N-3 polyunsaturated fatty acids reduces post-operative atrial fibrillation incidence in patients undergoing "on-pump" coronary artery bypass graft surgery.

BACKGROUND: The aim of this study was to evaluate the efficacy of preoperative and postoperative therapy with n-3 polyunsaturated fatty acids in reducing the incidence of atrial fibrillation after coronary artery bypass graft surgery. METHODS: 201 patients undergoing coronary artery bypass graft surgery were randomized to 1) a control group (105 patients), or 2) n-3 polyunsaturated fatty acids 2 g/day group (96 patients) for at least 5 days before surgery and until hospital discharge. Groups were further subdivided in four subgroups according to the operative technique: "off-pump" or "on-pump". The primary end point was to evaluate the reduced incidence of postoperative in-hospital atrial fibrillation in the (N-3 PUFA) group. Secondary end points were the impact of the surgical technique on the incidence of postoperative arrhythmia and the impact of n-3 polyunsaturated fatty acids therapy on post-operative hospital length of stay. RESULTS: The overall incidence of post-operative atrial fibrillation was 17.4% (35/201). The arrhythmia occurred in 11.4% (11/96) of the patients in therapy with n-3 polyunsaturated fatty acids and in 22.8% (24/105) in the control groups. In particular, the statistical analysis of subgroups showed a significant reduction of postoperative atrial fibrillation only in the group including patients treated with n-3 polyunsaturated fatty acids undergoing "on-pump" coronary artery bypass graft surgery. The length of hospital stay did not differ among all groups. CONCLUSIONS: N-3 polyunsaturated fatty acids administration significantly reduces the incidence of post-operative atrial fibrillation in patients undergoing "on-pump" coronary artery bypass graft surgery. N-3 polyunsaturated fatty acids therapy is not associated with a shorter hospital stay.

A case of quadricuspid aortic valve characterized by echocardiography and magnetic resonance imaging.

We report a rare subtype of quadricuspid aortic valve (QAV) associated with moderate aortic regurgitation in a 17-year old woman symptomatic for palpitations. The patient was admitted to our department for cardiac evaluation due to a previous diagnosis of bicuspid aortic valve; she underwent a new two-dimensional echocardiography revealing a rare type of quadricuspid aortic valve with a moderate regurgitation. For further investigating potentially associated abnormalities, patient was referred to Cardiac MRI; MRI showed no other abnormalities and confirmed echocardiographic findings. Quadricuspid aortic valve is a rare form of congenital valvular anomaly often occasionally diagnosed. In most cases this malformation causes a valve dysfunction, commonly aortic regurgitation, and can be associated with other cardiac abnormalities such as ventricular or atrial septal defect, anomalies of coronary arteries, patent ductus arteriosus, subaortic fibromuscolar stenosis and mitral valve malformation.

Cardiac surgery practice during the COVID-19 outbreak: a regionwide survey.

BACKGROUND: Health systems worldwide have been overburdened by the "COVID-19 surge". Consequently, strategies to remodulate non-COVID medical and surgical care had to be developed. Knowledge of the impact of COVID surge on cardiac surgery practice is mainstem. Present study aims to evaluate the regional practice pattern during lockdown in Campania. METHODS: A multicenter regional observational 26-question survey was conducted, including all adult cardiac surgery units in Campania, Italy, to assess how surgical practice has changed during COVID-19 national lockdown. RESULTS: All centers adopted specific protocols for screening patients and personnel. A significant reduction in the number of dedicated intensive care unit (ICU) beds (-30.0%±38.1%, range: 0-100%) and cardiac operating rooms (-22.2%±26.4%, range: 0-50%) along with personnel relocation to other departments was disclosed (anesthesiologists -5.8%±11.1%, range: 0-33.3%; perfusionists -5.6%±16.7%, range: 0-50%; nurses -4.8%±13.2%, range: 0-40%; cardiologists -3.2%±9.5%, range: 0-28.6%). Cardiac surgeons were never reallocated to other services. Globally, we witnessed dramatically lower adult cardiac surgery case volumes (335 vs. 667 procedures, P<0.001), as institutions and surgeons followed guidelines to curtail non-urgent operations. CONCLUSIONS: This regional survey demonstrates major changes in practice as a response to the COVID-19 pandemic. In this respect, this experience might lead to the development of permanent systems-based plans for future pandemic and may effectively help policy decision making when prioritizing healthcare resource reallocation during and after the pandemic.

Cardiac surgery practice during the COVID-19 outbreak: a multicentre national survey.

OBJECTIVES: Healthcare systems worldwide have been overburdened by the coronavirus disease 2019 (COVID-19) outbreak. Accordingly, hospitals had to implement strategies to profoundly reshape both non-COVID-19 medical care and surgical activities. Knowledge about the impact of the COVID-19 pandemic on cardiac surgery practice is pivotal. The goal of the present study was to describe the changes in cardiac surgery practices during the health emergency at the national level. METHODS: A 26-question web-enabled survey including all adult cardiac surgery units in Italy was conducted to assess how their clinical practice changed during the national lockdown. Data were compared to data from the corresponding period in 2019. RESULTS: All but 2 centres (94.9%) adopted specific protocols to screen patients and personnel. A significant reduction in the number of dedicated cardiac intensive care unit beds (-35.4%) and operating rooms (-29.2%), along with healthcare personnel reallocation to COVID departments (nurses -15.4%, anaesthesiologists -7.7%), was noted. Overall adult cardiac surgery volumes were dramatically reduced (1734 procedures vs 3447; P < 0.001), with a significant drop in elective procedures [580 (33.4%) vs 2420 (70.2%)]. CONCLUSIONS: This national survey found major changes in cardiac surgery practice as a response to the COVID-19 pandemic. This experience should lead to the development of permanent systems-based plans to face possible future pandemics. These data may effectively help policy decision-making in prioritizing healthcare resource reallocation during the ongoing pandemic and once the healthcare emergency is over.

Relation of Prolonged Pacemaker Dependency After Cardiac Surgery to Mortality.

Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. A multicenter retrospective study was designed to assess pacemaker dependency (PMD) and long-term mortality after cardiac surgery procedures. Between 2004 and 2016, PPI-patients from 18 centers were followed. Time-to-event data were evaluated with semiparametric regression Cox models and semiparametric Fine and Gray model for competing risk framework. Of 859 (0.90%) PPI-patients, 30% were pacemaker independent (PMI) at 6 months. PMD showed higher mortality compared with PMI (10-year survival 80.1% ± 2.6% and 92.2% +2.4%, respectively, log-rank p-value < 0.001) with an unadjusted hazard ratio for death of 0.36 (95% CI 0.20 to 0.65, p< 0.001 favoring PMI) and an adjusted hazard ratio of 0.19 (95% CI 0.08 to 0.45, p< 0.001 with PMD as reference). Crude cumulative incidence function of restored PMI rhythm at follow-up at 6 months, 1 year and 12 years were 30.5% (95% CI 27.3% to 33.7%), 33.7% (95% CI 30.4% to 36.9%) and 37.2% (95% CI 33.8% to 40.6%) respectively. PMI was favored by preoperative sinus rhythm with normal conduction (SR) (HR 2.37, 95% CI 1.65 to 3.40, p< 0.001), whereas coronary artery bypass grafting and aortic valve replacement were independently associated with PMD (HR 0.63, 95% CI 0.45 to 0.88, p = 0.006 and HR 0.807, 95% CI 0.65 to 0.99, p = 0.047 respectively). Time-to-implantation was not associated with increased rate of PMI. Although 30% of PPI-patients are PMI after 6 months, PMD is associated with higher mortality at long term.

Surgery for prosthetic valve endocarditis: a retrospective study of a national registry.

OBJECTIVES: We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design. METHODS: Data regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study. RESULTS: Overall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P < 0.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P < 0.001) and median logistic EuroSCORE (14%, 21%, 23%, P = 0.025). Older age, female sex, preoperative serum creatinine >-2 mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (OR = 1.02; P = 0.03), renal insufficiency (OR = 2.1; P = 0.05), triple valve surgery (OR = 6.9; P = 0.004) and shock (OR = 4.5; P < 0.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (OR = 3; P < 0.001), Enterococcus (OR = 2.3; P = 0.01) and female sex (OR = 1.5; P = 0.03) independently predicted complications, whereas ejection fraction was protective. CONCLUSIONS: PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patient's haemodynamic status and microbiological factors.

The use of "LAST" operation in high risk patient.

BACKGROUND: The LAST operation, in spite of few drawbacks, represents a good option for single Left Anterior Descending (LAD) revascularization. This procedure does not allow multivessel revascularization, where hybrid procedure have been previous described. We report preliminary experience with the LAST operation performed in high risk patients. MATERIAL AND METHODS: From October 2004 to February 2005, 11 male high risk patients (mean age 74 +/- 8 years) underwent the LAST operation. Mean predicted death with EUROSCORE and Parsonnet score were 29% and 31% respectively. All patients had a proximal LAD lesion either not suitable for PTCA and multivessel coronary artery disease. The mean preoperative Ejection Fraction was 42 +/- 5% (27-55%). Four patients (36.4%) had previous surgical myocardial revascularization. An incision of about 6 cm was made in the appropriate intercostal space and the LIMA (Left Internal Mammary Artery) was harvested using a special costal retractor. After heparin administration the LIMA is distally divided to check the adequacy of the blood flow. Following the insertion of a temporary intracoronary shunt, the LIMA was LAD anastomosis was carried out with a continuous 8-0 polypropylene suture. RESULTS: No hospital or late mortality was observed. Uneventful conversion to midline sternotomy was necessary in one patient with low value of mammary flow. All patients were discharged within the first postoperative week. CONCLUSIONS: The use of the LAST operation enhances the role of minimally invasive surgery also in high risk patients who need coronary revascularization.

Antiplatelet versus oral anticoagulant therapy as antithrombotic prophylaxis after mitral valve repair.

OBJECTIVE: To verify the rate of thromboembolic and hemorrhagic complications during the first 6 months after mitral valve repair and to assess whether the type of antithrombotic therapy influenced clinical outcome. METHODS: Retrospective data were retrieved from 19 centers. Inclusion criteria were isolated mitral valve repair with ring implantation. Exclusion criteria were ongoing or past atrial fibrillation and any combined intraoperative surgical procedures. The study cohort consisted of 1882 patients (aged 58 ± 15 years; 36% women), and included 1517 treated with an oral anticoagulant (VKA group) and 365 with antiplatelet drugs (APLT group). Primary efficacy outcome was the incidence of arterial thromboembolic events within 6 months and primary safety outcome was the incidence of major bleeding within 6 months. Propensity matching was performed to obtain 2 comparable cohorts (858 vs 286). RESULTS: No differences were detected for arterial embolic complications in matched cohort (1.6% VKA vs 2.1% APLT; P = .50). Conversely, patients in the APLT group showed lower incidence of major bleeding complications (3.9% vs 0.7%; P = .01). Six-month mortality rate was significantly higher in the VKA group (2.7% vs 0.3%; P = .02). Multivariable analysis in the matched cohort found VKA as independent predictor of major bleeding complications and mortality at 6 months. CONCLUSIONS: Vitamin K antagonist therapy was not superior to antiplatelet therapy to prevent thromboembolic complications after mitral valve repair. Our data suggest that oral anticoagulation may carry a higher bleeding risk compared with antiplatelet therapy, although these results should be confirmed in an adequately powered randomized controlled trial.

On-pump versus off-pump coronary artery bypass surgery in high-risk patients: operative results of a prospective randomized trial (on-off study).

OBJECTIVE: To analyze the risk reduction of cardiopulmonary bypass complications between on-pump and off-pump coronary artery bypass grafting in high-risk patients. METHODS: This multicenter, prospective, randomized, parallel trial enrolled patients for elective or urgent isolated coronary artery bypass grafting with an additive European System for Cardiac Operative Risk Evaluation of 6 or more. The patients in cardiogenic shock were excluded. The composite primary end point included operative mortality, myocardial infarction, stroke, renal failure, reoperation for bleeding and adult respiratory distress syndrome within 30 days after surgery. The total sample size was 693 patients, according to a scheduled interim analysis at 400 patients enrolled (α-spending = 0.029, Pocock method). RESULTS: A total of 411 patients were included in the interim analysis. Randomization assigned 203 patients to on-pump and 208 patients to off-pump treatment. Of the 411 patients, 24 crossed over; thus, 195 patients were actually treated on-pump and 216 off-pump. According to the intention to treat analysis, the rate of the composite primary end point was significantly lower (unadjusted P = .009, adjusted P = .010) in the off-pump group (5.8% vs 13.3%). The risk of experiencing the primary end point was significantly greater for the on-pump group (unadjusted odds ratio, 2.51; 95% confidence interval, 1.23-5.10; P = .011; adjusted odds ratio, 3.07; 95% confidence interval, 1.32-7.14; P = .009). CONCLUSIONS: Off-pump coronary artery bypass grafting reduces early mortality and morbidity in high-risk patients.