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.

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.

Aortic Valve Replacement: Understanding Predictors for the Optimal Ministernotomy Approach.

INTRODUCTION: The most common minimally invasive approach for aortic valve replacement (AVR) is the partial upper mini-sternotomy. The aim of this study is to understand which preoperative computed tomography (CT) features are predictive of longer operations in terms of cardio-pulmonary bypass timesand cross-clamp times. METHODS: From 2011 to 2022, we retrospectively selected 246 patients which underwent isolated AVR and had a preoperative ECG-gated CT scan. On these patients, we analysed the baseline anthropometric characteristics and the following CT scan parameters: aortic annular dimensions, valve calcium score, ascending aorta length, ascending aorta inclination and aorta-sternum distance. RESULTS: We identified augmented body surface area (>1.9 m2), augmented annular diameter (>23 mm), high calcium score (>2500 Agatson score) and increased aorta-sternum distance (>30 mm) as independent predictors of elongated operation times (more than two-fold). CONCLUSIONS: Identifying the preoperative predictive factors of longer operations can help surgeons select cases suitable for minimally invasive approaches, especially in a teaching context.

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.

Survival and Recurrence of Endocarditis following Mechanical vs. Biological Aortic Valve Replacement for Endocarditis in Patients Aged 40 to 65 Years: Data from the INFECT-Registry.

BACKGROUND: Infective endocarditis (IE) is a serious disease, and in many cases, surgery is necessary. Whether the type of prosthesis implanted for aortic valve replacement (AVR) for IE impacts patient survival is a matter of debate. The aim of the present study is to quantify differences in long-term survival and recurrence of endocarditis AVR for IE according to prosthesis type among patients aged 40 to 65 years. METHODS: This was an analysis of the INFECT-REGISTRY. Trends in proportion to the use of mechanical prostheses versus biological ones over time were tested by applying the sieve bootstrapped t-test. Confounders were adjusted using the optimal full-matching propensity score. The difference in overall survival was compared using the Cox model, whereas the differences in recurrence of endocarditis were evaluated using the Gray test. RESULTS: Overall, 4365 patients were diagnosed and operated on for IE from 2000 to 2021. Of these, 549, aged between 40 and 65 years, underwent AVR. A total of 268 (48.8%) received mechanical prostheses, and 281 (51.2%) received biological ones. A significant trend in the reduction of implantation of mechanical vs. biological prostheses was observed during the study period (p < 0.0001). Long-term survival was significantly higher among patients receiving a mechanical prosthesis than those receiving a biological prosthesis (hazard ratio [HR] 0.546, 95% CI: 0.322-0.926, p = 0.025). Mechanical prostheses were associated with significantly less recurrent endocarditis after AVR than biological prostheses (HR 0.268, 95%CI: 0.077-0.933, p = 0.039). CONCLUSIONS: The present analysis of the INFECT-REGISTRY shows increased survival and reduced recurrence of endocarditis after a mechanical aortic valve prosthesis implant for IE in middle-aged patients.

Surgical removal of a bullet in the heart through a trans-mitral approach: a case report.

Background: Retained cardiac missiles have been considered bullets, shrapnel, or pellets included in the heart or the pericardial sac. In asymptomatic patients with retained cardiac missiles, the role of surgery is still debated. Case summary: We describe the case of successful surgical treatment of a retained missile localized within the left ventricle in close proximity of the posterior mitral leaflet. The operation was performed through a transatrial approach, detaching the posterior mitral leaflet. The post-operative course was uneventful. The patient was discharged on the seventh post-operative day. At 30-day follow-up visit, the patient was in good conditions, with normal mitral valve function. Discussion: The management of retained cardiac missiles should be individualized. If a decision is made to operate, multiple imaging techniques including echocardiography and computed tomography scan are mandatory to precisely locate the bullet.

3D mitral annulus echocardiography assessment in patients affected by degenerative mitral regurgitation who underwent mitral valve repair with flexible band.

BACKGROUND: Degenerative mitral valve (MV) regurgitation (DMR) shows significative mitral annulus (MA) alterations; mitral valve repair (MVR) seeks to restore annular geometry and function, and the current use of flexible band seams to respect most annular mobility reducing parietal stress. Parameters of MV geometry obtained by 3D transesophageal echocardiography (3D-TTE) analysis are crucial for surgical planning and postoperative success. The aim of this study was to assess, by means of a dedicated software, the variations of MA geometry and function in patients affected by DMR compared to controls and after MVR with flexible band. METHODS: We enrolled 32 patients (cases) with severe DMR who underwent MVR using flexible band; we compare this group with 20 controls. The TEE with 3D MV images acquisition was performed in both groups and then analyzed in postprocessing by using a dedicated software. RESULTS: There were no anthropometrics differences between cases and controls, both presented normal left ventricular ejection fraction. DMR group showed a significant increase of annulus dimensional parameters (p = .001) and alteration of nonplanarity comparing to controls (p < .05). The annuloplasty with flexible band induces a considerable reduction of MV dimensions comparing to preoperative data and restores physiological mobility and nonplanarity. There were no statistical differences between postoperative DMR and controls data, except for nonplanarity parameters (p ~.05), maybe influenced by hemodynamic settings. CONCLUSIONS: MVR with annuloplasty using flexible band appears able to reinstate a more physiological anatomic conformation of the MA, without compromising its dynamic properties.

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.

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.

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.

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.

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.

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.

Hutchinson-Gilford Progeria Syndrome and Severe Aortic Stenosis: A New Hope for Treatment.

Hutchinson-Gilford progeria syndrome is an autosomal dominant, rare, fatal pediatric segmental premature aging disease. Cardiovascular and cerebrovascular diseases constitute the major cause of morbidity and mortality. Patients with the syndrome and severe aortic valve stenosis have been described in the literature, and for all of them a strategy of conservative management has been followed. We describe the first successful treatment of a 23-year-old Hutchinson-Gilford progeria syndrome patient with severe aortic stenosis who underwent transapical transcatheter aortic valve replacement.

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.