Infective endocarditis in octogenarians. A retrospective study in a single, high-volume surgical centre.

BACKGROUND: Infective endocarditis (IE) is a severe disease associated with high morbidity and mortality. Little is known about the best management of elderly patients with IE. In these patients, surgery may be challenging. Our study aimed to describe IE's features in octogenarians and to identify the independent predictors of mortality, focusing on the prognostic impact of disability. METHODS: We retrospectively analyzed 551 consecutive patients admitted to a single surgical centre with a definite diagnosis of non-device-related infective endocarditis; of these, 97 (17.6%) were older than 80 years. RESULTS: In patients under eighty, males were mostly involved with a sex ratio exceeding 2:1. This ratio was inverted in older people, where the female gender represented 53.6% of the total. Enterococci (29.8 vs. 17.4%, p = 0.005) were significantly more frequent than in younger people. Comorbidities were more frequent in elderly patients; consequently, EuroSCORE II was higher (median ± IQR 16.4 ± 21.1 vs. 5.0 ± 10.3, p = 0.001). In octogenarians, IE was more frequently left-sided (97.9 vs. 89.8%, p = 0.011). Octogenarians were more often excluded from surgery despite indication (23.7 vs. 8.1%, p = 0.001) and had higher three-year mortality (45.3 vs. 30.6%, p = 0.005) than younger patients. In elderly patients, age did not independently predict mortality, while exclusion from surgery and a high grade of disability did. CONCLUSIONS: Octogenarians with IE have specific clinical and microbiological characteristics. Older patients are more often excluded from surgery, and the overall prognosis is poor. Age per se should not be a reason to deny surgery, while disability predicts futility.

Impact of cardiac surgery on left-sided infective endocarditis with intermediate-length vegetations.

OBJECTIVE: The best strategy to manage patients with left-sided infective endocarditis (IE) and intermediate-length vegetations (10-15 mm) remains uncertain. We aimed to evaluate the role of surgery in patients with intermediate-length vegetations and no other European Society of Cardiology guidelines-approved surgical indication. METHODS: We retrospectively enrolled 638 consecutive patients admitted to three academic centres (Amiens, Marseille and Florence University Hospitals) between 2012 and 2022 for left-sided definite IE (native or prosthetic) with intermediate-length vegetations (10-15 mm). We compared four clinical groups: medically (n=50) or surgically (n=345) treated complicated IE, medically (n=194) or surgically (n=49) treated uncomplicated IE. RESULTS: Mean age was 67±14 years. Women were 182 (28.6%). The rate of embolic events on admission was 40% in medically treated and 61% in surgically treated complicated IE, 31% in medically treated and 26% in surgically treated uncomplicated IE. The analysis of all-cause mortality showed the lowest 5-year survival rate for medically treated complicated IE (53.7%). We found a similar 5-year survival rate for surgically treated complicated IE (71.4%) and medically treated uncomplicated IE (68.4%). The highest 5-year survival rate was observed in surgically treated uncomplicated IE group (82.4%, log-rank p<0.001). The analysis of the propensity score-matched cohort estimated an HR of 0.23 for uncomplicated IE treated surgically compared with medical therapy (p=0.005, 95% CI: 0.079 to 0.656). CONCLUSIONS: Our results suggest that surgery is associated with lower all-cause mortality than medical therapy in patients with uncomplicated left-sided IE with intermediate-length vegetations even in the absence of other guideline-based indications.

Impact of septic cerebral embolism on prognosis and therapeutic strategies of infective endocarditis: a retrospective study in a surgical centre.

BACKGROUND: Infective endocarditis still has high mortality and invalidating complications, such as cerebral embolism. The best strategies to prevent and manage neurologic complications remain uncertain. This study aimed to identify predictors of cerebral septic embolism and evaluate the role of surgery in these patients in a real-world surgical centre. METHODS: We retrospectively analyzed 551 consecutive patients admitted to our department with a definite diagnosis of non-device-related infective endocarditis; of these, 126 (23%) presented a neurologic complication. RESULTS: Cerebral embolism was significantly more frequent in patients with large vegetations (p = 0.004), mitral valve infection (p = 0.001), and Staphylococcus aureus infection (p = 0.025). At multivariable analysis, only vegetation length was an independent predictor of cerebral embolism (HR per unit 1.057, 95% CI 1.025-1.091, p 0.001), with a best predictive threshold of 10 mm at ROC curve analysis (AUC 0.54, p = 0.001). Patients with neurologic complications were more often excluded from surgery despite an indication to it (16% vs 8%, p = 0.001). If eligible, they were treated within two weeks from diagnosis in similar proportions as patients without cerebral embolism with a similar survival rate. Predictors of mortality were hemorrhagic lesions (p = 0.018), a GCS < 14 (p = 0.001) or a severe degree of disability (p = 0.001) at presentation. The latter was the only independent predictor of mortality at multivariable analysis (HR 2.3, 95% CI 1.43-3.80, p = 0.001). CONCLUSIONS: The present study highlights the prognostic value of functional presentation and the safety of cardiac surgery, when feasible, in patients with cerebral septic embolism.

Double-valve infective endocarditis: clinical features and prognostic impact-a retrospective study in a surgical centre.

Most cases of infective endocarditis (IE) involve a single valve, and little is known concerning IE that simultaneously affects two valves. The involvement of more than one valve may imply more severe and extensive cardiac lesions. In these patients, surgery may be challenging. We aimed to determine the clinical characteristics, the therapeutic strategy, and the prognostic impact of double-valve IE (DVIE). We retrospectively included in the analysis that 440 consecutive patients with definite active IE in a single surgical centre. DVIE occurred in 75 of the total enrolled 440 patients (17%) and involved mostly the combination of mitral and aortic valves (N = 63, 84%). Most patients had double-native IE (N = 45, 60%). Staphylococci were less frequent in patients with double-valve than single-valve IE (SVIE). The proportion of patients undergoing valve repair among those treated surgically was higher for patients with DVIE than for SVIE (p < 0.03). Valve repair of at least one valve was associated with non-significant better survival than double replacement. DVIE was associated with higher all-cause mortality than SVIE (p < 0.013) and a higher relapse rate (p = 0.023). DVIE was not associated with a higher risk of composite non-fatal adverse events. DVIE represents a considerable proportion of overall cases of IE, mainly involving aortic and mitral valves, with a jet lesion on the mitral valve; Staphylococcus is significantly less frequent than in SVIE; DVIE is independently associated with higher mortality and relapse rate; finally, mitral valve repair is feasible in a considerable proportion of surgical cases.

Heart valve disease in hypocomplementemic urticarial vasculitis syndrome: from immune-mediated degeneration to embolic complications of infective endocarditis-a case report.

BACKGROUND: Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare disease due to small vessel inflammation and characterized by chronic urticarial vasculitis and arthritis. Multi-organ manifestations may include glomerulonephritis, ocular inflammation (uveitis, episcleritis), and recurrent abdominal pain. To the best of our knowledge, just other nine cases of HUVS with cardiac valvular involvement have been reported in the literature. CASE SUMMARY: A 32-year-old woman presented to the emergency department because of a cerebral haemorrhage. She suffered from a severe HUVS form with cardiac valvular involvement. In the previous years, she underwent cardiac surgery twice for aortic and mitral valves immune-mediated degeneration. The neurologic event was secondary to Listeria monocytogenes aortic endocarditis, complicated by a cerebral embolism and periaortic abscess. DISCUSSION: Patients with HUVS rarely present valvular heart disease. The latter is mostly secondary to an inflammatory process. Valve degeneration and immunosuppressive therapy increase the risk of infective endocarditis, with dramatic consequences for the prognosis of these patients. Valvular involvement is a sporadic but potentially fatal complication of HUVS, which should be taken in mind in the multidisciplinary evaluation of these patients.

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.

Cardiogenic Shock in Obstructive Hypertrophic Cardiomyopathy Plus Apical Ballooning: Management With VA-ECMO and Myectomy.

A patient with known obstructive hypertrophic cardiomyopathy developed worsening left ventricular outflow tract obstruction, severe mitral regurgitation, and apical ballooning leading to cardiogenic shock, a combination in which treatment of each component could worsen the others. Emergency veno-arterial extracorporeal membrane oxygenation, levosimendan, and noradrenaline transiently restored adequate systemic perfusion and gas exchange. Surgical myectomy offered a more definitive solution. (Level of Difficulty: Intermediate.).

A new-onset pulmonary artery stenosis in a young man: case report.

BACKGROUND: Poorly differentiated and undifferentiated sarcomas are the most common primary tumours of the pulmonary arteries. They usually affect large-calibre vessels and present with predominantly intraluminal growth. Dyspnoea, cough, chest pain, and haemoptysis are the most common presenting symptoms. Clinical and imaging manifestations can mimic pulmonary embolisms and correct diagnosis may require multimodal imaging. The overall prognosis is poor; however, early diagnosis and complete surgical resection seem to improve the prognosis. CASE SUMMARY: A 31-year-old male was admitted to our department after a pre-syncopal episode associated with dyspnoea of recent onset. Echocardiography showed a mass with irregular borders attached to the pulmonary artery trunk, almost obliterating its lumen and determining a flow acceleration with a peak velocity and gradient, respectively, of 3.8 m/s and 60 mmHg. At cardiac magnetic resonance imaging and positron emission tomography-computed tomography scan, the mass had inhomogeneous contrast impregnation and an intense 18-fluorodeoxyglucose uptake, both findings are highly suggestive of an angiosarcoma of the pulmonary artery. Biopsy specimens were taken through bronchoscopy but the material was insufficient for diagnosis. The patient decided to continue treatment in another hospital, where he died a few months later. DISCUSSION: The presence of a unique mass involving the main trunk of the pulmonary artery or proximal branches associated with rapidly progressive dyspnoea in a patient at low risk for pulmonary embolism should raise the suspicion of primary sarcoma of the pulmonary artery. There are no guidelines for the treatment. Surgery and neo/adjuvant chemotherapy are reported in literature but burdened by bias and concerning a small number of cases.

Endocarditis with spondylodiscitis: clinical characteristics and prognosis.

BACKGROUND: The association of infective endocarditis (IE) with spondylodiscitis (SD) was first reported in 1965, but few data are available about this issue. This study aimed to evaluate the prevalence of SD in patients with IE, and to determine the clinical features and the prognostic impact of this association. METHODS: We retrospectively analysed 363 consecutive patients admitted to our Department with non-device-related IE. Radiologically confirmed SD was revealed in 29 patients (8%). Long-term follow-up (average: 3 years) was obtained by structured telephone interviews; in 95 cases (13 of whom had been affected by SD), follow-up echocardiographic evaluation was also available. RESULTS: At univariable analysis, the combination of IE with SD was associated with male gender (p = 0.017), diabetes (p = 0.028), drug abuse (p = 0.009), Streptococcus Viridans (p = 0.009) and Enterococcus (p = 0.015) infections. At multivariable analysis, all these factors independently correlated with presence of SD in patients with IE. Mortality was similar in patients with and without SD. IE relapses at 3 years were associated with the presence of SD (p = 0.003), Staphylococcus aureus infection (p < 0.001), and drug abuse (p < 0.001) but, at multivariable analysis, only drug abuse was an independent predictor of IE relapses (p < 0.001; HR 6.8, 95% CI 1.6-29). At echocardiographic follow-up, SD was not associated with worsening left ventricular systolic function or valvular dysfunction. CONCLUSIONS: The association of IE with SD is not rare. Hence, patients with IE should be screened for metastatic infection of the vertebral column, especially if they have risk factors for it. However, SD does not appear to worsen the prognosis of patients with IE, either in-hospital or long-term.

Predictors of mortality and adverse events in patients with infective endocarditis: a retrospective real world study in a surgical centre.

PURPOSE: Mortality in infective endocarditis (IE) is still high, and the long term prognosis remains uncertain. This study aimed to identify predictors of long-term mortality for any cause, adverse event rate, relapse rate, valvular and ventricular dysfunction at follow-up, in a real-world surgical centre. METHODS: We retrospectively analyzed 363 consecutive episodes of IE (123 women, 34%) admitted to our department with a definite diagnosis of non-device-related IE. Median follow-up duration was 2.9 years. Primary endpoints were predictors of mortality, recurrent endocarditis, and major non-fatal adverse events (hospitalization for any cardiovascular cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence), and ventricular and valvular dysfunction at follow-up. RESULTS: Multivariate analysis independent predictors of mortality showed age (HR per unit 1.031, p < 0.003), drug abuse (HR 3.5, p < 0.002), EUROSCORE II (HR per unit 1.017, p < 0.0006) and double valve infection (HR 2.3, p < 0.001) to be independent predictors of mortality, while streptococcal infection remained associated with a better prognosis (HR 0.5, p < 0.04). Major non-fatal adverse events were associated with age (HR 1.4, p < 0.022). New episodes of infection were correlated with S aureus infection (HR 4.8, p < 0.001), right-sided endocarditis (HR 7.4, p < 0.001), spondylodiscitis (HR 6.8, p < 0.004) and intravenous drug abuse (HR 10.3, p < 0.001). After multivariate analysis, only drug abuse was an independent predictor of new episodes of endocarditis (HR 8.5, p < 0.001). Echocardiographic follow-up, available in 95 cases, showed a worsening of left ventricular systolic function (p < 0.007); severe valvular dysfunction at follow-up was reported only in 4 patients, all of them had mitral IE (p < 0.03). CONCLUSIONS: The present study highlights some clinical, readily available factors that can be useful to stratify the prognosis of patients with IE.

Cardiac Metastasis of Sacral Chordoma.

Chordoma is a rare tumor, usually diagnosed when the disease is advanced. Despite its slow growth, it is locally aggressive and has a poor long-term prognosis. Surgery is the mainstay treatment. Although cardiac metastases are very rare, the heart is frequently involved in systemic neoplastic diseases. This report describes a typical case of metastatic chordoma: the age at first diagnosis, the site of the primary tumor, and the slow growth of the cardiac metastasis were all typical features. Surgical excision of the mass from the right ventricular outflow tract is described together with echocardiographic, radiologic, and histopathologic characteristics of the metastatic chordoma.

Overweight and aging increase the risk of atrial fibrillation after cardiac surgery independently of left atrial size and left ventricular ejection fraction.

BACKGROUND: Body mass index (BMI), age, left atrium (LA) dimension and left ventricular ejection fraction (LVEF) have been linked to post-operative atrial fibrillation (POAF) after cardiac surgery. The aim of this study was to better define the role of these risk factors. METHODS: This retrospective cohort study evaluated 249 patients (without prior atrial dysrhythmia) undergoing cardiac or aortic surgery. Prior to surgery, the following data were collected: age, BMI, LA diameter, LA area, LVEF, thyroid stimulating hormone (TSH), creatinine and the presence of arterial hypertension (AH) and diabetes. Intraoperative data such as operation time, total clamp time, cardiopulmonary bypass time, and presence of pericardial/pleural effusion were also collected. Only patients without pre- and post-surgery prophylactic anti-arrhythmic therapy were included. RESULTS: Patients with (N = 127, 51%) and without POAF (N = 122, 49%) were compared. No difference was observed for sex, LA diameter, LA area, LVEF, TSH, diabetes and use of ACE inhibitors or statins prior to intervention. Moreover, no difference was observed in terms of operation time, total clamp time, cardiopulmonary bypass time, and presence of pericardial/pleural effusion. However, patients with POAF were older (70.6 ± 10.7 vs. 60.4 ± 16.4 years, p = 0.001), had higher BMI (26.8 ± 4.5 vs. 24.9 ± 3.6 kg/m2, p = 0.001), higher baseline creatinine (1.06 ± 0.91 vs. 0.88 ± 0.32 mg/dL, p = 0.038) and a higher frequency of arterial hypertension (73.2% vs. 50%, p = 0.001) and Bentall procedure (24.4% vs. 9.8%, p = 0.023). Multivariate analysis showed that the only independent predictors of POAF were age (OR = 1.05, 95%CI 1.02-1.07, p = 0.001) and BMI (OR = 1.11 95%CI 1.03-1.2,p = 0.006). CONCLUSIONS: These findings suggest that advanced age and a higher BMI are strong risk factors for POAF in patients without previous AF even in the presence of comparable LA dimensions and LVEF.

Embolic risk stratification and prognostic impact of early surgery in left-sided infective endocarditis.

BACKGROUND: In patients with left-sided infective endocarditis (IE) and heart failure associated with large vegetations, early surgery prevents embolic events. However, optimal timing of surgery for other indications is still unresolved particularly when the presence of large vegetations represents the sole indication. METHODS: We retrospectively analyzed 308 consecutive patients admitted to our department with definite left-sided IE. Of these patients, 243 (79%) underwent cardiac surgery (complicated IE), 34 patients with uncomplicated IE received medical treatment, 24 were not operated due to prohibitive general conditions and 7 refused surgery. Long-term follow-up was obtained by structured telephone interviews. RESULTS: During the 6-year follow-up (average 121.8 weeks ± 76), patients not operated because of general conditions or refusal had the worst prognosis, while outcome in operated patients for complicated IE was comparable to that of uncomplicated IE treated medically. Early (<2 weeks from diagnosis) surgery was associated with better survival compared to delayed surgery (HR 0.58, p = 0.23). Embolic events were detected at admission in 38% of cases; Staphylococcus Aureus etiology and vegetation size were independently associated with embolism (OR 2.4, p = 0.01; OR 1, p=0.008 respectively). CONCLUSIONS: Compared to uncomplicated medically-treated patients, complicated IE showed comparable survival when managed aggressively by surgical intervention, whereas a conservative approach was associated with an adverse prognosis. Staphylococcus Aureus infection and vegetation size were independent predictors of systemic embolism. Our data support aggressive surgical management of complicated IE patients and highlight the importance of etiological characterization in clinical decision-making.

Six-month prognostic impact of hemodynamic profiling by short minimally invasive monitoring after cardiac surgery.

Introduction: Studies have shown that a hemodynamic-guided therapy improves the post operative outcomes of high-risk patients.This study, evaluated if a short period through minimally invasive hemodynamic monitoring, pressure recording analytical method (PRAM), on admission to a post-cardiac surgery step-down unit (SDU), may identify patients at higher risk of 6-month adverse events after cardiac surgery. Methods: From December 2016-May 2017,173 patients were admitted in SDU within 24-48 hours of major cardiac surgery procedure, and submitted to clinical, laboratoristic and echocardiographic evaluation and a 1-hour PRAM recording to obtain a "biohumoral snapshot" of individual patient's.156 173 patients (17 patients were lost at follow-up) were phone interviewed six months after surgery,to evaluate, as a composite end-point, the adverse events during follow-up. A multivariable logistic regression analysis was used to identify a model clinical-biohumoral (CBM) and clinical-biohumoral hemodynamics (CBHM). Results: No data from past clinical history and no conventional risk score (EuroScore II, STS score)independently predicted the risk of 6-month major events in our study. The risk of adverse events at six-month follow-up was directly related, in the CBM, to sustained post-operative cardiac arrhythmias, higher values of NT-proBNP and of arterial pH; inversely related to values of hs-C-reactive protein (hs-CRP) and, in the CBHM, to low values of cardiac cycle efficiency (CCE) and dP/dtmax. Conclusion: Our study although limited by its observational nature and by the limited number of patients enrolled, showed that a short period of minimally invasive hemodynamic monitoring increased the accuracy to identify patients at major risk of mid-term events after cardiac surgery.

Primary cardiac sarcoma: a case report of a therapeutic challenge.

BACKGROUND: Primary cardiac sarcomas are very rare and the prognosis is poor both because the diagnosis is typically made at an advanced stage of the disease and because data are insufficient to identify a standard treatment. Surgical resection is the cornerstone of therapy with the need to develop new therapeutic strategies. CASE SUMMARY: We present a case of a young man admitted to the emergency department due to worsening dyspnoea. A left-sided sarcoma was diagnosed and treated with surgery, chemo- and radiation therapy, and subsequently with heart transplant for local recurrence of the disease. Endomyocardial biopsy made during the routine follow-up period was complicated by pericardial tamponade and cardiogenic shock and the patient was managed with veno-arterial extracorporeal membrane oxygenation, until recovery of left ventricular function (left ventricular ejection fraction of 55%). After 1 year a kidney transplant was performed. After 42 months from diagnosis, the patient is in good general condition. DISCUSSION: Primary cardiac sarcomas are treated with surgery to reach R0 (free resection margins) and with chemo- and radiation therapy with adjuvant purposes. Auto-transplantation is also performed, while conventional heart transplant must be customized on an individual basis, after excluding metastases. A multidisciplinary assessment should be performed and the single patient treated with a personalized approach, in relation to his performance status, location of the mass, and stage of the disease.

Timing of invasive septal reduction therapies and outcome of patients with obstructive hypertrophic cardiomyopathy.

BACKGROUND: Whether early vs. delayed referral to septal reduction therapies (SRT, alcohol septal ablation or surgical myectomy) bears prognostic relevance in hypertrophic obstructive cardiomyopathy (HOCM) is unresolved. We analyzed the impact of SRT timing on the outcome of HOCM patients. METHODS: We followed 126 patients for 5 ±â€¯4 years after SRT (mean age 53 ±â€¯15 years; 55 post-ASA and 71 post-SM). Based on time-to-treatment (TTT; from HOCM diagnosis to SRT), patients were divided into three groups: "<3" years, N = 50; "3-5" years, N = 25; ">5" years, N = 51. RESULTS: Patients with TTT > 5 years were younger at diagnosis and more often had atrial fibrillation (AF). Left ventricular outflow tract (LVOT) gradients were comparable in the 3 TTT groups. Two patients died peri-operatively, all with TTT > 5. Long-term, 8 patients died (3 suddenly and 5 due to heart failure). Mortality increased progressively with TTT (2% vs. 4% vs. 12% for TTT "<3", "3-5", and ">5" years, p for trend = 0.039). Independent predictors of disease progression (new-onset AF, worsening to NYHA III/IV symptoms, re-intervention or death) were TTT ("3-5" vs. "<3" years: HR: 4.988, 95%CI: 1.394-17.843; ">5" vs. "<3" years: HR: 3.420, 95%CI: 1.258-9.293, overall p-value = 0.025), AF at baseline (HR: 1.896, 95%CI: 1.002-3.589, p = 0.036) and LVOT gradient (HR per mm Hg increase: 1.022, 95%CI: 1.007-1.024, p = 0.023). CONCLUSIONS: Delay in SRT referral has significant impact on long-term outcome of patients with HOCM, particularly when >5 years from first detection of gradient, even when successful relief of symptoms and gradient is achieved. Earlier interventions are associated with lower complication rates and better prognosis, suggesting the importance of timely SRT to maximize treatment benefit and prevent late HOCM-related complications.

Sinus Rhythm Restoration after Radiofrequency Ablation Improves Survival in Patients Undergoing Mitral Valve Surgery : A Eight Year Single Center Study.

BACKGROUND: The usefulness of radiofrequency (RF) ablation in restoring sinus rhythm in patients with permanent atrial fibrillation (AF) undergoing surgery for mitral valve has been demonstrated. But whether sinus rhythm recovery affects long-term survival is less clear. METHODS: This study included 301 consecutive patients (126 men and 175 women, age 69±6 years) undergoing radiofrequency ablation of persistent atrial fibrillation along with mitral valve surgery. Radiofrequency ablation was performed using unipolar probe in 55.3%, bipolar probe in the remaining 44.7% of cases. RESULTS: Four patients died during hospitalization. At follow-up, sinus rhythm was present in 76% of the surviving patients. 71 patients never recovered sinus rhythm after hospital discharge. Mortality and recurrent hospitalization were significantly lower in patients with sinus rhythm at the end of follow-up in comparison to permanent AF. The incidence of stroke was also lower in patients with stable sinus rhythm. Larger atria, pulmonary hypertension and history of rheumatic disease were associated with the persistence of AF despite radiofrequency ablation. Although survival and functional capacity were significantly lower in patients with permanent AF at multivariate analysis only age and pulmonary artery pressure before surgery were independently associated with mortality. CONCLUSION: Sinus rhythm restoration by RF ablation in patients undergoing mitral valve surgery is associated with an improved long-term survival. However our results suggest that a more severe hemodynamic impairment, expressed by higher pulmonary artery pressure, and increasing age are the only independent factors related to long-term survival.

Role of mitral valve repair in active infective endocarditis: long term results.

BACKGROUND: Although mitral valve repair is at present the technique of choice in mitral regurgitation (MR) due to degenerative valve disease, long term results in patients with active mitral infective endocarditis (IE) are still under evaluation. METHODS: In the study were included 34 consecutive patients (22 males; mean age, 60 years; range 32-84 years) referred to our institution between January 1, 2005 to December 31, 2011 who were treated with valve repair for mitral valve (MV) active infective endocarditis. Eighteen patients underwent isolated MV repair. Aortic valve replacement and respectively repair were performed in 9 and 2 patients with concomitant aortic involvement. Blood cultures were positive in 30 (17 Staphylococcus, 13 Streptococcus, 1 g negative, 2 enterococcus). RESULTS: Four patients died during hospital stay (11%) due to multi system organ failure as a consequence of severe septic shock (2 patients), cardiogenic shock (1 case) and respiratory failure (1 patient). At an average follow up of 48 months in patients discharged alive from hospital survival was 96.7% (29 out of 30). None developed more than mild- to moderate mitral valve regurgitation during follow-up and we found a significant improvement in functional capacity and left ventricular ejection fraction associated with a significant decrease of pulmonary artery pressure. The only recurrence of endocarditis occurred in a drug addict patient. CONCLUSIONS: Present investigation suggest that in patients with active mitral valve endocarditis MV repair, when technically feasible, is associated with a favorable clinical long term outcome. None of the patients alive at the end of follow-up developed severe mitral regurgitation. Moreover mortality and reinfection rate are uncommon and functional improvement.

The rise of new technologies for aortic valve stenosis: A comparison of sutureless and transcatheter aortic valve implantation.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) and sutureless aortic valve replacement (SU-AVR) are suitable alternatives to conventional surgery. The aim of this study is to compare early outcomes of patients undergoing TAVI and SU-AVR. METHODS: Data were analyzed on patients who underwent TAVI and patients who underwent SU-AVR. Two matched cohorts (TAVI vs SU-AVR) were created using propensity scores; all analyses were repeated for transapical TAVI and transfemoral TAVI, separately. Outcomes were defined according to Valve Academic Research Consortium-2 criteria. RESULTS: A total of 2177 patients were included in the analysis: 1885 (86.6%) treated with TAVI; 292 (13.4%) treated with SU-AVR. Mortality in unmatched TAVI and SU-AVR patients was 7.1% and 2.1%, respectively, at 30 days, and 12.9% and 4.6%, respectively, at 1 year. No differences were found in 30-day mortality in the 214 matched patient pairs (3.7% vs 2.3%; P = .4), but patients treated with TAVI showed a lower incidence of device success (85.9% vs 98.6%; P < .001) and pacemaker implantation (2.8% vs 9.4%; P = .005), and a higher incidence of any paravalvular leakage (PVL). CONCLUSIONS: SU-AVR is associated with better device success and a lower incidence of PVL, compared with TAVI. Nevertheless, patients treated with SU-AVR were more likely to receive a permanent pacemaker. SU-AVR and TAVI provide good results in patients who have severe symptomatic aortic valve stenosis. Given the multiple therapeutic options available, patients may receive the treatment that is most appropriate for their clinical and anatomical characteristics.