Effect of Hospital-associated SARS-CoV-2 Infections in Cardiac Surgery. A Multicenter Study.

BACKGROUND: The effect of hospital-associated SARS-CoV-2 infections in cardiac surgery patients remains poorly investigated, and current data are limited to small case series with conflicting results. METHODS: A multicenter European collaboration was organized to analyze the outcomes of patients who tested positive with hospital-associated SARS-CoV-2 infection after cardiac surgery. The study investigators hypothesized that early infection could be associated with worse postoperative outcomes; hence 2 groups were considered: (1) an early hospital-associated SARS-CoV-2 infection group comprising patients who had a positive molecular test result ≤7 days after surgery, with or without symptoms; and (2) a late hospital-associated SARS-CoV-2 infection group comprising patients whose test positivity occurred >7 days after surgery, with or without symptoms. The primary outcome was 30-day mortality. Secondary outcomes included all-cause mortality or morbidity at early follow-up and SARS-CoV-2-related hospital readmission. RESULTS: A total of 87 patients were included in the study. Of those, 30 were in the early group and 57 in the late group. Overall, 30-day mortality was 8%, and in-hospital mortality was 11.5%. The reintubation rate was 11.4%. Early infection was significantly associated with higher mortality (adjusted OR, 26.6; 95% CI, 2, 352.6; P < .01) when compared with the late group. At 6-month follow-up, survival probability was also significantly higher in the late infection group: 91% (95% CI, 83%, 98%) vs 75% (95% CI, 61%, 93%) in the early infection group (P = .036). Two patients experienced COVID-19-related rehospitalization. CONCLUSIONS: In this multicenter analysis, hospital-associated SARS-CoV-2 infection resulted in higher than expected postoperative mortality after cardiac surgery, especially in the early infection group.

Parannular Elliptical Posterior Resection: A Low-Impact Reparative Technique for Mitral Valve Prolapse.

OBJECTIVE: Although effective, Carpentier technique for mitral regurgitation presents two "Achille's heel": the resection of the whole prolapsing section of posterior mitral leaflet (PML) including chordae tendinae and the annular distortion due to plication. An alternative technique of limited PML resection, which preserves mitral anatomy decreasing the impact on valve function, and 9-year outcome are presented. METHODS: Since April 2005 till March 2014, of 205 patients affected by mitral prolapse scheduled for repair (mitral valve repair), 54 patients have been included in the study. The rationale of the new technique was to limit PML resection to achieve a fair reduction of the prolapsing scallop(s) height, to avoid leaflet and annular distortion, and to spare the coaptation surface and other substantial structures. According to the observation that the posterior smooth zone of PML is quite free from chordal insertions, an elliptical slice of tissue was resected from this area. Annuloplasty and neochordal insertion when indicated completed the procedure. RESULTS: Up to 9 years of follow-up was 98% complete. One in-hospital death, two late noncardiac deaths, one redo operation due to endocarditis were reported. On late follow-up, 92% patients were on New York Heart Association class I. Late echocardiography showed stability of repair (regurgitation grade of ≤1 in 92% of patients). Nearly two third of valves preserved good PML mobility. CONCLUSIONS: The parannular elliptical posterior leaflet resection, providing excellent stable midterm results, seems to be a safe alternative method for repair of PML prolapse. It avoids distortion and weakening of annulus and leaflet, and it allows restoring a proper coaptation surface and maintains a satisfactory PML motion.

Modified elephant trunk technique for chronic aortic dissection: the "double elephant trunk".

The most widely used technique for chronic dissection of the aortic arch and thoracoabdominal aorta is the "elephant trunk" (ET). A technique, in which an original modification of the ET technique was necessary to avoid visceral malperfusion due to the obliteration of the patent false lumen from where splanchnic arteries arose, is presented.

[Rare endocarditis due to Abiotrophia defectiva. Case report and literature review]. / Rara endocardite da Abiotrophia defectiva. Presentazione di un caso e revisione della letteratura.

Endocarditis by Abiotrophia defectiva is rare but associated with high rates of complications and mortality. The microbiological identification is challenging. Two cases without preexisting valvulopathy and one case with mitral-aortic involvement are described in the literature. A case of this subacute form of endocarditis, with normal mitral and aortic valves, is reported. Surgery was necessary, and mitral repair and aortic homograft implantation were performed with good 3-month results. In case of subacute endocarditis, especially when etiology is difficult to detect, Abiotrophia defectiva should be suspected.

Obstruction of the tricuspid valve orifice by a huge right atrial myxoma associated with the Carney complex: a case report.

Carney complex (CNC) is an inherited autosomal dominant disorder associated with multiple neoplasms. Myxomas associated with CNC differ from their sporadic forms because the former usually develop at a younger age and they may be multicentric and have a tendency to recur. Furthermore, their localization may be atypical. We report the case of a 57-year-old man, with a huge right atrial myxoma obstructing the tricuspid valve orifice. A diagnosis of CNC was established by genetic analysis. The importance of early diagnosis and an adequate follow-up is emphasized.

Posterior mitral leaflet: new anatomical insight and review of nomenclature (mitral valve anatomy).

OBJECTIVES: Previous studies described single components of the mitral valve, but somewhat lacked the spatial analysis of their relationship. Moreover, further information is necessary regarding reconstructive surgery. The current work aimed at in-depth analysis of the anatomy of the posterior mitral leaflet (PML) and its changes due to degenerative disease, completing the already existing anatomical information about PML and proposing a reorganization of the actual terminology. METHODS: Nine normal PMLs harvested from cadavers have been compared with 12 pathological specimens from partial resection of PML in the course of valve repair in adult patients. Dimensions of smooth and rough surfaces of the PML have been measured and compared and their dimensional relationships have been assessed; the chance of finding chordae tendineae inserting into the smooth, periannular portion of PML as well as their type have been checked. MEDLINE has been searched for the most relevant publications about PML anatomy. RESULTS: Observation of normal specimens has confirmed the presence of three types of chordae tendineae: marginal, intermediate and basal, but between the last two, there is some of alternative nature. In degenerative mitral valve disease, the rough part is only 13% greater than the smooth one. In collagen degeneration, both parts contribute in more or less equal proportion to the dimensional increase of the middle scallop, so that the ratio between rough and smooth surface is maintained as in normal specimens. CONCLUSION: This study reorganizes the previously proposed terminology of PML chordae tendineae. The research identifies the complemental and alternative presence of 'strut' and 'basal' chordae of PML, and it specifies the dimensions of the different anatomical components of the leaflet, in particular of the intermediate scallop. The observations give an accurate anatomical reference for the space of mitral reconstruction with minimal functional impact.

Is lower limb venous drainage during peripheral extracorporeal membrane oxygenation necessary?

Extracorporeal membrane oxygenation (ECMO) is becoming a gold standard in acute heart failure, not responsive to inotrops and intra-aortic balloon contrapulsation. This diffusion is due to the possibility to implant it through peripheral cannulation and to perform long-time assistance. Nevertheless, this technique implies some problems concerning inferior limb perfusion. It is widely accepted that arterial distal cannulation and perfusion of the limb is mandatory, especially for long periods of assistance; but the necessity to implant a distal venous drainage is still discussed. We would like to present our experience on peripheral ECMO where we could avoid venous distal drainage uneventfully.

Repair of posterior left ventricular aneurysm through transatrial approach.

Repair of posterior left ventricular ischemic aneurysms implies an extracardiac approach to reshape the ventricular geometry frequently associated with mitral surgery. A transatrial technique was described for lesions following mitral surgery or for subvalvular idiopathic cases. A transmitral approach was used for ischemic or traumatic pseudoaneurysm. We describe a case of postinfarction posterior true aneurysm with associated mitral incompetence. Both lesions were treated through an intracardiac approach. The posterior mitral leaflet was detached posteriorly to close the aneurysm with a patch, and the valve replaced sparing all subvalvular apparatus. This technique seems to be safe and allows to treat both lesions avoiding ventriculotomy.

Postinfarction septal dissection and rupture evolved as an inferobasal pseudoaneurysm: a specific anatomical pattern.

In rare cases of posterior myocardial infarction, septal rupture is the consequence of a dissecting interventricular hematoma that evolves as a fibrotic septal chamber with two separate communications, towards left and right ventricle. This unusual anatomical pattern is generally unsuspected and described as a normal interventricular defect associated with a basal left ventricular aneurysm or pseudoaneurysm. We present a case where echocardiography and ventricular angiography did not detect this situation. As surgical implications are important, this peculiar anatomical pattern should be suspected especially in patients with asymptomatic postinfarction posterior septal rupture or in those with minimal clinical impairment.

An unusual left ventricular outflow pseudoaneurysm: usefulness of echocardiography and multidetector computed tomography for surgical repair.

Left ventricular outflow tract (LVOT) pseudoaneurysm is a rare but potentially lethal complication, mainly after aortic root endocarditis or surgery. Usually it originates from a dehiscence in the mitral-aortic intervalvular fibrosa and it arises posteriorly to the aortic root. Due to these anatomical features, its imaging assessment is challenging and surgical repair requires complex procedures. An unusual case of LVOT pseudoaneurysm is described. It was detected by transthoracic ecocardiography 7 months after aortic root replacement for acute endocarditis. Multidetector computed tomography (MDCT) confirmed the presence of a pouch located between the aortic root and the right atrium. Computed tomography also detected the origin of the pseudoaneurysm from the muscular interventricular septum of the LVOT, rather below the aortic valve plane. It was repaired with an extracardiac surgical approach, sparing the aortic root bioprosthesis previously implanted. The high-resolution three-dimensional details provided by the preoperative MDCT allowed us to plan a simple and effective surgical strategy.

Off-pump technique: a systematic alternative for myocardial revascularization?

OBJECTIVE: Many studies failed to show that off-pump myocardial revascularization achieved better results than on-pump revascularization, and also invited a lot of criticism for the criteria used for selection and inclusion of patients. To avoid these limitations, we systematically treated all candidates for coronary surgery with this technique evaluating early and follow-up results. METHODS: In 257 prospective consecutive patients, off-pump myocardial revascularization was performed by the same surgeon without any exclusion criteria. Hospital mortality and main postoperative complications were analysed. After a mean follow-up of 27.50 months, 245 patients (98.4%) were contacted to evaluate late mortality, recurrence of angina, myocardial infarction and need for new revascularization. RESULTS: Conversion to extracorporeal circulation was necessary in 10 cases. Hospital mortality was eight patients (3.11%). Postoperative complications were reexploration for bleeding (2.72%), myocardial infarction (1.17%), atrial fibrillation (21.01%), stroke (0.39%) and renal failure (3.5%). Follow-up overall mortality was 16 patients (6.53%) with two cardiac-related deaths (0.82%). Total cardiac events at follow-up occurred in 20 patients (8.16%). There were two cardiac deaths, angina in 15 cases, silent myocardial ischaemia in two and myocardial infarction in one. New revascularization procedures were necessary in seven cases (2.86%). Statistical results showed that the European System for Cardiac Operative Risk Evaluation rate was predictor of 30-day and overall mortality. Multivariate analysis showed that age was a predictor of overall mortality whereas female sex was a predictor of cardiac events. CONCLUSION: In conclusion, systematic off-pump surgery was not associated with a higher rate of mortality, morbidity and cardiac events compared to on-pump technique.

Short-term hemodynamic performance of the Sorin Freedom SOLO stentless valve.

BACKGROUND AND AIM OF THE STUDY: The new Sorin Freedom SOLO pericardial stentless valve is designed for supra-annular implantation, and requires only one running suture. It can be implanted with a short cross-clamp time, and is designed to offer the same hemodynamic advantages of other stentless valves. The study aim was to evaluate the prospective postoperative and two-month follow up hemodynamic performance of this bioprosthesis. METHODS: Thirty patients (13 males, 17 females; mean age 75.6 +/- 6.21 years) with severe aortic stenosis underwent valve replacement with the Sorin Freedom SOLO stentless valve. All patients underwent transthoracic echocardiography before surgery, before hospital discharge, and at two months' follow up. The peak and mean transprosthetic gradients, telediastolic and telesystolic diameters, septal and posterior wall thicknesses, total and indexed ventricular mass volume and left ventricular ejection fraction were evaluated. RESULTS: Both, the transprosthetic peak gradient and mean gradient decreased significantly during the first two months (p < 0.05 and p < 0.001, respectively). The telediastolic diameter was significantly reduced between preoperative evaluation and follow up (p < 0.05). The interventricular septum thickness was decreased significantly after two months (p <0.001), as was the posterior wall thickness, albeit to a lesser degree (p < 0.05). Both, total and indexed ventricular mass volume showed a significant regression at the two months follow up (p < 0.001). CONCLUSION: The Sorin Freedom SOLO stentless valve shows good hemodynamic performance, with an early and highly progressive left ventricular remod eling. If these data are confirmed in future studies, the SOLO prosthesis might represent a safe alternative to the use of conventional stentless valves.

Surgical treatment of ascending aorta and innominate artery trunk aneurysm with displaced brachiocephalic vessels.

The surgical treatment of ascending aortic and arch aneurysms, even though technically complex and requiring care to avoid neurological sequelae, is well established. Nevertheless, the presence of a significant innominate artery trunk aneurysm implies an adaptation of the surgical options available. We report a case of an aortic aneurysm that involved the ascending aorta, the proximal transverse arch and the brachiocephalic trunk with cranial displacement of the right subclavian and common carotid arteries. This pattern, meant that it was mandatory to change the usual surgical approach. We resected the ascending aorta and the proximal aortic arch replacing them with a dacron prosthesis in a usual fashion. Nevertheless, we were compelled to perform the anastomoses of the innominate trunk branches in an extrathoracic fashion. Furthermore, to ensure an uninterrupted cerebral perfusion, the usual surgical steps were personalized. The anatomical findings, computed tomographic images, surgical technique, cerebral protection and postoperative evaluation are described.

Triangular resection and folding of posterior leaflet for mitral valve repair.

The conventional treatment of mitral insufficiency, due to posterior leaflet prolapse, is quadrangular resection. This technique sacrifices a great amount of valve tissue resulting in leaflet stiffness and altered annular geometry. To avoid such problems we performed a small triangular leaflet resection sparing the second-order chordae, a folding plasty, implantation of artificial chordae, and annuloplasty. Fourteen patients underwent this procedure. No hospital death and no repair failure were observed. Echocardiography at 12 months on 12 patients showed trivial incompetence in three and mild in one and an overall improvement of end-diastolic and end-systolic diameters. Our technique has the main objectives of sparing second-order chordae and subvalvular apparatus in order to preserve mobility of the posterior mitral leaflet, left ventricular geometry, and function. Preliminary results are encouraging.