Outcomes of Minimally Invasive Aortic Valve Replacement in Obese Patients: A Propensity-Matched Study

INTRODUCTION

Obese patients are at risk of complications after cardiac surgery. The aim of this study is to investigate safety and efficacy of a minimally invasive approach via upper sternotomy in this setting.

METHODS

We retrospectively reviewed 203 obese patients who underwent isolated, elective aortic valve replacement between January 2014 and January 2023 - 106 with minimally invasive aortic valve replacement (MIAVR) and 97 with conventional aortic valve replacement (CAVR). To account for baseline differences, a propensity-matching analysis was performed obtaining two balanced groups of 91 patients each.

RESULTS

The 30-day mortality rate was comparable between groups (1.1% MIAVR vs. 0% CAVR, P=0.99). MIAVR patients had faster extubation than CAVR patients (6 ± 2 vs. 9 ± 2 hours, P<0.01). Continuous positive airway pressure therapy was less common in the MIAVR than in the CAVR group (3.3% vs. 13.2%, P=0.03). Other postoperative complications did not differ significantly. Intensive care unit stay (1.8 ± 1.2 vs. 3.2 ± 1.4 days, P<0.01), but not hospital stay (6.7 ± 2.1 vs. 7.2 ± 1.9 days, P=0.09), was shorter for MIAVR than for CAVR patients. Follow-up survival was comparable (logrank P-value = 0.58).

CONCLUSION

MIAVR via upper sternotomy has been shown to be a safe and effective option for obese patients. Respiratory outcome was promising with shorter mechanical ventilation time and reduced need for post-extubation support. The length of stay in the intensive care unit was reduced. These advantages might be important for the obese patient to whom minimally invasive surgery should not be denied.

The multidisciplinary Heart Team approach for patients with cardiovascular disease: a step towards personalized medicine

AIMS

Despite general agreement on the benefits of the Heart Team approach for patients with cardiac diseases, few data are available on its real impact on the decision-making process. The aim of the study is to define the evolution over time of the level of agreement with the systematic discussion of patients in the Heart Team and to evaluate the adherence to the Heart Team recommendations and the impact of the Heart Team on the clinical outcome of the patients.

METHODS

In 2015--2016, an experienced cardiac surgeon and a cardiologist independently reviewed clinical data of a series of 100 patients (Group 1, G1) and subsequently for each patient recommended treatment (surgical, percutaneous, hybrid or medical therapy) or further diagnostic investigations. The next day, each case was discussed by the Hospital Heart Team. The Heart Team recommendation, the subsequent treatment received by the patient and the in-hospital outcome were recorded. The same study procedure was repeated in 2017 in a second (G2) and in 2018 in a third (G3) group, both of them including 100 patients.

RESULTS

Complete agreement in treatment selection by the cardiac surgeon, cardiologist and the Heart Team was observed in 43% of cases in G1 and in 70% and 68% in G2 and G3, respectively (G1 vs. G2: P  < 0.001, G1 vs. G3: P  = 0.01, G2 vs. G3: P  = 0.30). Agreement was less frequent in patients with a higher risk profile and in patients with aortic valve stenosis. The Heart Team decision was implemented in 95% of cases with a 30-day mortality of 0.67%.

CONCLUSION

Agreement in treatment selection among the cardiac surgeon, cardiologist and Heart Team appears to be low in the initial experience. Subsequently, it seems to steadily increase over time up to a limit, when it reaches a plateau of stable results. Heart Team clinical cases discussion, based on both guidelines and multidisciplinary experience, represents a key step in defining the best patient treatment pathway, potentially improving the decision-making process and clinical results.

Comparison of De-Kay repair versus De Vega suture for functional tricuspid regurgitation: a preliminary experience

BACKGROUND

In patients undergoing mitral valve surgery, restrictive suture annuloplasty (De Vega) for less-than-severe functional tricuspid regurgitation has been proven to be safe and effective. The aim of this study is to determine whether the adjunct of the plication of the posterior tricuspid leaflet with the same running suture (bicuspidized De Vega or "De Kay") is equally safe and effective.

METHODS

Single center, retrospective study on patients submitted to suture repair of the tricuspid valve during mitral valve surgery, with either conventional or De Kay, between January 2014 and December 2020. Comparison was based on degree of residual tricuspid valve regurgitation and right ventricular assessment at discharge.

RESULTS

Over the course of the study period, 255 patients undergoing mitral valve surgery had a dilated (>40 mm or >20 mm/m²) tricuspid valve annulus, with less-than-severe tricuspid regurgitation. Conventional De Vega was employed in 166 patients (65.1%) and De Kay in the remaining 89 (34.9%). At discharge the adjunct of postero-septal commissure plication has similar outcomes to the classic De Vega repair. It seems to preserve right ventricular function.

CONCLUSIONS

De Kay repair guarantees the same tricuspidal regurgitation reduction as compared with conventional De Vega early after surgery.

Performance, clinical outcomes and implementation of an original heart valve clinic model

BACKGROUND

Valvular heart disease (VHD) requires optimized outpatient management that is generally considered to be best delivered by a dedicated, multidisciplinary team (Heart Valve Clinic [HVC]). Although HVC is promoted by clinical guidelines and organized in many centers, real world outcome assessments are limited. Thus, we evaluated the performance, clinical and management outcomes during a 6-year experience with an original HVC model.

METHODS

By interrogating the local database, 1047 consecutive patients admitted to the HVC from January 2015 to October 2020 were found. Management and mortality were checked for all patients. After 3 years of HVC activity, in order to improve appropriateness and efficiency, access priority criteria were introduced. Thus, the study population was divided in two period subgroups (before and after access criteria introduction) that were compared.

RESULTS

A total of 1047 consecutive patients admitted to the HVC constituted the study population; 346 patients (33%) were recommended for invasive treatment. After a mean follow-up of 25.7±3.1 months, 37 patients (3.5%) died. When comparing study periods, statistically significant increase inpatients' complexity and VHD severity was noticed in Period 2, also translating into higher rate of referral to intervention (39.0% vs. 29.4% in Period 1; P=0.001). Finally, despite higher rate of elderly and frail patients, operative mortality was not jeopardized.

CONCLUSIONS

The present study reports a comprehensive assessment of the characteristics and outcomes achieved through an original HVC model. Standardization of access criteria supports the HVC improvement.

Extensive corpus callosum ischemia after coronary artery bypass grafting on extracorporeal circulation

INTRODUCTION

Heart surgery can be associated with adverse ischemic brain events.

CASE REPORT

Here, we describe two patients who presented extensive infarction of the corpus callosum and of other brain watershed areas following coronary artery bypass grafting (CABG) on extracorporeal circulation (ECC).

DISCUSSION

Infarction of the corpus callosum is an extremely rare condition due to its abundant blood supply. Our findings are noteworthy since they diverge from classical brain watershed infarcts and from other cases of corpus callosum involvement. This suggests that in some cases, CABG surgery on ECC may be associated to a profound impairment of intracerebral circulation. However, it is also possible that the corpus callosum is particularly vulnerable to yet unknown metabolic modifications connected to ECC.

CONCLUSIONS

Further studies are needed in order to investigate the complex response of brain circulation and metabolism during heart surgery with ECC.

818 Impaired clinical outcome and increased postoperative complications in COVID-19 patients undergoing cardiopulmonary bypass

Objective

Previous studies reported unfavorable results in COVID-19 patients who underwent cardiac surgery. Complications most frequently observed were respiratory failure and higher incidence of thromboembolic events. We present our single-center experience in patients with perioperative diagnosis of COVID-19 infection undergoing cardiac surgery with extracorporeal circulation.

Methods

In this observational matched case-control (propensity match 1:2) study, we collected data of patients undergoing open heart cardiac surgery from January 2020 to May 2021, having positive perioperative diagnosis of COVID-19 infection confirmed by polymerase Chain Reaction-PCR (study group). Patients were compared with 56 corresponding controls (control group) who matched for age, sex, body mass index (BMI) and Euro-Score II.

Results

In the study period 1060 patients underwent cardiac surgery with cardiopulmonary bypass (CPB). Among them, 28 consecutive patients, aged 70.1±9.3 years, had perioperative diagnosis of COVID-19 infection. Four (14%) patients underwent emergency surgery for type-A aortic dissection, 2 (7%) patients died in the Intensive Care Unit for severe respiratory failure, shock and multiple organ failure. Significant bleeding complications occurred in 14 (50%) patients in the study group (vs 6% in the control group, p=<0.05). In the study group, 11 (39%) patients required early surgical reexploration for bleeding, 5 presented cardiac tamponade, 5 (18%) underwent multiple surgical revisions for recurrent bleeding. Three (11%) patients required late chest drainage of a massive sero-hemorrhagic pleural effusion, 1 (4%) presented late postoperative intracranial hemorrhage. Fourteen (50%) patients had severe thrombocytopenia (vs 9% in the control group, p=<0.05). In the study group blood components transfusion and procoagulant drugs administration increased (79% and 78% vs 18% and 11% in the control group, respectively, p=<0.05). In the study group 6 (21%) patients presented postoperative acute renal failure (2% in the control group, p=<0.05), 7 (25%) acute respiratory failure (p=<0.05) requiring prolonged postoperative orotracheal intubation. Sternal dehiscence was observed in 4 (14%) patients in the study group (vs 4% in the control group, p=< 0.05). Complications significantly influenced hospital stay length (20 ± 3.1 vs 8.1 ± 3.9 days, p=< 0.05). In the multivariable logistic regression model the SARS-CoV-2 infection and renal failure were independent factors associated with severe postoperative complications (p=<0.01).

Conclusions

Clinical outcome of open heart cardiac surgery patients with perioperative COVID-19 infection appears significantly impaired in terms of mortality and postoperative complications. CPB-related inflammatory reaction could likely exacerbate the deleterious effect of COVID-19 on the respiratory and renal systems, as well as on the coagulation pathways. Early and late hemorrhagic complications were very frequent with significantly increased surgical reexplorations for bleeding, a higher incidence of severe thrombocytopenia, of blood components transfusion and procoagulant drugs administration. The increased surgical risk should suggest a cautious attitude in indicating open heart surgery in patients with perioperative COVID-19 infection and surgery should be limited to not postponable or to urgent cases.

Bleeding Complications in Patients With Perioperative COVID-19 Infection Undergoing Cardiac Surgery: A Single-Center Matched Case-Control Study

Objective

Previous studies reported a poor outcome in patients with coronavirus 2019 (COVID-19) undergoing cardiac surgery. Complications most frequently described were respiratory failure, renal failure, and thromboembolic events. In their recent experience, the authors observed a very high incidence of bleeding complications. The purpose of the study was to investigate a possible significant correlation between perioperative COVID-19 infection and hemorrhagic complications compared to non-COVID-19 patients.

Design

Single-center, observational, retrospective, matched case-control (1:2) study involving patients who underwent open-heart cardiac surgery from February 2020 and March 2021 with positive perioperative diagnosis of COVID-19 infection, matched with patients without COVID-19 infection.

Setting

Cardiac surgery unit and intensive care unit of a university tertiary center in a metropolitan area.

Participants

In the study period, 773 patients underwent cardiac surgery on cardiopulmonary bypass (CPB). Among them, 23 consecutive patients had perioperative diagnosis of COVID-19 infection (study group). These patients were compared with 46 corresponding controls (control group) that matched for age, sex, body mass index, and Society of Thoracic Surgeons score.

Interventions

Open-heart cardiac surgery on CPB.

Measurements and Main Results

In the study group, 2 patients (9%) died in the intensive care unit from severe respiratory failure, shock, and multiple organ failure. In the study group, patients showed a significantly higher incidence of bleeding complications (48% v 2%, p = 0.0001) and cases of surgical reexploration for bleeding (35% v 2%, p = 0.0001), a higher incidence of severe postoperative thrombocytopenia (39% v 6%, p = 0.0007), and a higher need of blood components transfusions (74% v 30%, p = 0.0006). Chest tubes blood loss and surgical hemostasis time were markedly prolonged (p = 0.02 and p = 0.003, respectively).

Conclusions

A worrisome increased risk of early and late bleeding complications in COVID-19 patients was observed, and it should be considered when assessing the operative risk. CPB-related inflammatory reaction could exacerbate the deleterious effect of COVID-19 on the coagulation system and likely deviate it toward a hemorrhagic pattern.

Implantable ventricular assistance systems (VAD) as a bridge to transplant or as 'destination therapy'

Heart failure is a complex clinical syndrome associated with a high mortality and morbidity rate. Despite the extensive pharmacological armamentarium, a non-negligible percentage of patients develop advanced heart failure and require further therapies. In these circumstances, heart transplantation remains the treatment of choice, but the limited number of donors and the reduction of potential candidates have made necessary to develop new technologies. Since the 1980s, left ventricular assist devices (LVADs) have been introduced and have completely revolutionized the landscape of advanced heart failure treatments. This article has identified the categories of patients who can benefit from the implantation of an LVAD and summarized the new classifications. In addition, the main LVADs are described, analysing the results of the main clinical studies, with particular reference to adverse events. Although there is no perfect LVAD, a multidisciplinary team approach, dedicated to the treatment of advanced heart failure, can guide the choices on the best device to implant, in order to minimize complications and improve the patient’s quality of life.

Heart Valve Critical Pathway and Heart Valve Clinic: Novel Benchmarks for Modern Management of Valvular Heart Disease

The growing burden of valvular heart disease in Western countries represents a challenge for the daily clinical practice, especially in the light of the ever-increasing number of therapeutic options. The Euro Heart Survey showed that, among elderly subjects with severe, symptomatic valve dysfunction, surgery is denied for 33% of patients with aortic stenosis and for 50% of patients with mitral regurgitation. Current management (from diagnosis to follow-up) is often fragmented in multiple-sometimes unnecessary-steps. Such a "patchy" approach may translate into a suboptimal management, especially in the geriatric population. New healthcare models exist that can coordinate care, reduce fragmentation, limit costs and, ultimately, improve outcomes: the clinical pathways.

Influence of cardiopulmonary bypass set-up and management on clinical outcomes after minimally invasive aortic valve surgery

INTRODUCTION

Minimally invasive aortic valve replacement (MIAVR) requires changes in cannulation strategy and cardiopulmonary bypass (CPB) management when compared to the conventional approach (CAVR). We aimed at evaluating if these differences could influence perfusion-related quality parameters and impair postoperative outcomes.

METHODS

Overall, 339 consecutive patients underwent MIAVR or CAVR between 2014 and 2020 and were analyzed retrospectively. To account for baseline differences, a propensity-matching analysis was performed, obtaining two groups of 97 patients each.

RESULTS

MIAVR group had longer CPB time [107 (95-120) vs 95 (86-105) min, p = .003] than CAVR group. Of note, average pump flow rate index [2.4 (2.2-2.5) vs 2.7 (2.4-2.8) l/min/m², p = .004] was lower in the MIAVR group. Mean arterial pressure was 73 = 9 mmHg vs 62 = 11 mmHg for the MIAVR and CAVR group, respectively (p < .001). Cell-salvaged blood was most commonly used in the MIAVR group (25.8% vs 11.3%, p = .02). Finally, CPB temperature was 32.8°C (32.1-34.8) for MIAVR group vs 34.9°C (33.2-36.1) for the CAVR group (p = .02). Postoperative complications were similar between groups.

CONCLUSIONS

In conclusion, despite differences in CPB parameters in patients undergoing CAVR and MIAVR, the incidences of adverse outcomes were similar. However, compared to CAVR, MIAVR was associated with shorter durations of mechanical ventilation and hospital stay as well as less transfusion of blood products.

Observe the Unexpected: A Strange History of Bioprosthesis in a Patient in Dialytic Treatment

A 73-year-old male with a history of right nephrectomy due to cancer in 1996 was referred to our hospital for dyspnea and acute chest pain. In May 2007, the Shelhigh® No-React® valved bioconduit was implanted using the Bentall-De Bono procedure due to the finding of severe aortic valve insufficiency and acute type A aortic dissection. Nine months after discharge, he was placed on chronic renal dialysis. The patient’s condition was followed carefully after being placed on dialysis, and now, thirteen years later the implanted aortic valve is still moving freely without signs of calcification.

Minimally Invasive Aortic Valve Surgery in Octogenarians: Reliable Option or Fallback Solution?

OBJECTIVE

Aortic valve disease is more and more common in western countries. While percutaneous approaches should be preferred in older adults, previous reports have shown good outcomes after surgery. Moreover, advantages of minimally invasive approaches may be valuable for octogenarians. We sought to compare outcomes of conventional aortic valve replacement (CAVR) versus minimally invasive aortic valve replacement (MIAVR) in octogenarians.

METHODS

We retrospectively collected data of 75 consecutive octogenarians who underwent primary, elective, isolated aortic valve surgery through conventional approach (41 patients, group CAVR) or partial upper sternotomy (34 patients, group MIAVR).

RESULTS

Mean age was 81.9 ± 0.9 and 82.3 ± 1.1 years in CAVR and MIAVR patients, respectively (P = 0.09). MIAVR patients had lower 24-hour chest drain output (353.4 ± 207.1 vs 501.7 ± 229.9 mL, P < 0.01), shorter mechanical ventilation (9.6 ± 2.4 vs 11.3 ± 2.3 hours, P < 0.01), lower need for blood transfusions (35.3% vs 63.4%, P = 0.02), and shorter hospital stay (6.8 ± 1.6 vs 8.3 ± 4.3 days, P < 0.01). Thirty-day mortality was zero in both groups. Survival at 1, 3, and 5 years was 89.9%, 80%, and 47%, respectively, in the CAVR group, and 93.2%, 82.4%, and 61.8% in the MIAVR group, with no statistically significant differences (log-rank test, P = 0.35).

CONCLUSIONS

Aortic valve surgery in older patients provided excellent results, as long as appropriate candidates were selected. MIAVR was associated with shorter mechanical ventilation, reduced blood transfusions, and reduced hospitalization length, without affecting perioperative complications or mid-term survival.

The treatment of mitral insufficiency in refractory heart failure

Secondary mitral insufficiency (SMI) is caused by dilatation and left ventricular dysfunction and is a frequent finding in patients with heart failure (HF). It is associated with a mortality of between 40% and 50% at 3 years. The first-line treatment is represented by medical therapy, possibly associated, when indicated, with cardiac re-synchronization. If the patient remains symptomatic, corrective action should be considered. Surgery is indicated in cases of severe SMI with ejection fraction >30% and the need for myocardial revascularization. The management of patients in whom revascularization is not an option remains extremely complex and the evidence in this field is extremely limited. Percutaneous transcatheter therapies, reparative or replacement, are rapidly emerging as valid alternatives in cases of patients at high surgical risk. In particular, edge-to-edge repair (MitraClip) has proven effective in improving symptoms and reducing hospitalizations for HF. However, neither transcatheter nor surgical mitral repair or replacement has been shown to significantly improve prognosis, with mortality remaining high (14–20% at 1 year). Randomized trials aimed at assessing the effect of these treatments and establishing their long-term outcomes are urgently required.

Unexpected diagnosis following screening breast ultrasound

Any instrumental examination may lead to unexpected diagnosis that in turn can radically change the clinical pathway of a patient.

Psychological Effects of Skin Incision Size in Minimally Invasive Valve Surgery Patients

Objective

Clinical benefits of minimally invasive cardiac valve surgery (MIVS) have been reported. Improved postoperative mental status was never analyzed with dedicated psychological tests. In the present study we intend to investigate potential benefits of MIVS for patient psychological well-being, with special attention to the relevance of the patient perception of the chest surgical scar, of the self body image and cosmetic aspects.

Methods

Between 2016 and 2017, 87 eligible patients, age 66.5 ± 14.5 years, operated on for heart valve surgery, underwent either conventional full sternotomy (CS; n = 48) or MIVS by V-shape hemi-sternotomy approach ( n = 39). Before selection of the surgical approach, patients had undergone preoperative evaluation of their psychological status using Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory Form Y (STAI-Y), and EuroQol-5D (EQ-5D) psychological tests. Six months postoperatively, patients filled in dedicated questionnaires to assess their psychological status, quality of life, and subjective perception, thus repeating the above-mentioned tests and adding the Body Image Questionnaire (BIQ) and Patient and Observer Scar Assessment Scale (POSAS) v2.0 tests for scar-healing process evaluation.

Results

No patient died during the study.The 4 post-test scales of psychological well-being (BDI-II P = 0.04, STAI-Y P = 0.04, 2 indices of EQ-5D P = 0.03, P = 0.01) showed significant differences between the MIVS group and CS group, with MIVS-small incision patients having lower level of depression and anxiety symptoms and better quality of life. Mean score differences of scar perception (BIQ and POSAS v2.0) were significant, with MIVS patients having evaluated the scar quality significantly better than CS patients.

Conclusions

MIVS appears associated with significant esthetical and related psychological benefits, as documented by technical tests. These findings should be considered when selecting the most appropriate technique for heart valve surgery.

Delayed massive subcutaneous emphysema following Robicsek closure

A surgical procedure may lead to unusual and unexpected clinical scenario. Good medical practice should always keep it in mind. So, a broken sternal steel wire was the rare cause of massive emphysema.

Improved Patient Recovery With Minimally Invasive Aortic Valve Surgery: A Propensity-Matched Study

Objective

Despite conflicting evidence available, minimally invasive aortic valve replacement (MIAVR) is increasingly used as an alternative to full sternotomy. We sought to compare early outcomes of aortic valve replacement through a full sternotomy (conventional aortic valve replacement [CAVR]) and upper ministernotomy (MIAVR).

Methods

We analyzed 297 patients having undergone primary, elective, isolated MIAVR or CAVR between January 2014 and June 2018. Following propensity score matching, 120 patients remained in each group.

Results

MIAVR required longer bypass (93 ± 26 vs 81 ± 24 minutes, P < 0.01) and operative times (214 ± 39 vs 182 ± 37 minutes, P < 0.01). However, aortic cross-clamp times were comparable (57 ± 17 vs 54 ± 14 minutes for MIAVR and CAVR, respectively, P = 0.14). MIAVR had less 24-hour blood loss (253 ± 204 vs 323 ± 296 mL, P = 0.03), less red blood cells transfusions [1.4 packs (1.1 o 1.9) vs 2.1 packs (1.8 to 2.7), P = 0.01], and shorter assisted ventilation time (7.1 ± 3.3 vs 9.7 ± 3.8 hours, P < 0.01) when compared to CAVR. These results led to significantly shorter intensive care unit and hospital stays for MIAVR patients (2.5 ± 1.3 vs 3.4 ± 1.1 days, P < 0.01 and 6.9 ± 4.1 vs 8.2 ± 4.8 days, P = 0.03, respectively). Thirty-day mortality and clinical outcomes did not differ significantly among groups.

Conclusions

MIAVR through upper ministernotomy was shown to be as safe and reliable as CAVR. Patient recovery time was improved by shortening mechanical ventilation and reducing blood loss and transfusions. These results may be significant for high-risk patients undergoing aortic valve surgery.

Total Surgical Plication of Left Ventricular Aneurysm Using the BioVentrix Revivent Myocardial Anchoring System

Surgical ventricular reconstruction (SVR) is the therapy of choice for patients with left ventricular dilatation, apical and anterolateral transmural scar, and low ejection fraction. STICH trial did not show that SVR led to improved survival but several observational studies did. However, because of the considerable operative risk, open heart surgery is considered risky in debilitated patients and clinical results are controversial. Alternative less invasive strategies for left ventricular aneurysm repair have been proposed. We present a case of a left ventricular aneurysm repair using the less invasive ventricular enhancement technique (LIVE) with the Revivent TC system (BioVentrix Inc., San Ramon, CA) in a totally surgical approach, instead of a hybrid interventional-surgical one, as previously described.

Aortic Valve Replacement in Elderly Patients With Small Aortic Annulus: Results With Three Different Bioprostheses

Objectives

Aortic valve replacement (AVR) in patients with small aortic annulus (diameter ≤21 mm) is considered a challenging scenario because of technical aspects and the high risk of patient-prosthesis mismatch (PPM). The choice of the appropriate prosthesis is crucial, and at the moment, an ideal device has yet to be identified. We compare clinical and hemodynamic results after AVR with three bioprostheses with different design and characteristics.

Methods

We retrospectively evaluated 76 consecutive patients from two cardiac surgery centers who underwent AVR (Trifecta = 24; Edwards INTUITY Elite valve system = 26, and Perceval = 26) for severe aortic stenosis between 2013 and 2017. Patients selected were older than 75 years and with an annulus diameter ≤21 mm at preoperative echocardiogram. Reinterventions and combined procedures were excluded. Minimally invasive AVR was performed in 44 (57.8%) patients. Telephonic interview was obtained at 2.9 ± 0.5 years and echocardiographic follow-up at 2.2 ± 0.8 years.

Results

Clinical outcome was similar in the three groups. At follow-up, Trifecta patients presented significantly higher peak and mean transprosthetic pressure gradients ( P = 0.04 and 0.01). Effective orifice area and left ventricular mass regression were comparable, although an advantage was observed in Perceval patients without reaching the statistical significance. Incidence of moderate ( P = 0.2) and severe PPM ( P = 0.7) was comparable.

Conclusions

Despite higher postoperative pressure gradients observed with the Trifecta valve, all three prostheses (Trifecta, Edwards INTUITY Elite, and Perceval) have proven to be reliable when implanted in small aortic annuli, with good clinical outcome and favorable left ventricular mass regression.

Outcomes of Surgery for Severe Aortic Regurgitation with Systolic Left Ventricular Dysfunction

BACKGROUND AND AIM OF THE STUDY

Management of patients with aortic regurgitation (AR) and severe impairment of left ventricular (LV) function characterized by an ejection fraction (EF) ≤35% is challenging. Conflicting results regarding perioperative and long-term survival of these patients have been reported. The study aim was to compare in-hospital outcomes and long-term survival of patients with AR and severe LV dysfunction versus moderate dysfunction (35% <EF <50%) versus preserved LV function (EF ≥50%).

METHODS

Between January 2006 and December 2013, a retrospective review was conducted of 119 consecutive patients with severe isolated AR who underwent aortic valve replacement at our institution. Overall, 17 patients (14%) had severe LV dysfunction, 26 (22%) had moderate LV dysfunction, and 76 (64%) had a preserved LV function.

RESULTS

Patients with severely depressed EF were older and more severely symptomatic according to NYHA classification. Operative mortality was 0% in all groups. At a median echocardiographic follow up of 21 months, a statistically significant reverse remodelling of the left ventricle and an improvement in EF of the low-EF group were found. Survival for the overall population was 98.3%, 80.7% and 48.1% at one, five, and nine years, respectively. Long-term postoperative survival was not affected by baseline EF (p = 0.635), but age >70 years and NYHA class III/IV symptoms were predictive of survival.

CONCLUSIONS

In-hospital and long-term survival was similar in patients with severe LV dysfunction and with preserved or moderately reduced LV function. Positive reverse LV remodelling and improved LV function was evident at the two-year echocardiographic follow up in these patients, who should not be denied aortic valve surgery.

Rapid-deployment or transcatheter aortic valves in intermediate-risk patients?

Background Transcatheter aortic valve implantation and rapid-deployment aortic valve replacement represent two emerging therapies for patients with intermediate surgical risk and severe aortic stenosis. However, head-to-head comparisons between such novel therapies are lacking. Methods Severe aortic stenosis patients with intermediate surgical risk treated with rapid-deployment valve replacement at our institution were identified and compared with a propensity-matched population of patients who underwent transcatheter aortic valve replacement. Postoperative echocardiographic findings, in-hospital and midterm clinical outcomes were compared. Results We identified 60 patients who received transcatheter ( n = 30) or rapid-deployment ( n = 30) valve replacement. On postoperative echocardiography, freedom from paravalvular regurgitation was higher in the rapid-deployment valve group ( p < 0.001), while postoperative mean transprosthetic gradient was lower in the transcatheter valve group ( p = 0.03). Permanent pacemaker implantation was required more frequently in transcatheter valve patients ( p = 0.01). Postoperative atrial fibrillation was more common in the rapid-deployment valve group ( p = 0.03). Hospital mortality was similarly low in both groups ( p = 0.33). At midterm follow-up, mortality was comparable ( p = 0.42) but the rapid-deployment valve group still had a lower degree of paravalvular regurgitation. Conclusions Transcatheter and rapid-deployment valve replacement are promising treatment options for patients with intermediate surgical risk. These two techniques are associated with specific patterns of prosthesis function and postoperative complications. Further evaluation of the clinical impact of these therapies in this patient population is needed.

Fungal Endocarditis Due to Aspergillus oryzae: The First Case Reported in the Literature

Infective endocarditis (IE) is a severe disease with high mortality and morbidity. Prosthetic valve endocarditis is a life-threatening complication which can occur in less than 10% of patients with valve prosthesis. A fungal etiology of IE is rare and accounts for only 2-4% of all case of endocarditis, but is associated with a higher mortality and morbidity. Herein is reported the first case of fungal endocarditis of aortic valve prosthesis due to Aspergillus oryzae in a 67-year-old caucasian man who nine years previously underwent mitral and aortic valve replacement with mechanical prostheses, and tricuspid annuloplasty for acute IE due to Enterococcus spp. Seven months previously, the patient also underwent a redo cardiac procedure to replace a mitral valve prosthesis with a new mechanical device due to a leakage. Aspergillus oryzae showed impressive growth with strong and unexpected virulence in both local and systemic settings.

Angina in left main coronary artery occlusion by pulmonary artery aneurysm

A 51-year-old woman with exercise angina and a history of pulmonary artery hypertension related to a previous pulmonary thromboembolism, was referred to our hospital. Computed tomography and coronary angiography showed a 95-mm aneurysm of the main pulmonary artery, which totally occluded the left main coronary artery.

After a multidisciplinary evaluation, we recommended heart-lung transplantation, but the patient refused any kind of surgical procedure. Due to the chronic occlusion, stenting of the left main coronary artery was unfeasible. With no other options available, we could only start pulmonary antihypertensive therapy. At the 1-year follow-up, the patient reported relief of her angina.

Mini-aortic surgery with percutaneous cannulation and rapid-deployment valve

Background

We aimed to evaluate the results of the combined use of rapid-deployment valves, percutaneous cardioplegia delivery and left heart venting during minimally invasive aortic valve replacement surgery.

Methods

We identified 2 propensity-matched cohorts of patients who underwent primary elective isolated minimally invasive aortic valve surgery at our center over a 3-years period: 30 patients in group A had a conventional valve prosthesis and 30 patients in group B received a rapid-deployment valve using percutaneous cardioplegia delivery and percutaneous left heart venting. Skin incision length, intraoperative times, postoperative hospital outcomes, and 30-day echocardiographic results were compared between the 2 groups.

Results

Patients in group B had significantly shorter operative times and shorter skin incisions compared to group A (total operative time 196.0 ± 40.6 vs. 225.1 ± 30.8 min, respectively, p < 0.003; cardiopulmonary bypass time 79.9 ± 10.6 vs. 92.9 ± 17.2 min respectively, p < 0.001; crossclamp time 52.3 ± 9.6 vs. 74.9 ± 10.2 min, respectively, p < 0.001; incision length 3.6 ± 0.5 vs. 6.0 ± 0.6 cm, respectively, p < 0.001). Postoperative hospital outcomes and echocardiographic evaluation showed no significant differences.

Conclusions

The combined use of rapid-deployment valves, percutaneous cardioplegia, and left heart venting is safe and effective and allows a significant reduction of the skin incision together with a significant reduction of intraoperative times without affecting hospital outcomes or hemodynamic performance of the prosthetic valves.

The Same Angiographic Factors Predict Venous and Arterial Graft Patency: A Retrospective Study

To evaluate the value of angiographic factors in predicting failure of both venous and arterial coronary artery bypass graft. We retrieved from our angiographic database 148 patients who underwent venous and/or arterial CABG and for whom a control coronary angiography at more than 1 month after surgery was available. Pre-CABG and follow-up angiographies were analyzed in order to evaluate diameter stenosis (DS,%), stenosis length (mm), Bogaty score (extent index), Sullivan score, and Gensini score for the extent of coronary artery disease, and Jeopardy Duke score for the extent of myocardial area supplied by an artery. Thirty-nine patients (26%) experienced graft failure at follow-up (mean follow-up 11.3 ± 4.6 months). Patients with venous graft failure [26 (20%)] had significantly smaller DS (P = 0.013), shorter stenosis length (P = 0.01), and lower extent index (P = 0.015), Sullivan score (P = 0.013), Gensini score (P = 0.04) as compared with those without venous graft failure. Patients with arterial graft failure [13 (11%)] had significantly lower DS (P = 0.008), shorter stenosis length (P = 0.001), and lower extent index (P = 0.03) and Sullivan score (P = 0.023) as compared with those without arterial graft failure. Venous and arterial graft failure are associated with less severe stenosis and less extensive atherosclerosis of the grafted vessel.

The radial artery: a forgotten conduit

We reviewed the published literature on the clinical and angiographic outcome of radial artery (RA) grafts and on the comparison between the RA and the other conduits used in coronary operations. The RA is a better graft than the saphenous vein and comparable to the right internal thoracic artery (RITA); moreover, the RA seems a better choice than the RITA in patients at risk of sternal or pulmonary complications. We conclude that the RA should be preferred to the saphenous vein and considered at least equivalent to the RITA as the second conduit during every elective coronary artery bypass procedure.

Myocardial revascularization with both internal thoracic arteries 25 years after delayed repair for aortic coarctation

Aortic coarctation has been reported to cause alterations in the internal thoracic arteries that make these vessels unsuitable to be used as grafts for myocardial revascularization, especially if coarctation repair was performed in adulthood. This is the first reported bilateral internal thoracic grafting for myocardial revascularization in a patient who had undergone aortic coarctation repair 25 years earlier.