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Limited data are available on the use of the prone position in cardiac surgery. Concerns in performing this maneuver in open cardiac surgery due to the risk of post-sternotomy wound infections and hemodynamic instability do not seem to be supported by existing evidence. Indeed, available data show that prone positioning may improve gas exchange in cardiac surgery patients as well. However, previous studies of prone positioning in this setting were heterogeneous in patient characteristics and outcomes evaluated. As a result, whether prone positioning also may be effective in reducing mortality in patients with postoperative acute respiratory failure, particularly in those who underwent surgery under extracorporeal circulation, remains to be clearly elucidated. The aim of this article is to provide an overview of available literature, which seems to suggest the efficacy of prone positioning, and to make an in-depth analysis of the studies on this topic by evaluating the efficacy of this maneuver on hard endpoints.

Background The hybrid approach has become the most effective treatment option for restoring sinus rhythm and reducing the risk of atrial fibrillation (AF) recurrence. However, several issues remain to be clearly defined, including the appropriate timing of the staged procedure and the most effective strategy. Methods Over a 12-year period of activity, we performed 609 AF ablation procedures via a right mini-thoracotomy. From this general population, 60 patients underwent a hybrid procedure with catheter ablation performed at least 4 weeks after the surgical procedure to confirm if effective complete electrical isolation of pulmonary veins was achieved. In 20 patients, the second stage procedure was performed during the same hospitalization due to patient’s electrical instability. The results obtained in immediate versus staged patients were compared. Results All patients were discharged after the first stage procedure in sinus rhythm. The 20 immediate patients had a shorter hospital stay compared with the staged patients, in whom the two hospitalizations resulted in a longer hospital stay (immediate 5.5 ± 1.6 days versus staged 8.7 ± 1.4, P Conclusion The hybrid approach for the treatment of AF was safe and effective in immediate restoring sinus rhythm and in its maintenance at follow-up. Our preliminary results show that both immediate and staged procedures show similar efficacy but this result is strongly influenced by the concomitant ablation of the Bachmann’s bundle, which appears to be the most important component of the treatment strategy in order to reduce the risk of recurrent AF.

Primary malignant cardiac tumors represent (PMCTs) a very rare disease with an incidence of 0.009%

Background. The effect of metabolic syndrome (MetS), defined as insulin resistance along with two or more of: obesity, atherogenic dyslipidaemia and elevated blood pressure, on post-operative complications after isolated heart valve intervention remains controversial. We hypothesized that MetS may negatively influence the post-operative course in these patients. Methods. Patients from 10 cardiac units who underwent isolated valve intervention (mitral ± tricuspid repair/replacement (MVS) or aortic valve replacement (SAVR), or transcatheter aortic valve replacement (TAVR) were included. MetS was defined according to the WHO criteria. Primary outcome was in-hospital mortality and overall post-operative length of stay. Relevant post-operative complications were also recorded. Results. From 2010 to 2019, 17283 patients underwent valve intervention. The MVS, SVAR and TAVR accounted for the 39.4%, 48.2% and 12.3% respectively of the whole. MetS compared to no-MetS was associated to higher mortality in the MVS group (6.5% vs. 2%, pConclusion. MetS was associated to more post-operative complications, with higher mortality in the MVS group. In the TAVR cohort, post-operative complications and mortality rate did not differ between patients with and without MetS, however length of stay was longer in the MetS group.

Catheter-based or surgical procedures in patients with long-standing persistent atrial fibrillation (LSPAF) remain a challenge. As a result, different approaches including hybrid (surgical and endocardial) ablation have been developed. Bachmann’s bundle (BB) is a mainly epicardial structure capable of sustaining arrhythmic reentry that could be involved in the development and perpetuation of atrial fibrillation. We investigated the efficacy and safety of an adjunctive BB ablation in LSPAF patients undergoing hybrid ablation. In a two-arm non-randomized study, consecutive LSPAF patients undergoing epicardial isolation of pulmonary veins with left atrial posterior wall (box lesion) with (n = 30, BB group) and without additional BB ablation (n = 30, CONV group) were enrolled in the study. All patients underwent an endocardial procedure within 6 weeks post-surgery to assess for potential lesion gaps and additional atrial substrate modification. The primary endpoint was freedom from AF through 12 months of follow-up. The two-staged hybrid ablation was successfully completed in all patients. One-year freedom from atrial arrhythmias recurrence rates was 96.6% in the BB group vs 76.6% in the CONV group (p = 0.025). At procedure completion, 30 (100%) and 17 (56%) patients had a spontaneous cardioversion in BB and CONV group, respectively (p < 0.001). No significant differences in quality of life or complication rates were observed. This initial experience shows, for the first time, that adjunctive BB ablation in the setting of hybrid ablation for LSPAF is a feasible and effective approach in increasing maintenance of sinus rhythm without increasing complication rates.

Insufflation of carbon dioxide (COFrom January 2018 to November 2021, we retrospectively collected data of one hundred consecutive patients undergoing minimally invasive mitral valve repair (MIMVR). Of these, fifty patients were insufflated with continuous COIn all patients that received continuous field flooding COContinuous field flooding insufflation of CO

Mitral valve surgery (MVS) is evolving. Compared to standard sternotomy (S-MVS), minimally invasive method (Mini-MVS) has been increasingly adopted in the last years with encouraging results for both repairs and replacements. We evaluated trends of surgical approaches and operative outcomes in a multicenter study involving 10 cardiac surgical centers in Italy.Patients who received isolated mitral valve surgery, including only a concomitant tricuspid valve repair, from January 2011 up to December 2017. Minimally invasive approach (right anterior mini-thoracotomy) and standard sternotomy was performed in 2602 and 1947 patients, respectively. Stratifying by surgery, 1493 patients per group were paired using a propensity matching procedure.The minimally invasive approach has been progressively more frequent over the years (from 27.5% in 2011 to 71.7% in 2017). Compared to S-MVS, Mini-MVS patients were younger with less preoperative comorbidities and less frequently operated for valve replacement or in association with tricuspid repair. The 30-day mortality was lower in the Mini-MVS (overall 1.2% vs 2.7%; p 0.001) as well as the incidence of most postoperative complications. Subjects paired by propensity score had similar 30-day mortality (1.9% vs 1.8%, p = 0.786) but lower blood transfusion and permanent pace-maker insertion. Cardiopulmonary bypass and cross-clamp time, initially longer in the Mini-MVS patients, became shorter in recent years for the minimally invasive approach.In a large multi-institutional recent cohort, minimally invasive mitral valve surgery has drastically increased being the preferred technique and appears to be safe with procedural duration shorter than the beginning.

There is high demand for minimally invasive mitral valve repair; however, it is unclear whether the minimally invasive approach provides the same performance as conventional sternotomy in a context of complex mitral valve disease. Here, we compared outcomes of minimally invasive and sternotomy procedures for bileaflet and Barlow's mitral valve disease.We performed a pooled meta-analysis of studies reporting early and late follow-up of mitral valve repair for complex mitral valve regurgitation. The primary outcome was moderate mitral valve regurgitation recurrence and need for reoperation. Secondary outcomes included operation time, reopening for bleeding, associated tricuspid procedures, failed repair, and inhospital mortality. Incidence rates were calculated for long-term follow-up. Effect estimates were calculated as incidence rates with 95% confidence intervals. When Kaplan-Meier curves were available, event rates were estimated from the curves with Plot Digitizer software; otherwise, reported event rates were used to calculate incidence rates.Eighteen studies including 1905 patients (654 minimally invasive and 1251 sternotomy) with a mean follow-up of 51.6 months (range, 14 to 138) were meta-analyzed with a random model. There were no significant between-group differences in moderate mitral valve regurgitation recurrence and reoperation (minimally invasive vs sternotomy, 1.7% [95% confidence interval, 1.0% to 2.9%] vs 1.3% [95% confidence interval, 0.9% to 1.8%], P = .22). Patients in the minimally invasive group were exposed to significantly longer cross-clamp and cardiopulmonary bypass times (P.01); however, there were no additional between-group differences in secondary outcomes.This meta-analysis has demonstrated that minimally invasive and sternotomy approaches produce comparable results for complex mitral valve repair.

Background The use of transcatheter aortic valve implantation (TAVI) continues to grow worldwide. Despite increased operator experience, evolution of the technique, and deflectable catheters, major complications still occur in ≤ 6% up to 8% of cases. Such major complications have been associated with a 2- to threefold increase in 30-day mortality. Complications specifically involving the aorta, aortic valve annulus, or left ventricle are rare, occurring in only 0.2–1.1% of cases. Case presentation We report the case of a 65-year-old female patient with left ventricular lateral wall perforation during incomplete implantation of a TAVI device, and successive percutaneous completion after surgical repair of the lesion under cardiopulmonary bypass. The surgical strategy and the type of surgical treatment depend on the type of perforation. In general, repair of the lesion and aortic valve replacement are performed. Removal of the TAVI prosthesis and excision of the native aortic valve are standard parts of this repair. Conclusion Here we propose a safe alternative for the completion of the TAVI approach after surgical repair, which requires close coordination between the members of the heart team (anesthesiologist, perfusionist, cardiologist, nurse and cardiac surgeon).

Little is known about the safety and clinical utility of retrograde autologous priming (RAP) in patients undergoing minimally invasive mitral valve surgery. The study authors hypothesized that RAP would increase the oxygen delivery index (DO2i) while decreasing red blood cell transfusion requirements compared to valve surgery without RAP.The study was an observational analysis.A single institutional study.The authors analyzed data from 500 consecutive patients who underwent minimally invasive isolated mitral valve repair from December 31, 2012, to December 31, 2019.RAP was performed in 235 patients (47%) prior to the initiation of cardiopulmonary bypass (CPB).A continuous monitoring system was used for DO2 management during CPB. The mean arterial pressure was maintained between 55 and 70 mmHg, and the cardiac index was set at 2.4 L/min/mIn a minimally invasive mitral valve context, RAP was safe and associated with better DO2i, higher hematocrit, and fewer intraoperative and postoperative red blood cell transfusions.

Background Patients with coronary artery disease and concomitant heart failure (left ventricular ejection fraction Materials and methods In this single-centre control study, 60 end-stage coronary artery disease patients undergoing isolated coronary artery bypass grafting (CABG) were included. Patients were divided into two groups of 30 patients each undergoing CABG using MiECC or conventional extracorporeal circulation (cECC). Results In the MiECC group, oxygen delivery index (DO2i) was 305 mL/min/m2 in relation to indexed oxygen extraction ratio (O2ERi) 21.5%, whereas in the cECC group DO2i was 288 mL/min/m2 in relation to O2ERi 25.6% (p = 0.037). Lactate levels > 3 mmol/L were reported in 7 MiECC patients vs 20 cECC patients (p = 0.038), with blood glucose peak. Mean nadir hemoglobin values during cardiopulmonary bypass (CPB) were 9.7 g/dL in the MiECC group vs 7.8 g/dL in the cECC group (p = 0.044). Cardiac index during CPB was 2.4 L/min/m2 in both groups. Red blood cell units administered were 8 vs 21 units in the MiECC vs cECC group (p = 0.022). A glycemic peak was recorded in 7 patients of the MiECC group and in 20 patients of the cECC group (p = 0.037). Conclusion In end-stage coronary artery disease, the MiECC technique was associated with a higher DO2i compared to cECC. MiECC patients showed a significant reduction in red blood cell unit administration and peak intraoperative lactate levels, which correlated with better postoperative outcome.

Infective endocarditis is a life-threatening condition and despite advances in antibiotic therapy, about one-third of patients require surgical treatment. The choice of the most appropriate surgical treatment is crucial. The study by Asen Petrov et al. paves the way for a new, safe, simple, and useful Calamari technique for the treatment of aortic valve endocarditis complicated by aortic root abscess (ARA). This technique was initially described in a series of five patients. The most interesting part of the study is that the procedure was effective (only one patient died 30 days after surgery) and fast (mean cardiopulmonary bypass time 90 ± 10.30 min; mean cross-clamp time 73.6 ± 12.12 min). As reported by Leontyev et al., the procedure of choice in ARA is represented by a wide range of procedures ranging from aortic valve replacement with debridement of the abscess to reconstruction of the intervalvular fibrous body and replacement of both the mitral valve and the aortic root. Alternatively, pericardial patch reconstruction is required in approximately one-third of cases. Radicality is key but a fast procedure is very important. In this scenario, the Calamari procedure is very useful, especially for its rapid execution (short cardiopulmonary bypass and cross-clamp time) which is associated with a reduction in mortality. A simple procedure to treat complex diseases. However, this procedure needs to be performed on more patients and its outcomes should be compared in trials with the other available techniques for the treatment of ARA.

Intraoperative temperature regimen usually is planned preoperatively by a "team." Selecting and understanding the impact of the temperature regimen (normothermia, or mild, moderate, or severe hypothermia) usually are related to the type of cardiac surgery (eg, using circulatory arrest or open-heart surgery). Cardiopulmonary bypass constitutes a challenging situation for monitoring temperature because of the rapid and extraordinary degree of heat transferred through the bypass circuit during heating and cooling. The core compartment undergoes the fastest temperature changes because of the rapid rate of blood reinfused into the organs. In modern cardiac surgery, different types and technologies of heater-cooler devices can be used in clinical practice, thanks to the development process that took its cue from past experiences. In this context, the authors review the role of thermal exchange in cardiac surgery and the progress achieved from first-to-second-generation heater-cooler devices.

OBJECTIVES Each surgical risk prediction model requires a validation analysis within a large ‘real-life’ sample. The aim of this study is to validate the age, creatinine and ejection fraction (ACEF) II risk score compared with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II. METHODS All patients operated on at 8 Italian cardiac surgery centres in the period 2009–2019 with available data for the calculation of EuroSCORE II and ACEF II were included in the study. Mortality was recorded and receiver operating characteristic curves were plotted for the overall study population and for different patient subgroups according to the type of surgery. RESULTS A total of 14 804 patients were enrolled [median age of 70 (62–77) years, 35.4% female], and among these, 3.1% underwent emergency surgery. Thirty-day mortality was 2.84% (n = 420). In the total population, the area under the curve with EurosCORE II was significantly higher than that recorded with ACEF II [0.792, 95% confidence interval (CI) 0.79–0.8 vs 0.73, 95% CI 0.73–0.74; P CONCLUSIONS In both the overall population and patient subgroups, EuroSCORE II proved to be more accurate than ACEF II. However, in patients undergoing bypass surgery, ACEF II proved to be an easy and simple to use risk score, demonstrating comparable risk prediction performance with the more complex EuroSCORE II.

BACKGROUND AND AIM OF THE STUDY The debate on the usefulness of the minimally invasive approach in mitral valve surgery is still open. The aim of this study is to describe a single-center case series of all comers undergoing minimally invasive mitral valve reconstruction. METHODS From 2010 to 2019, all the data recorded in the medical records of 893 consecutive patients undergoing mitral valve reconstruction through a right mini-thoracotomy were retrospectively collected. All patients were contacted by telephone for remote evaluation and integration of echocardiographic information on surgical results. RESULTS Mean age was 62.2 ± 14.5; 447 (50%) were female and mean log EuroSCORE was 2.5 ± 2.8%. At a mean follow-up of 4.1 ± 2.2 years (median 3.9), a total of 24 deaths (2.68%) were recorded. Twenty-four patients required rehospitalization for cardiac causes, 13 (1.4%) patients had at least moderate mitral insufficiency on follow-up echocardiography and, of these, seven patients underwent reoperation (0.8%). The cumulative hazard showed that 8.3% of patients experienced at least one event at 5 years. NYHA class improved significantly with 874 patients in NYHA class I, 13 in NYHA class II, 6 in NYHA class III, and 0 in NYHA class IV at last follow-up (p

Background This study was conducted to compare the outcomes of prosthetic ring versus autologous pericardial strip for the treatment of functional tricuspid regurgitation during left-sided valve surgery by minimally invasive approach. Methods From January 2008 and July 2016, autologous pericardial strip (group P-TAP) was used in 109 patients, and prosthetic ring (group R-TAP) in 115 patients. The primary outcomes were long-term overall survival, development of patch degeneration, and significant tricuspid regurgitation recurrence. The second outcome was the assessment of right ventricular functional parameters. Results Operative mortality was 1 case (0.9%) in the R-TAP group. At the time of hospital discharge only one patient (0.9%) in the R-TAP group had grade III+ tricuspid regurgitation, and none had grade IV+. Mean follow-up was 94.1 ± 24.5 months. Mild and moderate tricuspid regurgitation recurrence was 3.7% and 4.5% (P-TAP vs. R-TAP groups, p = 0.99). Severe regurgitation was observed in 1.8% of cases only in the R-TAP group (p = 0.49). There were no reoperations. Late mortality was 3.7% and 5.4% (P-TAP vs. R-TAP groups, p = 0.75). Freedom from death, all causes, were comparable among groups (log-rank p = 0.45). There were no statistically significant differences between two groups in TAPSE, left ventricular end-diastolic diameter, left ventricular ejection fraction, and left atrial diameter. Conclusions Tricuspid annuloplasty using an autologous pericardial strip in patients undergoing minimally invasive surgery is associated to similar long results (survival, late tricuspid regurgitation, and functional echocardiographic parameters) than annuloplasty with a prosthetic ring. In particular, the pericardial strip over time does not develop any degeneration or retraction.

Background Much debate is still going on about the best ablation strategy—via endocardial or epicardial approach—in patients with atrial fibrillation (AF), and evidence gaps exist in current guidelines in this area. More specifically, there are no clear long-term outcome data after failed surgical AF ablation. Methods Since June 2008, 549 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency device was used (151 patients), whereas from 2011 to 2020 a bipolar radiofrequency device was used (398 patients). Patients were scheduled for surgery on the basis of the following criteria: recurrent episodes of paroxysmal or persistent lone AF refractory to maximally tolerated antiarrhythmic drug dosing and at least one failed cardioversion attempt. Besides the recommended follow-up by the local cardiologist, starting from 2021, surviving patients were asked to undergo assessment of left ventricular function and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF. Results At a mean follow-up of 77 months, the rate of AF recurrence was 20.7% (n = 114). On multivariate analysis, impaired left ventricular ejection fraction (58 patients, 51%, p = 0.002), worsening of European Heart Rhythm Association (EHRA) symptom class (37 patients, 32%, p = 0.003) and cognitive decline or depression (23 patients, 20%, p = 0.023) during follow-up were found to be significantly associated with AF recurrence. Conclusions Surgical AF ablation through a right minithoracotomy is safe, but a better outcome could be achieved using a hybrid approach. Patients after initial failed surgical AF ablation show worsening of cardiac function, clinical status and quality of life at follow-up compared to patients with successful AF ablation.

This article introduces management algorithms to support operators in choosing the best strategy for metabolic management during cardiopulmonary bypass using artificial intelligence systems. We developed algorithms for the identification of the optimal way for assessing metabolic parameters. Different management algorithms for extracorporeal procedures interfaced with metabolic monitoring systems already exist on the market and are applied in clinical practice. These algorithms could provide guidance for selecting the best metabolic strategy with the aim at reducing human error and optimizing management.

OBJECTIVES Small aortic prosthetic valves have been associated with suboptimal performance due to patient–prosthesis mismatch (PPM). This meta-analysis compared the outcomes of patients with a small root who received tissue versus mechanical aortic valves. METHODS A systematic literature review identified 7 candidate studies; of these, 5 met the meta-analysis criteria. We analysed outcomes for a total of 680 patients (227 tissue valves and 453 mechanical valves) using random effects modelling. Each study was assessed for heterogeneity and quality. The primary end point was mortality at follow-up. Secondary end points included intraoperative and postoperative outcomes, the rate of PPM and left ventricle mass regression and major cardiac and prosthesis-related adverse events at follow-up. RESULTS There was no between-group difference in mortality at follow-up [incidence rate ratio 1, 95% confidence interval (CI) 0.50–2.01; P = 0.99]. The tissue group had a higher rate of PPM (odds ratio 17.19, 95% CI 8.6–25.78; P = 0.002) and significantly less reduction in ventricular mass (weighted mean difference 40.79, 95% CI 4.62–76.96; P = 0.02). There were no significant differences in the incidence of structural valve disease at follow-up compared to that in the mechanical valve group. There was also no between-group difference in aggregated adverse events at follow-up (P = 0.68). CONCLUSIONS Tissue and mechanical valves were associated with similar mortality rates; however, patients receiving tissue valves had a higher rate of PPM and significantly less left ventricle mass regression. These findings indicate that patients receiving small tissue valves may require closer clinical surveillance than those receiving mechanical valves.

Background Elevated plasma free hemoglobin is associated with multi-organ injury. In this context, minimally invasive extracorporeal technologies represent a way to reduce this complication following cardiac surgery. Methods We present a pilot study focused on plasma free hemoglobin levels in 40 patients undergoing isolated coronary artery bypass grafting (CABG). The same circuits for minimally invasive extracorporeal circulation (MiECC) were used in all patients. The ECMOLIFE magnetic levitation pump was used in the study group (n = 20), and the AP40 Affinity CP centrifugal blood pump was used in the control group (n = 20). Results In the immediate postoperative period, plasma free hemoglobin (PFH) and lactate dehydrogenase (LDH) were significantly lower in the study group than in the control group (10.6 ± 0.7 vs 19.9 ± 0.3 mg/dL, p = 0.034; and 99.16 ± 1.7 vs 139.17 ± 1.5 IU/L, p = 0.027, respectively). Moreover, patients treated with the magnetic levitation pump showed lower creatinine and indirect bilirubin (0.92 vs 1.29 mg/dL, p = 0.030 and 0.6 ± 0.4 vs 1.5 ± 0.9 mg/dL, p = 0.022, respectively) at 24 h after the procedure, and received fewer transfusions during the whole postoperative period (3 vs 9 red blood cell units (RBC), p = 0.017). Conclusion Our pilot study suggests that the use of magnetically levitated centrifugal pumps for extracorporeal circulation support is associated with a lower risk of hemolysis, though larger studies are warranted to confirm our results.

Background The debate on the best treatment strategy for atrial fibrillation (AF) has expanded following the introduction of the so-called “hybrid procedure” that combines minimally invasive epicardial ablation with endocardial catheter ablation. However, the advantage of the hybrid approach over conventional epicardial ablation remains to be established. Methods From June 2008 to December 2020, 609 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency (RF) device was used, whereas from 2011 to 2020 a bipolar RF device was used. In addition, between September 2016 and April 2017, 60 patients underwent endocardial completion of epicardial linear ablation. In 30 of these latter patients, surgical isolation of the Bachmann’s bundle (BB) was also performed. Starting from 2021, surviving patients at follow-up were asked to undergo electrocardiographic evaluation and left ventricular function assessment and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF. Results The ablation procedure was completed in all patients. Upon discharge, 30 (4.9%) patients showed recurrence of AF, whereas the remaining patients (95.1%) were in sinus rhythm. All patients in whom a hybrid approach was used either with or without BB ablation were discharged in sinus rhythm. After a mean follow-up of 74 months, 122 (20%) patients developed recurrent AF, including 19.9% in whom a unipolar RF device was used, 21% in whom a bipolar RF device was used, 23% who had undergone a hybrid procedure without BB ablation and 3.3% who had undergone a hybrid procedure with BB ablation. On multivariate analysis, reduced left ventricular ejection fraction, worsening of European Heart Rhythm Association symptom class, and cognitive impairment or depression during follow-up were found to be significantly associated with AF recurrence. Conclusions Surgical AF ablation through a right minithoracotomy is safe and may allow the creation of additional linear lesions, particularly in the BB. The placement of adjunctive linear lesions in the setting of a hybrid procedure can be more effective in reducing the risk for AF recurrence than isolated surgical ablation or hybrid ablation without the addition of further linear lesions, with no incremental risk to the patient.

Infective endocarditis represents a surgical challenge associated with perioperative mortality. The aim of this study is to evaluate the predictors of operative mortality and long-term outcomes in high-risk patients. We retrospectively analyzed 123 patients operated on for infective endocarditis from January 2011 to December 2020. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long term follow-up was made to asses late prognosis. Preoperative renal failure, an elevation EuroSCORE II and prior aortic valve re-replacement were found to be preoperative risk factors significantly associated with mortality. In-hospital mortality was 27% in patients who had previously undergone aortic valve replacement (n = 4 out of 15 operated, p = 0.01). Patients who were operated on during the active phase of infective endocarditis showed a higher mortality rate than those operated on after the acute phase (16% vs. 0%; p = 0.02). The type of prosthesis used (biological or mechanical) was not associated with mortality, whereas cross-clamp time significantly correlated with mortality (mean cross-clamp time 135 ± 65 min in dead patients vs. 76 ± 32 min in surviving patients; p = 0.0005). Mean follow up was 57.94 ± 30.9 months. Twelve patients died (11.65%). Among the twelve mortalities, five were adjudicated to cardiac causes and seven were non-cardiac (two cancers, one traumatic accident, one cerebral hemorrhage, two bronchopneumonia, one peritonitis). Overall survival probability (freedom from death, all causes) at 3, 5, 7 and 8 years was 98.9% (95% CI 97–100%), 96% (95% CI 92–100%), 85.9% (95% CI 76–97%), and 74% (95% CI 60–91%) respectively. Our study demonstrates that an early surgical approach may represent a valuable treatment option for high-risk patients with infective endocarditis, also in case of prosthetic valve endocarditis. Although several risk factors are associated with higher mortality, no patient subset is inoperable. These findings can be helpful to inform decision-making in heart team discussion.

Background We sought to determine if a modified technique for ascending aorta replacement with sinotubular junction reduction and stabilization was safe. Methods This technique was performed by suspension of the three commissures, invagination of the aortic Dacron graft and advancing the graft into the ventricles. We included patients with dilatation of the ascending aorta, normal sinuses of Valsalva dimension (25 mm) and with various degree of aortic insufficiency (from grade 1 to 3). Results From April to October 2019, 20 patients were recruited from two centers; mean age was 66.9 ± 12.8 years, 13 were male; grade 1, 2 and 3 was present in 12, 2 and 6 patients, respectively. All patients underwent ascending aorta replacement with modified technique; an additional open subvalvular ring was used in 8 patients with aortic insufficiency ≥ 2; cusps repair was performed in 6 patients (5 plicating central stitches/1 shaving); concomitant coronary artery bypass grafting was performed in 10 patients. There was no 30-day mortality. One patient was re-explored for bleeding. All patients completed six-month follow-up; at the transthoracic echocardiography, there was no aortic insufficiency ≥ 1 except one patient with aortic insufficiency grade 1 who underwent ascending aorta replacement and subvalvular ring; no patients underwent reintervention. Conclusions This modified technique for ascending aorta replacement and sinotubular junction stabilization was safe. It could be associated with other aortic valve sparing techniques. However, such remodeling approach has to be validated in a larger cohort of patients with longer follow-up.

OBJECTIVES Female sex is an established risk factor for postoperative complications after heart surgery, but the influence of sex on outcomes after minimally invasive cardiac surgery (MICS) for valvular replacement/repair remains controversial. We examined whether the role of sex as a risk factor varies by surgical approach [MICS vs conventional sternotomy (ST)] and further assessed outcomes among female patients including in-hospital mortality and postoperative complications by surgical approach. METHODS We analysed data from a multicentre registry for patients who underwent isolated aortic valve and mitral surgery with MICS or ST. The primary outcome was in-hospital mortality. Propensity score matching was used to minimize between-group differences. RESULTS Among the 15 155 patients included in the study, 7674 underwent MICS (50.6%). Female sex was equally distributed in the MICS and ST groups (47.3% vs 47.6%, respectively). Risk for surgery was higher in the ST group than in the MICS group {EuroSCORE II: 4.0 [standard deviation (SD): 6.8] vs 3.7 [SD: 6.4]; P = 0.005}, including among female patients only [ST vs MICS 4.6 (SD: 6.9) vs 4.2 (SD: 6.3); P = 0.04]. Mortality did not significantly vary by procedure among women [MICS vs ST, 2.4% vs 2.8%; hazard ratio 1.09, 95% confidence interval 0.71–1.73; P (surgical approach × sex) = 0.51]. The results also did not vary after adjusting for confounders. CONCLUSIONS Female sex was associated with higher mortality in patients undergoing valve surgery, regardless of surgical approach. In female patients, MICS did not provide any benefits over ST in terms of in-hospital deaths or postoperative complications. Subject collection 117, 125.

There is limited evidence as to the pharmacokinetic changes expected in adults with extracorporeal technologies. Drugs may be taken up by various components of the cardiopulmonary bypass circuit itself. Issues include the increased volume of the circuit leading to haemodilution; the sequestration of lipophilic drugs within the circuit tubing; and the absorption of proteins, especially albumin, onto the circuit, which can result in increased free drug. However, in this context, the aspect of pharmacokinetics and pharmacodynamics during minimally invasive extracorporeal circulation has not been described and evidenced by scientific studies. In this single-centre control study of 60 patients undergoing isolated coronary artery bypass grafting, we present the results focused on postoperative albumin values and intraoperative propofol dosages in patients undergoing surgery with minimally invasive (n = 30) versus conventional extracorporeal circulation (n = 30). In the minimally invasive extracorporeal circulation group, a lower propofol dosage titrated to a bispectral index of 40–45 was used during coronary artery bypass grafting, and an improvement of postoperative concentration of serum albumin was observed compared to the conventional extracorporeal circulation group.

The inflammatory response in cardiac surgery using extracorporeal circulation (ECC) has been widely discussed in the literature with analysis on cytokines released in humans; demonstrating manifold trigger causes. To mitigate this response—mainly linked to the contact and recognition by the blood of a “non-self” surface—many efforts have been made to make the circuits of the extra-corporeal circulation “biomimetics”; trying to emulate the cardio-vascular system. In other words, biomedical companies have developed many biocompatible products in order to reduce the invasiveness of the ECC. One of the techniques used to reduce the contact of blood with “nonself” surfaces is the “coating” of the internal surfaces of the ECC. This can be done with phospholipidic, electrically neutral, and heparin derivates with anticoagulant activity. The coating can be divided into two categories: the “passive coating” with Phosphorylcholine by biomedical companies and the administration of albumin added to the “priming” during the filling of the circuit by the perfusionist. Alternatively, we have the “active” coating: treatment of the internal surfaces in contact with the blood with neutral proteins and heparin. The latter are different according to the production company, but the aim is always to maintain high levels of systemic and local anticoagulation, inactivating the “contact” coagulation between the blood and the surfaces. A recent study demonstrates that the use of an “active coating” is associated with better preservation of the endothelial glycocalyx compared with “passive coating” circuits.

Objective Cardiac tumors are rare conditions. The vast majority of them are benign yet they may lead to serious complications. Complete surgical resection is the gold standard treatment and should be performed as soon as the diagnosis is made. Median sternotomy (MS) is the standard approach and provides excellent early outcomes and durable results at follow-up. However, minimally invasive (MI) is gaining popularity and its role in the treatment of cardiac tumors needs further clarification. Methods A systematic literature review identified 12 candidate studies; of these, 11 met the meta-analysis criteria. We analyzed outcomes of 653 subjects (294 MI and 359 MS) with random effects modeling. Each study was assessed for heterogeneity. The primary endpoints were mortality at follow-up and tumor relapse. Secondary endpoints included relevant intraoperative and postoperative outcomes; tumor size was also considered. Results There were no significant between-group differences in terms of late mortality (incidence rate ratio [IRR]: MI vs. MS, 0.98 [95% confidence interval [CI]: 0.25-3.82], p = .98). Few relapses (IRR: 1.13; CI: 0.26-4.88; p = .87) and redo surgery (IRR: 1.92; 95% CI: 0.39-9.53; p = .42) were observed in both groups; MI approach resulted in prolonged operation time but that did not influence the clinical outcomes. Tumor size did not significantly differ between groups. Conclusion Both MI and MS are associated with excellent early and late outcomes with acceptable survival rate and low incidence of recurrences. This study confirms that cardiac tumor may be approached safely and radically with a MI approach.

OBJECTIVES We performed a literature meta-analysis to estimate the rate of pacemaker implantation after Perceval sutureless aortic valve replacement. METHODS Pertinent articles were identified from the PubMed, Google Scholar, Ovid MEDLINE and Ovid EMBASE databases. Eligible studies reported the de novo incidence of postoperative pacemaker implantation after Perceval valve surgery. Among 394 articles retrieved, 26 studies including 9492 patients met the inclusion criteria. RESULTS The pooled event rate for postoperative pacemaker implantation was 7% [95% confidence interval (CI) 6–9%]; however, significant heterogeneity was observed across studies. In a sub-analysis, there was no difference between the rates of pacemaker implantation calculated from multicentre and registry studies (8 studies, 6845 patients; 7%, 95% CI 5–10%) and single-centre studies (18 studies, 2647 patients; 7%, 95% CI 5–9%; P = 0.75). Implantation rates were similar in high-volume studies (16 studies, 9121 patients; 7%, 95% CI 5–8%) than in low-volume studies (10 studies, 371 patients; pooled rate: 7%, 95% CI 4–14%; P = 0.5). Postoperative pacemaker implantation rates tended to decrease over time. CONCLUSIONS With a pooled event rate of 7%, postoperative pacemaker implantation remains an important limitation of Perceval sutureless valve surgery, although we observed a degree of variability across included studies. The resultant findings provide a useful estimate for physicians and patients and can serve as a benchmark for future comparative studies. PROSPERO registration number CRD42020188397.

Importance. Observational studies have suggested that the use of radial artery grafts for coronary artery bypass grafting may improve clinical outcomes compared with the use of saphenous vein grafts, but this has not been confirmed in randomized trials.Objective. To compare clinical outcomes between patients receiving radial artery or saphenous vein grafts for coronary artery bypass grafting at long-term follow-up.Design, Setting, and Participants. Patient-level pooled analysis comparing radial artery and saphenous vein grafts in adult patients undergoing isolated coronary artery bypass grafting from five countries (Australia, Italy, Serbia, South Korea, and United Kingdom; enrollment years: 1997 to 2009, follow-up completed in 2019).Intervention. Patients were randomized to receive either radial artery or saphenous vein grafts for coronary artery bypass grafting.Main outcomes and measures. The primary outcome was a composite of death, myocardial infarction or repeat revascularization, and the secondary outcome was a composite of death or myocardial infarction.Results. 1036 patients (534 radial artery group) were randomized (mean age 66.6 vs 67.1 years, males 70.4% vs 69.9% in the radial artery and the saphenous vein groups, respectively); 942 (90.9%) of the originally randomized patients completed 10 years of follow-up (510 radial artery group). At a median follow-up of 10 years (interquartile range 10-11), the use of the radial artery was associated with a statistically significant reduction in the incidence of the composite outcome of death, myocardial infarction or repeat revascularization (220 vs 237 events; 41 vs 47 events per 1000 patient-years; hazard ratio[HR] 0.73, 95%confidence interval[CI] 0.61-0.88, pConclusions and relevance. In this individual participant data meta-analysis with a median follow up of 10 years, among patients undergoing coronary artery bypass grafting, the use of the radial artery compared with saphenous vein grafts was associated with a lower risk of a composite of cardiovascular outcomes.

Surgical treatment of atrial fibrillation generally consists in the isolation of the pulmonary veins ("box-lesion"). Bachmann's bundle is a cardiac structure that may play an important role in the genesis of the atrial fibrillation. Surgical isolation of such bundle has not been reported before. We aim to describe how to perform minimally invasive epicardial pulmonary vein isolation along with the isolation of the Bachmann's bundle. Adding the surgical ablation line of Bachmann's bundle is a feasible, fast, and easy procedure that may be contribute to the reduction of atrial fibrillation relapses.

Chronic secondary mitral valve regurgitation is associated with a poor prognosis. Yet, in contrast to primary mitral regurgitation, there is no clear evidence that a reduction in regurgitation improves survival. The limited availability of data regarding secondary mitral regurgitation has resulted in a low level of evidence for treatment recommendations. We evaluated the influence of minimally invasive mitral valve annuloplasty on survival, freedom from recurrent regurgitation, and other echocardiographic parameters in patients with "standalone" secondary mitral valve regurgitation.The analysis included patients with severe secondary mitral regurgitation, left ventricular function40%, and persistent symptoms, despite optimal medical therapy. We excluded patients who were eligible for coronary artery revascularisation or cardiac resynchronisation therapy (i.e., not standalone mitral regurgitation). After discharge, patients were scheduled for outpatient clinic follow-up at 1, 3, 6, and 12 months.From 2012 to 2018, 54 consecutive patients underwent minimally invasive mitral valve annuloplasty for severe standalone secondary mitral regurgitation. All patients were discharged with no or trivial residual regurgitation. The mean duration of follow-up was 33.5±16.8 months. Overall survival was 90% at 4 years postprocedure. Freedom from moderate regurgitation or reintervention was 89% at the 4-year follow-up. There was a low incidence of readmission for heart failure and patients showed consistent improvements in left ventricular function and symptoms.Mitral valve repair with reduction and stabilisation of the annulus may be beneficial for symptomatic patients with secondary stand-alone mitral regurgitation.

We described an alternative technique for ascending aorta replacement with sinotubular junction reduction and stabilization. This technique is performed by suspending the 3 commissures, invaginating the aortic polyester fiber graft, and advancing the graft into the ventricles. The proximal anastomosis is performed with 2 suture lines. This procedure is easy, fast, and hemostatic. It can be adopted in some cases of ascending aorta dilatation with aortic regurgitation due to loss of the sinotubular junction.

Spinal cord ischemia remains a dreadful complication after thoracoabdominal aortic aneurysm repair. The role of cerebrospinal fluid drain in such patients needs further clarifications. Tam and colleagues carried out an interesting decision analysis study that supports the routine use of the cerebrospinal fluid drain after thoracoabdominal aneurysm repair. They also demonstrated that the use of the cerebrospinal drain was safe. Here, we firstly discuss the paper's finding and methodology and, secondly, we try to simply explain what a decision analysis study is and, broadly, and how to construct a Markov model.

It is generally accepted that radial artery (RA) grafts have better mid-term patency rate compared to saphenous vein grafts. However, the clinical correlates of the improved patency rate are still debated. Observational studies have suggested increased survival and event-free survival for patients who receive an RA rather than a saphenous vein, but they are open to bias and confounders. The only evidence based on randomized data is a pooled meta-analysis of 6 randomized controlled trial comparing the RA and the saphenous vein published by the RADial artery International Alliance (RADIAL). In the RADIAL database, improved freedom from follow-up cardiac events (death, myocardial infarction and repeat revascularization) was found at 5-year follow-up in the RA arm. The most important limitation of the RADIAL analysis is that most of the included trials had an angiographic follow-up in the first 5 years and it is unclear whether the rate of repeat revascularization (the main driver of the composite outcome) was clinically indicated due to per-protocol angiographies. Here, we present the protocol for the long-term analysis of the RADIAL database. By extending the follow-up beyond the 5th postoperative year (all trials except 1 did not have angiographic follow-up beyond 5 years), we aim to provide data on the role of RA in coronary artery bypass surgery with respect to long-term outcomes.

Background We used a large patient-level data set including 6 angiographic randomized controlled trials (RCTs) on coronary artery bypass conduits to explore incidence and determinants of coronary graft failure. Methods Patient-level angiographic data of 6 RCTs comparing long-term outcomes of the radial artery and other conduits were joined. Primary outcome was graft occlusion at maximum follow-up. The analysis was divided as (1) left anterior descending coronary (LAD) distribution and (2) non-LAD distribution (circumflex and right coronary artery). Mixed-model multivariable Cox regression including all baseline characteristics with stratification by individual trials was used to identify predictors of graft occlusion. Results Included were 1091 patients and 2281 grafts, consisting of 921 left internal mammary arteries, 74 right internal mammary arteries, 710 radial arteries, and 576 saphenous veins. All left internal mammary arteries were used on the LAD, the other conduits were used on the non-LAD distribution. Mean angiographic follow up was 65 ± 29 months. Occlusion rates were 2.3% for the left internal mammary arteries, 13.5% for the left internal mammary arteries, 9.4% for the right internal mammary arteries, and 17.5% for the saphenous veins. At multivariable analysis, type of conduit used, age, female sex, left ventricular ejection fraction of less than 0.50, and use of the Y graft were significantly associated with graft occlusion in the non-LAD distribution. Conclusions Our analyses showed that failure of the left internal mammary arteries-to-LAD bypass is a very uncommon event. For the non-LAD distribution, the nonuse of radial artery, age, female sex, left ventricular ejection fraction of less than 0.50, and use of the Y graft configuration were significantly associated with midterm graft failure.

BACKGROUND: Few studies have evaluated the effect of chronic calcium-channel blocker therapy (CCB) on the angiographic and clinical outcome of radial artery (RA) grafts used for coronary bypass surgery. OBJECTIVES: The purpose of this study was to evaluate if CCB influences midterm clinical and angiographic outcomes of RA grafts. METHODS: Patient-level data of 6 angiographic randomized trials evaluating RA graft status at midterm follow-up were joined in this observational analysis. Cox regression and propensity score methods were used to evaluate the effect of CCB on the incidence of a composite of major adverse cardiac events (MACE) (death, myocardial infarction, and repeat revascularization) and graft occlusion. RESULTS: The study population included 732 patients (502 on CCB). The median clinical follow-up was 60 months. The cumulative incidence of MACE at 36, 72, and 108 months was 3.7% vs. 9.3%, 13.4% vs. 17.6%, and 16.8% vs. 20.5% in the CCB and no CCB groups, respectively (log-rank p = 0.003). Protocol-driven angiographic follow-up was available in 243 patients in the CCB group and 200 in the no CCB group. The median angiographic follow-up was 55 months. The cumulative incidence of RA occlusion at 36, 72, and 108 months was 0.9% vs. 8.6%, 9.6% vs. 21.4%, and 14.3% vs. 38.9% in the CCB and no CCB groups, respectively (log-rank p < 0.001). After controlling for known confounding, CCB therapy was found to be consistently associated with a significantly lower risk of MACE (multivariate Cox hazard ratio: 0.52; 95% confidence interval: 0.31 to 0.89; p = 0.02) and RA graft occlusion (multivariate Cox hazard ratio: 0.20; 95% confidence interval: 0.08 to 0.49; p < 0.001). CONCLUSIONS: In patients with RA grafts CCB is associated with significantly better midterm clinical and angiographic RA outcomes.