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Multiple valve heart disease refers to the simultaneous presence of several valvular anomalies, while mixed valvular heart disease refers to the combination of stenotic lesions or regurgitation affecting the same valve. The pathophysiology of multiple and mixed valvular heart disease depends on the combination of affected valves and the severity of the individual valvular defects. Imaging is essential for diagnosis and assessment of disease severity. The treatment of combined valvular defects currently represents a challenge for both cardiac surgeons and interventional cardiologists since only few data in the literature address the clinical and therapeutic decision-making process related to these complex lesions. These are heterogeneous conditions, which differ from each other in the combination of the valves involved, in the pathogenesis with which they develop, in the severity of the individual lesions, in the associated surgical risk, in the possibility of being repaired, and in the undergoing transcatheter treatments. In addition to the severity of the individual valve defects, the choice of treatment also depends on the ventricular function and the general condition of the patient. This work aims to provide a review of the state of the art regarding the possible management strategies of the most common multiple valve diseases in clinical practice.

Bicuspid aortic valve (BAV) disease is a spectrum of anomalies ranging from mild underdevelopment of a commissure to severe underdevelopment of two interleaflets triangles. Many different classifications of BAV, based on the echocardiographic, surgical or pathological appearance of the valve, and more recently on cardiac CT, have been proposed. We describe a simple technique, based on three-dimensional curved multiplanar reconstruction images, to obtain a pathology-like visualization of the full line of insertion (Hinge) of the aortic valve leaflets and of the interleaflet triangles with cardiac CT. This method could help to obtain a detailed categorization of any specific BAV anatomy based on the degree of underdevelopment (or on the absence) of one interleaflet triangle. Adherence to this concept could help to improve the imaging based analysis of BAV patients undergoing TAVR, and could lead to the adoption of a BAV classification based on the effective pathologic appearance of the valve also for patients undergoing TAVR.

Laser ablation in conjunction with Raman spectroscopy can be used to attain a controllable reduction of the thickness of exfoliated black phosphorus flakes and simultaneous measurement of the local temperature. However, this approach can be affected by several parameters, such as the thickness-dependent heat dissipation. Optical, thermal, and mechanical effects in the flakes and the substrate can influence the laser ablation and may become a source of artifacts on the measurement of the local temperature. In this work, we carry out a systematic investigation of the laser thinning of black phosphorus flakes on SiO2/Si substrates. The counterintuitive results from Raman thermometry are analyzed and elucidated with the help of numerical solutions of the problem, laying the groundwork for a controlled thinning process of this material.

Background MitraClip is a percutaneous way of treatment of mitral regurgitation. Recent trials demonstrate its value in modifying prognosis of patients with functional mitral regurgitation. During MitraClip implant imaging with 3D TEE is mandatory to guide the procedure and monitoring the results. Unfortunately, laceration of mitral leaflets is a well-described complication of Percutaneous Mitral valve repair by implantation of MitraClip. 3D TEE can be useful even to detect complication of the procedure and in particular leaflets lacerations. Here we describe a case where 3D TEE was capable to recognize and visualize a laceration in the anterior leaflet (AL) and we assume some mechanisms leading to this complication. Methods An 83 years old man with post-ischemic severe functional mitral regurgitation underwent to MitraClip implantation. The mitral valve shows a severe tenting and annulus was deformed and dilated. The procedure was performed under fluoroscopic and 3D TEE guidance (Philips iE33). Due to the large central regurgitation and large coaptation gap, we decide to implant MitraClip XTR, this is the larger device 5 mm longer. Results A single MitraClip XTR was implanted in the central scallop (A2-P2) in the region of the larger jet, after device positioning a further jet was detected in the region of implant and the original jet was unchanged. Using 3D color complete volume and X-plane reconstructions we recognize that the jet originates between the clip and the basal aspects of AL. Without color Doppler in 3D zoom and X plane reconstruction, a continuum solution was suspected in the body of AL but the shadow of the delivery system partially masked the region. After removal of the device, perforation of AL was clearly depicted also with 3D zoom without color Doppler. The patient was surgically treated and inspection confirmed the laceration and shows a worn thin AL. The laceration of AL can be caused by the tension on a thinned tissue carried out by the large device. The severe tethering and annular dilatation with a marked distance between anterior and posterior leaflet at the tip of the device may have been a determinant factor in the tear occurrence. Conclusion 3D TEE can clearly depict lacerations of leaflets during MitraClip implantation. Preoperative extensive analysis of valve geometry and inspection of leaflets searching for a thinned region can avoid intraoperative complications. The distance between leaflets at the expected tips of the MitraClip can be a predictive parameter of tension applied on the leaflets and of the risk of tearing. Abstract 1634 Figure. Image 1

Background Ascending thoracic aortic aneurysm (ATAA) is a major cause of morbidity and mortality worldwide. The pathogenesis of medial degeneration of the aorta remains undefined. High-throughput secretome analysis by mass spectrometry may be useful to elucidate the molecular mechanisms involved in aneurysm formation as well as to identify biomarkers for early diagnosis or targets of therapy. The purpose of the present study was to analyze the secreted/released proteins from ATAA specimens of both tricuspid aortic valve (TAV) and bicuspid aortic valve (BAV) patients. Methods Aortic specimens were collected from patients undergoing elective surgery and requiring graft replacement of the ascending aorta. Each sample of the ascending aortic aneurysm, 4 BAV (3 males; aged 53.5 ± 11.4 years) and 4 TAV (1 male; 78 ± 7.5 years), was incubated for 24 h in serum-free medium. Released proteins were digested with trypsin. Peptide mixtures were fractioned by nano-high performance liquid chromatography and analyzed by mass spectrometry. Following identification of differentially expressed proteins, quantitative real time polymerase chain reaction (qRT-PCR) analysis was performed. Results The comparison between the proteins released from BAV and TAV aneurysmatic tissues showed significantly diverging expression fingerprints in the two groups of patients. Bioinformatics analysis revealed 38 differentially released proteins; in particular 7 proteins were down-regulated while 31 were up-regulated in BAV with respect to TAV. Most of the proteins that were up-released in BAV were related to the activation of transforming growth factor (TGF)-β signaling. Latent TGF-β binding protein 4 (LTBP4) exhibited one of the highest significant under-expressions (10-fold change) in BAV secretomes with respect to TAV. qRT-PCR analysis validated this significant difference at LTBP4 gene level (BAV: 1.03 ± 0.9 vs TAV: 3.6 ± 3.2; p Conclusion Hypothesis-free secretome profiling clearly showed diverging expression fingerprints in the ATAA of TAV and BAV patients, confirming the crucial role of TGF-β signaling in modulating ATAA development in bicuspid patients.

Purpose. The left atrial appendage (LAA) is responsible for thrombus formation in patients with atrial fibrillation. The evaluation of both LAA function and morphology is crucial for the patient characterization and the preprocedural planning of LAA closure intervention. Despite the availability of 3D imaging modalities, the current standard image analysis is based on manual delineation of the LAA contours on 2D views. Methods. In this study, a comprehensive approach based on a full 3D analysis of the tomographic dataset by surface extraction and processing (3D-S) is presented. The proposed method allows extracting functional and morphologic information in the entire cardiac cycle by minimalizing manual user interaction. The proposed methodology has been validated on ten computer tomography datasets. Results. The proposed 3D-S method was feasible in all cases. Reproducibility was improved with respect to the reference 2D manual procedure (2D-S) (coefficient of variation 2.9 vs. 4.1% for diastolic ostium area; 3.8 vs. 6.1% for systolic ostium area; 2.4 vs. 5.3% for diastolic LAA volume; 2.7 vs. 5.9% for systolic LAA volume; and 7.7 vs. 17.1% for LAA ejection fraction). No significant differences were found between 2D-S and 3D-S measurements. Conclusions. In this study, we introduced a fully 3D approach for LAA characterization, allowing the simultaneous assessment of LAA function and geometry. The proposed approach could be used to improve the patient selection and the best sizing of the device for LAA closure and to allow a patient-specific 3D printing.

Significant underexpansion or distortion of valved stents may be associated with altered leaflet function, leading to increased transprosthetic gradients and, possibly, early structural degeneration. We investigated the relationship between a computed tomography measure of the degree of oversizing and the early hemodynamic and clinical outcomes in patients undergoing aortic valve replacement with the Perceval sutureless aortic valve (LivaNova, Saluggia, Italy).The degree of oversizing of the implanted prosthesis was calculated as the ratio between the patients' aortic annulus cross-sectional area and the ex vivo cross-sectional area of the implanted prosthesis in 151 Perceval patients who underwent preoperative cardiac computed tomography. This value was then entered in a multivariate analysis to ascertain its role as a predictor of increased postoperative gradient.The operative mortality was 1.3%. Procedural success, defined as having a normally functioning valve in the proper anatomical location, was achieved in 150 patients (99.3%). The mean transprosthetic gradient was 13.4 ± 5.0 mm Hg, and 23 patients (15.2%) showed a gradient of 20 mm Hg or more at discharge or at the 1-month follow-up. The degree of oversizing of the implanted prosthesis was the most important predictor of increased postoperative gradient (odds ratio, 1.264; 95% confidence interval, 1.147 to 1.394; p0.0001). Interestingly, other relevant factors (patients' body surface area, prosthesis size) were not associated with increased gradients.Our study demonstrates that excessive oversizing should be avoided in Perceval patients and suggests that a different sizing algorithm, possibly based on cardiac computed tomography, should be developed. Further studies are needed to optimize the sizing strategy for the Perceval sutureless valve.

A 78-year-old man was referred for surgical treatment of a 55 x 59 mm abdominal aortic aneurysm (AAA). However, clinical and instrumental data revealed a more complex case than was initially thought, the patient having a large AAA in the setting of severe symptomatic aortic stenosis with multiple comorbidities. Following multidisciplinary discussion, a combined transcatheter aortic valve implantation and endovascular aneurysm repair was performed. The present case represents a good example of the importance of the heart team in the project of tailored operative strategies, and in the optimization of the interventional therapy for the individual patient.

ObjectiveThe angiotensin-converting enzyme (ACE) is highly expressed in the aneurysmal vascular wall, in both animal models and human disease. Genetic variations in ACE could be crucial in determining the risk of thoracic aortic aneurysm (TAA). The aim of the present study was to examine the role of ACE insertion/deletion polymorphism on the risk of TAA in patients with bicuspid aortic valves or tricuspid aortic valves.MethodsWe enrolled 216 patients (158 men; age, 58.9 ± 14.9 years) with TAA, associated with bicuspid aortic valves (n = 105) and tricuspid aortic valves (n = 111) compared with 312 patients (252 men; age, 54.6 ± 11.0 years) with angiographically proven coronary artery disease and 300 healthy controls (91 men; age, 40.4 ± 10.5 years).ResultsThe genotype distribution of ACE insertion/deletion was significantly different between the patients with TAA compared with both the control group (P = .0005) and the coronary artery disease group (P = .03). The genotypes were not different between the control group and the coronary artery disease group (P = .3). Compared with the controls, both the bicuspid aortic valve patients (P = .0008) and tricuspid aortic valve patients (P

During political races, candidates have to decide how to deal with the negative remarks from opposing candidates: just ignore or counterattack? In two studies, we investigated some of the consequences of this choice. In Study 1, participants were presented with a political candidate who systematically attacked his opponent and with the reactions of the attacked candidate: across conditions, the attacked candidate only focused on his political program or counterattacked. Results showed an overt condemnation of the choice to counterattack but a higher spontaneous conformity toward the candidate who counterattacked. Study 2 replicated and extended these results indicating that the gender of the attacked candidate did not affect the results. Moreover, Study 2 showed that conformity toward the attacked candidate was positively related to the predicted chances of winning the election. Results are discussed in relation to their theoretical and applied implications. Copyright © 2012 John Wiley & Sons, Ltd.

Objective: We report our experience with the transapical transcatheter “Valve in valve” implantation (T-VIV) in patients with a failed mitral or tricuspid bioprosthesis; we briefly review the pertinent literature, and discuss some technical aspects of this procedure. Background: Redo valve surgery for failure of a mitral or tricuspid bioprosthesis might become extremely challenging, both because of the patients' condition, which is frequently poor, and for the technical aspects of the operation itself, that can be very demanding. T-VIV has been widely employed with good results for the treatment of aortic bioprosthesis failure, and could represent an attractive option in this setting. Methods: Four patients with multiple comorbidities (age: 63-83 years; logistic Euroscore: 37.2-81.5) underwent T-VIV at our institution for failure of a mitral [3] or tricuspid [1] bioprosthesis. A 26mm Sapien valve was used in all cases. All the mitral procedures were performed via a transapical approach. The tricuspid procedure was performed via a transjugular approach. Results: The first mitral procedure was complicated by the splaying of the xenograft stents and embolization of the valve. The procedure was converted to conventional surgery, and the patient died on postoperative day 1. In the subsequent procedures, the valve was positioned more atrially, and was fixed to the malfunctioning xenograft sewing ring. All subsequent procedures were successful, all patients were discharged home and were alive and well at follow-up. Conclusions: The results of T-VIV procedure in the mitral position have been suboptimal, and four of the sixteen patients reported to date died. However, all patients were extremely diseased, and some of the reported failures were related to amendable technical factors relative to the surgical access or to the valve deployment technique. With increasing experience, this procedure might become indicated as an alternative to conventional surgery in selected patients, encouraging increased use of bioprosthesis, and marking a pivotal change in the management of valvular disease. © 2011 Wiley Periodicals, Inc.

Purpose The Cobra Adhere XL (Estech, San Ramon, CA) is a multiple-electrode, temperature-controlled, monopolar radiofrequency probe with a vacuum-assisted stabilization system. We evaluated this new technology for epicardial ablation of atrial fibrillation in mitral valve patients through a right mini-thoracotomy. Description Between June and August 2008, 12 patients underwent minimal invasive surgery for mitral disease and ablation for atrial fibrillation with the Cobra Adhere XL (Estech). Three patients had paroxysmal atrial fibrillation. Off-pump pulmonary vein isolation was performed with an epicardial oval lesion parallel to the mitral plane. In 10 patients, an endocardial lesion to the mitral annulus was added. Evaluation There were no operative deaths or major postoperative complications. At a mean follow-up of 8.76 ± 1.0 months, 11 patients (91.67%) were in stable sinus rhythm. Echocardiography underscored a complete recovery of atrial transport function in most of these patients (90.91%). No major cardiac and cerebrovascular events occurred during follow-up. Conclusions Left-side ablation combined with minimally invasive surgery for mitral disease can be easily, safely, and effectively performed with the Cobra Adhere XL probe.

2 new cases of triosephosphate isomerase (TPI) deficiency associated with severe haemolytic anaemia in 2 unrelated Italian families are described. Only 1 case was extensively investigated. TPI deficiency was detectable in erythrocytes, leucocytes, platelets and plasma. The mutant enzyme showed normal Km for GAP and increased Km for DHAP, with an higher than normal equilibrium constant, decreased thermostability, and abnormal electrophoretic pattern due to the lack of the fastest moving component. The immunological characterization revealed a lower than normal inactivation by specific antiserum, while the double immunodiffusion pattern and the precipitin curve were normal. Lymphocyte, granulocyte and platelet functions were impaired.

Transcatheter valve-in-valve implantation is an emerging treatment option for high-risk patients with failing mitral bioprostheses. The presence of a paravalvular leak is considered a contraindication to this procedure that would leave the patient with significant residual regurgitation. The case is described of a patient with a severely degenerated 29 mm Carpentier-Edwards mitral bioprosthesis successfully treated by simultaneous transapical transcatheter valve-in-valve implantation and paraprosthetic leak occlusion. The potential advantages of this approach are discussed.

Aneurysms of the right aortic arch with an aberrant left subclavian artery are rare. We report the case of a 77-year-old woman with a Kommerell's diverticulum aneurysm, who underwent a successful hybrid repair, combining surgical off-pump bypass of the aortic arch vessels followed by endovascular aneurysm repair.(J Card Surg 2010;25:67-69)

We report a case of myocardial infarction at a young age in a subject heterozygous for the G20210A prothrombin gene variant and homozygous for the C677T MTHFR polymorphism, who presented a strong family history of atherothrombosis. Genetic screening for inherited thrombophilia, especially in the presence of a strong familiarity, may be a critical information for secondary prevention of arterial thrombosis.

Transcatheter aortic valve implantation (TAVI) is a valuable alternative for aortic valve replacement in selected high-risk candidates. Accurate preoperative assessment of the aortic annular dimensions is crucial for the success of TAVI, since choice of an incorrectly sized prosthesis may result in catastrophic complications. These complications include annular rupture and coronary arterial obstruction, if the prosthesis is too big, or prosthesis migration and severe paravalvular leakage, if the prosthesis is too small. According to current recommendations, the choice of prosthesis size is based on transoesophageal echocardiography (TEE) measurements. However, TEE results are dependent on operator experience. Moreover, recent research has shown that TEE can significantly underestimate annular dimensional measurements. Alternative sizing methods based on Multidetector Computed Tomography (MDCT) or manometry during balloon aortic valvuloplasty have therefore been developed. We present a brief overview of the imaging modalities available for preoperative assessment of annular size and discuss their potential advantages and limitations.

To report the procedural and long-term follow-up data (mean, 43 ± 29 months; range, 12-90 months) of endovascular stent grafting (ESG) of acute thoracic aortic syndromes (ATAS) with a proximal landing zone extension strategy.From November 1999 to May 2008, 26 patients (25 males, 1 female; mean age, 57.9 ± 17 years) with ATAS underwent ESG at our institution. Underlying pathologies were: penetrating aortic ulcer (n=7); rupture of a descending aorta aneurysm (n=5), post-traumatic false aneurysm (n=5); acute type B dissection (n=6) and traumatic descending aorta transection (n=3).ESG was performed successfully in all patients. In 5 patients (19%), an extra-anatomic revascularization of the supra-aortic vessels was performed. In 19 patients (73%), overstenting of the left subclavian artery, without preliminary revascularization, was performed. The mean proximal landing zone length was 57 ± 19 mm. No intraprocedural deaths occurred; 3 patients died postoperatively (1 from an unrelated cause, 1 from a myocardial infarction and 1 for the sequelae of an ischemic stroke). One patient underwent cardiac surgery for post-procedural retrograde type-A dissection. Follow up involved a computed tomography (CT) scan at 1, 3, 6 and 12 months, then yearly thereafter. At follow up, no deaths or major complications occurred. The CT scans revealed 1 small type-IB endoleak at 1 year.In ATAS patients treated with ESG, the extension of the proximal landing zone, despite the need of subclavian coverage or hybrid procedures, is associated with an immediate procedural outcome and low morbidity at follow-up.

Objective: To improve the long-term results of acute type A dissection repair, we developed a technique that combines radical surgical resection, and, at the same time, creates a safe and long landing zone for subsequent endovascular procedure on the descendingaorta. Methods: Since November 2006, 23 patients (62 13 years) underwent aortic arch replacement concomitant with prophylactic debranching of the supraaortic vessels, with a specially designed arch graft. The technique consists of replacing the ascending aorta and the aortic arch, and, at the same time, relocating the origin of the supra-aortic vessels just above the sinotubular junction creating a long and safe proximal landing zone for subsequent stent-graft deployment. Perfusion was antegrade through the ascending aorta during cooling and through the vascular prosthesis during rewarming. Distal arch anastomosis was performed under moderate hypothermic circulatory arrest for 25 7 min and antegrade selective cerebral perfusion (46 14 min). Cardiopulmonary bypass and aortic cross-clamp time were 138 46 and 63 22 min. Results: Hospital mortality was 4.3% (1/23). Postoperative morbidity includes five acute renal failures and four lung failures. No major neurological complications were observed. At follow-up (22 10 months), survival was 100% and two patients required an endovascular thoracic aorta repair for aneurysmal enlargement. In both cases, the stent grafts were successfully released in the landing zone created at the time of primary repair. Conclusions: Our technique extends the suitability of endovascular therapies during type A acute dissection repair, creating a long and stable landing zone that allows safe performance of a second endovascular step if needed, both in the short- and long term. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

We report a case of a delayed retrograde dissection occurred after endovascular repair of ruptured type B aortic dissection. A 75-year-old male, presented with acute hemothorax and aortic arch fissuration. He was successfully treated with descending aorta and aortic arch stenting. After six days, he developed retrograde type A dissection with aortic root involvement and aortic valve incompetence. The entire ascending aorta and the ventral part of the arch were successfully replaced by a composite graft; in addition, aortic valve was replaced with prosthesis. Patient had an uncomplicated course and radiologic follow-up at one month revealed a sealed fissuration and no signs of endoleak. Endovascular repair of acute ruptured aorta, although life saving may be associated with potentially lethal complications, and it requires close monitoring with prolonged hospital stay to recognize and treat promptly these fatal complications.

Fig. 1. Left ventriculography shows displacement of the prosthesis from the native aortic annulus. During the first surgery, the valve was implanted by putting interrupted Ethibond 3/0 suture and then a continuous 4/0 polypropylene suture re-enforced with pericardial patch. During the surgery it was noted that suture was mainly on the implant side. AA: ascending aorta; LV: left ventricle; RV: right ventricle; PsA: pseudo-aneurysm; Pt: stentless aortic root prosthesis.

Progressive dilatation of the aortic root and ascending aorta is frequent in patients with bicuspid aortic valve, and isolated dilatation of the noncoronary sinus has been reported. We describe our technique for the selective replacement of the noncoronary sinus of Valsalva in patients with bicuspid aortic valve.

Introduction: The usual treatment options for clinically localized prostate cancer carry a significant risk of lasting side effects, including urinary, bowel, and sexual dysfunction, that can alter overall the patient’s quality of life. The aim of this research is to evaluate the impact of treatment timing (age at time of treatment, follow-up duration, age at time of follow-up), pretreatment tumor characteristics (clinical stage, Gleason score, PSA), and posttreatment outcomes (hormonal status, biochemical recurrence), on health-related quality of life (HRQOL) among men who had undergone radical treatment for prostate cancer. Materials and Methods: 595 patients with prostate cancer who had undergone either radical prostatectomy or external beam radiation as primary therapy between 1988 and 2000 were selected for this retrospective, cross-sectional study. The enrolled subjects were asked to complete the Italian validated version of University of California-Los Angeles Prostate Cancer Index. Clinical parameters, hormone therapy status and posttreatment outcomes were considered to perform uni- and multivariate analyses. Results: Both uni- and multivariate analyses demonstrated that timing of radical treatment is a critical predictive factor for sexual activity. Pretreatment tumor characteristics had a significant impact on urinary function, urinary bother and sexual function. Hormone treatment exclusively influenced sexual function and sexual bother, while biochemical recurrence can also worsen urinary symptoms and urinary bother. Conclusion: Our findings suggest that treatment timing, pretreatment tumor characteristics and posttreatment outcomes may have an impact on HRQOL in patients who have undergone radical treatment for prostate cancer: all these items should be considered in order to achieve an accurate interpretation of prostate cancer treatment outcomes.

The non-thyroidal illness syndrome (NTIS) is considered a transient and completely reversible phenomenon, but it has been shown that it may last for several days postoperatively after coronary artery bypass grafting (CABG) surgery. This study was undertaken to assess thyroid function 6 months after uncomplicated CABG. The thyroid profile was evaluated in 40 consecutive patients undergoing CABG preoperatively, at 0, 12, 48, and 120 h postoperatively, and at 6-month follow-up. Triiodothyronine (T3), free T3 (FT3), free thyroxine (FT4) and thyroid stimulating hormone (TSH) were assayed using a microparticle enzyme immunoassay. T4 and total serum thyroid hormone-binding capacity (T-uptake) were measured on the same samples using a fluorescence polarization immunoassay. Patients with severe systemic illness and patients treated with amiodarone were excluded. All patients were euthyroid at admission. Mean age was 67.4+/-9.0 years. There were 31 (77.5%) men. Typical NTIS was observed in all patients, and the FT3 concentration was still reduced by postoperative day 5 (p

Objective: Despite improved perioperative management, atrial fibrillation (AF) after coronary artery bypass grafting (CABG) remains a relevant clinical problem, whose pathogenetic mechanisms remain incompletely explained. A reduced incidence of postoperative AF has been described in CABG patients receiving IV tri-iodothyronine (T3). This study was designed to define the role of thyroid metabolism on the genesis of postoperative AF. Methods and results: Free T3 (fT3), free thyroxine (fT4), and thyroid stimulating hormone were assayed at admission in 107 consecutive patients undergoing isolated CABG surgery. Patients with thyroid disease or taking drugs known to interfere with thyroid function were excluded. A preoperative rhythm other than sinus rhythm was considered an exclusion criterion. Thirty-three patients (30.8%) had postoperative AF. An older age (P ¼ 0:03), no therapy with b-blockers (P ¼ 0:08), chronic obstructive pulmonary disease (P ¼ 0:08), lower left ventricle ejection fraction (P ¼ 0:09) and lower fT3 concentration (P ¼ 0:001), were univariate predictors of postoperative AF. On multivariate analysis, low fT3 concentration and lack of b-blocking therapy were independently related with the development of postoperative AF (odds ratio, OR, 4.425; 95% confidence interval, CI, 1.745‐ 11.235; P ¼ 0:001 and OR 3.107; 95% CI 1.087 ‐8.875; P ¼ 0:03, respectively). Postoperative AF significantly prolonged postoperative hospital stay (P ¼ 0:002). Conclusions: Low basal fT3 concentration can reliably predict the occurrence of postoperative AF in CABG patients. q 2003 Elsevier B.V. All rights reserved.

Accurate preoperative assessment of the aortic annulus dimension is crucial for the success of transcatheter aortic valve implantation (TAVI). All the available imaging modalities, however, have some weak points, and the ‘gold standard’ to be used is still under debate. In this context, the recent work by Dr Blanke and coworkers is a commendable attempt to develop a standardized, easy to reproduce method for the identification and measurement of the aortic annulus [1, 2]. A very interesting finding of this study is the close correlation found between the preoperative cross-sectional area (CSA) of the virtual ring passing through the nadir of the three aortic cusps and the postoperative CSA. This observation would suggest that preoperative determination of the CSA could help in predicting the final form and size of the aortic annulus in most TAVI patients [1]. However, the behaviour of the aortic root and aortic annulus is not always predictable based on the preoperative exams [3]. This is partly due to intrinsic anatomic properties of the aortic root—the ‘virtual ring’ is largely inhomogeneous, coursing through the muscular septum, the membranous septum and the mitro-aortic curtain. Moreover, leaflet and annular calcifications are often asymmetrical, adding further complexity to any attempt to predict the final shape of the prosthetic valve, the displacement of the native calcified leaflets and the sealing of the annulus around the prosthesis. A very good exemplification of this problem is given by the bicuspid aortic valve, which is usually ovoidal and heavily calcified, and may fail to adapt to the circular transcatheter valve [4]. For this reason, we have developed a simple method to analyse the reaction of the aortic root to the balloon inflation, and to obtain a dynamic measure of the CSA. In the uncertain cases (‘borderline’ annulus, important discrepancy between TEE and CT measurements, massive and/or eccentric calcifications), we proceed to a ‘calibrated’ balloon valvuloplasty. A conventional valvuloplasty balloon (Cristal Balloon, Balt, Montmorency, France) is inflated with a diluted contrast agent through a threeway stopcock. When the waist generated on the balloon profile by the aortic annulus is stretched, the stopcock is closed and an aortography is performed to exclude the presence of aortic regurgitation. The amount of contrast agent used to inflate the balloon is carefully recorded, and the balloon is deflated and withdrawn. On the bench, the balloon is inflated again to the same volume, and is then sized with a sizing plate (Amplatzer sizing plate, AGA Medical Italia, Milan, Italy). This simple manoeuvre allows us to accurately measure the aortic annulus, to estimate the risk of postoperative paraprosthetic leakage and to check the relationships between the dislocated aortic valve leaflets and the coronary arteries ostia. In our experience, this procedure has led to a change in the size of the percutaneous prosthesis in three patients, and to the conversion to transapical approach in two patients needing a 29 mm prosthesis. In conclusion, we believe that the CT protocol described by Blanke could greatly enhance our ability to evaluate the anatomy of the aortic root preoperatively. In doubtful cases, however, calibrated balloon valvuloplasty could add fundamental dynamic information, allowing us to ‘feel’ the aortic annulus while measuring it [3].

Background The purpose of our study was to investigate the potential contribution of germline mutations in NOTCH1, GATA5 and TGFBR1 and TGFBR2 genes in a cohort of Italian patients with familial Bicuspid Aortic Valve (BAV). Methods All the coding exons including adjacent intronic as well as 5′ and 3′ untranslated (UTR) sequences of NOTCH1, GATA5, TGFBR1 and TGFBR2 genes were screened by direct gene sequencing in 11 index patients (8 males; age = 42 ± 19 years) with familial BAV defined as two or more affected members. Results Two novel mutations, a missense and a nonsense mutation (Exon 5, p.P284L; Exon 26, p.Y1619X), were found in the NOTCH1 gene in two unrelated families. The mutations segregated with the disease in these families, and they were not found on 200 unrelated chromosomes from ethnically matched controls. No pathogenetic mutation was identified in GATA5, TGFBR1 and TGFBR2 genes. Conclusions Two novel NOTCH1 mutations were identified in two Italian families with BAV, highlighting the role of a NOTCH1 signaling pathway in BAV and its aortic complications. These findings are of relevance for genetic counseling and clinical care of families presenting with BAV. Future studies are needed in order to unravel the still largely unknown genetics of BAV.

Background Traditionally, in patients with mitral regurgitation (MR) a successful mitral valve repair is considered when residual MR by post-pump transesophageal echocardiography (TEE) is less than moderate or absent. Little is known about the prognostic value of less than moderate (mild or mild-to-moderate) residual MR for the early outcome of patients treated with mitral valve repair. Methods Eligible for this study were patients undergoing isolated mitral valve repair. Patients with moderate or severe residual MR after valve repair were excluded. The primary endpoint of the study was the composite of death or need of reintervention. Results A total of 98 patients (54 with no residual MR-Group 1, and 44 with less than moderate residual MR-Group 2) were analyzed. Of these, 72% presented with New York Heart Association (NYHA) 3/4, and 38% were women. The primary endpoint of the study occurred in 3 (5.5%) patients in Group 1 and 6 (13.6%) patients in Group 2 MR (P = 0.31). There was a trend toward a higher incidence of use of inotropic drugs post-interventional (P = 0.12), and a longer hospital stay among patients with less than moderate residual MR (P = 0.18). Conclusion In our study population, patients with less than moderate residual MR had a trend toward a higher risk of early adverse outcomes as compared with patients with no residual MR by post-pump TEE. Studies with a larger patient population and longer follow-up data may be useful to better define the clinical significance of residual mild MR after mitral vale repair.