Platelet Reduction after Transcatheter Aortic Valve Implantation: Results from the PORTRAIT Study.

Background: An unexplained condition that follows transcatheter aortic valve implantation (TAVI) is platelet count reduction (PR). According to published research, patients with balloon-expandable valves (BEVs) had a greater PR than those with self-expandable valves (SEVs). Objectives: The purpose of this study was to investigate the incidence and clinical effects of PR following TAVI. Methods: In total, 1.122 adult TAVI patients were enrolled. Propensity score matching was carried out in a 1:1 ratio between patients with BEVs and those with SEVs. The analysis included changes in platelet count, in-hospital mortality, and early postoperative adverse events. Results: Notably, 632 patients were matched (BEV:316; SEV:316). All patients' post-procedural platelet counts changed according to a parabolic curve, using a mixed regression model for repeated analyses (estimate = -0.931; standard error = 0.421; p = 0.027). The platelet count varied comparably in patients with BEVs and SEVs (estimate = -4.276, standard error = 4.760, p = 0.369). The average time for obtaining the nadir platelet count value was three days after implantation (BEV: 146 (108-181) vs. SEV: 149 (120-186); p = 0.142). Overall, 14.6% of patients (92/632) had post-procedural platelet count <100,000/µL. There was no difference between the two prosthesis types (BEV:51/316; SEV:41/316; p = 0.266). Thrombocytopenia was found to be significantly linked to blood product transfusions, lengthier stays in the intensive care unit and hospital, and in-hospital mortality. Conclusions: TAVI, irrespective of the type of implanted valve, is linked to a significant but temporary PR. Thrombocytopenia increases the risk of serious complications and in-hospital death in TAVI patients. To explore and clarify the causes and associated effects, further prospective research is necessary.

Platelet Reduction after Aortic Bioprosthesis Implantation: Results from the PORTRAIT Study.

Background: Platelet count reduction (PR) is a common but unclear phenomenon that occurs after aortic bioprosthesis valve implantation (bio-AVR). This study aimed to investigate the occurrence and clinical impact of PR in patients receiving stented, rapid deployment (RDV), or stentless bioprostheses. Methods: 1233 adult bio-AVR patients were enrolled. Platelet count variation, early post-operative adverse events, and in-hospital mortality were analysed. Results: 944 patients received a stented valve, an RDV was implanted in 218 patients, and 71 patients had a stentless bioprosthesis. In all groups, the platelet count at discharge was lower than the baseline values (p < 0.001). The percentage of PR was 27% in the stented group, 56% in the RDV group, and 55% in the stentless group. A higher platelet reduction, reaching the minimum platelet value, was observed in the RDV (mean: -30.84, standard error (SE): 5.91, p < 0.001) and stentless (mean: 22.54, SE: 9.10, p = 0.03) groups compared to the stented group. A greater PR occurred as the size of the bioprosthesis increased in RDV (p = 0.01), while platelet count variation was not directly proportional to the stented bioprosthesis size (p < 0.001). PR was not affected by cardiopulmonary bypass (mean: -0.00, SE: 0.001, p = 0.635) or cross-clamp (mean: -0.00, SE: 0.002, p = 0.051) times in any of the groups. RDV subjects experienced more in-hospital adverse events. PR was found to be associated with ischemic strokes in the overall population. Conclusions: Bio-AVR is associated with significant but transient PR. RDV patients more likely experience significant PR and related adverse clinical events. PR is associated with ischemic strokes, regardless of the bioprosthesis type.

Mid-term results of endoscopic mitral valve repair and insights in surgical techniques for isolated posterior prolapse.

BACKGROUND: The adoption of minimally invasive techniques to perform mitral valve repair surgery is increasing. This is enhanced by the compelling evidence of satisfactory short-term results and lower major morbidity. We analyzed mid-term follow-up results of our experience, and further compared two techniques: isolated leaflet resection and neochord implantation for posterior leaflet prolapse. METHODS: Data for all consecutive endoscopic mitral valve repairs via video-assisted right anterior mini-thoracotomy were analyzed between December 2012 and September 2021. The early and mid-term follow-up results were ascertained. The main outcome was the incidence of mortality and the recurrence of significant mitral regurgitation during follow-up which were summarized by the Kaplan-Meier estimator and compared between treatment arms using the stratified log-rank test. Secondary outcomes were the early-postoperative results including 30-days mortality and the occurrence of major complications. RESULTS: A total of 309 patients were included. Along with ring annuloplasty, 136 (44.4%) patients received posterior leaflet resection (122 isolated) whereas 97 (31.1%) underwent posterior leaflet chords implantation (88 isolated). Forty-nine patients had annuloplasty alone. In-hospital mortality was 1.0%. Mean follow-up was 28.8 ± 22.0 months (maximum 8.3 years). Kaplan-Meier survival rate at 5 years was 97.3 ± 1.0%, mitral regurgitation ([Formula: see text]3+) or valve reoperation free-survival at 5 years was estimated as 94.5 ± 2.3%. Subgroup time-to-event analysis for the indexed outcomes showed no statistical significance between the techniques. CONCLUSIONS: Endoscopic mitral valve repair is safe and associated with excellent short- and mid-term outcomes. No differences were found between leaflet resection and gore-tex chords implantation for posterior leaflet prolapse.

[Ross procedure in a patient with mitro-aortic endocarditis]. / Intervento di Ross in paziente con endocardite infettiva mitro-aortica.

Infective endocarditis (IE) affecting the heart valves is burdened by a high risk of mortality and complications. In the aortic valve IE, when valve replacement is essential, there is evidence of good results with the use of pulmonary autographs (Ross procedure), but the application of this technique remains limited due to its poor dissemination. We present a complex case of mitro-aortic IE treated with the Ross procedure associated with removal of vegetation from the mitral valve in a 28-year-old patient undergoing hemodialytic treatment, already undergoing cardiac surgery through sternotomy in the past.

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.

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.

External aortic cross-clamping and endoaortic balloon occlusion in minimally invasive mitral valve surgery.

BACKGROUND: Minimally invasive cardiac surgery has increasingly been used for patients with valvular pathology. Two techniques of aortic occlusion are utilized with this technique: transthoracic aortic clamp (TTC) and endoaortic balloon occlusion (EAO). Both possibilities present peculiar advantages and limitations whose current evidence is based on few observational studies. We performed an analysis with the primary objective to evaluate outcomes and the incidence of major complications of these two techniques. METHODS: The data of 258 patients who underwent minimally invasive mitral valve surgery through right mini-thoracotomy from January 2013 to July 2018 were reviewed. One hundred sixty-five patients were operated on with TTC and in 93 cases EAO was used. Univariate and multivariate analyses were performed to identify predictors of adverse outcome. RESULTS: The mean age of the cohort was 60.4±13.9 years, patients with TTC were significantly older and had higher EuroSCORE II and reoperations were carried out mostly with EAO. Isolated mitral valve surgery was mostly performed (74%) and in 26% of the cases, other procedures were combined. No differences were detected in terms of types of operation, cardiopulmonary bypass (CPB) and cross-clamp times between the two techniques. Similar postoperative troponin I and CK-Mb values were recorded. Twenty-four patients (11%) suffered at least one complication. Of note, a new neurologic deficit occurred in six patients; in four cases a cerebral stroke, with all patients in the EAO group (P=0.06). There was no case of aortic dissection, no patient suffered peripheral ischemia nor femoral vessels complications. Thirty-day mortality was 1.9% (TTC 1.2% vs. EAO 3.2%; P=0.51), 30-day mortality excluding reoperations was 1.2% (TTC 1.2% vs. EAO 1.1%; P=0.61). CONCLUSIONS: Both techniques proved to be safe. Although non-statistically significant, there was a higher rate of cerebral stroke in the EAO group. However, EAO system shows technical advantages in avoiding tissue dissection and remains our choice in redo operations.

Development and results of Puglia adult cardiac surgery registry.

AIMS: To evaluate the feasibility of a cardiac surgery registry and to describe patients' characteristics, type of procedures performed, incidence of postoperative complications with short and middle-term mortality. METHODS: A database with clinical information and details on cardiac surgical operations was implemented by Puglia Health Regional Agency to collect data of each cardiac surgery procedure performed in the seven adult cardiac surgery centres of the region. Health regional agency personnel guaranteed data accuracy and quality control procedures. Mortality after the discharge was evaluated for residents in Puglia by linking clinical data to the Health Information System. RESULTS: From January 2011 to December 2012, 6429 operations were performed. All operations were included in the registry with very high completeness of collected data (95.3% per patient). The majority of the operations performed were coronary artery bypass graft alone (41.1%), valve surgery alone (26.2%), coronary artery bypass graft and valve surgery (11.4%), or valve with other surgery (11.8%). During a median follow-up of 12 months (interquartile range 6-18 months), 211 deaths were detected after the discharge. Overall, cumulative mortality from the operation was 8.2% at 6 months and 9.5% at 12 months. CONCLUSION: Implementation of a regional clinical registry of cardiac surgery is feasible with a great level of accuracy and the evaluation of mid-term mortality overcomes the limited value of hospital mortality. An accurate cardiac surgery registry elicits epidemiologic evaluations, comparisons between expected and observed mortality, incidence of postoperative complications and encourages a reliable public reporting.

Prospective, randomized clinical trial of the FloSeal matrix sealant in cardiac surgery.

BACKGROUND: Topical hemostatic agents composed of a gelatin-based matrix and thrombin have been reported to be effective, in addition to traditional means, in terminating bleeding during cardiac operations. We compared a hemostatic matrix sealant agent (FloSeal; Baxter Inc, Deerfield, IL) with alternative topical hemostatic agents in a mixed cohort of elective cardiac and thoracic aortic operations. METHODS: Following sample size calculation, in a prospective randomized study design, 209 patients were treated with FloSeal matrix sealant (FloSeal group) and 206 patients received alternative agents as topical hemostatic materials (comparison group). FloSeal is composed of a self-expandable gelatin matrix component and purified bovine thrombin. Comparisons included hemostatic patches or sponges composed of either oxidized regenerated cellulose or purified porcine skin gelatin. Study endpoints were the following: rate of successful intraoperative hemostasis (identified by cessation of bleeding) and time required for hemostasis; overall postoperative bleeding; rate of transfusion of blood products; rate of surgical revision for bleeding; postoperative morbidity; and intensive care unit stay. RESULTS: Statistically higher rates of successful hemostasis and shorter time-to-hemostasis were observed in the FloSeal group (p < 0.001 both). Time-to-event analysis confirmed this finding (p = 0.0025). Postoperative bleeding and rate of transfusion of blood products were statistically decreased in the FloSeal group (p < 0.001 both). Rates of revision for bleeding and of minor complications were not statistically different among groups in the overall cohort, but were significantly lesser in the FloSeal group if only patients with overt intraoperative bleeding are considered (p = 0.04 both). The advantages observed in the FloSeal group were not offset in patients undergoing systemic hypothermia. CONCLUSIONS: The topical hemostatic agent used in the FloSeal group is effective in terminating intraoperative bleeding as an adjunct to traditional surgical methods for stopping bleeding. Its judicious use is associated with lesser need for transfusion of blood products and rate of revision for bleeding. Its cost-utility profile should be addressed in dedicated trials.

BNP in mitral valve restrictive annuloplasty for ischemic mitral regurgitation.

Restrictive annuloplasty with undersized mitral rings is used to correct functional mitral regurgitation (MR) in patients with ischemic left ventricular dysfunction. Seventeen patients with severe coronary artery disease, previous myocardial infarction, moderate/severe functional MR and heart failure symptoms were prospectively evaluated. All patients received CABG associated with restrictive annuloplasty. Preoperatively and 6 months after the operation, clinical evaluation, echocardiography and blood sampling for BNP measurement were performed. Operative mortality occurred in 1 patient. MR degree decreased from 3.8+/-0.3 to 1.0+/-0.7 (p<0.01), LVEF increased from 36+/-11% to 43+/-8% (p<0.05), left ventricular end diastolic diameters changed from 54.7+/-5.2 mm to 51.5+/-5.8 mm (p=0.51). NYHA class improved from 2.94+/-1.02 to 1.21+/-0.42 (p<0.01). Mean plasma BNP levels decreased from 471+/-248 pmol/l to 55.6+/-52.8 pmol/l (p<0.05). Restrictive mitral annuloplasty is a safe procedure to be associated to CABG operation. We demonstrated mid-term reduction of BNP plasma values after MR correction thus suggesting the effectiveness of surgical treatment in modifying natural history of the disease.

Preoperative C-reactive protein predicts mid-term outcome after cardiac surgery.

BACKGROUND: C-reactive protein (CRP) is a known risk factor for cardiovascular events in the healthy population and in patients with coronary artery disease. High CRP levels before cardiac surgery are associated with worse short-term outcome, but its role after discharge home remains unknown. The study objective was to evaluate the effect of CRP on short-term and mid-term outcome after cardiac surgery. METHODS: From August 2000 to May 2004, values for preoperative CRP were available for 597 unselected patients undergoing cardiac operations. CRP was used to divide this cohort in two groups: a low inflammatory status (LHS) group of 354 patients with CRP of less than 0.5 mg/dL, and a high inflammatory status (HIS) group of 243 patients with a CRP of 0.5 mg/dL or more. Follow-up lasted a maximum of 3 years (median, 1.8 +/- 1.5 years) and was 92.6% complete. RESULTS: In-hospital mortality was 8.2% in the HIS group and 3.4% in the LIS group (odds ratio [OR], 2.61; p = 0.02). Incidence of postoperative infections was 16.5% in the HIS group and 5.1% in the LIS group (OR, 3.25; p = 0.0001). Sternal wound infections were also more frequent in the HIS group (10.7% versus 2.8%; OR, 3.43; p = 0.002). During follow-up, the HIS group had worse survival (88.5% +/- 2.9% versus 91.9% +/- 2.5%; OR, 1.93; p = 0.05) and a higher need of hospitalization for cardiac-related causes (73.6% +/- 6% versus 86.5% +/- 3.2%; OR, 1.82; p = 0.05). CONCLUSIONS: Patients undergoing cardiac surgery with a CRP level of 0.5 mg/dL or more are exposed to a higher risk of in-hospital mortality and postoperative infections. Despite surgical correction of cardiac disease, a high preoperative CRP value is an independent risk factor for mid-term survival and hospitalization for cardiac causes.

Cardiac troponin I release after coronary artery bypass grafting operation: effects on operative and midterm survival.

BACKGROUND: Markers of myocardial necrosis are usually elevated in patients who have undergone a coronary bypass operation with cardiac arrest. The preferred marker in detecting acute myocardial ischemia is cardiac troponin I (cTnI). However, its ability to predict short-term and, particularly, midterm outcome after coronary bypass operations is uncertain. METHODS: Two hundred thirty unselected patients undergoing surgical revascularization had cTnI measured preoperatively and 11 times postoperatively. Receiver operating characteristic curves were constructed using cTnI postoperative peak values in order to assess the prognostic sensitivity and specificity of the test. The cut-off value of 13 ng/mL was used to assess the prognostic significance of the peak cTnI postoperative release for short-term and midterm outcomes. RESULTS: One hundred forty-six patients (63.5%) had postoperative cTnI peak values less than 13 ng/mL (mean peak value, 6.6 +/- 3.1 ng/mL) and 84 patients (36.5%) had postoperative cTnI peak values greater than 13 ng/mL (mean peak value, 45.5 +/- 59.9 ng/mL). Patients with peak cTnI greater than 13 ng/mL were older and had higher preoperative cTnI values. They required both longer cross-clamp time and CPB time. Moreover, hospital death in the cTnI greater than 13 ng/mL group (9.5% versus 0.7%, p = 0.0009) was significantly higher. Multivariate analysis showed that cTnI greater than 13 ng/mL was the only independent predictor of hospital death (odds ratio 10.33, p = 0.04) and hospital death from cardiac causes. A 2-year follow-up demonstrates that cTnI postoperative release had no influence on midterm mortality and hospitalization for due to cardiac illness. CONCLUSIONS: Cardiac troponin I is a valuable marker for immediate myocardial damage after coronary bypass operations. Its postoperative release does not predict midterm outcome.

Blood damage related to cardiopulmonary bypass: in vivo and in vitro comparison of two different centrifugal pumps.

Cardiopulmonary bypass (CPB) induces hemolysis and the activation of the inflammatory and coagulation systems. Several components of the CPB equipment may contribute to such phenomenon. We tested the effects of two differently designed centrifugal pumps (Bio-Pump, Medtronic and Revolution, Cobe) on several markers of hemolysis, coagulation, and inflammation: plasma free hemoglobin,prothrombin fragment 1.2, platelet factor 4, and P-selectin. Twenty patients requiring coronary artery bypass grafting were randomized to undergo CPB with one of the study centrifugal pumps, and 10 experiments (5 for each pump) were performed with a closed loop circuit to assess pumps' performances over 6 circulation hours using human blood. CPB induced a significant elevation of all the tested markers. Neither in the in vivo nor in the in vitro study were significant differences observed between the groups. Because the Revolution centrifugal pump, which was recently designed and distributed, produced results comparable with those obtained with the BioPump, it should be considered as safe as the Bio-Pump to perform clinical CPB.

Midterm evaluation of the Sorin Bicarbon heart valve prosthesis: single-center experience.

BACKGROUND: The purpose of this study was to perform midterm evaluation of the clinical performance of the Sorin Bicarbon mechanical heart valve prosthesis. METHODS: From November 1992 to December 2002, 328 patients underwent isolated aortic (AVR; 156) or mitral (MVR; 172) valve replacement with the Sorin Bicarbon mechanical valve. Concomitant surgery was performed in 83 patients (25.2%). RESULTS: Total hospital mortality was 5.2%. Survival at 7 years was 79.5% for AVR and 82.4% for MVR. Kaplan-Meier freedoms from valve-related complications were as follows: thromboembolism 92.7% (AVR 94.8%, MVR 92.1%); bleeding 93% (AVR 91.9%, MVR 94.5%); nonstructural dysfunction 96.6% (AVR 94.7%; MVR 97.9%); endocarditis 97.7% (AVR 97.4%, MVR 98.1%); and reoperation 95.7% (AVR 96.6%, MVR 93.9%). Overall freedom from valve-related death was 93.2% (AVR 99.3%, MVR 91.2%). At the end of follow-up, 88.9% of survivors were in New York Heart Association class I or II. CONCLUSIONS: The Sorin Bicarbon valve is a satisfactory mechanical valve prosthesis with low mortality and morbidity and good functional results.