There is, I think, something ethereal about i —the square root of minus one. I remember first hearing about it at school. It seemed an odd beast at that time—an intruder hovering on the edge of reality.

Usually familiarity dulls this sense of the bizarre, but in the case of i it was the reverse: over the years the sense of its surreal nature intensified. It seemed that it was impossible to write mathematics that described the real world in …

I and i

Background Many patients with severe aortic stenosis and coexisting conditions are not candi dates for surgical replacement of the aortic valve. Recently, transcatheter aortic-valve implantation (TAVI) has been suggested as a less invasive treatment for high-risk patients with aortic stenosis. Methods We randomly assigned patients with severe aortic stenosis, whom surgeons considered not to be suitable candidates for surgery, to standard therapy (including balloon aortic valvuloplasty) or transfemoral transcatheter implantation of a balloon-expandable bovine pericardial valve. The primary end point was the rate of death from any cause. Results A total of 358 patients with aortic stenosis who were not considered to be suitable candidates for surgery underwent randomization at 21 centers (17 in the United States). At 1 year, the rate of death from any cause (Kaplan–Meier analysis) was 30.7% with TAVI, as compared with 50.7% with standard therapy (hazard ratio with TAVI, 0.55; 95% confidence interval [CI], 0.40 to 0.74; P<0.001). The rate of the composite end point of death from any cause or repeat hospitalization was 42.5% with TAVI as com pared with 71.6% with standard therapy (hazard ratio, 0.46; 95% CI, 0.35 to 0.59; P<0.001). Among survivors at 1 year, the rate of cardiac symptoms (New York Heart Association class III or IV) was lower among patients who had undergone TAVI than among those who had received standard therapy (25.2% vs. 58.0%, P<0.001). At 30 days, TAVI, as compared with standard therapy, was associated with a higher incidence of major strokes (5.0% vs. 1.1%, P = 0.06) and major vascular complications (16.2% vs. 1.1%, P<0.001). In the year after TAVI, there was no deterioration in the functioning of the bioprosthetic valve, as assessed by evidence of stenosis or regurgitation on an echocardiogram. Conclusions In patients with severe aortic stenosis who were not suitable candidates for surgery, TAVI, as compared with standard therapy, significantly reduced the rates of death from any cause, the composite end point of death from any cause or repeat hospitalization, and cardiac symptoms, despite the higher incidence of major strokes and major vascular events. (Funded by Edwards Lifesciences; ClinicalTrials.gov number, NCT00530894.)

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Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery

Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

A b s t r ac t Background The use of transcatheter aortic-valve replacement has been shown to reduce mortality among high-risk patients with aortic stenosis who are not candidates for surgical replacement. However, the two procedures have not been compared in a randomized trial involving high-risk patients who are still candidates for surgical replacement. Methods At 25 centers, we randomly assigned 699 high-risk patients with severe aortic stenosis to undergo either transcatheter aortic-valve replacement with a balloon-expandable bovine pericardial valve (either a transfemoral or a transapical approach) or surgical replacement. The primary end point was death from any cause at 1 year. The primary hypothesis was that transcatheter replacement is not inferior to surgical replacement. Results The rates of death from any cause were 3.4% in the transcatheter group and 6.5% in the surgical group at 30 days (P = 0.07) and 24.2% and 26.8%, respectively, at 1 year (P = 0.44), a reduction of 2.6 percentage points in the transcatheter group (upper limit of the 95% confidence interval, 3.0 percentage points; predefined margin, 7.5 percentage points; P = 0.001 for noninferiority). The rates of major stroke were 3.8% in the transcatheter group and 2.1% in the surgical group at 30 days (P = 0.20) and 5.1% and 2.4%, respectively, at 1 year (P = 0.07). At 30 days, major vascular compli- cations were significantly more frequent with transcatheter replacement (11.0% vs. 3.2%, P<0.001); adverse events that were more frequent after surgical replacement included major bleeding (9.3% vs. 19.5%, P<0.001) and new-onset atrial fibrillation (8.6% vs. 16.0%, P = 0.006). More patients undergoing transcatheter replacement had an improvement in symptoms at 30 days, but by 1 year, there was not a significant between-group difference. Conclusions In high-risk patients with severe aortic stenosis, transcatheter and surgical proce- dures for aortic-valve replacement were associated with similar rates of survival at 1 year, although there were important differences in periprocedural risks. (Funded by Edwards Lifesciences; Clinical Trials.gov number, NCT00530894.)

/pdf/transcatheter-versus-surgical-aortic-valve-replacement-in-1g5w8nl0h8.pdf

Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients

2018 ESC/EACTS Guidelines on myocardial revascularization.

Background and purpose Patients with aortic valve (AV) pathology and severe comorbidities should benefit from reduced myocardial ischemic and extracorporeal circulation (ECC) time. Sutureless implantation of AV prosthesis may reduce myocardial ischemic and ECC time significantly. The authors report on their preliminary results with the first implants of the 3F-Enable sutureless AV prosthesis. Material and methods The 3F-Enable prosthesis was implanted in five patients. Prostheses sizes were 27 mm (n = 3), 23 mm (n = 1), and 21 mm (n = 1), respectively. Intraoperatively, at patient's discharge as well as 3 and 6 months postoperatively, the AV prosthesis was evaluated by echocardiography. Results ECC time was 87 +/- 36 min (range 49-141 min), myocardial ischemic time 55 +/- 27 min (range 32-97 min), and AV implant time 184 +/- 195 s (range 10-420 s). The latest postoperative echo (5.2 +/- 1 months postoperatively) revealed a fully competent AV in three patients, in two patient paravalvular leakage was detected at the severity of an aortic regurgitation (AR) II degrees , and AR II degrees -III degrees , respectively. The mean pressure gradients were 5.8 +/- 1.3 mmHg (range 4.2-7.1 mmHg), valve orifice area was 3.2 +/- 0.4 cm2 (range 2.6-3.6 cm2). Conclusion The first clinical results of the 3F-Enable sutureless AV prosthesis are feasible; however, a paravalvular leakage was detected in two patients (40%). Thus, device and procedural enhancements are required to assure positioning and anchoring of the prosthesis.

[Early single-center experience with the 3F-enable aortic valve bioprosthesis].

Die Malperfusion der Aorta und ihrer Seitenaste ist eine haufige Komplikation der Aortendissektion. Die durch die akute Aortendissektion drohende Minderperfusion von Organen ist eine der Hauptursachen fur die hohe Mortalitat und Morbiditat bei diesen Patienten. Daher sind eine schnelle Diagnose, die Identifizierung der ischamiegefahrdeten Organe und die umgehende Einleitung einer Therapie zur Reperfusion erforderlich, bevor es zu bleibenden Endorganschaden kommt. Erschwert wird dies durch die haufig initial nur diskret bestehenden Symptome, die durch eine verzogerte Therapie letztendlich fatal enden konnen.

Malperfusion bei Aortendissektion

The euroSCORE is a widely applied scoring system to estimate perioperative risk in patients undergoing cardiac surgery. It acknowledges an increased risk in women but does not apply a gender-specific weighing of individual risk indicators. We separately investigated the performance of the euroSCORE for men and women. Cardiac surgical patients operated in 2002 and 2003 (n = 1930) served as training group. Patients operated in 2004 served as validation group (n = 870). Using binary regression analysis, we developed a gender-specific model on the basis of the original euroSCORE risk indicators. The individual risk indicators were assigned gender-specific correlation coefficients. Applying ROC analysis to the validation group, the original euroSCORE performed well, with an area under curve (AUC) of 0.758, for men but poor, with an AUC 0.676, for women. After gender-specific re-weighing, ROC analysis revealed considerably improved predictive values of the modified euroSCORE. AUC for women increased to 0.755, AUC for men further increased to 0.772. The original euroSCORE failed to accurately predict perioperative mortality in women. A binary regression model, assigning a gender-specific weight to each of the risk indicators of the original euroSCORE, considerably improved the predictive power of the modified euroSCORE.

Does the euroSCORE equally well predict perioperative cardiac surgical risk for men and women

From the Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China; Vascular & Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, United Kingdom; and Department of Thoracic and Cardiovascular Surgery, West German Heart Center Essen, University Hospital Essen, Essen, Germany. Informed consents for publications have been obtained from patients involved. Disclosures: Drs Bashir and Jakob are consultants to CryoLife. Dr Bashir received an educational grant from CryoLife for the preparation of this manuscript. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Received for publication March 21, 2021; accepted for publication March 22, 2021; available ahead of print March 21, 2021. Address for reprints: Randolph H. L. Wong, MBChB, FRCS, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China (E-mail: wonhl1@surgery.cuhk.edu.hk). JTCVS Techniques 2021;7:36-4

Management of left subclavian artery in total arch replacement and frozen elephant trunk procedure

The efficacy of the phosphodiesterase inhibitor enoximone for reversal of severe postcardiotomy low cardiac output syndrome was investigated in 13 cases of cardiogenic shock refractory to conventional treatment consisting of β-adrenergic agonists (n = 13) combined with vasodilators (n = 7), and intra-aortic balloon counterpulsation (n = 5). Following a bolus of 1 mg/kg enoximone, cardiac and stroke volume indices increased from 1.56 ± 0.27 l/min/m2 and 16.3 ± 3.3 ml/m2, respectively, to 2.72 ± 0.67 and 27.8 ± 7.1 (both p<0.001). Mean arterial pressure fell, from 77 ± 11 to 68 ± 9 mmHg (p<0.05), as did atrial filling pressures (LAP and RAP), LAP from 21.3 ± 5.5 to 15.9 ± 2.9 and RAP from 16.6 ± 2.3 to 13.7 ± 2.1 mmHg (both p<0.01). The heart rate rose by only 5 %. Enoximone therapy was maintained by a continuous infusion (5–7.5 ug/kg/min) for 40.6 ± 8.6 hours (range 14–92). All hemodynamic parameters remained stable throughout treatment. Six patients died of sepsis and/or multiorgan failure but seven were ...

Heinz Jakob

Papers

[Early single-center experience with the 3F-enable aortic valve bioprosthesis].

Malperfusion bei Aortendissektion

Does the euroSCORE equally well predict perioperative cardiac surgical risk for men and women

Management of left subclavian artery in total arch replacement and frozen elephant trunk procedure

Efficacy of phosphodiesterase inhibitor enoximone in management of postcardiotomy cardiogenic shock.