High-Sensitivity Troponin I after Cardiac Surgery and 30-Day Mortality.

BACKGROUND: Consensus recommendations regarding the threshold levels of cardiac troponin elevations for the definition of perioperative myocardial infarction and clinically important periprocedural myocardial injury in patients undergoing cardiac surgery range widely (from >10 times to ≥70 times the upper reference limit for the assay). Limited evidence is available to support these recommendations. METHODS: We undertook an international prospective cohort study involving patients 18 years of age or older who underwent cardiac surgery. High-sensitivity cardiac troponin I measurements (upper reference limit, 26 ng per liter) were obtained 3 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We performed Cox analyses using a regression spline that explored the relationship between peak troponin measurements and 30-day mortality, adjusting for scores on the European System for Cardiac Operative Risk Evaluation II (which estimates the risk of death after cardiac surgery on the basis of 18 variables, including age and sex). RESULTS: Of 13,862 patients included in the study, 296 (2.1%) died within 30 days after surgery. Among patients who underwent isolated coronary-artery bypass grafting or aortic-valve replacement or repair, the threshold troponin level, measured within 1 day after surgery, that was associated with an adjusted hazard ratio of more than 1.00 for death within 30 days was 5670 ng per liter (95% confidence interval [CI], 1045 to 8260), a level 218 times the upper reference limit. Among patients who underwent other cardiac surgery, the corresponding threshold troponin level was 12,981 ng per liter (95% CI, 2673 to 16,591), a level 499 times the upper reference limit. CONCLUSIONS: The levels of high-sensitivity troponin I after cardiac surgery that were associated with an increased risk of death within 30 days were substantially higher than levels currently recommended to define clinically important periprocedural myocardial injury. (Funded by the Canadian Institutes of Health Research and others; VISION Cardiac Surgery ClinicalTrials.gov number, NCT01842568.).

Oral Anticoagulation Use and Left Atrial Appendage Occlusion in LAAOS III.

BACKGROUND: LAAOS III (Left Atrial Appendage Occlusion Study III) showed that left atrial appendage (LAA) occlusion reduces the risk of ischemic stroke or systemic embolism in patients with atrial fibrillation undergoing cardiac surgery. This article examines the effect of LAA occlusion on stroke reduction according to variation in the use of oral anticoagulant (OAC) therapy. METHODS: Information regarding OAC use was collected at every follow-up visit. Adjusted proportional hazards modeling, including using landmarks of hospital discharge, 1 and 2 years after randomization, evaluated the effect of LAA occlusion on the risk of ischemic stroke or systemic embolism, according to OAC use. Adjusted proportional hazard modeling, with OAC use as a time-dependent covariate, was also performed to assess the effect of LAA occlusion, according to OAC use throughout the study. RESULTS: At hospital discharge, 3027 patients (63.5%) were receiving a vitamin K antagonist, and 879 (18.5%) were receiving a non-vitamin K antagonist oral anticoagulant (direct OAC), with no difference in OAC use between treatment arms. There were 2887 (60.5%) patients who received OACs at all follow-up visits, 1401 (29.4%) who received OAC at some visits, and 472 (9.9%) who never received OACs. The effect of LAA occlusion on the risk of ischemic stroke or systemic embolism was consistent after discharge across all 3 groups: hazard ratios of 0.70 (95% CI, 0.51-0.96), 0.63 (95% CI, 0.43-0.94), and 0.76 (95% CI, 0.32-1.79), respectively. An adjusted proportional hazards model with OAC use as a time-dependent covariate showed that the reduction in stroke or systemic embolism with LAA occlusion was similar whether patients were receiving OACs or not. CONCLUSIONS: The benefit of LAA occlusion was consistent whether patients were receiving OACs or not. LAA occlusion provides thromboembolism reduction in patients independent of OAC use.

Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke.

BACKGROUND: Surgical occlusion of the left atrial appendage has been hypothesized to prevent ischemic stroke in patients with atrial fibrillation, but this has not been proved. The procedure can be performed during cardiac surgery undertaken for other reasons. METHODS: We conducted a multicenter, randomized trial involving participants with atrial fibrillation and a CHA2DS2-VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating greater risk of stroke) who were scheduled to undergo cardiac surgery for another indication. The participants were randomly assigned to undergo or not undergo occlusion of the left atrial appendage during surgery; all the participants were expected to receive usual care, including oral anticoagulation, during follow-up. The primary outcome was the occurrence of ischemic stroke (including transient ischemic attack with positive neuroimaging) or systemic embolism. The participants, research personnel, and primary care physicians (other than the surgeons) were unaware of the trial-group assignments. RESULTS: The primary analysis population included 2379 participants in the occlusion group and 2391 in the no-occlusion group, with a mean age of 71 years and a mean CHA2DS2-VASc score of 4.2. The participants were followed for a mean of 3.8 years. A total of 92.1% of the participants received the assigned procedure, and at 3 years, 76.8% of the participants continued to receive oral anticoagulation. Stroke or systemic embolism occurred in 114 participants (4.8%) in the occlusion group and in 168 (7.0%) in the no-occlusion group (hazard ratio, 0.67; 95% confidence interval, 0.53 to 0.85; P = 0.001). The incidence of perioperative bleeding, heart failure, or death did not differ significantly between the trial groups. CONCLUSIONS: Among participants with atrial fibrillation who had undergone cardiac surgery, most of whom continued to receive ongoing antithrombotic therapy, the risk of ischemic stroke or systemic embolism was lower with concomitant left atrial appendage occlusion performed during the surgery than without it. (Funded by the Canadian Institutes of Health Research and others; LAAOS III ClinicalTrials.gov number, NCT01561651.).

Addressing inadequate blood flow during normothermic regional perfusion for in-situ donation after circulatory death grafts preservation.

Donation after circulatory death (DCD) has emerged as attainable strategy to tackle the issue of organ shortage, expanding the donor pool. The DCD concept has been applied to the multiple declinations of circulatory arrest, as per the Modified Maastricht Classification. Notwithstanding, whichever the scenario, DCD donors experience a variable warm ischemia time whose correlation with graft dysfunction is ascertained. This applies to both "controlled" (cDCD) donors (i.e., the timespan from the withdrawal of life-sustaining therapies to the onset of in-situ perfusion), and "uncontrolled" DCD (uDCD) (i.e., the low-flow period during cardiopulmonary resuscitation - CPR). This sums up to the no-flow time from cardiac arrest to the start of CPR for uDCD donors, and to the no-touch period for both uDCDs and cDCDs. Static and hypothermic storage may not be appropriate for DCD grafts. In order to overcome this ischemic insult, extracorporeal membrane oxygenation devices are adopted to guarantee the in-situ grafts preservation by means of techniques such as the normothermic regional perfusion (NRP) which consists in a selective abdominal perfusion obtained via the endovascular or surgical occlusion of the thoracic aorta. The maintenance of an adequate pump flood throughout NRP is therefore a sine qua non to accomplish the DCD donation. The issue of insufficient pump flow during NRP is prevalent and clinically significant but its management remains technically challenging and not standardized. Hereby we propose a systematic algorithmic approach to address this relevant occurrence.

Narrative review of the systemic inflammatory reaction to cardiac surgery and cardiopulmonary bypass.

BACKGROUND: Data from large cardiac surgery registries have been depicting a downward trend of mortality and morbidities in the last 20 years. However, despite decades of medical evolution, cardiac surgery and cardiopulmonary bypass still provoke a systemic inflammatory response, which occasionally leads to worsened outcome. This article seeks to outline the mechanism of the phenomenon. METHODS: A thorough review of the literature has been performed. Criteria for considering studies for this non-systematic review were as follows: observational and interventional studies investigating the systemic inflammatory response to cardiac surgery, experimental studies describing relevant molecular mechanisms, and essential review studies pertinent to the topic. RESULTS: The intrinsic variability of the inflammatory response to cardiac surgery, together with its heterogenous perception among clinicians, as well as the arduousness to early discriminate high-responder patients from those who will not develop a clinically relevant reaction, concurred to hitherto unconclusive randomized controlled trials. Furthermore, peremptory knowledge about the pathophysiology of maladaptive inflammation following heart surgery is still lacking. CONCLUSIONS: Systemic inflammation following cardiac surgery is a frequent entity that occasionally becomes clinically relevant. Specific genomic differences, age, and other preoperative factors influence the magnitude of the response, which elements display extreme redundancy and pleiotropism that the target of a single pathway cannot represent a silver bullet.

Acute iatrogenic complications after mitral valve repair.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair is the procedure of choice to correct mitral regurgitation. However, some dangerous iatrogenic complications can occur at the end of the procedure. Therefore, we sought to review the most frequent and clinically relevant acute iatrogenic complication following mitral valve repair. METHODS: A thorough review of the literature has been performed. Criteria for considering studies for this non-systematic review were as follows: observational and interventional studies investigating the acute iatrogenic complications following mitral valve repair, and essential review studies pertinent to the topic. RESULTS: The most frequent is the systolic anterior motion. Due to a systolic dislocation of the anterior leaflet toward the outflow tract, it causes both obstruction of the outflow tract and mitral regurgitation. Often it is due to excess of catecholamines or to reduced filling of the left ventricle but sometimes needs further surgical maneuvers, focused on moving posteriorly the coaptation line. It can be obtained by shortening the posterior leaflet or increasing the size of the ring or applying an Alfieri stitch to limit the movements of the anterior leaflet. Another complication, often underdiagnosed and potentially lethal, is the injury of the circumflex artery that happens at the level of the anterolateral commissure or P1 zone. Two mechanisms are involved. The first one is the direct injury of the artery by a stitch (roughly 25% of the patients present a distance artery-annulus <3 mm. The second one is the distortion of the artery, attracted toward the annulus by a misplaced stitch. The attraction causes kinking with stenosis of different degrees till functional occlusion. However, the artery has to be far from the annulus and the atrial tissue has to be stiff and resistant, as after an infective process, to move the circumflex artery toward the annulus without tearing. Positioning the stitches very close to the mitral leaflets in the dangerous area is the only prevention to the complication. The treatment in the operating theater is partial or total removal/reimplantation of the annular sutures or coronary artery bypass grafting to the circumflex area. If the injury is demonstrated only after coronary angiography, percutaneous revascularization can be attempted before further surgical treatment. CONCLUSIONS: Acute iatrogenic complication after mitral repair exists and may compromize patient outcome. Raising awareness about these issues, the precautions to prevent them, and the manners of resolution is therefore mandatory.

Mitral valve repair with artificial chords: Tips and tricks.

Mitral valve regurgitation (MR) is a common valvular disorder occurring in up to 10% of the general population. Mitral valve reconstructive strategies may address any of the components, annulus, leaflets, and chords, involved in the valvular competence. The classical repair technique involves the resection of the prolapsing tissue. Chordal replacement was introduced already in the '60, but in the mid '80, some surgeons started to use expanded polytetrafluoroethylene (ePTFE) Gore-Tex sutures. In the last years, artificial chords have been used also using transcatheter approach such as NeoChord DS 1000 (Neochord) and Harpoon TSD-5. The first step is to achieve a good exposure of the papillary muscles that before approaching the implant of the artificial chords. Then, the chords are attached to the papillary muscle, with or without the use of supportive pledgets. The techniques to correctly implant artificial chords are many and might vary considerably from one center to another, but they can be summarized into three big families of suturing techniques: single, running or loop. Regardless of how to anchor to the mitral leaflet, the real challenge that many surgeons have taken on, giving rise to some very creative solutions, has been to establish an adequate length of the chords. It can be established based on anatomically healthy chords, but it is important to bear in mind that surgeons work on the mitral valve when the heart is arrested in diastole, so this length could fail to replicate the required length in the full, beating heart. Hence, some surgeons suggested techniques to overcome this problem. Herein, we aimed to describe the current use of artificial chords in real-world surgery, summarizing all the tips and tricks.

The influence of metabolic syndrome in heart valve intervention. A multi-centric study.

BACKGROUND: The effect of metabolic syndrome (MetS), defined as insulin resistance along with two or more of: obesity, atherogenic dyslipidaemia and elevated blood pressure, on postoperative complications after isolated heart valve intervention remains controversial. We hypothesized that MetS may negatively influence the postoperative course in these patients. METHODS: Patients from 10 cardiac units who underwent isolated valve intervention (mitral ± $\pm $ tricuspid repair/replacement (mitral valve surgery [MVS]) or surgical aortic valve replacement (SAVR), or transcatheter aortic valve replacement (TAVR) were included. MetS was defined according to the World Health Organization criteria. Primary outcome was in-hospital mortality and overall postoperative length of stay (LOS). Relevant postoperative complications were also recorded. RESULTS: From 2010 to 2019, 17,283 patients underwent valve intervention. The MVS, SVAR, and TAVR accounted for the 39.4%, 48.2%, and 12.3% respectively of the whole. MetS compared to no-MetS was associated to higher mortality in the MVS group (6.5% vs. 2%, p < .001), but not in the SAVR and TAVR group. In both surgical cohorts, MetS was associated with increased complications including red blood cells transfusion, renal failure, mechanical ventilation time, intensive care and overall postoperative LOS (11 (9) vs. 10 (6), p < .001 and 10 (6) versus 10 (5) days, p = .002, MVS and [SAVR]). No differences were found in the TAVR cohort, with similar mortality and complications. CONCLUSION: MetS was associated to more postoperative complications, with higher mortality in the MVS group. In the TAVR cohort, postoperative complications and mortality rate did not differ between patients with and without MetS, however LOS was longer in the MetS group.

A historical appraisal of the techniques of left ventricular volume reduction in ischemic cardiomyopathy: Who did what?

Resection or exclusion of scars following a myocardial infarction on the left anterior descending artery territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a "revisitation" of what described before. In some case, old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world.

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.

Brain and lower body protection during aortic arch surgery.

BACKGROUND: Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (antegrade cerebral perfusion [ACP]), or retrograde. In recent years nadir temperature progressively increased to 26°C-28°C (moderately hypothermic circulatory arrest [MHCA]), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10 min of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming [DR]) can provide a neuroprotection and a lower body protection similar to that provided by MHCA + ACP. METHODS: A total of 210 patients were included in the study. DHCA + DR was used in 59 patients and MHCA + ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE), or permanent (permanent neurologic deficit [PND]), and need of renal replacement therapy (RRT). RESULTS: Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%), and PNDs in 10 (4.8%). A total of 23 patients (10.9%) needed RRT. Death + PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs, and death + PND, but need of RRT (odds ratio [OR]: 7.39, confidence interval [CI]: 1.37-79.1) and composite endpoint (OR: 8.97, CI: 1.95-35.3) were significantly lower in DHCA + DR group compared with MHCA + ACP group. CONCLUSIONS: The results of our study demonstrate that DHCA + DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA + ACP. However, the data suggests that DHCA + DR when compared with MHCA + ACP provides better renal protection and reduced prevalence of composite endpoint.

Prognostic value of SARS-CoV-2 on patients undergoing cardiac surgery.

OBJECTIVE: To analyze Italian Cardiac Surgery experience during the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) identifying risk factors for overall mortality according to coronavirus disease 2019 (COVID-19) status. METHODS: From February 20 to May 31, 2020, 1354 consecutive adult patients underwent cardiac surgery at 22 Italian Centers; 589 (43.5%), patients came from the red zone. Based on COVID-19 status, 1306 (96.5%) were negative to SARS-CoV-2 (COVID-N), and 48 (3.5%) were positive to SARS-CoV-2 (COVID-P); among the COVID-P 11 (22.9%) and 37 (77.1%) become positive, before and after surgery, respectively. Surgical procedures were as follows: 396 (29.2%) isolated coronary artery bypass grafting (CABG), 714 (52.7%) isolated non-CABG procedures, 207 (15.3%) two associate procedures, and three or more procedures in 37 (2.7%). Heart failure was significantly predominant in group COVID-N (10.4% vs. 2.5%, p = .01). RESULTS: Overall in-hospital mortality was 1.6% (22 cases), being significantly higher in COVID-P group (10 cases, 20.8% vs. 12, 0.9%, p < .001). Multivariable analysis identified COVID-P condition as a predictor of in-hospital mortality together with emergency status. In the COVID-P subgroup, the multivariable analysis identified increasing age and low oxygen saturation at admission as risk factors for in-hospital mortality. CONCLUSION: As expected, SARS-CoV-2 infection, either before or soon after cardiac surgery significantly increases in-hospital mortality. Moreover, among COVID-19-positive patients, older age and poor oxygenation upon admission seem to be associated with worse outcomes.

Minimally invasive tricuspid valve surgery without caval occlusion: Short and midterm results.

OBJECTIVE: The use of minimally invasive or transcatheter interventions rather than standard full sternotomy operations to treat tricuspid valve (TV) disease is increasing. The debate however is still open regarding venous drainage management during cardiopulmonary bypass (CPB) and wheatear or not superior and inferior vena cava should be occluded during the opening of the right atrium to avoid air entrance in the venous line. The aim of the present study is to report operative outcomes and midterm follow-up results of minimally invasive TV surgery performed without caval occlusion. METHODS: A retrospective outcome evaluation from institutional records was performed with prospective data entry. Considered were consecutive patients who underwent right mini-thoracotomy TV surgery isolated or combined with mitral valve surgery during the period from June 2013 to February 2020. A telephone and echocardiographic follow-up was performed. RESULTS: During the study period, 68 consecutive patients underwent minimally invasive TV surgery without occlusion of cava veins. The mean age was 69 ± 14 years and 48 (70%) were female. All operations were performed safely without air-lock during CPB. A perioperative cerebral stroke occurred in one patient. The survival at a 5- and 8-year follow-up was 100% and 79%, respectively. No severe tricuspid regurgitation was evident at echocardiographic follow-up. CONCLUSION: Our results show that performing tricuspid surgery without caval occlusion is safe. The air was captured by the active vacuum drainage system without causing damage. Midterm follow-up data confirm that a minimally invasive approach does not alter the quality of surgery.

The secret life of the mitral valve.

In secondary mitral regurgitation, the concept that the mitral valve (MV) is an innocent bystander, has been challenged by many studies in the last decades. The MV is a living structure with intrinsic plasticity that reacts to changes in stretch or in mechanical stress activating biohumoral mechanisms that have, as purpose, the adaptation of the valve to the new environment. If the adaptation is balanced, the leaflets increase both surface and length and the chordae tendineae lengthen: the result is a valve with different characteristics, but able to avoid or to limit the regurgitation. However, if the adaptation is unbalanced, the leaflets and the chords do not change their size, but become stiffer and rigid, with moderate or severe regurgitation. These changes are mediated mainly by a cytokine, the transforming growth factor-ß (TGF-ß), which is able to promote the changes that the MV needs to adapt to a new hemodynamic environment. In general, mild TGF-ß activation facilitates leaflet growth, excessive TGF-ß activation, as after myocardial infarction, results in profibrotic changes in the leaflets, with increased thickness and stiffness. The MV is then a plastic organism, that reacts to the external stimuli, trying to maintain its physiologic integrity. This review has the goal to unveil the secret life of the MV, to understand which stimuli can trigger its plasticity, and to explain why the equation "large heart = moderate/severe mitral regurgitation" and "small heart = no/mild mitral regurgitation" does not work into the clinical practice.

An observational, prospective study on surgical treatment of secondary mitral regurgitation: The SMR study. Rationale, purposes, and protocol.

The natural history of secondary mitral regurgitation (MR) is unfavorable. Nevertheless, there are no evidence that its correction can improve the outcome. If from one side the original cause of secondary MR can be such to limit the possibilities of improvement, from the other side it is possible that the surgical technique widely applied to repair, restrictive mitral annuloplasty, is not adequate to correct the regurgitation. The addition of valvular and/or subvalvular techniques has been considered a possible technical solution. However, we do not know the prevalence of each technique, how many times mitral replacement is used to correct secondary MR. This aspect is of particular importance, as we know that a successful mitral repair causes a better left ventricular systolic remodeling than a unsuccessful repair or replacement. This study is a prospective, observational registry, conceived to understand what is done in the real world. Any surgeon will use the technique he thinks the most suitable for the patient. Every year, for 5 years, patients will have a clinical and echocardiographic follow-up, to evaluate the risk factors for a worse result (death, rehospitalization for heart failure, reoperation for MR return, moderate, or more MR return). This knowledge will give us the possibility to understand which is the technique, or the strategy, more efficient to treat this disease and the real efficacy of the surgical treatment.

Right ventricular assessment can improve prognostic value of Euroscore II.

BACKGROUND: The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery. METHODS: This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC <35%, TAPSE <17 mm, and TDI S' <9.5 mm RESULTS: Among the entire cohort, 624 (70%) showed normal RV, 92 (10%) isolated RV dilatation, 154 (17%) isolated RV dysfunction, and 25 (3%) both RV dilatation and dysfunction. Non-surviving patients showed a significantly higher rate of RV alteration at multivariable analysis, RV status was found to be an independent predictor for higher in-hospital mortality beside Euroscore II. CONCLUSIONS: This prospective multicenter observation study shows the importance to assess RV preoperatively and to include both RV function and dimension in a risk score model such as Euroscore II to implement its predictivity, since PH cannot always mirror the status of the right ventricle.

Prevalence and Clinical Impact of Systemic Inflammatory Reaction After Cardiac Surgery.

OBJECTIVES: Cardiac surgery induces a systemic inflammatory reaction that has been associated with postoperative mortality and morbidity. Many studies have characterized this reaction through laboratory biomarkers while clinical studies generally are lacking. This study aimed to assess the incidence of postoperative systemic inflammation after cardiac surgery, and the association of postoperative systemic inflammation with preoperative patients' characteristics and postoperative outcomes. DESIGN: Retrospective analysis of prospectively collected data. Analysis of the overall population and of propensity-matched subgroups. SETTING: Cardiac surgery intensive care unit. PATIENTS: Adult patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) between June 2016 and June 2017. INTERVENTIONS: Mixed cardiac surgery operations on CPB. MEASUREMENTS AND MAIN RESULTS: During the study period, 502 patients underwent cardiac surgery with CPB. One hundred forty-two patients (28.3%) fulfilled SIRS criteria at 24 hours. After performing a multivariate analysis to adjust for the procedure type and preoperative systemic inflammatory reaction syndrome (SIRS) parameters, the occurrence of SIRS was associated inversely with age and extracardiac arteriopathy, and it was associated positively with preoperative white blood cell count. Vasopressors were used more frequently in SIRS patients who further experienced longer mechanical ventilation time and length of stay in the intensive care unit (ICU). The incidence of a composite outcome including death, transient ischemic attack/stroke, renal replacement therapy, bleeding, postoperative intra-aortic balloon pump insertion, and a length of stay in ICU >96 hours was more frequent in SIRS-positive patients. There was no difference between overall and matched subgroups for in-hospital mortality. CONCLUSION: In this retrospective study, the clinical signs of SIRS were detected in a substantial percentage of patients who underwent cardiac surgery. The postoperative SIRS criteria were associated with a more complicated postoperative course and higher postoperative morbidity.

Outcomes after Ross procedure in adult patients: A meta-analysis and microsimulation.

OBJECTIVE: We conducted a meta-analysis to estimate the risk of adverse events, life expectancy, and event-free life expectancy after the Ross procedure in adults. METHODS: We searched databases for reports evaluating the Ross procedure in patients aged more than or equal to 16 years of age. A microsimulation model was used to evaluate age- and gender-specific life expectancy for patients undergoing the Ross procedure. RESULTS: Data were pooled from 63 articles totaling 19 155 patients from 20 countries. Perioperative mortality was 2.5% (95% confidence interval [CI]: 1.9-3.1; N = 9978). We found a mortality risk of 5.9% (95% CI: 4.8-7.2) at a mean follow-up of 7.2 years (N = 7573). The rate of perioperative clinically significant bleeding was 1.0% (95% CI: 0.1-3.0); re-exploration for bleeding 4.6% (95% CI: 3.1-6.3); postoperative clinically significant bleeding from 30 days until a mean of 7.1 years was 0.5% (95% CI: 0.2-1.0). At a mean of 6.9 years of follow-up, reintervention rate of any operated valve was 7.9% (95% CI: 5.7-10.3). The risk of valve thrombosis was 0.3% (95% CI: 0.2-0.5) at 7.6 years; peripheral embolism 0.3% (95% CI: 0.2-0.4) at 6.4 years; stroke 0.9% (95% CI: 0.7-1.2) at 6.5 years; and endocarditis 2.1% (95% CI: 1.6-2.6) at 8.0 years. Microsimulation reported a 40-year-old undergoing the Ross procedure to have a life expectancy of 35.4 years and event-free life expectancy of 26.6 years. CONCLUSIONS: Ross procedure in nonelderly adults is associated with low mortality and low risk of adverse events both at short- and long-term follow-up. The surgical community must prioritize a large, expertize-based randomized controlled trial to definitively address the risks and benefits of the Ross procedure compared to conventional aortic valve replacement.

Reliability of Percutaneous Pulmonary Vent and Coronary Sinus Cardioplegia in the Setting of Minimally Invasive Aortic Valve Replacement: A Single-Center Experience.

OBJECTIVES: Evaluating the efficacy of 2 new percutaneous devices specifically designed to be placed through the right internal jugular vein, therefore named "necklines," for achieving retrograde cardioplegia and pulmonary venting in the setting of minimally invasive aortic valve replacement (MIAVR). DESIGN: Case series. SETTING: University-affiliated private hospital. PARTICIPANTS: Patients undergoing MIAVR. INTERVENTIONS: Necklines were placed by the anesthesiologist using transesophageal electrocardiography, with pressure guidance before the surgical procedure was initiated. MEASUREMENTS AND MAIN RESULTS: The records of 51 consecutive patients who underwent MIAVR with necklines placement were reviewed retrospectively. The access for MIAVR was through either a J-hemisternotomy or a right anterior thoracotomy. The efficacy of the 2 catheters, successful placement rate, time needed to deploy catheters, and perioperative complications were recorded. Necklines were placed successfully in all patients in 23±13 minutes. A total of 110 doses of retrograde cardioplegia were delivered at a mean flow rate of 173±35 mL/min and a mean pressure of 41±6 mmHg. The pulmonary catheter ensured venting of the heart that was graded by surgeons as "excellent" in 33 patients, "sufficient" in 12 patients, and "not adequate" in 2 patients. There were no major adverse events or deaths. CONCLUSIONS: Necklines ensure effective retrograde cardioplegia and venting of the heart, provide optimal surgical vision and access during MIAVR, and allow surgeons to operate in an unobstructed surgical field. Nevertheless, additional studies are required to determine whether the use of necklines is associated with better outcomes than those with conventional methods.

Myocardial protection during minimally invasive cardiac surgery through right mini-thoracotomy.

BACKGROUND: Myocardial damage is an independent predictor of adverse outcome following cardiac surgery and myocardial protection is one of the key factors to achieve successful outcomes. Cardioplegia with Custodiol is currently the most used cardioplegia during minimally invasive cardiac surgery (MICS). Different randomized controlled trials compared blood and Custodiol cardioplegia in the context of traditional cardiac surgery. No data are available for MICS. AIM: The aim of this study was to compare the efficacy of cold blood versus Custodiol cardioplegia during MICS. METHOD: We retrospectively evaluated 90 patients undergoing MICS through a right mini-thoracotomy in a three-year period. Myocardial protection was performed using cold blood (44 patients, CBC group) or Custodiol (46 patients, Custodiol group) cardioplegia, based on surgeon preference and complexity of surgery. RESULTS: The primary outcomes were post-operative cardiac troponin I (cTnI) and creatine kinase MB (CKMB) serum release and the incidence of Low Cardiac Output Syndrome (LCOS). Aortic cross-clamp and cardiopulmonary bypass times were higher in the Custodiol group. No difference was observed in myocardial injury enzyme release (peak cTnI value was 18±46 ng/ml in CBC and 21±37 ng/ml in Custodiol; p=0.245). No differences were observed for mortality, LCOS, atrial or ventricular arrhythmias onset, transfusions, mechanical ventilation time duration, intensive care unit and total hospital stay. CONCLUSIONS: Custodiol and cold blood cardioplegic solutions seem to assure similar myocardial protection in patients undergoing cardiac surgery through a right mini-thoracotomy approach.