The importance of being the morning case in adult cardiac surgery: a propensity-matched analysis.

OBJECTIVES: The quality of the outcome after cardiac surgery with cardiopulmonary bypass depends on the patient demographics, co-morbidities, complexity of the surgical procedure and expertise of surgeons and the whole staff. The purpose of the present study is to analyse the timing of surgery (morning versus afternoon) with respect to morbidity and mortality in adult cardiac surgery. METHODS: The primary end point was the incidence of major morbidity defined according to a modified Society of Thoracic Surgeon criterion. We consecutively included all the adult (>18 years) patients receiving a cardiac surgery operation at our Institution. RESULTS: From 2017 through 2019, a total of 4003 cardiac surgery patients were operated. With a propensity-matching technique a final patient population of 1600 patients was selected, with 800 patients in the first-case surgery group and 800 in the second-case surgery group. Patients in the second-case group had a major morbidity rate of 13% vs 8.8% in the first-case group (P = 0.006), and a higher rate of 30-day mortality (4.1% vs 2.3%, P = 0.033). After correction for EuroSCORE and operating surgeon, the second-case group confirmed a higher rate of major morbidity (odds ratio 1.610, 95% confidence interval 1.16-2.23, P = 0.004). CONCLUSION: Our study suggests that patients operated as second cases are exposed to an increased morbidity and mortality probably due to fatigue, loss of attention and hurriedness in the operating room and decreased human resources in the intensive care unit.

Isthmic Aortic False Aneurysm Post-Patch Coarctation Aortoplasty: A Hybrid Solution.

We report a case of a 57-year-old female with dextrocardia and a solitary kidney. A patch aortoplasty for isthmic aortic coarctation repair was performed 40 years before when she was admitted to our department for dyspnea. Computed tomography scan showed a giant and saccular 10-cm diameter patch false aneurysm. The ascending aortic diameter was 34 mm and the echocardiography confirmed a severe aortic regurgitation of a bicuspid aortic valve. We decided to perform a 2-step approach: biologic aortic valve and ascending aorta replacement with total debranching of the epiaortic vessels and thoracic endovascular aneurysm repair for complete false aneurysm exclusion.

A new approach for severe aortic regurgitation in porcelain aorta with sutureless Perceval valve: A case report.

INTRODUCTION: The association of pure aortic regurgitation and porcelain aorta represents a challenging situation. In the Transcatheter Aortic Valve Implantation (TAVI) era, porcelain aorta (PA) becomes an additional risk for patient treatment and sometimes serves as the primary indication for the TAVI approach, even in low-risk patients. Devices currently on the market are not yet validated for the treatment of pure aortic regurgitation (AR) in PA and mid/long-term results are still not available. Furthermore, small calcified sinotubular junction and the association of small Valsalva sinus with low origin of coronaries ostia represent a relative contraindication of TAVI. PRESENTATION OF CASE: We report a case of severe symptomatic AR associated with a PA in a patient successfully treated with a sutureless Perceval valve. DISCUSSION: The sutureless Perceval valve may represent an excellent option. This valve requires less manipulation of the ascending aorta and no manipulation of the aortic annulus except for the aortic valve leaflets removal. Furthermore, it can be implanted also in a small and calcified sino-tubular junction because the valve is collapsible before the implant. CONCLUSION: The present case represents a proof that self-expandable cardiac valve technology can be employed to treat, either by surgery or by catheter, selected cases of AR. We have observed an excellent mid term result with no paravalvular leak at 2 years.

Early and Mid-Term Results of Rapid Deployment Valves: The Intuity Italian Registry (INTU-ITA).

BACKGROUND: Rapid deployment bioprostheses (RDBs) have been recently introduced into clinical practice for the treatment of severe aortic valve stenosis. The aim of this retrospective multicenter study was to assess early and mid-term clinical and hemodynamic outcomes of patients undergoing RDB implantation. METHODS: Data from a national registry that included patients who underwent isolated or combined aortic valve replacement with RDB in Italy were analyzed. Definitions of the European System for Cardiac Operative Risk Evaluation were used for preoperative variables and updated definitions from the Valve Academic Research Consortium were used for postoperative outcomes assessment. Univariable and multivariable analyses were performed to identify independent predictors of mortality. Follow-up was performed with clinical and echocardiographic examinations at each study site and, if this was not possible, through telephonic interviews. The Kaplan-Meier method was used for survival analysis. RESULTS: A total of 902 patients (December 2012 through November 2017) from 20 national centers were included in the registry. Device success was 95.9%, and 30-day all-cause mortality was 2.8%. Postoperative pacemaker implantation was needed in 63 patients (6.9%). At discharge, peak and mean transaortic gradients were 19 ± 7 mm Hg and 11 ± 4 mm Hg, respectively. Mild and moderate aortic regurgitation were found in 71 patients (8.2%) and in 10 patients (1.2%), respectively. Median follow-up time was 357 days (interquartile range: 103 to 638 days). Survival at 4 years was 86% ± 1%. Preoperative conduction disturbances and history of previous myocardial infarction were independently associated with mortality. CONCLUSIONS: Aortic RDBs provide good early and mid-term clinical and hemodynamic outcomes. These devices may be considered as a reasonable alternative to conventional bioprostheses, especially in minimally invasive and combined operations.

Distal Ulnar Artery Aneurysm Repair by End-to-End Technique: A Case Report.

We report the case of a 33-year-old man presented with a posttraumatic 20-mm left ulnar artery aneurysm without intraluminal thrombus in the left hypothenar eminence. The patient reported left hand paresthesia. Because of symptoms and the embolic risk, we decide to plan an aneurysm resection and an interposition graft with inverted basilic vein for adequacy diameter (∼2 mm), but an end-to-end anastomosis was performed instead. We think that the posttraumatic distal artery aneurysm could be treated without a bypass but, after a meticulous anatomic dissection, with a microvascular anastomosis between the artery stumps.

Safe Reentry for False Aneurysm Operations in High-Risk Patients.

BACKGROUND: In the absence of a standardized safe surgical reentry strategy for high-risk patients with large or anterior postoperative aortic false aneurysm (PAFA), we aimed to describe an effective and safe approach for such patients. METHODS: We prospectively analyzed patients treated for PAFA between 2006 and 2015. According to the preoperative computed tomography scan examination, patients were divided into two groups according to the anatomy and extension of PAFA: in group A, high-risk PAFA (diameter ≥3 cm) developed in the anterior mediastinum; in group B, low-risk PAFA (diameter <3 cm) was situated posteriorly. For group A, a safe surgical strategy, including continuous cerebral, visceral, and coronary perfusion was adopted before resternotomy; group B patients underwent conventional surgery. RESULTS: We treated 27 patients (safe reentry, n = 13; standard approach, n = 14). Mean age was 60 years (range, 29 to 80); 17 patients were male. Mean interval between the first operation and the last procedure was 4.3 years. Overall 30-day mortality rate was 7.4% (1 patient in each group). No aorta-related mortality was observed at 1 and 5 years in either group. The Kaplan-Meier overall survival estimates at 1 and 5 years were, respectively, 92.3% ± 7.4% and 73.4% ± 13.4% in group A, and 92.9% ± 6.9% and 72.2% ± 13.9% in group B (log rank test, p = 0.830). Freedom from reoperation for recurrent aortic disease was 100% at 1 year and 88% at 5 years. CONCLUSIONS: The safe reentry technique with continuous cerebral, visceral, and coronary perfusion for high-risk patients resulted in early and midterm outcomes similar to those observed for low-risk patients undergoing conventional surgery.

Human Cardiac Progenitor Spheroids Exhibit Enhanced Engraftment Potential.

A major obstacle to an effective myocardium stem cell therapy has always been the delivery and survival of implanted stem cells in the heart. Better engraftment can be achieved if cells are administered as cell aggregates, which maintain their extra-cellular matrix (ECM). We have generated spheroid aggregates in less than 24 h by seeding human cardiac progenitor cells (hCPCs) onto methylcellulose hydrogel-coated microwells. Cells within spheroids maintained the expression of stemness/mesenchymal and ECM markers, growth factors and their cognate receptors, cardiac commitment factors, and metalloproteases, as detected by immunofluorescence, q-RT-PCR and immunoarray, and expressed a higher, but regulated, telomerase activity. Compared to cells in monolayers, 3D spheroids secreted also bFGF and showed MMP2 activity. When spheroids were seeded on culture plates, the cells quickly migrated, displaying an increased wound healing ability with or without pharmacological modulation, and reached confluence at a higher rate than cells from conventional monolayers. When spheroids were injected in the heart wall of healthy mice, some cells migrated from the spheroids, engrafted, and remained detectable for at least 1 week after transplantation, while, when the same amount of cells was injected as suspension, no cells were detectable three days after injection. Cells from spheroids displayed the same engraftment capability when they were injected in cardiotoxin-injured myocardium. Our study shows that spherical in vivo ready-to-implant scaffold-less aggregates of hCPCs able to engraft also in the hostile environment of an injured myocardium can be produced with an economic, easy and fast protocol.

Atypical abnormal pulmonary vein drainage with atrial septal defect: surgical treatment.

Sinus venosus atrial septal defect (SV-ASD) usually coexists with partial anomalous pulmonary vein connection (PAPVC). It is a difficult diagnosis in transthoracic echocardiography (TTE) due to eccentric position of defects. We present a rare case of atypical anatomical variation in PAPVC, which was never described before. Two right pulmonary veins drained into superior vena cava, which overrode SV-ASD and interatrial septum, a third pulmonary vein into the right atrium. Complete diagnosis could not be set after TTE, nor transesophageal echocardiography, whereas angio-CT was finally conclusive. This diagnostic approach allowed the surgical planning.

Monophasic and biphasic electrical stimulation induces a precardiac differentiation in progenitor cells isolated from human heart.

Electrical stimulation (ES) of cells has been shown to induce a variety of responses, such as cytoskeleton rearrangements, migration, proliferation, and differentiation. In this study, we have investigated whether monophasic and biphasic pulsed ES could exert any effect on the proliferation and differentiation of human cardiac progenitor cells (hCPCs) isolated from human heart fragments. Cells were cultured under continuous exposure to monophasic or biphasic ES with fixed cycles for 1 or 3 days. Results indicate that neither stimulation protocol affected cell viability, while the cell shape became more elongated and reoriented more perpendicular to the electric field direction. Moreover, the biphasic ES clearly induced the upregulation of early cardiac transcription factors, MEF2D, GATA-4, and Nkx2.5, as well as the de novo expression of the late cardiac sarcomeric proteins, troponin T, cardiac alpha actinin, and SERCA 2a. Both treatments increased the expression of connexin 43 and its relocation to the cell membrane, but biphasic ES was faster and more effective. Finally, when hCPCs were exposed to both monophasic and biphasic ES, they expressed de novo the mRNA of the voltage-dependent calcium channel Cav 3.1(α1G) subunit, which is peculiar of the developing heart. Taken together, these results show that ES alone is able to set the conditions for early differentiation of adult hCPCs toward a cardiac phenotype.

Relationship between left atrial volume and atrial fibrillation following coronary artery bypass grafting.

BACKGROUND: Atrial fibrillation (AF) is a common complication of coronary artery bypass grafting (CABG). However, limited information is available about the role of preoperative echocardiographic left atrial evaluation to predict AF occurrence after CABG. Thus, we prospectively compared the ability of echocardiographic measurements of left atrial volume to predict AF in this setting. METHODS: From January to December 2009, 220 patients (75% males, 66.8 ± 10.0 years) met the inclusion criteria of our study (isolated and elective CABG, no valve surgery, no permanent AF, or other chronic atrial arrhythmias). The day before CABG a complete echocardiographic evaluation was performed with left atrial volume measurements. The primary endpoint of the study was postoperative AF (POAF) lasting >30 seconds. RESULTS: POAF was observed in 61 patients (27.7%). POAF patients showed increased left atrial M-mode anteroposterior dimension (41.2 ± 6.4 mm vs. 43.6 ± 7.3 mm; p = 0.020) and increased left atrial volume (59.0 ± 18.3 mL vs. 70.6 ± 28.1 mL; p = 0.0004). Left atrial volume was an independent risk factor for POAF (OR 10.03; 95% CI 10.01 to 10.05; p = 0.01), along with postoperative bleeding with hemoglobin levels below 8 g/dL (OR 20.84; 95% CI 10.12 to 70.19; p = 0.03) and preoperative left ventricular ejection fraction below 40% (OR 10.08; 95% CI 10.01 to 10.15; p = 0.02). Conversely, preoperative statin therapy exerted a protective role (OR 0.30; 95% CI 0.12 to 0.74; p = 0.009). CONCLUSION: Preoperative echocardiographic evaluation of patients with isolated CABG demonstrated that left atrium volume measurements were independently correlated to the occurrence of POAF. Further investigations should focus on the opportunity to target prophylactic antiarrhythmic treatments to patients with large left atrial volumes.

Myocardial systolic velocities and deformation assessed by speckle tracking for early detection of left ventricular dysfunction in asymptomatic patients with severe primary mitral regurgitation.

AIMS: In asymptomatic patients with severe primary mitral regurgitation (PMR), early detection of left ventricular (LV) dysfunction indicates the optimal timing of mitral valve surgery; however, normal ejection fraction (EF) and end-systolic diameter (ESD) can mask significant LV impairment. METHODS: We studied 28 asymptomatic patients (59 ± 13 years, 18 male) with severe PMR, EF > 60%, and ESD < 45 mm, and 10 age-matched healthy subjects. All underwent echocardiography with tissue velocity imaging to assess LV geometry, EF, and longitudinal systolic function; and two-dimensional speckle tracking to assess longitudinal strain (LS) and longitudinal strain rate (LSR), and radial strain (RS) and radial strain rate (RSR). Patients were reevaluated 14 days after successful mitral valve repair and divided in: IA, with a postoperative EF reduction >10% (13 patients) and IB, with an EF reduction <10% (15 patients). RESULTS: Patients with PMR had longitudinal dysfunction and decreased radial systolic deformation, by comparison with controls, although EF and ESD were similar. Subgroup IA had significantly lower S(TVI) , LS, and RS than IB (7.3 ± 0.9 vs 10.8 ± 1.5 m/s; -16.0 ± 4.2% vs -21.7 ± 2.1%; and 37.4 ± 2.5% vs 41.6 ± 2.4%; all p < 0.001) although preoperative LV mass index, LV diameters, and EF were similar. Multiple stepwise regression analysis showed that S(TVI) and the combination of S(TVI) and LS represent the main independent predictors for a postoperative EF reduction >10% (r(2) = 0.52, p < 0.001; and r(2) = 0.70, p < 0.001, respectively). CONCLUSION: Myocardial systolic velocities as well as radial and longitudinal LV deformation assessed by speckle tracking can detect subclinical LV dysfunction and predict impaired postoperative LV function in asymptomatic patients with severe PMR.

Mitral insufficiency due to an isolated anterior-leaflet cleft: correction with an autologous pericardial patch supported by artificial chordae.

Congenital clefts of the mitral valve without an associated atrioventricular canal defect are rare, and they may cause mitral insufficiency that requires surgical correction. Repair is typically by direct suture; however, if the cleft is especially wide, the use of this technique may distort the valve leaflet and cause poor coaptation with valvular insufficiency.Herein, we present the case of a 39-year-old woman who had severe mitral valve insufficiency secondary to a wide isolated cleft of the anterior mitral leaflet. The valve was reconstructed with an autologous pericardial patch supported by polytetrafluoroethylene neochordae and an implanted annuloplasty ring. Echocardiographic examination 1 year postoperatively showed excellent competence of the mitral valve and good coaptation of the leaflets. To our knowledge, this is the 1st report that describes the use of artificial neochordae to support an autologous pericardial patch in the repair of a cleft in the anterior mitral valve leaflet.

Aorto-pulmonary fistula as a late complication of multiple valve replacement after Streptococcus Bovis endocarditis in a patient with occult colon carcinoma.

We report a case of aorto-pulmonary fistula following multiple valve surgery in a patient with colon carcinoma who had had recurrent episodes of Streptococcus Bovis endocarditis. Diagnosis was made by transesophageal echocardiography and aortography. Patient underwent emergency percutaneous implantation of an aortic endoprosthesis, but he continued to deteriorate and the fatal outcome could not be changed. This case underscores the importance of examination of gastrointestinal tract in patients with Streptococcus Bovis endocarditis.

Cardiac resynchronization therapy as an adjunct to conventional surgical treatment for heart failure.

From March 2004 through October 2007, we prospectively evaluated the benefits of cardiac resynchronization therapy as an adjunct to conventional procedures in patients who were undergoing surgery for heart failure.Twenty severely symptomatic patients (14 men and 6 women, with a mean age of 70 +/- 8 years) who displayed advanced cardiomyopathy, QRS duration > or =130 ms, or mechanical dyssynchrony, underwent isolated or combined coronary artery revascularization and mitral valve overreduction. In all patients, an epicardial lead was secured to the left ventricular wall at the end of the procedure and its extremity was brought into a subclavian pocket. In 5 patients, a resynchronization device was implanted at the time of surgery; in 8, it was implanted at a later date; the remaining 7 patients are awaiting implantation. One patient died postoperatively of low-output syndrome. There was 1 noncardiac late death. Eighteen patients were alive at a mean postoperative follow-up of 21.6 +/- 15.2 months (range, 1-43 mo). There were no subsequent hospital admissions after discharge. New York Heart Association functional class and left ventricular performance were significantly and lastingly improved when cardiac resynchronization therapy was added to the surgical procedure. Despite the limitations inherent in the small number of patients and the relatively short duration of follow-up, this study suggests that patients with dilated cardiomyopathy and left ventricular dyssynchrony in whom surgical correction is indicated may benefit from cardiac resynchronization therapy using a resynchronization device connected to an epicardial lead secured to the left ventricle at the time of surgery.

The efficacy and safety of extending the ischemic time with a modified cardioplegic technique for coronary artery surgery.

BACKGROUND AND AIM: The need to intermittently discontinue the administration of cardioplegia in order to complete the surgical procedure is a major drawback of antegrade warm blood cardioplegia. An ischemic time of 15 minutes is generally considered safe based on empirical observation. The aim of this study was the evaluation of the efficacy and safety of an intermittent warm blood cardioplegia with intervals between administrations prolonged to 25 minutes. METHODS: Ninety-seven patients undergoing primary elective coronary artery revascularization were prospectively randomized into two groups. The first, Intermittent Antegrade Warm Blood Cardioplegia (IAWBC) group, comprising 49 patients, received standard intermittent antegrade warm blood cardioplegia repeated every 15 minutes. The second, Modified Intermittent Antegrade Warm Blood Cardioplegia (M-IAWBC) group, comprising 48 patients, received intermittent antegrade warm blood cardioplegia supplemented with magnesium sulfate (MgSO(4)), delivered in volumes proportional to the ventricular mass and repeated every 25 minutes. The clinical outcomes were evaluated. The levels of creatine kinase-MB (CK-MB) isoenzyme, in addition to the echocardiographic assessment of septal dyskinesia and tricuspid annulus plane systolic excursion (TAPSE), have been used as markers of myocardial damage. RESULTS: There were no statistically significant differences in clinical outcomes, need for inotropes and vasodilators, length of stay in the intensive care unit, and postoperative levels of CK-MB between the two groups. Likewise, postoperative echocardiographic assessment showed no relevant differences. CONCLUSIONS: Administration of warm antegrade cardioplegic solution supplemented with MgSO(4), delivered in volumes proportional to ventricular mass every 25 minutes, provides adequate myocardial protection for coronary artery surgery.

Severe post-ischemic elongation of the anterior papillary muscle: an unusual cause of mitral insufficiency in a 75-year-old man.

As a complication of myocardial ischemia, severe elongation of the anterior papillary muscle with resultant mitral valve insufficiency is a rare clinical finding. Using echocardiography, we accurately diagnosed this condition in a 75-year-old man. The patient underwent successful plication of the elongated anterior papillary muscle and the implantation of polytetrafluoroethylene neochordae tendineae.

[Aortic valve replacement on two octogenarians awake patients without tracheal intubation, with thoracic epidural anesthesia]. / Sostituzione valvolare aortica in due pazienti ottuagenari coscienti senza intubazione tracheale in anestesia peridurale toracica.

The association of advanced age with various comorbidities increases the risk of mortality and morbidity in cardiac surgery. The utilization of high thoracic epidural anesthesia (HTEA) in this setting presents numerous potential benefits, including early recovery of consciousness and of spontaneous ventilation, hemodynamic stability, enhanced analgesia, improved pulmonary function, and earlier recovery. Moreover, this anesthesiological technique allows the performance of surgical procedures on the conscious patient, thus making continuous monitoring of the cerebral function feasible. We have employed HTEA without tracheal intubation on 2 gravely compromised octogenarian patients who underwent aortic valve replacement for critical aortic stenosis. Epidural anesthesia without tracheal intubation in these patients permitted the avoidance of general anesthetics and allowed the continuous evaluation of their cognitive function. Further, by avoiding the positive pulmonary pressures of mechanical ventilators, the technique contributed to preserve physiologic intrapulmonary pressures, thus positively affecting the pulmonary circulation. In our opinion, the utilization of HTEA without tracheal intubation may decrease the surgical risk in selected patients.

High thoracic epidural anesthesia in cardiac surgery: risk factors for arterial hypotension.

There is an interest in the use of high thoracic epidural anesthesia in cardiac surgery, because experimental and clinical studies have suggested that central neuroaxial blockade attenuates the response to surgical stress and improves myocardial metabolism and perioperative analgesia-thus enabling earlier extubation and a smoother postoperative course. Matters of major concern in the adoption of high thoracic epidural anesthesia in cardiac surgery are neurologic injury secondary to neuroaxial hematoma and hypotension secondary to sympatholysis. The risk associated with possible neuraxial hematoma caused by high thoracic epidural anesthesia has been thoroughly investigated and largely discounted, but scant attention has been devoted to the onset of hypotensive episodes in the same setting. We analyzed the hypotensive episodes that occurred in a series of 144 patients who underwent on-pump cardiac surgery procedures. Among the patient variables that we tested in a multivariate logistic-regression model, only female sex was found to be significantly correlated with hypotension. In order to decrease the incidence and severity of hypotensive episodes resulting from anesthetic blockade, anesthesiologists need to monitor, with special care, women patients who are under high thoracic epidural anesthesia. Further studies are needed in order to determine why women undergoing open heart surgery under high thoracic epidural anesthesia are at a relatively greater risk of hypotension.