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The decision to treat moderate ischemic mitral regurgitation (IMR) at the time of coronary artery bypass surgery (CABG) remains controversial. We previously conducted a prospective randomized trial that showed a benefit of adding restricted annuloplasty to bypass surgery (CABG-Ring group) in terms of IMR grade, New York Heart Association classification, and left ventricle reverse remodeling. Here, we present the long-term (10 years) follow-up data from this randomized trial.The original trial arms accounted for 54 patients in the CABG-alone and 48 in the CABG-Ring group; patients were re-contacted for follow-up to obtain relevant clinical and echocardiographic information.The mean follow-up was 160.4 ± 45.5 months. Survival probabilities in the CABG-alone and CABG-Ring groups were 96% vs 93% at 3 years, 85% vs 89% at 6 years, 79% vs 85% at 9 years, 77% vs 83% at 12 years, and 72% vs 80% at 15 years, respectively (P = .18) Freedom from at least moderate IMR or reintervention at last follow-up was also higher in the CABG-Ring group (P.001). Compared with the CABG-alone group, the CABG-Ring group had a higher degree of left ventricular reverse remodeling (54.7 ± 6.9 mm vs 51.6 ± 6 mm, respectively; P = .03), lower New York Heart Association class (P.001), and a lower rate of rehospitalization (P = .002).Long-term follow-up data from our randomized trial further support the utility of performing restricted annuloplasty at the time of CABG to prevent further progression of IMR, mitral reintervention, and left ventricle remodeling. Untreated IMR was associated with significantly higher New York Heart Association class and rehospitalization.

The past 20 years have seen the growing range of valve lesion etiologies turn nonvalvular conditions into the primary causes of aortic regurgitation [1]. Valves present relatively small lesions of the leaflets and concomitant dilatation of the ascending aorta with aortic regurgitation that can be explained thanks to our improved knowledge of the functional aortic annulus’ role in valve function. The geometric relations and dynamic behavior of aortic root components have been seen to ensure valve competence when leaflets have no structural lesions [2].

Objective The assessment of the mitral valve apparatus (MVA) and its modifications during ischemic mitral regurgitation (IMR) is better performed by three-dimensional (3D) transesophageal echocardiography (TEE). The aim of our study was to carry out nonrestrictive mitral annuloplasty in addition to relocation of papillary muscles (PPMs) oriented by preoperative real-time 3D TEE through the mitral valve quantification dedicated software. Methods Since January 2008, a total of 70 patients with severe IMR were examined both before and after mitral valve repair. The mean (SD) coaptation depth and the mean (SD) tenting area were 1.4 (0.4) cm and 3.2 (0.5) cm2, respectively. Intraoperative 3D TEE was performed, followed by a 3D offline reconstruction of the MVA. A schematic MVA model was obtained, and a geometric model as a “truncated cone” was traced according to preoperative data. The expected truncated cone after annuloplasty was retraced. A conventional normal coaptation depth of approximately 6 mm was used to detect the new position of the PPMs tips. Results Perioperative offline reconstruction of the MVA and the respective truncated cone was feasible in all patients. The expected position of the PPMs tips, desirable to reach a normal tenting area with a coaptation depth of 6 mm or more, was obtained in all patients. After surgery, all parameters were calculated, and no statistically significant difference was found compared with the expected data. Conclusions Relocation of PPMs plus ring annuloplasty reduce mitral valve tenting and may improve mitral valve repair results in patients with severe IMR. This technique may be easily and precisely guided by preoperative offline 3D echocardiographic mitral valve reconstruction.

OBJECTIVES: The functional aortic valve annulus (FAVA) is a complex unit with proximal (aorto-ventricular junction) and distal (sinotubular junction) components. The aim of our study was to evaluate the impact of the total FAVA remodelling, using a prosthetic ring, on mid-term clinical and echocardiographic-RESULTS:-after aortic valve repair. METHODS: Since February 2003, 250 patients with tricuspid aortic valve insufficiency (AI) underwent aortic valve repair. FAVA dilatation was treated by prosthetic ring in 52 patients, by isolated subcommissural plasty in 62, by subcommissural plasty plus ascending aortic replacement in 57 and by David's reimplantation procedure in 79. Survival rate and freedom from recurrent AI greater than or equal to moderate were evaluated by Kaplan-Meier. RESULTS: Overall late survival was 90.4%. Late cardiac-related deaths occurred in 15 patients. At follow-up, 36 (16%) patients had recurrent AI greater than or equal to moderate because of cusp reprolapse and/or FAVA redilatation. Freedom from recurrent AI was significantly higher for patients who underwent David's procedure or FAVA remodelling by prosthetic ring than those who underwent isolated subcommissural plasty (P < 0.01) or subcommissural plasty plus ascending aortic replacement (P = 0.02). There was no statistical difference between David's procedure and prosthetic ring annuloplasty (P = 0.26).CONCLUSIONFAVA remodelling using a prosthetic ring is a safe procedure in aortic valve repair surgery thanks to long-term annulus stabilization and it is a pliable alternative to David's procedure in selected patients. This technique may be used in all patients with slight root dilatation to avoid aggressive root reimplantation. We also recommended total FAVA annuloplasty in all patients who underwent aortic valve repair to improve long-term repair-RESULTS:. © 2013 The Author.

Bicuspid aortic valve (BAV) is frequently associated with aortic insufficiency (AI) due to cusp disease and/or aortic root dilatation. Based on functional classification and morphology, a systematic surgical approach was used for aortic valve repair (AVr).From 2004 to 2014, 152 consecutive patients (mean age 55 ± 7 years) with BAV underwent AVr with or without concomitant aortic root surgery. Cusp pathology was treated with central plication in 60 (39.5%) patients, free edge reinforcement in 45 (29.6%), triangular resection in 28 (18.4%) and pericardial patch in 19 (12.5%). Aortic root dilatation was corrected with valve sparing reimplantation in 65 patients. Mean follow-up was 68 ± 36 months.In-hospital death was 1.3%. Overall 5-year survival was 88.6 ± 3.6%. Freedom from recurrent ≥ grade 2 AI requiring reoperation at 5-year was 93 ± 3.1%. Five-year freedom from reintervention was 98.4 ± 1.6%, 93.3 ± 6.4% and 82.6 ± 9.6 in the group of patients treated with AVr and reimplantation technique, AVr and subcommissural plasty and AVr repair alone (log-rank P = 0.005). Commissural orientation 160°, type 2 Siever's BAV and preoperative annulus diameter 29 mm were identified as predictors for recurrent ≥ grade 2 AI.BAV repair could be achieved with low incidence of recurrent AI, especially when concomitant annulus stabilization was performed. Systematic preoperative morphological and functional characteristics of the aortic valve should be carried out in order to reduce the risk of repair failure.

Controversies regarding the choice of annuloplasty rings for treatment of ischemic mitral regurgitation still exist. Aim of the study is to compare early performance of 2 different rings in terms of rest and exercise echocardiographic parameters (transmitral gradient, systolic pulmonary artery pressure, and mitral valve area), clinical outcomes, and recurrence of mitral regurgitation. From January 2008 till December 2013, prospectively collected data of patients who underwent coronary artery bypass grafting and undersizing mitral valve annuloplasty for severe chronic ischemic mitral regurgitation at our Institution were reviewed. A total of 93 patients were identified; among them 44 had semirigid Memo 3D ring implanted (group A) whereas 49 had a rigid profile 3D ring (group B). At 6 months, recurrent ischemic mitral regurgitation, equal or more than moderate, was observed in 4 and 6 patients in the group A and B, respectively (P = 0.74). Group A showed certain improved valve geometric parameters such as posterior leaflet angle, tenting area, and coaptation depth. Transmitral gradient was significantly higher at rest in the group B (P < 0.0001). During exercise, significant increase of transmitral gradient and systolic pulmonary artery pressure was observed in group B (P < 0.0001). Mitral valve area was not statistically significantly smaller at rest in between groups (P = 0.09); however, it significantly decreased with exercise in group B (P = 0.01). At midterm follow-up, patients in group B were more symptomatic. In patients with chronic ischemic mitral regurgitation, use of semirigid Memo 3D ring when compared to the rigid Profile 3D may be associated with early improved mitral valve geometrical conformation and hemodynamic profile, particularly during exercise. No difference was observed between both groups in recurrent mitral regurgitation.

Objective Conventional cardioplegic arrest coronary artery bypass grafting after ST-segment elevation myocardial infarction is associated with high mortality and morbidity. The benefits of off-pump surgery have been suggested. This study randomly evaluated the impact of the off-pump technique on clinical results. Methods Between February 2002 and October 2007, 128 patients with ST-segment elevation myocardial infarction who underwent myocardial revascularization within 48 hours from the onset of symptoms were randomly assigned to 2 groups: on-pump group (66 patients/51.5%) and off-pump group (63 patients/48.5%). The primary end point was the incidence of in-hospital death and outcomes (low cardiac output syndrome, prolonged mechanical and pharmacologic cardiac support, prolonged mechanical ventilation support, and postoperative length of stay in intensive care unit and hospital). The secondary end point was the evaluation of myocardial infarct size measured by the perioperative serum release of cardiac troponin I and the improvement of contractile cardiac function evaluated by the wall motion score index. Results Overall in-hospital mortality was 4.6%. In-hospital mortality was 7.7% (5 patients) in the on-pump group and 1.6% (1 patient) in the off-pump group ( P = .04). Statistically significant differences were found between the 2 groups concerning the incidence of low cardiac output syndrome ( P = .001), time of inotrope drugs support ( P = .001), time of mechanical ventilation ( P = .006), reoperation for bleeding ( P = .04), intensive care unit stay ( P = .01), and in-hospital stay ( P = .02). Statistically significant differences also were found between the 2 groups concerning the incidence of in-hospital death in patients who were admitted to surgery in cardiac shock ( P = .0018) and patients who underwent surgery within 6 hours from the onset of symptoms ( P = .0026). The procedure in 1 patient (1.6%) in the off-pump group was converted to the on-pump beating heart technique. The serum levels of cardiac troponin I were high in the on-pump group during the first 48 hours after surgery. Myocardial function was better in the off-pump group. There were no cardiac-related late deaths, and patients had no recurrent cardiac events. Conclusion Off-pump surgery reduced early mortality and morbidity in patients with ST-segment elevation myocardial infarction in respect to the conventional procedure. Off-pump surgery showed better results than on-pump surgery in patients who underwent surgery within 6 hours from the onset of symptoms and in patients with cardiogenic shock.

Mitral regurgitation (MR) is the second most common valvular heart disease after aortic valve stenosis. With increased understanding of the heterogenic pathophysiology of MR, cardiac surgeons have developed various techniques that increase the likelihood of successful mitral valve repair (MVR). Nowadays, a rate of repair >90% may be reached in some mitral valve reference centres. In recent years, the introduction of transcatheter mitral valve intervention techniques has opened up new frontiers in mitral therapy, specifically in patients at high risk for standard surgery. Current percutaneous technologies for MVR have been developed on the basis of some of the surgical principles. Based on current evidence, surgery remains the standard treatment for MR according to very long-term survival and durability of MVR using Carpentier's technique. Today, in clinical practice, only the MitraClip device may be considered as a real and effective alternative in selected patients with high or prohibitive risk for surgery.

Objectives The surgical approach for ischemic mitral regurgitation remains unclear. Many studies are in favor of adding the subvalvular procedure to mitral annuloplasty to reduce recurrent mitral regurgitation. This study reports the clinical and echocardiographic outcomes of papillary muscle relocation combined with mitral annuloplasty.Methods From 2003, 115 patients with severe ischemic mitral regurgitation who underwent papillary muscle relocation plus nonrestrictive mitral annuloplasty and coronary artery bypass grafting were retrospective analyzed. Patients' mean age was 52 ± 12.8 years, New York Heart Association class III or IV was 71%, and preoperative left ventricular ejection fraction was 43% ± 6%. The study end points were New York Heart Association functional class, reversal in left ventricle remodeling, reduction of mean tenting area and mean coaptation depth, freedom from cardiac-related deaths and events, and freedom from recurrent mitral regurgitation. Follow-up data were obtained in all patients and were 100% complete. Mean follow-up was 45 ± 6 months.Results Five-year freedom from cardiac-related death and events was 91.3% ± 1.6% and 84% ± 2.2%, respectively. Recurrent mitral regurgitation more than moderate occurred in 3 patients (2.7%). Reversal in left ventricular remodeling, measured by a change in the end-diastolic and systolic diameter, was observed in our patients (P

Background: The inflammatory cascade has been hypothesized to be an important mechanism of post-ischaemic myocardial reperfusion injury and several studies demonstrated that C1 esterase inhibitor (C1 -INH) is effective in post-ischaemia myocardial protection. Therefore, we aimed to investigate prospectively in a randomised double-blind study the cardioprotective effects of C1-INH in ST segment elevation myocardial infarction (STEMI) in patients who underwent emergent reperfusion with coronary artery bypass grafting (CABG). Methods: In this study, we enrolled 80 patients affected with STEMI who underwent emergent CABG. Patients were assigned in two groups (C1-INH group: receive 1000 Ul of C1-INH; and placebo group: receive a saline solution). The effects of C1-INH on complement inhibition, myocardial cell injury extension and clinical outcome were studied. Haemodynamic data and myocardial function were monitored. C1-INH, C3a, C4a complement activation fragments and cardiac troponin I (cTnl) serum levels were measured before, during and after surgery. Results: Patient characteristics were not different between the two groups. The overall in-hospital mortality rate was 6.2%. No statistical significant difference was observed between the two groups with regard to early mortality (p = 0.36). Statistical significant difference between the two groups was showed for cardiopulmonary bypass support (p = 0.04), administration of high dose of inotropes drugs (p = 0.001), time of intubation (p=0.03),intensive care unit (ICU)stay (p = 0.04) and in-hospital stay (p = 0.03). A significant improvement in mean arterial pressure (p = 0.03), cardiac index (p = 0.02) and stroke volume (p = 0.03) was showed in C1-INH group versus placebo group. The serum cTnl levels were significantly low in the C1-INH group versus placebo group after reperfusion, during the observation period. Plasma levels of C3a and C4a complement fragments were reduced significantly in C1-INH group. No drugs-related adverse effects were observed. Conclusions: The inhibition of the classic complement pathway by C1-INH appears to be an effective mean of preserving ischaemic myocardium from reperfusion injury as demonstrated by low serum cTnl levels in C1 -INH group. Therefore, the use of C1-INH during CABG as a rescue therapy in STEMI patients is probably an effective treatment to inhibit complement activity and to improve cardiac function and haemodynamic performance without impacting early mortality. Large randomised study should be performed to support our results.