Psychological assessment of patients on the heart transplant waiting list: A single center experience.

OBJECTIVE: To analyze the data of the psychological assessment, focusing attention on the quality of life and the psychological status of patients who are listed for heart transplant. METHODS: All heart failure patients listed for heart transplant at the Cardiac Surgery Unit of Bari University, Italy, were evaluated from September to November 2023, by administering the Symptom Checklist-90-R (SCL-90-R) and the Short Form Health Survey 36 (SF-36). RESULTS: Overall, 27 patients were studied. Mean age was 60 years, 88% were males. One third of the patients showed a clinically significant overall mental distress. The symptoms leading to domains such as somatization (55.55%), anxiety (40.74%) and depression (33.33%) were frequently observed. The majority of the population studied (96.30%) showed low levels of perceived physical health status, while 59,62% of them presented levels of perceived physical health status below normal ranges. CONCLUSIONS: Heart transplant candidates show elements of overall mental distress and low quality of life related to physical health status.

Can a "broken heart" successfully be transplanted? A brief report.

A 59-year-old woman, with dilated ischemic cardiomyopathy, was urgently admitted to our Intensive Care Unit for cardiogenic shock. ECMO VA was implanted and placed on the national emergency waitlist for transplantation. A potential donation was identified ten days later. The donor was a 58-year-old woman, with no cardiovascular risk factors, had died of a rupture of a cerebral aneurysm with left ventricle dysfunction due to Takotsubo syndrome. Brain injuries such as hemorrhage, trauma and stroke have been extensively documented in literature to cause a surge in stress hormones, such as catecholamines. Such a surge can have a direct effect on the heart, resulting in a transient myocardial dysfunction commonly referred to as "Takotsubo cardiomyopathy" or "broken heart syndrome". Many studies have shown that hearts that are dysfunctional at the start of transplant screening, with normal contractile function at the time of organ retrieval, have similar outcomes to hearts that do not have dysfunction. In our case, the transplanted heart, at the time of sampling, still had moderate dysfunction (EF 40%) which completely disappeared after the transplant.

Infective Endocarditis After Percutaneous Device Closure of Atrial Septal Defects: Incidence, Diagnosis, and Treatment. Case Report and Literature Review.

Infective endocarditis (IE) on atrial septal defect (ASD) closure devices, while extremely rare, has been reported to be more frequent early after the procedure. We describe a case of late IE after percutaneous closure of patent foramen ovale (PFO). We also performed a literature review on this subject. We reviewed a total of 42,365 patients who were treated with percutaneous devices: 13,916 for ostium secundum (OS) (32%), 24,726 for PFO (58%) and 3,723 for OS+PFO (8%). Among these patients, we identified 50 cases of IE after atrial septal defect device closure (0.001%). In contrast to previous reports, nearly 66% of IE in this setting occurred late, after at least 6 months from the procedure (33/50 patients). A statistical analysis clearly showed that the mean time from the procedure to IE increased in the last five years, probably associated with a change in antiplatelet therapy after ASD closure. Management of IE on an ASD occluder should always be discussed in the setting of a multidisciplinary heart team that includes a cardiologist, cardiac surgeon, and anesthetist. While surgical strategies gave excellent results, conservative management might be considered in cases of small IE vegetations and for patients in good general condition. However, in these cases, the patient must be closely observed with repeated blood and instrumental tests.

Retrograde Autologous Priming for Minimally Invasive Mitral Valve Surgery.

OBJECTIVES: Little is known about the safety and clinical utility of retrograde autologous priming (RAP) in patients undergoing minimally invasive mitral valve surgery. The study authors hypothesized that RAP would increase the oxygen delivery index (DO2i) while decreasing red blood cell transfusion requirements compared to valve surgery without RAP. DESIGN: The study was an observational analysis. SETTING: A single institutional study. PARTICIPANTS: The authors analyzed data from 500 consecutive patients who underwent minimally invasive isolated mitral valve repair from December 31, 2012, to December 31, 2019. INTERVENTION: RAP was performed in 235 patients (47%) prior to the initiation of cardiopulmonary bypass (CPB). MEASUREMENT AND MAIN RESULTS: A continuous monitoring system was used for DO2 management during CPB. The mean arterial pressure was maintained between 55 and 70 mmHg, and the cardiac index was set at 2.4 L/min/m2, with adjustments in accordance with DO2i. The trigger point for red cell blood transfusion during CPB was hemoglobin <7 g/dL. Baseline hematocrit was lower in the RAP group compared to the no-RAP group (33.4 ± 3.6 v 38.1 ± 4.9, respectively; p < 0.001). Both CPB and cross-clamp times were similar between groups. Hematocrit during CPB was significantly higher in the RAP group compared to the no-RAP group (27.6 ± 2.6 v 25.9 ± 5.1, respectively; p < 0.001). RAP was also associated with significantly higher mean DO2i (292 ± 19.5 v 282.9 ± 35.1 mL/min/m2, respectively; p < 0.001) and fewer red blood cells transfusions during the intraoperative and immediate postoperative periods (p < 0.001). CONCLUSIONS: In a minimally invasive mitral valve context, RAP was safe and associated with better DO2i, higher hematocrit, and fewer intraoperative and postoperative red blood cell transfusions.

Primary malignant cardiac tumors: Sex-related therapy and multidisciplinary approach as a new challenge for the future.

Primary malignant cardiac tumors represent (PMCTs) a very rare disease with an incidence of 0.009%1 (up to 10% of primary cardiac neoplasms) and are related to a very poor prognosis. The study by Mohamed Rahouma tries to give us information on sex differences in PMCTs, their incidence, behavior, and outcomes. Females were significantly older and had a lower stage of cancer. Males are known to have a more aggressive course and present at an earlier age. Sarcoma is the most common type of PMCTs in both males and females. There was no gender disparity in late mortality and patients who underwent surgery had a better prognosis than those who did not undergo surgery. Significant predictors of late mortality were found to be patients' high comorbidity index, angiosarcoma histology, and Stage III/IV. A challenge for cardiac surgeons is to improve survival in patients with cardiac malignancies, involving a multidisciplinary approach with oncologists, cardiologists, and radiologists. To pave the way for a significant improvement in survival in the future, more advanced sex-specific medical therapies for cancer such as novel chemotherapy agents, targeted immune therapies, genetic engineering need to be standardized to PMCTs and combined with radiological therapies such as gamma-knife and very advanced surgery to effectively treat even very aggressive forms of malignant tumors, with a significant impact on the patient's quality of life and survival.

The best is the enemy of the good, a simple technique to treat a complex disease: Calamari procedure.

Infective endocarditis is a life-threatening condition and despite advances in antibiotic therapy, about one-third of patients require surgical treatment. The choice of the most appropriate surgical treatment is crucial. The study by Asen Petrov et al. paves the way for a new, safe, simple, and useful Calamari technique for the treatment of aortic valve endocarditis complicated by aortic root abscess (ARA). This technique was initially described in a series of five patients. The most interesting part of the study is that the procedure was effective (only one patient died 30 days after surgery) and fast (mean cardiopulmonary bypass time 90 ± 10.30 min; mean cross-clamp time 73.6 ± 12.12 min). As reported by Leontyev et al., the procedure of choice in ARA is represented by a wide range of procedures ranging from aortic valve replacement with debridement of the abscess to reconstruction of the intervalvular fibrous body and replacement of both the mitral valve and the aortic root. Alternatively, pericardial patch reconstruction is required in approximately one-third of cases. Radicality is key but a fast procedure is very important. In this scenario, the Calamari procedure is very useful, especially for its rapid execution (short cardiopulmonary bypass and cross-clamp time) which is associated with a reduction in mortality. A simple procedure to treat complex diseases. However, this procedure needs to be performed on more patients and its outcomes should be compared in trials with the other available techniques for the treatment of ARA.

Minimally invasive mitral valve reconstruction: Is it an "all-comers" procedure?

BACKGROUND AND AIM OF THE STUDY: The debate on the usefulness of the minimally invasive approach in mitral valve surgery is still open. The aim of this study is to describe a single-center case series of all comers undergoing minimally invasive mitral valve reconstruction. METHODS: From 2010 to 2019, all the data recorded in the medical records of 893 consecutive patients undergoing mitral valve reconstruction through a right mini-thoracotomy were retrospectively collected. All patients were contacted by telephone for remote evaluation and integration of echocardiographic information on surgical results. RESULTS: Mean age was 62.2 ± 14.5; 447 (50%) were female and mean log EuroSCORE was 2.5 ± 2.8%. At a mean follow-up of 4.1 ± 2.2 years (median 3.9), a total of 24 deaths (2.68%) were recorded. Twenty-four patients required rehospitalization for cardiac causes, 13 (1.4%) patients had at least moderate mitral insufficiency on follow-up echocardiography and, of these, seven patients underwent reoperation (0.8%). The cumulative hazard showed that 8.3% of patients experienced at least one event at 5 years. NYHA class improved significantly with 874 patients in NYHA class I, 13 in NYHA class II, 6 in NYHA class III, and 0 in NYHA class IV at last follow-up (p < .001 from baseline as reference point). CONCLUSIONS: In a high-volume center, mitral valve surgery using a minimally invasive approach is a feasible treatment option for all-comers and is associated with excellent results that are maintained at clinical and echocardiographic follow-up.

A new technique to adjust the length of artificial chordae during mitral anterior leaflet repair.

BACKGROUND: Length measurement of artificial chordae remains a critical step during mitral valve repair (MVr). The aim of this study is to assess the effectiveness of a new length measuring technique. METHODS: All consecutive patients with anterior leaflet prolapse/flail who underwent MVr using the described method between January 2020 and January 2022 at our institution were included in the analysis. Clinical and transesophageal echocardiography data were collected postoperatively and at 1-year follow-up. The primary outcome was freedom from mitral regurgitation (MR). Secondary outcomes were presentation with New York Heart Association (NYHA) class <2 and leaflet coaptation length ≥10 mm. RESULTS: Of 25 patients, 16 (64%) were males. A total of 15 (60%) had isolated anterior leaflet disease, while 10 (40%) had concomitant posterior involvement. Twenty patients with isolated MR (80%) underwent right anterior mini-thoracotomy, while 5 (20%) with associated valvular or coronary disease underwent sternotomy. The median number of chordae implanted was 2 [1-4]. Postrepair intraoperative MR grade was 0 in 23 patients (92%) and 1 in 2 (8%). Thirty-day mortality was 0%. De novo atrial fibrillation was 20%. At follow-up, mortality was 0%. No patients presented with moderate or severe MR. A total of 22 patients (88%) were in NYHA class I, while 3 (12%) in class II. The coaptation length was 11 ± 1 mm. CONCLUSIONS: The short-term outcomes of the described technique are good with adequate leaflet coaptation in all treated patients. Long-term results are needed to assess the stability and durability of this repair technique.

A modified technique for aortic prosthesis implantation after prosthetic valve endocarditis complicated by complex paraannular aortic abscess.

The aim of this study is to describe a modified technique for aortic prosthesis implantation in the sinuses of Valsalva without the use of a patch for aortic annular reconstruction in patients with prosthetic valve endocarditis complicated by aortic abscess. From January 2008 to March 2021, 47 patients underwent aortic valve replacement due to prosthetic aortic valve endocarditis. The new aortic prosthesis was implanted into the sinuses of Valsalva above the abscess left open to drain. The first step consists in passing U-shaped stitches with pledgets through the aortic wall approximately 5-7 mm above the abscess involving the annulus. In the second step, the prosthesis is fixed to the aortic wall. In the third step, a 10 mm wide Teflon strip is positioned along the external course of the aortic wall and U-shaped stitches without pledgets are passed from the outside to the inside to definitively fix the prosthetic annulus to the sinuses of Valsalva. In-hospital mortality was 8.5% (4/47 patients). Mean follow-up was 62 ± 37.7 months. Four patients died (9.3%). Predicted probability of cardiac vs non-cardiac mortality was not statistically significant (p = 0.88). Overall survival probability (freedom from all-cause death) at 3, 7 and 9 years was 97%, 87.5% and 75%, respectively. No patients presented with grade 2 or 3 peri-prosthetic leak, nor had endocarditis. Prosthetic valve endocarditis complicated by complex paraannular aortic abscess can be successfully addressed with good long-term results by using our alternative technique.

Minimally invasive approaches to primary cardiac tumors: A systematic review and meta-analysis.

OBJECTIVE: Cardiac tumors are rare conditions. The vast majority of them are benign yet they may lead to serious complications. Complete surgical resection is the gold standard treatment and should be performed as soon as the diagnosis is made. Median sternotomy (MS) is the standard approach and provides excellent early outcomes and durable results at follow-up. However, minimally invasive (MI) is gaining popularity and its role in the treatment of cardiac tumors needs further clarification. METHODS: A systematic literature review identified 12 candidate studies; of these, 11 met the meta-analysis criteria. We analyzed outcomes of 653 subjects (294 MI and 359 MS) with random effects modeling. Each study was assessed for heterogeneity. The primary endpoints were mortality at follow-up and tumor relapse. Secondary endpoints included relevant intraoperative and postoperative outcomes; tumor size was also considered. RESULTS: There were no significant between-group differences in terms of late mortality (incidence rate ratio [IRR]: MI vs. MS, 0.98 [95% confidence interval [CI]: 0.25-3.82], p = .98). Few relapses (IRR: 1.13; CI: 0.26-4.88; p = .87) and redo surgery (IRR: 1.92; 95% CI: 0.39-9.53; p = .42) were observed in both groups; MI approach resulted in prolonged operation time but that did not influence the clinical outcomes. Tumor size did not significantly differ between groups. CONCLUSION: Both MI and MS are associated with excellent early and late outcomes with acceptable survival rate and low incidence of recurrences. This study confirms that cardiac tumor may be approached safely and radically with a MI approach.

Minimally Invasive Mitral Valve Repair for Standalone Secondary Mitral Regurgitation.

BACKGROUND: Chronic secondary mitral valve regurgitation is associated with a poor prognosis. Yet, in contrast to primary mitral regurgitation, there is no clear evidence that a reduction in regurgitation improves survival. The limited availability of data regarding secondary mitral regurgitation has resulted in a low level of evidence for treatment recommendations. We evaluated the influence of minimally invasive mitral valve annuloplasty on survival, freedom from recurrent regurgitation, and other echocardiographic parameters in patients with "standalone" secondary mitral valve regurgitation. METHODS: The analysis included patients with severe secondary mitral regurgitation, left ventricular function <40%, and persistent symptoms, despite optimal medical therapy. We excluded patients who were eligible for coronary artery revascularisation or cardiac resynchronisation therapy (i.e., not standalone mitral regurgitation). After discharge, patients were scheduled for outpatient clinic follow-up at 1, 3, 6, and 12 months. RESULTS: From 2012 to 2018, 54 consecutive patients underwent minimally invasive mitral valve annuloplasty for severe standalone secondary mitral regurgitation. All patients were discharged with no or trivial residual regurgitation. The mean duration of follow-up was 33.5±16.8 months. Overall survival was 90% at 4 years postprocedure. Freedom from moderate regurgitation or reintervention was 89% at the 4-year follow-up. There was a low incidence of readmission for heart failure and patients showed consistent improvements in left ventricular function and symptoms. CONCLUSIONS: Mitral valve repair with reduction and stabilisation of the annulus may be beneficial for symptomatic patients with secondary stand-alone mitral regurgitation.

Deceptive appearance of a rapidly growing left atrial myxoid sarcoma with pancreatic metastasis.

The third case reported in the literature of a left atrial neoplasm characterized by a very deceptive, low grade cellular component at its early stage of growth, so as to be diagnosed as a myxoma is presented. Two months after surgical excision, regrowth of the mass occurred, producing a pancreatic mass also. The new atrial mass was excised; a left atrial myxoid sarcoma and a pancreatic metastasis were diagnosed. One week later the atrial sarcoma grew again. This time surgery was contraindicated and the patient underwent chemotherapy with a satisfactory control of the sarcoma growth. The myxoid sarcoma may present with the deceptive appearance of a myxoma in their early stages. Therefore, patients who have undergone surgical removal of a myxoma should have a close follow-up to monitor unexpected malignant turnover.

A modified surgical ablation line for atrial fibrillation. The Bachmann line.

Surgical treatment of atrial fibrillation generally consists in the isolation of the pulmonary veins ("box-lesion"). Bachmann's bundle is a cardiac structure that may play an important role in the genesis of the atrial fibrillation. Surgical isolation of such bundle has not been reported before. We aim to describe how to perform minimally invasive epicardial pulmonary vein isolation along with the isolation of the Bachmann's bundle. Adding the surgical ablation line of Bachmann's bundle is a feasible, fast, and easy procedure that may be contribute to the reduction of atrial fibrillation relapses.

Redo mitral valve repair with complete ring implantation over an open band.

We present a case of redo mitral valve surgery after failed repair that consisted of implantation of a complete ring over an open band implanted several years prior. The patient presented with severe central mitral regurgitation. During surgical intervention, the open band was identified consolidated with the native annulus. We elected not to remove the posterior annulus given the presence of calcification. Instead, a new complete ring was secured with single sutures posteriorly over the band and anterior to the native annulus. This approach was safe, fast, and achieved a significant reduction in annulus circumference with no residual mitral regurgitation.

Fibonacci's Golden Ratio-An Innovative Approach to the Design and Management of Extra-Corporeal Circulation.

Technological advances in the field of extracorporeal circulation (ECC) over the past decade have led to numerous methods for monitoring metabolism and coagulation during cardiopulmonary bypass (CPB), as well as materials with improved biocompatibility, which has reduced the risk associated with cardiopulmonary bypass. However, ECC is still predominantly based on a traditional design that involves the use of roller pumps. This exposes the patient to a variety of pathophysiological consequences, both intra- and postoperative, such as postoperative cognitive disorders, hemolysis and hemodilution, systemic inflammation and changes in coagulation. This article describes the advantages of an ECC circuit inspired by the Fibonacci Golden Ratio, which does not use a roller pump, in a prospective study on patients undergoing elective cardiac surgery, compared to conventional ECC. During CPB, echocardiography was used to estimate the quality of fluid dynamics in the extracorporeal circuit and the patient's arterial vessels, a DO2 management system was used to evaluate metabolism, and an electronic system was used to determine gaseous microemboli (GME) counts. Fibonacci ECC offered superior intraoperative fluid dynamics, reduced the production of and improved the elimination of GME, and improved intraoperative metabolism, particularly with regard to oxygen delivery and extraction. The improvements in fluid dynamics and metabolic variables were associated with a reduction in the incidence of pathophysiological events compared to the conventional system, particularly regarding transitory cognitive disorders, and a shorter stay in intensive care.

Cryoglobulinemia: the "cold" problem in cardiac surgery, a single-center experience and a literature review.

Cardiac surgery with cardiopulmonary bypass (CBP) is essential for different cardiac procedures in order to perform surgery with a clear sight field.To safely perform surgery with CPB and preserve brain, kidney, and patient tissue from ischemic damage, cold cardioplegia, and mild to deep hypothermia are induced during the operation.Cryoglobulinemia is a hematological/infective-related disease (in certain cases idiopathic) in which temperature-dependent antibodies tend to aggregate and form emboli in the vascular system causing tissue damage if exposed to low temperature.The patient with cryoglobulinemia (known and unknown) can be at risk of a major ischemic event during CPB and induced hypothermia.This article's aim is to evaluate the present scientific literature in order to understand how, in years, the therapeutic or preventive approach, is evolving, and to analyze and make improvements to the management of a cryoglobulinemic patient who must undergo elective or emergency cardiac surgery.In the last part of our article, we expose our single-center experience during a 32-month-long period of survey.In all cases, our medical team (anesthesiologists, perfusionists, and cardiac surgeons) opted for a normothermic cardiopulmonary bypass to lower the risk of cryoglobulin-associated complications.In our experience, along with therapeutic intervention to lower the cryoglobulin titer, normothermic management of cardiopulmonary bypass is as safe as hypothermic management.Notwithstanding our results, further studies with a larger population are needed to confirm this perioperative management in a cardiac surgery setting.

Cardiac Surgery in Nonagenarians Following the TAVI/TMVI Era: A Multicenter 23-Year Comparative Analysis.

BACKGROUND: Studies reporting on the outcome of 90-year-old patients undergoing cardiac surgery are scant in literature; and currently, those regarding the implementation of trans-catheter techniques number even fewer. METHODS: We compared patients aged >89 years operated on between 1998 and 2008 at 8 Italian cardiac surgery centers, with patients of the same age operated on between 2009 and 2021. All of the patients were operated on with "open" surgery, with the exclusion of percutaneous valve repair/implantation procedures. RESULTS: The patients of the two groups (group 98-08-127 patients, and group 09-21-101 patients) had comparable preoperative risk factors in terms of the LogEuroSCORE (98-08: 21.3 ± 6.1 vs. 09-21: 20.9 ± 11.1, p = 0.12). There was a considerable difference in the type of surgery (isolated valve, isolated coronary, and combined surgery, 46.5, 38.5, and 15% vs. 52, 13, and 35% in 98-08 and 09-21, respectively, p = 0.01). Analogous operating durations were recorded (cross-clamp time: 98-08: 46 ± 28 min vs. 09-21: 51 ± 28 min, p = 0.06). The number of packed bypasses was lower in 09-21 (1.3 ± 0.6 vs. 2.4 ± 1.2, p = 0.001). In the postoperative period, there was a statistically significant difference in the 30-day survival in favor of the "more recent" patients (98-08: 17 deaths (13.4%) versus 09-21: 6(5.9%); p = 0.001), also confirmed in the subgroups (12.2% vs. 0% in isolated coronary surgery, p < 0.001; and 12.3% vs. 0% in isolated valve surgery, p < 0.001). CONCLUSIONS: Accurate pre-, intra-, and post-operative evaluation/management to reduce biological impacts facilitate significant improvements in the outcomes in nonagenarian patients when compared to the results recorded in previous years.