COVID 19- Perspective of an Italian Center.

Italy has been hard hit by severe acute respiratory syndrome coronavirus 2 infection with more than 240,000 cases and 35,000 deaths. During the acute phase of the pandemic, the Italian government decided on the lockdown which lasted about 2 months. During this period, all surgical activities were limited to nondeferable procedures only. The sudden closure posed problems with the management of the heart surgery waiting which at that time included 135 patients. Among these were selected cases with the worst clinical characteristics that were progressively operated on. Compared with a similar period in 2019, the cardiac surgery activity of the "Lancisi Cardiovascular Center" in Ancona has been reduced by 65%. With pandemic mitigation, heart surgery activity has gradually resumed but many open questions remain. Above all, there is the problem of living with a low but persistent level of presence of the virus with the need to organize the activity to ensure patients and staff safety and an optimal level of performance.

Enhanced recovery after minimally invasive heart valve surgery: Early and midterm outcomes.

BACKGROUND: Although the use of protocols for "enhanced recovery after surgery" (ERAS) have been associated with improved results in different surgical specialties, only a few data are available for ERAS in cardiac surgery. This study aimed to compare 30-day outcomes of patients undergoing ultra-fast-track minimally invasive valve surgery (UFT-MIVS) versus conventional MIVS (c-MIVS). METHODS: The key features of UFT-MIVS approach involves: 1) less invasive valve surgery techniques, 2) normothermic cardiopulmonary bypass management, 3) UFT-anesthesia with table extubation, 4) immediate rehabilitation therapy and patient-family contact. Five-hundred and seventy-six consecutive patients who underwent aortic or mitral MIVS were analyzed (2016-2020). Treatment selection bias (UFT-MIVS vs. c-MIVS) was addressed by the use of propensity score (PS) matching. After PS-matching 2 well-balanced groups of 152 patients each were created. RESULTS: In the matched cohort, the overall 30-day mortality and stroke rates were 0.3% and 0.7%, respectively, with no difference between groups. UFT-MIVS resulted in lower rates of respiratory insufficiency and agitation/delirium compared with c-MIVS. Patients receiving UFT-MIVS were associated with significantly shorter intensive care unit length of stay and hospital stay. CONCLUSIONS: Our study confirms that MIVS is associated with excellent results in terms of early mortality and major postoperative complications rates. The implementation of UFT-MIVS protocol showed to be safe and was associated with improved clinical outcomes in regard to respiratory insufficiency, delirium and lengths of stay.

Conduction disorders after aortic valve replacement: what is the real impact of sutureless and rapid deployment valves?

BACKGROUND: Although sutureless and rapid deployment aortic valve replacement (SURD-AVR) has been associated with an increased rate of permanent pacemaker (PPM) implantation compared to conventional AVR (c-AVR), the predictors of new conduction abnormalities remain to be clarified. This study aimed to identify risk factors for conduction disorders in patients undergoing AVR surgery. METHODS: Data from 243 patients receiving minimally invasive AVR were prospectively collected. SURD-AVR was performed in 103 (42.4%) patients and c-AVR in 140 (57.6%). The primary endpoint was the occurrence of new-onset conduction disorders, defined as first degree atrioventricular (AV) block, advanced AV block requiring PPM implantation, left anterior fascicular block (LAFB), left bundle branch block (LBBB) and right bundle branch block (RBBB). RESULTS: The unadjusted comparison revealed that SURD-AVR was associated with a higher rate of advanced AV block requiring PPM when compared with c-AVR (10.5% vs. 2.1%, P=0.01). After adjusting for other measured covariates (OR: 1.6, P=0.58) and for the estimated propensity of SURD-AVR (OR: 5.1, P=0.1), no significant relationship between type of AVR and PPM implantation emerged. On multivariable analysis, preoperative first-degree AV block (OR: 6.9, P=0.04) and RBBB (OR: 6.9, P=0.03) were independent risk factors for PPM. Subgroup analysis of patients with normal preoperative conduction revealed similar incidence of PPM between SURD-AVR and c-AVR (1.3% vs. 1.9%, P=0.6). When compared with c-AVR, SURD-AVR was associated with a greater incidence of postoperative new onset LBBB (18.1% vs. 3.2%, P<0.001). This finding was confirmed after adjusting for the estimated propensity of SURD-AVR (OR: 6.3, P=0.009). CONCLUSIONS: Our study revealed that the risk of PPM implantation in patients receiving surgical AVR is heavily influenced by the presence of pre-existing conduction disturbances rather than the type of valve prosthesis. Conversely, SURD-AVR emerged as an independent predictor for LBBB and was associated with an increased risk of PPM in patients presenting with RBBB.

Surgery for Bentall endocarditis: short- and midterm outcomes from a multicentre registry.

OBJECTIVES: Endocarditis after the Bentall procedure is a severe disease often complicated by a pseudoaneurysm or mediastinitis. Reoperation is challenging but conservative therapy is not effective. The aim of this study was to assess short- and midterm outcomes of patients reoperated on for Bentall-related endocarditis. METHODS: Seventy-three patients with Bentall procedure-related endocarditis were recorded in the Italian registry. The mean age was 57 ± 14 years and 92% were men; preoperative comorbidities included hypertension (45%), diabetes (12%) and renal failure (11%). The logistic EuroSCORE was 25%; the EuroSCORE II was 8%. RESULTS: Preoperatively, 12% of the patients were in septic shock; left ventricular-aortic discontinuity was present in 63% and mitral valve involvement occurred in 12%. The most common pathogens were Staphylococcus aureus (22%) and Streptococci (14%). Reoperations after a median interval of 30 months (1-221 months) included a repeat Bentall with a bioconduit (41%), a composite mechanical (33%) or biological valved conduit (19%) and a homograft (6%). In 1 patient, a heart transplant was required (1%); in 12%, a mitral valve procedure was needed. The hospital mortality rate was 15%. The postoperative course was complicated by renal failure (19%), major bleeding (14%), pulmonary failure (14%), sepsis (11%) and multiorgan failure (8%). At multivariate analysis, urgent surgery was a risk factor for early death [hazard ratio 20.5 (1.9-219)]. Survival at 5 and 8 years was 75 ± 6% and 71 ± 7%, with 3 cases of endocarditis relapse. CONCLUSIONS: Surgery is effective in treating endocarditis following the Bentall procedure although it is associated with high perioperative mortality and morbidity rates. Endocarditis relapse seems to be uncommon.

Ultra fast track surgery: a rapid deployment aortic valve replacement through a J-ministernotomy.

Aortic valve surgery has been undergone continuous development over the last years, involving less invasive techniques and the use of new technologies to reduce the traumatic impact of the intervention and extend the operability toward increasingly high-risk patients. Minimally invasive aortic valve replacement (AVR) has gradually been recognized as a less traumatic technique compared to median sternotomy, becoming first choice approach in numerous experienced centers. Herein we present our multidisciplinary minimally invasive approach for AVR, involving: (I) reduced chest incision; (II) rapid deployment AVR; (III) minimally invasive extracorporeal circulation system; and (IV) ultra fast track (UFT) anaesthetic management.

Prosthetic valve endocarditis: predictors of early outcome of surgical therapy. A multicentric study.

OBJECTIVES: Prosthetic valve endocarditis (PVE) is an uncommon yet dreadful complication in patients with prosthetic valves that requires a distinct analysis from native valve endocarditis. The present study aims to investigate independent risk factors for early surgical outcomes in patients with PVE. METHODS: A retrospective cohort study was conducted in 8 Italian Cardiac Surgery Units from January 2000 to December 2013 by enrolling all PVE patients undergoing surgical treatment. RESULTS: A total of 209 consecutive patients were included in the study. During the study period, the global rate of surgical procedures for PVE among all operations for isolated or associated valvular disease was 0.45%. Despite its rarity this percentage increased significantly during the second time frame (2007-2013) in comparison with the previous one (2000-2006): 0.58% vs 0.31% (P < 0.001). Intraoperative and in-hospital mortality rates were 4.3% and 21.5%, respectively. Logistic regression analysis identified the following factors associated with in-hospital mortality: female gender [odds ratio (OR) = 4.62; P < 0.001], shock status (OR = 3.29; P = 0.02), previous surgical procedures within 3 months from the treatment (OR = 3.57; P = 0.009), multivalvular involvement (OR = 8.04; P = 0.003), abscess (OR = 2.48; P = 0.03) and urgent surgery (OR = 6.63; P < 0.001). CONCLUSIONS: Despite its rarity, PVE showed a significant increase over time. Up to now, in-hospital mortality after surgical treatment still remains high (>20%). Critical clinical presentation and extension of anatomical lesions are strong preoperative predictors for poor early outcome.

Cannulation of the brachiocephalic trunk during surgery of the thoracic aorta: a simplified technique for antegrade cerebral perfusion.

Here we present our simplified technique of cannulation of the brachiocephalic trunk for cardiopulmonary bypass and antegrade cerebral perfusion institution.

The changing face of cardiac surgery patients: an insight into a Mediterranean region.

OBJECTIVES: Data of 9 years of surgical activity (on about 10000 patients), obtained from the database of our cardiac surgery care centre, were analysed to assess time-related variations in demographics, clinical and surgical characteristics. METHODS: Data of patients submitted to major cardiac surgery procedures between 1999 and 2007 were examined using the chi-square test, analysis of variance (ANOVA) test or non-parametric tests, where applicable. The 'linear-by-linear' association test was used to verify the existence of a time-related trend. A value of p<0.05 was considered significant. RESULTS: In the time interval of 9 years, there was an increment of valve procedures and a decrease in coronary revascularisation surgery. Patients aged 75 years or more at the time of operation increased from 17% in 1999 to 29% in 2005, and the percentage of patients aged 80 or more demonstrated a threefold increase. Operated patients had more co-morbidity (the rate of hypertension rate 43.7% in 1999 and 68.9% in 2007, and obese patients were 13% in 1999 and 17.5% in 2007) and had worse functional and cardiac status (reduced ejection fraction (EF), haemodynamic instability and shock). As a consequence, there was an increased calculated surgical risk. At the same time, there was no significant increment in the observed mortality (3.1% in 1999 vs 3.8% in 2007 for all patients and 1.6% compared with 1.5% in isolated coronary artery bypass graft (CABG) patients). CONCLUSIONS: These changes can reflect both a variation in the characteristics of the population and a major evolution in intervention cardiology and also impose more intensive and extensive postoperative treatment and less invasive cardiac surgery practice.

Atrial myxoma: a 25-year single-institutional follow-up study.

OBJECTIVE: A single-institutional study on atrial myxoma. Patient data and data obtained from the survivors during follow-up were reviewed. METHODS: We studied 109 patients (61.5% female) who underwent surgical excision of atrial myxoma between January 1980 and December 2005. Mean age at the time of surgery was 60 +/- 14 years (range 1-83 years). Overall survival and atrial myxoma recurrence were determined by Kaplan-Meier analysis. Linearized rates of recurrence at follow-up are reported. RESULTS: One hundred and two (93.6%) of the 109 tumours were found in the left atrium. Comparative mean age distribution revealed a significant difference between patients operated on between 1980 and 1992 and patients operated on between 1993 and 2005 (55 +/- 15 and 63 +/- 13 years, respectively; P < 0.05). All patients survived the operation. Three patients were lost to follow-up. The 15-year and 25-year survival rates were 91 +/- 4% and 72 +/- 12%, respectively. Survival of patients after myxoma removal did not significantly differ from the expected survival of the general population. Recurrent myxomas developed in two patients (mean age 50 +/- 7 years) with a 25-year freedom from reoperation of 96 +/- 3% and a linearized rate of 0.17 +/- 0.12%/year. CONCLUSIONS: Myxomas tend to be observed in a more elderly and higher-risk population, often at an early stage. The extended follow-up of patients with intracardiac myxomas shows that surgical excision of such tumours is curative with low mortality and good long-term outcome.