Transapical Mitral Valve Replacement: 1-Year Results of the Real-World Tendyne European Experience Registry

BACKGROUND

Early studies of the Tendyne transcatheter mitral valve replacement (TMVR) showed promising results in a small selective cohort.

OBJECTIVES

The authors present 1-year data from the currently largest commercial, real-world cohort originating from the investigator-initiated TENDER (Tendyne European Experience) registry.

METHODS

All patients from the TENDER registry eligible for 1-year follow-up were included. The primary safety endpoint was 1-year cardiovascular mortality. Primary performance endpoint was reduction of mitral regurgitation (MR) up to 1 year.

RESULTS

Among 195 eligible patients undergoing TMVR (median age 77 years [Q1-Q3: 71-81 years], 60% men, median Society of Thoracic Surgeons Predicted Risk of Mortality 5.6% [Q1-Q3: 3.6%-8.9%], 81% in NYHA functional class III or IV, 94% with MR 3+/4+), 31% had "real-world" indications for TMVR (severe mitral annular calcification, prior mitral valve treatment, or others) outside of the instructions for use. The technical success rate was 95%. The cardiovascular mortality rate was 7% at 30 day and 17% at 1 year (all-cause mortality rates were 9% and 29%, respectively). Reintervention or surgery following discharge was 4%, while rates of heart failure hospitalization reduced from 68% in the preceding year to 25% during 1-year follow-up. Durable MR reduction to ≤1+ was achieved in 98% of patients, and at 1 year, 83% were in NYHA functional class I or II. There was no difference in survival and major adverse events between on-label use and "real-world" indications up to 1 year.

CONCLUSIONS

This large, real-world, observational registry reports high technical success, durable and complete MR elimination, significant clinical benefits, and a 1-year cardiovascular mortality rate of 17% after Tendyne TMVR. Outcomes were comparable between on-label use and "real-world" indications, offering a safe and efficacious treatment option for patients without alternative treatments. (Tendyne European Experience Registry [TENDER]; NCT04898335).

Surgical Challenges in Infective Endocarditis: State of the Art

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.

28 CONSTRICTIVE PERICARDITIS: A ROOM FOR MULTI-MODALITY IMAGING

Introduction

The diagnosis of constrictive pericarditis can be challenging through conventional imaging. Novel imaging techniques have been proposed to improve it.

Clinical Case

A 74-year-old man with a previous diagnosis of heart failure with preserved ejection fraction and permanent atrial fibrillation (AF) was admitted because of worsening dyspnea, peripheral edema, and ascites refractory to diuretics therapy. ECG revealed low QRS voltages and AF with normal heart rate and laboratory exams detected increased values of BNP and hepatic stasis indices; blood count and CRP were normal. Echocardiography revealed mildly reduced bi-ventricular pump function (left ventricular ejection fraction = 52%, right ventricular fractional area change = 25%) and slightly increased wall thickness. Atria were moderately dilated (left and right atrium 46 and 44 ml/mq, respectively) and mitral and tricuspid annuli were dilated too. There was inferior vena cava plethora, moderate atriogenic tricuspid regurgitation and mild-to-moderate atriogenic mitral regurgitation. A paradoxical interventricular septal motion and significant respiratory changes on trans-mitral (>25%) and trans-tricuspid (>30%) pulsed Doppler were noted; however, there was no "annulus reversus" (lateral and septal e’ 13 and 11 cm/sec, respectively) at TDI analysis. In contrast, 2D-speckle-tracking global longitudinal strain showed impaired deformation ​​of the lateral segments with relative sparing of the septal segments. The latter pattern has been recently described as "strain reversus" or "hot septum sign". The findings were suspected of constrictive pericarditis, but a chest Computed Tomography excluded pericardial calcifications. Cardiac magnetic resonance (CMR) was then performed revealing a "septal shift" at cine-real time sequences analysis. The pericardium was slightly thickened (4-5 mm) with widespread late gadolinium enhancement but without signs of acute inflammation at T2-weighted imaging. Tricuspid regurgitation was confirmed to be "moderate" after phase-contrast imaging. Cardiac catheterization finally revealed normal coronary arteries and confirmed the diagnosis of constrictive pericarditis (square root sign, equalization of bi-ventricular end-diastolic pressures). The patient underwent pericardiectomy and tricuspid and mitral valve repair and was asymptomatic at 6-months follow-up.

Conclusions

Constrictive pericarditis represents a potentially reversible cause of heart failure but can be easily missed through conventional imaging. In the present case, advanced echocardiography and CMR were essential to come up with an accurate diagnosis, guiding the patient's clinical management with excellent outcome.

760 IMPACT OF COMORBIDITIES AND PATIENTS PREFERENCE ON THE CHOICE BETWEEN PERCUTANEOUS OR SURGICAL REVASCULARIZATION FOR LEFT MAIN CORONARY ARTERY DISEASE

Background

Recent evidence has rendered percutaneous coronary intervention (PCI) a valuable alternative to coronary artery bypass grafting (CABG) in patients with left main coronary artery disease (LMCAD). Nevertheless, the optimal management and patients selection is still subject to discussion

Methods

We retrospectively included 431 patients treated with PCI and 324 patients treated with CABG with the primary objective of comparing procedural failure according to revascularization strategy. Secondary endpoints were post procedural and clinically relevant myocardial infarction, in-hospital stroke, major bleeding defined according to the Bleeding Academic Research Consortium (BARC) criteria, death, and 1-year major adverse cardiac events (MACE).

Results

There was no observed difference in the rates of procedure failure in patients who received PCI compared to patients who received CABG (4.6% vs 3.7%, respectively) odds ratio [OR] 1.26; (95% confidence intervals [CI] 0.58-2.9, p= 0.52.) There was no significant difference in the defined ischemic outcome for PCI vs CABG (0.9% vs 2.4%, respectively) OR 0.37; (95% CI 0.08-1.4), P = 0.09. There was a mild increase in periprocedural myocardial infarction (MI) after PCI (4.2% vs 1.5%) compared to CABG; (OR = 2.8; 95% CI 0.99-9.8, P = 0.034). On the contrary there was a higher risk of major bleeding and transfusions in the patients who had been treated with CABG who has a clinical profile suited for PCI.

Conclusions

PCI did not significantly increase the risk for procedural failure or ischemic events compared to CABG in patients with LM CAD. The higher risk for post-procedural MI after PCI was offset by a higher risk for major bleeding events and transfusion requirements in those undergoing CABG, especially for those who were clinically suited for PCI.

898 ROLE OF 3D ECHOCARDIOGRAPHY IN AORTIC VALVE ABNORMALITIES: TWO CASES REPORT

Introduction

Aortic valves with a number of cusps different from two or three are infrequent congenital anomalies that might manifest with valvular disease in young patients. We present two cases of unicuspid and quadricuspid aortic valve diagnosed in our Center.

Clinical Cases

Case 1. A 23-year-old asymptomatic male was admitted to our Hospital because of the necessity of bone marrow transplantation for Hodgkin lymphoma. He had a previous diagnosis of bicuspid aortic valve and presented a 5/6 mid-systolic harsh murmur, heard best at the right upper sternal border and radiating to the neck. ECG showed sinus rhythm with left ventricular hypertrophy. BNP was in normal range (31 pg/ml).

At trans-thoracic echocardiography, there was severe aortic stenosis [peak/mean gradient of 100/67 mmHg with an aortic valve area of 1.04 cm2 (0.54 cm2/m2); V max was 5 m/s] without regurgitation and dilation of the ascending aorta (39 mm), however the morphology of the aortic valve remained undefined. Left ventricle showed hypertrophy (maximum wall thickness = 13 mm) with normal volumes and systolic function. Thus, the patient underwent to 3D-Transesophageal echocardiography, which demonstrated unicuspid aortic valve with a lone commissure between L-NC and anterior calcification. After multidisciplinary discussion, the patient underwent close follow-up and aortic valve replacement was planned after the bone marrow transplantation.

Case 2. A 21-year-old male was referred by general practitioner to our outpatient clinic for palpitations. Cardiovascular physical examination and ECG were normal with no evidence of arrhyhtmia or cardiac murmurs.

Transthoracic echocardiography revealed central mild aortic valve regurgitation in a suspected quadricuspid aortic valve (i.e., an X-shaped commissure pattern during diastole and a rectangular appearance during systole in the parasternal short-axis view). Left ventricular size and function and ascending aorta dimensions were normal. There was no associated congenital cardiovascular abnormality. 3D-Transesophageal echocardiography confirmed the evidence of a quadricuspid aortic valve. The cusps appeared to be of different size: two equal larger cusps and two equal smaller cusps (Type C, Hurwitz and Robert's classification), thin and mobile. The patient was advised to echocardiographic follow-up at intervals of 12 months.

Conclusions

We describe two cases of aortic valve congenital anomalies in two coetaneous patients with completely different impacts on hemodynamics. Severe aortic stenosis complicated unicuspid aortic valve whereas quadricuspid aortic valve was associated with mild aortic regurgitation. 3D-Transesophageal echocardiography was essential for accurate morphological characterization of the aortic valves.

759 LEFT MAIN PERCUTANEOUS OR SURGICAL REVASCULARIZATION AND SUBSEQUENT RISK OF ACUTE KIDNEY INJURY: INSIGHTS FROM THE LUCKY REGISTRY

Background

Recent evidence has rendered percutaneous coronary intervention (PCI) a valuable alternative to coronary artery bypass grafting (CABG) in patients with left main coronary artery disease (LMCAD). Nevertheless, the optimal management and patients selection is still subject to discussion

Methods

We retrospectively included 431 patients treated with PCI and 324 patients treated with CABG with the primary objective of comparing procedural failure according to revascularization strategy. Secondary endpoints were post procedural and clinically relevant myocardial infarction, in-hospital stroke, major bleeding defined according to the Bleeding Academic Research Consortium (BARC) criteria, death, and 1-year major adverse cardiac events (MACE).

Results

There was no observed difference in the rates of procedure failure in patients who received PCI compared to patients who received CABG (4.6% vs 3.7%, respectively) odds ratio [OR] 1.26; (95% confidence intervals [CI] 0.58-2.9, p= 0.52.) There was no significant difference in the defined ischemic outcome for PCI vs CABG (0.9% vs 2.4%, respectively) OR 0.37; (95% CI 0.08-1.4), P = 0.09. There was a mild increase in periprocedural myocardial infarction (MI) after PCI (4.2% vs 1.5%) compared to CABG; (OR = 2.8; 95% CI 0.99-9.8, P = 0.034). On the contrary there was a higher risk of major bleeding and transfusions in the patients who had been treated with CABG who has a clinical profile suited for PCI.

Conclusions

PCI did not significantly increase the risk for procedural failure or ischemic events compared to CABG in patients with LM CAD. The higher risk for post-procedural MI after PCI was offset by a higher risk for major bleeding events and transfusion requirements in those undergoing CABG, especially for those who were clinically suited for PCI.

Intracardiac hematoma treated conservatively by ECMO support

Clinical pathway of an intracardiac hematoma treated by ECMO support.

ESC guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 2-care pathways, treatment, and follow-up

AIMS

Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular (CV) disease in association with COVID-19.

METHODS AND RESULTS

A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, which was reported previously, focused on the epidemiology, pathophysiology, and diagnosis of CV conditions that may be manifest in patients with COVID-19. This second part addresses the topics of: care pathways and triage systems and management and treatment pathways, both of the most commonly encountered CV conditions and of COVID-19; and information that may be considered useful to help patients with CV disease (CVD) to avoid exposure to COVID-19.

CONCLUSION

This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.

Prognostic value of SARS-CoV-2 on patients undergoing cardiac surgery

Objective

To analyze Italian Cardiac Surgery experience during the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) identifying risk factors for overall mortality according to coronavirus disease 2019 (COVID‐19) status.

Methods

From February 20 to May 31, 2020, 1354 consecutive adult patients underwent cardiac surgery at 22 Italian Centers; 589 (43.5%), patients came from the red zone. Based on COVID‐19 status, 1306 (96.5%) were negative to SARS‐CoV‐2 (COVID‐N), and 48 (3.5%) were positive to SARS‐CoV‐2 (COVID‐P); among the COVID‐P 11 (22.9%) and 37 (77.1%) become positive, before and after surgery, respectively. Surgical procedures were as follows: 396 (29.2%) isolated coronary artery bypass grafting (CABG), 714 (52.7%) isolated non‐CABG procedures, 207 (15.3%) two associate procedures, and three or more procedures in 37 (2.7%). Heart failure was significantly predominant in group COVID‐N (10.4% vs. 2.5%, p = .01).

Results

Overall in‐hospital mortality was 1.6% (22 cases), being significantly higher in COVID‐P group (10 cases, 20.8% vs. 12, 0.9%, p < .001). Multivariable analysis identified COVID‐P condition as a predictor of in‐hospital mortality together with emergency status. In the COVID‐P subgroup, the multivariable analysis identified increasing age and low oxygen saturation at admission as risk factors for in‐hospital mortality.

Conclusion

As expected, SARS‐CoV‐2 infection, either before or soon after cardiac surgery significantly increases in‐hospital mortality. Moreover, among COVID‐19‐positive patients, older age and poor oxygenation upon admission seem to be associated with worse outcomes.

Management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation: a consensus document of the ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the ESC Council on Valvular Heart Disease

Transcatheter aortic valve implantation (TAVI) is effective in older patients with symptomatic severe aortic stenosis, while the indication has recently broadened to younger patients at lower risk. Although thromboembolic and bleeding complications after TAVI have decreased over time, such adverse events are still common. The recommendations of the latest 2017 ESC/EACTS Guidelines for the management of valvular heart disease on antithrombotic therapy in patients undergoing TAVI are mostly based on expert opinion. Based on recent studies and randomized controlled trials, this viewpoint document provides updated therapeutic insights in antithrombotic treatment during and after TAVI.

Targeting Alcohol Septal Ablation in Patients with Obstructive Hypertrophic Cardiomyopathy Candidates for Surgical Myectomy: Added Value of Three-Dimensional Intracoronary Myocardial Contrast Echocardiography

Background: Myocardial contrast two-dimensional echocardiography (MC-2DE) is widely used to address alcohol septal ablation (ASA) in obstructive hypertrophic cardiomyopathy (HCM). Owing to its limited cut-planes, MC-2DE may inaccurately identify the contrast misplacement associated with an unsuccessful or complicated ASA outcome. Objective: The aim of this study was to assess the added value of myocardial contrast three-dimensional echocardiography (MC-3DE) compared with MC-2DE to identify the appropriate matching between the target septal zone (TSZ) and coronary artery branch for safe and long-term effective ASA in HCM patients. Methods: A consecutive series of 52 symptomatic obstructive HCM patients referred for isolated surgical myectomy (SM) was analyzed with MC-2DE and MC-3DE following injection of echocontrast into one or more septal branches. MC-2DE and MC-3DE patterns were categorized according to complete (Type 1) or incomplete (Type 2) TSZ covering, high-risk (Type 3) exceeding TSZ, or life-threatening outside TSZ distribution (Type 4). Results: MC-2DE per patient analysis showed a Type 1 pattern in 32 patients and Types 2–4 in the remaining 20 patients; subsequent MC-3DE analysis provided a re-phenotyping of MC-2DE findings in 22 of the 52 patients (42%), showing a high-risk Type 2 pattern in 17 of the 32 patients with Type 1, and a new life-threatening Type 4 in three patients with Type 2, respectively. All patients with MC-3DE Type 1 pattern underwent safe and effective ASA with a long-term uneventful follow-up, while the remaining patients underwent SM. Conclusions: Refining high risk or life-threatening contrast misplacement, MC-3DE is more accurate than conventional MC-2DE to target safe and long-term effective septal reduction with ASA in obstructive HCM patients referred for isolated SM.

Impella 5.0 support before, during, and after surgical ventriculoplasty following acute myocardial infarction in the COVID-19 era: a case report

Background

Left ventricular (LV) aneurysms complicate anterior myocardial infarctions (MIs) in 8–15% of cases. In case of associated LV dysfunction, rapidly evolving heart failure may follow, and urgent surgery becomes life-saving.

Case summary

Following an acute anterior MI treated by percutaneous coronary intervention, which resulted in apical hypokinesis, depressed LV function, and moderate mitral regurgitation, a 70-year-old male patient kept in contact with our cardiology department through phone calls. Over 6 weeks, the patient's conditions worsened. For fear of contracting COVID-19, he refused to attend to the Emergency Room. Conditions did not improve despite medical therapy adjustments, and he was admitted to hospital following a syncope. Computed tomography scan revealed pneumonia, and he was placed in a ‘grey’ ward while waiting for nose-swab results for COVID-19. A rapid escalation of treatment was necessary as conditions did not improve with low-dose inotropes, and he required invasive ventilation. An Impella 5.0 was implanted as support prior to surgery, was maintained during the procedure and as a means of weaning off extracorporeal circulation. Surgery was successful and Impella 5.0 was removed on postoperative Day 5.

Discussion

To date, Impella use in cardiothoracic surgery has been described in case of ventricular septal rupture or as a bridge to permanent LV assist device. In our case, Impella 5.0 was implanted, used as a bridge to surgery, and as postoperative support in a patient with evolving cardiogenic shock due to LV aneurysm and depressed LV ejection fraction following acute MI, in the difficult setting of the COVID-19 pandemic.

Single-center experience with partial support device in destination therapy for end-stage heart failure

Ventricular assist devices (VADs) are considered the standard of care for end-stage heart failure (HF) patients. Despite increasing confidence in the technology, evidence data, endorsement by scientific societies and guidelines, the number of implants reached a steady state and is not increasing at the expected pace. This is most likely related to complications that are still burdening the technology and consequently excluding the most needy, ill, and fragile population. In this manuscript we are reporting a single-center experience in a very fragile, elderly and end-stage HF population, with a superficial, partial support device: the CircuLite Synergy. The patients were included in the pre-CE mark clinical study and consequently the device underwent technical adjustment during the support, based on the complications recorded. At our institution were implanted 6 patients overall: 3 patients survived to discharge and 2 survived up to 5 years. Most of the complications recorded were due to patients' frailty and overall clinical conditions. The initial experience with the CircuLite Synergy device is proving that a more "superficial" device might be more tolerable in an elderly, frail population. Partial support has proven hemodynamically efficacious and efficient in relieving heart failure symptoms, improving medical therapy tolerability, and improving quality of life. Unfortunately, the technology was not made available due to financial uncertainty and poor management, but we hope that once the concept has been proved someone will collect the legacy.

Single-Cell Sequencing of Mouse Heart Immune Infiltrate in Pressure Overload-Driven Heart Failure Reveals Extent of Immune Activation

BACKGROUND

Inflammation is a key component of cardiac disease, with macrophages and T lymphocytes mediating essential roles in the progression to heart failure. Nonetheless, little insight exists on other immune subsets involved in the cardiotoxic response.

METHODS

Here, we used single-cell RNA sequencing to map the cardiac immune composition in the standard murine nonischemic, pressure-overload heart failure model. By focusing our analysis on CD45⁺ cells, we obtained a higher resolution identification of the immune cell subsets in the heart, at early and late stages of disease and in controls. We then integrated our findings using multiparameter flow cytometry, immunohistochemistry, and tissue clarification immunofluorescence in mouse and human.

RESULTS

We found that most major immune cell subpopulations, including macrophages, B cells, T cells and regulatory T cells, dendritic cells, Natural Killer cells, neutrophils, and mast cells are present in both healthy and diseased hearts. Most cell subsets are found within the myocardium, whereas mast cells are found also in the epicardium. Upon induction of pressure overload, immune activation occurs across the entire range of immune cell types. Activation led to upregulation of key subset-specific molecules, such as oncostatin M in proinflammatory macrophages and PD-1 in regulatory T cells, that may help explain clinical findings such as the refractivity of patients with heart failure to anti-tumor necrosis factor therapy and cardiac toxicity during anti-PD-1 cancer immunotherapy, respectively.

CONCLUSIONS

Despite the absence of infectious agents or an autoimmune trigger, induction of disease leads to immune activation that involves far more cell types than previously thought, including neutrophils, B cells, Natural Killer cells, and mast cells. This opens up the field of cardioimmunology to further investigation by using toolkits that have already been developed to study the aforementioned immune subsets. The subset-specific molecules that mediate their activation may thus become useful targets for the diagnostics or therapy of heart failure.

Mitral Valve Stenosis after Transcatheter Aortic Valve Replacement: Case Report and Review of the Literature

Mitral stenosis is a rare and potentially severe complication of transcatheter aortic valve replacement (TAVR). Given the anatomic coupling and interdependence of the aortic and mitral valves, it comes by itself that procedures (either surgical or percutaneous) involving the aortic valve imply the risk of altering mitral valve function. Indeed, transcatheter aortic prostheses may impair adequate anterior mitral leaflet (AML) opening, especially when implanted in a "low" position, thus resulting in high transvalvular gradients. Hereby, we report the case of a 71-year-old male with symptomatic severe aortic stenosis and a history of previous surgical mitral valve repair who underwent TAVR with a self-expandable prosthesis. Notwithstanding an acceptable angiographic position, the prosthetic frame was shown to interfere with the AML, as evidenced by augmented transmitral gradients; nonetheless, pulmonary artery pressures remained unchanged, and the patient experienced symptomatic improvement. Therefore, a conservative approach was chosen and the patient was discharged home after medical therapy optimization. Moreover, we provide a review of the available literature regarding the incidence, predictors and possible management of this infrequent complication.

[Coronary artery disease: when to withhold a decision and call in the Heart Team? Almost every time]

The multidisciplinary discussion is a well-established method, highly widespread in different medical disciplines, with documented optimal results. This practice, despite mandate by international guidelines, is not universally applied to guide treatment in coronary artery disease (CAD) patients. The literature provides data both on overtreatment or undertreatment in different patient subsets, clearly suggesting its strong need. Randomized trials, meta-analyses and registries provide evidence-based treatment options for different patient subsets suffering from different conditions, although results are applicable only to highly selected populations enrolled in clinical trials, making generalizability of results to routine practice limited. CAD patients are usually elderly and with a comorbidity burden that does not allow for the simple application of clinical trial results to obtain the best clinical practice. Thus, multidisciplinary discussion within the Heart Team, through different professional expertise sharing, allows to select the best treatment option for the individual patient.

Prosthetic valve endocarditis: predictors of early outcome of surgical therapy. A multicentric study

OBJECTIVES

Prosthetic valve endocarditis (PVE) is an uncommon yet dreadful complication in patients with prosthetic valves that requires a distinct analysis from native valve endocarditis. The present study aims to investigate independent risk factors for early surgical outcomes in patients with PVE.

METHODS

A retrospective cohort study was conducted in 8 Italian Cardiac Surgery Units from January 2000 to December 2013 by enrolling all PVE patients undergoing surgical treatment.

RESULTS

A total of 209 consecutive patients were included in the study. During the study period, the global rate of surgical procedures for PVE among all operations for isolated or associated valvular disease was 0.45%. Despite its rarity this percentage increased significantly during the second time frame (2007-2013) in comparison with the previous one (2000-2006): 0.58% vs 0.31% (P < 0.001). Intraoperative and in-hospital mortality rates were 4.3% and 21.5%, respectively. Logistic regression analysis identified the following factors associated with in-hospital mortality: female gender [odds ratio (OR) = 4.62; P < 0.001], shock status (OR = 3.29; P = 0.02), previous surgical procedures within 3 months from the treatment (OR = 3.57; P = 0.009), multivalvular involvement (OR = 8.04; P = 0.003), abscess (OR = 2.48; P = 0.03) and urgent surgery (OR = 6.63; P < 0.001).

CONCLUSIONS

Despite its rarity, PVE showed a significant increase over time. Up to now, in-hospital mortality after surgical treatment still remains high (>20%). Critical clinical presentation and extension of anatomical lesions are strong preoperative predictors for poor early outcome.

Cardiac Paraganglioma Arising From the Right Atrioventricular Groove in a Paraganglioma-Pheochromocytoma Family Syndrome With Evidence of SDHB Gene Mutation: An Unusual Presentation

Primary cardiac paragangliomas are extremely rare. Recently this neoplasm has been associated with a familiar syndrome as a result of mutation of genes that encode proteins in the mitochondrial complex II. We report a case of a 46-year-old woman having cases of vertebral paraganglioma in her family showing an unusual anatomic and clinical presentation of cardiac paraganglioma and expressing a genetic mutation never associated before with cardiac localization of this neoplasm.

Anticoagulation management in patients undergoing open heart surgery by activated clotting time and whole blood heparin concentration

Objective: To investigate the changes in perioperative anticoagulation management using a heparin-concentration-based system (HMS), and its effect on postoperative outcome. Methods: A total of 39 patients undergoing elective primary open heart surgery were randomly assigned to a heparin-concentration-based system approach (study group: 17 patients) or a standard ACT-based anticoagulation system (control group: 22 patients). Measurements and main results: Patients in the study group received a statistically significant higher dose of heparin (median 29 000 IU with IQR 22 500 33 500 IU versus median 19 000 IU with IQR 17 775 21 500 IU; p <0.001) and a smaller dose of protamine (median 170 mg with IQR 145 190 mg versus median 200 mg with IQR 180-250 mg; p=0.008) compared to the control group. Postoperative platelet count was significantly higher in the study group (164± 45×109/L versus 125±27 × 109/L, p=0.002). None of the study patients, but six patients in the control group required transfusion of blood products (p=0.02). No differences were recorded in postoperative antithrombin activity, bleeding, and other clinical outcomes. Conclusion: he HMS system, by facilitating maintenance of a stable heparin concentration, and by determining an appropriate dose of protamine, is associated with reduced platelet consumption and does not increase AT-III consumption and postoperative bleeding.

Prevention of atrial fibrillation and inflammatory response after on-pump coronary artery bypass using different statin dosages: a randomized, controlled trial

BACKGROUND

This randomized controlled trial aimed to evaluate the effects of seven-day preoperative treatment with two different dosages of atorvastatin on the incidence of postoperative atrial fibrillation (POAF) and release of inflammatory markers such as high-sensitive C-reactive protein (hsCRP) and interleukin-6 in patients undergoing elective first-time on-pump coronary artery bypass grafting (CABG).

METHODS

The cohort study comprised 212 consecutive patients, already taking statins, who underwent elective first-time CABG with cardiopulmonary bypass without history of atrial fibrillation (AF). Patients were randomly divided into two groups: those who received atorvastatin 40 mg (TOR40 group, 111 patients) and those who received 80 mg (TOR80 group, 101 patients) once a day for 7 days before the planned operation. The primary endpoint was the incidence of AF. The secondary endpoints were the postoperative variations of inflammatory markers, hospital length of stay, and the incidence of major adverse cardiac and clinical events.

RESULTS

A total of 26 patients (23.6 %) pretreated with atorvastatin 40 mg and 16 (15.8 %) patients pretreated with atorvastatin 80 mg had postoperative AF but the difference did not reach the statistical significance (p = 0.157). Median values of interleukin-6 and hsCRP at 12 and 24 h did not have differences between the two groups. No statistically significant differences in the other secondary endpoints were detected.

CONCLUSIONS

According to our result, 7-day preoperative treatment with a high dose of atorvastatin is associated with a trend to a decrease in the incidence of POAF compared with treatment at a lower dose, although it does not impact on the level of inflammatory markers.

CLINICAL TRIAL REGISTRATION

European Clinical Trials Database (EudraCT: 2006-005757-30).

'Early' and 'late' timing for renal replacement therapy in acute kidney injury after cardiac surgery: a prospective, interventional, controlled, single-centre trial

OBJECTIVES

Acute kidney injury after cardiac surgery (CS-AKI) is strongly associated with in-hospital mortality and morbidity. We aimed to investigate whether 'early' or 'late' initiation of renal replacement therapy (RRT) in patients with CS-AKI is associated with a survival benefit or more favourable outcomes.

METHODS

All patients who had undergone cardiac surgery at 'Ospedali Riuniti' of Ancona from July 2011 to February 2013 were prospectively enrolled and divided into two treatment groups: the 'early' approach was used during the first 10 months, and the 'late' approach during the next 10 months. 'Early' RRT was started after 6 h of urine output less than 0.5 ml/kg/h, whereas in the 'late' group, therapy started on the basis of persistent (>12 h) oliguria. A total of 1658 patients were enrolled in the trial. The primary outcome was operative mortality, and the secondary outcomes were length of intensive care unit and hospital stay.

RESULTS

The total number of patients treated with RRT was 59 (3.6%): 46 (5.5%) in the 'early' group and 13 (1.6%) in the 'late' group (P < 0.0001). Although RRT was significantly less utilized in the 'late' group, no significant difference in the primary and secondary outcomes was found, but a trend towards a better outcome in the 'late' group was observed. Furthermore, we found a significant difference in mortality between the two approaches in the subgroups of patients with preoperative renal dysfunction and in patients suffering from CS-AKI with a clear advantage of the late strategy.

CONCLUSIONS

Our results do not support the use of early RRT in CS-AKI.

CLINICAL TRIAL REGISTRATION

This trial is registered in the clinicaltrial.gov registry: NCT01961999.

Saphenous Vein Graft Wrapping by Nitinol Mesh: A Word of Caution

BACKGROUND

Saphenous vein conduits are still used in a large proportion of coronary artery bypass graft (CABG) operations. A recently commercialized nitinol mesh seems to improve venous graft patency. The aim of this study was to control nitinol mesh vein graft patency in a series of isolated CABG patients by computed tomographic (CT) scan.

METHODS

In 25 patients (mean age: 61.0 ± 9.65 years), operated for isolated CABG, the eSVS nitinol mesh (Kips Bay Medical Inc., Minneapolis, Minnesota, United States) was used to wrap one vein graft in each patient. Nitinol mesh vein graft was used to revascularize the right coronary (4 patients; 16%), the posterior descending (18 patients; 72%), and the obtuse marginal (3 patients; 12%) arteries. CT scans were performed at 1, 6, and 12 months postoperatively.

RESULTS

The procedure was uneventful in all patients. CT controls showed an overall patency rate of 86.9, 42.7, and 34.1% at 1, 6, and 12 months, respectively. The 4 mm mesh had a significantly higher patency rate at 12 months (83.33%) than the 3.5 mm one which showed quite unsatisfactory results (20%) (p = 0.02). Patients with graft occlusion underwent stress testing which was mildly positive in two cases. One of them underwent a percutaneous revascularization.

CONCLUSION

Despite promising early results, use of nitinol mesh for saphenous veins was disappointing in our experience. Further refinements are probably needed.

Conventional surgery results in patients originally referred for transcatheter aortic valve implantation

AIMS

Transcatheter aortic valve implantation (TAVI) is increasingly considered as a viable alternative to conventional aortic valve replacement (AVR) in high-risk patients. Long-term results, however, are still scarce and medical community hesitates in enlarging indications to lower-risk patients. Moreover, available devices are expensive and a strict potential candidate selection is necessary.

METHODS

From April 2008 to August 2012, a total of 212 patients, originally referred for percutaneous treatment, were thoroughly evaluated by the aortic team of our department in order to choose the optimal procedure. Of them, 55 patients (35 women; 20 men) were considered as still acceptable candidates for conventional AVR.

RESULTS

Mean age was 80.7 ± 4.7 years; mean additive and logistic Euroscore I were 9.7 ± 1.8 and 17.8 ± 9.5%, respectively. Mean Euroscore II was 7.9 ± 5.5%. Mean New York Heart Association class was 2.9 ± 0.5. The majority of patients (87.2%) presented a geriatric frailty score of 0-1. Four patients showed a heavily calcified ascending aorta, and five patients (9%) underwent reoperations. Hospital mortality was 10.9% (six patients). Mean follow-up was 535.9 ± 407.4 days (range: 6-1365 days). Six other patients died during this period for a mean survival of 74.4 ± 6.9% at 2 years. Mean New York Heart Association class at 1 year was 1.25 ± 0.5 (P < 0.01 vs. preoperative value).

CONCLUSION

AVR should be indicated with caution in high-risk patients originally referred for TAVI. Despite medium-term results being good, with excellent functional status, hospital mortality is not negligible.

Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis

OBJECTIVE

To investigate whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease.

DESIGN

Bayesian network meta-analyses to combine direct within trial comparisons between treatments with indirect evidence from other trials while maintaining randomisation.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

A strategy of initial medical treatment compared with revascularisation by coronary artery bypass grafting or Food and Drug Administration approved techniques for percutaneous revascularization: balloon angioplasty, bare metal stent, early generation paclitaxel eluting stent, sirolimus eluting stent, and zotarolimus eluting (Endeavor) stent, and new generation everolimus eluting stent, and zotarolimus eluting (Resolute) stent among patients with stable coronary artery disease.

DATA SOURCES

Medline and Embase from 1980 to 2013 for randomised trials comparing medical treatment with revascularisation.

MAIN OUTCOME MEASURE

All cause mortality.

RESULTS

100 trials in 93,553 patients with 262,090 patient years of follow-up were included. Coronary artery bypass grafting was associated with a survival benefit (rate ratio 0.80, 95% credibility interval 0.70 to 0.91) compared with medical treatment. New generation drug eluting stents (everolimus: 0.75, 0.59 to 0.96; zotarolimus (Resolute): 0.65, 0.42 to 1.00) but not balloon angioplasty (0.85, 0.68 to 1.04), bare metal stents (0.92, 0.79 to 1.05), or early generation drug eluting stents (paclitaxel: 0.92, 0.75 to 1.12; sirolimus: 0.91, 0.75 to 1.10; zotarolimus (Endeavor): 0.88, 0.69 to 1.10) were associated with improved survival compared with medical treatment. Coronary artery bypass grafting reduced the risk of myocardial infarction compared with medical treatment (0.79, 0.63 to 0.99), and everolimus eluting stents showed a trend towards a reduced risk of myocardial infarction (0.75, 0.55 to 1.01). The risk of subsequent revascularisation was noticeably reduced by coronary artery bypass grafting (0.16, 0.13 to 0.20) followed by new generation drug eluting stents (zotarolimus (Resolute): 0.26, 0.17 to 0.40; everolimus: 0.27, 0.21 to 0.35), early generation drug eluting stents (zotarolimus (Endeavor): 0.37, 0.28 to 0.50; sirolimus: 0.29, 0.24 to 0.36; paclitaxel: 0.44, 0.35 to 0.54), and bare metal stents (0.69, 0.59 to 0.81) compared with medical treatment.

CONCLUSION

Among patients with stable coronary artery disease, coronary artery bypass grafting reduces the risk of death, myocardial infarction, and subsequent revascularisation compared with medical treatment. All stent based coronary revascularisation technologies reduce the need for revascularisation to a variable degree. Our results provide evidence for improved survival with new generation drug eluting stents but no other percutaneous revascularisation technology compared with medical treatment.

Pulmonary pseudoaneurysm: uncommon complication after total aortic arch operation

Pulmonary pseudoaneurysms are an uncommon but life-threatening condition of congenital or acquired cause, most commonly involving the branch pulmonary arteries and generally requiring emergent intervention. We describe a case of postoperative main pulmonary artery pseudoaneurysm after a complex aortic arch procedure, in which thoracic computed tomography provided full information for its definition before surgical correction.

Absorption of carbon dioxide during endoscopic vein harvest

OBJECTIVES

Carbon dioxide (CO(2)) insufflation was used by some devices for endoscopic vein harvest to create a subcutaneous tunnel and facilitate the vein harvest. In the literature, some cases of CO(2) micro- and macro-embolisms or hypercarbia during this procedure are described. The purpose of this study was to evaluate if the use of an open CO(2) system rather than a sealed system might be associated with different CO(2) absorption during the procedure.

METHODS

Patients were randomized into two groups: those patients in the first group were submitted to endoscopic vein harvest using a sealed CO(2) insufflation; in the second group, the harvest was undertaken with an open CO(2) insufflation. Partial pressure of CO(2) in the arterial blood (PaCO(2)) and end-tidal CO(2) (ETCO(2)) was recorded following anaesthesia induction and before the endoscopic procedure (T0), every 10 min during the endoscopic step (T1) and end after 10 min from the CO(2) insufflation termination (T2).

RESULTS

A total of 60 patients were enrolled. PaCO(2) increased significantly between T0, T1 and T2 in both groups (P = 0.0001) during the endoscopic harvest, but the PaCO(2) level was significantly higher in the group that used the sealed system (44.5 ± 7.9 vs 39.7 ± 7.9 mmHg) at the end of the procedure (P = 0.01). No significant differences between end-tidal CO(2) measured at the same intervals between groups were detected.

CONCLUSIONS

There was a constant increase in the blood gas concentration compared with the basal pre-procedure values. Sealed systems were associated with a significantly higher CO(2) concentration at the end of the procedure compared with the open ones.