Infective endocarditis in intravenous drug abusers: clinical challenges emerging from a single-centre experience.

BACKGROUND: Intravenous drug abuse (IDA) is a known risk factor for infective endocarditis (IE) and is associated with frequent relapses, but its prognostic impact is still debated. The potential futility of surgery in this population is a further issue under discussion. We aimed to describe the clinical characteristics, the therapeutic strategy, and the prognosis associated with IDA in IE. METHODS: We retrospectively analysed 440 patients admitted to a single surgical centre for definite active IE from January 2012 to December 2020. RESULTS: Patients reporting IDA (N = 54; 12.2%) were significantly younger (p < 0.001) and presented fewer comorbidities (p < 0.001). IDA was associated with a higher proportion of relapses (27.8 vs. 3.3%, p < 0.001) and, at multivariable analysis, was an independent predictor of long-term mortality (HR 2.3, 95%CI 1.1-4.7, p = 0.015). We did not register multiple relapses in non-IDA patients. Among IDA patients, we observed 1 relapse after discharge in 9 patients, 2 relapses in 5 patients and 3 relapses in 1 patient. In IDA patients, neither clinical and laboratory variables nor the occurrence of even multiple relapses emerged as indicators of an adverse risk-benefit ratio of surgery in patients with surgical indication. CONCLUSIONS: IE secondary to IDA affects younger patients than those with IE not associated with IDA. Probably due to this difference, IE secondary to IDA is not associated with significantly higher mortality, whereas the negative, long-term prognostic impact of IDA emerges in multivariate analysis. Considering the good prognosis of patients with uncomplicated IE treated medically, surgery should be reserved to patients with a strict- guidelines-based indication. However, since there are no clear predictors of an unfavourable risk-benefit ratio of surgery in patients with surgical indication, all patients with a complicated IE should be operated, irrespective of a history of IDA.

COVID-19 in patients recovering from cardiac surgery: A surprising mild disease course.

BACKGROUND: We describe the baseline, operative, and postoperative features of a group of 18 patients who contracted the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection in a rehabilitation facility after cardiac surgery, and present some potential explanations for the surprisingly benign course of the COVID-19 in this cohort. METHODS: All patients were operated on an urgent or emergency basis (acute aortic syndrome, 3; refractory heart failure, 12; and endocarditis, 3) during the first lockdown period of the COVID-19 pandemic. The mean age was 70 years, and 12 patients were male. After the diagnosis of COVID-19, patients were treated according to the most recent recommendations. Eleven asymptomatic patients were discharged home or to a COVID-19 hotel and underwent close monitoring. Patients with fever, dyspnea, or a significant rise of the polymerase chain reaction levels were hospitalized, three received antivirals, three azithromicyne, and five hydroxychloroquine. Nasal swabs were repeated on a weekly basis, and all patients were quarantined until the collection of two consecutive negative samples. RESULTS: Diversely from other observations on perioperative COVID-19 reporting mortality rates of 30%-40%, the COVID-19 had a benign course in our cohort: only seven patients required hospitalization, and one required short intensive care unit admission. There were no deaths, and at the latest follow-up, all patients had been discharged home. COMMENT: Our data show that the SARS-CoV2 infection after cardiac surgery may have a benign course. Further studies are needed to investigate the relationship between the timing of the infection, some potentially protective therapies (e.g., anticoagulants), and the course of the COVID-19.

Long-term outcomes after transcatheter aortic valve implantation in failed bioprosthetic valves.

AIMS: Due to bioprosthetic valve degeneration, aortic valve-in-valve (ViV) procedures are increasingly performed. There are no data on long-term outcomes after aortic ViV. Our aim was to perform a large-scale assessment of long-term survival and reintervention after aortic ViV. METHODS AND RESULTS: A total of 1006 aortic ViV procedures performed more than 5 years ago [mean age 77.7 ± 9.7 years; 58.8% male; median STS-PROM score 7.3% (4.2-12.0)] were included in the analysis. Patients were treated with Medtronic self-expandable valves (CoreValve/Evolut, Medtronic Inc., Minneapolis, MN, USA) (n = 523, 52.0%), Edwards balloon-expandable valves (EBEV, SAPIEN/SAPIEN XT/SAPIEN 3, Edwards Lifesciences, Irvine, CA, USA) (n = 435, 43.2%), and other devices (n = 48, 4.8%). Survival was lower at 8 years in patients with small-failed bioprostheses [internal diameter (ID) ≤ 20 mm] compared with those with large-failed bioprostheses (ID > 20 mm) (33.2% vs. 40.5%, P = 0.01). Independent correlates for mortality included smaller-failed bioprosthetic valves [hazard ratio (HR) 1.07 (95% confidence interval (CI) 1.02-1.13)], age [HR 1.21 (95% CI 1.01-1.45)], and non-transfemoral access [HR 1.43 (95% CI 1.11-1.84)]. There were 40 reinterventions after ViV. Independent correlates for all-cause reintervention included pre-existing severe prosthesis-patient mismatch [subhazard ratio (SHR) 4.34 (95% CI 1.31-14.39)], device malposition [SHR 3.75 (95% CI 1.36-10.35)], EBEV [SHR 3.34 (95% CI 1.26-8.85)], and age [SHR 0.59 (95% CI 0.44-0.78)]. CONCLUSIONS: The size of the original failed valve may influence long-term mortality, and the type of the transcatheter valve may influence the need for reintervention after aortic ViV.

Incidence, predictors, and clinical outcomes of coronary obstruction following transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: insights from the VIVID registry.

Aims: There are limited data on coronary obstruction following transcatheter valve-in-valve (ViV) implantation inside failed aortic bioprostheses. The objectives of this study were to determine the incidence, predictors, and clinical outcomes of coronary obstruction in transcatheter ViV procedures. Methods and results: A total of 1612 aortic procedures from the Valve-in-Valve International Data (VIVID) Registry were evaluated. Data were subject to centralized blinded corelab computed tomography (CT) analysis in a subset of patients. The virtual transcatheter valve to coronary ostium distance (VTC) was determined. A total of 37 patients (2.3%) had clinically evident coronary obstruction. Baseline clinical characteristics in the coronary obstruction patients were similar to controls. Coronary obstruction was more common in stented bioprostheses with externally mounted leaflets or stentless bioprostheses than in stented with internally mounted leaflets bioprostheses (6.1% vs. 3.7% vs. 0.8%, respectively; P < 0.001). CT measurements were obtained in 20 (54%) and 90 (5.4%) of patients with and without coronary obstruction, respectively. VTC distance was shorter in coronary obstruction patients in relation to controls (3.24 ± 2.22 vs. 6.30 ± 2.34, respectively; P < 0.001). Using multivariable analysis, the use of a stentless or stented bioprosthesis with externally mounted leaflets [odds ratio (OR): 7.67; 95% confidence interval (CI): 3.14-18.7; P < 0.001] associated with coronary obstruction for the global population. In a second model with CT data, a shorter VTC distance predicted this complication (OR: 0.22 per 1 mm increase; 95% CI: 0.09-0.51; P < 0.001), with an optimal cut-off level of 4 mm (area under the curve: 0.943; P < 0.001). Coronary obstruction was associated with a high 30-day mortality (52.9% vs. 3.9% in the controls, respectively; P < 0.001). Conclusion: Coronary obstruction following aortic ViV procedures is a life-threatening complication that occurred more frequently in patients with prior stentless or stented bioprostheses with externally mounted leaflets and in those with a short VTC.

Incidence and outcomes of emergent cardiac surgery during transfemoral transcatheter aortic valve implantation (TAVI): insights from the European Registry on Emergent Cardiac Surgery during TAVI (EuRECS-TAVI).

Aims: Life-threatening complications occur during transcatheter aortic valve implantation (TAVI) which can require emergent cardiac surgery (ECS). Risks and outcomes of patients needing ECS during or immediately after TAVI are still unclear. Methods and results: Incidence, risk factors, management, and outcomes of patients requiring ECS during transfemoral (TF)-TAVI were analysed from a contemporary real-world multicentre registry. Between 2013 and 2016, 27 760 patients underwent TF-TAVI in 79 centres. Of these, 212 (0.76%) patients required ECS (age 82.4 ± 6.3 years, 67.5% females, logistic EuroSCORE: 17.1%, STS-score 5.8%). The risk of ECS declined from 2013 (1.07%) to 2014 (0.70%) but remained stable since. Annual TF-TAVI numbers have more than doubled from 2013 to 2016. Leading causes for ECS were left ventricular perforation by the guidewire (28.3%) and annular rupture (21.2%). Immediate procedural mortality (<72 h) of TF-TAVI patients requiring ECS was 34.6%. Overall in-hospital mortality was 46.0%, and highest in case of annular rupture (62%). Independent predictors of in-hospital mortality following ECS were age > 85 years [odds ratio (OR) 1.87, 95% confidence interval (95% CI) (1.02-3.45), P = 0.044], annular rupture [OR 1.96, 95% CI (0.94-4.10), P = 0.060], and immediate ECS [OR 3.12, 95% CI (1.07-9.11), P = 0.037]. One year of survival of the 114 patients surviving the in-hospital period was only 40.4%. Conclusion: Between 2014 and 2016, the need for ECS remained stable around 0.7%. Left ventricular guidewire perforation and annular rupture were the most frequent causes, accounting for almost half of ECS cases. Half of the patients could be salvaged by ECS-nevertheless, 1 year of all-cause mortality was high even in those ECS patients surviving the in-hospital period.

Outcomes of Video-assisted Minimally Invasive Cardiac Myxoma Resection.

BACKGROUND: Myxomas are the most frequent cardiac tumours. Their diagnosis requires prompt removal. In our centre, for valve surgery we use a minimally invasive approach. Here, we report our experience of cardiac myxoma removal through right lateral mini-thoracotomy (RLMT) with particular focus on its feasibility, efficacy and patient safety. METHODS: Between February 2006 and January 2017, 30 consecutive patients (aged 66±12.6years, range 35-83 years) underwent atrial myxoma resection through video-assisted RLMT. Percutaneous venous drainage was performed in all patients and direct cannulation of the ascending aorta was performed in 28 out of 30 (93.3%). The diagnosis of atrial myxoma was confirmed by histology. RESULTS: Complete surgical resection was achieved in all patients. The mean cardiopulmonary bypass (CPB) time was 76.5±40.8minutes and average aortic cross-clamping time was 41.5±29.8minutes. No patient suffered postoperative complications. Five patients (16.7%) received a blood transfusion. Mechanical ventilation ranged from 3 to 51hours (median 6hours), intensive care unit (ICU) stay ranged from 1 to 5days (median 1day). Total hospital length of stay (HLOS) was 5.6±2 days. Home discharge rate was 56.7%. No in-hospital mortality was reported. During follow-up (55.6±32.3 months; range 4-132 months), one tumour recurrence was observed. There were three late non-cardiac deaths. Overall survival was 100%, 85.7% and 85.7% at 1, 5 and 10 years, respectively. CONCLUSIONS: The use of video-assisted RLMT is an effective and reproducible strategy in all patients requiring expedited surgery for left atrial myxoma, independently of coexisting morbidity such as systemic embolisation or previous surgery. This technique leads to complete tumour resection, prompt recovery, early home discharge and high freedom from both symptoms and tumour recurrence.

Successful percutaneous implantation of symetis ACURATE neo transcatheter aortic bioprosthesis for the treatment of pure aortic regurgitation.

Transcatheter aortic valve implantation (TAVI) was initially developed for the treatment of calcific aortic stenosis. In the recent years, however, TAVI has been used to treat selected patients with pure, severe AR. We report successful transfemoral implantation of a Symetis ACURATE neo bioprosthesis in a severely symptomatic, 87-year-old woman with pure AR and major comorbidities. We decided to use the ACURATE neo bioprosthesis for some of its features appeared to us as potentially useful in the setting of pure AR: the stabilization arches ensure perfect coaxial alignment and extreme stability of the device during deployment, and the "waist" and the skirt were considered useful to obtain a good seal in the absence of significant valvular and annular calcifications. Finally, we decided to use a self-expanding valve to minimize the trauma to the aortic annulus. The procedure was successful and the patient was discharged home on postoperative day 3. At the 3-month control echocardiography, there was no residual AR, and the mean transprosthetic gradient was 3 mm Hg. The current case demonstrates that percutaneous TAVI with the ACURATE neo bioprosthesis may be used to treat pure, isolated AR in selected patients. The device has several interesting features that could make it advantageous in this setting. © 2016 Wiley Periodicals, Inc.

Sutureless Aortic Valve Replacement: An Easy and Safe Approach for Patients with Anomalous Left Circumflex Coronary Artery.

An anomalous origin of the left circumflex coronary artery (LCx) from the right sinus of Valsalva is a frequent coronary problem. This particular condition, though usually silent, is associated with an increased incidence of serious complications during surgical aortic valve replacement (AVR) and transcatheter aortic valve implantation. Here, the cases are described of four patients with an anomalous origin of the LCx from the right sinus of Valsalva who underwent sutureless AVR with the Sorin Perceval S prosthesis. The possible advantages of this approach are also discussed.

Surgical resection of colorectal carcinomas metastatic to the heart.

Colorectal carcinomas metastatic to the heart are rare. We present a case of colonic carcinoma metastatic to the right atrium and discuss the management and prognosis of these rare lesions.

Large Abdominal Aortic Aneurysm in a High-Risk Surgical Patient: Combined Percutaneous Transfemoral TAVI and EVAR Procedure.

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.