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Background: Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (antegrade cerebral perfusion [ACP]), or retrograde. In recent years nadir temperature progressively increased to 26°C–28°C (moderately hypothermic circulatory arrest [MHCA]), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10 min of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming [DR]) can provide a neuroprotection and a lower body protection similar to that provided by MHCA + ACP. Methods: A total of 210 patients were included in the study. DHCA + DR was used in 59 patients and MHCA + ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE), or permanent (permanent neurologic deficit [PND]), and need of renal replacement therapy (RRT). Results: Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%), and PNDs in 10 (4.8%). A total of 23 patients (10.9%) needed RRT. Death + PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs, and death + PND, but need of RRT (odds ratio [OR]: 7.39, confidence interval [CI]: 1.37–79.1) and composite endpoint (OR: 8.97, CI: 1.95–35.3) were significantly lower in DHCA + DR group compared with MHCA + ACP group. Conclusions: The results of our study demonstrate that DHCA + DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA + ACP. However, the data suggests that DHCA + DR when compared with MHCA + ACP provides better renal protection and reduced prevalence of composite endpoint. [ABSTRACT FROM AUTHOR]

Based on Carpentier's classification and principles, the techniques for mitral valve repair continue to evolve. We herein report our experience with the morphofunctional echocardiographic analysis of single mitral leaflets, as different anatomic features, even if conflicting, may coexist not only in the two leaflets but in the same leaflet as well. A classification is proposed, based on the length (normal, short, or long) and mobility (normal, restricted, or excessive) of mitral leaflets. The surgical techniques adopted for mitral valve repair are the direct consequence of this analysis. [ABSTRACT FROM AUTHOR]

Introduction: In this prospective multicenter analysis, we aimed to investigate the predictive role of neutrophil/lymphocyte ratio (NLR) in permanent pacemaker implantation (PPI) in patients undergoing transcatheter aortic valve replacement (TAVR). Materials and Methods: One hundred and seventy‐nine consecutive patients without previous PPI underwent TAVR from February 2017 to September 2021. Patients were further divided based on presence (n = 48) and absence of conduction abnormalities (CAs) at hospital admission (n = 131). Results: In patients with previous CAs, NLR values did not differ significantly between patients requiring PPI (n = 16, 33%) and those not requiring it. In contrast, in patients with no CAs at hospital admission, NLR values measured at admission and on TAVR day were significantly higher in patients requiring PPI (n = 17, 13%) (4.07 ± 3.22 vs. 3.01 ± 1.47, p =.025, and 10.81 ± 7.81 vs. 5.84 ± 3.78, p =.000, respectively). Multivariable analysis showed that NLR at TAVR day was an independent predictor of PPI in patients without CAs (OR 1.294; 95% CI 1.028–1.630; p =.028), but not in those with previous CAs. ROC curve analysis showed that the cut point was a NLR value of >7.25. Time to PPI was delayed till 21 days in patients without CAs. Conclusions: In this prospective study, higher NLR values on the day of TAVR day were associated with an increased PPI rate in patients undergoing TAVR with no previous CAs. It is advisable, being inflammation part of the process, to prolong the time of observation for all patients without CAs till at least 21 days not to miss any new CA necessitating PPI. [ABSTRACT FROM AUTHOR]

Mitral valve regurgitation (MR) is a common valvular disorder occurring in up to 10% of the general population. Mitral valve reconstructive strategies may address any of the components, annulus, leaflets, and chords, involved in the valvular competence. The classical repair technique involves the resection of the prolapsing tissue. Chordal replacement was introduced already in the '60, but in the mid '80, some surgeons started to use expanded polytetrafluoroethylene (ePTFE) Gore‐Tex sutures. In the last years, artificial chords have been used also using transcatheter approach such as NeoChord DS 1000 (Neochord) and Harpoon TSD‐5. The first step is to achieve a good exposure of the papillary muscles that before approaching the implant of the artificial chords. Then, the chords are attached to the papillary muscle, with or without the use of supportive pledgets. The techniques to correctly implant artificial chords are many and might vary considerably from one center to another, but they can be summarized into three big families of suturing techniques: single, running or loop. Regardless of how to anchor to the mitral leaflet, the real challenge that many surgeons have taken on, giving rise to some very creative solutions, has been to establish an adequate length of the chords. It can be established based on anatomically healthy chords, but it is important to bear in mind that surgeons work on the mitral valve when the heart is arrested in diastole, so this length could fail to replicate the required length in the full, beating heart. Hence, some surgeons suggested techniques to overcome this problem. Herein, we aimed to describe the current use of artificial chords in real‐world surgery, summarizing all the tips and tricks. [ABSTRACT FROM AUTHOR]

Background and Aim of the Study: Mitral valve repair is the procedure of choice to correct mitral regurgitation. However, some dangerous iatrogenic complications can occur at the end of the procedure. Therefore, we sought to review the most frequent and clinically relevant acute iatrogenic complication following mitral valve repair. Methods: A thorough review of the literature has been performed. Criteria for considering studies for this non‐systematic review were as follows: observational and interventional studies investigating the acute iatrogenic complications following mitral valve repair, and essential review studies pertinent to the topic. Results: The most frequent is the systolic anterior motion. Due to a systolic dislocation of the anterior leaflet toward the outflow tract, it causes both obstruction of the outflow tract and mitral regurgitation. Often it is due to excess of catecholamines or to reduced filling of the left ventricle but sometimes needs further surgical maneuvers, focused on moving posteriorly the coaptation line. It can be obtained by shortening the posterior leaflet or increasing the size of the ring or applying an Alfieri stitch to limit the movements of the anterior leaflet. Another complication, often underdiagnosed and potentially lethal, is the injury of the circumflex artery that happens at the level of the anterolateral commissure or P1 zone. Two mechanisms are involved. The first one is the direct injury of the artery by a stitch (roughly 25% of the patients present a distance artery‐annulus <3 mm. The second one is the distortion of the artery, attracted toward the annulus by a misplaced stitch. The attraction causes kinking with stenosis of different degrees till functional occlusion. However, the artery has to be far from the annulus and the atrial tissue has to be stiff and resistant, as after an infective process, to move the circumflex artery toward the annulus without tearing. Positioning the stitches very close to the mitral leaflets in the dangerous area is the only prevention to the complication. The treatment in the operating theater is partial or total removal/reimplantation of the annular sutures or coronary artery bypass grafting to the circumflex area. If the injury is demonstrated only after coronary angiography, percutaneous revascularization can be attempted before further surgical treatment. Conclusions: Acute iatrogenic complication after mitral repair exists and may compromize patient outcome. Raising awareness about these issues, the precautions to prevent them, and the manners of resolution is therefore mandatory. [ABSTRACT FROM AUTHOR]

Background and Aim of the study: Wrapping of the ascending aorta (AA), isolated or associated with aortoplasty, has never been completely accepted. Some complications, as folding of the aortic wall, compression of the vasa vasorum and changes in the flow pattern, with consequent dilatation of the proximal arch, have been described. We used fresh autologous pericardium (FAP), so far never reported, to wrap the AA, with the aim to stabilize its size when moderately dilated, maintaining the preoperative dimension or limiting the reduction to a few millimeters. Materials and Methods: From 2015 to 2019, 10 patients, who were operated on for valve or coronary surgery or both, underwent wrapping of the AA with FAP. Mean age was 69 ± 7 years and EuroSCORE II 3.5 ± 1.7. Four patients had moderately impaired ejection fraction (35%–49%). Results: There was no early or late mortality. One patient was reoperated on after 48 months for severe mitral regurgitation. At a follow‐up of 53 ± 14 months, a transthoracic echocardiogram showed that the AA size reduced slightly but significantly, from 45.2 ± 2.0 to 42.5 ± 4.1 mm, p =.03. The diameter of the proximal arch remained unchanged, from 37.1 ± 1.6 to 36.3 ± 2.9 mm, p =.20. Conclusions: In the presence of moderately dilated AA, wrapping can be a reasonable option. The use of FAP stabilizes the size of the aorta after a follow‐up of 53 months. Maintaining a size similar to the preoperative one avoids the complications related to the procedure. [ABSTRACT FROM AUTHOR]

Resection or exclusion of scars following a myocardial infarction on the left anterior descending artery territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a "revisitation" of what described before. In some case, old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world. [ABSTRACT FROM AUTHOR]

Atrial fibrillation in patients with heart failure due to ventricular dyssynchrony needs decision‐making on the rate and rhythm control strategies together with cardiac resynchronization therapy and antithrombotic prophylaxis. Transvenous biventricular pacing and percutaneous appendage closure in patients with heart failure and atrial fibrillation with high bleeding risk are valid therapeutic options but anatomical exclusion criteria could be present. Here, we report two patients who underwent successful totally thoracoscopic concomitant left appendage occlusion and epicardial left ventricular lead implantation. [ABSTRACT FROM AUTHOR]

The long‐term outcome of patients undergoing mitral valve repair (MVr) is based on what happens during the more or less 60 min of aortic cross‐clamping necessary to transform a leaking valve into a well‐functioning one. As a consequence, the experience of the surgeon performing the procedure is the only determinant of the success rate that deserves to be taken into account. It is clear from the literature that the number of cases/year is inversely related to the number of early and late deaths, repair failures, and reoperations. However, there is no agreement on the minimum caseload/year that represents the threshold to identify surgeons that can perform or not MVr. This problem then cannot be regulated by specific guidelines of Scientific Societies, but only by the ethical perception, we have of our profession. [ABSTRACT FROM AUTHOR]

Objective: For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches to establish the possible gold standard.Methods: A systematic search was performed to identify all publications reporting the outcomes of four approaches for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis.Results: There were 31 included studies with 9663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA, and 6.4% RRA; early TR moderate-or-more was 9.6%, 4.8%, 4.6%, and 3.8%; late mortality was 22.5%, 18.2%, 11.9%, and 11.9%; late TR moderate-or-more was 27.9%, 18.3%, 14.3%, and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (-85% vs. no TA; -64% vs. SA; -32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches; however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes.Conclusions: Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provide more stable FTR across time. [ABSTRACT FROM AUTHOR]

Surgical coronary revascularization remains the preferred strategy in a significant portion of patients with coronary artery disease due to superior long‐term outcomes. However, there is a significant risk of perioperative neurologic injury that has influenced guideline recommendations. These complications occur in 1%–5% of patients, ranging from overt neurologic deficits with permanent disability, to subtle cerebral defects noted on neuroimaging that may result in slow cognitive and functional decline. The primary mechanism by which these events occur is thromboembolism from manipulation of the ascending aorta. This occurs during cardiopulmonary bypass, aortic cross‐clamping, and partial occlusion clamping (side clamp). Elderly patients and patients with aortic atheroma are, therefore, at significantly increased risk. Initial surgical techniques addressed this by aggressively debriding or replacing the ascending aorta during coronary artery bypass grafting (CABG). Strategies then moved toward minimizing aortic manipulation through pump‐assisted beating heart surgery and off‐pump surgery with partial occlusion clamping or proximal anastomosis devices. Finally, anaortic off‐pump CABG aims to avoid all manipulation of the ascending aorta through advanced off‐pump grafting techniques combined with in situ and composite grafts. This has been demonstrated to result in the greatest reduction in risk. Establishing successful anaortic off‐pump CABG programs requires subspecialization and focused interest groups dedicated to advancing CABG outcomes. [ABSTRACT FROM AUTHOR]

Choosing to perform mitral valve (MV) repair or replacement remains a hot and highly debated topic. The current guidelines seem to be conflicting in this specific field and the evidence at our disposal are scarce, only one small randomized trial and few larger retrospective studies. The meta‐analysis by Gamal and coworkers tries to summarize the current evidence, concluding that MV replacement for the treatment of ischemic mitral regurgitation (MR) is at least as safe as repair and certainly offers a more stable result over time than the latter. Obviously, the implantation of a prosthesis, especially a mechanical one, brings with it a series of problems, such as anticoagulation and, above all, a possible lack of ventricular remodeling, especially if a chordal sparing replacement is not performed. It must be said, on the other hand, that isolated annuloplasty cannot act as a counterpart to replacement, because ischemic MR cannot be considered only an annular disease. Therefore, wanting to mimic the nature that, after an infarction, enacts a series of changes involving also the mitral leaflets and chordae, the surgeons are called to act also on these two entities and not only to downsize the annulus. In a nutshell, a procedure should not be opposed in a fundamentalist way to another one, but we must accept the concept of armamentarium where both procedures are present and tail on the single patient, and also on the surgeon's expertize, the technique guaranteeing the best possible result. [ABSTRACT FROM AUTHOR]

The COVID‐19 pandemic has remarkably impacted the hospital management and the profile of patients suffering from acute cardiovascular syndromes. Among them, acute infective endocarditis (AIE) represented a rather frequent part of these urgent/emergent procedures. The paper by Liu et al. has clearly shown the higher risk features which patients with a diagnosis of AIE presented at hospital admission during the first part (first and second waves) of the outbreak, often requiring challenging operations, but fortunately not associated with the worse outcome if compared to results obtained before the SARS‐2 pandemic. The report discussed herein presents several other aspects worth discussion and comments, particularly in relation to hospital management and postdischarge outcome which certainly deserve to be highlighted, but also further investigations. [ABSTRACT FROM AUTHOR]

The meta‐analysis by He et al. has the worth to cover, as much as possible, a gap of scientific evidence were conducting a randomized trial appears very complex for ethical and logistical reasons. The authors concluded that mitral valve repair (MVP) provides better‐pooled results, both early and late, with respect to mitral valve replacement. However, the superiority of MVP is driven by some single large cohort studies where surgeons had wide experience in the field of MVP for infective endocarditis. This finding is also confirmed by other studies. But if mitral repair produces such a better short‐ and long‐term survival than replacement, why are there no clear indications from consensus and guidelines pushing surgeons toward the pursuit of a reconstructive procedure at almost any cost? We wonder to repair or not to repair, is that really the question? The AATS consensus suggests repairing "whenever possible" but without providing more specific indications. If the two primary goals of surgery are total removal of infected tissues and reconstruction of cardiac morphology, including repair or replacement of the affected valve(s), probably MVP should be performed in case of less extensive tissue detriment by the infection. In more wide valve involvement, MVP may be the choice but only in very expert hands and in Centers with a very large volumes of valve repairing. This decision cannot, therefore, be the result of the choice of an individual but must derive from a careful multidisciplinary discussion to be held in an EndoTeam. [ABSTRACT FROM AUTHOR]

In secondary mitral regurgitation, the concept that the mitral valve (MV) is an innocent bystander, has been challenged by many studies in the last decades. The MV is a living structure with intrinsic plasticity that reacts to changes in stretch or in mechanical stress activating biohumoral mechanisms that have, as purpose, the adaptation of the valve to the new environment. If the adaptation is balanced, the leaflets increase both surface and length and the chordae tendineae lengthen: the result is a valve with different characteristics, but able to avoid or to limit the regurgitation. However, if the adaptation is unbalanced, the leaflets and the chords do not change their size, but become stiffer and rigid, with moderate or severe regurgitation. These changes are mediated mainly by a cytokine, the transforming growth factor-β (TGF-β), which is able to promote the changes that the MV needs to adapt to a new hemodynamic environment. In general, mild TGF-β activation facilitates leaflet growth, excessive TGF-β activation, as after myocardial infarction, results in profibrotic changes in the leaflets, with increased thickness and stiffness. The MV is then a plastic organism, that reacts to the external stimuli, trying to maintain its physiologic integrity. This review has the goal to unveil the secret life of the MV, to understand which stimuli can trigger its plasticity, and to explain why the equation "large heart = moderate/severe mitral regurgitation" and "small heart = no/mild mitral regurgitation" does not work into the clinical practice. [ABSTRACT FROM AUTHOR]

Background: The aim of the present retrospective study was to evaluate the influence of preoperative right ventricular (RV) and tricuspid valve (TV) remodeling on the fate of tricuspid annuloplasty (TA) and right ventricle.Methods: From May 2009 to December 2015, 423 patients who had undergone TA for functional tricuspid regurgitation (TR) were included in the study. Residual and recurrent TR were defined as moderate or more TR at discharge and follow-up, respectively. RV remodeling was defined as RV dysfunction and/or dilation.Results: Residual TR after TA was recorded in 54 patients (13%). Five-year freedom from TR recurrence was 81% ± 3% in patients without residual TR and 41 ± 8 in patients with residual TR (P < .001). In patients without residual TR, the following risk factors for recurrent TR and late RV remodeling were identified: preoperative systolic pulmonary artery pressure, preoperative RV remodeling, severe preoperative TR or less than severe TR but with TV apparatus remodeling, and etiology of mitral regurgitation. Cox analysis with time-dependent variables confirmed TR recurrence (hazard ratio [HR]: 3.1) and late RV remodeling (HR: 6.5) as risk factors for lower survival. No protective effect of either flexible band or rigid ring TA compared with DeVega procedure was found. Similarly, preoperative atrial fibrillation and pacemaker dependency, late failure of mitral valve surgery did not affect the fate of TR.Conclusions: Prophylactic TA should be encouraged among surgeons. TA at the time of left-sided valve surgery should take into consideration not only annular size, but also tethering severity and RV remodeling. [ABSTRACT FROM AUTHOR]

Background and Aim Of the Study: The outcome of mitral valve (MV) repair for chronic ischemic mitral regurgitation (IMR) is suboptimal, due to the high recurrence rate of moderate or severe mitral regurgitation (MR) during follow-up. The MV adapts to new MR increasing its area to cover the enlarged annular area (mitral plasticity). As this process is often incomplete, we aimed to evaluate if augmenting the anterior leaflet (AL) and cutting the second-order chords (CC) together with restrictive mitral annuloplasty, a strategy we call "surgical mitral plasticity," could improve the midterm results of MV repair for IMR.Materials and Methods: From November 2017 to October 2019, 22 patients with chronic IMR underwent surgical mitral plasticity. Mean age was 73 ± 7 years and six were female. Mean ejection fraction was 32% ± 11%, IMR grade was moderate in 10 and severe in 12. Mean clinical and echocardiographic follow-up was 12 ± 6 months.Results: There was no early death, and one patient died 6 months after surgery. Ejection fraction improved from 32% ± 15% to 40% ± 6% (P = .031). IMR was absent or mild in all patients, and none showed recurrent moderate or more IMR. Tenting area decreased significantly from 2.5 ± 0.5 to 0.5 ± 0.3 cm² and coaptation length increased from 1.9 ± 0.7 to 7.8 ± 1.6 mm. All patients were in New York Heart Association class I or II.Conclusions: Mitral plasticity, if uncomplete, is ineffective in preventing IMR to become significant. Surgical mitral plasticity, by completing incomplete process of MV adaptation, has a strong rationale, which however needs to be validated with longer follow-up. [ABSTRACT FROM AUTHOR]

Background and Aim: Second-order chord tethering of the anterior leaflet is a risk factor for failure of posterior leaflet prolapse repair.Materials and Methods: We describe two cases of second-order chord tethering of the anterior leaflet associated with severe mitral regurgitation due to prolapse or chordal rupture of the anterior leaflet, causing early and late failure of repair.Results: We described two cases where this phenomenon happened.Conclusions: Our cases demonstrate that the second-order chords of the prolapsing AL can be tethered and that this aspect should be carefully evaluated before surgery, as it can progress over time, affecting the results of surgical repair. [ABSTRACT FROM AUTHOR]

Ischemic mitral regurgitation (IMR) is generally perceived as a disease with a normal mitral valve (MV) and a regurgitation based on left ventricular and annular changes, overlooking the importance of MV size and remodeling, which should be considered as one of the most important variables. The adaptive mechanism of the MV components following the onset of IMR is focused on the increase of chordae tendinae length and leaflets area and length to prevent the development of significant IMR and is multifactorial. Mitral valve enlargement in chronic aortic regurgitation as a compensatory mechanism to prevent functional mitral regurgitation in the dilated left ventricle. [Extracted from the article]

Background: We sought to identify subgroups of patients at a higher probability of tricuspid annuloplasty (TAP) failure early after surgery.Methods: From May 2009 to December 2015, 688 patients undergoing TAP for functional tricuspid regurgitation (FTR) at a single institution were included in the study. In all patients, a complete transthoracic echocardiographic evaluation of right ventricle (RV) and tricuspid valve (TV) apparatus was collected.Results: Twenty-six patients (3.8%) died within the first 30 days of surgery. Residual TR after TAP was recorded in 85 (12.4%), moderate in 80 (11.7%) and severe in 5 (0.7%). Preoperative TV apparatus remodeling was associated with residual TR; in particular, the following cutoffs were identified: TV coaptation depth ≥6.5 mm, tenting area ≥0.85 cm2 , and tricuspid annulus ≥35 mm. The entire cohort was stratified in three subsets: patients having preoperative mild/moderate TR without preoperative TV apparatus and/or RV remodeling (n = 178); patients having mild/moderate TR with TV apparatus and/or RV remodeling (n = 317); patients with severe TR regardless of TV apparatus and/or RV remodeling (n = 193). Residual TR was 2.8%, 10.4%, and 24.3%, respectively (P < 0.001). At multivariable analysis, patients showing preoperative mild/moderate TR with TV apparatus and/or RV remodeling as well as patients with severe TR were at significantly higher risk for early failure. No difference was found regarding the type of TV repair performed.Conclusions: Prophylactic TAP should be encouraged among surgeons even earlier than guidelines recommend, and decision-making for the treatment of low-grade FTR at the time of left-sided valve surgery should take into consideration not only annular size but also tethering severity and RV dilatation. [ABSTRACT FROM AUTHOR]

The impact of prosthesis-patient mismatch on long-term survival after aortic valve replacement: a systematic review and meta-analysis of 34 observational studies comprising 27 186 patients with 133 141 patient-years. The fallacy of indexed effective orifice area charts to predict prosthesis-patient mismatch after prosthesis implantation. Keywords: aortic valve; aortic valve replacement; patient prosthesis mismatch EN aortic valve aortic valve replacement patient prosthesis mismatch 978 980 3 02/17/21 20210301 NES 210301 In this issue of the Journal, Luthra et al.,1 using the effective orifice area (EOA) as provided by the manufacturers, found that long-term survival in patients who underwent aortic valve replacement (AVR) was influenced by the absolute EOA or indexed EOA (iEOA). [Extracted from the article]

In the last decades, the overlapping areas of intervention between cardiac surgeons and interventional cardiologists are rocketing, especially in the field of treatment of heart valve disease. But, while for the aortic valve the competition, even for nonhigh risk patients, has become tightened, in the context of mitral regurgitation, the surgery seems to not have competitors. In fact looking the results of studies published so far, a question arises: Is surgery the fair competitor for the Mitraclip? The meta‐analysis by Abdul Khader et al. summarized few evidences present in this field, only 11 observational studies and 1 randomized trial, providing an awesome response: "NO." Is therefore not a case if recently two trials, MITRA‐FR and COAPT, chose to use as competitor for MitraClip, more rightly, medical therapy instead of surgery. In conclusions, in case of mitral regurgitation (MR), surgery is still largely the gold standard treatment and so MitraClip cannot be mention at all as competitor of surgery. It can be the right choice of case of primary MR where patients showed high risk for surgery. In case of secondary MR, especially with large and poor left ventricle we should wait for a clear answer on its role, yet. [ABSTRACT FROM AUTHOR]

An editorial is presented where in the editor discusses the failure of annuloplasty alone to correct ischemic mitral regurgitation (IMR) based on two randomized controlled trails that explores the effectiveness of Mitral valve repair (MVr) in patients with IMR. The article reports that the trials demonstrated a lack of efficacy of MVr for any grade of IMR. It is noted that the trials indicated that most surgeons address only the annulus to repair IMR.

Since the first in‐human implantation, trans‐catheter aortic valve replacement (TAVR) has shown an exciting development in both technical and technological terms, becoming the standard of care for many patients, even not only inoperable ones. Although trans‐femoral (TF) access has the scepter of first‐line route for TAVR, in some cases, this access is not feasible, so several alternative routes were introduced over time. The network meta‐analysis by Hameed et al. has the great merit to provide a comprehensive picture. Hence, through either direct and indirect comparison, the authors confirmed as TF is the gold standard as access, followed by trans‐carotid and trans‐subclavian. Conversely, trans‐thoracic (trans apical and trans‐aortic) routes are the least safe and should be reserved only to sporadic cases. [ABSTRACT FROM AUTHOR]

The meta-analysis by Di Tommaso et al. demonstrated as elderly patients with mitral regurgitation (MR) undergoing mitral valve repair had lower short-term mortality and higher long-term survival with respect to patients undergoing mitral valve replacement. The benefit of repair is such, that initial surgical strategy is advisable in the elderly even in case of mild symptoms if compared with conservative management. However, even if repair can be performed in presence of some specific etiologies, as degenerative MR or secondary MR, there are always cases where a replacement can be an acceptable solution compared to a repair with uncertain future, regardless of our believes and our technical ability. [ABSTRACT FROM AUTHOR]

Mitral valve (MV) repair for mitral regurgitation (MR) due to posterior leaflet (PL) prolapse is achieved nowadays with a great success rate and a good survival, similar, in certain subgroups, to that of the normal population.1 Carpentier et al.2 defined the terms and put the principles which, with some modifications, are still followed by many surgeons. Chan et al.15 reported 110 patients who had MV repair for MV prolapse and found that 20% of patients had a MV area less than or equal to 1.5 cm², with a mean gradient more than or equal to 5 mmHg. However, around 25% of patients in the respect group and 40% of patients in the resection group had a MV area less than 1.5 cm SP 2 sp , and severe mitral stenosis (MS) mandates a strict follow-up according to the American and European guidelines.10,11 Those areas are definitely smaller than usual. [Extracted from the article]

The article presents a case study of a 60-year old male with angina who underwent coronary angiography which showed three vessel disease and intercoronary fistula and aneurysmal dilatation from right coronary artery.

A 74-year-old woman showed electrocardiographic signs of severe lateral ischemia with no hemodynamic consequence after mitral valve repair for severe mitral regurgitation. An angiogram showed interruption of the proximal circumflex artery. The patients then underwent an on-pump beating heart marginal branch revascularization. A new angiogram performed before discharge showed a widely patent graft. (J Card Surg 2010;25:163-165) [ABSTRACT FROM AUTHOR]

Background: Different techniques have been proposed to measure the correct length of artificial chordae. We herein describe a new simple method to measure the chordal length in complex chordal replacement. Method: Chordal replacement was used by us for two different purposes: (1) to maintain the correct chordal length for the anterior leaflet (AL) and (2) to eliminate any movement of the posterior leaflet (PL) to fix it. To reach this goal, the AL is pulled up to the maximum extent and the new chordae are tied 5 mm higher than the related border. On the contrary, in the PL the new chordae are tied at the level of the related border. Results: From March 2006 to March 2007, at the University of Catania, this technique was used in 32 patients (16 for correction of PL prolapse, 6 patients for correction of AL prolapse, and in 10 patients for correction of both leaflets prolapse). The number of chordae per patients was 8.6 for the PL and 6.8 for the AL. No patient died or had major complications. After a mean follow-up of 5 ± 2 months, two-dimensional echocardiography showed that all the patients had no or trivial mitral regurgitation (MR). The echocardiogram showed a correct movement of the new chordae. Conclusions: This technique allows to easily establish the length of the new chordae of the AL and, if necessary, of the PL in complex mitral valve repair. [ABSTRACT FROM AUTHOR]

Entrapment and detachment of guidewire fractures during percutaneous coronary intervention (PCI) are very rare, but can lead to life-threatening complications such as embolization, thrombus formation, and perforation. Surgical extraction of the remnant fragments is recommended if the percutaneous retrieval is not possible. We present a case of remnant guidewire into the left anterior descending artery (LAD) and aorta that led to acute coronary thrombosis following primary angioplasty. Surgical retrieval was possible only through a left main (LM) approach. (J Card Surg 2012;27:307-308) [ABSTRACT FROM AUTHOR]