121 consecutive elective aortic arch replacements (2014-2025). From June 2022, patients (n = 38) were intended for TBP; earlier cases (n = 83) underwent conventional techniques. TBP comprised continuous warm myocardial, selective cerebral, and retrograde visceral perfusion. Outcomes included intraoperative characteristics, biochemical markers, and clinical outcomes. Results: Baseline demographics were similar (male 65.8% vs 53.0%, P = .188; median age 63.9 [IQR 60.5-72.4] vs 66.1 [IQR 58.7-70.6] years, P = .915). TBP-patients presented with greater surgical complexity (more concomitant procedures: 65.8% vs 45.8%, P = .041; chronic dissection: 18.4% vs 0.0%, P < .001; active infection at time of surgery: 15.8% vs 3.6%, P = .027). TBP reduced myocardial ischaemia time (median 65.0 [IQR 39.0-98.5] vs 122.0 [IQR 93.0-170.0] min, P < .001) and circulatory arrest use (18.4% vs 86.7%, P < .001), and demonstrated lower peak lactate levels (median 2.2 [IQR 1.5-4.6] vs 3.9 [IQR 2.9-5.2] mmol/L, P < .001), shorter ICU stay (median 2.0 [IQR 1.0-7.0] vs 4.0 [IQR 3.0-8.0] days, P = .006), and improved one-year survival (92.1% vs 72.3%, P = .025). Multivariable analysis confirmed TBP’s independent survival benefit (HR = 0.187, 95% CI 0.044-0.807, P = .025). Sensitivity analyses were directionally consistent. Conclusions: TBP appeared as a feasible and safe approach in elective aortic arch surgery, associated with improved clinical outcomes and offering comprehensive organ protection. TBP may expand surgical candidacy in high-risk patients.

Objectives: Valve-sparing aortic root replacement (VSARR) is technically demanding and may vary in institutional procedural volumes, rendering the establishment of thresholds for centres of expertise challenging. This study aims to identify an annual case volume that could define a high-volume centre for VSARR using data from the Heart Valve Society Aortic Valve (HVS AV) database. Methods: All consecutive elective patients undergoing VSARR within the HVS AV database were included. The primary early outcome was a composite of mortality, thromboembolic events, reinterventions, intraoperative conversions, and recurrent aortic regurgitation grade ≥2 within 30 days. The primary long-term outcome was freedom from AV reintervention. Volume-outcome (V-O) associations were modelled using restricted cubic splines; the high-volume threshold was derived using the elbow method. Analyses were adjusted for EuroSCORE II. Results: In total, 2668 patients from 37 centres were included. Annual volume was not significantly associated with the early composite outcome (P = .8003). However, a significant non-linear V-O association was found for long-term AV reintervention-free survival (P = .0023), with improved outcomes at centres performing ≥12 cases per year (95% CI, 10-12). These results were consistent in sensitivity analyses (P < .0001). Conclusions: An annual institutional volume of ≥12 VSARRs is associated with improved long-term valve durability and survival, while early postoperative outcomes appear less sensitive to annual case load given their low event rates. This high-volume threshold may serve as a benchmark for centres already experienced in AV and/or root surgery and guide quality improvement efforts.

Children and adolescents with congenital aortic stenosis often need multiple reoperations due to early intervention and somatic growth. When valve replacement is considered, selecting an optimally sized prosthesis is essential. The Konno aortoventriculoplasty enables annular enlargement to accommodate larger valves. Patients with unicuspid or bicuspid valves are increasingly recognized as having intrinsic and extrinsic risk factors for aortopathy, sometimes progressing to aneurysmal degeneration requiring concomitant root replacement. We describe a surgical approach combining the Konno procedure with a Bentall operation for selected patients.

Objectives: Transcatheter treatment for valvular heart diseases has markedly expanded its indications due to reduced invasiveness and hospitalization time. Despite favourable results, several peculiar and more frequent shortcomings than occur with a surgical-based implant have been reported. This review provides the currently available information regarding a transcatheter heart valve (THV) implant and reoperation, focusing on recent available data about surgical management strategies for THV degeneration. Methods: For this narrative review, we searched Medline through the end of March 2025 using medical subject headings and text words supplemented by scanning the bibliographies of recovered articles. The terms “transcatheter valve degeneration,” “TAVI degeneration,” “surgical treatment,” and “surgical explant” have been combined using the Boolean operator “AND”. Results: Currently available articles focus specifically on the aortic THV explant. Peculiar intraoperative (like coronary ostium, aortic wall and annular injury due to THV explant) or short-term postoperative complications related to THV explant have been reported. Thirty-day mortality has been shown to range between 12% and 32.6%, and only short and heterogeneous follow-up periods are available to date. A careful work-up to indicate that the valve-in-valve procedure is not feasible or not appropriate when facing degenerated THV and a cautious, detailed plan of the surgical explant have been recently recommended. Conclusions: THV explants due to valve degeneration are rapidly increasing, but, due to the related risk for intra- and post-procedural complications, careful preoperative evaluation and intraoperative handling are warranted.

Objectives: This investigation aimed to compare different minimally invasive techniques, namely, mini-sternotomy (MS), mini-thoracotomy (MT), and totally thoracoscopic (TT) approaches for the surgical treatment of aortic valve disease, emphasizing their respective benefits and limitations to guide clinical decision-making. Methods: A systematic search was conducted in Medline, Web of Science, Scopus, Wiley Online Library, Google Scholar, and ProQuest. Studies were appraised using the Newcastle-Ottawa Scale. A frequentist network meta-analysis (NMA) with a random-effects model was employed to give reflective ranks and compare outcomes across techniques. Treatment ranking was based on p-scores, with MS as the reference. Higher p-scores indicate greater certainty of superiority over competing interventions. The primary outcome was mortality. Results: Twenty-five observational studies (n = 34 573 patients) were included. Mortality did not differ between techniques (p-score: MS [0.85] ∼ MT [0.34] ∼ TT [0.31]). TT had longer cardiopulmonary bypass (mean difference [MD]: 41.04 [95% CI, 10.98-71.10]) and cross-clamp times (MD: 30.31 [95% CI, 5.81-54.80]) but offered the shortest intensive care unit (ICU) length of stay (p-score: TT [0.98] > MT [0.51] > MS [0.01]; MD: −16.00 [95% CI, −26.62 to −5.38]), reduced hospital stay (MD: −2.07 [95% CI, −3.77 to −0.37]), and fewer complications, including neurological events (odds ratio: 1.79 [95% CI, 1.03-3.13]), blood loss (MD: 208.85 mL [95% CI, 102.29-315.40]) compared to MS. MT showed similar outcomes to MS, except for longer operative times (MD: 29.84 [95% CI, 8.35-51.32]) and shorter ICU stays (MD: −5.88 [95% CI, −11.10 to −0.67]). Conclusions: TT may offer advantages such as shorter hospital stays, reduced neurological complications, and less bleeding as compared to MS, although it is associated with longer operative times. However, as all included studies were observational, the findings should be interpreted with caution, and further NMA including only randomized trials is warranted.

Objectives: The definitions of periprocedural myocardial infarction (PMI) after coronary artery bypass grafting (CABG) are heavily debated. A European Association for Cardiothoracic Surgery (EACTS)-endorsed international survey was conducted to evaluate current clinical practices and to reach a consensus-based agreement on the diagnostic characteristics required for a potential future PMI definition. Methods: The questionnaire complied with the CHERRIES guideline. A pilot version underwent iterative testing. The final version was distributed to all members of EACTS and allied specialties. The questionnaire evaluated definitions, biomarkers, and required diagnostic accuracy and was distributed between August-November 2024. Results: The questionnaire was completed by 175 respondents (surgeons: 71.4%, cardiologists: 20.6%, intensivists: 5.1%, other: 2.9%) from 29 countries. A specific definition of PMI was used by 46.4% of respondents (Universal Definition of Myocardial Infarction [UDMI]-4: 67.4%, Society of Cardiovascular Angiography and Interventions [SCAI]: 16.3%, second Academic Research Consortium [ARC-2]: 6.1%, other: 10.2%). Respondents identified biomarker concentrations defining PMI with supporting (imaging) evidence (high-sensitivity cardiac troponin T [hs-cTnT]: 489 ng/L, high-sensitivity cardiac troponin I [hs-cTnI]: 425 ng/L, CKMB-mass: 90ug/L, CKMB-activity: 100 U/L) and without (hs-cTnT: 931 ng/L, hs-cTnI: 1458 ng/L, CKMB-mass: 100ug/L, CKMB-activity: 300UL). The lowest acceptable sensitivity and specificity thresholds for a future definition were 95% [90%-95%] and 90% [80%-95%], respectively, while sensitivity was deemed more important than specificity (79.8% vs 20.2%, P < .001). Conclusions: The use of PMI definitions varies widely, though UDMI-4 is most frequently employed. Our findings highlight the need for a standardized, CABG-specific PMI definition with robust diagnostic accuracy to enable consistent diagnoses and a common clinical language.

Aims: Several clinical factors, such as ageing and atrial dilatation, are associated with post-discharge atrial fibrillation (late-POAF) after cardiac surgery, but it is currently unknown if atrial histological characteristics are linked to late-POAF. Therefore, the aim of this study was to determine the association of atrial histological characteristics with POAF incidence and burden during 2.5 years of continuous rhythm monitoring after cardiac surgery. Methods and results: Consecutive patients with and without AF history were prospectively included. Intraoperatively, biopsies were taken of left (LAA) and right atrial appendages (RAA), and all patients received an implantable loop recorder for 2.5 years. Biopsies were analysed for overall and endomysial fibrosis, cardiomyocyte diameter, capillary density and size, and fibroblast density. POAF incidence was defined as any AF episode during the follow-up, while POAF burden was the percentage of time in AF. A total of 133 patients were included (90 without and 43 with AF history). Late-POAF occurred in 53 patients (40.8%). While several histological traits were associated with POAF incidence in the unadjusted analyses, none of the histological traits were significantly associated with POAF incidence after adjustments for clinical confounders. Increased RAA endomysial fibrosis was the only histological trait significantly associated with increased overall (St. Beta = 0.32, 95% CI: 0.06–0.58, P = 0.017) and late-POAF burden (St. Beta = 0.43, 95% CI: 0.13–0.72, P = 0.006) after adjusting for age, sex, type of surgery, reduced LV function, RA volume, and AF history. Conclusion: Increased RAA endomysial fibrosis appears to be associated with increased late-POAF persistence, reflected by increased burden, but not with incidental late-POAF recurrences.