St. Jude Medical Trifecta aortic valve: results from a prospective regional multicentre registry.

BACKGROUND: The Trifecta aortic bioprosthesis (St. Jude Medical, Inc., St. Paul, MN, USA) is a stented pericardial heart valve with excellent preliminary results. Aim of the study was to evaluate its early clinical and hemodynamic performances in a multicenter regional registry. METHODS: Between January 2011 and June 2012, 178 consecutive patients undergoing aortic valve replacement with the Trifecta bioprosthesis were prospectively enrolled at 9 Italian centers. Clinical and echocardiographic data were collectedat discharge, 6-months and at 1-year postoperatively. RESULTS: The average age was 75.4 ± 7.7 years,and 95 (53 %) were men. Indication for valve replacement included stenosis in 123 patients (69 %), mixed lesions in 25 (14 %), and regurgitation in 30 (17 %). Ninety-three (52 %) patients were in NYHA functional class III/ IV. Hospital mortality accounted for 5 (2.8 %) patients. No valve-related perioperative complications were encountered. Median follow-up was 20.5 months (range: 1-34). Early (≤6 months) complications included one thromboembolic event, one major bleeding, and 3 endocarditis (2 explants). Two late (>6 months) thromboembolic events and two endocarditis (1 explant) were registered. No valve thrombosis or structural deterioration were observed after discharge. At 30-months, freedom from all-cause mortality was 87 %, freedom from valve-related mortality 99.4 %, freedom from endocarditis 97.5 %, and freedom from valve explants 98 %. At 1-year, mean gradients ranged from 8 to 16 mmHg, and effective orifice area indexes from 1.0 to 1.2 cm(2)/m(2) for valve sizes from 19 to 27 mm, respectively. No patients had severe prosthesis-patient mismatch. CONCLUSIONS: Trifecta bioprosthesis provided favourable clinical and hemodynamic results over time.

Type 2 diabetes mellitus is associated with faster degeneration of bioprosthetic valve: results from a propensity score-matched Italian multicenter study.

BACKGROUND: The present study was aimed at determining the impact of type 2 diabetes mellitus (DM) on postoperative bioprosthetic structural valve degeneration. METHODS AND RESULTS: Twelve Italian centers participated in the study. Patient data refer to bioprosthetic implantations performed from November 1988 to December 2009, which resulted in 6184 patients (mean age 71.3±5.4 years, 60.1% male) being enrolled. Of these patients, 1731 (27.9%) had type 2 DM. The propensity score-matching algorithm successfully matched 1113 patients with type 2 DM with the same number of no-DM patients. The postmatching standard differences were less than 0.1 for each of the covariates, and 64.2% of DM patients were matched. The early (30 days) mortality rate was 7.8% (n=87) versus 2.9% (n=33) in patients with or without type 2 DM (P<0.001), respectively. Seven-year freedom from valve deterioration was significantly lower in patients with DM (73.2% [95% confidence interval, 61.6-85.5] versus 95.4% [95% confidence interval, 83.9-100], P<0.001). In Cox regression models with robust SEs that accounted for the clustering of matched pairs, DM was the strongest predictor of structural valve degeneration (hazard ratio 2.39 [95% confidence interval 2.28-3.52]). When we allowed for interaction between type 2 DM and other key risk factors, DM remained a significant predictor beyond any potentially associated variable. CONCLUSIONS: Patients with type 2 DM undergoing bioprosthetic valve implantation are at high risk of early and long-term mortality, as well as of structural valve degeneration.

Early clinical experience and echocardiographic results with a new semirigid mitral annuloplasty ring: the Sorin Memo 3D.

BACKGROUND: The Sorin Memo 3D (Sorin Biomedica Cardio S.r.L., Saluggia, Italy) is a new, complete semirigid annuloplasty ring. Clinical use, outcomes, and echocardiographic results are reported as an evaluation of its safety and efficacy in the treatment of mitral valve regurgitation (MVR). METHODS: This device was assessed in 63 patients (63.5% men; mean age, 70.2 +/- 10.3 years) who underwent MVR operations between January 2007 and June 2008. Functional classification was normal leaflet motion (type I; 1.6%), leaflet prolapse (type II; 66.7%), and restricted leaflet motion (type III; 31.7%). Valve disease was degenerative (68.25%), ischemic (25.4%), and nonischemic dilated cardiomyopathy (6.35%). RESULTS: Early mortality (< or = 30 days) was 3.3% (2 patients). Late mortality (11.2 +/- 5.1 months) was 4.9% (3 patients). No deaths were device-related. Thromboembolic stroke occurred in 3.3% and endocarditis in 1.6%. Freedom from reoperation was 98.4%. At 6 months, MVR was grade 0/1 in 93.7% and grade 2+ in 6.4%. Left end-diastolic ventricular diameters decreased significantly from 59.3 +/- 6.9 mm preoperatively to 50.6 +/- 12.2 mm at 6 months, pulmonary arterial pressure decreased from 44.8 +/- 7.1 mm Hg to 38.4 +/- 5.5 mm Hg, and left ventricular ejection fraction increased significantly from 0.469 +/- 0.129 to 0.582 +/- 0.106. New York Heart Association functional class was I in 81% and II in 13.8%. CONCLUSIONS: Early results indicate the Sorin Memo 3D ring safely and effectively minimizes secondary MVR resulting from all causes and preserves mitral annular flexibility and function at follow-up.

Determination of pump flow rate during cardiopulmonary bypass in obese patients avoiding hemodilution.

BACKGROUND AND AIM: During cardiopulmonary bypass the pump flow is usually set on 2.4 L/min/m(2) of body surface area (BSA) to guarantee adequate tissue perfusion without differences for patient constitutional type. The present study attempts to evaluate the adequacy of pump flow rate in obese patients, considering the ideal weight instead of the real one, avoiding the overflow side effects and hemodilution. METHODS: Obese patients with body mass index (BMI) > 30 presented for cardiac surgery were randomized in two groups: in one the cardiopulmonary bypass was led traditionally, in the other, pump flow rate was calculated on ideal BMI of 25. RESULTS: Demographics, preoperative tests, and monitoring data were registered. Mortality at hospital discharge and 30 days after were analyzed. The pump flow rate between the groups was different (4.46 vs. 4.87; p = 0.004); there were no differences in organ perfusion (SvO(2); diuresis) and mortality, but the study group presented fewer complications and blood transfusions. CONCLUSIONS: The BSA is widely used as the biometric unit to normalize physiologic parameters included pump flow rate, but it is disputable if this practice is correct also in obese patients. The study group, in which pump flow rate was set on ideal BSA, presented no difference in diuresis and mixed venous saturation but fewer complications and fewer perioperative blood transfusions.

Coronary artery aneurysm: management and association with abdominal aortic aneurysm.

BACKGROUND: Coronary artery aneurysm (CAA) is a dilatation that exceeds 1.5 times the diameter of a normal adjacent coronary artery. Several studies suggest that pathogenetic mechanisms involved in this disease and in abdominal aortic aneurysm (AAA) are similar. Surgery for CAA is mandatory when the aneurysm is three to four times larger than the original vessel diameter. We reviewed our experience in the surgical treatment of this unusual disease and analyzed its association with AAA. MATERIALS AND METHODS: Between October 1993 and March 2005, 11 patients (9 men; mean age=66 years) underwent surgery for CAA. In all cases, coronary aneurysms were diagnosed as incidental findings in coronary angiographies. The coronary aneurysms were isolated and longitudinally incised: the proximal and distal openings were identified and sutured. The sacs were obliterated with running sutures. Myocardial protection was achieved by retrograde cardioplegia only. Coronary artery bypass grafting was performed distally to the excluded aneurysms in all patients. RESULTS: One patient died of respiratory failure early after the operations; all other patients are alive, asymptomatic for angina, and free from repeated acute myocardial infarction after a median follow-up of 76 months (range=4-141 months). A total of six patients underwent surgical repair or endoprosthesis implantation because of AAAs. CONCLUSIONS: Our operative techniques ensured durable results. We recommend screening for abdominal aneurysms in all affected patients because of the frequent association between CAA and AAA as a result of their similar pathogenetic mechanism.

The role of zofenopril in myocardial protection during cardioplegia arrest: an isolated rat heart model.

BACKGROUND: Zofenopril has beneficial effects in acute myocardial infarction, and improves the functional recovery after ischemia and reperfusion. AIM OF THE STUDY: The aim of this study was to investigate the cardioprotective effects of zofenopril, when added to a standard cardioplegic solution or when orally administered as pretreatment. METHODS: A Langendorff model for isolated rat hearts was employed: three groups of eight hearts each were used, respectively, with plain St. Thomas cardioplegia as control (group A and C), and the same solution added with 12.5 mg of zofenopril (group B). The third group (C) was pretreated for 7days with oral administration of zofenopril (6.5 mg/day). The hearts had a baseline perfusion for 30 minutes with Krebs-Henseleit solution at 37 degrees C, cardioplegia administration for 3 minutes, then 30 minutes of ischemia without any perfusion, and finally 30 minutes of reperfusion with Krebs-Henseleit solution at 37 degrees C. RESULTS: Left ventricle developed pressure was significantly higher in the reperfusion period only in the pretreated group (group C) with respect to groups A and B (p = 0.016). Similar results were obtained regarding dP/dt curves (p = 0.020). No differences were demonstrated between groups for cellular viability expressed as creatine phospho-kinase (p = ns) and lactate dehydrogenase release (p = ns). CONCLUSIONS: Zofenopril as oral pretreatment showed protective effects in an isolated model of cardioplegic arrest, although improvements in myocardial viability (enzymatic release) could not be demonstrated. Further experimental and clinical evaluations are necessary to assess the direct cardioprotective effect of zofenopril, modifying the length of treatment and the dosage of the drug.

Asymptomatic cardiac papillary fibroelastoma: diagnostic assessment and therapy.

Papillary fibroelastoma is a rare benign cardiac tumor with elevated risk for embolization. This report describes the case of a 65-year-old man, admitted for the occasional finding of a round, pedunculate mass adherent to the chordae of the anterior mitral valve leaflet, mimicking an endocarditic mass. Appropriate diagnostic evaluations lead to the suspect of a papillary fibroelastoma. Because of the elevated risk of thromboembolism, surgery was emergently performed with complete removal of the mass and preservation of the integrity of the mitral valve. Histologic evaluation confirmed the diagnosis. Papillary fibroelastoma should be always considered in the differential diagnosis of intracardiac masses.

Surgical repair of post-infarction ventricular septal defect: 19 years of experience.

OBJECTIVES: To review our experience of surgical repair of post-infarction ventricular septal defect (VSD). METHODS: In the period 1983-2002, 50 patients underwent repair of VSD. Mean age was 66 years, male sex 52%. Infarct location was anterior in 60% and posterior in 40% of cases. Median interval between rupture and surgery was 2 days. Preoperative intra-aortic balloon counterpulsation was employed in 56%; a coronary angiogram was performed in 98% of cases. A patch repair technique was used in 90% of cases. Coronary bypass grafting was associated in 50% of patients. RESULTS: Mean aortic clamp time was 101+/-31 min. Global operative mortality was 36%, respectively 26.7% in anterior and 50% in posterior location (p=ns). Emergency operation and interval from rupture to surgery less than 3 days were univariate predictor of early mortality. Five years survival excluding operative deaths was 76%. CONCLUSIONS: The surgical repair of post-infarction VSD entails a high operative mortality; different techniques were employed with similar results. Emergency operation is associated with a worse short-term prognosis; long-term survival is acceptable.

Complete myocardial revascularization and sutureless technique for left ventricular free wall rupture: clinical and echocardiographic results.

Left ventricular free wall rupture (LVFWR) is one of the most dramatic complications of myocardial infarction. We present our mid-term clinical and echocardiographic results of LVFWR with patch and complete myocardial revascularization on viable tissue. From August 2000 to July 2005, 9 patients underwent surgery for LVFWR. Mean age was 68+/-S.D. 9.3 years. Mean interval time between AMI and LVFWR was 122.2+/-154.9 h. All patients presented for emergency surgery with cardiac tamponade at echocardiography. Three patients received IABP preoperatively. Eight had coronarography. Effective control of bleeding was achieved in all cases with a Teflon patch applied with Bioglue. Four patients had myocardial revascularization, all in ECC; two of them with cross-clamping. There was no operative death. Mean follow-up was 38.8+/-22.2 S.D. months. One further death occurred from myocardial infarction. All patients were in NYHA I-II. Survivors had follow-up transthoracic echocardiography: all patients had preserved left ventricular function with absence of restricted motion. There was no evidence of mitral regurgitation. Sutureless covering technique for LVFWR is related to excellent early and long-term clinical and echocardiographic results. Complete coronary artery bypass grafting improves long-term symptom-free survival. We have demonstrated that ECC and cross-clamping do not affect early survival.

["Hybrid" management of aortic coarctation associated with atrioventricular valve regurgitation in the adult]. / Trattamento "ibrido" della coartazione aortica associata a valvulopatia atrioventricolare nell'adulto.

The incidence of heart valve disease associated with aortic coarctation is 40% in patients < 30 years and 27% in younger patients. This report describes the case of a 41-year-old man, admitted for severe mitral and tricuspid valve incompetence, causing impairment of left ventricular function and pulmonary hypertension. During hospitalization an occasional finding of aortic coarctation was diagnosed. The optimal management of aortic coarctation associated with atrioventricular valve regurgitation remains a matter of debate. In this report the proper decision-making and the management are discussed.

19-year patency of a coronary-coronary venous bypass graft.

No data are available on the long-term outcome of coronary-coronary venous bypass grafting. We describe a case in which we successfully stented a discrete, critical stenosis of a coronary-coronary venous graft that had been placed 19 years earlier to minimize manipulation of a severely calcified ascending aorta. Coronary-coronary bypass grafting should be considered in cases involving severe aortic calcification, in situ grafts of inadequate length, and stenosed or occluded subclavian arteries. Such a bypass can be performed with either saphenous vein or arterial conduits, and it provides a flow rate similar to that of aortocoronary bypass. This option could be borne in mind as a 2nd-choice technique for the durable restoration of coronary blood flow in selected cases.

[Giant aneurysm of a saphenous vein graft with fistulization into the right atrium: differential diagnosis and treatment]. / Aneurisma gigante di un graft venoso aortocoronarico con fistolizzazione in atrio destro: diagnosi differenziale e trattamento.

The aneurysm of an aortocoronary saphenous vein graft is a rare but potentially fatal complication of coronary artery bypass grafting. This case came to our observation after a single episode of hypotension, followed by dyspnea in a man previously operated on for coronary artery bypass grafting. A para-hilar mass was found on routine roentgenogram. The spiral computed tomographic scan was suggestive for aortic pseudoaneurysm. The correct diagnosis was obtained by cardiac catheterization showing a giant graft aneurysm determining compression and fistulous communication into the right atrium. The difficult diagnosis and the surgical treatment are discussed.

Long-term results of the surgical treatment of chronic ischemic mitral regurgitation: comparison of repair and prosthetic replacement.

BACKGROUND AND AIM OF THE STUDY: The optimal management of chronic ischemic mitral regurgitation (CIMR) remains controversial. Herein, the authors reviewed the past 10 years of their experience to compare the long-term results of mitral valve repair with prosthetic replacement. METHODS: Between January 1993 and January 2003, 102 patients (mean age 67.8 years; range: 51-80 years) with a preoperative diagnosis of CIMR, underwent mitral valve repair (n = 61; 59.8%) or prosthetic replacement (n = 41; 40.2%), along with myocardial revascularization (2.5 +/- 1.0 distal anastomoses per patients, internal thoracic artery used in 78.5%). A Carpentier Classic ring was always used in the repair procedures. The two groups were homogeneous for preoperative characteristics and comorbidities. RESULTS: Total operative mortality was 7.8% (repair 8.2%; prosthesis 7.3%; p = NS). The five-year actuarial survival (operative mortality included) was 66.6 +/- 7.4% for repair and 73.4 +/- 8.7% for prosthesis (p = NS). Cox multivariate analysis showed as independent risk factor for late survival a preoperative left ventricular ejection fraction (LVEF) < or = 30% (RR 3.91; 95% CI = 1.47-10.38) and a preoperative pulmonary artery pressure (PAP) > or = 35 mumHg (RR 2.74; 95% CI = 1.07-7.02), while the type of mitral procedure was not significant. Patients with annular dilation as a mechanism of regurgitation were significant more likely to undergo repair rather than receive a prosthesis. Their preoperative LVEF and PAP were significantly worse than patients who had altered leaflet motion as a regurgitation mechanism. CONCLUSION: Prosthetic mitral replacement and valve repair offer very similar results for CIMR. When a perfect repair is not easily feasible, cardiac surgeons should not hesitate to perform mitral valve replacement, as it is an excellent alternative therapy, though long-term outcome is mainly dependent on preoperative condition.

Flow resistance over technical anastomoses in relation to the angle of distal end-to-side connections.

OBJECTIVE: The fluid dynamics within the anastomotic region may contribute to graft failure. The aim was to investigate how flow resistance is affected by anastomotic angle and viscosity. DESIGN: Technical end-to-side anastomoses of 3-mm inlet/outlet diameter were precision-drilled in plastic blocks at 90 degrees, 60 degrees, 45 degrees, and 30 degrees angles, with 0 degrees as control to calculate relative resistance. Five pressure loads of 200-1000 mmH (2) O and two fluid viscosities were tested using pulsatile perfusion. RESULTS: Absolute resistances showed a significant linear correlation with pressure, regardless of anastomotic angle and with similar slope values. Increased viscosity produced an upward shift in resistance but otherwise had no effect. However, the relative resistances showed transition zones at increased pressures, which were sensitive to viscosity. The 30 degrees angle produced less resistance than steeper angles. CONCLUSION: Previous studies gave contradictory results about the importance of anastomotic angle. Our findings suggest that in iso-diametrical technical anastomoses a low angle is favorable. The complexity of angularity in distal aorto-coronary anastomoses was illustrated by threshold phenomena at different pressures, possibly due to induced turbulence and anastomotic resonance.