Practical Suggestions for an Optimal Management of Vitamin K Antagonists: Italian Federation of Centers for the Diagnosis of Thrombotic Disorders and the Surveillance of the Antithrombotic Therapies (FCSA) Position Paper.

In the era of direct oral anticoagulants, vitamin K antagonists retain a clinically relevant role in thrombotic disorders. In Italy, approximately 20% of the patients on anticoagulant therapies receives a VKA, in most cases warfarin. The optimal management of this drug is challenging and cannot disregard its intricate and unpredictable pharmacokinetic properties and patient's thrombotic and bleeding risk. Several clinical issues encountered during warfarin treatment are still unanswered and are tentatively addressed by physicians. In this regard, the Italian Federation of Centers for the diagnosis of thrombotic disorders and the Surveillance of the Antithrombotic therapies (FCSA) provides some experience-based good clinical practice's suggestions on the following topics: (1) how to start the anticoagulant treatment with warfarin and warfarin induction regimen; (2) how to manage a subtherapeutic INR value; (3) how to manage a supratherapeutic INR value in asymptomatic patients; and (4) how to manage the association of warfarin with interfering drugs.

Hemodynamic Patterns of Spinal Cord Perfusion in Thoracoabdominal Aortic Aneurysm Repair.

Paraplegia in aortic surgery is due to its impact on spinal cord perfusion whose hemodynamic patterns (SCPHP) are not clearly defined. Detailed morphological analysis of vascular network and collateral network modifications within Monro-Kellie postulate due to the fixed theca confines was performed to identify SCPHP. SCPHP may begin with intraspinal "backflow" (I-BF), that is, hemorrhage from anterior and posterior spinal arteries, backward via the connected anterior and posterior radicular medullary arteries, through the increasing diameter and decreasing resistance of segmental arteries (SAs), off their aortic orifices outside vascular network at 0 operative field pressure. The I-BF blood bypasses both intra- and extraspinal capillary networks and causes depressurization (0 diastolic pressure) and full ischemia of dependent spinal cord. When the occlusion of those SAs orifices arrests I-BF, the hemodynamic pattern of intraspinal "steal" (I-S) may take place. The formerly I-BF blood, in fact, is now variably shared between the fraction maintained in its physiological intraspinal network and that keeping flowing as I-S through the extraspinal capillary network. I-S is, however, counteracted by the extraspinal "steal" from the connected mammary/paraspinous-independent extraspinal feeders, all physically competing for the same room left by the missed physiological SA direct aortic blood inflow. Steal phenomenon evolves within the 120-hour time frame of CNm, whose intraspinal anatomical changes may offer the physical basis within the Monro-Kelly postulate, respectively of the intraoperative and postoperative paraplegia. The current procedures could not prevent the unphysiological SCPHP but awareness of details of their various features may offer the basis for improvements tailored, to the adopted intra- and postoperative procedures.

CorMatrix Anterior Leaflet Augmentation of the Tricuspid Valve: Midterm Results.

BACKGROUND: Tricuspid annuloplasty is the most common surgical approach to correct tricuspid regurgitation (TR). In some patients, however, anterior leaflet patch augmentation may be necessary to optimize tricuspid competence. We reviewed our center cohort over the midterm and long term. METHODS: From January 2013 to August 2018, 424 tricuspid valve procedures were performed, of which 420 were repairs and 4 were replacements. Indications were either isolated severe TR or moderate or greater TR, concomitant with other surgery. In the repair cohort, we identified those that had a patch augmentation, and the database was interrogated for preoperative characteristics. The resulting patients had outpatient assessment (clinical and echocardiography) at 6 weeks and at a later interval. Additionally, a comparison was made between those who had good and poor results (moderate or greater TR or cardiac death). RESULTS: In the repair cohort, 19 patients underwent complex tricuspid valve repair with CorMatrix anterior leaflet augmentation. Preoperative characteristics were as follows: age, 65.5 ± 13.5 years; New York Heart Association (NYHA) class, 3.5 ± 0.5; left ventricular ejection fraction, 48.3% ± 5.9%; tricuspid annular plane systolic excursion, 17.1 ± 3.7 mm; right ventricle (good, mild, moderate, poor), 10, 5, 4, 0; annulus size, 40.9 ± 6.9 mm; mean tethering distance, 1.00 ± 0.3 cm; and mean tethering area, 1.53 ± 1.16 cm2. Mean follow-up was 2.1 ± 1.9 years, and survival at 2 years was 73.8%. There were 2 in-hospital deaths. Mean NYHA class was 1.0 ± 0.5 (6 weeks) and 1.5 ± 0.6 (later follow-up); mean residual TR grade was 0.5 ± 0.6 (6 weeks) and 1.3 ± 1.4 (follow-up). Ten of 13 survivors had a good result at last follow-up (TR 0 to 1). We compared the preoperative and operative data of this group versus those with poor results (TR >1 or cardiac mortality). Significant univariate predictors of poor results were larger preoperative tethering area (1.18 ± 0.43 versus 2.4 ± 1.5 cm2; P = .02), longer tethering distance (0.87 ± 0.21 versus 1.2 ± 0.19 cm; P = .007), or the presence of mild or greater TR at 6 weeks (0.2 ± 0.4 vs 1.25 ± 0.5; P = .03). CONCLUSIONS: CorMatrix anterior leaflet augmentation produces successful, stable repair in the majority of this complex population. The presence of even mild TR at 6 weeks' follow-up predicts a poor result. When the tethering area or the tethering distance is significantly high, replacement is probably a better option.

A Case of Postoperative Covid-19 Infection After Cardiac Surgery: Lessons Learned.

While the focus of the medical community is on the management of COVID-19 and its associated complex presentations, it is critical to recognize that patients will continue to present with other medical problems that require urgent therapeutic interventions. There is growing concern that such interventions might have an impact on the natural history of COVID-19. We present a case of a patient who presented with unstable angina and multivessel coronary artery disease for which coronary artery bypass surgery was indicated and performed. Unfortunately, he succumbed to respiratory complications attributed to COVID-19. Our experience suggests concern about adverse outcomes in patients undergoing cardiac surgery who might be infected with COVID-19. Clearly, additional investigations and experience are needed.

Transcatheter aortic valve implantation using the ACURATE neo in bicuspid and tricuspid aortic valve stenosis: a propensity-matched analysis of a European experience.

AIMS: The aim of this study was to assess the performance of a self-expanding valve in bicuspid aortic valve (BAV) stenosis. METHODS AND RESULTS: An international registry included a total of 712 patients with aortic stenosis treated with the ACURATE neo in bicuspid (n=54; 7.5%) or tricuspid (n=658; 92.4%) anatomy. The overall mean age was 81±5.6 years. At baseline, no significant differences were found between the two groups. BAV more frequently required both predilatation (94.4% vs. 78.1%, p=0.004) and post-dilation (57.4% vs. 38.7%, p=0.007). Moderate perivalvular regurgitation was more frequently found in patients with BAV (7.4% vs. 3.18%, p=0.0001). After propensity score matching (PSM), the rate of predilation and post-dilation was confirmed to be higher in the BAV group (94.4% vs. 66.6%, p=0.001, and 57.4% vs. 37.1%, p=0.034, respectively), while the incidence of moderate perivalvular regurgitation was similar between the two groups (BAV 3.1% vs. 5.5% in tricuspid anatomy, p=0.734). In unmatched cohorts, the 30-day outcome showed a higher rate of stroke in the BAV group (7.4% vs. 1.8%, p=0.001). After adjustment for PSM quintiles, the rate of stroke resulted in being similar (odds ratioadj 1.20, 95% confidence interval [CI]: 0.81-1.76, p=0.819). The other 30-day clinical endpoints were similar between the two populations. CONCLUSIONS: This preliminary analysis shows that the use of the ACURATE neo in bicuspid aortic valves is feasible and has acceptable 30-day outcomes. Larger studies are needed to confirm our preliminary findings.

[Early and mid-term results of the transapical aortic valve Symetis Acurate TA: a viable solution in high-risk patients with severe vascular disease]. / Risultati a breve e medio termine della valvola aortica transapicale Symetis Acurate TA: valida soluzione nei pazienti vasculopatici ad alto rischio.

BACKGROUND: Aortic valve stenosis is the most common valvular disease in the elderly. Transcatheter aortic valve implantation represents a viable alternative to conventional aortic valve replacement. In our Department, the transapical approach is the preferred method in patients with severe peripheral vascular disease. The aim of this study was to analyze the early and midterm results of Symetis Acurate TA implantation in our series. METHODS: From June 2013 to January 2017, 21 patients with severe peripheral vascular disease (11 male, mean age 78 ± 2.8 years) underwent transapical implantation of the Symetis Acurate TA device. Mean logistic EuroSCORE I was 21.9 ± 8.6, mean left ventricular ejection fraction was 51.9 ± 12.2%, and mean aortic gradient was 46.7 ± 12.3 mmHg. Valve implantation was performed through a left anterior minithoracotomy. Patients were followed up on a regular basis. Cardiac echocardiographic assessment was performed at 6 months post-implantation. RESULTS: Valve implantation was successful in all patients. Valve sizes were as follows: 7 size S, 6 size M, and 8 size L. Two patients died before hospital discharge (9.5%). Among survivors, 2 patients showed more than mild aortic regurgitation at discharge. Mean aortic gradient was 13.1 ± 4.3 mmHg (p<0.01). Median follow-up was 11.3 months. Mean NYHA class at follow-up was 1.9 ± 0.4 (p<0.05). Mean actuarial survival was 80%. CONCLUSIONS: Our series, even if small, demonstrates that transapical implantation of the Symetis Acurate TA device represents a viable solution in patients with severe peripheral vascular disease carrying a high operative risk. The relatively high operative mortality may be attributable to the learning curve of our team.

Cardiac Paraganglioma Arising From the Right Atrioventricular Groove in a Paraganglioma-Pheochromocytoma Family Syndrome With Evidence of SDHB Gene Mutation: An Unusual Presentation.

Primary cardiac paragangliomas are extremely rare. Recently this neoplasm has been associated with a familiar syndrome as a result of mutation of genes that encode proteins in the mitochondrial complex II. We report a case of a 46-year-old woman having cases of vertebral paraganglioma in her family showing an unusual anatomic and clinical presentation of cardiac paraganglioma and expressing a genetic mutation never associated before with cardiac localization of this neoplasm.

Saphenous Vein Graft Wrapping by Nitinol Mesh: A Word of Caution.

BACKGROUND: Saphenous vein conduits are still used in a large proportion of coronary artery bypass graft (CABG) operations. A recently commercialized nitinol mesh seems to improve venous graft patency. The aim of this study was to control nitinol mesh vein graft patency in a series of isolated CABG patients by computed tomographic (CT) scan. METHODS: In 25 patients (mean age: 61.0 ± 9.65 years), operated for isolated CABG, the eSVS nitinol mesh (Kips Bay Medical Inc., Minneapolis, Minnesota, United States) was used to wrap one vein graft in each patient. Nitinol mesh vein graft was used to revascularize the right coronary (4 patients; 16%), the posterior descending (18 patients; 72%), and the obtuse marginal (3 patients; 12%) arteries. CT scans were performed at 1, 6, and 12 months postoperatively. RESULTS: The procedure was uneventful in all patients. CT controls showed an overall patency rate of 86.9, 42.7, and 34.1% at 1, 6, and 12 months, respectively. The 4 mm mesh had a significantly higher patency rate at 12 months (83.33%) than the 3.5 mm one which showed quite unsatisfactory results (20%) (p = 0.02). Patients with graft occlusion underwent stress testing which was mildly positive in two cases. One of them underwent a percutaneous revascularization. CONCLUSION: Despite promising early results, use of nitinol mesh for saphenous veins was disappointing in our experience. Further refinements are probably needed.

Conventional surgery results in patients originally referred for transcatheter aortic valve implantation.

AIMS: Transcatheter aortic valve implantation (TAVI) is increasingly considered as a viable alternative to conventional aortic valve replacement (AVR) in high-risk patients. Long-term results, however, are still scarce and medical community hesitates in enlarging indications to lower-risk patients. Moreover, available devices are expensive and a strict potential candidate selection is necessary. METHODS: From April 2008 to August 2012, a total of 212 patients, originally referred for percutaneous treatment, were thoroughly evaluated by the aortic team of our department in order to choose the optimal procedure. Of them, 55 patients (35 women; 20 men) were considered as still acceptable candidates for conventional AVR. RESULTS: Mean age was 80.7 ±â€Š4.7 years; mean additive and logistic Euroscore I were 9.7 ±â€Š1.8 and 17.8 ±â€Š9.5%, respectively. Mean Euroscore II was 7.9 ±â€Š5.5%. Mean New York Heart Association class was 2.9 ±â€Š0.5. The majority of patients (87.2%) presented a geriatric frailty score of 0-1. Four patients showed a heavily calcified ascending aorta, and five patients (9%) underwent reoperations. Hospital mortality was 10.9% (six patients). Mean follow-up was 535.9 ±â€Š407.4 days (range: 6-1365 days). Six other patients died during this period for a mean survival of 74.4 ±â€Š6.9% at 2 years. Mean New York Heart Association class at 1 year was 1.25 ±â€Š0.5 (P < 0.01 vs. preoperative value). CONCLUSION: AVR should be indicated with caution in high-risk patients originally referred for TAVI. Despite medium-term results being good, with excellent functional status, hospital mortality is not negligible.

Ten years' follow-up of single-surgeon minimally invasive reparative surgery for degenerative mitral valve disease.

OBJECTIVE: Granted that minimally invasive mitral valve (MV) surgery short-term results were found to be equivalent to those achieved with traditional sternotomy with respect to perioperative morbidity and echocardiographic outcomes, little is known about the long-term efficacy of this approach. This report analyzes a 10-year single-surgeon experience with minimally invasive MV surgery through a right minithoracotomy with peripheral cannulation and external aortic cross-clamping and MV repair (MVR) by direct vision. METHODS: We studied 179 patients (48% female) who underwent MVR between December 1999 and December 2010. Mean age was 40.2 ± 10.1 years (range, 15-67 years). One hundred seventy patients (95.0%) had degenerative diseases, and nine patients (5.0%) had endocarditic diseases. Repair techniques for degenerative disease with posterior leaflet prolapse (74 patients, 43.5%) consisted of quadrangular resection (QR) and annuloplasty (AP) combined with sliding plasty (49 patients, 58.1%); for anterior leaflet prolapse (28 patients, 16.5%) and bileaflet prolapse (66 patients, 38.8%), edge-to-edge repair (EE) and AP; in 2 patients (1.2%), annular dilatation alone consisting of AP. Repair techniques for endocarditic disease consisted of EE in six patients (66.7%), perforation closure in two patients (22.2%), and QR combined with AP in one patient (11.1%). RESULTS: All patients survived the operation and were discharged with MV regurgitation (MR) less than 2+/4+. At 10 years' follow-up, overall survival was 98.7% ± 1.2%, freedom from redo was 98.5% ± 1.1%, freedom from MR recurrence (>2+/4+) in QR and in EE repair were, respectively, 91.7% ± 2.2% and 90.0% ± 2.4% (P = not significant). The linearized rates of overall mortality, MR recurrence (>2+/4+), and redo at follow-up are 0.10% ± 0.10% per year, 0.63% ± 0.26% per year, and 0.21% ± 0.15% per year, respectively. CONCLUSIONS: Minimally invasive MVR can be performed with very good perioperative and long-term results. Freedom from MR greater than 2+/4+ recurrence for patients with QR is equivalent to that with EE repair in our patient cohort.

Pulmonary pseudoaneurysm: uncommon complication after total aortic arch operation.

Pulmonary pseudoaneurysms are an uncommon but life-threatening condition of congenital or acquired cause, most commonly involving the branch pulmonary arteries and generally requiring emergent intervention. We describe a case of postoperative main pulmonary artery pseudoaneurysm after a complex aortic arch procedure, in which thoracic computed tomography provided full information for its definition before surgical correction.

Aortic arch patch aortoplasty for Ortner's syndrome in the age of endovascular stented grafts.

We present a case of hoarseness in a 68-year-old man with a post-traumatic saccular aortic arch aneurysm, effort dyspnea, and dysphonia. Oropharyngeal examination and flexible nasal endoscopy revealed left vocal fold palsy, with the left fold lying in the paramedian position. On account of these and other findings, we made the diagnosis of Ortner's syndrome. We treated the patient surgically by endoluminal repair with a Dacron patch. The postoperative course was uneventful. No additional procedure was necessary on the vocal folds, since he showed prompt postoperative speech improvement.We believe that an accurate evaluation should be made before switching a patient to endovascular treatment. Our case shows that careful preoperative planning, coupled with the most recent cerebral protection techniques, can enable a safe and straightforward surgical solution to a complex anatomic problem.

[Does cardiac surgery in women carry a higher risk than in men?]. / La cardiochirurgia nella donna: rischio più alto?

Cardiovascular diseases are the leading cause of death in women, and female patients exhibit peculiar features as to symptoms, diagnosis and treatment. This sex difference is also observed in cardiac surgery, with mortality and morbidity being higher in female patients. Whether female gender is an independent variable for mortality still remains controversial. This review summarizes the data available in the literature on cardiac surgery in the female population.

Coronary graft use of a new external mesh support.

Poor quality veins may result in early graft failure after coronary artery bypass grafting. Vein remodelling by means of external scaffolds has been attempted by various products. Here, we describe our use of a new external mesh support that is generally used in peripheral vascular bypasses in order to remodel a poor quality vein used in coronary revascularization. Early CT control demonstrated a good result.

Prosthetic valve endocarditis.

Prosthetic valve endocarditis (PVE) is associated with a high mortality during the early and midterm follow-up despite diagnostic and therapeutic improvements; its incidence is increasing and reaches 20-30% of all infective endocarditis episodes. In this review, changes in epidemiology, microbiology, diagnosis and therapy that have evolved in the past few years are analyzed. Staphylococci (both Staphylococcus aureus and coagulase-negative Staphylococcus) have emerged as the most common cause of PVE and are associated with a severe prognosis. Moreover, diagnosis may often be difficult because of its complications and extracardiac manifestations; thus, a comprehensive assessment of the clinical, echocardiographic and laboratory data must be performed. Early PVE, comorbidity, severe heart failure and new prosthetic dehiscence are predictors of mortality. Therapy is not indicated by evidence-based recommendations but mostly on identification of the high-risk conditions. A PVE is a common indication for surgery, whereas medical treatment alone may be achieved in a few instances. Systematic prophylaxis should be used to prevent this severe complication of cardiac valve replacement.

Syncope triggered by a giant unruptured sinus of Valsalva aneurysm.

Sinus of Valsalva aneurysms are rare anomalies, most often caused by congenital absence of muscular and elastic tissue in the aortic wall of the sinus. The indication for surgical repair is controversial at the time of diagnosis. As well, the repair technique depends on how many sinuses are dilated, whether the aneurysm is ruptured and whether the aneurysm is symptomatic. We report a case of a single unruptured sinus of Valsalva aneurysm of a 54-year-old woman.