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Introduction Hereditary Angioedema is a rare disease caused by C1 esterase inhibitor deficiency leading to diffuse and potentially life-threatening oedema formation. Preventing attacks is critical, particularly for patients undergoing cardiac surgery. Case Report We report a case of a 71-years-old woman with a history of Hereditary Angioedema scheduled for open-heart surgery on Cardiopulmonary Bypass. Multidisciplinar teamwork and patient-targeted strategy were crucial to obtain a favorable outcome. Discussion Cardiac surgery is a major stressor for Angioedema attacks because of Complement cascade and inflammatory response activation leading to potential life-threatening oedema formation. In literature only few cases of complex open heart surgery under Cardiopulmonary Bypass are described. Conclusion Continuous updating and multidisciplinarity are key elements to manage patients with Hereditary Angioedema in cardiac surgery in order to reduce morbidity and mortality.

Aortic root disease can be treated with different surgical techniques. The surgical approach of choice depends on patients’ comorbidities and aortic valve conditions. We describe an operation combining a Sleeve aortic rootplasty with an aortic valve replacement, as an alternative to the classical Bentall procedure. The patient, a 63-year-old man, was admitted to our institution in April 2019 with severe aortic regurgitation, left ventricle dysfunction (ejection fraction = 44%), and aortic root ectasia (476 mm). Since a sparing aortic valve procedure was judged not feasible because of the thickness and retraction of the leaflets, we decided to perform a procedure through a sleeve operation to treat the aortic ectasia and a standard bioprosthetic aortic valve replacement to treat the aortic regurgitation. The patient had an uneventful postoperative course and was discharged on the sixth postoperative day with aspirin as sole antiplatelet treatment. This procedure may be considered an alternative to the Bentall operation. In fact, it may also offer complete treatment for the aortic root disease, avoiding coronary complications due to coronary ostia manipulation and reimplantation.

Objective To compare different vascular approaches on clinical outcome of patients undergoing transcatheter aortic valve implantation (TAVI) with self-expandable bioprosthesis. Methods We included all the patients undergoing CoreValve implantation at our institute between September 2007 and March 2014. They were divided into four groups based on the vascular approach: percutaneous transfemoral (pTF), cut-down transfemoral (cTF), transaxillary (TAx) and transaortic (TAo). Clinical outcomes were evaluated according to Valve Academic Research Consortium-2 recommendations. Results Out of 322 consecutive patients, 170 (53%) underwent pTF, 76 (23%) cTF, 32 (10%) TAx and 44 (14%) TAo approach. Although the TAx and TAo patients had a higher risk profile, they had a similar outcome compared with the pTF and cTF groups; in particular, there were no differences regarding cardiovascular and all-cause mortality at 30 days, 1 and 2 years, as well as stroke, myocardial infarction, bleeding, major vascular complications, permanent pacemaker implantation and acute kidney injury rates. The observed device success rate was higher in the TAo than in the other approaches (88.6 versus 65.9, 68.7 and 76.3% in the pTF, cTF and TAx groups, respectively; P = 0.019). No differences occurred regarding 30-day early safety and 1-year clinical efficacy across the four groups. Fluoroscopy time, amount of contrast medium used and minor vascular complications were significantly higher in pTF patients, as well as in-hospital stay in the TAo group. Atrial fibrillation and prosthetic valve regurgitation, but not the vascular approach, were independent predictors of all-cause mortality. Conclusion A more invasive vascular approach, for CoreValve implantation, even in higher risk patients, does not affect early-term, mid-term and long-term outcomes.

Background Refractory vascular spasm (RVS) concomitantly involving the entire coronary artery system and grafted conduits after coronary artery bypass grafting (CABG) surgery is a rare, but dreadful event. No consensus exists in terms of appropriate management. Methods Between 1986 and 2009, 5,762 patients underwent isolated CABG at our institution, and 7 patients experienced RVS involving the coronary arteries and implanted conduits. Mean age was 65.6 years and 3 were female. All patients received from 3 to 5 distal anastomoses, including use of the left internal mammary artery. During the same time period, 18 patients experienced perioperative vasospasm of a single coronary artery or of a grafted conduit. Results All diffuse RVS events occurred between 3 and 8 hours after surgery. All patients had diffuse ischemic-like electrocardiographic changes, and 5 patients rapidly developed cardiogenic shock in the intensive care unit. Angiography was quickly performed in all patients and showed diffuse RVS involving either the native coronary arteries or the anastomosed arterial and venous conduits. The first 5 patients of this series died in the catheterization lab due to rapidly evolving refractory cardiogenic shock and unresponsive cardiac arrest, despite intraaortic counterpulsation and aggressive pharmacologic interventions (selective vasodilators and systemic inotropes). In the last 2 patients, extracorporeal membrane oxygenation was quickly instituted (1 in the catheterization lab, 1 in the operating room) and RVS could be successfully managed with complete resolution of ongoing vasospasm. In the single vascular spasm, there was only 1 death for refractory cardiac arrest, whereas all the other patients were successfully treated with direct infusion of vasodilators. Conclusions Diffuse RVS after CABG is a rare but lethal condition. Our experience, although limited, indicates that in such cases an aggressive treatment, that is, prompt extracorporeal membrane oxygenation institution and controlled cardiocirculatory assistance, represents the preferred solution to face such a dramatic event and may save patient lives.

We hypothesized that a preoperative symmetric pattern with anterior mitral leaflet (AML) tethering predominance is related to lack of LVRR after restrictive annuloplasty.In 300 patients with surgical annuloplasty for chronic ischemic mitral regurgitation the AML and posterior mitral leaflet (PML) tethering angles were quantified and patients were divided on the basis of the preoperative anterior/posterior tethering angle ratio: there were 144 patients with symmetric (Group 1) and 156 with asymmetric (Group 2) preoperative tethering pattern patients underwent echocardiography preoperatively, at discharge and at follow-up appointments (6 months [IQR 5-8 months]; late, 48 months [15-63 months]). Reverse remodeling was defined as a reduction in left ventricular end systolic volume index15%.LVRR was higher in the asymmetric group at discharge (69.2% vs. 9.7%, p0.001), early (70.55% vs. 10.45%, p0.001 and late follow up (81.4% vs. 4.8%, p0.001). At multivariable regression analysis corrected by significant key factors of LVRR, symmetric leaflet tethering (OR, 4.8 [95% CI 2.9-5.6], p0.001), anterior tethering angle alpha'39.5 degrees (OR, 5.0 [95% CI 2.0-6.6], p0.001), coaptation height11 mm (OR, 2.5 [95% CI 1.1-3.3], p=0.006) and coaptation lengthor =8 mm at the end of procedure (OR, 2.0 [CI 0.8-3.0], p=0.01) were independent predictors of LVRR. Compared with patients with asymmetric pattern (adjusted OR 0.2 [95% CI 0.03-1.6), those with symmetric pattern had4-fold odds for lack of LVRR.The preoperative symmetric pattern with AML prevalence was strongly associated with lack of reverse remodeling after annuloplasty. An accurate echocardiographic evaluation of the tethering mechanisms should be incorporated into clinical risk assessment and prediction models.

The aim of our study was to examine the effects of statin therapy (atorvastatin) on post-implant structural changes of bovine pericardial tissue in a subcutaneous animal model.Sixty male C57BL/6 mice underwent subcutaneous dorsal implantation of bovine pericardial fragments. Animals were randomized to treatment with atorvastatin (50 mg/kg) (statin group - SG) or to vehicle (control group - CG). After 1.5 months, all fragments were explanted and submitted to histopathological assessment (semi-quantitative analysis) to elucidate extent of inflammatory infiltrate, signs of tissue injury, or presence of microcalcification. Calcium determination of the implanted pericardial tissue was also performed by inductively coupled plasma mass spectrometry (ICP-MS) assessment. ICP-MS analysis showed that pericardial fragments in SG had significantly (p0.01) less calcium content than CG (625+/-142 vs. 962+/-590 microg/g, respectively). Light microscopy showed marked inflammatory infiltrates and tissue injury of pericardial specimens in CG animals, whereas SG animals maintained a better preserved original pericardial structure.Our findings indicate that atorvastatin significantly attenuates the post-implant structural degeneration of artificial valve bovine pericardial tissue in a subcutaneous animal model. Further observations are mandatory to assess the effects of statins on the implanted bioprosthetic valve tissue in the blood circulation.

The aim of the study was to evaluate the effects of phosphorylcholine coating (PC) on intra-operative extracorporeal circulation (ECC) management and perioperative outcome. One hundred and twenty consecutive cardiac surgery patients were enrolled for the study. Patients were randomly assigned to ECC with PC circuits (60 patients) or to corresponding non-coated circuits (60 patients). Trans-oxygenator pressure drop, blood flows, flow resistances and ECC parameters were recorded at surgery before ECC institution and every 10 min thereafter until ECC discontinuation. Postoperative variables (hematological parameters, drainage blood loss, mechanical ventilation time, incidence of atrial fibrillation, use of blood products) were also assessed and compared between groups. No differences were found between the two groups in terms of demographics, operative, and hematological profiles. PC showed, at equal pump flows, to significantly (P

Aims This study was aimed at exploring the predictive value of Doppler-Derived Mitral Deceleration Time (DT) on left ventricular reverse remodelling (LVRR) in patients with chronic ischaemic mitral regurgitation (CIMR) undergoing combined undersized mitral annuloplasty (UMRA) and coronary artery bypass grafting (CABG). Methods and results Two hundred and fifteen patients undergoing combined UMRA and CABG for CIMR between September 2001 and September 2007 in our Institution were divided into four groups on the basis of baseline DT: Group 1, normal ( n = 48), Group 2, impaired relaxation ( n = 61), Group 3, pseudonormal ( n = 50), and Group 4, restrictive ( n = 56). Echocardiograms were performed, pre-operatively, at discharge and at follow-up appointments (100% complete, early, median 6 months [interquartile range 4–8 months]) and late, median 38 months (17–61 months). Left ventricular reverse remodelling, defined as a reduction in ESV > 15%, occurred in 95.7, 96.3, 88.3, and 0% in Groups 1, 2, 3, and 4, respectively ( P < 0.001). Logistic regression analysis showed that DT ≤ 125 ( P < 0.001) was a strong predictor of LVRR after annuloplasty. Conclusion Pre-operative assessment of DT adds significant information to commonly used indexes of global and regional function, and represent a very easy and cost-effective tool to accurately identify CIMR patients who can really benefit from annuloplasty.

Long-term durability of combined coronary artery bypass grafting and of undersized mitral ring annuloplasty (UMRA) is uncertain. A considerable number of patients show recurrent regurgitation. This study examines the difference in the benefit of UMRA on clinical end points and recurrence of mitral regurgitation between responders and nonresponders of left ventricular reverse remodeling.Study eligibility criteria were fulfilled by 204 patients with chronic ischemic mitral regurgitation (CIMR) who survived combined coronary artery bypass grafting and reductive annuloplasty between September 2001 and September 2006. Patients underwent echocardiography preoperatively, at discharge, and at follow-up appointments (100% complete). Median early follow-up was 6 months (interquartile range [IRQ], 3 to 8 months; late follow-up, 35 months (IRQ, 21 to 50 months). Reverse remodeling was considered a reduction in left ventricular end systolic volume index exceeding 15%.There were 84 responders (41.2%) of reverse remodeling (age, 68 +/- 7.4 years; 51 men) and 120 nonresponders (58.8%; age, 67 +/- 7.6 years; 78 men). Nonresponders had a higher recurrence of mitral regurgitation (p0.001), higher reoperation rate for failed repair (p0.001), and significantly larger left ventricular volumes and dimension at any study point (p0.001), with significant late increase of sphericity indexes exceeding preoperative values (p0.001). At multivariable analysis, a baseline myocardial performance index of less than 0.90 (p0.001), a systolic sphericity index of less than 0.72 (p0.001), and wall motion score index of less than 1.59 (p = 0.003) were independent predictors of reverse remodeling.Our experience suggests that more information on possible echo predictors of an inadequate result may improve preoperative decision making of CIMR patients for UMRA.

Background: The 6-min walking test (6MWT) is a simple test, which does not require expensive equipment or advanced training. It has been used in heart failure patients to assess exercise tolerance, the effects of therapy and prognosis. Accordingly, post-surgical cardiac rehabilitation may be a potential field of application of this test. Materials and method: One thousand three hundred seventy patients (70% males, mean age 64 10 years), consecutively admitted for intensive cardiac rehabilitation, underwent 6MWT within 15 days after different types of cardiac surgery (67% coronary artery bypass graft (CABG), 25% valve replacement, 4% both, 4% other). The 6MWT was repeated in a subgroup of 348 patients after 15 3 days of an in-hospital cardiac rehabilitation programme. Results: 6MWT (expressed as absolute value in metres and as a percentage of the predicted value) was well tolerated in all patients. The mean distance walked in 1370 patients was 304 89 m (corresponding to 58 15% of the predicted value). Distances walked were significantly shorter in older patients than younger (p < 0.05) and in women compared to men (251 78 m, 53 15%, vs 328 34 m, 60 14%, p < 0.001). Furthermore, the absolute distance walked in 6 min was significantly shorter in diabetics compared to non-diabetics (283 85 m vs 302 87 m, p = 0.001) and in no CABG compared to CABG patients (285 91 m vs 303 84 m, p < 0.001); no relation was found between distance walked and left ventricular ejection fraction (p = 0.5). Gender, age,comorbiditiesandtypeofsurgerywereindependentlyassociatedwith6MWTinthemultivariatemodel.Inthesubgroupofpatientsrepeating the 6MWT after the rehabilitation programme, the distance walked significantly increased (from 281 90 m, 51 76%, to 411 107 m, 77 81%, p < 0.001). The extent of improvement observed was similar according to sex, age, presence/absence of diabetes and type of surgery. Conclusions: Our data suggest that 6MWT is feasible and well tolerated in adult and older patients shortly after uncomplicated cardiac surgery and provides reference values for distance walked after cardiac surgery in this population. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: Prosthetic valve dysfunction after mitral valve replacement (MVR) may be caused by several factors, which often lead to repeated surgery. One of the most frequent determinants of reoperation is periprosthetic leakage (PPL). A few published reports have analysed PPL incidence and postoperative results after MVR, but no specific attention has been paid towards the potential relation between anatomical factors and PPL occurrence, particularly not bacterial-related. The aim of this study was to evaluate the location of PPL after MVR through a multicentre retrospective study.Methods:BetweenJanuary1985andNovember2005,135patients underwent reoperation atfourinstitutionsbecause ofPPL after MVR and met the study inclusion criteria. The mitral valve annulus (MVA) was analysed in a clockwise format, indicating 12 o’clock as the mid-point of anterior annulus as viewed from the atrium. Results: Overall hospital mortality was 3.7% (five patients). Repair of PPL was carried out in 83 cases whereas prosthetic valve replacement was necessary in 52 cases. The total number of sectors involved in PPL was 244. PPL occurred more frequently between hour 5 and hour 6, and hour 10 and hour 11, with the risk of leakage being, 2.8 and 2.0 times higher, respectively, thaninanyotherportionoftheMVA.Conclusions:OurstudysuggeststhatPPLoccursmorefrequentlyatantero-lateralandposteromedial segments of MVA. This finding might be linked to unusual anatomical and functional factors of the MVA and may call for adjunctive care to these sectors of MVA when performing suture placement during MVR.

Alpha1‐antitrypsin deficiency (A1ATD) is usually linked to chronic lung dysfunction and chronic liver disease. Recent evidence have shown involvement also of the cardiovascular system. Indeed, dissection of the thoracic aorta or of the coronary arteries, and intra-cerebral aneurysms has been shown to represent concomitant vascular adverse events and apparently related to the impaired vascular wall integrity, strictly related to the elastase levels which are usually modulated by the A1AT. The case herein reported describes a patient affected by A1ATD associated with a large pseudoaneurysm of the left ventricle without any known predisposing factors to pseudoaneurysm development (coronary artery disease, acute myocardial infarction, taruma and myocarditis) indicating that the connective tissue impairment documented in A1ATD may also affect the myocardial structure, ultimately leading to weakened wall integrity, sudden rupture and pseudoaneurysm formation successfully managed by a surgical approach.

Emergency surgery for acute vein graft perforation and balloon entrapment during percutaneous angioplasty is reported here. Prompt extracorporeal circulation through peripheral cannulation enabled the control of systemic perfusion despite cardiac arrest. Vein graft repair was achieved by an autologous pericardial patch. Appropriate and tailored mechanical circulatory support allowed successful extracorporeal circulation withdrawal, limited intraoperative cardiac damage, and postoperative controlled recovery of ventricular function with ultimate favorable outcome.

Coronary-to-bronchial anastomosis (CBA) is a rare anomaly. This vascular abnormality may be subclinical or be responsible for several pathophysiological events and symptoms involving the respiratory and/or the coronary system. We report the case of a patient with hemoptysis caused by this anomalous coronary-to-bronchial communication, who was concomitantly affected by aortic stenosis and coronary artery disease requiring surgical treatment. A coronary angiogram clearly demonstrated the abnormal vascular connection between the proximal right coronary artery and the bronchial arteries of the left inferior right lobe. The coronary branch was intra-operatively identified and ligated, in association with aortic valve replacement and coronary artery bypass, with an uneventful postoperative course and resolution of the respiratory symptoms. This case presents an unusual cause of hemoptysis due to CBA in patients with other cardiac comorbidities, which required surgical treatment, allowing direct ligation of the CBA. A review of the clinical and therapeutic characteristics of such a peculiar vascular abnormality is also provided.

Primary cardiac angiosarcoma (AS) is an extremely rare malignanttumor associated with a dismal prognosis due to a rapid infiltratinggrowthandasystemicspread.Symptomsaregenerallylinkedtocardiactamponadeorcontractileimpairment,butaspecificmanifestationsmayalsocharacterizetheclinicalscenario.Thediagnosisisusuallysuggestedby transthoracic echocardiography and confirmed at computer tomog-raphy (CT) or at magnetic resonance imaging (MRI), although specifichistopathologicalandimmunohistochemicalassessmentsmaybeneed-ed at time [1].WedescribeacaseofafemalepatientadmittedtoourIntensiveCareUnit for severe respiratory insufficiency requiring mechanical ventila-tion and initially attributed to non cardiac-related disease because ofgenericsymptoms,withafinaldiagnosisofASresponsibleforacompli-cated and dismal clinical course.A 29-year-old woman was referred to our hospital for progressiveshortnessofbreathandrespiratorydistresswhichrequiredtrachealintu-bation immediately after hospitaliz ation and admittance to the IntensiveCareUnit.Thepatienthadbeenrecentlyhospitalizedtwiceinanotherpe-ripheralhospital forspontaneouspn eumothorax,enter orrhagiaandperi-cardialtamponade.Insuchpreviousadmittancesshehadbeensubmittedtocomplete,althoughnotconclusive,workup(includingpercutaneouspericardial fluid drainage with fluid assessment for tuberculosis orneoplastic cells, echocardiography, bronchoscopy and colonoscopy).Evidence of blood in the rectal ampulla had been found during thoseassessments,withembolizationofaninferiormesentericarterybranchthought to beresponsible for the intestinalbleeding. Noother findingshad been reported.Chest X-ray carried out in the ICU showed a right pneumothorax(Fig. 1A) that was immediately drained. ECG showed sinus rhythmand low voltage. The transesophageal echocardiography showed amarked pericardial effusion, percutaneously drained, an aneurismaticinteratrial septum, a large patent foramen ovale (8–10 cm), a giantright appendage, and a highly echogenic mass at the posterior wall.The atrial mass presented a mobile component with irregular profile,and crossed the tricuspid orifice, without apparent infiltration of thevalvular apparatus (Fig. 1B).The thoracic MRI confirmed the presence of the cardiac mass andshowedunspecifiednodulesspreadinbothlungs( Fig.1C).Atransvenousmyocardial biopsy was performed unsuccessfully, since the sample wasnot representative. Surgical resection of the cardiac mass was considerednot indicated because of the uncertain nature of the cardiac mass and thepoor patient clinical conditions.A sudden blindness and coma subsequently occurred. The brain CTscan documented several hemorrhagic lesions around the tentoriumterritory (Fig. 1D). Blood tests were within normal levels except fromhighPCR, procalcitonin,increasedspecific neuronal enolase, and severeanemia and thrombocytopenia (30,000).After this neurological event, patient general conditions further dete-riorated until the exitus at one week after the ICU admission.The autopsy revealed a cardiac mass consistent with spindle sarco-ma cells, secondary tumor localizations as well as several hemorrhagicareas in the brain and in both lungs. Immunohistochemical stainsshowed a positivity for the endothelial marker CD31, CD34, Fly1 andnegativity for the ORF 73 cytokeratin 7 and 20 and actin.The diagnosis of primary cardiac AS was finally confirmed (Fig. 2).Primary cardiac tumors are extremely rare with an incidence rang-ing between 0.001% and 0.03% in autopsy series [1]. Malignant cardiacneoplasmsoccurmoreoftenasmetastasisoflymphoma,leukemia,mel-anoma, and lung cancer. In adults, malignant primary tumors of theheart are quite rare (25% of all cardiactumors) and includeAS, rhabdo-myosarcoma and fibrosarcoma [1].While the most common benign primary tumors of the heart areusually single and affect the left cardiac side, malignant tumors distrib-ute equally between both sides of the heart. Angiosarcoma is the most

Background— The present study was aimed at determining the impact of type 2 diabetes mellitus (DM) on postoperative bioprosthetic structural valve degeneration. Methods and Results— Twelve Italian centers participated in the study. Patient data refer to bioprosthetic implantations performed from November 1988 to December 2009, which resulted in 6184 patients (mean age 71.3±5.4 years, 60.1% male) being enrolled. Of these patients, 1731 (27.9%) had type 2 DM. The propensity score–matching algorithm successfully matched 1113 patients with type 2 DM with the same number of no-DM patients. The postmatching standard differences were less than 0.1 for each of the covariates, and 64.2% of DM patients were matched. The early (30 days) mortality rate was 7.8% (n=87) versus 2.9% (n=33) in patients with or without type 2 DM ( P P Conclusions— Patients with type 2 DM undergoing bioprosthetic valve implantation are at high risk of early and long-term mortality, as well as of structural valve degeneration.

Lung erosion represents a dreadful complication in patients affected by thoracic aortic aneurysms. Intraoperative occurrence of severe bleeding and extensive air leakage from the pulmonary erosion is usually quite particularly dangerous and challenging because of fragile lung tissue to be repaired, hypo-coagulative state, and the need for full mechanical ventilation. We report the case of a patient who had uncontrollable pulmonary bleeding and marked air leakage from an aortic aneurysm-induced lung erosion and laceration, which were effectively treated with a hemostatic patch (Tachosil, Nycomed, Linz, Austria) after unsuccessful conventional surgical approaches.

No data exist in the English-language literature about patients with Barlow disease associated to Steinert syndrome and little is known about the employment of hypothermic cardiopulmonary bypass (CPB) and hyperkalemic cardioplegia in these patients. We present our experience with six patients affected by myxomatous degeneration associated to Steinert disease undergoing complex mitral valve repair. In all patients we employed mild hypothermic CPB (31 degrees C) and myocardial protection was achieved, in the entire cohort, by the use of blood hyperkalemic cold cardioplegia. The postoperative course was uneventful in all patients and neither shivering nor generalized muscle contraction were observed. Furthermore, all patients have remained well on an outpatient basis. Hypothermic CPB and hyperkalemic cardioplegia can be safely employed in patients with Steinert syndrome requiring complex cardiac surgery. Further large studies are necessary to confirm our findings.

BackgroundWe investigated leaflet and subvalvular configurations to identify mechanisms leading to recurrent mitral regurgitation after combined undersized mitral annuloplasty and coronary artery bypass and to preoperatively recognize patients who are unlikely to benefit from this approach.MethodsAmong 261 subjects with chronic ischemic mitral regurgitation undergoing undersized annuloplasty and coronary bypass surgery at one institution between September 2001 and September 2007, 31 were excluded: 4 had intraoperative annuloplasty failure, 12 showed residual regurgitation, and 15 had incomplete echocardiograms available. The study population consisted of 230 patients who were divided into 2 groups: patients without (group 1, n = 176) or with (group 2, n = 54) late recurrent mitral regurgitation. Fifty healthy subjects were used as control subjects. Serial echocardiographic analysis was performed preoperatively, at discharge, and at follow-up appointments (early: median, 6 months [interquartile range, 5–6 months; late: median, 33 months [interquartile range, 17–51 months]).ResultsSubjects with late regurgitation had preoperatively more symmetric tethering (P < .001), more accentuated anterior mitral leaflet tethering (P < .001), and more restricted anterior leaflet excursion (P = .003) than patients in group 1. Postoperatively, tethering of the posterior leaflet increased (P < .001) and was predominant in both groups, whereas tethering of the anterior leaflet was reduced at discharge (P = .01 and P = .03, respectively), remaining constant afterward. Multivariable analysis showed an anterior tethering angle of 39.5° or greater (P < .001), an anterior/posterior tethering angle ratio of 0.76 or greater (P < .001), an anterior leaflet excursion angle of 35° or less (P = .001), and a coaptation height of 11 mm or greater (P = .04) to be predictors of recurrent mitral regurgitation.ConclusionsPreoperative symmetric tethering with anterior mitral leaflet predominance was strongly associated with recurrence of mitral regurgitation. Measures of leaflet tethering resulted in fundamental findings to identify ischemic patients who can really benefit from restrictive annuloplasty. Further larger studies are necessary to confirm our results.

Objective: To evaluate postoperative outcome of emergency surgery for acute severe mitral regurgitation (ASMR) from a multicentre experience. Methods: In six centres, 279 patients (mean age 62 +/- 14years, 62% female) undergoing emergency surgery for ASMR from December 1986 to March 2007 were analysed and followed up. Aetiology included acute myocardial infarction (AM]) in 126 patients (group 1, 45%), degenerative mitral valve disease in 74 (group 2, 26%), and acute endocarditis (AE) in 79 (group 3, 28%). Preoperatively, all patients were in haemodynamic instability, with 185 patients in cardiogenic shock (66%), 184 (66%) intubated, and 61 (22%) on IABP, respectively. Valve repair was performed in 76 (27%), whereas 203 (73%) underwent valve replacement. Median follow-up (98% complete) was 70.8 months (inter-quartile range 59.8-86.66 months). Results: Overall 30-day mortality was 22.5% (63/279). Early death was significantly tower in group 2 (p < 0.001 and p = 0.005 vs group 1 and 3, respectively) whereas no difference was detected between group 1 and 3. At logistic regression analysis AMI, AE, shock, left ventricular dysfunction, and coronary artery disease were predictors of early death. Overall 15-year survival was 67 +/- 10%. Survival was lower in group 1 (39 +/- 11%) than in group 2 (75 +/- 9%) and group 3 (77 +/- 10%). Cox regression found AMI, and associated coronary artery disease to be predictors of late death. Overall 15-year actuarial and actual freedom from cardiac-related events were 44 +/- 9% and 28 +/- 10%, respectively, with the worst outcome in the presence of AE. Associated coronary artery disease, AE, AMI, preoperative atrial fibrillation, and chronic renal failure were independent predictors of cardiac-related events. Conclusions: Emergency surgery for ASMR remains a surgical challenge for high incidence of early and late cardiac-retated events, particularly in patients with associated coronary artery disease and acute endocarditis. Apparently, type of mitral valve surgical approaches (repair or replacement) did not provide any influence on postoperative outcome. (C) 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All. rights reserved.

Aims We present 5-year echocardiographic results of combined undersizing mitral ring annuloplasty (UMRA) and coronary artery bypass grafting (CABG) in chronic ischaemic mitral regurgitation (CIMR). Methods and results Two hundred and fifty-one patients (aged 68.4 ± 8.1, 62.5% male) undergoing combined CABG and UMRA in our Institution (Cardiac Surgery, Careggi Hospital, Florence, Italy) between September 2001 and March 2007 were prospectively enrolled in the study. Median follow up was 32.9 months [interquartile range (IQR) 17.5–51.6]. Fourteen patients with significant residual mitral regurgitation (MR) needing immediate intraoperative revision ( n = 3) or at discharge ( n = 11) were excluded from the study. Serial echocardiograms were performed in 220 survivors at baseline, discharge, and annually thereafter. Additionally, 17 patients died (2 early and 15 late deaths) and were also excluded from the study. MR remained stable at 1 year and re-increased at 3 years ( P < 0.001) and 5 years ( P < 0.001). Five-year actuarial survival was 83.2 ± 4.4. Five-year freedom from re-operation for failed repair was 78.2 ± 4.9%. Mean systolic and diastolic diameters decreased significantly at discharge ( P = 0.001 and P = 0.01, respectively) and at early follow up ( P = 0.004 and P = 0.02) but raised at 3 years ( P < 0.001) and 5 years ( P < 0.001). Systolic and diastolic sphericity indexes improved at discharge ( P < 0.001) remained stable at 1 year but they re-increased at 3-year control ( P = 0.006 and P = 0.03, respectively) with a late raise exceeding the pre-operative value ( P < 0.001). Left ventricular reverse remodelling was observed in 44.2% of the study population with 10.3% of patients showing further left ventricular dilatation. At multivariable model, end-systolic volume ≥145 mL, systolic sphericity index ≥0.7, myocardial performance index ≥0.9, and wall motion score index ≥1.5 were predictors of recurrent MR. Conclusion Our findings emphasize the need for improved repair technique and better patient selection to identify patients with anticipated repair failure who could benefit more from valve replacement or other procedure directly addressing ventricular tethering.

This study was aimed at exploring the predictive value of diastolic function on clinical outcome and recurrence of ischemic mitral regurgitation following combined undersized mitral annuloplasty (UMRA) and coronary artery bypass grafting (CABG).Two hundred-thirty-four patients with chronic ischemic mitral regurgitation (CIMR) who survived combined UMRA and CABG between September 2001 and September 2007, were divided into four groups on the basis of baseline deceleration time (DT) and systolic-diastolic pulmonary venous flow ratio (S/D): Group 1, normal (n=48), Group 2, impaired relaxation (n=61), Group 3, pseudonormal (n=60) and Group 4, restrictive (n=65). Echocardiograms were performed, preoperatively, at discharge and at follow-up appointments (early, 6 months [interquartile range, IQR] 3-8 months; late, 38 months [IQR17-53 months]).Early mortality rate was highest in the restrictive group (9.2%, p0.001). In addition 6-year actuarial survival was significantly lower in Group 4 (p=0.025). At late follow-up, among patients in Group 4, 58.4% (n=38) had an MR gradeor=2 (p0.001). Furthermore, DT140 ms and S/D0.80 were independent predictors of early (p0.001 and 0.004, respectively) and late (both p0.001) death. Finally DT140 ms was the only diastolic independent predictor of MR recurrence (p0.001).In patients with CIMR undergoing combined CABG and UMRA restrictive LV diastolic filling pattern is an important preoperative marker of high early and late death and recurrence of MR.

Background: Recombinant activated factor VII (rFVIIa) has been increasingly used to stop life-threatening bleeding following cardiac operations. Nonetheless, the issue of dosing, given the expense and potential for thrombotic complications, is still of major concern. We report our experience with small-dose rFVIIa in patients with refractory bleeding after cardiac surgery. Methods and results: From September 2005 to June 2007, 40 patients (mean age 70.1 � 9.2 years, 52.5 males) received a low dose of rFVIIa (median: 18 mg/kg, interquartile range: 9— 16 mg/kg)forrefractorybleedingaftercardiacsurgery. Fortypropensityscore-basedgreedymatchedcontrolswerecomparedtothestudygroup. Low dose of rFVIIa significantly reduced the 24-h blood loss: 1610 ml [ 1285—1800 ml] versus 3171 ml [2725—3760 ml] in the study and control groups, respectively (p < 0.001). Thus, hourly bleeding was 51.1 ml [34.7—65.4 ml] in patients receiving rFVIIa and 196.2 ml/h [142.1—202.9 ml] in controls (p < 0.001). Furthermore, patients receiving rFVIIa showed a lower length of stay in the intensive care unit (p < 0.001) and shorter mechanical ventilation time (p < 0.001). In addition, the use of rFVIIa was associated with reduction of transfusion requirements of red blood cells, fresh frozen plasma and platelets (all, p < 0.001). Finally, treated patients showed improved hemostasis with rapid normalization of coagulation variables (partial thromboplastin time, international normalized ratio, platelet count, p < 0.001). In contrast, activated prothrombin time and fibrinogen did not differ between groups (p = ns). No thromboembolic-relatedevent was detected in our cohort.Conclusions: In our experience low-dose rFVIIa was associated with reduced blood loss, improvement of coagulation variables and decreased need for transfusions. Our findings need to be confirmed by further larger studies. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Mitral insufficiency, as many other fields in medicine, has witnessed profound changes in terms of knowledge, diagnostic process and therapeutic options. Mitral valve reconstruction has become the treatment of choice in the presence of a regurgitant valve, although numerous preoperative and operative clues have been shown to predict less satisfactory results of valve repair in the long term, calling for a careful revision of postoperative data and search for novel techniques of valve repair or reconsider valve replacement as an acceptable therapy in peculiar cases. Old scenarios, like rheumatic valve disease or acute endocarditis, are continuously under reassessment in an attempt to distinguish patient subsets amenable to tailored therapies, whereas new fields of intervention, like dilated cardiomyopathy, or better appraisal of pathophysiological mechanisms, like ischaemic mitral insufficiency, are emerging and represent new indications for surgical solutions. The most recent advances in the understanding of how some aetiologies and related mechanisms of mitral insufficiency exert substantial influence on the postoperative results represent new tools in the guidance of a more appropriate surgical decision-making Mitral insufficiency, as many other fields in medicine, has witnessed profound changes in terms of knowledge, diagnostic process and therapeutic options. Mitral valve reconstruction has become the treatment of choice in the presence of a regurgitant valve, although numerous preoperative and operative clues have been shown to predict less satisfactory results of valve repair in the long term, calling fora careful revision of postoperative data and search for novel techniques of valve repair or reconsider valve replacement as an acceptable therapy in peculiar cases. Old scenarios, like rheumatic valve disease or acute endocarditis, are continuously under reassessment in an attempt to, distinguish patient subsets amenable to tailored therapies, whereas new fields of intervention, like dilated cardiomyopathy, or better appraisal of pathophysiological mechanisms, like ischaemic mitral insufficiency, are emerging and represent new indications for surgical solutions. The most recent advances in the understanding of how some aetiologies and related mechanisms of mitral insufficiency exert substantial influence on the postoperative results represent new tools in the guidance of a more appropriate surgical decision-making.

Background Type 2 diabetes mellitus (DM) is known to negatively affect biological properties of venous vasculature, and, particularly, to reduce endothelium-derived nitric oxide release. This condition might influence venous graft function following coronary artery bypass surgery (CABG). The aim of this study was to evaluate the functional effects of a NO-releasing aspirin (NORA) on vein grafts (VG) of diabetics and control patients undergoing elective CABG. Methods In 40 consecutive ischemic heart disease patients, the effects of NORA were tested on segments of saphenous vein conduits harvested during elective CABG. Twenty patients had type-2 DM (mean age 69±2), whereas 20 patients had no DM (NDM) and represented the control group (mean age 67±4). Functional responses were tested by exposing VGs to NORA and to standard vasoactive agents in an organ-bath preparation. Histological features of VGs were also assessed by light and electronic microscopy. Results Significant impairment of endothelial-dependent vasodilation (acetylcholine induced) was documented in VGs of DM subjects. NORA induced a significant and comparable vascular relaxation in all venous segments of NDM and DM patients (56±12% of maximal relaxation vs 61±11% in the control group, respectively). Histology showed variable extent of vascular layer and cellular abnormalities in VGs of diabetics (intimal hyperplasia, calcific deposition, endothelial cell degeneration) likely responsible of the endothelial functional impairment, whereas control group VG showed preserved structures. Conclusions This preliminary study confirms the impairment of endothelium-dependent vasodilative property of VGs in DM patients. It also indicates that NORA effectively induces vasodilation of VGs which was effective also in DM patients thereby representing a promising therapy for diabetics undergoing CABG with the use of VGs, although further studies are mandatory to conclusively assess the safety and benefits of this pharmacological agent.

One of the most frequent causes of reoperation after heart valve replacement is periprosthetic leakage (PPL). Previous studies have failed to determine whether PPL is linked to specific anatomic details. The aim of this study was to examine the location within the aortic annulus where PPL occurs, and to evaluate the postoperative outcome after surgical correction.Between January 1985 and December 2001, 28 patients underwent reoperation because of PPL after aortic valve replacement. The aortic annulus was analyzed in a clockwise format with hour 1 corresponding to the commissure between the left coronary sinus and the right coronary sinus, hour 5 to the commissure between the right coronary sinus and the noncoronary sinus, and hour 9 to the commissure between the noncoronary sinus and the left coronary sinus.Overall operative mortality was 7.1% (2 patients). Repair of PPL was carried out in 8 patients whereas prosthetic valve replacement was necessary in 20 patients. Urgency or emergency operation (p0.0037), preoperative New York Heart Association class IV (p0.04), need for prosthetic valve replacement (p = 0.05), and implant of mechanical valve (p = 0.031) were independent determinants of dismal prognosis. Periprosthetic leakage occurred more frequently between hour 4 and hour 8 (19 patients), with the risk of leakage being two times greater than in other annular areas.Our study suggests that PPL occurs more frequently in a specific portion of the peculiar aortic annulus. In case of PPL diagnosis, a timely reoperation might decrease operative risks by avoiding emergency procedures and unfavorable preoperative clinical conditions, and preventing prosthetic valve replacement.

Aortic regurgitation (AR) and first-degree atrioventricular heart block (FDAVB) are encountered in ankylosing spondylitis (AS). This rheumatological disease also presents in 90% of the cases an immunogenetic marker that is Human Leucocyte Antigen-B27 (HLA-B27). In this report we describe a case of a patient presenting with AR, FDAVB, aneurysm and thinning of the ascending aortic wall, aneurysm of the sinuses of Valsalva and inferior myocardial infarction-like electrocardiographic pattern with unknown cardiac AS and absence of other AS-related systemic manifestations.

Ten years earlier, she had receivedmediastinal radiation for thoracic non-Hodgkin’s lymphoma.Mitral valve disease was confirmed by intraoperative trans-esophageal echocardiography (TEE), and mild tricuspid regur-gitation (TR) with normal leaflet motion and a thickened hyper-reflecting pericardium were also observed. The transmitral andhepatic venous flows were normal, and the inferior vena cavawas slightly dilated. To cannulate the vena cava and access theright atrium, the surgeon stripped the pericardium before theinstitution of cardiopulmonary bypass (CPB). The mitral valvewas successfully repaired by means of an annuloplasty and ringimplantation; no residual MR was detectable afterward.Weaning from CPB was achieved with the use of norepi-nephrine, 0.06 g/kg/min, and a high preload. The patient hadan abnormally high central venous pressure of 27 mmHg with“ventricularization” of the right atrium pressure profile. Pulmo-nary artery pressure was within the normal range (20/7 mmHg).The TEE showed severe TR despite successful mitral valve repair(Fig 1). No new wall motion abnormalities were present, and rightand left ventricular function were excellent. What is the diagnosis?

Appropriate sternotomy and sternal closure are the most important factors in mechanical stability of the sternum and prevention of several postoperative complications. Easy techniques for identifying the sternal midline to facilitate opening and for obtaining reinforced closure are described. These techniques require minimal additional time. They are particularly indicated in patients at risk of sternotomy-related complications, and helpful to young surgeons in training.

Acute pulmonary embolism (PE) remains a lethal entity with a mortality ranging from 45% to 91% [1,2]. The main predisposing factor to acute PE is venous thrombosis of the lower limbs. Emboli may obstruct major or several peripheral pulmonary artery branches with severe hemodynamic compromise, thus representing a life-threatening complication. Other conditions may lead to intravenous thrombus eventually leading to acute PE. We describe a case of acute PE originating from thrombi attached to the central venous infusion lines in a patient submitted to coronary artery bypass grafting.

Figure 1: (A) Transoesophageal echocardiography and 64-slice multidetector computed tomography angiogram (small window) showing the lipoma as a 30 × 35-mm capsulated mass attached to the lateral wall of the right atrium. (B) Surgical view: a lipoma bulging from the right atrium as a spherical mass. (C) A lipoma in the surgeon’s hand. (D) Lipoma divided after removal. (E and F) Histological section at ×150 and ×200 magnification, respectively, showing adipose tissue intermixed with myocardium (haematoxylin and eosin stain). Asterisks denote the lipoma; RA: right atrium; LA: left atrium; SVC: superior vena cava; Ao: aorta; RAu: right auricle.

1010-7940/$ — see front matter # 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.ejcts.2006.06.022 draining to the coronary sinus (Fig. 1). Surgical treatment was revascularization of the diagonal branch (no reperfusion of the LAD) and ligation of the fistula. We report a case of a 63-year-old woman who was admitted at our institution for unstable angina with a severe coronary disease and circumflex coronary artery fistula

1010-7940/$ — see front matter # 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.ejcts.2005.11.034 preoperative echocardiographic assessment, was explanted for Bentall operation. After explantation the BSDP showed grooves on the occluder disc (Fig. 1). We report the case of a patient submitted to implantation of a Bjork-Shiley Delrin prosthesis (BSDP) on aortic position 31 years ago. The valve, despite optimal function at

Objective The results of mitral valve repair for anterior leaflet prolapse have been less gratifying than those reported for posterior leaflet prolapse. We compared the long-term durability of 2 different surgical techniques: the edge-to-edge repair, which is used for the treatment of anterior leaflet prolapse, and quadrangular resection, which has been adopted for correction of posterior leaflet prolapse. Methods From 1991 through April 2004, 133 patients with anterior leaflet prolapse and 605 with posterior leaflet prolapse caused by degenerative mitral disease underwent valve repair. The edge-to-edge repair was used for correction of anterior leaflet prolapse, and quadrangular resection of the posterior leaflet, with or without sliding plasty, was used for correction of posterior leaflet prolapse. All patients received a concomitant annuloplasty procedure. Results No hospital deaths occurred in the anterior leaflet prolapse group, whereas 2 (0.3%) patients died in the posterior leaflet prolapse group ( P = .7). Follow-up was 100% and 97.2% complete in the anterior and posterior leaflet prolapse groups, respectively. At 10 years, overall survival was 91% ± 4.06% for anterior leaflet prolapse and 93.5% ± 1.81% for posterior leaflet prolapse ( P = .18), and freedom from cardiac death was 95.8% ± 2.83% for anterior leaflet prolapse and 97.4% ± 0.95% posterior leaflet prolapse ( P = .27). Freedom from reoperation was 96% ± 2.3% in the anterior leaflet prolapse group and 96.5% ± 1.18% in the posterior leaflet prolapse group ( P = .37). At follow-up (mean, 4.5 ± 3.12 years; range, 1 month-13.2 years), New York Heart Association functional class I or II was documented in 93.2% of patients in the anterior leaflet prolapse group and 92.8% in the posterior leaflet prolapse group ( P = .98). Conclusions The long-term results of the edge-to-edge repair in the setting of anterior leaflet prolapse are similar to those obtained with quadrangular resection for the treatment of posterior leaflet prolapse.