Blood and lymphatic vessels contribute to the impact of the immune microenvironment on clinical outcome in non-small-cell lung cancer.

OBJECTIVES: Lymphangiogenesis plays a critical role in the immune response, tumour progression and therapy effectiveness. The aim of this study was to determine whether the interplay between the lymphatic and the blood microvasculature, tumour-infiltrating lymphocytes and the programmed death 1 (PD-1)/programmed death ligand 1 (PD-L1) immune checkpoint constitutes an immune microenvironment affecting the clinical outcome of patients with non-small-cell lung cancer. METHODS: Samples from 50 squamous cell carcinomas and 42 adenocarcinomas were subjected to immunofluorescence to detect blood and lymphatic vessels. CD3pos, CD8pos and PD-1pos tumour-infiltrating lymphocytes and tumour PD-L1 expression were assessed by immunohistochemical analysis. RESULTS: Quantification of vascular structures documented a peak of lymphatics at the invasive margin together with a decreasing gradient of blood and lymphatic vessels from the peritumour area throughout the neoplastic core. Nodal involvement and pathological stage were strongly associated with vascularization, and an increased density of vessels was detected in samples with a higher incidence of tumour-infiltrating lymphocytes and a lower expression of PD-L1. Patients with a high PD-L1 to PD-1 ratio and vascular rarefaction had a gain of 10 months in overall survival compared to those with a low ratio and prominent vascularity. CONCLUSIONS: Microvessels are an essential component of the cancer immune microenvironment. The clinical impact of the PD-1/PD-L1-based immune contexture may be implemented by the assessment of microvascular density to potentially identify patients with non-small-cell lung cancer who could benefit from immunotherapy and antiangiogenic treatment.

Impact of prosthesis-patient mismatch on cardiac events and midterm mortality after aortic valve replacement in patients with pure aortic stenosis.

BACKGROUND: Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of the prosthesis being implanted is too small in relation to body size, thus causing abnormally high transvalvular pressure gradients. The objective of this study was to examine the midterm impact of PPM on overall mortality and cardiac events after aortic valve replacement in patients with pure aortic stenosis. METHODS AND RESULTS: The indexed EOA (EOAi) was estimated for each type and size of prosthesis being implanted in 315 consecutive patients with pure aortic stenosis. PPM was defined as an EOAi < or =0.80 cm2/m2 and was correlated with overall mortality and cardiac events. PPM was present in 47% of patients. The 5-year overall survival and cardiac event-free survival were 82+/-3% and 75+/-4%, respectively, in patients with PPM compared with 93+/-3% and 87+/-4% in patients with no PPM (P< or =0.01). In multivariate analysis, PPM was associated with a 4.2-fold (95% CI, 1.6 to 11.3) increase in the risk of overall mortality and 3.2-fold (95% CI, 1.5 to 6.8) increase in the risk of cardiac events. The other independent risk factors were history of heart failure, NHYA class III-IV, severe left ventricular hypertrophy, and absence of normal sinus rhythm before operation. CONCLUSIONS: PPM is an independent predictor of cardiac events and midterm mortality in patients with pure aortic stenosis undergoing aortic valve replacement. As opposed to other risk factors, PPM may be avoided or its severity may be reduced with the use of a preventive strategy at the time of operation.

Factors affecting left ventricular remodeling after valve replacement for aortic stenosis. An overview.

Although a small percentage of patients with critical aortic stenosis do not develop left ventricle hypertrophy, increased ventricular mass is widely observed in conditions of increased afterload. There is growing epidemiological evidence that hypertrophy is associated with excess cardiac mortality and morbidity not only in patients with arterial hypertension, but also in those undergoing aortic valve replacement. Valve replacement surgery relieves the aortic obstruction and prolongs the life of many patients, but favorable or adverse left ventricular remodeling is affected by a large number of factors whose specific roles are still a subject of debate. Age, gender, hemodynamic factors, prosthetic valve types, myocyte alterations, interstitial structures, blood pressure control and ethnicity can all influence the process of left ventricle mass regression, and myocardial metabolism and coronary artery circulation are also involved in the changes occurring after aortic valve replacement. The aim of this overview is to analyze these factors in the light of our experience, elucidate the important question of prosthesis-patient mismatch by considering the method of effective orifice area, and discuss surgical timings and techniques that can improve the management of patients with aortic valve stenosis and maximize the probability of mass regression.

Minimally invasive aortic valve replacement with a sutureless valve through a right anterior mini-thoracotomy versus transcatheter aortic valve implantation in high-risk patients.

OBJECTIVES: The aim of this study was to compare early outcomes and mid-term survival of high-risk patients undergoing minimally invasive aortic valve replacement through right anterior mini-thoracotomy (RT) with sutureless valves versus patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis. METHODS: From October 2008 to March 2013, 269 patients with severe aortic stenosis underwent either RT with perceval S sutureless valves (n = 178 patients, 66.2%) or TAVI (n = 91, 33.8%: 44 transapical and 47 trans-femoral). Of these, 37 patients undergoing RT with the perceval S valve were matched to a TAVI group by the propensity score. RESULTS: Baseline characteristics were similar in both groups (mean age 79 ± 6 years) and the median logistic EuroSCORE was 14% (range 9-20%). In the matched group, the in-hospital mortality rate was 8.1% (n = 3) in the TAVI group and 0% in the RT group (P = 0.25). The incidence rate of stroke was 5.4% (n = 2) versus 0% in the TAVI and RT groups (P = 0.3). In the TAVI group, 37.8% (n = 14) had mild paravalvular leakage (PVL) and 27% (n = 10) had moderate PVL, whereas 2.7% (n = 1) had mild PVL in the RT group (P < 0.001). One- and 2-year survival rates were 91.6 vs 78.6% and 91.6 vs 66.2% in patients undergoing RT with the perceval S sutureless valve compared with those undergoing TAVI, respectively (P = 0.1). CONCLUSIONS: Minimally invasive aortic valve replacement with perceval S sutureless valves through an RT is associated with a trend of better early outcomes and mid-term survival compared with TAVI.

International Expert Consensus on Sutureless and Rapid Deployment Valves in Aortic Valve Replacement Using Minimally Invasive Approaches.

OBJECTIVE: To define the benefit of sutureless and rapid deployment valves in current minimally invasive approaches in isolated aortic valve replacement. METHODS: A panel of 28 international experts with expertise in both minimally invasive aortic valve replacement and rapid deployment valves was constituted. After thorough literature review, the experts rated evidence-based recommendations in a modified Delphi approach. RESULTS: No guideline could be retrieved. Thirty-three clinical trials and 9 systematic reviews could be identified for detailed text analysis to obtain a total of 24 recommendations. After rating by the experts 12, final recommendations were identified: preoperative computed tomographic scan as well as intraoperative transesophageal echocardiography are highly recommended. Suitable annular sizes are 19 to 27 mm. There is a contraindication for bicuspid valves only for type 0 and for annular abscess or destruction due to infective endocarditis. The use of sutureless and rapid deployment valves reduces extracorporeal circulation and aortic cross-clamp time and leads to less early complications as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions, paravalvular leakages and aortic regurgitation, and renal replacement therapy, respectively. These clinical outcomes result in reduced intensive care unit and hospital stay and reduced costs. The use of sutureless and rapid deployment valves will lead to a higher adoption rate of minimally invasive approaches in aortic valve replacement. Respect should be taken to a necessary short learning curve for both sutureless and minimally invasive programs. CONCLUSIONS: Sutureless and rapid deployment aortic valve replacement together with minimally invasive approaches offers an attractive option in aortic valve placement for patients requiring biological valve replacement.

Early and long-term outcomes of minimally invasive mitral valve surgery through right minithoracotomy: a 10-year experience in 1604 patients.

BACKGROUND: To report early and long-term outcomes of patients undergoing minimally invasive mitral valve surgery (MIMVS) through right mini-thoracotomy (RT) over a 10-year period. METHODS: From September 2003 to December 2013, a total of 1604 consecutive patients underwent MIMVS through RT. RESULTS: The mean age was 63 ± 13 years, 770 (48 %) patients were female and 218 (13.6 %) had previous cardiac operations. The most predominant pathology was degenerative disease (70 %), followed by functional mitral valve regurgitation (12 %), rheumatic disease (9.4 %), endocarditis (5 %) and prosthetic dysfunction (3.2 %). Mitral valve repair was performed in 1137 (71 %) patients and 476 (29 %) had mitral valve replacement. Direct aortic cannulation was achieved in 1325 (83 %) patients. Among patients with degenerative disease candidate for repair (n = 958), rate of mitral valve repair was 95 %. Repair techniques included annuloplasty (95 %), leafleat resection (63 %), neochordae implantation (16 %) and sliding plasty (11 %). Concomitant procedures included tricuspid valve repair (14.6 %), atrial fibrillation ablation (9.5 %) and atrial septal defect closure (3.2 %). Overall in-hospital mortality was 1.1 %. Thirty-four patients (2.1 %) had conversion to sternotomy. Incidence of stroke was 2 %. Overall survival at 10 years was 88 ± 2 %. Freedom from reoperation at 10 years was 94 ± 2 % for repair and 80 ± 6 % for replacement. Freedom from recurrent mitral regurgitation >3+ at 10 years was 90 ± 3 %. CONCLUSIONS: Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity, high rate of mitral valve repair and excellent late results.

Isolation and Characterization of Human Lung Lymphatic Endothelial Cells.

Characterization of lymphatic endothelial cells from the respiratory system may be crucial to investigate the role of the lymphatic system in the normal and diseased lung. We describe a simple and inexpensive method to harvest, isolate, and expand lymphatic endothelial cells from the human lung (HL-LECs). Fifty-five samples of healthy lung selected from patients undergoing lobectomy were studied. A two-step purification tool, based on paramagnetic sorting with monoclonal antibodies to CD31 and Podoplanin, was employed to select a pure population of HL-LECs. The purity of HL-LECs was assessed by morphologic criteria, immunocytochemistry, flow cytometry, and functional assays. Interestingly, these cells retain in vitro several receptor tyrosine kinases (RTKs) implicated in cell survival and proliferation. HL-LECs represent a clinically relevant cellular substrate to study lymphatic biology, lymphoangiogenesis, interaction with microbial agents, wound healing, and anticancer therapy.

Cardioprotection by Targeting the Pool of Resident and Extracardiac Progenitors.

The adult heart has the capacity to generate new myocytes that are markedly enhanced in acute and chronic heart failure of ischemic and non-ischemic origin. In addition, a pool of blood trafficking progenitor cells able to sense myocardial damage may home to the sites of injury participating to cardiac repair. This new view of myocardial biology leads to an expanding long-term research and therapeutic goals for cardioprotection. A fundamental concept to be analyzed is whether cardiac diseases are influenced by changes in the properties of tissue specific and circulating progenitors. Loss of self-renewal capacity, impaired growth or increased susceptibility to death may lead to a reduction of progenitors and leave myocardial damage unrepaired. Cardiac progenitors generate all myocardial cell lineages, thus impairment in their growth is expected to be critically involved in the structural and functional modifications of the heart. The fact that, in addition to well known effects of anthracyclines, also new drugs that target molecular pathways implicated in cell death and growth can be cardiotoxic further supports our hypothesis. Understanding the role of resident and extracardiac progenitors in the pathogenesis of cardiomyopathies of different etiology will provide not only a better comprehension of cardiac homeostasis but will also open new avenues for therapeutic interventions. The progress toward effective myocardial regeneration based on exploiting the self-renewal potential of the myocardium and the systemic pool of cardiogenic cells should advance the likelihood of efficient cardioprotection and restoration of cardiac function.

Determinants of postinfarction remodeling affect outcome and left ventricular geometry after surgical treatment of ischemic cardiomyopathy.

OBJECTIVE: To identify the effects of the time between myocardial infarction and surgery, the site of infarction, mitral involvement on ventricular geometry, and clinical outcome in the treatment of ischemic cardiomyopathy in patients with heart failure. METHODS: Sixty-nine consecutive patients with ischemic cardiomyopathy, indexed end-systolic volume > or =50 mL/m(2), ejection fraction < or =35%, and heart failure underwent surgery 81.9 +/- 100.8 months after myocardial infarction, using different techniques of ventricular restoration. Thirteen geometric parameters were studied pre- and postoperatively. Paired and unpaired t tests and general linear model for multivariate analysis were used to analyze subgroups. Logistic regression and Kaplan-Meier survival curves with pairwise log-rank were used to correlate covariates to clinical outcome. RESULTS: Longer time to surgery and posterior necrosis linearly correlated with higher left ventricular volumes (r(2) =.66) and diameters (r(2) =.40). High grade of mitral regurgitation was always present in posterior infarctions. Hospital mortality was 4.3%. Complicated postoperative course was predicted by mitral surgery (P =.004) and longer time to surgery (P =.04). Survival was significantly lower in the posterior infarction (P =.0002) and mitral surgery (P =.001) subgroups. At a mean follow-up of 1.9 +/- 1.3 years, functional status and geometrical restoration are influenced by the studied covariates. CONCLUSIONS: Longer time to surgery after myocardial infarction, its posterior location, and significant mitral regurgitation can affect left ventricular remodeling, surgical restoration, and clinical outcome in patients with ischemic cardiomyopathy.

Uncommon presentation and surgical correction of unroofed coronary sinus syndrome.

A 59-year-old man with signs and symptoms of congestive heart failure, occurring a few months after an infective episode, underwent cardiac investigations revealing severe biventricular dysfunction, persistent left superior vena cava with almost completely unroofed coronary sinus, and critical stenosis of the proximal right coronary artery. Surgical correction of the congenital malformation associated with revascularization of the right coronary allowed a prompt recovery of clinical conditions and ventricular function.

Mass regression in aortic stenosis after valve replacement with small size pericardial bioprosthesis.

BACKGROUND: The aim of the study was to determine whether left ventricular mass regression is influenced by valve size after the implantation of a Carpentier-Edwards Perimount (CEP) pericardial bioprosthesis for pure aortic stenosis. METHODS: Patients receiving 19-mm, 21-mm, and 23-mm CEP aortic valves underwent echocardiography preoperatively and at least 1 year after surgery (mean, 2.3 +/- 1 years) and the echocardiograms were compared within and between groups. RESULTS: The study involved a total of 88 patients: 34 receiving 19-mm CEPs, 29 receiving 21-mm CEPs, and 25 receiving 23-mm CEPs. The mean postoperative prosthetic gradients were respectively 20.6 +/- 6.6 mm Hg, 17.9 +/- 5.8 mm Hg, and 13.2 +/- 4.1 mm Hg (p = 0.0001); the mean postoperative valve areas were respectively 1.24 +/- 0.16 cm(2), 1.45 +/- 0.2 cm(2), and 1.63 +/- 0.21 cm(2) (p = 0.0001). In comparison with the preoperative echocardiographic measurements absolute left ventricular mass significantly decreased by -54.1 +/- 48.8 g, -54.1 +/- 55.1 g, and -74.4 +/- 57.4 g respectively with no statistically significant between-group difference (analysis of variance) but ventricular septum and posterior wall thickness significantly decreased in each group (p < 0.05). CONCLUSIONS: The implantation of 19-mm, 21-mm, and 23-mm CEP aortic prostheses significantly reduces left ventricular mass without any size-related differences.

Aortic valve disease with severe ventricular dysfunction: stentless valve for better recovery.

BACKGROUND: Stentless bioprostheses and homografts show better hemodynamic profiles compared with conventional stented bioprostheses and mechanical valves. Few data are available on stentless aortic valve implantation for patients with severe left ventricular dysfunction. The aim of this retrospective study was to assess the potential benefits of stentless aortic valve implantation for patients undergoing isolated aortic valve replacement with left ventricular ejection fraction < or = 35%. METHODS: From November 1988 through March 2000, 53 patients (45 men and 8 women, aged 64.2 +/- 15.2 years) with a LVEF < or = 35% (mean EF, 28.7 +/- 5.4%) underwent isolated, primary aortic valve replacement for chronic aortic valve disease. Twenty patients received stentless aortic valves and 33 patients received conventional stented bioprostheses and mechanical valves. Predictive factors for LVEF recovery at echocardiographic follow-up (36.2 +/- 32.1 months) were analyzed by simple and multiple regression analysis. RESULTS: There were no significant differences between groups in early and late mortality. Stentless aortic valve implantation required a longer aortic cross-clamp time (p = 0.037). The stentless aortic valve group showed a better LVEF recovery (p = 0.016). Stentless aortic valves had a larger indexed effective orifice area compared with conventional stented bioprostheses and mechanical valves (p < 0.0001). A smaller indexed effective orifice area (p = 0.0008), chronic obstructive pulmonary disease (p = 0.015), and implantation of a conventional stented bioprosthesis or mechanical valve (p = 0.016) were related to reduced LVEF recovery by univariate analysis. A larger indexed effective orifice area (p = 0.024) was an independent predictive factor for a better LVEF recovery by multivariate analysis. CONCLUSIONS: Stentless aortic valve implantation for patients with severe left ventricular dysfunction, even if technically more demanding, is a safe procedure that warrants a larger indexed effective orifice area leading to an enhanced LVEF recovery.

Mid-term results of cardiac autotransplantation as method to treat permanent atrial fibrillation and mitral disease.

OBJECTIVES: The results of current surgical options for the treatment of permanent atrial fibrillation (AF) associated with mitral surgery are widely different, particularly in very enlarged left atria. The aim of this study was to assess the mid-term efficacy of cardiac autotransplantation for this goal, through a consistent reduction of left atrium volume and a complete isolation of the pulmonary veins. METHODS: From April 2000 to September 2002, 30 patients (male/female 5/25) underwent cardiac autotransplantation for the treatment of mitral valve disease and concomitant permanent AF (>1 year). Surgical technique of bicaval heart transplantation was modified maintaining the connection of inferior vena cava in all but three cases. Twenty-eight patients had mitral valve replacement and two had mitral valve repair. Associated procedures were: aortic valve replacement (6 cases), tricuspid valve repair (2 cases), coronary re-vascularization (2 cases) and right atrium volume reduction (4 cases). RESULTS: No hospital death occurred; 1 patient died 3 months post-operatively for pneumonia. At a mean follow-up of 21.1+/-7.7 months (range 6-35), 26 patients (89.7%) were in sinus rhythm and 3 (10.3%) in AF. Santa Cruz Score was 0 in 3 patients, 2 in 2 patients and 4 in the remaining 24 patients (82.7%). Mean left atrial diameter and volume decreased from 65.1+/-16.4 mm (range 50-130 mm) to 49.9+/-8.4 mm (range 37-78) (P < 0.001) and from 118.3+/-68.4 ml (range 60-426) to 69.4+/-34.1 ml (range 31-226) (P = 0.001), respectively, after the operation. CONCLUSIONS: Cardiac autotransplantation is a safe and effective option for the treatment of permanent AF in patients with mitral valve disease and severe dilation of left atrium.

Cardiac autotransplantation for the treatment of permanent atrial fibrillation combined with mitral valve disease.

OBJECTIVE: The results of current surgical options for the treatment of permanent atrial fibrillation associated with mitral valve surgery are widely different, particularly for extremely dilated left atria. The aim of this study is to assess the efficacy of cardiac autotransplantation in restoring a normal sinus rhythm via a consistent reduction in the left atrium volume associated with a complete isolation of the pulmonary veins. METHODS: From April 2000 to April 2002, 28 patients (men/women, 5/23) underwent cardiac autotransplantation for the treatment of mitral disease and concomitant permanent atrial fibrillation (>1 year). A modified surgical technique derived from bicaval heart transplantation procedures maintained the connection of the right atrium with the inferior vena cava in all but 3 cases. In 2 patients, the mitral valve was repaired, and it was replaced in 26 patients. Associated procedures were 6 aortic valve replacements, 2 tricuspid valve annuloplasties, and 2 coronary revascularizations. RESULTS: No hospital deaths were recorded, but 1 patient died of pneumonia 3 months postoperatively. At a mean follow-up period of 17.2 +/- 6.7 months (range, 6-30 months), 24 patients (88.9%) were in sinus rhythm, and 3 (11.1%) were in atrial fibrillation. The Santa Cruz Score was 0 for 3 patients, 2 for 1 patient, and 4 for the remaining 23 patients (85.2%). The mean left atrial diameter decreased from 65.4 +/- 17.1 mm (range, 50-130 mm) before the operation to 48.4 +/- 5.6 mm (range, 37-78 mm) postoperatively (P <.001), and the mean left atrial volume decreased from 119 +/- 70.5 mL (range, 60-426 mL) to 69.1 +/- 35.1 mL (range, 31-226 mL) (P <.0001). CONCLUSION: Cardiac autotransplantation is a safe and effective surgical option for the treatment of permanent atrial fibrillation in patients with long-lasting mitral valve disease and severe enlargement of the left atrium.

Myectomy-myotomy associated with aortic valve replacement for aortic stenosis: effects on left ventricular mass regression.

BACKGROUND: Left ventricular outflow tract dynamic obstruction may develop after aortic valve replacement for aortic stenosis with a higher mortality and morbidity and may persist until left ventricular mass regression occurs. The aim of this study was to ascertain the effects of myectomy-myotomy on the left ventricular mass and mean wall thickness regression and on left ventricular mass normalization at least 1 year postoperatively. METHODS: A total of 162 patients including 71 with myectomy-myotomy (group I) and 91 without (group II) were studied at pre- and postoperative echocardiography. RESULTS: The relative left ventricular regression, after adjustment by ANCOVA analysis, was significantly greater in group I than in group II (-24.6 +/- 14.7 and -16.8 +/- 17.8%, p = 0.004) and the absolute mean wall thickness regression was greater in group I than in group II (-1.6 +/- 1.3 vs -1.1 +/- 1.6 mm, p = 0.019). Multivariable analysis showed myectomy-myotomy as an independent predictor of left ventricular mass regression. CONCLUSIONS: Myectomy-myotomy may improve left ventricular mass regression after aortic valve replacement for pure aortic stenosis.

Ross procedure for severe congenital aortic regurgitation in a three-month-old patient.

We here describe the case of an infant with severe aortic regurgitation due to a congenital dysplastic aortic valve. Surgical treatment (autograft replacement of the aortic valve) was carried out when the patient was 3 months old. The technical aspects and the results of instrumental examination during follow-up are discussed.

Off-pump coronary surgery in a single center experience: from selective to systematic use.

BACKGROUND: The feasibility of the systematic use of the off-pump technique for myocardial revascularization was investigated. METHODS: From September 1997 to June 2001, 1221 isolated coronary artery bypass grafting operations were performed consecutively: 771 (group A) were completed with cardiopulmonary bypass, and 450 (group B) without. Since July 2000 all patients were considered as potential candidates for off-pump coronary artery bypass. In group B, a specific original instrumentation was used for coronary stabilization. RESULTS: The differences in the preoperative data were: a higher age, a higher incidence of chronic obstructive pulmonary disease and a left ventricular ejection fraction < 30% in group B; a higher incidence of critical left main stenosis in group A. More grafts per patient were completed in group A (3.0 +/- 1.4 vs 2.2 +/- 0.9, p < 0.001). The hospital mortality (group A 1.0%, group B 0.7%) and the incidence of perioperative myocardial infarction (group A 2.5%, group B 1.1%) and that of cerebrovascular accidents (group A 1.4%, group B 0.9%) were comparable. Bleeding (610 +/- 370 vs 496 +/- 215 ml, p < 0.001), the transfusion rate (36 vs 19.7%, p < 0.001), the intubation time (13.4 +/- 3.5 vs 8.3 +/- 5 hours, p < 0.001), the intensive care unit stay (1.7 +/- 2.7 vs 1.2 +/- 2.1 days, p < 0.001) and the hospital stay (5.8 +/- 3 vs 5.1 +/- 3.2 days, p < 0.001) were lower in group B. At follow-up, the mortality (2.5 vs 1.1%), the rate of recurrence of angina (2.5 vs 2.0%), and those of re-angiography (4.1 vs 5.3%) and of new revascularization (1.6 vs 1.1%) were similar. The actuarial survival rates were 99.8, 98.6 and 96.3% in group A, and 98.8, 96.7 and 96.7% in group B at 1, 2 and 3 years of follow-up respectively (log rank p = 0.3387). CONCLUSIONS: The increase in the use of off-pump coronary artery bypass up to its systematic empolyment is feasible. The early and intermediate results are satisfactory.

[Myocardial revascularization without extracorporeal circulation in patients with multivessel coronary disease]. / Rivascolarizzazione miocardica senza circolazione extracorporea in pazienti con malattia coronarica multivasale.

BACKGROUND: Some criticisms have been addressed to off-pump coronary surgery technique concerning the possibility of its systematic use with the respect of the completeness of revascularization. We report our experience with off-pump revascularization in patients with multivessel coronary disease. METHODS: Between September 1997 and April 2003, 868 patients with multivessel coronary disease were scheduled for off-pump surgical revascularization. From September 2000, the percentage of patients operated on without cardiopulmonary bypass has been stably > 90%. Fifteen patients (1.7%) had a conversion to cardiopulmonary bypass for anatomical reasons (n = 6) or clinical instability (n = 9). RESULTS: An average of 2.5 +/- 0.8 (range 1-5) anastomoses per patient were completed. Bilateral mammary artery was used in 573 patients (66%); totally arterial revascularization was accomplished in 479 patients (55.2%). In-hospital mortality rate was 0.6% (5 patients). Total incidence of non-fatal postoperative complications (bleeding requiring re-exploration, perioperative myocardial infarction, stroke, new onset of acute renal failure) was 3.5%. Mean postoperative hospital stay was 4.8 +/- 3.8 days. At a mean follow-up of 21.6 +/- 15.6 months (range 1-65 months), the postoperative actuarial survival rates were 97.3, 93.7 and 86.7% at 1, 3 and 5 years postoperatively. Actuarial freedom rates from new revascularization were 98.7, 96.6 and 96.6% at 1, 3 and 5 years postoperatively. CONCLUSIONS: Early- and intermediate-term results of this study demonstrate the feasibility of off-pump revascularization in all patients with multivessel coronary disease, respecting the criterion of complete myocardial revascularization.

[Off-pump myocardial revascularization in patients with multivessel coronary disease]. / Rivascolarizzazione miocardica senza circolazione extracorporea in pazienti con malattia coronarica multivasale.

BACKGROUND: Some criticisms have been addressed to off-pump coronary surgery technique concerning the possibility of its systematic use with the respect of the completeness of revascularization. We report our experience with off-pump revascularization in patients with multivessel coronary disease. METHODS: Between September 1997 and April 2003, 868 patients with multivessel coronary disease were scheduled for off-pump surgical revascularization. From September 2000, the percentage of patients operated on without cardiopulmonary bypass has been stably > 90%. Fifteen patients (1.7%) had a conversion to cardiopulmonary bypass for anatomical reasons (n = 6) or clinical instability (n = 9). RESULTS: An average of 2.5 +/- 0.8 (range 1-5) anastomoses per patient were completed. Bilateral mammary artery was used in 573 patients (66%); totally arterial revascularization was accomplished in 479 patients (55.2%). In-hospital mortality rate was 0.6% (5 patients). Total incidence of non-fatal postoperative complications (bleeding requiring re-exploration, perioperative myocardial infarction, stroke, new onset of acute renal failure) was 3.5%. Mean postoperative hospital stay was 4.8 +/- 3.8 days. At a mean follow-up of 21.6 +/- 15.6 months (range 1-65 months), the postoperative actuarial survival rates were 97.3, 93.7 and 86.7% at 1, 3 and 5 years postoperatively. Actuarial freedom rates from new revascularization were 98.7, 96.6 and 96.6% at 1, 3 and 5 years postoperatively. CONCLUSIONS: Early- and intermediate-term results of this study demonstrate the feasibility of off-pump revascularization in all patients with multivessel coronary disease, respecting the criterion of complete myocardial revascularization.

Minimally invasive aortic valve replacement with Perceval S sutureless valve: early outcomes and one-year survival from two European centers.

OBJECTIVE: The aim of our study was to evaluate the early outcomes and 1-year survival of patients undergoing minimally invasive aortic valve replacement with the Perceval S sutureless valve for severe aortic stenosis. METHODS: From March 2010 to March 2013, 281 high-risk patients underwent minimally invasive aortic valve replacement with the Perceval S sutureless valve through either right anterior minithoracotomy (n = 164) or upper ministernotomy (n = 117) at 2 cardiac centers. RESULTS: The overall in-hospital mortality was 0.7% (2 patients). The overall median cardiopulmonary bypass and crossclamp time was 81 minutes (interquartile range, 68-98) and 48 minutes (interquartile range, 37-60), respectively. Postoperative stroke occurred in 5 patients (1.8%). The incidence of paravalvular leak greater than 1 of 4 and atrioventricular block requiring pacemaker implantation was 1.8% (5 patients) and 4.2% (12 patients), respectively. No migration occurred, and the mean postoperative gradient was 13 ± 4 mm Hg. At a median follow-up of 8 months (interquartile range, 4-14), the overall survival was 90%. CONCLUSIONS: Minimally invasive aortic valve replacement with the Perceval S sutureless valve in high-risk patients is a safe and reproducible procedure associated with excellent hemodynamic results, postoperative outcomes, and 1-year survival.