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Background: Off-pump was compared with on-pump coronary artery bypass graft surgery to evaluate the impact of cardiopulmonary bypass on the incidence of postoperative acute renal failure (ARF). Methods: From November 1994 to December 2001, 2,943 patients having multivessel surgical disease underwent myocardial revascularization. Ninety patients were excluded because of incompleteness of data, intraoperative death, or preoperative chronic dialysis. The analysis was split: one analysis included 1,724 (862 each group) of 2,618 patients with normal preoperative creatinine (<1.5 mg/dL), and the second analysis included 160 (80 each group) of 215 patients with preoperative abnormal renal function; in both analyses matched groups were selected applying propensity score. Results: In the group with normal preoperative creatinine, the incidence of 30-day ARF was 5.4% (2.9% off-pump versus 7.9% on-pump; p < 0.001). Stepwise logistic regression confirmed that cardiopulmonary bypass was an independent variable for increased postoperative ARF incidence (odds ratio, 3.3), as well as age and reduced left ventricular ejection fraction. Receiver operating characteristic curves showed that cardiopulmonary bypass duration was a predictor of higher ARF incidence (area under the curve, 0.79) with a cutoff value of 66 minutes. In the patients with abnormal renal function preoperatively, the incidence of ARF was similar between the groups (16.3% on-pump versus 12.5% off-pump; p = 0.499). Acute renal failure had an important impact on early (odds ratio, 3.6) and late mortality (hazard ratio, 4.1). Conclusions: Off-pump surgery plays an important renoprotective role and provides better early and late outcome in patients with normal preoperative creatinine. When the preoperative creatinine is abnormal, the surgical strategy does not seem to have any influence. The occurrence of ARF significantly impairs early and long-term mortality, and the surgical strategy does not improve outcomes. [Copyright &y& Elsevier]

Background: This study analyzes retrospectively a cohort of patients with ischemic cardiomyopathy (ejection fraction ≤0.30) who underwent isolated coronary artery bypass grafting to evaluate the impact of no-to-moderate mitral regurgitation (MR) on long-term results. Methods: From January 1988 to December 2002, 6,108 patients had isolated coronary artery bypass grafting. Two hundred thirty-nine (3.9%) had ischemic cardiomyopathy; 60 patients had no, 102 had mild, and 77 had moderate MR. Using propensity score, a group of 70 patients with no or mild MR (group A) was case-matched with a group of 70 patients with moderate MR (group B) to obtain two groups with similar preoperative characteristics. Results: Nine patients (6.4%) died within the first 30 days; all deaths were cardiac-related. There was no difference in the early results between groups. Patients in group B showed lower freedom from death, from cardiac death, from cardiac death and ischemic events, and from death and New York Heart Association class III and IV than patients in group A. Cox analysis confirmed that moderate MR was an independent variable for worse late outcome in this subgroup of patients. Functional and echocardiographic results, after a mean of 62 ± 28 months in 87.8% of survivors, showed a significant impairment of New York Heart Association class (from 2.2 ± 0.5 to 2.8 ± 0.6; p < 0.001) and MR degree (from 2.0 to 2.7 ± 1.0; p = 0.023) in patients with preoperative moderate MR. Conclusions: This study confirms that moderate ischemic MR has an important negative impact on survival and quality of life of patients with severely impaired left ventricular function, treated by coronary artery bypass grafting alone. [Copyright &y& Elsevier]

Background: The concept of overreduction of the posterior annulus was applied in surgical treatment of degenerative mitral valve disease. Methods: From April 1993 to November 2004, 141 patients underwent overreduction of the posterior annulus of the mitral valve in mitral valve repair for degenerative disease. Mean scallop involvement per patient was 2.3 and increased to 3.0 in the last period. Correction of the prolapse of the posterior leaflet included resection with focal sliding (n = 100), or application of artificial chordae (n = 28), with (n = 11) or without (n = 17) plication of one or more scallops. The anterior leaflet prolapse was corrected with edge-to-edge technique (n = 20) or chordal replacement (n = 28). An overreducting ring, 40 (n = 81) or 50 (n = 60) mm long (autologous pericardium in 64 cases and Sovering Miniband [Sorin, Saluggia, Italy] in 77) was used in all the patients. Results: Three patients died in the early period (2.1%) and 3 (2.1%) were reoperated on from 3 to 24 months due to endocarditis (2 cases) and failure of repair (1 case). Ten-year freedom from death any cause was 91.6%, from reoperation 96.4%, from death any cause and reoperation 87.7%, from death any cause, reoperation, and New York Heart Association class III-IV 79.8%. Sixty-four patients out of 68 who survived more than 2 years (94.1%) at a mean follow up of 4.2 ± 2.5 years had no or 1+ residual mitral regurgitation. Conclusions: Although the complexity of mitral valve repair for degenerative disease increased, results of surgery remained stable. Apposition of a posterior overreductive ring was useful to cover any mistake performed during the correction. [Copyright &y& Elsevier]

Introduction: In this prospective multicenter analysis, we aimed to investigate the predictive role of neutrophil/lymphocyte ratio (NLR) in permanent pacemaker implantation (PPI) in patients undergoing transcatheter aortic valve replacement (TAVR). Materials and Methods: One hundred and seventy‐nine consecutive patients without previous PPI underwent TAVR from February 2017 to September 2021. Patients were further divided based on presence (n = 48) and absence of conduction abnormalities (CAs) at hospital admission (n = 131). Results: In patients with previous CAs, NLR values did not differ significantly between patients requiring PPI (n = 16, 33%) and those not requiring it. In contrast, in patients with no CAs at hospital admission, NLR values measured at admission and on TAVR day were significantly higher in patients requiring PPI (n = 17, 13%) (4.07 ± 3.22 vs. 3.01 ± 1.47, p =.025, and 10.81 ± 7.81 vs. 5.84 ± 3.78, p =.000, respectively). Multivariable analysis showed that NLR at TAVR day was an independent predictor of PPI in patients without CAs (OR 1.294; 95% CI 1.028–1.630; p =.028), but not in those with previous CAs. ROC curve analysis showed that the cut point was a NLR value of >7.25. Time to PPI was delayed till 21 days in patients without CAs. Conclusions: In this prospective study, higher NLR values on the day of TAVR day were associated with an increased PPI rate in patients undergoing TAVR with no previous CAs. It is advisable, being inflammation part of the process, to prolong the time of observation for all patients without CAs till at least 21 days not to miss any new CA necessitating PPI. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 60-year old male with angina who underwent coronary angiography which showed three vessel disease and intercoronary fistula and aneurysmal dilatation from right coronary artery.

We report how to perform a complete open-heart ablation with bipolar radiofrequency through a transseptal incision. The connecting left atrial lines were performed by inserting one jaw of the clamp through a stab wound in the posterior left atrium, beneath the right inferior pulmonary vein. Twenty-five patients underwent concomitant ablation with the described technique in three different centers. All the left lines were easily performed. No ablation-related complication occurred. At 11 ± 6 months, 80% of the patients were free from arrhythmias. [ABSTRACT FROM AUTHOR]

The meta‐analysis by He et al. has the worth to cover, as much as possible, a gap of scientific evidence were conducting a randomized trial appears very complex for ethical and logistical reasons. The authors concluded that mitral valve repair (MVP) provides better‐pooled results, both early and late, with respect to mitral valve replacement. However, the superiority of MVP is driven by some single large cohort studies where surgeons had wide experience in the field of MVP for infective endocarditis. This finding is also confirmed by other studies. But if mitral repair produces such a better short‐ and long‐term survival than replacement, why are there no clear indications from consensus and guidelines pushing surgeons toward the pursuit of a reconstructive procedure at almost any cost? We wonder to repair or not to repair, is that really the question? The AATS consensus suggests repairing "whenever possible" but without providing more specific indications. If the two primary goals of surgery are total removal of infected tissues and reconstruction of cardiac morphology, including repair or replacement of the affected valve(s), probably MVP should be performed in case of less extensive tissue detriment by the infection. In more wide valve involvement, MVP may be the choice but only in very expert hands and in Centers with a very large volumes of valve repairing. This decision cannot, therefore, be the result of the choice of an individual but must derive from a careful multidisciplinary discussion to be held in an EndoTeam. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES Since 2000, we anastomosed the saphenous vein graft to the right coronary artery system using the stump of the right internal thoracic artery as inflow. The long-term results of patients where the right coronary artery was grafted with the right internal thoracic artery or the ascending aorta as saphenous vein inflow has not been reported. METHODS From 2000 to 2018, 699 consecutive patients had right internal thoracic artery elongated with saphenous vein (I-graft group, n  = 358, 51.2%) or saphenous vein from the aorta (Ao-graft group, n  = 341, 48.8%) on right coronary artery system. Inclusion criteria were age ≤75 years, bilateral internal thoracic arteries as a Y graft on the left system (three-vessel disease, n  = 603, 86.3%) or as a left internal thoracic artery on left anterior descending and right internal thoracic artery elongated with saphenous vein on the right coronary artery system (two-vessel disease, n  = 96, 13.7%), only 1 saphenous vein per patient. Propensity-matching identified 272 patients per group. One-hundred and twenty-two patients underwent coronary computed tomographic angiography to asses grafts patency after a median follow-up of 88 (65–93) months. RESULTS In the paired samples, there was no difference in the early outcome. Ten-year survival and freedom from death, non-fatal acute myocardial infarction and repeat revascularization were higher in I-graft group: 90.6 [standard error (SE): 2.0] vs 78.2 (SE: 5.3), P  = 0.0266, and 85.2 (SE: 2.4) vs 69.9 (SE: 5.3), P  = 0.0179. Saphenous vein graft, at a long-time follow-up, showed a higher patency rate (81.6% (SE: 7.0) vs 50.7% (SE: 7.9), P  < 0.0001) and a smaller internal lumen diameter (2.7, standard deviation: 0.4 vs 3.4, standard deviation: 0.6 mm, P  < 0.0001) when right internal thoracic artery was the inflow. CONCLUSIONS Grafting the right coronary artery with saphenous vein may entail higher patency rate and better outcome when the inflow is the right internal thoracic artery than when is the ascending aorta. Prospective randomized data are needed to test this hypothesis. [ABSTRACT FROM AUTHOR]

Entrapment and detachment of guidewire fractures during percutaneous coronary intervention (PCI) are very rare, but can lead to life-threatening complications such as embolization, thrombus formation, and perforation. Surgical extraction of the remnant fragments is recommended if the percutaneous retrieval is not possible. We present a case of remnant guidewire into the left anterior descending artery (LAD) and aorta that led to acute coronary thrombosis following primary angioplasty. Surgical retrieval was possible only through a left main (LM) approach. (J Card Surg 2012;27:307-308) [ABSTRACT FROM AUTHOR]

Objectives: We evaluated results of an echocardiographically based strategy combining mitral annuloplasty with other procedures to treat chronic ischemic mitral regurgitation. Methods: From March 2006 to February 2009, 147 patients underwent mitral valve surgery for chronic ischemic mitral regurgitation. Mean effective regurgitant orifice was 36 ± 11 mm2, and ejection fraction was 35% ± 9%. On the basis of echocardiographic findings, in 10 cases a prosthesis was inserted and mitral annuloplasty was performed in 137 cases, isolated in 83, associated with chordal cutting in 12 cases (in 5 anterior leaflet was augmented with pericardial patch), and with exclusion of anteroseptal (n = 35) or inferior (n = 7) scars in 42. Results: Thirty-day mortality was 4.8%; 3-year survival was 86% ± 3%. None of the 126 survivors were in New York Heart Association functional class III or IV. Among 117 survivors of mitral valve repair, after 18 ± 6 months mean effective regurgitant orifice reduced from 34.1 ± 10.2 mm2 to 2.3 ± 0.4 mm2 (P < .001). Nine patients showed residual effective regurgitant orifice 10 to 19 mm2. Reverse remodeling was present in 69 patients (59.0%), no remodeling in 40 (34.1%), and continuous remodeling in 8 (6.9%). Ejection fraction changed from 37% ± 10% to 43% ± 10% (P <.001), improving in 47, remaining unchanged in 63, and worsening in 7. Conclusions: Echocardiographically based strategy contributed to reduced postoperative mitral regurgitation persistence (effective regurgitant orifice ≥10 mm2 in 7.7% of cases, with no patients showing effective regurgitant orifice ≥20 mm2 ). All patients remained in New York Heart Association functional class I or II, but more than mitral annuloplasty was performed in close to 40%. [Copyright &y& Elsevier]

Mitral valve regurgitation (MR) is a common valvular disorder occurring in up to 10% of the general population. Mitral valve reconstructive strategies may address any of the components, annulus, leaflets, and chords, involved in the valvular competence. The classical repair technique involves the resection of the prolapsing tissue. Chordal replacement was introduced already in the '60, but in the mid '80, some surgeons started to use expanded polytetrafluoroethylene (ePTFE) Gore‐Tex sutures. In the last years, artificial chords have been used also using transcatheter approach such as NeoChord DS 1000 (Neochord) and Harpoon TSD‐5. The first step is to achieve a good exposure of the papillary muscles that before approaching the implant of the artificial chords. Then, the chords are attached to the papillary muscle, with or without the use of supportive pledgets. The techniques to correctly implant artificial chords are many and might vary considerably from one center to another, but they can be summarized into three big families of suturing techniques: single, running or loop. Regardless of how to anchor to the mitral leaflet, the real challenge that many surgeons have taken on, giving rise to some very creative solutions, has been to establish an adequate length of the chords. It can be established based on anatomically healthy chords, but it is important to bear in mind that surgeons work on the mitral valve when the heart is arrested in diastole, so this length could fail to replicate the required length in the full, beating heart. Hence, some surgeons suggested techniques to overcome this problem. Herein, we aimed to describe the current use of artificial chords in real‐world surgery, summarizing all the tips and tricks. [ABSTRACT FROM AUTHOR]

Background and Aim of the Study: Mitral valve repair is the procedure of choice to correct mitral regurgitation. However, some dangerous iatrogenic complications can occur at the end of the procedure. Therefore, we sought to review the most frequent and clinically relevant acute iatrogenic complication following mitral valve repair. Methods: A thorough review of the literature has been performed. Criteria for considering studies for this non‐systematic review were as follows: observational and interventional studies investigating the acute iatrogenic complications following mitral valve repair, and essential review studies pertinent to the topic. Results: The most frequent is the systolic anterior motion. Due to a systolic dislocation of the anterior leaflet toward the outflow tract, it causes both obstruction of the outflow tract and mitral regurgitation. Often it is due to excess of catecholamines or to reduced filling of the left ventricle but sometimes needs further surgical maneuvers, focused on moving posteriorly the coaptation line. It can be obtained by shortening the posterior leaflet or increasing the size of the ring or applying an Alfieri stitch to limit the movements of the anterior leaflet. Another complication, often underdiagnosed and potentially lethal, is the injury of the circumflex artery that happens at the level of the anterolateral commissure or P1 zone. Two mechanisms are involved. The first one is the direct injury of the artery by a stitch (roughly 25% of the patients present a distance artery‐annulus <3 mm. The second one is the distortion of the artery, attracted toward the annulus by a misplaced stitch. The attraction causes kinking with stenosis of different degrees till functional occlusion. However, the artery has to be far from the annulus and the atrial tissue has to be stiff and resistant, as after an infective process, to move the circumflex artery toward the annulus without tearing. Positioning the stitches very close to the mitral leaflets in the dangerous area is the only prevention to the complication. The treatment in the operating theater is partial or total removal/reimplantation of the annular sutures or coronary artery bypass grafting to the circumflex area. If the injury is demonstrated only after coronary angiography, percutaneous revascularization can be attempted before further surgical treatment. Conclusions: Acute iatrogenic complication after mitral repair exists and may compromize patient outcome. Raising awareness about these issues, the precautions to prevent them, and the manners of resolution is therefore mandatory. [ABSTRACT FROM AUTHOR]

Background and Aim of the study: Wrapping of the ascending aorta (AA), isolated or associated with aortoplasty, has never been completely accepted. Some complications, as folding of the aortic wall, compression of the vasa vasorum and changes in the flow pattern, with consequent dilatation of the proximal arch, have been described. We used fresh autologous pericardium (FAP), so far never reported, to wrap the AA, with the aim to stabilize its size when moderately dilated, maintaining the preoperative dimension or limiting the reduction to a few millimeters. Materials and Methods: From 2015 to 2019, 10 patients, who were operated on for valve or coronary surgery or both, underwent wrapping of the AA with FAP. Mean age was 69 ± 7 years and EuroSCORE II 3.5 ± 1.7. Four patients had moderately impaired ejection fraction (35%–49%). Results: There was no early or late mortality. One patient was reoperated on after 48 months for severe mitral regurgitation. At a follow‐up of 53 ± 14 months, a transthoracic echocardiogram showed that the AA size reduced slightly but significantly, from 45.2 ± 2.0 to 42.5 ± 4.1 mm, p =.03. The diameter of the proximal arch remained unchanged, from 37.1 ± 1.6 to 36.3 ± 2.9 mm, p =.20. Conclusions: In the presence of moderately dilated AA, wrapping can be a reasonable option. The use of FAP stabilizes the size of the aorta after a follow‐up of 53 months. Maintaining a size similar to the preoperative one avoids the complications related to the procedure. [ABSTRACT FROM AUTHOR]

Atrial fibrillation in patients with heart failure due to ventricular dyssynchrony needs decision‐making on the rate and rhythm control strategies together with cardiac resynchronization therapy and antithrombotic prophylaxis. Transvenous biventricular pacing and percutaneous appendage closure in patients with heart failure and atrial fibrillation with high bleeding risk are valid therapeutic options but anatomical exclusion criteria could be present. Here, we report two patients who underwent successful totally thoracoscopic concomitant left appendage occlusion and epicardial left ventricular lead implantation. [ABSTRACT FROM AUTHOR]

The isolated tricuspid valve (TR) has evolved into an entity in its own right. In contrast to TR treatment in left valve surgery, the benefit of surgery for isolated TR remains controversial. In this context, transcatheter valve interventions (TTVI) are becoming increasingly important. In this report, we present our experience with TricValve in a single center. From March 2022 to September 2023, 13 patients with at least severe isolated TR were scheduled for TricValve implantation. The mean age was 81 years (77–87), 5 were female and 8 were male. All patients were older than 70 years and had at least severe TR, hepatic or peripheral congestion and high surgical risk. No procedure failure or device embolization was recorded. One case died in hospital 6 days after implantation and 1 case died after 124 days from irreversible renal and hepatic failure. The survival rate was 80.2% ± 12.8; the proportion of patients in NYHA class I increased significantly to 45% at follow-up. Among the 11 survivors, the median NT -proBNP decreased from 2873 to 148 pg/mL at follow-up (p = 0.003). In addition, a significant reduction in furosemide dosage from 125 mg to 50 mg at follow-up was observed over time. Finally, TR grade improved significantly along with RV size. This procedure appears to be safe and effective in carefully selected patients. Given the extreme simplicity of the procedure, the TricValve will increasingly represent one of the most viable treatment options for this patient group in the future. [Display omitted] • A significant upward trend of isolated severe or more TR due to permanent AF, especially in the elderly population, was confirmed; • TricValve is considered as a good alternative therapy for patients with severe symptomatic TR; • The end-stage patients may not benefit from this therapy. • TricValve is able to improve functional status, • TricValve is able to reduce tricuspid regurgitation rate, hospitalization rates, NT -proBNP levels diuretic dose over time [ABSTRACT FROM AUTHOR]

Objective: For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches to establish the possible gold standard.Methods: A systematic search was performed to identify all publications reporting the outcomes of four approaches for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis.Results: There were 31 included studies with 9663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA, and 6.4% RRA; early TR moderate-or-more was 9.6%, 4.8%, 4.6%, and 3.8%; late mortality was 22.5%, 18.2%, 11.9%, and 11.9%; late TR moderate-or-more was 27.9%, 18.3%, 14.3%, and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (-85% vs. no TA; -64% vs. SA; -32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches; however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes.Conclusions: Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provide more stable FTR across time. [ABSTRACT FROM AUTHOR]

Surgical coronary revascularization remains the preferred strategy in a significant portion of patients with coronary artery disease due to superior long‐term outcomes. However, there is a significant risk of perioperative neurologic injury that has influenced guideline recommendations. These complications occur in 1%–5% of patients, ranging from overt neurologic deficits with permanent disability, to subtle cerebral defects noted on neuroimaging that may result in slow cognitive and functional decline. The primary mechanism by which these events occur is thromboembolism from manipulation of the ascending aorta. This occurs during cardiopulmonary bypass, aortic cross‐clamping, and partial occlusion clamping (side clamp). Elderly patients and patients with aortic atheroma are, therefore, at significantly increased risk. Initial surgical techniques addressed this by aggressively debriding or replacing the ascending aorta during coronary artery bypass grafting (CABG). Strategies then moved toward minimizing aortic manipulation through pump‐assisted beating heart surgery and off‐pump surgery with partial occlusion clamping or proximal anastomosis devices. Finally, anaortic off‐pump CABG aims to avoid all manipulation of the ascending aorta through advanced off‐pump grafting techniques combined with in situ and composite grafts. This has been demonstrated to result in the greatest reduction in risk. Establishing successful anaortic off‐pump CABG programs requires subspecialization and focused interest groups dedicated to advancing CABG outcomes. [ABSTRACT FROM AUTHOR]