Micro-Invasive 3D Endoscopic Mitral Valve Surgery.

Since its introduction in 1995, minimally invasive mitral valve surgery (MIMVS) has been shown to be a valid alternative to conventional sternotomy and several studies have reported excellent clinical outcomes. While MIMVS is now a commonly performed procedure, it is still difficult to standardize. We proprose here a "road to safer surgery", and offer some tips and tricks that could be useful in its learning and performance, and may help surgeons minimize the risk of major complications. With the introduction of 3D vision with a 3D videothoracoscope for 4K stereoscopic acquisition, a medical LCD ultra-HD monitor and active 3D glasses, it is possible to obtain a very realistic view of the surgical field and the mitral valve anatomy, while significantly reducing the learning curve. We describe the procedure step-by-step, with details from the pre-operative phase to the end of the operation. The procedure is structured in consecutive stages: patient induction and positioning, thoracoscopic access and port placement, surgical field exposure, and operative technique.

The HAS-BLED Score is Associated With Major Bleeding in Patients After Cardiac Surgery.

OBJECTIVE: The Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol (HAS-BLED) score has been developed to predict the risk of potential bleeding in anticoagulated patients affected by atrial fibrillation. The aim of this study was to test the hypothesis that the HAS-BLED score is associated with major bleeding also in patients after cardiac surgery. DESIGN: Prospective, single-center nonrandomized study. SETTING: Single hospital center. PARTICIPANTS: Patients. INTERVENTIONS: Standard cardiac operation and analysis of major bleeding events. A total of 1,173 consecutive adult patients who underwent cardiac surgery were recruited. Major bleeding was defined according to the Bleeding Academy Research Consortium classification (3, 4, 5). Bleeding events were classified as early bleeding (within 48 hours after the operation) and late bleeding (after 48 hours and within 90 days, postoperatively). Patients were followed after the discharge for 120 days, through outpatient clinic visits and by phone calls. MEASUREMENT AND MAIN RESULTS: A total of 29 (2.5%) patients experienced early bleeding events (2.5%), while 34 (2.9%) experienced late bleeding events. Univariate and multivariable analysis did not find that the HAS-BLED score was associated with early bleeding, but it was associated significantly with late bleeding (odds ratio [OR], 1.86; 95% confidence intervals [CI] 1.32-2.62, and OR 1.67; 95% CI 1.19-2.35, respectively). CONCLUSION: The HAS-BLED score is associated with increased risk of major bleeding events after cardiac surgery procedures. This may help to plan the standard anticoagulation/antiplatelet therapy in cardiac surgical patients with a higher HAS-BLED score.

An optimized procedure for on-tissue localized protein digestion and quantification using hydrogel discs and isobaric mass tags: analysis of cardiac myxoma.

An optimized workflow for multiplexed and spatially localized on-tissue quantitative protein analysis is here presented. The method is based on the use of an enzyme delivery platform, a polymeric hydrogel disc, allowing for a localized digestion directly onto the tissue surface coupled with an isobaric mass tag strategy for peptide labeling and relative quantification. The digestion occurs within such hydrogels, followed by peptide solvent extraction and identification by liquid chromatography coupled to high-resolution tandem mass spectrometry (LC-MS/MS). Since this is a histology-directed on-tissue analysis, multiple hydrogels were placed onto morphologically and spatially different regions of interest (ROIs) within the tissue surface, e.g., cardiac myxoma tumor vascularized region and the adjacent hypocellular area. After a microwave digestion step (2 min), enzymatically cleaved peptides were labeled using TMT reagents with isobaric mass tags, enabling analysis of multiple samples per experiment. Thus, N = 8 hydrogel-digested samples from cardiac myxoma serial tissue sections (N = 4 from the vascularized ROIs and N = 4 from the adjacent hypocellular areas) were processed and then combined before a single LC-MS/MS analysis. Regulated proteins from both cardiac myxoma regions were assayed in a single experiment. Graphical abstract The workflow for histology-guided on-tissue localized protein digestion followed by isobaric mass tagging and LC-MS/MS analysis for proteins quantification is here summarized.

Circulating non-hematological cells during cardiopulmonary bypass: new findings in cardiac surgery procedures.

BACKGROUND: Several factors have been historically advocated to explain the coagulative and inflammatory disorders following cardiopulmonary bypass (CPB). In this paper, we describe the presence of circulating non-hematological cells, introduced within the bloodstream during CPB. We defined the origin of the cells and tested their impact on coagulation. METHODS: We collected peripheral arterial blood samples in twenty consecutive coronary artery bypass graft cases at four different surgical moments and assessed the presence and nature of circulating cells with the use of the CELLSEARCH® Test, immunocytochemistry and immunofluorescence, evaluating the expression of cytokeratin and calretinin. The effect of the circulating non-hematological cells on coagulation was tested in vitro, using the ROTEM assay. RESULTS: A mean of 263.85 ± 57.5 (median 258.5) cells were present in the samples following the suction of blood from the surgical field while all the other samples were negative (zero cells) (p<0.00001). Immunologic tests confirmed the mesothelial origin of the cells. The ROTEM® assay of the blood samples contaminated by the mesothelial cells presented longer clotting times (53.4 ± 8.2 secs 48.3 ± 8.9 sec, p=0.05), longer clot formation times (137.1 ± 31.5 sec vs 111.9 ± 25.2 sec, p=0.009), smaller alfa angle amplitudes (66.7 ± 9.1° vs 71.1 ± 5.1°, p=0.04) and maximum clot firmness times (59.0 ± 5.4 sec vs 61.9 ±4.6 sec, p=0.004) than the controls. CONCLUSION: The presence of circulating non-hematological cells during CPB with a mesothelial immunophenotype alters in vitro coagulation assays. This finding can help to further understand the pathophysiology of CPB.

Distinctive phenogroup to differentiate diagnosis of cardiac myxoma vs cardiovascular disease examining blood-based circulating cell biomarkers.

Cardiac myxoma (CM) is a potentially life-threatening disease because frequently asymptomatic or debuts with aspecific manifestations. Definitive diagnosis is established by histopathological assessment including tumor and endothelial cell markers. To derive a specific panel of circulating cells antigenically detectable, pre-surgery peripheral blood samples of CM patients were analyzed. Pre-surgery peripheral blood samples from patients with CM were simultaneously analyzed for Circulating tumor cells (CTCs) and circulating endothelial cells (CECs) that were matched with tumor tissue profiles and with patient-derived xenografts (PDXs) distinguishing tumor regions. Moreover, CECs values in CM patients were further matched with CEC's levels in cardiovascular disease and control subjects. The blood-derived cytological specimens detected at least 1-3 CTCs/ml in 10 tested CM samples (p = 0.0001) showing specific CM features preserved in the central zones of the tumor. The central zone of the primary tumor, supported by a vessel density rate (55 ± 7%), with a proliferative profile of 32 ± 3% and a percentage of Calretininpos cells (p = 0.03), is the principal site of CTCs (r = 00) dissemination. The subsets of endothelial cells recognized in the blood were indifferent to their topological distribution within the tumor and corresponding PDXs. With further refinement and validation in large cohorts, multiparametric liquid biopsies can optimally integrate clinically informative datasets and maximize their utility in pre-surgery evaluation of CM patients. Blood-derived culture's protocol provides a versatile method capable of viable analysis of CTCs of non-hematological rare tumors which conventional antibody-mediated analytical platform is unable to perform. Distinctive blood- based cell phenotype contributes to differentiate CM from other differentials assuring its prompt surgical resection by combining blood-based cell biomarkers integrated with clinically informative datasets.

Massive Thrombosis of Mitral Bioprosthesis Due to SARS-CoV-2 Infection.

Thromboembolic events have been reported as frequent and fearsome complications in patients affected by SARS-CoV-2 infection. Patients undergoing cardiac valve replacement exhibit an increased risk of valve thrombosis, even with prosthetic biological valves, and especially in the first period after surgery. The management of these patients is challenging and requires prompt interventions. We report the case of a young woman infected by SARS-CoV-2 three months after double cardiac valve replacement that developed a massive prosthetic biological valve thrombosis despite optimal anticoagulant therapy.

On-Tissue Hydrogel-Mediated Nondestructive Proteomic Characterization: Application to fr/fr and FFPE Tissues and Insights for Quantitative Proteomics Using a Case of Cardiac Myxoma.

PURPOSE: The application of a methodology for quantitative protein analysis from formalin-fixed and paraffin-embedded (FFPE) tissue by using hydrogels. Miniaturized polymeric gels are placed onto histologically defined tissue regions in order to perform localized digestion for bottom-up proteomics. Hydrogel-extracted peptides are then labeled with tandem mass tags (TMT) reagents for relative protein quantification. A cardiac myxoma biopsy is used. EXPERIMENTAL DESIGN: Multiple hydrogels, incorporating the proteolytic enzyme trypsin, are placed on serial tissue sections, and processed for digestion and TMT derivatization. SCX fractionation before LC-MS/MS analysis and bioinformatics analysis are carried out. RESULTS: Two histologically different areas on both FFPE and frozen sections of the same cardiac myxoma biopsy are compared. In total, 1949 (FFPE) and 2491 (frozen) proteins are identified, with a total overlap of 56%. The quantitative comparison highlighted 15 (FFPE) and 138 (frozen) differentially expressed proteins between myxoma regions. CONCLUSION: The methodology successfully detects numerous protein signals from FFPE and frozen specimens and is able to differentiate between tissue regions. A fast and reliable tissue preparation for quantitative protein analysis by minimum sample manipulation is developed. This offers an option for on-tissue proteomics analysis while preserving the inherent spatial information on the tissue.

Identification of mesothelial cells in intraoperative blood salvage.

Intraoperative auto-transfusion with the use of cell saver systems is routinely used to reduce the rate of packed red blood transfusion in major surgery. Nevertheless some concerns have been raised on possible risks of coagulation disorders. The aim of the study was to analyze the blood processed by the cell saver, ready to be re-infused to the patient, in order to individuate unexpected cellular components, that can favor coagulopathy. We tested the blood processed by the cell saver in thirteen patients undergoing coronary bypass surgery with Cellsearch®, ScreenCell®, Cytology and Immunofluorescence. Those four methods allowed us to look for the presence of unexpected cells, quantify and characterize them. Furthermore, the blood processed by the cell saver was mixed with the patient's peripheral blood and analyzed with the ROTEM® thromboelastography. The Cellsearch® revealed and counted a mean number of 1241 unexpected cells/7.5 ml in the blood processed by the cell saver. The ScreenCell® and Cytology confirmed the presence of non-hematological cells. Immunofluorescence showed positivity for Calretinin and WT-1, confirming the mesothelial origin. Moreover we detected a peculiar arrangement of the platelets around the mesothelial cells in a "cloud" form, suggesting platelet activation. The ROTEM® analysis showed a significantly longer clot formation time, smaller clot amplitude and maximum clot firmness, compared to controls. In conclusion we demonstrated the presence of mesothelial cells in the cell saving blood, ready to be auto-transfused. This finding can contribute to develop a platelet depletion coagulopathy, with coagulation factors consumption.

Innate immunity in cardiac myxomas and its pathological and clinical correlations.

Cardiac myxomas are the most common benign cardiac tumor. We investigated the immunohistochemical properties of 11 surgically excised cardiac myxomas, in order to analyze the correlation between macrophages and mast cell populations and clinical parameters. CD68+/CD163-/iNOS- (M0) cells represent the most abundant macrophage phenotype; however, CD68+/CD163+ cells (M2) were also frequent. CD68+/iNOS+ (M1) elements were rare. Mast cells, defined as a population of c-kit (CD117)+ and/or tryptase+ cells were also detected. Statistical analysis showed significant correlations between c-kit (CD117)+ and tryptase, CD68 and erythrocyte sedimentation rate (ESR), ESR and red blood cell count (RBC), and prothrombin time and platelet count. The inverse correlation between RBCs in peripheral blood and ESR suggested that anemia associated with chronic inflammatory disease is a noncasual event in patients suffering from cardiac myxoma. Mechanical hemolysis may be only a minor component of anemia, according to the lack of correlation between echographic surface and RBCs. Moreover, tumor size did not correlate with ESR, showing that inflammatory state may depend from both tumor cells population and inflammatory infiltrate. In the future, modulation of macrophage polarization in cardiac myxomas might represent important therapeutic target.

Ischemic mitral valve regurgitation: the new challenge for magnetic resonance imaging.

Ischemic mitral valve regurgitation (IMVR) refers to mitral regurgitation in patients with ischemic heart disease (IHD) in the presence of a structurally normal mitral valve. IMVR contributes significantly to morbidity and mortality in patients with IHD. The thresholds for clinical management, surgical intervention, and the choice of surgical procedure continue to evolve and independent determinants for surgical success in the pre- and post-operative evaluation of IMVR are still controversial. Although echocardiography has been valued as the gold standard in the evaluation of IMVR, new technologies such as magnetic resonance imaging (MRI) may be seen as applicable to the investigation of this complex pathology. MRI may allow for detection of parameters that could help clinicians and surgeons to better assess IMVR and eventually guide appropriate treatment whenever necessary. The present article discusses the main parameters that should be routinely investigated while adopting MRI technology to assess patients with IMVR. The review is the result of a multidisciplinary approach to this complex etiopathogenic entity and involves expertise spanning from radiology, cardiology, to cardiac surgery.

Prosthesis embolization into the left ventricle during transcatheter aortic valve implantation.

: Images and movie clips documenting the rare occurrence of a percutaneous prosthesis embolization into the left ventricle are presented. The case outcome and the circumstances leading to the event are discussed.

A normogram to anticipate dimension of neo-sinuses of valsalva in valve-sparing aortic operations.

OBJECTIVE: The aim of the present study was to define a method to pre-determine the correct size of neo-sinuses of Valsalva in the reimplantation type of valve-sparing aortic operation. METHODS: The objective was achieved in three steps: (1) evaluation in the healthy population, of the normal size of sinuses of Valsalva expressed as the area surrounding fully opened aortic cusps, the so-called beyond leaflets area; (2) elaboration of a normogram by which, given a known annular diameter, it is possible to select the appropriate graft size to obtain a normal beyond leaflets area; (3) validation of the normogram by comparing, in a population of 20 patients undergoing a valve-sparing procedure, the predicted and observed beyond leaflets area. RESULTS: The following values for beyond leaflets area were observed: mean normal 320.6+/-120.6mm(2), mean predicted 355+/-63.2mm(2), mean observed 364.7+/-72.8mm(2).No significant differences were obtained for predicted versus observed values. Regression analysis showed a linear distribution with an r value of 0.95. CONCLUSIONS: We proposed a simplified approach for sizing of the neo-aortic root in the reimplantation type of valve-sparing aortic operation focussed on the size of sinuses of Valsalva. Our normogram showed to be reliable in anticipating beyond leaflets area. It can be helpful in avoiding the selection of an undersized or excessively oversized graft.

Surgical treatment of systemic embolization by cardiac metastasis of lung cancer.

Pulmonary vein infiltration from a malignant lung neoplasm is a serious condition that may result in a constant source of systemic emboli. Although surgery is often indicated to prevent recurrent embolism, aggressive approaches have shown a high rate of perioperative morbidity. We herein report the case of a patient diagnosed with lung cancer infiltrating the cardiac chambers through the left superior pulmonary vein, who was treated by left pulmonary vein patch closure as a preventive and less invasive measure to reduce the thromboembolic risk.

Extracorporeal membrane oxygenation for graft failure after heart transplantation: a multidisciplinary approach to maximize weaning rate.

OBJECTIVES: Primary graft failure (PGF) after heart transplantation is a detrimental complication, and carries high morbidity and mortality. The aim of this study was to analyze the results of our multidisciplinary approach in supporting patients affected with PGF after heart transplantation. METHODS: Out of 114 consecutive patients receiving orthotopic heart transplantation between January 2006 and July 2013, 18 (15.7%) developed PGF requiring veno-arterial extracorporeal membrane oxygenator (VA-ECMO) support. Fourteen patients were male and the mean age was 49±11 years. General principles in treating the patients were based on a low dose of adrenaline (0.05 mic/kg per min) infusion; femoral intra-aortic balloon pump (13 of the 18 patients); low dose of vasoconstrictors; careful fluid balance; daily echocardiographic transesophageal monitoring. RESULTS: Mean graft recipient pulmonary vascular resistance was 3.6±3.2 WU. Five patients had absolute contraindication to IABP placement. The mean left ventricle ejection fraction pre-VA-ECMO was 18.4%±10.2%. The mean VA-ECMO and IABP support times were 6.7±3.2 and 9.2±7.6 days, respectively. Mean VA-ECMO flow was 4164±679 l/min. The mean left ventricle ejection fraction increased to 43.4%±17.7% at the end of support. Weaning and discharge rates in patients treated with VA-ECMO+IABP were 84% and 53%, respectively. Causes of death were primarily end-stage organ failure. CONCLUSIONS: A multidisciplinary evaluation of ECMO patients done by intensivists, cardiologists, and surgeons may influence weaning and survival rate. Our approach seems to be a safe and reproducible strategy for avoiding left ventricle distension and fluid overload, and for detecting complications that negatively affect outcomes.

Can learning to interpret pump messages help lead to an early diagnosis of HeartWare ventricular assist device thrombosis?

Left ventricular assist device thrombosis is a detrimental complication that, if not properly diagnosed and treated, can lead to low output syndrome and death. When ongoing thrombus formation is caused by inappropriate anticoagulation, timely identification is possible, and could perhaps be the key to successful treatment.