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Objective The study objective was to evaluate the short- and long-term outcomes of patients with ischemic cardiomyopathy after surgical ventricular restoration and to identify risk factors related to poor results. Methods Between August 2002 and April 2016, 62 patients affected by ischemic cardiomyopathy underwent surgical left ventricular restoration at our unit. Patients' mean age at operation was 63 years (39-79 years). Mean ejection fraction was 29.6%. The Surgical Treatment for Ischemic Heart Failure trial criteria have been used as indications for surgery. Fifty-seven patients (91%) received surgical myocardial revascularization. Mitral valve repair was performed in 39 patients (63%). The surgical technique consisted of the classic Dor operation or a different approach reducing the equatorial diameter of the left ventricle and avoiding the use of a patch. The data were analyzed retrospectively for perioperative results and short- and long-term clinical outcomes. Results One patient died of noncardiac causes within 30 days (1.6%). All-cause death occurred in 36 patients (58%) during follow-up (0.6-14.7 years; median follow-up time, 7.02 years), of whom 15 died of cardiac causes. Age, need for preoperative intra-aortic balloon pump, reduction less than 35% of postoperative left ventricular end-diastolic and end-systolic volumes, type of surgical technique, and ejection fraction less than 25% were identified as risk factors for late cardiac mortality. Perioperative levosimendan administration and presence of preoperative moderate to severe mitral regurgitation influenced early and intermediate-term outcomes, but no statistical relevance on long-term results was demonstrated. Conclusions Patients with ischemic dilative cardiomyopathy have favorable short- and long-term outcomes after ventricular restoration. Age, preoperative ejection fraction less than 25%, inadequate left ventricular surgical reverse remodeling, and type of surgical technique negatively affect long-term survival.

To compare the early and midterm clinical outcomes of patients undergoing two different surgical procedures (stentless biological Bentall [SBB] vs. valve-sparing David Reimplantation [VSDR]) for aortic root dilatation, with or without concomitant aortic valve pathology.A population of 106 patients underwent aortic root replacement from 2004 to 2015 at our unit. Mean age at operation was 63.1 ± 10 years. The patients were retrospectively assigned to 2 groups according to surgical procedure. David operation was carried out in 52 patients (group A-VSDR) and stentless biological Bentall in 54 patients (group B-SBB). Preoperative characteristics were similar in the 2 cohorts, except for age and EuroSCORE. Mean follow-up time was 7.09 years (0.26-14.50 years), and 96% complete. Patients were evaluated and analyzed for intra-operative results and long-term clinical outcomes.Intraoperative mortality was 0% in both groups. Overall survival probability at 11 years was 91.8% in group A and 73.8% in group B (p = .004). Cardiac mortality at 11 years was similar in the 2 groups (p = .116). Freedom from structural valve deterioration at 11 years was 88.8% (VSDR) and 90.6% (SBB) [p = .689]. Freedom from reoperation at 11 years did not differ between the groups (83.6% VSDR vs. 98.5% SBB, p = .574). Freedom from major adverse cardiac and cerebrovascular events at 11 years was 76.7% (VSDR) versus 80.1% (SBB) (p = .542). Mean gradient at last follow-up was lower in VSDR group (8.13 vs. 11.70 mmHg, p .001).David reimplantation and stentless biological Bentall procedures achieve excellent and comparable results at midterm follow-up. David operations provide superior hemodynamic performance preserved over time and may be preferred in younger, active patients.

Patients affected by severe aortic root pathology require an operation to replace the dilated aortic root and repair or replace the aortic valve, which is very frequently involved in the disease. Among the surgical options available for aortic root replacement, the Bentall operation and the David aortic valve reimplantation procedure are the most commonly used by surgeons. This article provides an overview of the Bio-Bentall and David operations. It illustrates their surgical details and discusses the correct indications for both procedures to achieve excellent long-term outcomes. Finally, the authors present their experience with the physiologic treatment of aortic root pathology by using stentless Bio-conduits and David reimplantation in a cohort of patients with long-term follow-up. A comparative analysis of early and late results along with an evaluation of possible benefits and drawbacks related to each technique concluded that both procedures were effective in correcting the aortic root pathology, and the results were adequate and stable over time. Since hemodynamic performance was more improved after the David operation, it should be preferred, whenever feasible, in younger and active patients.

Background This study evaluated the early and intermediate-term clinical and hemodynamic results after implant of the Medtronic 3F (Minneapolis, MN) stentless aortic valve. Methods Between March 2007 and August 2015, 226 consecutive patients affected by aortic valve disease received a 3F valve at our unit by a single surgeon. The valve in 30 patients was included in a tubular prosthesis for a Bentall procedure. Size ranged between 21 and 29, age at operation was 74.17 ± 8.58 years, mean logistic European System for Cardiac Operative Risk Evaluation was 9.73 ± 6.00, and 51.3% of patients received a concomitant procedure. For isolated valve replacement, mean extracorporeal circulation time was 92 ± 17 minutes, and cross-clamp time was 73 ± 11 minutes. Follow-up was 100% complete and was a mean of 63 ± 2.4 months (range, 6-138 months). Primary end points were early and late mortality, freedom from endocarditis, freedom from structural valve deterioration, and freedom from valve-related reoperation. Results Early mortality after isolated aortic valve replacement was 1.7%. Of the 59 (25.3%) late overall deaths, 15 (6.6%) were cardiac-related, and survival rate was 93% at 10 years. At follow-up, 97% of patients were in New York Heart Association class I or II. Actuarial freedom from reoperation due to structural deterioration was 100% at 5 years and 96% at 10 years. Freedom from endocarditis at 10 years was 97%. Mean aortic pressure gradient measured by echocardiography was 11.5 mm Hg at hospital discharge and 10.4 mm Hg at the last follow-up. Conclusions The 3F valve is a user-friendly third-generation stentless aortic prosthesis with proven durability and remarkable hemodynamic performance preserved over time. The 3F is particularly useful in cases of expected patient/prosthesis mismatch

This report discusses the case of a patient with an aortic root aneurysm who had previously undergone aortic valve replacement with a large mechanical prosthesis that proved to be normally functioning at the time of reoperation. This report describes a technique of replacing the aortic root while retaining the existing aortic valve, similar to the completion Bentall procedure, using a 32-mm Valsalva graft by suturing the skirted portion of the graft to the sewing ring of the mechanical valve. The ability of the skirt to increase its diameter is the key to this approach.

BACKGROUND The present study reports perioperative changes in PCT levels occuring in cardiac patients with acute mesenteric ischemia (AMI) undergoing laparotomy. The aim of this study was to demonstrate that PCT kinetics may confirm the presence of AMI after cardiac surgery, distinguishing between bowel infarction and diffuse ischemia. METHODS PCT values from adult patients undergoing laparotomy for AMI after elective or urgent cardiac surgery (January 2010 - December 2019) were determinated at the ICU admission after cardiac surgery, 24 hours later and at the onset of clinical symptoms. Patients affected by diffuse intestinal ischemia with no need for bowel resection were allocated to Group A (n.8), patients presented with intestinal necrosis requiring small or large bowel resection were allocated to Group B (n.12). RESULTS At the beginning of the abdominal symptoms, PCT levels increased in both group, compared to those immediately after cardiac surgery. The PCT increasing resulted much more evident in patients presenting with intestinal necrosis - Group B (20.65 ng/ml [IQR8.47-34.5] vs. 4.31 ng/ml [IQR 8.47-34.5], p

Reoperations for deteriorated stentless bioprostheses are quite challenging procedures. Calcification of the aortic annulus and of the subcoronary root makes often impossible the removal of the failed valve, living a complex Bentall operation or a high-risk transcatheter aortic valve implantation valve-in-valve procedure as the only options, particularly in cases of small-size prostheses. The Perceval sutureless prosthesis (LivaNova PLC, London, UK) can be a valid alternative for failed stentless valve replacement. We report our experience with 3 complex cases of degenerated Sorin Pericarbon Freedom prosthesis treated successfully by means of Perceval sutureless implantation and demonstrating the reproducibility and the safety of this surgical approach.

Background: The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery. Methods: This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC

OBJECTIVES The shape of the aortic annulus is still under debate. Recent findings suggest a possible gradual spectrum of circularity from tricuspid aortic valves (TAVs), to type 1 bicuspid aortic valves (BAVs) to type 0 BAVs. BAVs have been recently classified in a symmetrical (type A), asymmetrical (type B) or very asymmetrical (type C) phenotype according to the commissural orientation (CO) (160°–180°, 140°–159° and 120°–139°, respectively). The aim of this study is to verify in BAVs the correlation between the aortic annular shape and the CO of valve cusps and to suggest a new anatomical and geometric classification of BAVs based on CO and annular shape. METHODS We retrospectively selected 191 consecutive patients who underwent both electrocardiography-gated computed tomography scan of the aortic root and transthoracic echocardiography between January 2016 and June 2019. The population was divided into 2 groups: 54 BAVs and 137 TAVs. We analysed the subgroup of BAV patients and divided them into group A, group B and group C depending on the CO. The shape of the aortic annulus was considered ‘circular’ or ‘elliptic’ according to the ellipticity index (EI).We studied the possible correlation between CO and annular shape in BAVs. We also analysed the subgroup of TAV patients studying their annular shape and EI. RESULTS After univariate linear regression, BAV patients showed a significant correlation between the CO and the EI (R = −0, 445, R2 = 0, 198, P = 0.001). As the CO decreases, the EI increases and approaches an elliptical shape. After grouping BAVs according to the CO, a mean EI of 1.10 ± 0.07 was found in group A, 1.13 ± 0.08 in group B, 1.18 ± 0.07 in group C, P = 0.0097 indicating a gradual spectrum of ellipticity with the decrease of CO. TAVs subgroup showed a mean EI of 1.27 ± 0.09, suggesting that the more the CO is reduced in BAVs, the more the annulus probably tends towards the very elliptical shape of TAVs. CONCLUSIONS This study shows a linear correlation between CO and annular shape in BAVs. In particular, the aortic annulus follows a continuous spectrum of ellipticity depending on the CO. These findings lay the groundwork for a new anatomical classification of BAVs based on CO and annular shape.

We present the case of a 73-year-old male patient undergoing a modified Bentall-DeBono procedure in 2015 due to aortic stenosis and aortic aneurism involving the root. A bioprosthetic stented conduit made with a stented Edwards Perimount 21-mm bioprosthesis and a Vascutek Valsalva 28-mm Dacron graft was implanted along with a mitral annuloplasty. Five years later, due to early degeneration of the bioprosthesis and a progression of the mitral disease, he underwent a second surgical procedure where a Medtronic Mosaic 27-mm valve prosthesis was implanted in mitral position and a sutureless Livanova Perceval 23-mm valve in aortic position. Because of the difficulty in removing the previously implanted aortic prosthesis, the Perceval valve was inserted inside the frame of the PeriMount as an open "valve-in-valve" procedure. In October 2020, the patient underwent a ViV TAVI with a 23-mm Edwards Sapien 3 (Edwards Lifescience). After induction of general anesthesia and heparin administration, the procedure was performed via right femoral artery approach with preimplantation of two Proglides. After transfemoral insertion of a 14-French sheath, the aortic valve was crossed with a 0.035-in. straight guide-wire, taking care to avoid crossing the crowns of Perceval frame. After exchange of the standard wire with an extra-stiff 0.035-in. Safari wire, the Sapien-3 valve was advanced across the two previously implanted surgical valves and deployed at the level of the Perceval ring. After bioprosthesis deployment, peak-to-peak left ventricular aortic gradient was reduced from 51 to 16 mmHg.

OBJECTIVES: Aortic valve-sparing operations have been shown to produce fewer valve-related complications than valve replacement. The aortic root is a morphological and functional unit in which the annulus plays an important role on dynamism, shape and geometry of the valve with different results in bicuspid aortic valves (BAVs) or tricuspid aortic valves (TAVs). The aim is to evaluate the differences in the size and shape of the aortic annulus between native BAVs and TAVs using ECG-gated computed tomography (CT) after a reimplantation procedure. METHODS: We selected 35 patients scheduled for aortic valve reimplantation who underwent good-quality preoperative and postoperative ECG-gated contrast-enhanced CT scan of the aortic root. Twenty-three patients had TAV, 8 patients type 1 BAV and 4 patients type 0 BAV. Major diameter and minor diameter, perimeter (P) and area (A) were measured. The shape of the aortic annulus was considered ‘circular’ or ‘elliptic’ according to the Ellipticity Index. We also selected a subgroup of 18 patients (9 TAVs and 9 BAVs) to evaluate annular shape and size variations through the cardiac cycle and to study the expansibility both in the preoperative and in the postoperative phases. RESULTS: Preoperative CT scans showed an elliptic shape of TAVs (Ellipticity Index 1.3 ± 0.1), a circular shape of type 0 BAVs (1.1 ± 0.1) and an intermediate behaviour of type 1 BAVs, suggesting a possible gradual spectrum of circularity from TAVs to type 1 BAVs to type 0 BAVs. Postoperative CT scans did not show any significant difference in annular shape among the 3 groups, which demonstated a similar roundness, obviating the preoperative differences. Analysing the expansibility of the aortic annulus during the cardiac cycle, we observed that it was completely absent in the preoperative phase in BAVs, while in the postoperative phase, both TAVs and BAVs showed a small but similar expansibility after the annular reduction. CONCLUSIONS: There is a possible gradual spectrum in terms of shape, from native TAVs, to type 1 BAVS to type 0 BAVs. These differences are eliminated in the postoperative phase, suggesting an active role of the annuloplasty on the geometry of the aortic annulus. The preoperative analysis showed a complete inelasticity of BAVs, which was partly restored in the postoperative phase.

This study applied advanced 4-dimensional flow magnetic resonance imaging processing to assess differences in aortic flow dynamics after valve sparing root replacement, with and without reconstruction of the Valsalva sinuses.We enrolled patients after valve sparing root replacement with a straight tubular prosthesis (n = 10) or with a prosthesis with Valsalva neosinuses (n = 10); age-matched subjects without cardiovascular diseases served as controls (n = 10). 4-Dimensional flow magnetic resonance imaging acquisitions were performed on a 3.0T magnetic resonance imaging unit. In-house processing was used to segment the aortic lumen and extract the volumetric 4-dimensional flow velocity field. Velocity flow streamlines were computed to compare the amount of rotational flow and wall shear stress. Occurrence of abnormal wall shear stress (WSS) was estimated within the descending aorta of each surgical group.Physiologic-like sinus vortices were visible in the aortic root when using the prosthesis with neosinuses, whereas straight tubular graft revealed localized intrados malrotations (P = .003 for organized vortical structures vs neosinuses graft and P .001 vs control). In the ascending aorta, recreation of the sinuses resulted in significantly lower velocity and WSS than in the straight tubular graft (P .001) and controls (P .001), these alterations were attenuated in the mid-descending aorta. Incidence of abnormal WSS was markedly higher in the straight tube grafts than neosinus of Valsalva grafts.Re-creation of the sinuses of Valsalva during valve-sparing root replacement is associated with more physiologic flow and significantly lower WSS in the aortic root. Lower WSSs in the distal thoracic aorta is a novel finding with potential implications on distal aortic remodeling.

Background: Extracorporeal treatment may be useful during sepsis, but definitive recommendations are lacking. Aim of this study is to review retrospectively the medical records of septic patients submitted to continuous renal replacement therapy (CRRT) with the adsorbing membrane oXiris and evaluate (1) the safety of the device, (2) the cardiorenal response, and (3) the immunological response. Materials and Methods: The medical records of 60 septic patients submitted to CRRT with the membrane oXiris from April 2011 to December 2018 have been reviewed. The adsorbing membrane oXiris® (Baxter, IL, USA) was used through a Prisma plataform (Prismaflex – Baxter, IL, USA). At basal time (T0), at 24 h (T1), and at the end of the treatment (T2) were analyzed the clinical data, the cytokines, and the time course of endotoxin. Results: Sixty patients were included in the study. In total, 85% of patients had acute kidney injury (AKI). Every CRRT treatment was of 72 ± 13 h, with the consumption of 3.2 ± 1 filters. No AE events were reported. The main cardiorenal and respiratory parameters improved with a decrease of the noradrenaline dosage. Cytokines, procalcitonin, and endotoxin activity assay decreased too. SOFA total improved from 12.4 ± 2 to 9 ± 2. Conclusion: In sepsis/septic shock patients with AKI, CRRT with the adsorbing membrane oXiris may be safe and improves the cardiorenal – function and the clinical condition. The effect on cytokines and endotoxin may explain in part these results. A RCT is warranted to confirm these data.

Background: Low preoperative haemoglobin is frequently observed in heart surgery patients and is associated with a significant decrease in haemoglobin between post-operative days 2 and 3, known as haemoglobin drift. Overall, these patients tend to receive many RBC transfusions. Since iron homeostasis is often impaired in these patients, restoration of iron availability might override iron-restricted erythropoiesis. However, reduced tolerance to oral iron salts has limited this strategy to intravenous iron administration. Study Design and Methods: The purpose of this study was to assess whether preoperative supplementation with oral sucrosomial iron, a new iron-delivery technology with improved tolerance and bioavailability, might be an effective strategy for this patient population. One thousand consecutive patients were randomized and received either a one-month course of sucrosomial iron (60 mg/day) or no treatment prior to elective heart surgery at a single high-volume centre (ClinicalTrials.gov NCT03560687). Primary end-points were haemoglobin concentration on the day of hospital admittance and number of blood transfusions. Secondary end-points were haemoglobin drift, tolerance of treatment and cost-effectiveness of sucrosomial iron administration. Results: Baseline haemoglobin in the treatment group was higher (by 0.67 g/dL; p

In the original pre-formed Valsalva graft, the skirt is the defining feature. It is a self-expanding portion, obtained by 90° rotation of the Dacron fabric corrugation with respect to the rest of the graft. Due to this manufacturing feature, the skirt length is equal to the graft diameter and, once pressurized, it expands by 25-30% (up to 10 mm) from the nominal size. Proximal to this bulged portion, a small collar completes the prosthesis. By virtue of this anatomical design, the Valsalva graft is recommended for most aortic root surgeries including valve-sparing and Bentall procedures. The skirt, by recreating the pseudo-sinuses, represents the key feature of the graft when used for aortic valve-sparing procedures (remodeling and reimplantation). However, in the Bentall procedure, the graft collar is an important feature because it is useful to attach the Valsalva graft to the valve prosthesis sewing ring when making a valved conduit. Moreover, once the graft is pressurized, the whole volume of the skirt better accommodates the struts and the leaflets of biological and mechanical prostheses. Furthermore, the expanded skirt reduces the distance and the tension on the coronary button anastomosis, increasing safety and possibly reducing complication rates. This review demonstrates the versatility of the Valsalva graft in various scenarios of aortic root surgery, with special emphasis on different uses of the skirt and the collar.

OBJECTIVES Endocarditis after the Bentall procedure is a severe disease often complicated by a pseudoaneurysm or mediastinitis. Reoperation is challenging but conservative therapy is not effective. The aim of this study was to assess short- and midterm outcomes of patients reoperated on for Bentall-related endocarditis. METHODS Seventy-three patients with Bentall procedure-related endocarditis were recorded in the Italian registry. The mean age was 57 ± 14 years and 92% were men; preoperative comorbidities included hypertension (45%), diabetes (12%) and renal failure (11%). The logistic EuroSCORE was 25%; the EuroSCORE II was 8%. RESULTS Preoperatively, 12% of the patients were in septic shock; left ventricular-aortic discontinuity was present in 63% and mitral valve involvement occurred in 12%. The most common pathogens were Staphylococcus aureus (22%) and Streptococci (14%). Reoperations after a median interval of 30 months (1–221 months) included a repeat Bentall with a bioconduit (41%), a composite mechanical (33%) or biological valved conduit (19%) and a homograft (6%). In 1 patient, a heart transplant was required (1%); in 12%, a mitral valve procedure was needed. The hospital mortality rate was 15%. The postoperative course was complicated by renal failure (19%), major bleeding (14%), pulmonary failure (14%), sepsis (11%) and multiorgan failure (8%). At multivariate analysis, urgent surgery was a risk factor for early death [hazard ratio 20.5 (1.9–219)]. Survival at 5 and 8 years was 75 ± 6% and 71 ± 7%, with 3 cases of endocarditis relapse. CONCLUSIONS Surgery is effective in treating endocarditis following the Bentall procedure although it is associated with high perioperative mortality and morbidity rates. Endocarditis relapse seems to be uncommon.

We report long-term outcome after two-stage, “one lung repair” in a four-year-old boy with tetralogy of Fallot and congenital absence of the left pulmonary artery. The operation was carried out two years after a palliative aortopulmonary central shunt and was uneventful. Twenty-six years later, the patient is in excellent clinical condition, with normal peripheral oxygen saturation. A recent radionuclide lung scan and cardiac magnetic resonance imaging show the pulmonary flow entirely directed into the right lung. In selected cases, the long-term prognosis of patients with tetralogy of Fallot and true absence of left pulmonary artery after “one lung repair” may be excellent.

Background To analyze the long-term results after Bentall operation using the stentless Shelhigh No-React (NR)-2000 bio-root prosthesis. Material From 2004 to 2008, 26 consecutive, nonselected patients (mean age at surgery: 67 ± 9 years) underwent a Bentall operation using a stentless Shelhigh valved conduit at our institution. Mean preoperative Logistic-EuroSCORE was 17.1 ± 12.9. The mean size of the aortic root was 53.2 ± 5 mm. The mean preoperative ejection fraction was 55 ± 7.4%. Three patients had a bicuspid valve. One patient with acute endocarditis and one patient with type A aortic dissection were operated on an emergency. Three patients (11.54%) had a previous cardiac operation. The Button-Bentall technique was used in all cases. Seven patients (26.92%) received an associated procedure. The mean size of the implanted prosthesis was 26.1 ± 2.2. Follow-up ranged between 6 and 174 months (mean 93.4 ± 59.1 months). Primary endpoints consisted of early and late mortality, freedom from acute endocarditis, freedom from structural valve deterioration, and freedom from valve-related-reoperation. Results Two patients died in hospital, while 10 patients died during follow-up time, of which three for cardiac causes (12.5%). Overall survival probability was 52.9% at 15 years. Freedom from acute endocarditis was 95.7% at 5 and 15 years. Freedom from severe aortic incompetence due to structural deterioration was 100% at 5 and 10 years, 90.9% at 15 years. The mean aortic gradient at follow-up was 11.4 ± 5 mm Hg. Freedom from valve-related reoperation was 100% at 5 and 10 years, 90.9% at 15 years. Conclusions In our experience, Bentall's operation using the Shelhigh NR-2000 stentless bio-conduit provided satisfactory early and long-term results. However, our findings are not consistent with unfavorable long-term outcomes following the implantation of this device reported by other authors.

Information on the long-term safety, efficacy and durability of third-generation stentless aortic valves is lacking.In this single-centre, single-surgeon retrospective observational study, between 2003 and 2015, consecutive, non-selected aortic valve replacement (AVR) patients were implanted with the LivaNova-Sorin Pericarbon Freedom™, a third-generation stentless aortic xenograft. Changes in clinical and echocardiographic parameters were examined, as were mortality, structural valve deterioration and reoperation, according to age at 5, 10 and 14 years.The mean logistic EuroSCORE was 8.5% in 22 AVR patients (mean age 68.3 years; range 15-89 years). Many patients [n = 139 (43%)] underwent a concomitant procedure. Before AVR, 68.0% of patients were in New York Heart Association (NYHA) Class I or II, and at discharge, mean gradient was 10.0 ± 4.3 mmHg. Follow-up lasted up to 8.9 ± 2.8 years. At the last follow-up, 95.6% of patients were in New York Heart Association Class I or II, the mean gradient was 8.0 ± 3.5 mmHg (P 0.001) and reduction in interventricular septum thickness and improvement of ejection fraction were significant (both P 0.001). Early 30-day in-hospital mortality was 1.6% overall and 0% in the AVR-only population. Overall survival probability was 99.9%, 87.9% and 82.7% at 5, 10 and 14 years. Freedom from structural valve deterioration at 14 years was 67.5%, 88.9% and 68.2% in AVR patients overall, in those aged70 years and in those aged 60-70 years, respectively. Freedom from reoperation at 14 years was 70.3%, 88.3% and 78.0% in the corresponding groups.Sorin Pericarbon Freedom is a valuable aortic bioprosthesis with favourable haemodynamics, particularly in smaller annuli, and durability similar to that of stented valves, which make Sorin Pericarbon Freedom a useful option in AVR.

OBJECTIVES Valve-sparing operations and root replacement with a biologic composite conduit are viable options in aortic root aneurysm. This study was conceived to compare the early and mid-term results of these 2 procedures. METHODS From September 2002 to November 2015, 749 consecutive patients underwent either a valve-sparing operation or a root replacement with a biologic composite conduit at 2 institutions. Propensity score matching was used to compare similar cohorts of patients in the overall population and in the ≤ 55 and ≥ 65-year age groups. RESULTS Overall operative mortality was 0.4%, mean age 57.4 ± 14.3 years, 84.6% were male. Individuals in the biologic composite conduit group were older and had worse preoperative risk profiles [chronic pulmonary disease (5.5% vs 0.9%; P = 0.001), diabetes (6.4% vs 1.5%; P = 0.001) and NYHA > 2 (25.2% vs 5.2%; P

OBJECTIVES Bentall procedure is the gold standard for aortic root pathologies when valve repair is not feasible. The development of durable bioprosthetic valves and improved vascular conduits allowed the implementation of bioprosthetic composite grafts; hereby, we performed a retrospective analysis of long-term follow-up of Bentall procedure using the Valsalva graft and the Perimount Magna Ease prosthesis. METHODS From June 2000 to March 2019, 309 patients received an aortic root and valve replacement with a bioprosthetic composite graft. The mean age was 69 ± 6.9 years, and the majority were men (88%); most of them were affected by aortic stenosis (86%) and the mean aortic root diameter was 48.6 ± 5.5 mm. RESULTS Freedom from cardiac death was 76.8% [confidence interval (CI) 32.5–94.0] at 16 years. Freedom from thromboembolism, haemorrhage, structural valve deterioration and infective endocarditis was 98.2% (CI 96.0–98.9), 95.2% (CI 87.1–98.2), 87.5% (CI 63.2–97.1) and 79.6% (CI 45.3–95.6) at 16 years, respectively. Freedom from reoperation was 74.7% (CI 41.9–90.6). CONCLUSIONS These data indicate that, in experienced centres, the Bentall procedure is a safe and effective intervention. This is the first long-term follow-up that analyses the results after implantation of a composite graft made with the Perimount Magna Ease aortic valve and the Valsalva graft.

Objectives. The aim of this study is to assess long-term-outcomes of patients with concomitant CAD and COD treated with different revascularization strategies. Background. Multisite artery disease is common and patients with combined disease have poor prognosis. The best therapeutic strategy for patients with concomitant carotid obstructive disease (COD) and coronary artery disease (CAD) remains controversial. Methods. This observational registry enrolled, between January 2006 and December 2012, 1022 consecutive patients from high volume institutions with concomitant CAD and COD suitable for endovascular, surgical, or hybrid revascularization in both territories selected by consensus of a multidisciplinary team. Results. The cumulative incidence of 5-year major cardiovascular events (MACCE) including cardiovascular death, myocardial infarction (MI), or stroke in the overall population was 12%. The incidence of 5-year MACCE was not statistically different in the surgical, endovascular, or hybrid patients group (10.1% vs. 13.0% vs. 13.2%, P = .257, respectively). However, the hybrid group exhibited rates of myocardial infarction, chronic kidney disease, and cumulative incidence of all clinical events higher than the surgical group. After propensity score matching, the incidence of 5-year MACCE was similar in the three groups (13.0% vs. 15.0% vs. 16.0%, p = .947, respectively). Conclusions. An individualized revascularization approach of patients with combined CAD and COD yields very good results at long-term follow-up, despite the high risk of this multilevel population even when the baseline clinical features are equalized.

Objective: To compare the early and mid-term clinical outcomes of patients undergoing two different surgical procedures (Bio-Bentall vs. David) for aortic root dilatation isolated or in association...

When the original monograph on valvular prostheses was published in Surgical Technology International, back in 1993, transcatheter technology had not yet been invented. These techniques have been gradually revealed in subsequent issues. When we first considered writing a paper that described both surgical and transcatheter prosthesis, we realized that such a combined paper would be impractically large. Therefore, we decided to split our survey into more than one paper. This paper seeks to address the paucity of information available regarding transcatheter aortic valve implantation (TAVI) and similar devices. This publication may serve as a reference point for critically organizing information on an evolving topic. The following article deals with the large number of transcatheter devices related to valvular and ventricular pathologies: TAVI for the aortic and mitral valves, with a focus on indications, techniques and complications, as well as specific aortic devices, and devices to treat mitral regurgitation with non-conventional access. Every effort has been made to make the content relevant and up-to-date, which proved to be particularly challenging due to the continuous technological evolution which characterizes this field.

The study aim was to investigate the hemodynamic behavior over time and ease of implant and durability of the Sorin Pericarbon Freedom (SPF)® stentless pericardial aortic xenograft.Between March 2003 and April 2010, a total of 251 consecutive, non-selected patients (mean age 70.1 years; range: 17-89 years; 17.1% aged80 years) received a SPF bioprosthesis as an aortic valve substitute at the authors' institution. All implantations were performed by a single surgeon using a classical, double-line, subcoronary implant technique. Of these patients. 108 (43%) underwent a concomitant procedure. The mean logistic EuroSCORE was 8.3. Patients were followed for complications and hemodynamic evaluation. Echocardiographic controls and clinical data were obtained at discharge, and at six months' and eight years' follow up.The in-hospital/30-day mortality was 1.2% for the entire group, but 0% for patients with isolated valve replacement. A total of 27 deaths had occurred at the time of the last follow up (22 were due to non-cardiac causes). At follow up (mean 3.7 years; range: 0-7.8 years), 91.1% of survivors were in NYHA classes I or II. Freedom from reoperation and from structural valve deterioration was 96.0% and 96.8%, respectively, at 7.8 years. The mean pressure gradient of the series (measured using echocardiography) was 10.3 ± 4.5 mmHg at discharge, and 8.3 ± 4.5mmHg at the time of the last follow up. The mean effective orifice area was 1.85 ± 0.70 cm2 for the entire series, and there was an absence of prosthesis-patient mismatch in 90% of patients.The study results confirmed the favourable hemodynamic behavior, low risk of implantation and acceptable durability of the pericardial stentless SPF aortic prosthesis. The data also endorsed use of the SPF as an aortic valve substitute, even in a young and active population, and particularly in the presence of a small aortic annulus. The accuracy of implantation remains a crucial factor for durability and subsequent satisfactory hemodynamic performance. A longer follow up would provide further information with regards to complications and durability of the SPF prosthesis.

Composite valve graft implantation described by Bentall and De Bono is a well-documented technique of aortic root replacement used for a large spectrum of pathologic conditions involving the aortic valve and the ascending aorta. While mechanical valves were initially used, biological prostheses were later introduced in order to avoid long-term anticoagulation and its related complications. The increasing age of patients who undergo aortic root surgery, and data supporting the use of a biological aortic valve in the younger population, have significantly increased the need for a composite biological valved conduit. However, parallel to the increased use of biological valve in the context of a Bentall operation, aortic valve-sparing (AVS) operation have also been performed in a growing number of patients. Sarsam and David described the remodeling and the reimplantation procedures more than 25 years ago with the aim of sparing otherwise normal aortic valves in the presence of a root aneurysm. Important achievements in this discipline have occurred over the past decade including development and refinement of valve preserving aortic root replacement techniques, development of a classification system for aortic insufficiency, surgical approaches to cusp disease with different cusp anatomy. Both procedures can now provide excellent root reconstruction and adequate clinical results in terms of late valve durability. The AVS technique offers several advantages over the Bentall procedure, such as no need for oral anticoagulation and lifestyle adjustments. AVS operations have become established alternatives to Bentall procedures for patients with aortic root pathology. However, data comparing the safety and durability of these approaches are lacking.

BACKGROUND We conducted a prospective single-blind randomized study to assess whether a single 80,000 IU dose of human recombinant erythropoietin (HRE), given just 2 days before cardiac surgery, could be effective in reducing perioperative allogeneic red blood cell transfusion (aRBCt). STUDY DESIGN AND METHODS Six-hundred patients presenting with preoperative hemoglobin (Hb) level of not more than 14.5 g/dL were randomly assigned to either HRE or control. The primary endpoint was the incidence of perioperative aRBCt. The secondary endpoints were mortality and the incidence of adverse events in the first 45 days after surgery, Hb level on Postoperative Day 4, and number of units of RBC transfusions in the first 4 days after surgery. RESULTS A total of 17% (HRE) versus 39% (control) required transfusion (relative risk, 0.436; p

A recent randomized controlled trial showed that patients undergoing ascending aorta surgery treated with HEMOPATCH to control bleeding had a significantly better hemostasis success rate than with dry or wet gauze compression or similar standard of care (SOC).To compare the cost-effectiveness using two different agents for hemostasis (HEMOPATCH vs dry or wet gauze compression or similar SOC) in cardiac surgery from the European hospital perspective.A literature-based cost-effectiveness model estimating average cost per successful hemostasis event was developed based on the hemostasis efficacy difference (HEMOPATCH = 97.6%, SOC = 65.8%, p .001). Additional clinically significant end-points studied in the trial (blood transfusions and surgical revisions) were also analyzed. It was assumed that each surgery utilized two units of HEMOPATCH (dimensions of 4.5 × 9 cm) and two units of SOC. Product acquisition costs for HEMOPATCH and SOC were included along with outcome-related costs derived from the literature and inflation-adjusted to 2017 EUR and GBP. Results are presented for an average hospital with an annual case load of 574 cardiac surgeries. One-way and probabilistic sensitivity analyses were performed.Considering only product acquisition cost, HEMOPATCH had an incremental cost-effectiveness ratio (ICER) of €1,659, €1,519, €1,623, and £1,725 per hemostasis success when compared to SOC for Italy, Spain, France, and the UK, respectively. However, when considering the cost and potential difference in the frequency of transfusions and revisions compared to SOC, the use of HEMOPATCH was associated with an annual reduction of six revisions and 60 transfusions, improving the ICER to €1,440, €1,222, €1,461, and £1,592, respectively. Sensitivity analysis demonstrated model robustness.This analysis supports the use of HEMOPATCH over SOC in cardiac surgery in European hospitals to improve hemostasis success rates and potential cost offsets from reduced transfusions, complications, and surgical revisions.

Aims The aim of this study was to evaluate the clinical and echocardiographic results and the predictors of outcomes in patients undergoing valve-sparing operation (VSO) at two aortic centers. In addition, we sought to evaluate the potential effect of recreation of the sinuses of Valsalva (SV) on the outcome of valve-sparing procedures. Methods During a 14-year period, 328 patients underwent aortic valve-sparing root replacement at two institutions. Clinical and echo evaluation was performed 6 months after surgery and every year thereafter or in case of clinical symptoms. Propensity weighting and propensity-weighted risk competing analysis were used. Results No operative mortality was reported; the most common complication was revision for bleeding, occurring in 15 patients (4.6%). At a mean follow-up of 30.0 ± 33.9 months, two patients died (0.6%). Recurrent aortic insufficiency (AI) >2+ was found in 11 patients (3.3%); five (1.5%) underwent reoperation. Recreation of the SV did not affect clinical outcome and aortic valve status. Need for aortic valve repair was the only independent predictor of recurrent AI, whereas a bicuspid aortic valve was a protective factor. Conclusions Re-creation of the SV does not affect short-term outcomes following VSO.

Objectives Optimal management of poststernotomy mediastinitis is controversial. Negative pressure wound treatment improves wound environment and sternal stability with low surgical invasiveness. Our protocol was based on negative pressure followed by delayed surgical closure. The aim of this study was to provide the results at early follow-up and to identify the risk factors for adverse outcome. Methods In 5400 cardiac procedures, 44 consecutive patients with mediastinitis were enrolled in the study. Mediastinitis treatment was based on urgent debridement and negative pressure as the first-line approach. After wound sterilization, chest closure was achieved by elective pectoralis muscle advancement flap. Each patient's hospital data were collected prospectively. Variables included patient demographics and clinical and biological data. Acute Physiology and Chronic Health Evaluation (APACHE) II score was calculated at the time of diagnosis and 48 hours after debridement. Focus outcome measures were mediastinitis-related death and need for reintervention after pectoralis muscle closure. Results El Oakley type I and type IIIA mediastinitis were the most frequent types (63.6%). Methicillin-resistant Staphylococcus aureus was present in 25 patients (56.8%). Mean APACHE II score was 19.4 ± 4 at the time of diagnosis, and 30 patients (68.2%) required intensive care unit transfer before surgical debridement. APACHE II score improved 48 hours after wound debridement and negative pressure application (mean value, 19.4 ± 4 vs 7.2 ± 2; P = .005) independently of any other variables included in the study. One patient in septic shock at the time of diagnosis died (2.2%). Conclusions Negative pressure promotes a significant improvement in clinical status according to APACHE II score and allows a successful elective surgical closure.

Aortic valve sparing procedures became more popular in the last decades due to the better understanding of aortic root physiology. Searching for an optimal root reconstruction several modifications have been proposed to the original reimplantation (David) and to the remodeling (Yacoub) technique. Currently, the most adopted technique worldwide is the reimplantation because of its peculiar characteristics of annular stabilization, support of the aortic wall, and better hemostatic efficacy. The remodeling technique aims for optimal root restoration, but does not prevent annular dilatation and may be associated with a higher risk of bleeding. The main theoretical issue with the classic reimplantation operation is the elimination of Valsalva’s sinuses which play a fundamental role in regulating leaflet dynamics. On the other hand, data on long-term aortic valve performance in classic reimplantation procedures without sinuses appears to hold well the test of time. However, over the time this technique has been often modified attempting to re-create sinuses, it is therefore difficult to draw definite conclusions. In the last decade, the use of “anatomic” Dacron graft designed specifically for root reconstruction or specific modifications to the straight Dacron graft, led to a standardization of the technique and consequently to a stable improvement of the results and to the diffusion of the reimplantation. However, long-term durability of the spared valve assessed by the incidence of residual aortic valve insufficiency and/or the need for reoperation during the follow-up is still to be clarified. Overall, the results are satisfactory especially in consideration of the relatively “young age” of this technique. A spared aortic valve with moderate valve regurgitation and/or eccentric aortic jet soon after the procedure, will invariably lead to a later need for reoperation. Therefore, a good coaptation height inside a repaired root warrant long-lasting results.

Hemostasis is a critical component of all surgical procedures and especially cardiac surgery. In addition to traditional means, topical hemostatic agents have been reported to be extremely effective in terminating bleeding during cardiac procedures. We compared a hemostatic matrix sealant agent (HEMOPATCH Baxter Healthcare Corporation, Deerfield, IL) with alternative topical hemostatic treatment in patients undergoing ascending aorta surgery with moderate bleeding.Following sample size calculation, in a prospective randomized study design, 85 patients were treated with HEMOPATCH matrix sealant and 85 patients received alternative treatment (dry or wet gauze compression or similar [control group]). The primary outcome measure was the percentage of patients with successful hemostasis within three minutes of HEMOPATCH or traditional treatment application. Other study outcome measures were postoperative blood loss and the rate of transfusion of blood products.A statistically higher rate of successful hemostasis within three minutes was observed in the HEMOPATCH group (97.6% [83/85] vs. 65.8% [56/85] in the control group; p0.001). The percentages of patients with postoperative bleeding and the rate of transfusion were lower in the HEMOPATCH group than in the control group.The use of HEMOPATCH is effective in terminating bleeding in patients undergoing ascending aorta cardiac procedures. Fewer patients treated with HEMOPATCH required blood transfusion. The cost-utility profile of HEMOPATCH should be addressed in dedicated trials.