Background and aim of the study Guidelines on myocardial revascularization indicate for type V myocardial infarction (MI) that postoperative troponin elevations need not be exclusively ischemic but may also be caused by direct epicardial injury. Additional complexity arises from the introduction of high-sensitive troponin markers. The present study attempts to contribute to the understanding of postoperative high-sensitive cardiac troponin T (hs-cTnT) increase. Methods Type of surgery, potential factors affecting the postoperative hs-cTnT increase, and possible thresholds indicative of type V MI were analyzed. Results Among 400 included patients, 2.8% had intervention-related ischemia analogous to the type V MI definition. Receiver-operating characteristics confirmed good discriminatory power for hs-cTnT and creatine kinase myocardial band (CK-MB), with ischemia indicating thresholds for hs-cTnT (1705.5 ng/l) and for CK-MB (113 U/l). The median postoperative hs-cTnT/CK-MB increase differed significantly depending on the type of surgery, with the highest increase after mitral valve and the lowest after off-pump coronary surgery. Regression analysis confirmed Maze procedure (p<0.001), cardiopulmonary bypass time (p=0.03), emergency indications (p= 0.01) and blood transfusion (p=0.02) as significant factors associated with hs-cTnT increase. In contrast, CK-MB increase was also associated with mortality (p=0.002). Intra-pericardial defibrillation was the only ischemia-independent factor additionally associated with proposed thresholds (p<0.001). Conclusions The present results confirm the influence of the type of surgery and other intervention-related parameters on the postoperative hs-cTnT increase. Type V MI-indicating thresholds may require reassessment, especially using high-sensitive markers.

Background: Sutureless bioprothesis aortic valves simplify surgery for aortic valve replacement (AVR) but some anatomical features of the recipients aortic annulus might preclude anchoring and lead to paravalvular leak. Sub-commissural annuloplasty (SCAP) has been sporadically proposed to secure implantation under these circumstances. This study evaluated whether SCAP affects early postoperative outcomes after sutureless Perceval-S implantation. Methods: We included all patients who underwent AVR (isolated or combined with coronary bypass) with the Perceval-S valve from March 2016 to August 2019. SCAP was performed each time the surgeon deemed it useful to improve anchoring, including after primary implantation failure. Results: One hundred and three patients were included. Mean age was 73.9±7.2 years and 36(35%) were women. SCAP was performed in 34(33%) patients, significantly more frequently in patients with large aortic annulus or bicuspid aortic valve. Perceval-S implantation was successful in 100(97%) patients and SCAP allowed successful redeployment of the same Perceval S valve in 4(28%) of first implantation failures. Thirty-day mortality was 2% (n=2), of which one was related to the procedure. There was no significant difference in the incidence of postoperative conduction disorders between patients with and without SCAP (respectively, 3[9%] vs 7[10%], p=1.0). More than trivial paravalvular leak was noted in 1(1%) patient without SCAP. Postoperative peak and mean pressure gradients were lower in patients with than in those without SCAP (respectively, 19.0±7.9 mmHg vs 23.1±7.0 mmHg, p=0.001; and 10.4±4.1 versus 12.6±3.7 mmHg, p=0.001). Conclusions: SCAP is a safe, simple and reproducible technique that might facilitate Perceval-S aortic valve implantation.