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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

Summary This meta-analysis was designed to assess the effect of the use of arterial conduits (ACs) versus great saphenous vein (GSV) grafts as a third conduit for revascularization of the right coronary artery system, in addition to the bilateral internal mammary artery on the left coronary artery. PubMed and OVID’s version of MEDLINE were searched from January 2000 to September 2017 for relevant publications. The primary end point was the long-term mortality rate. The secondary end point was early mortality, defined as either in-hospital death or death within 30 days after the operation. Meta-regression was used to evaluate the effect of female gender and diabetes on the primary and secondary outcomes. A total of 10 studies (4121 patients) were selected for the systematic review and meta-analysis comparing ACs (1619) versus the GSV (2502), 6 (2548) comparing the GSV (2548) versus the right gastroepiploic artery (1023) and 5 comparing the GSV (2548) versus the radial artery (596). The pooled analysis did not show any difference between ACs and the GSV in terms of long-term mortality rates [hazard ratio (HR) = 0.75, 95% confidence interval (CI) = 0.56–1.01; P = 0.061]. When using the leave-one-out analysis, after the exclusion of 1 study (outlier), ACs were significantly associated with lower long-term mortality rates (HR = 0.67, 95% CI = 0.54–0.83; P

Ventricular remodeling after an acute myocardial infarction (AMI) includes changes in shape and, more importantly, in volume, together with a reduction of the systolic function, measured as ejection fraction or other parameters. Left ventricular volume reduction (LVVR) was conceived to reverse symptoms of heart failure by reducing LV size, improving, as a consequence, the systolic function in patients with remodeled heart after a myocardial infarction, mainly in the left anterior descending (LAD) territory. In the recent era the need for a more physiological shape is associated with the changing pattern of septoapical scars. The reduction of distensibility increases the end-diastolic pressure (and consequently pulmonary pressure) and affects remote zones earlier than in patients with dyskinetic areas. A number of volume-related or shape-related techniques have been described. The outcome of patients who underwent the Dor operation is satisfying. Survival at 5 years ranges from 61.5% to 72.9%. At 5 and 20 years freedom from death due to any cause has been 60% and 36.1%, respectively. Only a few papers have compared volume-related techniques with shape-related techniques. A 7-year survival of 61.5% vs. 72.1%, respectively (P = 0.041) has been reported, and our group has shown improved freedom from cardiac death in patients who underwent shape-related LVVR (86.6% vs. 76.3%, P = 0.032).

Female sex is perceived as an important risk factor for surgery and is included in the most diffused operative risk scores, as EuroSCORE II (1) and STS score (2). In a recent paper, it was again emphasized that in a ‘real world’ unselected cohort of patients who underwent myocardial revascularization, survival was superior as well as the rate of major adverse cardiovascular events (MACE) was inferior with coronary artery bypass grafting (CABG) rather than with percutaneous coronary intervention (PCI) in men, but not in women. Outcomes of women were worse than men and were equivalent with both procedure (3).

Our goal was to compare the observed and the expected rates of postoperative cerebrovascular accidents (CVA) in a large cohort of consecutive patients undergoing off-pump coronary artery bypass grafting (CABG) using the ∏-circuit as a no-touch technique.From January 2001 to May 2016, 3081 patients were consecutively submitted to an off-pump CABG operation using the ∏-circuit. A CVA was defined as a neurological deficit, lasting less (transient ischaemic attack) or more (stroke) than 24 h, diagnosed by a neurologist and confirmed by a computed tomography or magnetic resonance imaging scan of the brain. The primary end point was to compare the observed and the expected rates of CVAs; the latter was obtained using the Society of Thoracic Surgeons' calculator. The secondary end point was to compare the observed and the expected mortality rates using the Society of Thoracic Surgeons' calculator and the prevalence of postoperative complications. Moreover, we identified some subgroups at higher risk.The postoperative rate of CVAs was 0.5% (14 cases): 2 (0.1%) were transient ischaemic attacks and 12 (0.4%) were strokes. The mean expected CVA rate (1.6%) was significantly higher than the observed rate (P 0.001). None of patients who experienced postoperative CVAs died. The observed mortality was 1.3% (40 patients) vs the expected mortality (2.6%), which was significantly higher (P 0.001). Multivariable analysis identified age70 years old, diabetes, extracardiac vasculopathy and chronic renal failure as risk factors for postoperative CVAs. However, in all the subgroups of risk, except for those with chronic renal failure, the use of the ∏-circuit was associated with a low rate of CVAs.The ∏-circuit should be included as a possible choice among no-touch techniques. The observed rate of CVAs of 75% is lower than the expected rate.

Objective To evaluate the additive and independent prognostic value of abnormal right ventricle (aRV) and pulmonary hypertension (PH) in patients undergoing mitral-tricuspid surgery. Methods From January 2009 to December 2012, 541 patients underwent mitro-tricuspid surgery. The entire cohort was divided into 6 subgroups: 63 cases had normal RV and no PH (Group A), 180 normal RV but moderate PH (Group B), 101 normal RV but severe PH (Group C), 15 abnormal RV and no-PH (Group D), 86 abnormal RV and moderate PH (Group E) and 96 abnormal RV and severe PH (Group F). Results Forty-two (7.8%) patients died in hospital due to any cause: 1.6% in group A, 3.9% in group B, 8.9% in group C, 13.3% in group D, 9.3% in group E, 15.6% in group E, p =0.005. Among 78 patients with no-PH, mortality was significantly higher in patients with aRV (1.6%vs 13.3%. p =0.03). Among 344 patients with normal RV, mortality was significantly higher in patients with severe PH (1.6% vs 3.9% vs 8.9%. p=0.03). Comparing the presence of both abnormal RV and severe PH with the remaining patients, mortality was significantly higher in the first group (15.6% 6.1%, p =0.004). Multivariable analysis confirmed either the independent or the additive role of RV and PH. Conclusions In patients undergoing mitral-tricuspid valve surgery, the presence of either RV dysfunction/dilatation or severe pulmonary hypertension, might play an independent prognostic role for mortality. The worst scenario is surely the contemporary presence of both conditions.

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

Mitral valve (MV) repair for degenerative mitral regurgitation (MR) is achieved nowadays with a great success rate and a good survival, similar, in certain subgroups, to that of the normal population (1).

Background The aim of this retrospective study was to identify clinical, humoral and echocardiographic variables predicting rehospitalization and poor quality of life (QOL) in patients with reduced or mid-range ejection fraction heart failure. Methods From 2009 to 2012, 310 patients were admitted having signs and symptoms of heart failure with reduced ejection fraction. All the patients were followed by phone, calling the patients or the referring general practitioner. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used as the instrument to evaluate QOL: MLHFQ less than 24 is a good QOL, 24-45 is moderate QOL and more than 45 is poor QOL. The primary event was poor QOL and/or rehospitalization at 4 years. Results Seventy-nine patients died at median time of 21 months; 4-year survival was 72 ± 3%. Rehospitalization due to heart failure was recorded in 60 cases. Among 231 survivors, MLHFQ score was good in 99 (42%), moderate in 50 (21%) and poor in 88 (37%). Four-year freedom from death, poor QOL or rehospitalization was 51 ± 3%. Multivariable analysis identified the following risk factors: heart rate at discharge at least 70 bpm, ischemic heart disease, atrial fibrillation, hypercholesterolemia, chronic pulmonary disease, N-terminal pro brain natriuretic peptide at discharge, severe tricuspid regurgitation and mitral regurgitation more than moderate. Conclusion Clinical, laboratory and echocardiographic profile is crucial to predict long-term QOL of patients admitted for heart failure.

The surgical treatment of concomitant cardiac disease and lung cancer represents a challenge. We report the case of a 66-year-old high-risk female patient with severe aortic stenosis as well as severely impaired left ventricular function associated with coronary artery disease involving the left anterior descending artery complicated from a severe functional mitral regurgitation in which an early-stage non-small cell carcinoma was incidentally discovered during workup. Because of the possibility of potential negative impact of cardiopulmonary bypass on the cancer prognosis and the severe impairment of systolic function of the left ventricle that impeded the treatment of lung cancer as the first step of such a complex treatment, we planned to treat all the diseases in a single-stage procedure. Using an automated delivering system composed of a ventricular connector (Correx AVB; Correx, Inc, Waltham, MA USA), we were able to perform an apicoaortic bypass as well as a left anterior descending revascularization using the left internal thoracic artery, both on a beating heart without the aid of cardiopulmonary bypass and a three-segmentectomy of the left upper lobe with the removal of paraaortic nodes. Six months postoperatively, she was asymptomatic with a noticeable increase of systolic function, a mild mitral incompetence, and no appearance of tumor recurrence. To the best of our knowledge, this is the first case described in the literature in which three major problems involving cardiac valves, coronary arteries, and the lung have been treated in one stage without cardiopulmonary bypass.

We report a case of a woman at 32nd gestational week, admitted for resting dyspnea, showing left atrial (LA) myxoma. Cardiac myxomas are the most common primary benign tumors of the heart. The incidence of cardiac myxomas diagnosed in pregnancy is extremely low. In the present case, cesarean delivery and concomitant surgical resection of LA myxoma were both delayed after corticosteroid prophylaxis in order to reduce neonatal cerebral, intestinal, and pulmonary complications. .

The aim of this review article is to summarize current knowledge of the pathophysiology underlying right ventricular failure (RVF), focusing, in particular, on right ventricular assessment and prognosis. The right ventricle (RV) can tolerate volume overload well, but is not able to sustain pressure overload. Right ventricular hypertrophy (RVH), as a response to increased afterload, can be adaptive or maladaptive. The easiest and most common way to assess the RV is by two-dimensional (2D) trans-thoracic echocardiography measuring surrogate indexes, such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler velocity of the lateral aspect of the tricuspid valvular plane. However, both volumes and function are better estimated by 3D echocardiography and cardiac magnetic resonance (CMR). The prognostic role of the RV in heart failure (HF), pulmonary hypertension (PH), acute myocardial infarction (AMI), and cardiac surgery has been overlooked for many years. However, several recent studies have placed much greater importance on the RV in prognostic assessments. In conclusion, RV dimensions and function should be routinely assessed in cardiovascular disease, as RVF has a significant impact on disease prognosis. In the presence of RVF, different therapeutic approaches, either pharmacological or surgical, may be beneficial.

Tricuspid valve (TV) endocarditis is a common complication in intravenous drug addicts. In case of TV replacement, the main issue is the high risk of new endocarditis on TV prosthesis. On November 2014, a 44 year-old male patient with a history of intravenous drug addiction was referred for TV endocarditis owing to Staphylococcus aureus and severe regurgitation complicated by pulmonary embolism and heart failure. Preoperative echocardiography showed a large vegetation of the anterior leaflet (1.95 × 0.92 cm) covering a huge hole in the leaflet itself. Herein, a novel technique for the treatment of massive endocarditis of the TV is described. Complete anterior leaflet reconstruction was achieved with a huge equine pericardium patch along with native chordae tendinae reimplantation onto the free edge of the patch. Finally, a ring annuloplasty was performed to stabilize the valve reconstruction. The postoperative course was uneventful with evidence of trivial tricuspid regurgitation and no signs of IE recurrence. Complete reconstruction of the anterior leaflet with a patch of xenopericardium and native chordae tendinae reimplantation might be an alternative technique to TV replacement.

Transit-time flow measurement (TTFM) is a reliable method to check the graft function intraoperatively in coronary surgery. The given parameters are: Mean Graft Flow (MGF); Pulsatility Index (PI) and Insufficiency Ratio (%BF). Some cutoffs of these parameters have been identified as predictors for unfair 1-y clinical outcome: mean graft flow (MGF) less than 20 ml/min and high pulsatility index greater than 5. Other cutoffs have been found as related to postoperative angiography: MGF 15 ml/min or less and pulsatility index at least 3 (sensitivity 94%; specificity 61%); MGF less than 15 ml/min and pulsatility index greater than 3 for left coronary artery or pulsatility index greater than 5 for right coronary artery (sensitivity 96%; specificity 77%); MGF 15 ml/min or less and pulsatility index at least 5.1 left coronary artery (sensitivity 98%; specificity 26%). Hence, with the need to improve the diagnostic accuracy of TTFM, high-resolution epicardic coronary ultrasound module has been added to graft flow evaluation providing 2D ultrasound imaging (either in short-axis or long-axis) and color-flow mapping, allowing an accurate morphological evaluation of body graft and anastomosis. An intraoperative method aimed to verify coronary grafts should be easy to handle, not time consuming, minimally invasive, easily meaningful and relatively cheap; in addition, it should offer objective parameters more than qualitative criteria. We herein report the results of our experience with intraoperative graft verification with TTFM and high-resolution imaging along with a systematic review of the literature in this field with the aim to provide a road map to be followed.

Sometimes, patients scheduled for cardiac operations other than coronary artery bypass may be unsuitable for preoperative coronary angiography. We routinely use intraoperative high-resolution epicardial ultrasound to select the proper target for the graft and to check graft anastomosis integrity. We describe 3 patients who could not undergo preoperative coronary angiography for different reasons. In all cases, we discovered significant stenosis in the left anterior descending coronary artery, which required bypass grafting. Intraoperative verification by transit-time flow measurements confirmed the significant stenosis detected by imaging.

Objective In vitro tests demonstrated that the new cone-bearing configuration of the Jarvik 2000 (Jarvik Heart Inc, New York, NY) left ventricular assist device exhibits better hydraulic efficiency than the previous pin-bearing design. We investigated the long-term outcomes of patients who received the Jarvik 2000 left ventricular assist device, depending on bearing design. Methods A retrospective review of prospectively collected data from 18 centers included in the Italian Registry was performed. From May 2008 to September 2013, 99 patients with end-stage heart failure were enrolled. Patients were divided into 2 groups according to their Jarvik 2000 suspending mechanism: Group pin included patients with pin bearings (May 2008 to June 2010), and group cone included patients with newer cone bearings (July 2010 to September 2013). The 2 groups did not differ significantly in terms of baseline characteristics. Results A total of 30 of 39 patients (group pin) and 46 of 60 patients (group cone) were discharged. During follow-up, 6 patients underwent transplantation, and in 1 patient the left ventricular assist device was explanted. The cumulative incidence competing risk of the entire cohort for noncardiovascular-related death was 28% (20%-40%); the cumulative incidence competing risk for cardiovascular-related death was 56% (42%-73%): 71% in group pin versus 26% in group cone ( P = .034). The multivariate analyses confirmed that the pin-bearing design was a risk factor for cardiovascular death, along with Interagency Registry for Mechanically Assisted Circulatory Support class. Right ventricular failures and ischemic and hemorrhagic strokes were significantly higher in group pin. Conclusions Patients with the new pump configuration showed a better freedom from cardiovascular death and lower incidence of fatal stroke and right ventricular failure. Further studies are needed to prove the favorable impact of pump-enhanced fluid dynamics on long-term results.