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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.

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.

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.

Objective The Valsalva graft is a specifically designed Dacron graft that, on implantation and pressurization, generates pseudosinuses of Valsalva. We reviewed a multicenter experience of the reimplantation procedure with the Valsalva graft in patients with aneurysms involving the aortic root. Methods A total of 278 patients underwent valve-sparing aortic root replacement using the Valsalva graft at 4 different Italian cardiac surgery centers and were studied by clinical assessment and echocardiography. Of the 278 patients, 220 were men (79%), with a mean age of 56 ± 15 years. Of the patients, 42 (15%) had Marfan syndrome, 31 (11%) had a bicuspid aortic valve, 13 (5%) had acute aortic dissection, and 136 (49%) had grade 3 or 4+ aortic insufficiency. Concomitant cardiac procedures were performed in 78 patients (28%). Additional aortic leaflet repair was necessary in 25 patients (9%). The mean crossclamp time was 120 ± 27 minutes. Results There were 5 (1.8%) operative and 5 (1.8%) late deaths. The mean follow-up was 52 ± 28 months (range, 2–112 months) and was 100% complete. The cumulative actuarial survival was 95.2% (268 patients). A total of 32 patients (11%) had grade 3 to 4+ aortic insufficiency, and 17 of these required late aortic valve replacement (range, 3–78 months). At 10 years of follow-up, the freedom from aortic valve reoperation rate was 91%, and the rate of freedom from residual aortic insufficiency not needing reoperation was 88%. Conclusions The reimplantation type of valve-sparing procedure can be facilitated by the use of the Valsalva graft and can be performed with satisfactory perioperative and midterm results. How an optimal root reconstruction will affect the second decade of follow-up has yet to be determined.

Objectives Implanting expanded polytetrafluoroethylene neochordae is an established technique in treating complex mitral regurgitation. Difficulty in obtaining reliable preoperative and intraoperative measurements of an ideal neochordae length, as well as the unfeasibility of adjusting lengths once set in place with traditional techniques, led us to develop a system that allows rapid change of length after the evaluation of valve continence with hydrostatic tests. Methods The system consists of two components: a papillary component with arrest knots at constant intervals and a leaflet component with a reversible noose-lace to fix the loop to 1 of the knots on the papillary component. After implantation and coupling of the two components at a presumable optimal length, a prosthetic ring is sutured in place. Hydrostatic testing is then performed. Optimal chordae length can be obtained by releasing the noose-lace and sliding it over another fixing-knot. The adjustment can be performed as often as required without placing stress on the anatomic structures. Results Twenty patients underwent repair with this technique. No deaths or major adverse events occurred. All patients underwent echocardiography, both at discharge and 6 months after the operation. A total of 14 patients had no residual insufficiency, 5 patients had mild or trivial postoperative insufficiency without progression of regurgitation at the sixth month, and only 1 patient had mild insufficiency at discharge progressing to moderate insufficiency at the sixth month. Conclusion This new technique facilitates an otherwise complicated procedure. Short-term results are satisfactory, but further follow-up is required.

Background Structural valve deterioration (SVD) is the Achilles' heel of bioprostheses. Its correlation with younger age is well known. In recent years we exclusively reserved use of small-size Mitroflow valve prostheses (LivaNova, London, United Kingdom) to an older patient population with small aortic annuli. This study aimed to assess the incidence of SVD and its effect on patient survival and need for reoperation. Materials and Methods Two hundred five patients (aged 75.9 ± 5.3 years; range, 62-92 years) underwent aortic valve replacement with a 19-mm or 21-mm Mitroflow valve prosthesis between 2005 and 2011. The great majority was female (n = 170; 83%). In half of patients it was an isolated procedure. All valve prostheses were implanted in a supra-annular position using pledgeted sutures. A 19-mm valve was implanted in 93 patients (45.3%), whereas in 112 patients (54.6%) a 21-mm valve was used. Results Twenty-three patients (11.2%) were diagnosed with early SVD by echocardiography. Average time from surgery to diagnosis of SVD was 64.3 ± 26.8 months. Ten patients needed a reoperation for SVD. Average time from surgery to a second operation was 45.7 ± 35.7 months. Overall survival was 64.5% and 42.3% at 5 and 9 years, respectively. Cumulative freedom from SVD at 5 and 9 years was 94.8% ± 1.6% and 77.4% ± 5.4%, respectively. In 4 patients death was linked to the presence of SVD. There were no differences in mortality, reoperation, or SVD between the 2 Mitroflow valve sizes. Conclusions Small-size Mitroflow pericardial valve prostheses have shown a worrisome incidence of SVD even in patients aged >70 years. Based on this experience we have discontinued their use.

Objective The Bentall procedure is routinely performed using a straight Dacron graft coupled with a mechanical or a biologic valve. Creation of coronary ostia buttons significantly reduces tension on the coronary anastomoses and consequently the incidence of pseudoaneurysm formation. We sought to evaluate if the use of a specifically designed graft with a sinuslike root portion that bulges out upon pressurization can reduce stress on coronary anastomoses. A finite element computer-assisted stress analysis was used to simulate these 2 different anatomic conditions and to analyze tension in computed tomographic scans obtained from patients operated on with either a straight or a "sinus" graft. Methods Theoretical models of the procedures with finite element computer-aided design technique were created and tested with the Abaqus Standard Suite, verifying the pattern of stress and strain when a uniform pressure of 200 mm Hg was applied to the model. Next, using SimpleWare SCanIP technology, computed tomographic scans of patients having both procedures were used to obtain finite element mesh models. A uniform pressure of 200 mm Hg was then applied, and the distribution of stress and strain was analyzed. Results Von Mises Charts are color-coded, computational, 3-dimensional stress-pattern graphics that show that stress around the coronary ostia in a standard straight graft model is nearly double compared with the model with sinuses (peak stress of 0.4 Mpa for the sinus model and 0.7 Mpa for the traditional straight model). In computed tomographic scan reconstructions, the stress contour is uniformly distributed in the graft with sinuses, and it is highly concentrated around the ostia in the straight graft. Accordingly, higher-peak stress values are registered in the straight configuration (1.8 MPa for the sinus graft and 2.5 MPa for standard graft). Conclusion Even though finite elements technique is necessarily a simplification of a real biologic environment, all tests seem to indicate that a standard tubular graft gives a higher stress to coronary sutures. Relieving the stress on the coronary anastomoses by using a graft with preformed sinuses of Valsalva may decrease the incidence of postoperative complications such as bleeding and late pseudoaneurysm formation.

Objectives We sought to evaluate the effects of the reimplantation type versus the remodeling type of aortic valve–sparing technique on the geometry of the same aortic root. Methods Fifteen fresh isolated porcine hearts with normal aortic valves and a standard aortoventricular junction size of 23 mm were processed. An aortic valve–sparing replacement was performed by reimplanting the native aortic root inside a 28-mm Valsalva graft (Vascutek Ltd, Renfrewshire, UK). Hearts were subsequently implanted with instruments in a test circuit, and the aortic roots were pressurized at a fixed pressure of 100 mm Hg. Diameters of the aortoventricular junction, of the sinuses, and of the sinotubular junction, as well as effective height and coaptation height of aortic valve leaflets, were measured by echography. Transition from the reimplantation to the remodeling configuration was then achieved by longitudinally cutting the skirt of the graft from the annulus to the top of each commissure. The same measurements were then repeated. Results After transition from the reimplantation to the remodeling configuration, significant increases in the sizes of the aortoventricular junction and of the sinuses were observed. Effective height and coaptation height significantly decreased, and the rounded cross-sectional profile of the aortic valve leaflets flattened. Conclusions In the same aortic root, transition from the reimplantation to the remodeling configuration of aortic valve–sparing surgery results in a significant increase in aortic root sizes and in a significant reduction of effective height and coaptation height, suggesting a less satisfactory result.