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Background Chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary arterial hypertension (PAH) are two forms of pulmonary hypertension (PH) characterized by obstructive vasculopathy. Endothelial dysfunction along with metabolic changes towards increased glycolysis are important in PAH pathophysiology. Less is known about such abnormalities in endothelial cells (ECs) from CTEPH patients. This study provides a systematic metabolic comparison of ECs derived from CTEPH and PAH patients. Methods Metabolic gene expression was studied using qPCR in cultured CTEPH-EC and PAH-EC. Western blot analyses were done for HK2, LDHA, PDHA1, PDK and G6PD. Basal viability of CTEPH-EC and PAH-EC with the incubation with metabolic inhibitors was measured using colorimetric viability assays. Human pulmonary artery endothelial cells (HPAEC) were used as healthy controls. Results Whereas PAH-EC showed significant higher mRNA levels of GLUT1, HK2, LDHA, PDHA1 and GLUD1 metabolic enzymes compared to HPAEC, CTEPH-EC did not. Oxidative phosphorylation associated proteins had an increased expression in PAH-EC compared to CTEPH-EC and HPAE. PAH-EC, CTEPH-EC and HPAEC presented similar HOXD macrovascular gene expression. Metabolic inhibitors showed a dose-dependent reduction in viability in all three groups, predominantly in PAH-EC. Conclusions A different metabolic profile is present in CTEPH-EC compared to PAH-EC and suggests differences in molecular mechanisms important in the disease pathology and treatment.

Background Heart transplant (HT) remains the last treatment option for patients with non-obstructive hypertrophic cardiomyopathy (HCM) who develop end-stage heart failure (HF). Early identification of patients who may require a HT in the future is crucial in order to advise them, establish the appropriate follow-up and determine the appropriate time to include them in the waiting list. Objectives Our study sought to find predictive factors related with requiring HT during follow-up in patients with HCM. Methods Consecutive patients with HCM referred to a HCM monographic clinic from 2018 to 2020 (HCM controls) and transplanted patients due to HCM in the same tertiary HT hospital since 2003 (cases) were included. Baseline (on the date of HCM diagnosis) and longitudinal data regarding clinical, genetic, ECG and echocardiographic variables were retrospectively evaluated. Follow-up was registered from HCM diagnosis to HT (in cases) or last medical check up (controls). Results A total of 157 patients (24 HCM-HT cases and 133 HCM controls) were included (45±19 yo; 57% male). At the time of MCH diagnosis (Table), cases were significantly younger than controls, were more frequently symptomatic and showed significantly higher BNP levels and more advanced diastolic dysfunction (larger left atrium, higher E/A ratio and lower e'); also, HCM-HT reported more family history and had higher proportion of pathogenic mutations (being MYH7 the most frequently involved). Left ventricular (LV) systolic function was slightly reduced in HCM-HT cases. In contrast, HCM controls were more frequently diagnosed by casual findings or family screening and had more LV outflow tract obstruction at first medical evaluation. LV maximal wall thickness (MWT) did not differ between groups. During a median follow-up since HCM diagnosis of 6.2 years (median follow-up of 8.9 and 7.1 years in cases and controls, respectively), HCM-HT cases presented a higher incidence of sustained ventricular tachycardia or ICD therapy (HR=4.0; CI95%:1.6–10.0 p=0.03) and HF admissions (HR=3.9; CI95%:1.8–8.1 p Conclusions The presence of symptoms in a young non-obstructive HCM patient, along with family history and a pathogenic mutation, should advice clinicians a closer follow-up and early transfer to a HT referral center, especially if associated with diastolic dysfunction and high BNP values. Funding Acknowledgement Type of funding sources: None. Table 1

Surgical re-explorations represent 3–5% of all cardiac surgery. Concerns regarding mortality and major morbidity of re-explorations in the intensive care unit (ICU) setting exist. We sought to investigate whether they may have different outcomes compared with those performed in the operating room (OR). Single center retrospective review of patients who underwent mediastinal re-exploration in the ICU or in the OR after cardiac surgery. Mediastinal re-explorations were also classified as: “planned” and “unplanned”. Primary outcome was 30-day mortality, secondary outcomes include deep sternal wound infection (DSWI), sepsis, ICU and hospital length of stay, prolonged intubation (&gt, 72 h), tracheostomy, pneumonia, acute kidney injury requiring dialysis and stroke. Between 2010 and 2019, 195 of 7263 patients (2.7%) underwent mediastinal re-exploration after cardiac surgery. More patients in the ICU group experienced two or more re-explorations (30.3% vs 2.3%, p &lt, 0.001), a higher incidence of postoperative pneumonia (22% vs 7%, p = 0.004), prolonged intubation (46.8% vs 19.8%, p &lt, 0.001) and longer hospital stay (30.3 ± 34.2 vs. 20.8 ± 18.3 days, p = 0.014). There were no differences in mortality between ICU and OR (16.5% vs. 13.9%, p = 0.24) nor in sepsis (14.7% vs 7%, p = 0.91) and DSWI rates (1.8% vs 1.2%, p = 0.14). Re-explorations in the ICU were not associated with increased mortality, sepsis and mediastinitis rate.

Rationale: Pulmonary endarterectomy (PEA) resected material offers a unique opportunity to develop an in vitro endothelial cell model of chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to comprehensively analyze the endothelial function, molecular signature and mitochondrial profile of CTEPH-derived endothelial cells to better understand the pathophysiological mechanisms of endothelial dysfunction behind CTEPH, and to identify potential novel targets for the prevention and treatment of the disease. Methods: Isolated cells from specimens obtained at PEA (CTEPH-EC), were characterized based on morphology, phenotype and functional analyses (in vitro and in vivo tubule formation, proliferation, apoptosis, and migration). Mitochondrial content, morphology, and dynamics, as well as high-resolution respirometry and oxidative stress, were also studied. Results: CTEPH-EC displayed a hyperproliferative phenotype with an increase expression of adhesion molecules and a decreased apoptosis, eNOS activity, migration capacity and reduced angiogenic capacity in vitro and in vivo compared to healthy endothelial cells. CTEPH-EC presented altered mitochondrial dynamics, increased mitochondrial respiration and an unbalanced production of reactive oxygen species and antioxidants. Conclusions: Our study is the foremost comprehensive investigation of CTEPH-EC. Modulation of redox, mitochondrial homeostasis and adhesion molecule overexpression arise as novel targets and biomarkers in CTEPH.

Hypertrophic cardiomyopathy (HCM) is a complex, underestimated, multifaceted disease frequently associated with left ventricular outflow tract (LVOT) obstruction. It is clearly demonstrated that this is due not only to septal hypertrophy but also to systolic anterior motion (SAM) of mitral valve leaflets secondary to mitral valve/subvalvular apparatus abnormalities. Surgical treatment involves performing an extended septal myectomy, eventually followed by ancillary procedures to those structures responsible for maintaining LVOT obstruction, if necessary. In this review, we describe the spectrum of possible surgical techniques beyond septal myectomy and their pathophysiologic rationale.

Trasplante combinado de corazón e hígado; Cardiomiopatía Trasplantament combinat de fetge i cor; Cardiomiopatia Combined heart-liver transplant; Cardiomyopathy Background Uhl's anomaly is an extremely rare congenital heart defect characterized by absence of the right ventricle myocardium and preserved left ventricular myocardium. Although the disease has a poor prognosis and is generally fatal in the perinatal period, some patients may reach adulthood. Methods We describe a case of Uhl's anomaly complicated with heart failure and decompensated cardiac cirrhosis in a 42-year-old man treated by combined heart-liver transplant. Results The patient underwent heart transplant using the bicaval technique followed by subsequent liver transplant with the piggyback technique without venovenous bypass. Total ischemia time was 108 minutes for the heart and 360 and 25 minutes of cold and warm ischemia, respectively, for the liver. No intraoperative complications occurred. The patient was discharged without severe complications on postoperative day 22. Pathologic examination of the organs reported advanced cirrhosis of the liver and severe dilated myocardiopathy of right ventricle with absence of myocardium and a normal left ventricle. Twenty-seven months after the transplant the patient has been free from hospital admissions, with normal function of both transplanted organs. Conclusions We report the first successful combined heart-liver transplant for Uhl's anomaly indication in an adult patient. Despite of the insufficient knowledge of natural history of this exceptional disease, we successfully apply the management principles of other end-stage right heart disorders complicated with liver failure.

Introduction and objectives: Septal myectomy remains the first septal reduction therapy for hypertrophic obstructive cardiomyopathy in young patients and those requiring concomitant procedures. Its role in advanced ages is questioned due to perceived increased risk. We assess the outcomes of surgical relief of obstruction in patients beyond 65 years old. Methods: A single-center retrospective review of patients ≥ 65 years old undergoing septal myectomy through median sternotomy between April 2015 and February 2020. Results: We identified 52 patients. Mean age was 71.8 ± 4.9 years, 36 (69.2%) were females. All were symptomatic. Mean highest LVOT gradient was 90 ± 39 mmHg. All patients had systolic anterior motion (SAM) of the mitral valve and 36 (69.2%) ≥ moderate mitral regurgitation. Additional LVOT interventions beyond myectomy were performed in 34 (65.4%). At least one other cardiac concomitant procedure was performed 44 (84.6%). No perioperative mortality in elective surgery occurred. One patient (1.9%) developed atrio-ventricular block. Postoperative mean gradient was 4.3 ± 1.9 mmHg, with 46 (88.4%) achieving complete resolution of obstruction. Mitral regurgitation was reduced to grade ≤ I in 46 (88.5%). Mean follow-up time was 2.3 ± 1.2 years and 82% of patients were in NYHA I. Survival at 2 years was 98%. Conclusion: Septal myectomy in the elderly is a safe and effective operation despite the need for concomitant procedures. LVOT interventions beyond septal myectomy to relieve obstruction are common in this advanced cohort of hypertrophic cardiomyopathy patients. This operation carried at experienced centers seems an unmatched therapeutic option.

Heparin-induced thrombocytopaenia (HIT) complicates the management of patients in need for mechanical circulatory support awaiting heart transplantation. The limited available treatment options are fraught with complications and limitations in their applicability. We report on the combined use of therapeutic plasma exchange therapy and intravenous immunoglobulin, used in 3 consecutive heparin-induced thrombocytopaenia-positive patients on temporary mechanical circulatory support awaiting urgent heart transplant. This combined approach allowed us to use heparin safely.

Objective: Surgical repair remains the standard treatment for severe mitral regurgitation (MR) due to mitral prolapse. Minimally-invasive mitral valve surgery (MIMVS) has been increasingly performe...

Pulmonary embolism and concomitant floating aortic thrombus are a rare and potentially life-threatening association. Several therapeutic options are available and best management can be controversial when these conditions coexist. We describe a case of a 79-year-old woman presented with massive pulmonary embolism and simultaneous floating thrombus in the ascending aorta. She underwent concomitant ascending aortic replacement and surgical pulmonary embolectomy with an uneventful postoperative recovery. Open surgical repair is a one stage repair approach that may offer the most efficient treatment to allow survival.

Long-term real-world outcomes are critical for informing decisions about biological (Bio) or mechanical (Mech) prostheses for aortic valve replacement, particularly in patients aged between 50 and 65 years. The objective was to compare long-term survival and major adverse cardiac and cardiovascular events (ie, stroke, reoperation, and major bleeding) within this population.This was a multicenter observational study including all patients aged between 50 and 65 years who underwent an aortic valve replacement because of severe isolated aortic stenosis between the years 2000 and 2018. A total of 5215 patients from 27 Spanish hospitals were registered with a follow-up of 15 years. Multivariable analyses, including a 2:1 propensity score matching (1822 Mech and 911 Bio) and competing risks analyses were applied.Bio prostheses were implanted in 19% of patients (n = 992). No significant differences were observed between matched groups in long-term survival (hazard ratio [HR], 1.14; 95% confidence interval [CI], 0.88-1.47; P = .33). Stroke rates were higher for Mech prostheses, but not significant (HR, 0.72; 95% CI, 0.50-1.03; P = .07). Finally, higher rates of major bleeding were found in the Mech group (HR, 0.65; 95% CI, 0.49-0.87; P = .004), whereas reoperation was more frequent among the Bio group (HR, 3.04; 95% CI, 1.80-5.14; P .001). Bio prostheses increased from 13% in the period from 2000 to 2008 to 24% in 2009 to 2018.Long-term survival was comparable among groups in patients between 50 and 65 years of age. Mech prostheses were associated with a higher risk of major bleeding, whereas Bio prostheses entailed higher reoperation rates. Bio prostheses seem a reasonable choice for patients between 50 and 65 years in Spain.

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary arterial hypertension (PAH) are two subtypes of pulmonary hypertension (PH). Endothelial dysfunction is believed the main cause of the hyperproliferative and antiapoptotic phenotype in PH characterized by increased glycolysis in PAH. It is unknown whether PAH and CTEPH share the same metabolic abnormalities. The aim of our study is to perform a systematic metabolic comparison of endothelial cells (ECs) derived from PAH and CTEPH patients. Methods: ECs from human pulmonary artery endothelial cells HPAECs (n=3), CTEPH (n=7) and PAH (n=6) were expanded until the same passage. Metabolic targets were analysed by qRT-PCR and Western Blot. Viability and migration were studied using MTT and wound healing assay. Supernatants were assessed by BGEM Test Cards. All values are shown as mean±SD. The analysis was performed using one-way ANOVA (p Results: Gene and protein expression of key glycolytic enzymes were significantly upregulated in PAH-ECs compared to CTEPH-ECs and HPAECs. Mitochondrial enzymes, pentose phosphate pathway and glutamine metabolism-related enzymes were upregulated in PAH-ECs compared to the CTEPH-ECs and HPAECs. Both PAH and CTEPH-ECs showed significant higher viability compared to HPAECs. Acidification of the supernatant was detected in both patients’ lines. Statistical higher glucose and lower lactate concentration in the supernatant were shown in HPAECs compared to patient cell lines. Conclusion: PAH-ECs were found to be metabolically different than CTEPH-ECs indicating distinct pathogenic mechanisms in the development of the two PH subtypes. This creates the opportunity to specifically target the distinct metabolic abnormalities in both diseases.

Objective: To evaluate current results of surgical aortic valve replacement (SAVR) ± coronary artery bypass grafting surgery. Design: Independent, multicenter, prospective registry. Setting: Tertiary university hospitals. Participants: The study comprised 1,192 consecutive patients, stratified as low-, intermediate-, and high-risk according to EuroSCORE II ( 9, respectively). Interventions: SAVR ± coronary artery bypass grafting surgery. Measurements and Main Results: Thirty-day mortality and major morbidity, 2-year actuarial survival and freedom from stroke, and independent predictors of mortality in each risk category were assessed. These data were considered in light of published randomized controlled trials. Thirty-day mortality was 1.0%, 3.0% and 2.1% in the low-, intermediate-, and high-risk patients, with a 2-year actuarial survival of 98.6%, 93.8%, and 94.0%, respectively. Preoperative atrial fibrillation (odds ratio [OR] 8.3), minithoracotomy access (OR 5.8), postoperative dialysis (OR 3.4), type V acute myocardial infarction (OR 20.4), and moderate aortic regurgitation (OR 28.8) predicted 30-day mortality in the low-risk group. Preoperative dialysis (OR 18.3), critical state (OR 36.7), postoperative transfusions of plasma (OR 1.9 per unit transfused), and de-novo dialysis (OR 6.2) predicted 30-day mortality in the intermediate-risk group. Prior cardiac surgery (OR 18.1), postoperative extracorporeal membrane oxygenation (OR 9.8), and gastrointestinal complications (OR 17.2) predicted 30-day mortality in the high-risk group. Although baseline differences existed, low-risk patients demonstrated low 30-day mortality and 30-day to 12-month stroke in light of the PARTNER 3 and EVOLUT Low Risk trial results. Intermediate-risk patients demonstrated low 30-day to 2-year mortality, when the PARTNER 2 trial was considered, and low 30-day to 2-year stroke, when the PARTNER 2 and SURTAVI trials were considered. High-risk patients showed low 30-day to 2-year mortality in light of the results of the PARTNER 1 and CoreValve US trials. Conclusions: SAVR is still a safe and effective surgery for aortic stenosis regardless of risk category.

For the first time, the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery have joined forces to develop consensus guidelines for the management of atrial fibrillation (AF). One of the main issues is the integrated care of patients with AF, with emphasis on multidisciplinary teams of general physicians, cardiologists, stroke specialists and surgeons, together with the patient's involvement for better management of AF. These guidelines also help in the detection of risk factors and concomitant cardiovascular diseases, stroke prevention therapies, including anticoagulation and antiplatelet therapies after acute coronary episodes, major haemorrhages or strokes. In the field of ablation, surgery plays an important role as concomitant with other surgical procedures, and it should be considered in symptomatic patients with the highest level of evidence. Asymptomatic patients with mitral insufficiency should also be considered for combined mitral and AF surgery if they have new-onset AF. In patients with stand-alone AF, recommendations for minimally invasive ablation have an increased level of recommendation and should be considered as the same level as catheter ablation in patients with persistent or long-standing persistent AF or with paroxysmal AF who fail catheter ablation. Surgical occlusion or exclusion of the left atrial appendage may be considered for stroke prevention in patients with AF about to have surgery. Nevertheless, not enough is known to avoid long-term anticoagulation in patients at risk of stroke even if the left atrial appendage has been excluded. These Guidelines provide a full spectrum of recommendations on the management of patients with AF including prevention, treatment and complications based on the latest published evidence.

Early degeneration of tricuspid bioprostheses is a rare, but extremely serious, complication. Several mechanisms have been described, both for surgically implanted and transcatheter bioprosthesis. We report a case of early degeneration of tricuspid porcine bioprosthesis and a subsequent transcatheter valve-in-valve bovine prosthesis due to severe fibrosis with leaflet retraction in a patient with restrictive cardiomyopathy who finally underwent orthotopic heart transplantation.

The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC Endorsed by the European Stroke Organisation (ESO)

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by non-resolution of thrombi that obstruct main pulmonary arteries and secondary cause vascular remodeling of the pulmonary vasculature. Endothelial cells (EC) lining the vascular wall are an important component in vascular disease development. We speculated that metabolic dysregulation of EC contribute to cellular changes that promote vascular remodeling in CTEPH. Methods: This study used endothelial cells (EC-CTEPH, n=12) isolated from specimen extracted at pulmonary endarterectomy. Expression levels of metabolic enzymes were studied at mRNA and protein level by RT-PCR and western blot, respectively. Glucose consumption and lactate production was measured in the supernatant overlying EC-CTEPH and HPAE using BGEM test cards. Results: EC-CTEPH showed significantly lower mRNA levels of all glycolytic enzymes analyzed compared to HPAE. Additionally, protein levels of HK2, PFKFB3 and LDH-A were reduced in EC-CTEPH compared to HPAE. Transcript levels of PDK1, inhibitor of PDHA1, and GLUD1, involved in glutamine metabolism, were also downregulated. Fatty acid and pentose phosphate metabolism did not present significant differences between EC-CTEPH and HPAE. A lower glycolytic flux in EC-CTEPH, when compared to HPAE, was observed in terms of glucose consumption and lactate production. Conclusion: Our results showed that EC in human CTEPH present a reduced glycolytic metabolism compared to healthy EC. TCA and glutamine metabolism were also downregulated in EC-CTEPH. Other metabolic pathways such as FAO and PPP did not show a compensatory upregulation. More studies need to be performed to determine the role of our findings in EC-CTEPH pathogenesis.

PURPOSE OF REVIEW Given its rarity little is known about natural history, surgical indications, and results of acute non-A non-B dissections. With this review, we aim to review the current knowledge of this subject. RECENT FINDINGS non-A non-B aortic dissections should be differentiated from type B aortic dissections. A strikingly high proportion of these patients have a complicate course requiring treatment and the mortality of patients treated with medical therapy is substantially higher compared to type B dissections. Surgical and endovascular treatment can be accomplished safety, with very good results in terms of mortality and morbidity also in the acute setting. Several treatments options are available including endovascular repair with thoracic endovascular aortic repair (TEVAR) associated with Chimney grafts or carotid to subclavian by pass, open arch replacement mainly by means of the frozen elephant trunk technique and hybrid arch repair with debranching of the supra-aortic vessel and zone 0 TEVAR. SUMMARY considering the high rate of complication, the high mortality of patients managed medically and the safety of surgical and endovascular repair, early invasive treatment of non-A non-B dissections may be further considered. The treatment should be tailored to the morphology of the dissected aorta with TEVAR reserved to more distal lesions and open arch replacement with the FET technique for more proximal lesions.

Aims: Our objectives were to compare effectiveness and long-term prognosis after epicardial thoracoscopic atrial fibrillation (AF) ablation vs. endocardial catheter ablation, in patients with prior failed catheter ablation or high risk of failure. Methods and results: Patients were randomized to thoracoscopic or catheter ablation, consisting of pulmonary vein isolation with optional additional lines (2007–2010). Patients were reassessed in 2016/2017, and those without documented AF recurrence underwent 7-day ambulatory electrocardiography. The primary rhythm outcome was recurrence of any atrial arrhythmia lasting >30 s. The primary clinical endpoint was a composite of death, myocardial infarction, or cerebrovascular event, analysed with adjusted Cox proportional hazard ratios (HRs). One hundred and 24 patients were randomized with 34% persistent AF and mean age 56 years. Arrhythmia recurrence was common at mean follow-up of 7.0 years, but substantially lower with thoracoscopic ablation: 34/61 (56%) compared with 55/63 (87%) with catheter ablation [adjusted HR 0.40, 95% confidence interval (CI) 0.25–0.64; P

Resumen Introduccion Analizar las indicaciones, acciones y resultados de las operaciones realizadas en la Unidad de Cuidados Intensivos (UCI) de Cirugia Cardiovascular. Metodos Analisis retrospectivo de pacientes adultos consecutivos intervenidos en la Unidad de Cuidados Intensivos (UCI). Se incluyeron todas las intervenciones practicadas. Se realizo estadistica descriptiva. Resultados Entre 2008 y 2013 se intervinieron 3379 pacientes adultos consecutivos. Se practicaron en la UCI 124 intervenciones en 109 pacientes, 70 hombres (64,2%) y 39 mujeres (35,8%) con un promedio de edad de 61,6 anos (12-80). Ello ha representado un 3,2%. Durante el mismo periodo de tiempo, se intervinieron en quirofano 185 pacientes por taponamiento cardiaco/hemorragia postoperatoria (5,5%). Las intervenciones previas fueron por cardiopatia valvular (34,9%), patologia aortica (22,9%), cardiopatia isquemica (15,6%), valvular/isquemica (12%), valvular/de la aorta (11%) y miscelanea (3,6%). Las indicaciones de intervencion fueron hemorragia persistente 54 (43,5%), taponamiento cardiaco 41 (33%), bajo gasto cardiaco 13 (10,5%), parada cardiaca/arritmias 8 (6,5%), insuficiencia respiratoria 6 (4,8%) e isquemia de extremidades 2 (1,7%). Las intervenciones fueron: exploracion mediastinica 73 (58,9%), colocacion/retirada de ECMO 17 (13,7%), cierre esternal 16 (12,9%), resucitacion abierta 9 (7,3%), drenaje subxifoideo 7 (5,6%) y embolectomia femoral 2 (1,6%). La mortalidad fue 33%. Hubo un caso de mediastinitis (0,9%), sin diferencias con la tasa de infecciones profundas en pacientes no intervenidos en UCI. Conclusiones La intervencion en UCI es una alternativa segura y de rescate en subgrupos especificos de pacientes. no incrementa el riesgo de infeccion, evita el transporte de pacientes inestables y permite ahorrar tiempo en la decision quirurgica postoperatoria.

Objective To analyse the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. Methods Retrospective analysis of consecutive non-selected adult patients operated in the ICU, with descriptive statistics. All operations performed were included. Results Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients 70 male (64.2%) and 39 female (35.8%), with a mean age of 61.6 years (12–80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/cardiac tamponade in the operating room. Previous interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischaemic heart disease (15.6%), combined valvular/ischaemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were: persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischaemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxiphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis 0.9%, with no difference from patients operated in the regular operating room. Conclusions Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings.

Long-term real-world outcomes are critical to support medical decisions about using biological (B) or mechanical (M) prostheses for aortic valve replacement (AVR), particularly in patients aged between 50 and 65 years. This study aims to provide new evidence from a large national database on long

Both stroke prevention and rhythm control therapy of atrial fibrillation (AF) have been shaped by interdisciplinary teams of surgeons and cardiologists. This chapter describes the roles of the AF Heart Team in supporting difficult management decisions in AF patients in need of advanced stroke prevention or rhythm control therapy options. It delineates the organizational structure of such AF Heart Teams and provides an outline of their potential role within integrated AF management.

There are major challenges ahead for clinicians treating patients with atrial fibrillation (AF). The population with AF is expected to expand considerably and yet, apart from anticoagulation, therapies used in AF have not been shown to consistently impact on mortality or reduce adverse cardiovascular events. New approaches to AF management, including the use of novel technologies and structured, integrated care, have the potential to enhance clinical phenotyping or result in better treatment selection and stratified therapy. Here, we report the outcomes of the 6th Consensus Conference of the Atrial Fibrillation Network (AFNET) and the European Heart Rhythm Association (EHRA), held at the European Society of Cardiology Heart House in Sophia Antipolis, France, 17-19 January 2017. Sixty-two global specialists in AF and 13 industry partners met to develop innovative solutions based on new approaches to screening and diagnosis, enhancing integration of AF care, developing clinical pathways for treating complex patients, improving stroke prevention strategies, and better patient selection for heart rate and rhythm control. Ultimately, these approaches can lead to better outcomes for patients with AF.

Background: Treatment of severe aortic valve stenosis (SAVS) is a hot topic due to improved life expectancy of general population, improvement of diagnostic tools, and consequent increased number of patients requiring aortic valve surgery. Traditional aortic valve replacement and recent transcatheter aortic prosthesis implantation have reported comparable or non-inferior mortality in randomised controlled trials (RCTs). However, RCTs have the limitation of the predefined inclusion/exclusion criteria, and cannot completely reflect the ‘real clinical world’. Recently sutureless prostheses, often implanted via minimally invasive approaches, have been reported as an alternative strategy. However, their definitive impact on clinical results is not yet completely evaluated because of the limited sample size of patients population of most of published studies, based on monocentric patients series. Methods: The aim of this prospective multicentre registry including all patients referred for aortic valve surgery and treated with all available techniques is to obtain a ‘real-world’ scenario of the clinical results arising from current surgical options. Results: The research protocol enrollment phase is ongoing. Therefore we have not yet results to publish. When available, the research findings deriving from E-AVR registry will be presented in the scientific community in international congresses and published in peer review international journals in the fields of cardiac surgery and cardiology. Conclusions: This multicenter, prospective, European registry has been designed with the aim to cast light on a lot of controversial issues, particularly those regarding the impact of patient baseline risk factors as well as treatment methods for SAVR, with or without coronary artery bypass grafting (CABG), on the prognosis after treatment. We believe that the information derived from this registry can provide deep knowledge on the causes that lead to adverse outcomes after SAVR, to avoid them, and finally to identify the best treatment option for SAVS for each patient.