Observed versus predicted mortality after isolated tricuspid valve surgery.

BACKGROUND: Aim of this study is to analyse the performances of Clinical Risk Score (CRS) and European System for Cardiac Operative Risk Evaluation (EuroSCORE)-II in isolated tricuspid surgery. METHODS: Three hundred and eighty-three patients (54 ± 16 year; 54% female) were enrolled. Receiver operating characteristic analysis was performed to evaluate the relationship between the true positive fraction of test results and the false-positive fraction for a procedure. RESULTS: Considering the 30-day mortality the area under the curve was 0.6 (95% confidence interval [CI] 0.50-0.72) for EuroSCORE II and 0.7 (95% CI 0.56-0.84) for CRS-score. The ratio of expected/observed mortality showed underestimation when considering EuroSCORE-II (min. 0.46-max. 0.6). At multivariate analysis, the CRS score (p = .005) was predictor of late cardiac death. CONCLUSION: We suggest using both scores to obtain a range of expected mortality. CRS to speculate on late survival.

Surgical management of multiple giant coronary artery aneurysms determining myocardial ischemia.

Coronary artery aneurysms (CAAs) are rare lesions in which the optimal management is poorly defined. We present a series of three patients with diffuse symptomatic coronary artery disease and giant CAAs, on the circumflex branch (6 × 5 cm - Patient 1), on the proximal right coronary artery (5 × 6 cm - Patient 2) and on the proximal left anterior descending (LAD) (4 × 5 cm - Patient 3). Standard coronary artery bypass grafting (LIMA-on-LAD plus sequential saphenous vein) and associated CAA exclusion by proximal and distal ligation was performed according to the coronary anatomy. Six month follow-up computed tomography scan control showed complete exclusion of the CAA in all three patients.

Minimally invasive implantation of a Sapien 3 Ultra Valve in a degenerated tricuspid bioprosthesis.

Surgical management of patients affected by structural valve deterioration of bioprostheses in tricuspid valve position represents a challenge. Furthermore, transcatheter valve-in-valve implantation (TVIVI) recently emerged as an interesting option in high-risk surgical patients. When surgery is performed, replacement of the dysfunctional tricuspid bioprosthesis could be a difficult procedure due to the risk of heart rupture during the prosthesis removal. Herein we report the case of a 52-year-old female patient in which a transcatheter TVIVI was successfully performed under direct vision as a bailout strategy due to the impossibility of bioprosthesis removal.

Minimally invasive transatrial repair of posterior left ventricular aneurysm.

Left ventricular aneurysms (LVA) are a complication of myocardial infarction, that rarely involve the posterior wall; surgical repair of posterior LVA poses a technical challenge when associated with concomitant mitral regurgitation. We describe a minimally invasive treatment of ischemic MR and concomitant patch exclusion of posterior LVA through a right minithoracotomy. Using a transatrial approach, the aneurysm is closed with a "U" shaped dacron patch, whose base is anchored to the mitral annulus. Two patients were operated by this method with excellent results.

Mitral Valve Repair with a Semi-Rigid C-Band Annuloplasty Ring in Ischemic Mitral Regurgitation: Still a Viable Surgical Option?

BACKGROUND: Ischemic mitral valve regurgitation (IMR) develops in approximately 10% of patients after myocardial infarction. Surgical management of IMR is controversial, as many series have failed to demonstrate the superiority of mitral valve repair (MVRep) over mitral valve replacement (MVR) in IMR. Moreover, in the setting of MVRep, the choice of ring type is the subject of much debate. The study aim was to evaluate the results of MVRep in IMR with the use of a semi-rigid incomplete C-ring. METHODS: Between January 2006 and May 2014, a total of 105 patients (79 males, 26 females; mean age 69 ± 8 years) underwent surgical MVRep using a semi-rigid incomplete ring (median size 30 mm) during coronary artery bypass grafting (CABG) to treat IMR. The patients' mean logistic EuroSCORE was 14 ± 12, and the preoperative left ventricular ejection fraction was 43 ± 11%. The mean duration of follow up was 48 ± 31 months, and was 100% complete. RESULTS: In-hospital mortality was 6.6% (n = 7). The main predictor of in-hospital mortality was cardiopulmonary bypass time (p <0.05). Echocardiography performed at discharge showed moderate mitral regurgitation (MR) in only one patient, and significant reductions in left ventricular end-diastolic diameter (p <0.0001) and MR grade (p <0.0001). After seven years, freedom from all-cause death was 73 ± 9%, while freedoms from recurrence of MR grade ≥2 and NYHA class >II were 95 ± 3% and 89 ± 4%, respectively. Freedom from reintervention was 100%. CONCLUSIONS: Despite the adverse prognosis of IMR, the present study demonstrated the effectiveness and durability of mitral valve repair with the use of a semi-rigid ring, as a concomitant procedure to CABG, showing good results in terms of recurrence of MR and event-free survival at mid-term follow up.

Transcatheter aortic valve replacement for a bicuspid aortic valve following replacement of the ascending aorta.

A normally functioning bicuspid aortic valve that is spared during replacement of the ascending aorta may ultimately require replacement due to structural deterioration. We report the use of transcatheter aortic valve replacement to replace a stenotic BAV 17 years following replacement of the ascending aorta.

Fate of Normally Functioning Bicuspid Aortic Valve in Patients Undergoing Ascending Aorta Surgery.

BACKGROUND AND AIM OF THE STUDY: Bicuspid aortic valve (BAV), though normally functioning, is frequently associated with dilatation of the aortic root and ascending aorta. Optimal surgical treatment remains controversial. The study aim was to evaluate the fate of the normally functioning spared BAV at long-term follow up. METHODS: Forty patients (26 males, 14 females; mean age 59 +/- 11 years; range: 38-81 years) who underwent aortic surgery for proximal aortic disease between 1996 and 2011, with spared BAV at surgery, were included in the study. The main indication for surgery was ascending aorta aneurysm. Of the patients, 37 had ascending aorta replacement and three underwent a semi-Yacoub procedure. Adjunctive subcommissural annuloplasty was performed in 12 cases. The clinical and echocardiographic follow up (median 62 months; range: 7-175 months) was 100% complete. RESULTS: In-hospital survival was 100%. Pre-discharge echocardiography showed no cases of significant aortic regurgitation (grade > or = 3+) or stenosis. The probability of survival at five and 10 years was 93 +/- 7% and 79 +/- 10%, respectively. Two surviving patients (5%) required reoperation for the development of aortic insufficiency. Freedom from aortic valve replacement was 100% and 90 +/- 10% at five and 10 years, respectively, and freedom from thromboembolic or bleeding events was 100% and 90 +/- 10% at five and 10 years, respectively. No cases of endocarditis were reported. The composite event-free survival at five and eight years was 85 +/- 6% and 69 +/- 11%, respectively. There were no cases of root enlargement during the follow up period. CONCLUSION: A spared BAV offers a good time-span of functional integrity. The conservative approach seems to be a valid strategy, with a low risk of reintervention and cardiovascular events during long term follow up, in selected patients.

Long-term mitral valve repair outcomes and hospital volume: 15 years' analysis of an administrative dataset.

BACKGROUND: Procedural volume has been documented as an important contributor to operative outcomes for most complex surgical procedures. Mitral valve repair (MVRep) has been associated with excellent results, and it is increasingly adopted in many cardiac surgical centers. We sought to investigate if procedural volume is associated with better clinical long-term outcomes after MVRep. METHODS: We analyzed the 10-year outcomes after MVRep by procedural volume for each cardiac surgery center in an Italian Region, Lazio, during the last 15 years, using a regional administrative dataset. RESULTS: Between 2006 and 2020, 4961 patients were treated in seven cardiac surgery centers for an isolated mitral valve surgery (2677 underwent MVRep). At multivariate analysis, mitral valve replacement (MVR) (vs. MVRep) resulted one of the independent predictors of 30-day mortality [adjusted odds ratio (OR) 3.40; 95% confidence interval (CI) 1.96-5.90; P  < 0.0001]. Notably, a clear association between hospital volume of mitral valve surgery (>40 per year) and high rate of MVRep (>50%) was found. At 10 years, the incidence of mortality and the rate of death and rehospitalization for heart failure after MVRep were significantly lower in high-volume vs. low-volume hospitals. CONCLUSION: Our data suggest that hospital volume is associated with a high rate of MVRep and long-term benefits in terms of mortality and recurrence of heart failure.

Extended septal myectomy for obstructive hypertrophic cardiomyopathy and its impact on mitral valve function.

AIMS: Septal myectomy is the treatment of choice for hypertrophic obstructive cardiomyopathy (HOCM). Around 30-60% of patients with HOCM have a secondary mitral valve regurgitation due to systolic anterior motion (SAM). We report our experience with extended septal myectomy and its impact on the incidence of concomitant mitral valve procedures. METHODS: This is a retrospective study on 84 patients who underwent SM from January 2008 to February 2022. Surgical procedure was performed according to the concept of 'extended myectomy' described by Messmer in 1994. Follow-up outcomes in terms of survival, hospital admissions for heart failure or MV disease, cardiac reoperations, and pacemaker (PMK) implantation were recorded. RESULTS: Mean age was 61 ±â€Š15 years. Mitral valve surgery was performed in seven cases (8%); particularly only one patient without degenerative mitral valve disease underwent mitral valve surgery, with a plicature of the posterior leaflet. In-hospital mortality was 5%. Mitral valve regurgitation greater than mild was present in four patients (5%) at discharge. Twelve-year survival was 78 ±â€Š22%. Cumulative incidence of rehospitalization for heart failure and rehospitalization for mitral valve disease was 10 ±â€Š4 and 2.5 ±â€Š2.5%, respectively. PMK implantation was 5% at discharge, with a cumulative incidence of 15 ±â€Š7%. Freedom from cardiac reoperations was 100%. CONCLUSION: Septal myectomy for HOCM is associated with good outcomes. Although concomitant surgery on the mitral valve to address SAM and associated regurgitation has been advocated, these procedures were needed in our practice only in patients with intrinsic mitral valve disease. Adequate myectomy addresses the underlying pathophysiology in most patients.

Panoramic on Epigenetics in Coronary Artery Disease and the Approach of Personalized Medicine.

Epigenetic modifications play a fundamental role in the progression of coronary artery disease (CAD). This panoramic review aims to provide an overview of the current understanding of the epigenetic mechanisms involved in CAD pathogenesis and highlights the potential implications for personalized medicine approaches. Epigenetics is the study of heritable changes that do not influence alterations in the DNA sequence of the genome. It has been shown that epigenetic processes, including DNA/histone methylation, acetylation, and phosphorylation, play an important role. Additionally, miRNAs, lncRNAs, and circRNAs are also involved in epigenetics, regulating gene expression patterns in response to various environmental factors and lifestyle choices. In the context of CAD, epigenetic alterations contribute to the dysregulation of genes involved in inflammation, oxidative stress, lipid metabolism, and vascular function. These epigenetic changes can occur during early developmental stages and persist throughout life, predisposing individuals to an increased risk of CAD. Furthermore, in recent years, the concept of personalized medicine has gained significant attention. Personalized medicine aims to tailor medical interventions based on an individual's unique genetic, epigenetic, environmental, and lifestyle factors. In the context of CAD, understanding the interplay between genetic variants and epigenetic modifications holds promise for the development of more precise diagnostic tools, risk stratification models, and targeted therapies. This review summarizes the current knowledge of epigenetic mechanisms in CAD and discusses the fundamental principles of personalized medicine.

Transcatheter aortic valve implantation in patients with age ≤70 years: experience from two leading structural heart disease centers.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is emerging as an appealing management strategy for patients with severe aortic stenosis at intermediate, high or exceedingly high risk, but its risk-benefit profile in younger patients is less certain. We aimed to explore the outlook of patients aged 70 years or less and undergoing TAVI at 2 high-volume Italian institutions. METHODS: We retrospectively collected baseline, imaging, procedural and outcome features of patients with age ≤70 years in whom TAVI was attempted at participating centers between 2012 and 2021. Non-parametric tests and bootstrap resampling were used for inferential purposes. RESULTS: A total of 39 patients were included, out of >3000 screened with heart team involvement and >1500 receiving TAVI. Most common or relevant indications for TAVI reduced life expectancy (e.g. cardiogenic shock or severe left ventricular systolic dysfunction), chronic obstructive pulmonary disease, morbid obesity, active or recent extra-cardiac cancer, porcelain aorta, neurologic disability, cirrhosis, or prior surgical aortic valve replacement, as well as extreme cachexia, and Hutchinson-Gilford progeria. At least two contemporary high-risk features were present in most cases. Transapical access was used in 5 (12.8%) cases, and a sheathless approach in 15 (38.5%). A variety of devices were used, including both balloon- and self-expandable devices. Clinical outcomes were satisfactory, despite the high-risk profile, at both short- and mid-term, with no in-hospital death, and 5.1% (95% confidence interval 0-12.8%) mortality at a median follow-up of 15 months (minimum 1; maximum 85). Notably, no case of significant valve deterioration requiring reintervention occurred. CONCLUSIONS: In carefully selected patients with 70 years or less of age and prohibitive risk for surgery or reduced life expectancy, TAVI represents a safe option with a favorable mid-term survival and low rate of adverse events.

Prognostic role of endocarditis in isolated tricuspid valve surgery. A propensity-weighted study.

OBJECTIVES: The role of the underlying etiology in isolated tricuspid valve surgery has not been investigated extensively in current literature. Aim of this study was to analyse outcomes of patients undergoing surgery due to endocarditis compared to other pathologies. METHODS: The SURTRI study is a multicenter study enrolling adult patients who underwent isolated tricuspid valve surgery (n = 406, 55 ± 16 y.o.; 56% female) at 13 international sites. Propensity weighted analysis was performed to compare groups (IE group n = 107 vs Not-IE group n = 299). RESULTS: No difference was found regarding the 30-day mortality (Group IE: 2.8% vs Group Not-IE = 6.8%; OR = 0.45) and major adverse events. Weighted cumulative incidence of cardiac death was significantly higher for patients with endocarditis (p = 0.01). The composite endpoint of cardiac death and reoperation at 6 years was reduced in the Group IE (63.2 ± 6.8% vs 78.9 ± 3.1%; p = 0.022). Repair strategy resulted in an increased late survival even in IE cases. CONCLUSIONS: Data from SURTRI study report acceptable 30-day results but significantly reduced late survival in the setting of endocarditis of the tricuspid valve. Multi-disciplinary approach, repair strategy and earlier treatment may improve outcomes.

Surgical Management of Acute Myocardial Infarction Caused by Intramural Anomalous Left Coronary Artery in a Young Female Athlete.

In the complex spectrum of coronary anomalies, the origin of the left coronary artery from the right sinus of Valsalva with intramural course could represent a catastrophic life-threatening condition leading to extensive myocardial infarction and sudden cardiac death, especially in young athletes. We report the case of a young female athlete with anomalous left coronary artery from the opposite sinus who survived a major non-ST-elevation myocardial infarction during the eighth kilometer of a running race. It was successfully treated by creating a neo-ostium of the left coronary artery in the left sinus at the point at which the artery left the aortic wall.

A Redo Percutaneous Emergency Intervention of Left Ventricular Assist Device Graft Occlusion.

In patients with advanced heart failure (HF), left ventricular assist devices (LVADs) have demonstrated to be effective in improving the quality of life and reducing further hospitalizations. Although uncommon, LVAD outflow graft obstruction (OGO) is a potentially life-threatening complication and percutaneous treatment has been proposed as a standard intervention strategy in such cases. We report the case of a 69 year old man admitted due to LVAD failure causing unstable HF. Past medical history included percutaneous intervention on the outflow graft with stent implantation one year before. The patient was under chronic treatment with vitamin K antagonists (VKA). Emergent percutaneous angiography was performed, showing recurrent OGO due to thrombosis located at a kinking site, distally to the previously treated segment. Using distal anchoring technique, a balloon-expandable 10 × 79 mm endoprosthesis (GORE® Viabahn® VBX) was effectively positioned and post-dilated. Final angiography confirmed the patency of the stent implanted one-year before. Despite the procedure succeeding in restoring LVAD function, the patient died due to septic shock ten days after. Our case suggests that recurrent OGO can be effectively treated with percutaneous redo and that long-term stent patency can be achieved with a standard antithrombotic treatment, despite further thrombotic events in other segments of the graft are still possible (especially at the kinking site). Moreover, other noncardiac conditions as infective complications, can dramatically impact the clinical course and lead to unfavorable outcomes.

Outcome of patients undergoing isolated tricuspid repair or replacement surgery.

OBJECTIVES: The interest in isolated tricuspid valve disease has rapidly increased recently. However, clinical trials and registry data are rare in the surgical literature. This study aimed to describe the early and long-term outcomes of a real-world experience in isolated tricuspid procedures comparing repair and replacement strategies. METHODS: The Surgical-Tricuspid study is a multicentre retrospective study that enrolled adult patients who had undergone isolated tricuspid valve surgery at 13 international sites. Propensity score-matched analysis was used to compare repair versus replacement. RESULTS: A cohort of 426 patients was enrolled [mean age: 55 (16) years; 56% female]. After matching, 175 comparable pairs were analysed. Preoperative left ventricular ejection fraction was 55(9) vs 56(9) (P = 0.8) while moderate-severe tricuspid regurgitation was present in 95% of cases. The 30-day mortality rate was 4.0% vs 8.0% in the repair and replacement groups, respectively (P = 0.115). The rates of re-exploration for bleeding (6.9% vs 13.1% P = 0.050), permanent pacemaker implantation (5.1% vs 12.0%; P = 0.022) and blood transfusion (46% vs 62%; P = 0.002) were higher in the replacement group. Cumulative survival rates at 3, 5 and 7 years in the repair group were 84 (3)%, 75 (4)% and 56 (9)% vs 71 (4)%, 66 (5)% and 58 (5)% in the replacement group (P = 0.001) while cumulative incidence for reoperation at 10 years did not differ between groups [repair 10 (1)% vs replacement 9 (1)%; P = 0.469]. CONCLUSIONS: The data from the Surgical-Tricuspid study reported a high risk for patients undergoing tricuspid surgery. Isolated valve repair offered reduced early and late mortality with no difference regarding reoperation rate when compared with replacement.

Beating Versus Arrested Heart Isolated Tricuspid Valve Surgery: Long-term Outcomes.

BACKGROUND: Isolated tricuspid valve (TV) surgery is a rare procedure generally considered at high risk for perioperative mortality and poor long-term outcomes. Surgical treatment can be performed with either an arrested heart (AH) or beating heart (BH) technique. The aim of this study was to compare the outcomes of isolated tricuspid surgery with 2 different approaches. METHODS: The Surgical-Tricuspid Study is a multicenter international retrospective study enrolling adult patients who underwent isolated TV procedures (n = 406; age 56 ± 16 years; 56% female) at 13 international sites. The AH and BH strategies were performed in 253 and 153 patients, respectively. Propensity score-matched analysis was used to compare groups. RESULTS: After matching, 129 pairs were obtained and analyzed. The 30-day mortality rate was 6.2% versus 5.0% in the AH and BH groups, respectively (P = .9). The rates of acute renal failure requiring replacement therapy (10% versus 3%; P = .02) and stroke (1.6% versus 0%; P = .08) were numerically higher in the AH group. The 6-year survival rate was 67% ± 6% versus 78% ± 5% in the AH and BH groups, respectively (P = .18), whereas freedom from cardiac death was 75% ± 5% versus 84% ± 4% (P = .21). The 6-year composite cardiac end point of cardiac death and reoperation rate was 60% ± 9% versus 86% ± 5% (P = .024) comparing AH-TV replacement and BH-TV repair groups. CONCLUSIONS: Isolated TV surgery performed with a BH strategy is a safe option and resulted in a trend of increased long-term survival and freedom from reoperation compared with the standard AH technique. Patients undergoing BH valve repair had the best long-term outcome.

A new device to treat mitral valve regurgitation: a proof of concept in bench test study.

Mitral valve repair is typically performed by implanting a ring-like device at the valve annulus to reshape the annulus and to improve leaflet coaptation. In most cases, some additional procedures are needed, including leaflet resection and artificial chordae implantation. However, artificial chordae implantation could be technically challenging and postoperative left ventricular remodeling could increase the risk of recurrent mitral regurgitation. We propose an innovative annular device made of chromo-cobalt, finalized not only to reshape the annulus but also to enable anchoring of leaflets to a fixed intraventricular structure. Durability evaluation of the device was tested by applying eight radial force vectors equally spaced along the ring and related fatigue analysis. To evaluate the efficacy of the mitral valvuloplasty using the tested ring, the device was implanted in five adult swine hearts. Functional analysis of the ring was performed by measuring left ventricular pressure and fluid volume loss, following implantation in normal and dysfunctional mitral valve leaflets. Both fatigue and functional analysis showed satisfactory and promising results in terms of durability and efficacy of mitral valve repair. Because of its favorable durability and functional characteristics this device appears promising and provides good results in terms of valve competence, thus avoiding both manipulations of papillary muscles and interference in left ventricular hemodynamics. However, an in vivo test is mandatory to fully understand the impact of the device on subvalvular apparatus.

Robotic transareolar mitral valve repair.

In recent years, the treatment of mitral valve disease with robotic surgery has been increasingly successful, having produced excellent postoperative results and significant cost-savings. However, minimal  experience exists with robotic mitral valve repair using transareolar access. We demonstrate mitral valve repair using the DaVinci Robot Xi through a transareolar approach, showing the technical details of our surgical technique.

Comparable outcomes between genders in patients undergoing surgical ventricular reconstruction for ischaemic heart failure.

AIMS: Female sex and heart failure (HF) are considered poor prognostic factors for surgery. We aimed to investigate the association between sex and surgical outcomes in patients with ischaemic HF undergoing surgical ventricular reconstruction and coronary artery bypass grafting. METHODS AND RESULTS: From July 2001 to June 2017, 648 patients [111 women (17%) and 537 men (83%)] were referred to our centre. Follow-up continued through June 2018. All patients underwent surgical ventricular reconstruction; coronary artery bypass grafting was performed in 582 patients (90%). Primary outcome was defined as all-cause mortality. Secondary outcome included all-cause mortality or all-cause hospitalization. Women were older (70 vs. 65 years, P < 0.0001) with lower body surface area (1.70 vs. 1.86 m2 , P < 0.0001). Women had more diabetes (36% vs. 24%, P = 0.005) and a higher New York Heart Association classification (Class III/IV 65.7% vs. 47.8%, P = 0.0006), without any significant difference in medical therapy except for a higher use of oral antidiabetic agents in women (P = 0.029). At baseline, the left ventricular (LV) end-diastolic volume index was significantly lower in women [median 107.06 (80.6-127.81) vs. 113. 04 (94.33-135.52) mL/m2 , P = 0.0078] but not the LV end-systolic volume index (ESVI) [median 73.45 (51.93-96.79) vs. 77.03 (60.33-95.71) mL/m2 , P = 0.1393] and the ejection fraction (median 31% vs. 32%, P = 0.150). Women had a higher rate of anterior remodelling (90.9% vs. 79.1%, P = 0.0129), without evidence of differences in mitral valve insufficiency (P = 0.761 for Grade 0 to 4) and mitral surgery (P = 0.810). After surgery, the percentage of reduction in LV ESVI was higher in women than in men (median ΔLV ESVI -42.06 vs. -31.99, P = 0.0003). Mortality within 30 days occurred in 43 patients (6.64%): 12 women (10.81%) and 31 men (5.77%, P = 0.0522). Over a median follow-up of 9.8 years, all-cause mortality occurred in 269 patients (41.64%), without significant difference between women (45.9%) and men (40.7%). There was no evidence of difference of all-cause death between sexes (log-rank = 0.2441). When considering mortality and first hospitalization as competing events, Gray's test showed no difference of cumulative incidence functions (all-cause hospitalization, all-cause death, and combined endpoint) according to sex (P = 0.909, P = 0.445, and P = 0.429, respectively). CONCLUSIONS: In this study, long-term outcomes for women and men with ischaemic HF undergoing complex cardiac surgery were equivalent. Albeit older and more symptomatic, women should not be denied this type of cardiac surgery.