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Postinfarction ventricular septal rupture (VSR) represents a well-known mechanical complication of myocardial infarction, determining cardiogenic shock with high mortality rates. Surgical correction requires significant expertise to avoid cardiac rupture, uncontrollable bleeding, residual shunts, heart failure, and death. In the last year, we observed a substantial increase of VSR at our hospital, related to the delayed presentation of people with acute chest pain to the emergency departments during the coronavirus disease 2019 pandemic. We discuss our innovative triple-layer patch technique in a recent consecutive series of 8 patients. This technique proved effective in all patients, with no residual shunt or cardiac rupture.

Purpose Neurological complications are considered as most frequent complications following left ventricular device device (VAD) implantation. The aim of this multicenter study is to investigate neurological complications in patients requiring durable VADs following extra-corporeal life support (ECLS) implantation. Methods Data of eleven high volume ECLS/VAD centers are collected and evaluated to identify patients who underwent durable mechanical circulatory support system implantation after ECLS systems between January 2010 and July 2018. Preoperative parameters and postoperative outcome are analysed. Data of patients who developed postoperative neurological complication will be analysed and compared. A total of 531 patients meets the inclusion criteria. Patients who were supported with pulsatile pumps, CardioWest TAH and DeBakey VADs will be excluded. The outcome of the remaining 501 patients (mean age 53 ±2 yo, 82% male, average ECLS support duration of 7 ± 7 days and average MELD score of 19 ± 8), who were supported with either HeartWare HVAD, HeartMate II or HeartMate III pumps will be analysed. Endpoints The primary endpoint will be freedom from stroke at 30, 180, and 360 days post implant. Association of stroke events with operative strategies (using heart lung machine vs. ECLS for VAD implantation) will be evaluated. Further, factors predicting stroke events in this patient population are analyzed. We hypothesize that postoperative (after VAD Implantation) stroke complications may be higher in this sick patient population on ECLS compared to traditional VAD candidates.

The prevalence of heart failure (HF) continues to rise over time, with aging of the population and increased survival of incident cases. Major improvements occurred in drug therapy but morbidity and mortality of HF patients remain high. Some non-pharmacologic approaches to HF are already part of standard treatment for HF, including implantable cardioverter-defibrillators, cardiac resynchronization therapy (CRT) and left ventricular assist devices (LVADs). A number of transcatheter treatments and devices have been developed to improve management of valvular heart diseases (VHD), and some of them are being used or tested in specific HF conditions. For example, transcatheter aortic valve implantation (TAVI) to unload the left ventricle in patients with moderate aortic stenosis (AS) and HF or TAVI for severe aortic regurgitation (AR) in patients with LVADs. Similarly, percutaneous mitral valve repair can be used to improve prognosis and quality of life in patients with functional mitral valve regurgitation, and has been proposed as a bridge-to-LVAD or to heart transplant in selected patients. Other devices have been specifically developed for the treatment of chronic HF. In this review we describe the main devices used in the treatment of HF associated with aortic and mitral valve disease, as well as novel transcatheter interventions for chronic HF with different pathophysiologic targets.

Background While patients with uncomplicated acute Type B aortic syndromes (ATBAS) are usually managed with optimal medical therapy, complicated ATBAS require a quick intervention to prevent life-threatening complications. If anatomical features are favorable, TEVAR is the preferred treatment option. Nevertheless, open surgery still plays a significant role in selected cases. The optimal approach to complicated ATBAS remains matter of debate. Purpose We retrospectively evaluated our seventeen-years' experience as regional referral center for acute aortic syndromes to analyze the outcomes of TEVAR and open surgery in cases of complicated ATBAS. Methods Between January 2000 and December 2016, 199 patients with ATBAS were referred to our hospital: 133 aortic dissections, 53 intramural hematomas, 13 penetrating ulcers. All patients were evaluated by a multidisciplinary aortic team. 113 patients (56.8%) received the optimal medical therapy being uncomplicated, while 86 (43.2%) patients admitted with or developing a complicated form of ATBAS underwent TEVAR or open surgery during the same hospital admission. Open surgical repair was performed in cases of unsuitable anatomy for TEVAR, retrograde involvement of the arch, ascending aorta ectasia or aneurysm. In-hospital outcomes, long term survival and freedom from reoperation were analyzed and compared between the groups. Results No differences were observed in terms of in-hospital mortality between uncomplicated and complicated ATBAS (13.3% versus 14.0% respectively [p=0.890]). Complicated ATBAS were treated for unstable anatomical evolution (34 patients), refractory pain or uncontrollable hypertension (19 patients), visceral or peripheral malperfusion (18 patients) or impending rupture in 15 patients. Sixty-eight patients (79%) underwent TEVAR while 18 underwent open surgery (16 frozen elephant trunk [FET] and 2 descending thoracic aorta replacement). Operative timing from the onset of symptoms did not differ between two groups (9+10 (TEVAR) versus 14+16 (Open) days [p=0.233]). In-hospital mortality was 13.2% in TEVAR group versus 16.7% in open surgery (p=0.709). Postoperative myocardial infarction, visceral and peripheral ischemia and neurological outcomes were similar in two groups (p>0.05), but acute kidney injury was higher in open surgery cohort (p=0.027). One, 5 and 10-years survival of uncomplicated ATBAS (medical therapy) were 75%, 58%, 34% vs. 76%, 65%, 58% in TEVAR and 83%, 76%, 76% in open surgery groups (Log rank p=0.329). Comparing TEVAR and open surgery, freedom from endovascular reoperation at 1 and 5 years was 86%, 78% vs. 66%, 60% respectively (Log rank p=0.091). Conclusions Surgical treatment options (open and TEVAR) modify the natural history of complicated acute type B aortic syndromes. Open surgery represents a good option in selected cases with in-hospital and long-term survival at least comparable to TEVAR. Funding Acknowledgement Type of funding source: None

This document is intended to provide an overview of the incidence and characteristics of acute type A aortic dissection in Bologna during the month of severe restrictions imposed by the National Italian government due to COVID-19 pandemic. Aspects on management and time to intervention are outlined.

Purpose The Multicenter Italian study on RAdial Mechanically Assisted Circulatory Support (MIRAMACS) represent the first national observational registry, gathering continuous-flow (CF) left ventricular (LVAD) and biventricular assist device (BiVAD) implantation performed in adult patients by high-volume, mechanical circulatory support (MCS) dedicated, Italian centres. Methods Seven participating hospitals contributed pre-, peri- and long-term postoperative data on LVAD implants to the registry. Data for all implants in adult patients (>18 years of age) performed between January 2000 to September 2020 were analysed. BiVADs were excluded in this preliminary analysis. This initial report focuses on patient demographics, survival, device types, adverse events and competing outcomes. Results A total of 515 patients received a CF LVAD. The mean age of LVAD recipients was 60±10 years. The majority of patients were male (89.3%). The adopted systems were: HeartWare HVAD (n=213), HeartMate III (n=140), HeartMate II (n=89), Jarvik 2000 (n=50), Berlin Heart Incor (n=19) and other brands (n=4). In 6.6% of patients the LVAD implantation was performed by usage of less invasive surgical approaches. Mortality at 30- and 90-days was 6.1% and 11.1%, respectively. A temporary right ventricular assist device (RVAD) support was necessary in 3.1% of patients. Mean follow-up time was 57±15 months. Heart transplantation was performed in 99 patients (19.2%). Survival at 1-year, 3-years, and 5-years of BTT cohort was 82.1%, 60.4% and 41.8%, respectively. Survival at 1-year, 3-years, and 5-years of DT cohort was 69.8%, 45.6% and 30.1%, respectively. Major bleeding, major infection, neurological events and device malfunction were reported in 40 (7.7%), 143 (27.7%), 97 (18.8%) and 36 (6.9%) patients, respectively. Conclusion This first MIRAMACS report reveals frequencies and results comparable with other registries. Overall success rate of CF LVAD patients seems to be satisfactory. Detailed prospective data collection, additional participating centres and further analyses may provide additional robust scientific contributions.

Purpose Early graft dysfunction (EGD) is a major cause of morbidity and mortality following heart transplantation (HT). The rate of severe EGD requiring inotropes and/or mechanical circulatory support such as veno-arterial extracorporeal membrane oxygenation (VA ECMO) ranges from 8-20%. Our objective was to systematically review studies that reported on mortality in adult HT recipients who developed severe EGD requiring VA ECMO and conduct a meta-analysis. Methods A systematic search of the literature was conducted until June 1, 2019. Eligible studies included full texts and abstracts published after 2009, ≥10 adults post-HT who developed EGD requiring VA ECMO and reported on mortality. The primary outcome of short-term mortality was defined as death at 30 days and/or hospital discharge and was analysed using a random effects model. A meta-regression analysis to explore heterogeneity based on a priori defined factors was performed. The quality of the evidence was assessed using the GRADE framework. Results Of 17 305 publications screened, 22 observational studies identified 242 deaths in 670 patients from 1987-2018 (Figure). 21 studies (95%) were retrospective and most (86%) were conducted at a single centre. The quality of the evidence was rated as moderate. 14 studies (64%) included patients requiring VA ECMO within 24h post-HT; the rest included an extended early post-HT period (up to 7 days). The median age of patients was 49 yrs (IQR 36-62), 18% (IQR 13-29) were female, 47% (IQR 39-77) had a prior sternotomy, and ischemic time was 198 (IQR 191-224) min. Pooled short-term mortality was 36.8% (95% CI 28.7-43.3, I2 =70%). In the meta-regression, short-term mortality was higher in studies with a higher proportion of females. Conclusion The use of VA ECMO for EGD post-HT is associated with significant clinical benefit with acceptable short-term survival. Future studies are needed to identify factors that may further improve outcomes for patients who experience EGD.

Purpose Chronic thromboembolic pulmonary hypertension (CTEPH) is the only type of pulmonary hypertension (PH) with a surgical resolution which is the Pulmonary Thrombo-Endarterectomy (PTE) operation. Fibrotic thrombus extraction allows pulmonary vascular resistances (PVR) reduction until normalisation in most of cases. However, this sentence might be controversial since results are conditioned by the center experience on patients's selection, operation's timing, skills and management of such complex pathology. Seventeen years performing PTE and our multidisciplinary approach allowed us to obtain very good results. In here we report our data progress and results of PTE for CTEPH. Methods A total of 177 patients underwent PTE from 2003 until 2020. From 2003 to 2012 (Group 1) 96 patients were operated avoiding Deep Hypothermic Circulatory Arrest (DHCA) being applied only when blood bronchial flow ruled out a complete endarterectomy. Group 2, included 81 patients operated rom 2012 until the present, when DHCA was routinely adopted. Furthermore, the event of the Balloon Pulmonary Angioplasty (BPA) in 2015, conceded us a therapeutic alternative in high risk or unsuitable PTE patients. The impact of these and other variables in patients population profile and results of both groups have been retrospectively compare and analysed. Results Most relevant preoperative differences were related to worst clinical status and associated pathologies in Group 1 and wider use of specific pulmonary vasodilator in Group 2. Cross clamp time as well as time of cardiopulmonary bypass were significantly shorter in Group 2 in spite of a mean DHCA time of 33 minutes. In-hospital mortality and need of postoperative ECMO was respectively 15.6% vs 3.7% and 15.6% vs 8.6% in group 1 and 2 (p 0.001). Pulmonary hemodynamic as well as long term outcome equally and significantly improved in both groups. Conclusion Our reported results demonstrate that, DHCA is the best approach to perform PTE for CTEPH. Certainly experience, protocols and a multidisciplinary approach contribute to obtain the best hemodynamics, surgical and clinical outcomes.

Purpose To investigate the predictive value of Acute Physiology, Age and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology (SAPS) II and Sequential Organ Failure Assessment (SOFA) scores for patient selection and timing to Extracorporeal Life Support (ECLS) as treatment of refractory cardiogenic shock. Methods Retrospective analysis of a prospectively-maintained operative dataset. Results Our study population included 185 patients receiving ECLS at our department between 2006 and 2018. Patient median age was 50.6 years; 62% were male. The most frequent reason for ECLS need, in our subset of patients, was post-cardiotomy syndrome (52.4%) followed by acute decompensation of chronic heart failure (17.5%), isolated right ventricular dysfunction (16.2%), acute myocardial infarction (10.2%) and myocarditis (3.7%). Median duration of ECLS was 8.9 days. Forty-one patients (22.2%) received heart transplantation. In-hospital mortality was 34.6% on ECLS running and 25.9% after ECLS removal. Multivariate regression analysis showed patient age, ECLS duration and bridge to transplantation (BTT) category as indipendent predictors of death (p Conclusion This study confirms the poor prognosis of critically ill patients receiving ECLS support. The APACHE II and SOFA scores, mainly, proved to be a reproducible evaluation tool with high prognostic abilities. In our population, age >65 years, ECLS duration >10 days and BTT ECLS intention appear to impact negatively.

Purpose Currently, guide for appropriate donor sizing in recipients mostly focuses on donor-recipient body weight matching. The purpose is to retrospectively determine the impact of predicted heart mass (pHM)-based size matching among recipients on heart transplantation (HT) outcomes. Methods According to our institutional registry, 512 consecutive adult patients underwent HT between January 2000 and August 2020. For each patient, pHM and donor-recipient pHM ratio have been calculated (4 patients were excluded for missing anthropometric data). Patients were partitioned into quintiles in terms of pHM ratio: Undersizing2 (n=101), Undersizing1 (n=102), Reference (n=102), Oversizing1 (n=102), Oversizing2 (n=101) with a mean pHM donor-recipient ratio of 0.81, 0.96, 1.04, 1.12, 1.28, respectively. Severe early graft failure, 30-day, 90-day and 1-year mortality were analyzed as early outcomes. Results Several characteristics were significantly different between groups. Recipients of the most oversized group were mostly male (p 0.05). Kaplan-Mayer and Cox-regression analysis after adjustment for pHM ratio subgroups did not show any difference in outcomes (p>0.05). Conclusion A wide range of pHM donor-recipient ratios seem to be safe (0.81-1.28). Providing a pHM-based oversized graft to more compromised patients may preserve good outcomes. Instead, low risk profile patients may have acceptable outcomes even in the presence of extremely undersized pHM ratio calculation. A careful allocation of organs, by considering a pHM ratio mismatch, may balance rescue preoperative clinical profiles and preserve HT outcomes.

Purpose Advanced Heart Failure (A-HF) is a clinical condition which interferes with patient identity and perception. Psychological reactions depend on the nature and severity of patient disease, personality and environmental factors. Our goal was to evaluate quality of life of outpatients with left ventricular assist device (LVAD), heart transplantation (HT) and optimal medical treatment (OMT) for heart failure (HF). We additionally analyzed two cohorts of patients resulting different in terms of objective disease severity, to assess eventual perceived quality of life differences. Methods We included all consecutive adult patients presenting at our outpatient clinic for routine follow-up between January and September 2019. Including criteria were: being subjected to right heart catheterization (RHC), presence of LVAD for at least 2 months, HT for at least 2 months. Clinical severity of HF has been stratified using RHC and 6-minute walk test. Psychological parameters were measured by Kellner Symptom Questionnaire, Brief-Illness Perception Questionnaire, and WHO Quality of Life -BREF. Results Overall population consisted of 179 patients (HT=90, LVAD=15, and OMT-HF =74). OMT-HF patients were stratified into advanced and non-advanced (A-HF/NA-HF). A-HF patients walked significant less meters (p 3 (p=0.89), walked meters (p=0.32), CI (p=0.82). In psychological well-being comparison between OMT, LVAD and HT, patients who underwent advanced surgical therapy showed better results in terms of anxiety (p=0.014), depression (p=0.003), anger (p=0.04) and illness perception (p Conclusion Patients undergoing a major surgical procedure, such as LVAD implantation or Heart Transplantation, showed overall better psychological parameters than patients with chronic heart failure treated with medical therapy.

Purpose Orthotopic heart transplantation (OHT) remains the gold standard for end-stage heart failure. The number of patients who have had at least one prior sternotomy while awaiting transplantation is increasing. Redo sternotomy before OHT may increase operative complexity thus affecting the outcomes. Methods We retrospectively analyzed patients who underwent OHT at our institution, during a 17-year period. All patients who underwent prior sternotomy were compared with those undergoing OHT with a virgin chest. Patients who underwent left ventricular assist device (LVAD) support as bridge to transplantation were excluded, in the study. Preoperative, intraoperative, and postoperative variables were analyzed. Short- and long-term outcomes/survival were studied. Primary and secondary graft failure after OHT were weighted. To account for bias in selection of patients a propensity score (PS) model was constructed and adopted. Kaplan-Meier survival estimates of overall and adverse events-free survival were compared using a paired analysis. Results A total of 461 adult patients underwent OHT, between 2000 and 2017. Unmatched population: No prior sternotomy OHT patients (n=343) vs. prior sternotomy OHT patients (n=118). PS matched population: No prior sternotomy OHT patients (n=118) vs. prior sternotomy OHT patients (n=118). Overall 30-day mortality was slightly lower in the prior sternotomy OHT group, but not significantly (13.3% vs 7.7%, p=0.14). The two groups showed similar perioperative outcomes. Long-term survival (5-year and 10-year) was similar in the two groups (80.9% vs. 75.7% and 72.5 vs. 67.4 %; log-rank, p=0.41). The subgroups analysis revealed prior valvular surgery associated with a coronary artery bypass grafting (CABG) procedure as risk factor for 30-day mortality (OR 6.2; p=0.01). Conclusion Redo sternotomy before OHT may increase operative complexity but not affecting the outcomes in terms of survival or allograft function.Type of prior surgical procedure should be properly weighted to preserve the outcomes at the time of OHT.

Purpose As Italy faced SARS-CoV-2 outbreak as first country outside China, and our hospital converted most of activities into the ones for COVID-19 patients (pts), we had to manage the need for continuing care of advanced heart failure (HF), heart transplant (HT) and LVAD pts. TM was a possible strategy, but its role in this very sick cohort is unknown. Methods During the lockdown (03-05/2020), we decided to make either a phone (PV) or an in presence (IV) visit, selecting for IV pts listed for HT, with LVAD, recently HT, scheduled for a biopsy within 6 months after HT or a RHC for listing eligibility. In PV, we assessed symptoms, blood pressure, drugs, and programmed a subsequent IV. All pts in IV group were triaged by phone for COVID-19 symptoms or contacts and if scheduled for RHC or biopsy received SARS-CoV-2 swab 48 h before the procedure. Study endpoints were: combined incidence at 6 months of MACE (HF hospitalization, CV death and need for anticipated IV) in HF/VAD group, and MACE, rejection and any cause- hospitalization in HT group. Results Among 448 pts (57±12y, 240 HT, 191 HF, 17 LVAD), 52% were managed by PV and a subsequent IV was scheduled after 3±2 months. Pts managed by PV were healthier: in HF-VAD group they were less frequently listed, had less Afib, LVAD (2/17) (p

Purpose Left ventricular assist devices (LVAD) have been developed to support cardiocirculatory function in patients with advanced heart failure, who are refractory to optimal medical treatment. This created the need to identify a professional figure for dedicated management of LVAD patients. Methods In this report, we analyzed all the accesses of all consecutive adult LVAD recipients at our outpatient care unit and the impact of VAD coordinator clinical/technical assessment on patients global management, at the time of COVID-19 pandemic in the period January to August 2020 Results During the study period, 19 LVAD patients had overall 357 contacts with the clinic, for different combinations of: advanced driveline dressing (n=280), log file analysis and technical check-up (n=200), clinical visit (n=102), ramp test (n=17). In the majority of accesses, the patient was seen by the VAD coordinator only, (n=238; 67%), mainly for driveline dressing, which was associated with technical check-ups in 89 cases.Overall, alarms were managed by technical check-ups and log file analyses in 14 cases (6 high priority alarms, 3 cases of high watt or low flow, and 5 cases of low-priority alarms). Ramp tests were performed during right heart catheterization, with contextual echocardiography performed by the VAD coordinator: in 11 out of 17 cases the ramp test led to medical therapy or LVAD settings optimization. Conclusion LVAD patients need frequent outpatients dedicated admissions for proper monitoring. The VAD coordinator is a key healthcare professional representing the main interface for LVAD patients, in support of physicians’ throughout the duration of mechanical support, to preserve optimal outcomes.

Background and purpose Extracorporeal membrane oxygenation (ECMO) is used as temporary life support in subjects with potentially reversible respiratory/cardiac failure. The principal purpose of this review was to assess the characteristics and potential advantages of physiotherapeutic interventions in subjects on awake ECMO support. Methods Seven databases were interrogated: we searched titles, abstracts and keywords using the Medical Subject Headings terms ‘extracorporeal membrane oxygenation’ and ‘rehabilitation’ linked with the Boolean operator ‘AND’. Results and conclusion In total, 216 citations were retrieved. Nine citations satisfied our inclusion criteria and were subjected to full-text analysis. The numbers of patients enrolled in the included studies (most of which were case series) were low (n = 52). We found no prospective studies or randomized controlled trials. Overall, subjects on awake ECMO usually received a combination of passive and active physiotherapy, and most achieved an acceptable degree of autonomy after treatment. Emerging research in the field affords preliminary evidence supporting the safety of early mobilization and ambulation in patients on awake veno-venous ECMO support. Copyright © 2015 John Wiley & Sons, Ltd.

Turnersyndrome(TS)isawell-definedautosomaldominantgenetic syndrome caused by a partial or complete monosomy of the chromosome X(45,X0). Cardiovascular complications are mostly responsible forreducedlifeexpectancy.Themaincardiacabnormalitiesarebicuspid aortic valve and aortic coarctation in approximately 16% and 11% of the patients, respectively [1]. A dilatation of major vessels is also observed, above all of the aorta and of the carotid and the brachial arteries. Aortic disease in TS is characterizedbya “connective tissue disorder”similarto that seen in Marfansyndrome. Ascending aorta dilatation is observed in 33% of the cases, and the incidence of aortic dissection is much higher than for women in general, occurring in the third and fourth decades of life [2]. We present a case of TS with bicuspid aortic valve plus hypoplastic aortic arch and chronic aneurysm of the descending thoracic aorta. Informed consent was obtained by the patient. The patient, a 38-year-old woman (Body Surface Area: 1.34 m 2 ; Aortic Size Index: 2.6 cm/m 2 ) with 45,X0 karyotype diagnosed at birth, presented a bicuspid aortic valve, an aortic coarctation, a left superior vena cava and patent ductus arteriosus. At 11 months, she underwent surgical repair of isthmic coarctation and patent ductus closure. After that, she was followed by regular examinations until the age of six, when she was operated on for an excision of a supravalvular mitral stenosis. During the following years, the patient had a normal quality of life up to 38 years when an echocardiogram showed mild aortic regurgitation

OBJECTIVES Extracorporeal membrane oxygenation (ECMO) is commonly used in children to allow recovery from ischemic injury or cardiac surgery, to support the circulation in case of end-stage cardiomyopathy, as bridge-to-bridge therapy and as bridge to transplantation as well. It has achieved success in providing cardiac support for these kind of patients with expected mortality due to severe myocardial dysfunction. In this modern era, ECMO support should be considered an important option for children with cardiopulmonary failure refractory to medical therapy or resuscitation. We report our experience in pediatric patients supported by ECMO for intraoperative cardiac failure between November 1991 and December 2006. METHODS AND RESULTS Sixty-six patients with a mean age of 5.2+/-4 years (range: 1 day-17 years) and mean weight of 14.3+/-11 kg (range: 2.8-69 kg) had intraoperative ECMO support for failure to wean off cardiopulmonary bypass (n=46, 69.7%), low cardiac output syndrome (n=8, 12.1%), isolated right ventricular failure (n=6, 9.1%), isolated left ventricular failure (n=3, 4.5%), malignant arrhythmia (n=1, 1.5%) and pulmonary hypertension (n=2, 3.1%). Mean duration of ECMO support was 5.1+/-3 days. Overall 30 (45.4%) patients were successfully weaned off ECMO and survived to decannulation. Overall 6 (9.1%) patients were successfully bridged to heart transplantation while on ECMO support. Thirty patients died (54.4%) (16 while on ECMO and 14 after decannulation) because of multi-factorial complications, i.e. cerebral hemorrhage, pulmonary failure, consumption coagulopathy and therapy-resistant myocardial insufficiency, leding to an overall hospital mortality rate of 45.4%. Mean survival time after decannulation was 28+/-16 h. Overall survival rate on ECMO as bridge to recovery and transplantation has been 54.5% with successful hospital discharge of patients. CONCLUSIONS Our experience shows that ECMO support can be offered intraoperatively to any children after palliative or corrective surgery for congenital heart disease with potentially reversible pulmonary, cardiac or cardiopulmonary failure. In the majority of patients who did not survive late after weaning from ECMO support, significant myocardial dysfunction persisted or pulmonary hypertensive events. Nevertheless, an acceptable proportion of patients who were successfully weaned from ECMO ultimately survived to leave the hospital.

Aortic valve-sparing operations have provided very good clinical outcomes. However, the absence of the sinuses of Valsalva might limit valve durability. The Gelweave Valsalva prosthesis, which presents pre-fashioned neo-sinuses, has been designed in order to avoid early leaflets deterioration. We report our results in 63 patients who underwent valve-sparing operations (reimplantation technique) using the Gelweave Valsalva graft. The main indication was ascending aorta aneurysm or annuloaortic ectasia, with or without aortic insufficiency. The operation was performed also in cases of Marfan syndrome, Bicuspid Aortic Valve (BAV), and acute Type A dissection. In-hospital mortality was of 4.7%, and two thirds were acute Type A dissection patients (P=0.01). There were no late deaths. Three years freedom from grade 3-4 AI and freedom from late aortic valve replacement were 91.7+/-4.3% and 93.8+/-5.1%, respectively. Aortic valve-sparing operations show good results in patients electively operated for aortic root ectasia. Aortic cusps repair may lead to late failure. Even if the Gelweave Valsalva prosthesis is easy to implant and it also reproduces pseudosinuses, a long-term follow up is necessary to determine if this graft may reduce leaflets deterioration.

Background The purpose of this study was to evaluate the efficacy of radiofrequency (RF) ablation in the treatment of atrial fibrillation, by comparatively analyzing the outcomes of the patients who underwent RF ablation with those of patients who underwent Cox/Maze III surgery. Methods Between April 1995 and June 2002, 70 patients underwent surgery for atrial fibrillation and open-heart surgery at the Department of Cardiovascular Surgery of the University of Bologna: 30 patients underwent the surgical Cox/Maze III procedure (group 1), and 40 patients underwent the RF ablation according to the Maze III configuration at least on the left atrium (group 2). There were 14 males and 56 females, with a mean age of 61.5 ± 12.5 years (range 22 to 80 years old). Results Groups 1 and 2 did not differ in terms of baseline characteristics. The perioperative mortality rate was not significantly different between the two groups (6.6% in group 1 vs 7.5% in group 2). The overall cumulative rates of sinus rhythm were 68.9% in group 1 and 88.5% in group 2 (not statistically significant). Biatrial contraction was assessed by transthoracic echocardiography in 70.4% of the patients in group 1 and 76.5% of the patients in group 2 ( p = 0.65). Conclusions The RF ablation procedure offers as good results as the Cox/Maze III operation, allowing recovery of the sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who underwent open heart surgery; it is a safe and effective means of curing atrial fibrillation with negligible technical and time requirements.

Objective We present the results obtained in 40 patients with chronic atrial fibrillation using direct intraoperative radiofrequency to perform atrial fibrillation surgery. Methods Between April 1995 and June 2002, 40 patients underwent surgery for atrial fibrillation using radiofrequency ablation and cardiac surgery at the Department of Cardiovascular Surgery of the University of Bologna. There were 8 men and 32 women with a mean age of 62 ± 11.6 years (range: 20 to 80 years). Results Concomitant surgical procedures were: mitral valve replacement (n = 13), mitral valve replacement plus tricuspid valvuloplasty (n = 11), combined mitral and aortic valve replacement (n = 8), and combined mitral and aortic valve replacement plus tricuspid valvuloplasty (n = 5). Moreover, 1 patient underwent tricuspid valvuloplasty plus atrial septal defect repair, another required aortic valve replacement plus coronary artery bypass graft, and a third underwent aortic valve replacement. After the mean follow-up time of 16.5 ± 2.5 months survival was 92.8% and the overall cumulative rate of sinus rhythm was 88.5%. Conclusions We conclude that the radiofrequency ablation procedure is a safe and effective means of curing atrial fibrillation with negligible technical and time requirements, allowing recovery of the sinus rhythm and atrial function in the great majority of patients with atrial fibrillation who underwent cardiac surgery (88.5% of our study population).

We present a case of a traumatic aorto-right ventricular fistula coexistent with aortic insufficiency due to perforation of the left coronary leaflet, which is a lesion rarely described in the literature. We compare our experience with reports from the literature.

An approach is reported for right ventricle temporary mechanical support in long-term axial left ventricular assist device (LVAD) patients preoperatively judged at high risk of right ventricular (RV) failure. The timing for RV assist device (RVAD) weaning and the technique for its removal through a right mini-thoracotomy are described. This strategy provides a good outcome in LVAD recipients avoiding the risk of immediate postoperative RV failure.

Objectives The excellent results with left ventricular assist devices (LVADs) have revolutionized the treatment options for end-stage heart failure. The use of pulsatile devices is associated with significant comorbidity and limited durability. The axial-flow HeartMate II LVAD represents the new generation of devices. The clinical use of this pump resulted in superior outcomes. We review the HeartMate II technology, management, clinical usage and our experience. Methods Between 3/2002 and 12/2008, 18 transplantable adult patients were supported on long-term HeartMate II LVAD at our institution (13 men, age 52 +/- 8.4 years, range: 31-64 years). Primary indications were: ischemic cardiomyopathy (CMP) (n = 13), idiopathic CMP (n = 5). All patients were in New York Heart Association (NYHA) Class IV heart failure. None of patients had prior open-heart surgery. Implantation via cannulation of the left ventricular apex and the ascending aorta was always elective. Results Mean support time was 217 +/- 212.3 days (range: 1-665 days). Early (30-day) mortality was 27.7% (five patients) with multiple organ failure and sepsis as main causes of death. Bleeding requiring reoperation occurred in six (33.3%) cases. Cerebral hemorrhage occurred in one patient. There were two driveline infections and no device failure. Twelve (66.6%) patients were successfully discharged home. Overall nine patients (50%) were transplanted and two patients are actually waiting for a suitable organ (n = 2 patients discharged home and n = 1 patient in hospital). At latest, follow-up survival rate after heart transplantation is 66.6% (six patients). Conclusion Long-term HeartMate II LVAD provides good mid-term, long-term results. This new technology requires delicate management. Functional status and quality of life greatly improve in patients who survive the perioperative period.

Introduction: Levitronix CentriMag is a novel extracorporeal magnetically levitated centrifugal blood pump designed for short-term mechanical circulatory support (MCS). The device, combined with BerlinHeart cannulas, can later be exchanged for a long-term BerlinHeart Excor device, if patients remain without myocardial recovery despite peripheral organ recovery. We reviewed our experience with this strategy. Methods: Inflow and outflow Berlin Heart cannulas were placed in traditional fashion. Titanium connectors were introduced between the cannulas and Levitronix circuit. Pump exchange was performed, without resternotomy, in the intensive care unit or operating room with the patient slightly sedated. Results: Between 12/2006 and 07/2007, 14 patients (13 men; age 50.2±16.1, range:24–73 years), out of an overall population of 39 consecutive cases supported with Levitronix at our institution, were judged to be candidates for BerlinHeart Excor. In 10 cases MCS was established in a biventricular,in 2 in a left ventricular and in 2 in a right ventricular configuration. Indications for primary support at implantation were: postcardiotomy cardiogenic shock (n=5) and bridge to decision regarding transplantation or permanent support (n=9) (7 dilated cardiomyopathy, 1 fulminant myocarditis, 1 acute myocardial infarction). The conversion to long-term device was performed after 7.4±3.8 (range: 1–16) days. One patient received successful transplantation. Eleven patients were discharged home and three of them are currently waiting for a suitable organ. One patient is on biventricular support as permanent solution. Two patients died of sepsis. At the latest follow-up, mean duration of support is 112.4±78 (range:10–210) days. Conclusions: Levitronix has proved useful and enabled patients to be bridged to long-term support. The exchange for Berlin Heart pumps produces good results, avoiding the risks of repeated sternotomy and reducing the costs involved.

Chronic functional pulmonary hypertension (FPH) secondary to end-stage cardiomyopathy constitutes a risk factor for graft right ventricular failure(RVF) after orthotopic hearttransplantation (HTx). Anovelform ofmechanicalassist circuit,the extracorporeal rightto leftatriumbypass (ECRLAB),hasbeenproposed.Since1998,atourinstitution,atotalofsixpatientswithFPHwhoexperiencedgraftRVFafterHTx,asischemicendstage cardiomyopathy, during the effort to wean from cardiopulmonary bypass, underwent ECRLAB support. There were five men and one woman withameanageof55 3.5years(49—59years).TheJostraRotaFlowpumpwasusedinfivepatientsandtheBio-Medicusinone.Meandurationof supportwas94.3 17.5 h (75—126 h).All(100%)patientsweresuccessfully weanedfromECRLAB support.Hemodynamicparametersimprovedin all patients. Two patients died from cerebral haemorrhage. Four (66.6%) patients were successfully discharged home. ECRLAB could be proposed during HTx in patients with increased preoperative transpulmonary gradient to promote the functional adaptation of the graft and avoid graft RVF, until the decline of pulmonary resistances. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Background This study evaluates the midterm clinical results of valve-preserving aortic root reconstruction by means of a modified conduit incorporating sinuses of Valsalva. Methods During a 5-year period, 151 patients with aneurysm of the aortic root underwent a reimplantation type of valve-sparing procedure using the Gelweave Valsalva prosthesis that incorporates sinuses of Valsalva. There were 121 males (80.1%), and the mean age was 56.4 ± 14.4 years (range, 14 to 83). Fourteen percent of the patients had Marfan syndrome and 8.6% had bicuspid aortic valve. Seven patients (4.6%) suffered from acute aortic dissection. Aortic replacement was extended to the arch in 14 patients (9.3%). Sixteen patients (10.6%) had associated cusp repair. Results In-hospital mortality was 3.3%, and it was significantly higher among patients operated on for acute dissection ( p = 0.001) and in symptomatic patients (III–IV New York Heart Association class; p = 0.021). Follow-up (mean, 18 months; range, 1 to 60) was 100% complete. There were 2 late deaths. Ten patients (6.8%) had 3 to 4+ aortic regurgitation, and 8 of these required late aortic valve replacement. Cusp repair was associated with a high incidence of late aortic valve replacement ( p = 0.005). At 5 years, freedom from aortic valve replacement and freedom from grade 3 to 4 aortic insufficiency was 90.8% ± 3.3% and 88.7% ± 3.6%, respectively. Conclusions The reimplantation valve-sparing procedure with the Gelweave Valsalva prosthesis provides satisfactory results for patients with aortic root aneurysm. Aortic cusp repair may lead to late aortic insufficiency. Proper leaflet evaluation is of paramount importance in preventing residual valve regurgitation.

Atrioventricular valve duplication, also known as double orifice valve, is an excitingly rare anomaly that can involve either the mitral or more uncommonly the tricuspid valve. Herein we describe a case of a double orifice tricuspid valve that prejudiced the complete repair in a symptomatic infant with tetralogy of Fallot.

Aneurysm development after repair of aortic coarctation is not a rare complication, but it is highly related to hypoplasia of the transverse aortic arch. The optimal management of such cases is not clearly established. We propose a single-stage transmediastinal re-repair using moderate hypothermic cardiopulmonary bypass and antegrade selective cerebral perfusion.

* Corresponding author. Address: Via Vittoria Colonna, 19, 20149 Milano, Italy. Tel.: C39 335 6548336; fax: C39 051 345990. E-mail address: emmanuel.villa@voila.fr (E. Villa). ostium. Imprecise stent positioning is disturbing in case of supplemental cardioplegia: unplanned conversion to retrograde infusion or neonatal arteriotomy-catheter for selective cannulation are needed (Fig. 1). European Journal of Cardio-thoracic Surgery 27 (2005) 712 www.elsevier.com/locate/ejcts

Purpose During recent years, mechanical circulatory support (MCS) devices have been increasingly used for long-term support. The Syncardia/CardioWest total artificial heart (TAH) has been implanted in over 1075 patients worldwide as a bridge to transplant. We reviewed data of patients supported more than one year to assess its safety and feasibility as destination therapy device. Methods and Materials 47 patients from 10 centers worldwide have been included in this retrospective study. Clinical data have been collected on survival, infections, thromboembolic and hemorrhagic events, device failure, antithrombotic therapy regimen and outcome. Results The median age was 49 years old, the median support time was 554 days (range 365 – 1373 days). The primary diagnosis was dilatative cardiomiopathy in 23 pts, Ischemic in 15 and other in 9. After at least one year of support patients have been successfully transplanted in 72% of cases, 24% died on device and 4 % are still supported. 4 patients (8%) had a device failure report but only for two patients it was the leading cause of death. Major complications were as follows: sistemic infections (19%; 3% leading death), drive line infections (20%, 0% leading death), ischemic (15%, 6% leading death) and hemorrhagic (23%, 6% leading death) events. Moreover antithrombotic regimen, hospital discharge, post operative rehabilitation period, drugs therapy and follow up management have been carefully investigated among our population of patience. Conclusions Cardiowest (t-TAH) has shown to be a reliable and effective device in replacing the entire heart. Device failure occurred rarely and only in two cases was the leading cause of death. The Syncardia TAH has emerged as a robust form of mechanical circulatory support for biventricular failure patients even in a setting of long term support. The dilemma of destination therapy is more ethical issue up to now considering the major impact in the quality of life of these patients.

underline the relative greater frequency of this complication in heterotaxy syndrome when associated with anomalous pulmonary and systemic venous connections, which can make surgical repair complicated with the need to create a tortuous and potentially obstructive pathway. Despite this concern, a recent report from our institution 5 has shown excellent outcome with cavopulmonary connection in patients with heterotaxy syndrome and anomalous pulmonary venous return. This is likely due to improved surgical technique and use of extracardiac conduit in cases with complex atrial and venous anatomy (18%). None of the 3 patients had evidence of obstruction at the pulmonary venous pathway early after the Fontan procedure, as determined by 2-dimensional echocardiography. Pulmonary venous obstruction developed slowly through a period of several months to years. In patient 2, pulmonary venous obstruction developed 4 months after device closure of the fenestration, suggesting that the additional scarring from device implantation contributed to the obstruction. The obstruction was due to fibrotic tissue at either the interatrial septum or in the interatrial course of the pulmonary veins (patient 2). To prevent this complication, and to ensure a wide open pulmonary venous outflow, particularly in patients with mitral atresia or stenosis, we currently enlarge the communication between the pulmonary veins and the right atrium by unroofing the coronary sinus posteriorly into the left atrium, in addition to resection of the interatrial septum. In conclusion, late onset obstruction of pulmonary venous pathway after lateral tunnel cavopulmonary connection is a rare but serious complication that may be prevented by unroofing the coronary sinus at the time of Fontan procedure.