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OBJECTIVES Papillary muscle rupture (PMR) is a rare but potentially fatal complication of acute myocardial infarction. The aim of this study was to analyse the patient characteristics and early outcomes of the surgical management of post-infarction PMR from an international multicentre registry. METHODS Patients underwent surgery for post-infarction PMR between 2001 through 2019 were retrieved from database of the CAUTION study. The primary end point was in-hospital mortality. RESULTS A total of 214 patients were included with a mean age of 66.9 (standard deviation: 10.5) years. The posteromedial papillary muscle was the most frequent rupture location (71.9%); the rupture was complete in 67.3% of patients. Mitral valve replacement was performed in 82.7% of cases. One hundred twenty-two patients (57%) had concomitant coronary artery bypass grafting. In-hospital mortality was 24.8%. Temporal trends revealed no apparent improvement in in-hospital mortality during the study period. Multivariable analysis showed that preoperative chronic kidney disfunction [odds ratio (OR): 2.62, 95% confidence interval (CI): 1.07–6.45, P = 0.036], cardiac arrest (OR: 3.99, 95% CI: 1.02–15.61, P = 0.046) and cardiopulmonary bypass duration (OR: 1.01, 95% CI: 1.00–1.02, P = 0.04) were independently associated with an increased risk of in-hospital death, whereas concomitant coronary artery bypass grafting was identified as an independent predictor of early survival (OR: 0.38, 95% CI: 0.16–0.92, P = 0.031). CONCLUSIONS Surgical treatment for post-infarction PMR carries a high in-hospital mortality rate, which did not improve during the study period. Because concomitant coronary artery bypass grafting confers a survival benefit, this additional procedure should be performed, whenever possible, in an attempt to improve the outcome. Clinical trial registration clinicaltrials.gov: NCT03848429.

Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction (AMI). Surgical repair, though challenging, is the only definitive treatment. However, given the rarity of this condition, results following surgery are still not well established. The aim of this study was to review a multicenter experience with the surgical management of post-infarction LVFWR and analyze the associated early outcomes. Background: Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction. Surgical repair, though challenging, is the only definitive treatment. Given the rarity of this condition, however, results after surgery are still not well established. The aim of this study was to review a multicenter experience with the surgical management of post-infarction LVFWR and analyze the associated early outcomes. Methods: Using the CAUTION (Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort Study) database, we identified 140 patients who were surgically treated for post–acute myocardial infarction LVFWR in 15 different centers from 2001 to 2018. The main outcome measured was operative mortality. Multivariate analysis was carried out by constructing a logistic regression model to identify predictors of postoperative mortality. Results: The mean age of patients was 69.4 years. The oozing type of LVFWR was observed in 79 patients (56.4%), and the blowout type in 61 (43.6%). Sutured repair was used in the 61.4% of cases. The operative mortality rate was 36.4%. Low cardiac output syndrome was the main cause of perioperative death. Myocardial rerupture after surgery occurred in 10 patients (7.1%). Multivariable analysis revealed that preoperative left ventricular ejection fraction (P

Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. A multi-center retrospective study was designed to assess pacemaker dependency (PMD) and long-term mortality after cardiac surgery procedures. Between 2004 and 2016, PPI-patients from 18 centers were followed. Time-to-event data were evaluated with semiparametric regression Cox models and semiparametric Fine and Gray model for competing risk framework. Of 859 (0.90%) PPI-patients, 30% were pacemaker independent (PMI) at 6 months. PMD showed higher mortality compared with PMI (10-year survival 80.1% +/- 2.6% and 92.2% +2.4%, respectively, log-rank p-value < 0.001) with an unadjusted hazard ratio for death of 0.36 (95% CI 0.20 to 0.65, p< 0.001 favoring PMI) and an adjusted hazard ratio of 0.19 (95% CI 0.08 to 0.45, p< 0.001 with PMD as reference). Crude cumulative incidence function of restored PMI rhythm at follow-up at 6 months, 1 year and 12 years were 30.5% (95% CI 27.3% to 33.7%), 33.7% (95% CI 30.4% to 36.9%) and 37.2% (95% CI 33.8% to 40.6%) respectively. PMI was favored by preoperative sinus rhythm with normal conduction (SR) (HR 2.37, 95% CI 1.65 to 3.40, p< 0.001), whereas coronary artery bypass grafting and aortic valve replacement were independently associated with PMD (HR 0.63, 95% CI 0.45 to 0.88, p = 0.006 and HR 0.807, 95% CI 0.65 to 0.99, p = 0.047 respectively). Time-to-implantation was not associated with increased rate of PMI. Although 30% of PPI-patients are PMI after 6 months, PMD is associated with higher mortality at long term. (C) 2020 The Author(s). Published by Elsevier Inc.

Background: The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery. Methods: This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC

BACKGROUND Isolated tricuspid valve (TV) surgery is a rare procedure generally considered at high risk for perioperative mortality and poor long-term outcomes. Surgical treatment can be performed with either an arrested heart (AH) or beating heart (BH) technique. The aim of this study was to compare the outcomes of isolated tricuspid surgery with 2 different approaches.METHODS The Surgical-Tricuspid Study is a multicenter international retrospective study enrolling adult patients who un- derwent isolated TV procedures (n = 406; age 56 +/- 16 years; 56% female) at 13 international sites. The AH and BH strategies were performed in 253 and 153 patients, respectively. Propensity score-matched analysis was used to compare groups.RESULTS After matching, 129 pairs were obtained and analyzed. The 30-day mortality rate was 6.2% versus 5.0% in the AH and BH groups, respectively (P = .9). The rates of acute renal failure requiring replacement therapy (10% versus 3%; P = .02) and stroke (1.6% versus 0%; P = .08) were numerically higher in the AH group. The 6-year survival rate was 67% +/- 6% versus 78% +/- 5% in the AH and BH groups, respectively (P = .18), whereas freedom from cardiac death was 75% +/- 5% versus 84% +/- 4% (P = .21). The 6-year composite cardiac end point of cardiac death and reoperation rate was 60% +/- 9% versus 86% +/- 5% (P - .024) comparing AH-TV replacement and BH-TV repair groups.CONCLUSIONS Isolated TV surgery performed with a BH strategy is a safe option and resulted in a trend of increased long-term survival and freedom from reoperation compared with the standard AH technique. Patients undergoing BH valve repair had the best long-term outcome. (C) 2022 by The Society of Thoracic Surgeons

Key Points Question What are the early outcomes of surgical treatment of postinfarction ventricular septal rupture? Findings In this cohort study of 475 patients from 26 different centers worldwide, the early mortality rate for surgically treated ventricular septal rupture was 40.4%, mostly due to low cardiac output, and it did not improve in the last 2 decades. Meaning The findings of this study suggest that patient-tailored preoperative and perioperative management of postinfarction ventricular septal rupture should be addressed to improve the current suboptimal survival rates., This cohort study assesses the clinical characteristics and early outcomes for patients who received surgery for postinfarction ventricular septal rupture and identifies factors independently associated with mortality., Importance Ventricular septal rupture (VSR) is a rare but life-threatening mechanical complication of acute myocardial infarction associated with high mortality despite prompt treatment. Surgery represents the standard of care; however, only small single-center series or national registries are usually available in literature, whereas international multicenter investigations have been poorly carried out, therefore limiting the evidence on this topic. Objectives To assess the clinical characteristics and early outcomes for patients who received surgery for postinfarction VSR and to identify factors independently associated with mortality. Design, Setting, and Participants The Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort (CAUTION) Study is a retrospective multicenter international cohort study that includes patients who were treated surgically for mechanical complications of acute myocardial infarction. The study was conducted from January 2001 to December 2019 at 26 different centers worldwide among 475 consecutive patients who underwent surgery for postinfarction VSR. Exposures Surgical treatment of postinfarction VSR, independent of the technique, alone or combined with other procedures (eg, coronary artery bypass grafting). Main Outcomes and Measures The primary outcome was early mortality; secondary outcomes were postoperative complications. Results Of the 475 patients included in the study, 290 (61.1%) were men, with a mean (SD) age of 68.5 (10.1) years. Cardiogenic shock was present in 213 patients (44.8%). Emergent or salvage surgery was performed in 212 cases (44.6%). The early mortality rate was 40.4% (192 patients), and it did not improve during the nearly 20 years considered for the study (median [IQR] yearly mortality, 41.7% [32.6%-50.0%]). Low cardiac output syndrome and multiorgan failure were the most common causes of death (low cardiac output syndrome, 70 [36.5%]; multiorgan failure, 53 [27.6%]). Recurrent VSR occurred in 59 participants (12.4%) but was not associated with mortality. Cardiogenic shock (survived: 95 [33.6%]; died, 118 [61.5%]; P

Hypertrophic Cardiomyopathy (HCM) is a pathological condition characterized by an abnormal thickening of the myocardium. When it affects the medio-basal portion of the septum, it is named Hypertrophic Obstructive Cardiomyopathy because it induces a flow obstruction in the left ventricle outflow tract, which may compromise the cardiac function and possibly lead to cardiac death. In this work, we investigate the hemodynamics of different HCM patients by means of computational hemodynamics, aiming at quantifying the effects of this pathology on blood flow and pressure gradients and thus providing clinical indications that may help diagnosis and the design of surgical treatment (septal myectomy). To this aim, we employ an enhanced version of an image-based computational pipeline proposed in a previous work, integrating fluid dynamics simulations with geometrical and functional data reconstructed from standard cine-MRI acquisitions. Blood flow is modelled as an incompressible Newtonian fluid, The corresponding Navier-Stokes equations are solved in a moving domain obtained from cine-MRI, whereas the valve leaflets are accounted for by a resistive method.

Background: To assess early and late mortality in patients with isolated acute tricuspid valve infective endocarditis (TVIE) using data from a multicenter registry.Methods: From 1983 to 2018, isolated acute TVIE was surgically treated in 157 (3.8%) patients [mean age 47 +/- 16 years (range 15-86 years), 25% females]. Of these, 142 (90%) had native tricuspid regurgitation, 7 (5%) native tricuspid valve (TV) steno-regurgitation, and 8 (5%) prosthetic TVIE. Intravenous drug use (IVDU) was recorded in 38% of patients, infection involved cardiac implantable electronic device leads in 21%, and vascular catheters for dialysis in 1%; in the remaining cases, the cause was unknown. The primary endpoint was in-hospital outcome, long-term freedom from recurrence and overall survival.Results: Overall, 77 (49%) patients underwent TV repair, 72 (46%) TV replacement, and 8 (5%) prosthetic TV replacement. Early mortality was 11% (n = 17). Expected early mortality according to EndoSCORE was 12%, with age (odds ratio 1.06) and redo (odds ratio 6.64) as risk factors. Late deaths occurred in 31 patients and TVIE recurrences in 4. Survival rates at 10, 20, and 25 years were 66%, 60%, and 44%, respectively. Risk factors were age [hazard ratio (HR) 1.06], mycotic TVIE (HR 4.2), IVDU (HR 4.90), infected prosthesis replacement (HR 4.4), and presence of cardiac implantable electronic device leads (HR 3.0). No significant difference was found in valve repair vs. replacement and in IVDUs vs. non-IVDUs.Conclusions: Patients with isolated acute TVIE undergoing surgical treatment show acceptable early and late outcomes. TVIE recurrence was low, and repair of the affected valve does not seem to confer any advantage either at early or long term up to 25 years. (C) 2019 Elsevier B.V. All rights reserved.

Infective endocarditis following a Mitraclip procedure might be an under-recognized complication. We describe the case of infective endocarditis by Bartonella henselae as a late complication in a patient with a previously implanted MitraClip system for mitral valve repair. Due to the severity of infection, surgical treatment was performed despite the high preoperative surgical risk, but recurrence of endocarditis of the biological valve implanted occurred. Although infection with Bartonella is known as a possible source of endocarditis, it has never been described before in relation to failed MitraClip therapy.

Objective: The aim of this multicenter study was to evaluated whether cold or warm cardioplegia are associated with postoperative atrial fibrillation (POAF) and the prognostic role of the latter on early stroke and neurological mortality.Method: This was a retrospective analysis of prospective collected data from 9 cardiac centers in Italy and the United States including patients undergoing surgery between 2010 and 2018. From the 9 institutional databases, 17,231 patients underwent isolated CABG on-pump, using either warm cardioplegia (n = 7730) or cold cardioplegia (n = 9501); among the latter group blood and crystalloid cardioplegia were used in 691 and 8810 patients, respectively. After matching, two pairs of 4162 patients (overall cohort 8324) were analyzed.Results: In matched population, the rate of POAF was 18% (1472 cases), 15% (608) in warm group versus 21% (864) in cold group (p < 0.001). Multivariable analysis confirmed that cold cardioplegia was associated with higher rate of POAF, along with age, hypercholesterolemia, LVEF, reoperation, preoperative IABP, previous stroke, cardiopulmonary and cross-clamp. Moreover, cold cardioplegia as well as POAF increased the rate of postoperative stroke as well as early mortality and neurological mortality Propensity-weighted cohort included 11,830 (70%) patients out of 17,231. After adjustment, both cold blood and cold crystalloid cardioplegia negatively influenced POAF, stroke and neurological mortality.Conclusions: Warm cardioplegia may reduce the rate of POAF in CABG patients with respect to cold cardioplegia, either blood or crystalloid. This has a prognostic impact on postoperative stroke and neurological mortality. (C) 2020 Elsevier B.V. All rights reserved.

Emerging studies address how COVID-19 infection can impact the human cardiovascular system. This relates particularly to the development of myocardial injury, acute coronary syndrome, myocarditis, arrhythmia, and heart failure. Prospective treatment approach is advised for these patients. To study the interplay between local changes (reduced contractility), global variables (peripheral resistances, heart rate) and the cardiac function, we considered a lumped parameters computational model of the cardiovascular system and a three-dimensional multiphysics model of cardiac electromechanics. Our mathematical model allows to simulate the systemic and pulmonary circulations, the four cardiac valves and the four heart chambers, through equations describing the underlying physical processes. By the assessment of conventionally relevant parameters of cardiac function obtained through our numerical simulations, we propose a computational model to effectively reveal the interactions between the cardiac and pulmonary functions in virtual subjects with normal and impaired cardiac function at baseline affected by mild or severe COVID-19.

BackgroundThe effect of COVID-19 on the cardiac function and on the vascular system increases the morbidity and mortality of infected subjects with cardiovascular diseases.ObjectivesTo provide preliminary results on cardiac global outcomes (such as cardiac output, ventricular pressures) obtained by means of computational models in plausible scenarios characterized by COVID-19.MethodsWe considered a lumped parameters computational model of the cardiovascular system, which models, from the mechanical point of view, the systemic and pulmonary circulations, the four cardiac valves and the four heart chambers, through mathematical equations of the underlying physical processes. To study the effect of COVID-19, we varied the heart rate, the contractility and the pulmonary resistances in suitable ranges.ResultsOur computations on individuals with both otherwise normal and impaired cardiac functions revealed that COVID-19 worsen cardiac function, as shown by a decrease of some cardiac biomarkers values such as cardiac output and ejection fraction. In the case of existing impaired cardiac function, the presence of COVID-19 lead to values outside the normal ranges.ConclusionsComputational models revealed to be an effective tool to study the effect of COVID-19 on the cardiovascular system. Such effect could be significant for patients with impaired cardiac function. This is especially useful to perform a sensitivity analysis of the hemodynamics for different conditions.CONDENSED ABSTRACTEmerging studies address how COVID-19 infection might impact the cardiovascular system. This relates particularly to the development of myocardial injury, acute coronary syndrome, myocarditis, arrhythmia, and heart failure. Prospective treatment approach is advised for these patients. By the assessment of conventional important biomarkers obtained with new sources as a 0-dimentional computational model, we propose a new study protocol as an effective method to evaluate short-term prognosis. The clinical protocol proposed will help to rapidly identify which patients require intensive monitoring, diagnostic strategy and most adequate therapy.

Systolic Anterior Motion (SAM) of the mitral valve – often associated with Hypertrophic Obstructive Cardiomyopathy (HOCM) – is a cardiac pathology in which a functional subaortic stenosis is induced during systole by the mitral leaflets partially obstructing the outflow tract of the left ventricle. Its assessment by diagnostic tests is often difficult, possibly underestimating its severity and thus increasing the risk of heart failure. In this paper, we propose a new computational pipeline, based on cardiac cine Magnetic Resonance Imaging (cine-MRI) data, for the assessment of SAM. The pipeline encompasses image processing of the left ventricle and the mitral valve, and numerical investigation of cardiac hemodynamics by means of Computational Fluid Dynamics (CFD) in a moving domain with image-based prescribed displacement. Patient-specific geometry and motion of the left ventricle are considered in view of an Arbitrary Lagrangian–Eulerian approach for CFD, while the reconstructed mitral valve is immersed in the computational domain by means of a resistive method. We assess clinically relevant flow and pressure indicators in a parametric study for different degrees of SAM severity, in order to provide a better quantitative evaluation of the pathological condition. Moreover, we provide specific indications for its possible surgical treatment, i.e. septal myectomy.

BACKGROUND: Patients with liver cirrhosis (LC) undergoing cardiac surgery (CS) face perioperative high mortality and morbidity, but extensive studies on this topic are lacking.METHODS: All adult patients with LC undergoing a CS procedure between 2000 and 2017 at 10 Italian Institutions were included in this retrospective cohort study. LC was classified according to preoperative Child-Turcotte-Pugh (CTP) score and Model for End-Stage Liver Disease (MELD) score. Early-term and medium-term outcomes analysis was performed in the overall population and according to CTP classes.RESULTS: The study population included 144 patients (mean age 66 ± 9 years, 69% male). Ninety-eight, 20, and 26 patients were in CTP class A, in early CTP class B (MELD score 12), respectively. The main LC etiologies were viral (43%) and alcoholic (36%). Liver-related clinical presentation (ascites, esophageal varices, and encephalopathy) and laboratory values (estimated glomerular filtration rate, serum albumin, and bilirubin, platelet count) significantly worsened across the CTP classes (P= .001). Coronary artery bypass grafting or valve surgery (87% bioprosthesis) were performed in 36% and 50%, respectively. Postoperative complications (especially acute kidney injury, liver complication, and length of stay) significantly worsened in advanced CTP class B (P= .001). Notably, observed mortality was 3-fold or 4-fold higher than the EuroSCORE (European System for Cardiac Operative Risk Evaluation) II-predicted mortality, in the overall population, and in the subgroups. At Kaplan-Meier analysis, 1-year and 5-year cumulative survival in the overall population was 82% ± 3% and 77% ± 4%, respectively. The 5-year survival in CTP class A, early CTP class B, and advanced CTP class B was 72% ± 5%, 68% ± 11%, and 61% ± 10%, respectively (P= .238).CONCLUSIONS: CS outcomes in patients with LC are significantly affected in relation to the extent of preoperative liver dysfunction, but in early CTP classes, medium-term survival is acceptable. Further analysis are needed to better estimate the preoperative risk stratification of these patients.

Background The impact of the coronary artery bypass grafting ( CABG ) technique (on‐ versus off‐pump, single versus multiple aortic clamping) on postoperative neurological outcome remains a matter of controversy. The aim of this study was to assess the association between the incidence of postoperative stroke and the degree of aortic manipulation in one of the largest contemporary CABG series. Methods and Results A retrospective, multicenter, international study was conducted in 25 388 patients undergoing isolated CABG procedures with on‐pump CABG ( ONCAB ) or off‐pump CABG ( OPCAB ) technique including single or multiple aortic clamping. Postoperative stroke was defined as a postoperative neurological deficit lasting more than 24 hours and associated with evidence of a brain lesion on computed tomography. The degree of aortic manipulation was assumed to be higher for on‐pump versus off‐pump surgery and for multiple versus single or no aortic clamping. Logistic regression and propensity matching were used. ONCAB procedures were performed in 17 231 cases and OPCAB in 8157. The incidence of postoperative stroke was significantly lower in the OPCAB group even after propensity matching (0.4% OPCAB versus 1.2% ONCAB , P =0.02). In the ONCAB group (but not in the OPCAB arm) the use of single aortic clamping was associated with significantly reduced postoperative stroke rate (odds ratio, 0.05; 95% CI , 0.008 to 0.07 [ P Conclusions OPCAB and the use of single aortic clamping in the ONCAB arm were associated with a reduced incidence of postoperative stroke. Our data confirm a strong association between aortic manipulation and neurological outcome after CABG surgery.

OBJECTIVES: We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design.METHODS: Data regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study.RESULTS: Overall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P -2 mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (OR = 1.02; P = 0.03), renal insufficiency (OR = 2.1; P = 0.05), triple valve surgery (OR = 6.9; P = 0.004) and shock (OR = 4.5; P CONCLUSIONS: PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patient's haemodynamic status and microbiological factors.

Coronary artery disease, caused by the buildup of atherosclerotic plaques in the coronary vessel wall, is one of the leading causes of death in the world. For high-risk patients, coronary artery bypass graft is the preferred treatment. Despite overall excellent patency rates, bypasses may fail due to restenosis. In this context, the purpose of this work was to perform a parametric computational study of the fluid dynamics in patient-specific geometries with the aim of investigating a possible relationship between coronary stenosis degree and risk of graft failure. Firstly, we propose a strategy to prescribe realistic boundary conditions in the absence of measured data, based on an extension of Murray's law to provide the flow division at bifurcations in case of stenotic vessels and non-Newtonian blood rheology. Then, we carry out numerical simulations in three patients affected by severe coronary stenosis and treated with a graft, in which the stenosis degree is virtually varied in order to compare the resulting fluid dynamics in terms of hemodynamic indices potentially involved in restenosis development. Our findings suggest that low degrees of coronary stenosis produce a more disturbed fluid dynamics in the graft, resulting in hemodynamic conditions that may promote a higher risk of graft failure.

A fast computational framework is devised to the study of several configurations of patient-specific coronary artery bypass grafts. This is especially useful to perform a sensitivity analysis of the hemodynamics for different flow conditions occurring in native coronary arteries and bypass grafts, the investigation of the progression of the coronary artery disease and the choice of the most appropriate surgical procedure. A complete pipeline, from the acquisition of patient-specific medical images to fast parameterized computational simulations, is proposed. Complex surgical configurations employed in the clinical practice, such as Y-grafts and sequential grafts, are studied. A virtual surgery platform based on model reduction of unsteady Navier-Stokes equations for blood dynamics is proposed to carry out sensitivity analyses in a very rapid and reliable way. A specialized geometrical parameterization is employed to compare the effect of stenosis and anastomosis variation on the outcome of the surgery in several relevant cases.

International audience; OBJECTIVE: To verify the rate of thromboembolic and hemorrhagic complications during the first 6 months after mitral valve repair and to assess whether the type of antithrombotic therapy influenced clinical outcome. METHODS: Retrospective data were retrieved from 19 centers. Inclusion criteria were isolated mitral valve repair with ring implantation. Exclusion criteria were ongoing or past atrial fibrillation and any combined intraoperative surgical procedures. The study cohort consisted of 1882 patients (aged 58 +/- 15 years; 36% women), and included 1517 treated with an oral anticoagulant (VKA group) and 365 with antiplatelet drugs (APLT group). Primary efficacy outcome was the incidence of arterial thromboembolic events within 6 months and primary safety outcome was the incidence of major bleeding within 6 months. Propensity matching was performed to obtain 2 comparable cohorts (858 vs 286). RESULTS: No differences were detected for arterial embolic complications in matched cohort (1.6% VKA vs 2.1% APLT; P = .50). Conversely, patients in the APLT group showed lower incidence of major bleeding complications (3.9% vs 0.7%; P = .01). Six-month mortality rate was significantly higher in the VKA group (2.7% vs 0.3%; P = .02). Multivariable analysis in the matched cohort found VKA as independent predictor of major bleeding complications and mortality at 6 months. CONCLUSIONS: Vitamin K antagonist therapy was not superior to antiplatelet therapy to prevent thromboembolic complications after mitral valve repair. Our data suggest that oral anticoagulation may carry a higher bleeding risk compared with antiplatelet therapy, although these results should be confirmed in an adequately powered randomized controlled trial

Background and aim:Endocarditis after Bentall procedure is a rare but severe complication. Infection usually involves the prosthesis, the annulus, and can lead to pseudoaneurysm or mediastinitis. Surgery in these patients is a challenge but conservative therapy, sometime preferred because of prohibi

Background Until now technologic evolution in coronary bypass surgery has focused on extracorporeal circulation, on operation without extracorporeal circulation, and on the exposure of the operative site. Recently a one-shot anastomotic device for the proximal anastomosis in coronary surgery was developed. We investigated whether the use of the aortic connector system (ACS) could facilitate the creation of aortosaphenous vein graft anastomoses in myocardial revascularization. Methods From November 2000, 40 ACS devices were used in 36 consecutive patients (mean age 70.7 ± 8.9 years); 12 patients (33.3%) underwent surgery on pump and 24 patients (66.6%) off pump; 50 distal anastomoses were performed. In all cases the connection with the ascending aorta was created before the distal anastomoses because of the necessity to slide the saphenous vein graft (SVG) over the vein transfer sheath. Intraoperative graft function was tested measuring blood flow by Doppler analysis. Postoperative evaluation of the anastomotic patency was carried out by early angiography in 34 patients (94.7%) but was excluded in 5 patients (5.3%) with extensive extracardiac vascular occlusive disease. Results Of 38 AC (95%) evaluated, 36 (94.7%) functioned properly. The end-to-side proximal anastomosis without aortic clamping is instantaneous, the quality of anastomoses was highly rated, no additional stitches were required, and all coronary arteries could be reached. Intraoperative quantity flow was measured by Doppler analysis and all but one showed good flow. Early postoperative angiography demonstrated good patency of the grafts in all cases but 2 (5.3%). At 1-year follow-up, 1 patient died of stroke; all other patients remained free of symptoms and no reoperation was required. Conclusions The use of ACS makes end-to-side anastomosis rapid, effective, and reproducible while eliminating aortic cross clamping; it opens a new era in beating or nonbeating coronary surgery. Long-term results are mandatory to confirm our favorable preliminary results.

Introduction: Permanent pacemaker (PPM) implantation represents a potential event after cardiac surgery. However, comprehensive investigation of robust patient cohorts in this respect is unavailable. Hypothesis: A multicenter retrospective study was undertaken to assess in-hospital and long-term postoperative outcome of a large patient population undergoing PPM soon after cardiac surgery procedures. Methods: Among 94.693 patients submitted to cardiac surgery procedures in 16 centers from 2000 to 2013, there were 1.156 patients (1.2 %) with PPM implantation during hospitalization postoperatively. Preoperative, in-hospital, and follow-up data were collected with a common dataset and analyzed. Follow-up was performed by direct visit, and PPM dependency was assessed by electrocardiogram and pacemaker check during periodic examinations. The identification of potential predictors of PPM dependency at follow-up was evaluated with a multivariate logistic regression. Results: Patient mean age was 69 years (range 17-92 years) and 53.4% were male. Preoperative electrocardiogram showed first degree atrio/ventricular block in 11.0% of patients, left bundle branch block in 11.1%, right bundle branch block in 11.0%, and atrial fibrillation in 22.8%, respectively. Most of the patients had had isolated aortic valve replacement (25.8%). Pacemakers were implanted after a median of 11 days after surgery. At follow-up, 43.6% of the patients did not show a PPM dependency with restoration of sinus rhythm. The multivariate logistic regression demonstrated that only preoperative right bundle branch block (p-value 0.031) and mitral valve repair (p-value 0.032) were independent risk factor for PPM dependency at follow-up. Conclusions: More than 40% of patients with PPM implantation shortly after cardiac surgery show recovery of sinus rhythm at follow-up. Wide variability of strategies and PM implant timing are currently applied in routine practice. Refinement of current guidelines in this setting based also on predictors of permanent conduction defects postoperatively are warranted.

Quadricuspid aortic valve is the rarest congenital anomaly of the semilunar valves. In the past it has been frequently detected incidentally at autopsy or during cardiac surgery. Recently, the evolution of diagnostic techniques with Doppler analysis has allowed to identify preoperatively this uncommon cardiac abnormality. We report a case of quadricuspid aortic valve diagnosed during surgery.

Objecti6e: Chordal transposition was advocated for correction of anterior mitral prolapse. We have evaluated the early and late results of this technique in different anatomical presentations. Methods: From 1986 to 1995, 185 mitral valve repairs were carried out for pure mitral regurgitation due to a degenerative disease. Eighty-nine patients had either an anterior prolapse (39) or prolapse of both leaflets (50) at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Twenty patients presented a complex pathology and 26 had chordal elongation of mural leaflet. Annular calcifications were found in 9 patients. Seven patients required shortening of transposed chordae and two patients the additional shortening of an anterior chorda. Results: Operative mortality was 3.3% and follow-up was 95% complete (average 41 months). There were five postreconstruction valve replacements (two earlier and three later) for a probability of freedom from late reoperation or 3 mitral regurgitation of 88.694.8% at 5 years. Of the patients 79% presented no or trivial residual MR, 17% moderate MR and 4% severe MR. The presence of a complex pathology or posterior chordal elongation did not influence the entity of postoperative residual regurgitation. On the contrary, the patients with annular calcifications had a residual regurgitation:left atrium area ratio greater than patients without annular calcification (15.8911.5% vs. 6.1 9.9%; P 0.009). Conclusions: Chordal transposition is an effective and easily carried out technique for the correction of anterior mitral prolapse. The presence of a complex pathology or posterior chordal elongation do not rule out the procedure. The absence of annular calcification is important in order to obtain a satisfactory correction. © 1997 Elsevier Science B.V.

Background Evolving technologies of proximal anastomosis devices meet the endeavor of surgeons to minimize manipulation of the ascending aorta during surgical myocardial revascularization. The objective of this study was to compare the patency rate of the saphenous vein coronary bypass grafts in which the proximal anastomoses were performed with automatic connector devices to the suture technique. Methods From September 2002 through July 2003, 86 patients underwent coronary artery bypass grafting with at least 1 vein graft anastomosed to the ascending aorta with the Symmetry G2 connector. Six-month clinical and angiographic follow-up, including Core-Lab quantitative coronary angiography (QCA) and corrected TIMI frame count (CTFC), was performed. Results Eighty patients had at least 1 connector successfully implanted. Freedom from MACE (cardiac mortality myocardial infarction and target vessel reintervention) was 72/80 (90%). Six patients underwent a target vessel reintervention on the connector grafts. Six-month (mean 193 ± 36 days) angiography patency rates for the connector grafts were 72/81 (88.89%), 37/40 (92.5%) in sutured grafts, and 60/62 (96.8%) in arterial grafts. By QCA, 64/65 (98.5%) patent connector-grafts were free from more than 50% stenosis (1 connector-graft with a 51% stenosis). CTFC showed 65/65 (100%) patent connector-grafts with nonrestrictive flow. Conclusions Saphenous vein grafts anastomosed to the aorta with the Symmetry G2 connector have early and midterm patency rates comparable to the conventional sutured anastomoses. These results support the efficiency of the second generation of symmetry aortic connectors.

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.

From 1986 to 1992 102 mitral valve repairs were done for mitral regurgitation due to a degenerative disease. Forty-eight patients had an anterior prolapse or prolapse of both leaflets at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Operative mortality was 2.9%, and follow-up (average 22 months) was 100% complete. There were three postreconstruction valve replacements (one earlier and two later) for a probability of freedom from reoperation of 91.5% +/- 5.2% at 3 years. Freedom from all morbidity was 85.5% +/- 5.5% at 3 years. Postoperative echocardiographic studies demonstrated a good mitral valve function: (1) Eighty-seven percent of patients presented no or mild residual regurgitation; (2) transmitral flow indexes were within the norm; (3) left ventricular outflow tract flow was normal in all patients. This study shows that chordal transposition is a safe and effective technique for prolapse of anterior or both leaflets and improves the chances of repair in patients with mitral degenerative disease.

The aim was to evaluate the characteristics of alpha adrenergic binding sites on human internal mammary arteries and the alpha adrenoceptor mediated vasoconstrictor response to catecholamines.Human internal mammary arteries were cut longitudinally, the intimal layer was scraped, and the arteries homogenised and centrifuged at 50,000 g to obtain a membrane pellet. Saturation isotherms with [3H]-prazosin were done with 50-100 micrograms plasma membranes per tube and increasing concentrations of [3H]-prazosin (non-specific binding: 2.5 mM noradrenaline plus superoxide dismutase and catalase). Kinetic isotherms were done with 100 micrograms plasma membranes and 1-5 nM [3H]-prazosin for time periods ranging from 1 to 90 min; at the equilibrium, dissociation of [3H]-prazosin was achieved by 10 microM prazosin. alpha 2 Adrenoceptor density on internal mammary artery membranes was assessed with [3H]-rauwolscine (non-specific binding: 1 microM yohimbine). Separation of membrane bound radioactivity was achieved by rapid vacuum filtration through Whatman GF/C fibre filters. Saturation isotherms were evaluated by Scatchard plots and kinetic data, and competition isotherms by Enzfitter analysis. Contractility studies were done with helical strips of artery (without adventitial layer) placed in a thermostated perfusion bath. Data were obtained in the presence of different concentrations of agonists and antagonist to obtain Schild plots. Antagonist drugs were employed at only one concentration for each preparation.Mammary arteries were collected from 51 patients (age range 42-65 years) undergoing surgery for coronary grafting.The binding of [3H]-prazosin to arterial plasma membrane was rapid and reversible. The K + 1 was 0.13 (SD 0.03) X 10(9) M.min-1 (n = 5) and the Kd, determined as a ratio between k-1/K + 1, was 0.34(0.01) nM (n = 5). [3H]-Prazosin binding, displaceable by 2.5 mM (-)-noradrenaline, was saturable and disclosed an alpha 1 adrenoceptor density of 30(3) fmol.mg-1 protein with a dissociation constant (Kd) of 215(50) pM (n = 18). The adrenergic agonists competed with [3H]-prazosin in the following order of potency: (-)-adrenaline [Ki = 0.6(0.1) microM; n = 5] greater than (-)-noradrenaline [Ki = 1.05(0.015) microM; n = 12] much greater than (-)-isoprenaline [Ki = 150(10) microM; n = 4]. Specific binding of [3H]-rauwolscine to IMA plasma membranes was negligible (about 2 fmol.mg-1 protein) (n = 15) with an unfavourable ratio of non-specific v specific binding. Catecholamines induced a dose dependent contractile response in arterial strips; (-)-noradrenaline: EC50 = 0.48(0.12) microM, n = 20; (-)-adrenaline: EC50 = 0.15(0.16) microM, n = 10; and methoxamine, a selective alpha 1 adrenergic agonist: EC50 0.67(0.15) microM, n = 10. The alpha 2 adrenoceptor agonists BHT-933, BHT-920, and guanabenz did not contract the arterial strips (up to 10 mM). Prazosin (0.03-0.1 microM) produced concentration dependent right shifts of the (-)-noradrenaline [pA2 = 9.83(0.11), n = 19], (-)-adrenaline [pA2 = 9.50(0.31), n = 10], and methoxamine [pA2 = 8.96(0.18), n = 10] concentration-response curve. CONCLUSIONS - Internal mammary artery plasma membranes possess alpha 1 adrenoceptors which are involved in the vasoconstrictor response to catecholamines. alpha 2 Adrenoceptors seem not to be involved.

Decreased myocardial beta-adrenergic receptor density has been demonstrated in experimental and clinical models of cardiac disease. Nevertheless, the individual role played by pressure or volume overload in determining the receptor downregulation has never been described in humans. Moreover, no data have been reported about the reversibility of the downregulation after non-pharmacological improvement of cardiac function. In the present study, we measured the myocardial beta-adrenergic and muscarinic receptor density, using an autoradiographic method, in 14 patients with cardiac pressure overload (aortic stenosis) and in five patients with cardiac volume overload (aortic regurgitation). Five patients with aortic stenosis were studied again six months after successful valve replacement. A significant lower density of beta-adrenergic receptors was observed in patients with a chronic pressure overload compared to those with a chronic volume overload (20+/-2 and 28+/-2 fmol/mg protein, respectively P

We studied the long-term results of a technique of mitral annuloplasty using autologous pericardium.Between June 1989 and December 1994, 113 mitral valvuloplasties were performed for myxomatous degenerative disease. Repair of isolated anterior leaflet prolapse was performed in 26 patients (23%), posterior leaflet prolapse in 38 (33.6%), and prolapse of both leaflets in 49 (43.4%). Posterior pericardial annuloplasty was performed in all patients. In 20 patients, the pericardial graft was marked with metal clips for postoperative cinefluoroscopic assessment of annulus motion.The operative mortality rate was 2.7% (3/113). One patient died of myocardial infarction and 2 of low cardiac output syndrome. One patient required replacement of the mitral valve 2 days after operation because of dehiscence of the annular plication. Follow-up (average length, 32.41 +/- 20.09 months; range 1 to 71 months) was 97% complete and revealed good clinical and functional results: 95 patients (84.1%) were in New York Heart Association class I and had no regurgitation or only mild residual regurgitation. Postoperative transmitral flow indices were almost normal (mitral valve area = 3.7 +/- 0.4 cm2; peak flow velocity = 1.06 +/- 0.2 m/s). Only 3 patients had reoperation within 3 years (actuarial 5-year reoperation-free rate, 89.7%) and event-free survival at 5 years was 91%. In patients with metal clips marking autologous pericardium, planimetry of the area derived by fluoroscopic examination showed systolic narrowing of annulus size (8.5% +/- 6.4%; p0.01) and a slight systolic fall in the anteroposterior diameter of the annulus contour (5.9% +/- 3.8%; p0.01).Posterior pericardial annuloplasty seems to be a safe, effective and easily performed technique and a more physiologic correction that preserves mitral annulus motion.

The safety and efficacy of amiodarone and propafenone in converting atrial fibrillation or flutter after cardiac surgery were compared in a randomized double-blind trial. Eighty-four patients with sustained atrial tachyarrhythmias of more than 30 min' duration, stable hemodynamic status and neither preoperative atrial arrhythmias nor treatment with other antiarrhythmis drugs, were randomized to receive amiodarone (46 patients: 5 mg/kg over 15 min and then 15 mg/kg over the subsequent 24 h for non-converting) or propafenone (38 patients: 2 mg/kg over 15 in and then 10 mg/kg over the subsequent 24 h for non-converting). Nine of the 46 patients (19.5%) receiving amiodarone converted to sinus rhythm within 1 h following bolus injection compared with 17 of 38 patients (44.7%) treated with propafenone (P < 0.05). Within the 24 h study, 38 of 46 patients (82.6%) given amiodarone and 26 of 38 patients (68.4%) given propafenone were converted to sinus rhythm (P = NS). A significantly progressive reduction in ventricular response, already evident at 10th min from the start of treatment, was achieved in both groups of patients. Side effects occurred in six patients given propafenone (15.7%) and in five given amiodarone (10.8%) (P = NS). The two drugs were equally effective in converting postoperative atrial fibrillation and/or flutter after 24 h although propafenone was superior within the first hour.

Cases of pericardial cyst have been reported by many authors, but the incidence of epicardial cyst originating directly from the epicardium in the pericardial cavity is extremely rare. A case of successful resection of epicardial cyst fortuitously discovered and diagnosed during cardiac operation is presented.

Since the introduction of the annuloplasty ring, many attempts have been made to obtain a flexible ring that preserves the physiological motion of the mitral annulus. We experimented with a new technique using autologous pericardium to construct a more flexible ring. Twenty patients underwent mitral valve repair for degenerative disease and were treated by a posterior pericardial annuloplasty and the usual valvuloplasty procedures. A long strip of pericardium was prepared, marked with metal clips and rolled up in a tubular fashion with the serosal surface on the outside. The pericardial tube was apposed on the posterior annulus just beyond the commissures. No patient required early or late reoperation. Doppler analysis showed good valve function: 18 patients had no or mild, and 2 had moderate regurgitation. Transmitral flow indexes were nearly normal (MVA = 3.7 +/- 0.4 cm2; flow velocity peak = 1.06 +/- 0.2 m/s). Fluoroscopic examination was employed for assessing annular motion using the metal clips as radiopaque markers. Planimetry of the hemiarea showed a mild narrowing (mean 8.5% +/- 6.4%) of annular size during ventricular systole. There was a trend toward a systolic reduction of the anteroposterior diameter of the annulus. These findings demonstrate that the mitral orifice preserves its flexible properties after this type of annuloplasty. Posterior pericardial annuloplasty seems to be a physiological correction of annular dilatation in patients with degenerative disease.

Coronary artery disease is one of the leading causes of death worldwide. The stenotic coronary vessels are generally treated with coronary artery bypass grafts (CABGs), which can be either arterial (internal mammary artery, radial artery) or venous (saphenous vein). However, the different mechanical properties of the graft can influence the outcome of the procedure in terms of risk of restenosis and subsequent graft failure. In this paper, we perform a computational fluid-structure interaction (FSI) analysis of patient specific multiple CABGs (Y-grafts) with the aim of better understanding the influence of the choice of bypass (arterial vs venous) on the risk of graft failure. Our results show that the use of a venous bypass results in a more disturbed flow field at the anastomosis and in higher stresses in the vessel wall with respect to the arterial one. This could explain the better long-term patency of the arterial bypasses experienced in the clinical practice. (C) 2017 IPEM. Published by Elsevier Ltd. All rights reserved.