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Background Mitral annular calcifications are considered a contraindication to open mitral valve repair/replacement, being associated with a significant risk of rupture of the atrioventricular groove or prosthesis detachment/paraprosthetic leak. Recently a scoring system has been proposed, to quantify the severity of MAC and predict the success of transcatheter valve in MAC implantation. Objective We present a series of consecutive patients with MAC undergoing sugical mitral valve replacement in recent years. Patients and methods 82 consecutive patients with MAC underwent open surgical correction from January 2019 at our centre. This was a complex cohort of patients with a high surgical risk profile (STS 5.3±3.2). The degree of MAC was moderate in 60 and severe in 22. Annular decalcification was required in 16 patients, and patch reconstruction of the AV groove in 4. The main predictor of the need for annular decalcification and reconstruction was the depth of calcium infiltration in the ventricular wall at CT. At intraoperative TEE only one patient had a significant paraprosthetic leak, that was repaired during a second short period of aortic cross-clamping. 30 days mortality was 1.2% (one patient), and 87% of patients were alive and well at one year. Comment The presence of significant mitral annular calcificaion per se should not be considered a contraindication to open mitral valve surgery. The depth of the calcifications in the ventricular wall, as measured at CT 3D multiplanar reconstructions is the best predictor of the need to decalcify/reconstruct the AV groove. Detailed imaging analysis is crucial for the success of the procedure. Funding Acknowledgement Type of funding sources: None.

This manuscript is compilation of insights on the food culture of Malolos, Bulacan and Mexico, Pampanga in the Philippines. The paper discusses factors that affect the food cultures in the said places. The paper has three major parts: (1) food as a social symbol; (2) food diversity; and (3) food history. The researchers resulted into a conclusion that the food cultures of Malolos, Bulacan and Mexico Pampanga have their own characteristics, especially in terms of the taste, but also share some similarities in terms of food preparation and some of its origins and symbols. These aspects were all affected by different factors such as foreign colonization, scarcity of food, availability of resources, religious beliefs, adaptability of the people in the current situation and innovation.

Background Fragmentation and deforestation are one of the greatest threats to forests, and these processes are of even more concern in the tropics, where the seasonal dry forest is possibly one of the most threatened ecosystems with the least remaining surface area. Methods The deforestation and fragmentation patterns that had occurred in Ecuadorian seasonal dry forests between 1990 and 2018 were verified, while geographic information systems and land cover shapes provided by the Ecuadorian Ministry of the Environment were employed to classify and evaluate three types of seasonal dry forests: deciduous, semi-deciduous, and transition. The study area was tessellated into 10 km2 hexagons, in which six fragmentation parameters were measured: number of patches, mean patch size, median patch size, total edge, edge density and reticular fragmentation index (RFI). The RFI was also measured both outside and inside protected natural areas (unprotected, national protected areas and protected forest). Moreover, the areas with the best and worst conservation status, connectivity and risk of disappearance values were identified by means of a Getis-Ord Gi* statistical analysis. Results The deforestation of seasonal dry forests affected 27.04% of the original surface area still remaining in 1990, with an annual deforestation rate of − 1.12% between 1990 and 2018. The RFI has increased by 11.61% as a result of the fact that small fragments of forest have tended to disappear, while the large fragments have been fragmented into smaller ones. The semi-deciduous forest had the highest levels of fragmentation in 2018. The three categories of protection had significantly different levels of fragmentation, with lower RFI values in national protected areas and greater values in protected forests. Conclusions The seasonal dry forest is fragmenting, deforesting and disappearing in some areas. An increased protection and conservation of the Ecuadorian seasonal dry forest is, therefore, necessary owing to the fact that not all protection measures have been effective.

Objectives To assess the cost-effectiveness (CE) of transcatheter aortic valve implantation (TAVI) in Italy, considering patient groups with different surgical risk. Methods A Markov model with a 1-month cycle length, comprising eight different health states, defined by the New York Heart Association functional classes (NYHA I–IV), with and without stroke plus death, was used to estimate the CE of TAVI for intermediate-, high-risk and inoperable patients considering surgical aortic valve replacement or medical treatment as comparators according to the patient group. The Italian National Health System perspective and 15-year time horizon were considered. In the base-case analysis, effectiveness data were retrieved from published efficacy data and total direct costs (euros) were estimated from national tariffs. A scenario analysis considering a micro-costing approach to estimate procedural costs was also considered. The incremental cost-effectiveness ratio (ICER) was expressed both in terms of costs per life years gained (LYG) and costs per quality adjusted life years (QALY). All outcomes and costs were discounted at 3% per annum. Univariate and probabilistic sensitivity analyses (PSA) were performed to assess robustness of results. Results Over a 15-year time horizon, the higher acquisition costs for TAVI were partially offset in all risk groups because of its effectiveness and safety profile. ICERs were €8338/QALY, €11,209/QALY and €10,133/QALY, respectively, for intermediate-, high-risk and inoperable patients. ICER values were slightly higher in the scenario analysis. PSA suggested consistency of results. Conclusions TAVI would be considered cost-effective at frequently cited willingness-to-pay thresholds; further studies could clarify the CE of TAVI in real-life scenarios.

Subconcussion can cause long-term consequences for patients. Increasing understanding of what causes the injury and how it can be assessed is important. This paper focuses on the pathophysiology, epidemiology, and assessment tools. Specific emphasis is placed on early diagnosis to implement treatment. Current research is targeting improved pharmaceutic and biomechanic innovations. Enhanced understanding of subconcussion will improve outcomes for patients and allow clinicians to implement treatments earlier.

The aim of this study was to investigate the outcome of patients undergoing synchronous carotid endarterectomy and coronary and/or other cardiac surgery. The impact of anesthesia on the outcome was examined.A retrospective single-center observational study was performed, to investigate the outcome of 127 consecutive adult patients submitted to synchronous surgery from 2011 to 2019. Cooperative patient general anesthesia for carotid endarterectomy followed by standard general anesthesia for cardiac surgery and standard general anesthesia for the whole surgery were compared after a propensity score analysis.Primary outcomes were 30-day mortality (3.1%), incidence of stroke (3.1%), and myocardial infarction (0.8%). Agitation upon awakening, postoperative cardiac troponin I release, the increase of serum creatinine, the occurrence of acute kidney injury and the need for continuous renal replacement therapy were the secondary outcomes. A binary logistic regression revealed that cardiopulmonary bypass use, standard general anesthesia for the whole surgery and the European risk score II, were the strongest predictors of any severe postoperative complications. After propensity score matching, general anesthesia for the whole surgery was significantly correlated with the occurrence of any severe postoperative complication (P=0.038).Synchronous surgery was performed with acceptable mortality and complication rate even in combination with other than isolated coronary surgery. Cooperative patient general anesthesia during carotid endarterectomy, was not inferior to general anesthesia in this setting.

The stock of therapeutic weapons available in metastatic colorectal cancer (mCRC) has been progressively grown over the years, with improving both survival and patients' clinical outcome: notwithstanding advances in the knowledge of mCRC biology, as well as advances in treatment, fluoropyrimidine antimetabolite drugs have been for 30 years the mainstay of chemotherapy protocols for this malignancy. 5-Fluorouracil (5FU) seems to act differently depending on administration method: elastomer-mediated continuous infusion better inhibits Thymidylate Synthase (TS), an enzyme playing a pivotal role in DNA synthetic pathway. TS overexpression is an acknowledged poor prognosis predicting factor. The simultaneous combination of 5FU and folinate salt synergistically strengthens fluorouracil cytotoxic effect. In our experience, levofolinate and 5FU together in continuous infusion prolong progression free survival of patients suffering from mCRC, moreover decreasing death risk and showing a clear clinical benefit for patients, irrespective of RAS mutational status, primitive tumor side and metastases surgery.

SummaryThe Ecuadorian coast has two main types of forests, which are differentiated by their phenology: dry forests are deciduous and more humid forests are evergreen. Less of the dry forests on the Ecuadorian coast is protected (13% of its area) than the evergreen forests (28%), and the area devoted to the protection of dry forests (1069 km2) is substantially less than the area devoted to the protection of evergreen forests (2800 km2). Yet the conservation status of dry forests is more critical, with 83% of their area classified as having very low connectivity, 70% as being highly fragile and 86% as being highly threatened. In addition, the dry forests have fewer protected areas than the evergreen forests. It is therefore necessary to increase the protection of deciduous ecosystems as part of a comprehensive national strategy because they support high levels of biodiversity and many endemic species.

Background Biological prosthesis are increasingly been used in young patients to avoid anticoagulation. The Edwards Inspiris aortic bioprosthesis is extremely promising in this population, since it has shown reduced calcification of the prosthetic leaflets in preclinical and early clinical studies. Little data are available, however, in patients younger than 65. This study investigates the haemodynamic performance and clinical outcome of the Inspiris bioprosthesis in patients aged < 50 years. Methods and Results Between may 2018 and December 2021, 58 patients aged 41 +/– 7,85 years underwent AVR with the Edwards Inspiris bioprosthesis at our institution. 23 of them (39.65%) were younger than 40, and 7 (12.06%) had a BMI >30 kgm2. A minimally invasive approach was used in all isolated AVR patients. Associated procedures were performed in 25 (43.10%) patients. There were 10 redo patients (17,24%). Two patients died (3.45%). Major complications included bleeding (4), respiratory failure (1) and BAV requiring PMK (1). The mean follow up was 26,60 +/– 11,29 months (range 2–43). Late valve–related events included endocarditis (2) requiring reoperation. There were no thromboembolic events, valve thrombosis or SVD cases. At follow up, all except one patients reported a significant improvement of their symptomatic status (96.29% were in NYHA≤II) and quality of life. The mean interval to return to the normal activity was of 5.37±3.3 months. Conclusion Our study demonstrates excellent early haemodynamics and promising results at up to 3 years in a cohort of very young patients. Further studies with longer follow–up are needed

The effect of hospital-associated SARS-CoV-2 infections in cardiac surgery patients remains poorly investigated, and current data are limited to small case series with conflicting results.A multicenter European collaboration was organized to analyze the outcomes of patients who tested positive with hospital-associated SARS-CoV-2 infection after cardiac surgery. The study investigators hypothesized that early infection could be associated with worse postoperative outcomes; hence 2 groups were considered: (1) an early hospital-associated SARS-CoV-2 infection group comprising patients who had a positive molecular test result ≤7 days after surgery, with or without symptoms; and (2) a late hospital-associated SARS-CoV-2 infection group comprising patients whose test positivity occurred7 days after surgery, with or without symptoms. The primary outcome was 30-day mortality. Secondary outcomes included all-cause mortality or morbidity at early follow-up and SARS-CoV-2-related hospital readmission.A total of 87 patients were included in the study. Of those, 30 were in the early group and 57 in the late group. Overall, 30-day mortality was 8%, and in-hospital mortality was 11.5%. The reintubation rate was 11.4%. Early infection was significantly associated with higher mortality (adjusted OR, 26.6; 95% CI, 2, 352.6; P.01) when compared with the late group. At 6-month follow-up, survival probability was also significantly higher in the late infection group: 91% (95% CI, 83%, 98%) vs 75% (95% CI, 61%, 93%) in the early infection group (P = .036). Two patients experienced COVID-19-related rehospitalization.In this multicenter analysis, hospital-associated SARS-CoV-2 infection resulted in higher than expected postoperative mortality after cardiac surgery, especially in the early infection group.

Background and aim One–shot long–lasting cardioplegia is particularly useful during right minithoracotomy mitral valve surgery (RT–MS), and the Servator H cristalloid solution has been widely used in this setting. However, the Servator H cardioplegia requires the administration of large volumes of fluids and the frequent recourse to ultrafiltration. we compared Servator H versus the Del Nido Cardioplegia, that contains blood and requires smaller volumes, in patients undergoing RT–MS. Methods 36 consecutive patients undergoing RT–MS (± tricuspid and AF surgery) were randomly assigned to receive Servator H or Del Nido Cardioplegia. There were no differences between the two groups at baseline. Results Although there were no differences in terms of mortality and incidence of major complications, the use of Servator H cardioplegia was associated with a significantly increased release of CK–MB (but not of TnI) during the early postoperative period. Moreover, patients receiving Servator H were more likely to require defibrillation or pacing after removal of the aortic cross–clamp (8, 40% vs 2, 12.5%), and experienced a significantly higher rate of postoperative atrial fibrillation (10, 50% vs 4, 25%, p < 0.05). Conclusion Our data show that the Del Nido cardioplegia could offer improved myocardial protection during minimally invasive mitral valve surgery, resulting in reduced need for post–cardioplegia defibrillation and of postoperative atrial fibrillation. This is consistent with the results of similar, recent research. Further studies on larger populations are needed to consolidate these data.

Background and aim Biological prosthesis are increasingly been used in young patients to avoid anticoagulation. The Edwards Inspiris aortic bioprosthesis is extremely promising in this population, since it has shown reduced calcification of the prosthetic leaflets in preclinical and early clinical studies. Little data are available, however, in patients younger than 65. This study investigates the haemodynamic performance and clinical outcome of the Inspiris bioprosthesis in patients aged < 50 years. Methods Between May 2018 and May 2022, 58 patients aged 41±7.8 years underwent AVR with the Edwards Inspiris bioprosthesis. Twenty–three (39.65%) were younger than 40, and 7 (12.06%) had a BMI >30 kgm2. A minimally invasive approach was used in all isolated AVR patients. Associated procedures were performed in 25 (43.10%) patients. There were 10 redo patients (17.2%). Results Major complications included bleeding (4), respiratory failure (1) and BAV requiring PMK (1). Two patients died (3.45%). The mean follow up was 29.6±12.3 months (range 10–51). Late valve–related events included endocarditis (2) requiring reoperation. There were no thromboembolic events, valve thrombosis or SVD cases. At follow up, all except one patient reported a significant improvement of their symptomatic status (96.29% were in NYHA II) and quality of life. The mean interval to return to the normal activity was of 5.37±3.3 months. Conclusion Our study demonstrates promising results at up to 4 years in a cohort of very young patients. Further studies with longer follow–up are needed.

Background Biological prostheses are increasingly been used in young patients to avoid anticoagulation. The Edwards Inspiris aortic bioprosthesis is extremely promising in this population, since it has shown reduced calcification of the prosthetic leaflets in preclinical and early clinical studies. Little data are available, however, in patients younger than 65. This study investigates the hemodynamic performance and clinical outcome of the Inspiris bioprosthesis in patients aged 56 ± 10.7 years. Methods and Results Between may 2018 and December 2022, 342 patients aged 56 ± 10.7 years underwent AVR with the Edwards Inspiris bioprosthesis at our institution. 37 of them (10.8%) were younger than 40, and 98 (28.6%) had a BMI >30 kgm2. A minimally invasive approach was used in all isolated AVR patients. Associated procedures were performed in 157 (45.9%) patients. There were 56 redo patients (16.4%). 7 patients died (2%). Major complications included bleeding (32), respiratory failure (20) and BAV requiring PMK (4). The mean follow up was 23 ± 15.2 months (range 2–55). Late valve–related events included endocarditis (5) requiring reoperation. There were no thromboembolic events, valve thrombosis or SVD cases. At follow up, all except four patients reported a significant improvement of their symptomatic status (98.8% were in NYHA II) and quality of life. Conclusion Our study demonstrates excellent early haemodynamics and promising results at up to four years in a cohort of very young patients. Further studies with longer follow–up are needed.

Background and Aim: Although the rate of TAVI–related complications has consistently reduced during the last decade, vascular complications still occur, and can be serious. Mixed reality (MR) can be defined as a three–dimensional real world simulation allowing the user to directly interact with it. The present study was designed to explore the potential of MR in facilitating the vascular access and navigation with large–bore devices. Methods 3D holograms were generated from the CT’s of 20 TAVI patients (age 81.2±6.8 years, STS score 5.1±2.1) and made available to 2 surgeons in training. Different layers were generated: Skin, Arterial tree, and Calcium. A needle simulator was also available. The vascular puncture was echo guided. 2 percutaneous suture system were used to secure the hemostasys. Results All the procedures were carried out through the planned access. In 2 patients intravascular lythoplasty was used. There were no vascular complications, and procedural success was 100%. A single puncture was necessary to obtain vascular access in 19/20 patients and in 2 cases the echo was not used, and the operator decided to switch to angio–guided puncture due to the bad quality of the echo images that were in contrast with MR. Conclusion MR can be used to predict the optimal puncture site for TAVI. The interactive 3D holograms can be used to identify relevant repere on the skin and to reduce the rate of vascular complications and could become a powerful tool for procedural planning, training and remote proctoring.

Background and aim Mechanical complications of TAVI may be catastrophic, and conversion to open surgery in this context has been associated with an extremely poor prognosis, with a mortality close to 50%. We report our recent experience on 9 patients requiring cardiac surgery during TAVI. Patients and methods: 9 patients undergoing various transcatheter procedures at a high volume centre required cardiac surgery for valve misplacement (2), valve embolization (2), annular rupture (3), acute coronary occlusion (1) and aortic dissection (1). Four patients were initially treated by a hybrid team including a cardiac surgeon performing transcatheter procedures (3 TAVI in NAVR and one transseptal Mitral VIV), while five were performed by an interventional cardiology team (all TAVI). Results The complications and the surgical procedures performed are reported in the table. Four patients underwent immediate conversion in the hybrid room, 3 underwent delayed conversion and two were managed conservatively. Eight patients survived and were discharged from the hospital. The only patient dying was a TAVI patient having aortic valve embolization. A second transcatheter valve was deployed too ventricular. The patient had cardiac arrest needing CRP and the surgical team was called to start ECMO assistance several minutes after the initial complication. Comment: Our small series suggests that prompt conversion to open surgery, especially if performed immediately by surgeons that were initially involved in the transcatheter procedure, might offer excellent results. We believe that hybrid teams may offer a significant benefit, especially in low–risk patients and during complex or off–label procedures.

Chordoma is a rare tumor, usually diagnosed when the disease is advanced. Despite its slow growth, it is locally aggressive and has a poor long-term prognosis. Surgery is the mainstay treatment. Although cardiac metastases are very rare, the heart is frequently involved in systemic neoplastic diseases. This report describes a typical case of metastatic chordoma: the age at first diagnosis, the site of the primary tumor, and the slow growth of the cardiac metastasis were all typical features. Surgical excision of the mass from the right ventricular outflow tract is described together with echocardiographic, radiologic, and histopathologic characteristics of the metastatic chordoma.