Brixia system of screws: a titanium modular system with wide applicability for reinforced sternal closure in cardiac and thoracic surgery.

The use of cannulated screws and titanium plates to reinforce the sternal closure or to treat sternal dehiscence after median sternotomy has already been suggested in several articles. The system proposed here has some important advantages over those already described. Moreover, thanks to its characteristics, this system can also be used to treat pathologies affecting the entire rib cage. The system consists of a first threaded cannulated screw that is inserted in the bone or chondral cartilage and accommodates a cap screw that is tightened into the first screw and fixes a plate according to the following scheme: a threaded cannulated screw/plate/cap screw (Brixia system of screws). This system allows the plates to be fixed on the anterior face of the ribs and/or sternum without the need to enlarge dissection of the tissue, thereby lowering the danger of haemorrhage and injury to the thoracic organs. For this reason, it is particularly suitable for treating post-sternotomy sternal dehiscence, but it can be used to reinforce the primary sternal closure (after median or transversal sternotomy) in high-risk patients with sternal dehiscence. Owing to the modular nature of the system, singular components can also be utilized independently.

Sleeve Technique Combined With Aortic Valve Replacement: A Simpler Alternative to the Bentall Procedure.

Aortic root disease can be treated with different surgical techniques. The surgical approach of choice depends on patients' comorbidities and aortic valve conditions. We describe an operation combining a Sleeve aortic rootplasty with an aortic valve replacement, as an alternative to the classical Bentall procedure. The patient, a 63-year-old man, was admitted to our institution in April 2019 with severe aortic regurgitation, left ventricle dysfunction (ejection fraction = 44%), and aortic root ectasia (476 mm). Since a sparing aortic valve procedure was judged not feasible because of the thickness and retraction of the leaflets, we decided to perform a procedure through a sleeve operation to treat the aortic ectasia and a standard bioprosthetic aortic valve replacement to treat the aortic regurgitation. The patient had an uneventful postoperative course and was discharged on the sixth postoperative day with aspirin as sole antiplatelet treatment. This procedure may be considered an alternative to the Bentall operation. In fact, it may also offer complete treatment for the aortic root disease, avoiding coronary complications due to coronary ostia manipulation and reimplantation.

Use of new cannulated screws for primary sternal closure in high risk patients for sternal dehiscence.

BACKGROUND: Median sternotomy is still the approach of choice for heart surgery and the most common sternal closure is conventional six-wire technique. Mediastinitis is the frightening complication of the median sternotomy and occurs from 1% up to 2.4% of cases with a mortality rate which ranges from 14% up to 47%. Many methods have been suggested to reinforce the sternum with the common goal to improve sternal stability and prevent mediastinitis, but there is not consensus among cardiac surgeons on the optimal way to close the sternum. For this reason, we report our experience with a sternal device that, although not entirely new as a concept, has new technical features and plays a new role in preventing sternal dehiscence, according to the most recent findings on mechanism which leads to sternal dehiscence. METHODS: We enrolled 62 high risk patients for sternal dehiscence (patients with 2 well established historical risk factors), and we closed the sternum of the patients with a new surgical option consisting of passing, in a conventional six-wire sternal closure, the last sixth steel wire (Ø 1.0 mm, n° 5) through a couple of titanium cannulated screws (Ø 5.5 mm, self-tap-ping with a length from 10 to 16 mm and 2-mm increments) inserted into the 5th or 6th couple of rib cartilages. RESULTS: Primary chest closure with cannulated screws was performed on 48 males and 14 females. The average age of patients was 67.6 years (range, 43-88 years). The average follow-up was 12.8±16.2 months (range, 1-41 months). Chronic obstructive pulmonary disease (COPD) was the most common preoperative risk factor. The average number of risk factors was 2.4 (range, 2-4). Coronary artery bypass grafting (CABG) was the most common cardiac procedure. There were no peri-operative deaths. BMI >30 Kg/m2 and diabetes were the associated of risk factors predisposing to superficial skin dehiscence. CONCLUSIONS: In our clinical experience with high risk patients, this surgical option suggests that there is evidence of an effective stabilization of standard sternal closure and this option seems a promising technique to prevent the domino effect which starts from the xifoid bone and proceeds to the manubrium with the effect of leading to sternal instability which is the first step to mediastinitis.

Role of different vascular approaches on transcatheter aortic valve implantation outcome: a single-center study.

OBJECTIVE: To compare different vascular approaches on clinical outcome of patients undergoing transcatheter aortic valve implantation (TAVI) with self-expandable bioprosthesis. METHODS: We included all the patients undergoing CoreValve implantation at our institute between September 2007 and March 2014. They were divided into four groups based on the vascular approach: percutaneous transfemoral (pTF), cut-down transfemoral (cTF), transaxillary (TAx) and transaortic (TAo). Clinical outcomes were evaluated according to Valve Academic Research Consortium-2 recommendations. RESULTS: Out of 322 consecutive patients, 170 (53%) underwent pTF, 76 (23%) cTF, 32 (10%) TAx and 44 (14%) TAo approach. Although the TAx and TAo patients had a higher risk profile, they had a similar outcome compared with the pTF and cTF groups; in particular, there were no differences regarding cardiovascular and all-cause mortality at 30 days, 1 and 2 years, as well as stroke, myocardial infarction, bleeding, major vascular complications, permanent pacemaker implantation and acute kidney injury rates. The observed device success rate was higher in the TAo than in the other approaches (88.6 versus 65.9, 68.7 and 76.3% in the pTF, cTF and TAx groups, respectively; P = 0.019). No differences occurred regarding 30-day early safety and 1-year clinical efficacy across the four groups. Fluoroscopy time, amount of contrast medium used and minor vascular complications were significantly higher in pTF patients, as well as in-hospital stay in the TAo group. Atrial fibrillation and prosthetic valve regurgitation, but not the vascular approach, were independent predictors of all-cause mortality. CONCLUSION: A more invasive vascular approach, for CoreValve implantation, even in higher risk patients, does not affect early-term, mid-term and long-term outcomes.

Hybrid aortic arch debranching with staged endovascular completion in DeBakey type I aortic dissection.

BACKGROUND: We assess midterm results of a hybrid approach to DeBakey type I aortic dissection using a new multibranched Dacron graft to create, by relocation of the inflow openings to the arch vessels toward the aortic root, a new aortic arch for an easier and safer second-staged endovascular stent grafting of the distal thoracic aorta. METHODS: From March 2006 to July 2008 24 patients with DeBakey type I aortic dissection underwent ascending aorta and aortic arch replacement with debranching of epiaortic vessels using a new prosthesis to create an optimal landing zone for possible subsequent endovascular stent grafting of the distal thoracic aorta. Fifteen patients, who postoperatively presented a residual patent distal false lumen, underwent a successful second-stage endovascular stent-graft implantation. RESULTS: One patient died after the surgical stage while there was no death after the endovascular stage with hospital mortality of 4.2%. Follow-up confirmed complete thrombosis of the residual distal false lumen in 95.6% and partial thrombosis in 4.4% of patients with no evidence of endoleaks in the cases that required the endovascular procedure. Overall actuarial survival at 28 months is 92.1% ± 7.9% with 100% freedom from reoperation. CONCLUSIONS: Hybrid treatment of DeBakey type I aortic dissection with aortic arch debranching, using a new multibranched prosthesis (Lupiae Graft; Vascutek Terumo Inc, Scotland, United Kingdom) is confirmed to facilitate the subsequent endovascular completion. Midterm results in terms of survival and distal false lumen thrombosis are satisfactory. Further study of this operation is warranted to confirm the effectiveness and the durability of this approach.

Clinical outcome of a simplified technique for aortic valve replacement with stentless bioprostheses.

BACKGROUND AND AIM OF THE STUDY: Aortic stentless bioprostheses provide good clinical and hemodynamic results, but may be difficult to implant. Their use is also contraindicated in the presence of a severely calcified aortic root. The study aim was to assess the mid-term results of a simplified implant technique of the Sorin Pericarbon Freedom stentless bioprosthesis (SPF), that allows its use in the presence of severe aortic root calcification. METHODS: Between 2001 and 2007, a total of 51 patients underwent aortic valve replacement (AVR) with the SPF, using a new technique which consisted of standard annular fixation and the fixation of each strut with a single 'U' stitch. The perioperative characteristics, early and late mortality and occurrence of valve-related events were evaluated. The overall mean cross-clamp and cardiopulmonary bypass times were 91.5 +/- 30.2 and 125.3 +/- 44.9 min, respectively, and 77.8 +/- 17.7 and 105.6 +/- 22.8 min, respectively, for AVR (these times were comparable to those required in patients receiving stented valve bioprostheses). The mean follow up period was 40.5 months (range: 3-75 months), and was 100% complete. RESULTS: Hospital mortality was 4% and survival 76.5 +/- 14.5% at six years. Late deaths occurred in eight patients; in four cases this was valve-related (1.9%/patient-year). Freedom from valve-related death and reoperation was 91 +/- 9% and 98 +/- 2% respectively, at six years. The mean transprosthetic gradients were 12.0 +/- 3.4, 9.9 +/- 2.6, 8.7 +/- 4.2, 5.2 +/- 3.9, 4.5 +/- 3.0 and 3.2 +/- 2.7 mmHg for the 19, 21, 23, 25, 27 and 29 mm valve sizes, respectively. No valvular or paravalvular regurgitation was recorded. CONCLUSION: This new implantation technique for the aortic SPF stentless bioprosthesis is simple, effective and versatile, and showed good early results. It may be applicable to other stentless bioprostheses, and also be particularly useful in patients with small aortic annulus and in those with a calcified aortic root.