Prognostic Value of APACHE IV Score in Patients Bridged to Heart Transplantation on ECMO.

BACKGROUND: Methods for risk stratification of candidates for heart transplantation (HTx) supported by extracorporeal membrane oxygenation (ECMO) are limited. We evaluated the reliability of the APACHE IV score to identify the risk of mortality in this patient subset in a multicenter study. METHODS: Between January 2010 and December 2022, 167 consecutive ECMO patients were bridged to HTx; they were divided into two groups, according to a cutoff value of APACHE IV score, obtained by receiver operating characteristic curve analysis for 90-day mortality. Kaplan-Meier survival curves were plotted, and compared through the log-Rank test. Cox regression model was used to estimate which factors were associated with survival. RESULTS: The 90-day mortality prediction of the APACHE IV score showed an area under the curve of 0.87 (95% CI: 0.80-0.94), with a cutoff value of 49 (specificity 91.7%-sensibility 69.6%). 125 patients (74.8%) showed an APACHE IV score value < 49 (Group A), and 42 (25.2%) ≥ 49 (Group B). 90-day mortality was 11.2% in Group A and 76.2% in Group B (p < 0.01). Survival at 1 and 5 years was 85.5%, 77% versus 23.4%, 23.4% (p < 0.01) in Groups A and B. Mortality correlated at univariable analysis with recipient age, body mass index, mechanical ventilation, APACHE IV score, and platelets number. At multivariable analysis only APACHE IV score (HR: 1.07 [1.05-1.09, 95% CI]) independently affected survival. CONCLUSIONS: The APACHE IV score represents a powerful predictor of survival in patients bridged to HTx on ECMO support, and could guide candidacy of patients on ECMO.

Metabolic Syndrome and Heart Transplantation: An Underestimated Risk Factor?

Metabolic Syndrome (MetS), a multifactorial condition that increases the risk of cardio-vascular events, is frequent in Heart-transplant (HTx) candidates and worsens with immunosuppressive therapy. The aim of the study was to analyze the impact of MetS on long-term outcome of HTx patients. Since 2007, 349 HTx patients were enrolled. MetS was diagnosed if patients met revised NCEP-ATP III criteria before HTx, at 1, 5 and 10 years of follow-up. MetS was present in 35% of patients pre-HTx and 47% at 1 year follow-up. Five-year survival in patients with both pre-HTx (65% vs. 78%, p < 0.01) and 1 year follow-up MetS (78% vs 89%, p < 0.01) was worst. At the univariate analysis, risk factors for mortality were pre-HTx MetS (HR 1.86, p < 0.01), hypertension (HR 2.46, p < 0.01), hypertriglyceridemia (HR 1.50, p=0.03), chronic renal failure (HR 2.95, p < 0.01), MetS and diabetes at 1 year follow-up (HR 2.00, p < 0.01; HR 2.02, p < 0.01, respectively). MetS at 1 year follow-up determined a higher risk to develop Coronary allograft vasculopathy at 5 and 10 year follow-up (25% vs 14% and 44% vs 25%, p < 0.01). MetS is an important risk factor for both mortality and morbidity post-HTx, suggesting the need for a strict monitoring of metabolic disorders with a careful nutritional follow-up in HTx patients.

Artificial Neochordae for Tricuspid Valve Repair in Adults: A Review.

Expanded polytetrafluoroethylene (ePTFE) neochordae are predominantly used for mitral valve repair (MVr), while the frequency of their employment in tricuspid valve surgery is not well assessed. We have performed a review of the available literature to verify incidence, indications, techniques, and outcomes of the use of artificial neochordae in a variety of tricuspid valve pathologies. We found a total of 57 articles reporting the use of ePTFE sutures in patients in whom tricuspid valve repair (TVr) was performed. From such articles, adequate information on the basic disease, surgical techniques, and outcomes could be obtained in 45 patients in whom the indication to the use of neochordae was posttraumatic tricuspid regurgitation (n = 24), infective endocarditis (n = 8), congenital valvular disease (n = 6), valve injury during cardiac neoplasm excision (n = 3) or following repeated endomyocardial biopsies after heart transplantation (n = 3), and tricuspid valve prolapse (n = 1). Implant techniques generally replicated those currently employed for MVr using artificial neochordae. There were no reported hospital deaths with stability of repair in most cases at follow-up controls. TVr using ePTFE neochordae has been reported so far in a limited number of patients. Nevertheless, it appears a feasible and reproducible technique to be added routinely to the surgical armamentarium during TVr.

Heart Transplantation in High-Risk Recipients Employing Donor Marginal Grafts Preserved With Ex-Vivo Perfusion.

Extending selection criteria to face donor organ shortage in heart transplantation (HTx) may increase the risk of mortality. Ex-vivo normothermic perfusion (EVP) limits ischemic time allowing assessment of graft function. We investigated the outcome of HTx in 80 high-risk recipients transplanted with marginal donor and EVP-preserved grafts, from 2016 to 2021. The recipients median age was 57 years (range, 13-75), with chronic renal failure in 61%, impaired liver function in 11% and previous cardiac surgery in 90%; 80% were mechanically supported. Median RADIAL score was 3. Mean graft ischemic time was 118 ± 25 min, "out-of-body" time 420 ± 66 min and median cardiopulmonary bypass (CPB) time 228 min (126-416). In-hospital mortality was 11% and ≥moderate primary graft dysfunction 16%. At univariable analysis, CPB time and high central venous pressure were risk factors for mortality. Actuarial survival at 1 and 3 years was 83% ± 4%, and 72% ± 7%, with a median follow-up of 16 months (range 2-43). Recipient and donor ages, pre-HTx extracorporeal life support and intra-aortic balloon pump were risk factors for late mortality. In conclusion, the use of EVP allows extension of the graft pool by recruitment of marginal donors to successfully perform HTx even in high-risk recipients.

Distal Reoperations after Repair of Acute Type A Aortic Dissection-Incidence, Causes and Outcomes.

Background and Aim of the Study: In patients with acute type A aortic dissection (A-AAD) whether initial repair should include also aortic arch replacement is still debated. We aimed to assess if extensive aortic repair prevents from reoperations patients with A-AAD. Methods: Outcomes after distal reoperation following repair of A-AAD (n = 285; 1977 to 2018) were analysed in 22 of 226 who underwent ascending aorta/hemiarch replacement (Group 1 R ) and 7 of 59 who had ascending aorta/arch replacement (Group 2 R ). Results: Distal reoperation was more common in Group 1 R (n = 22) than in Group 2 R (n = 0) (p < 0.001) while thoracic endovascular stenting was more frequent in Group 2 R (7 vs 3, p < 0.001). Indications for reoperation were pseudoaneurysm at distal anastomosis (n = 4, 18%) and progression of aortic dissection (n = 18, 82%) in Group 1 R . Indication for thoracic endovascular stenting was progressive aortic dissection in 3 patients of Group 1 R and in 6 of Group 2 R . Second reoperation was required in 2 patients from Group 1 R (2%) during a mean follow-up of 5 years. Median follow-up was 4 years in Group 1 R and 7 years in Group 2 R (p = 0.36). Hospital mortality was 14% in Group 1 R and 0% in Group 2 R (p = 0.3). Actuarial survival is 68 ± 10%, and 62 ± 11% for Group 1 R and 100% for Group 2 R at 5 and 10 years (p = 0.076). Conclusions: Distal reoperations after A-AAD repair have an acceptable mortality. An extensive initial repair has lower rate of reoperation and better mid-term survival and should be indicated especially for young patients in experienced centers.

Artificial chordae for mitral valve repair.

BACKGROUND: Mitral valve repair using expanded polytetrafluoroethylene sutures to replace mitral chordae tendineae is a well-established procedure. However, the incidence of neo-chordae failure causing recurrent mitral regurgitation is not well defined. METHODS: We have reviewed the reported cases of complications after mitral valve repair related to the use of neo-chordae. This study was mainly carried out through PubMed, Medline, and Google Chrome websites. RESULTS: We have identified a total of 26 patients presenting with rupture of polytetrafluoroethylene neo-chordae, mostly being described as isolated cases. Few other cases of recurrent mitral regurgitation with hemolysis were found, where reoperation was not caused by neo-chordal failure but most likely by technical errors. At pathological investigation the findings were substantially similar in all reported cases. The neo-chordae retained their length and pliability, became covered with host tissue and rupture was mainly related to suture size. Mild calcification was observed not interfering with chordal function; chordal infection did never occur. CONCLUSIONS: The use of artificial neo-chordae provides excellent late results with durable mitral valve repair stability. Chordal rupture may occur late postoperatively leading to reoperation because of recurrent mitral regurgitation. Despite its rarity, this potential complication should not be overlooked during follow-up of patients after mitral valve repair using artificial neo-chordae.

Use of Pericardium for Cardiac Reconstruction Procedures in Acquired Heart Diseases-A Comprehensive Review.

BACKGROUND: Reconstruction of cardiac structures has been the goal of many surgeons even before the advent of open-heart procedures with cardiopulmonary bypass. Unsatisfactory results with synthetic materials has switched the attention to biological tissues, among which pericardium, either autologous or of animal origin, has been widely used as patch material. METHODS: We have reviewed the literature to assess the effective role of pericardial tissue in the correction of various acquired cardiac lesions. Particularly, special attention was given not only to established techniques but also to detect any peculiar and unusual application of pericardium. RESULTS: Autologous pericardium is frequently used as patch material particularly when limited valvular lesions must be corrected, while xenograft pericardium appears particularly useful in patients with endocarditis and extensive destruction of the intracardiac structures by infection and abscesses. Pericardium is an extremely versatile material owing to its pliability and strength; however, it tends to calcify in the long term when in contact with blood, although stability of the repair is maintained in most cases. CONCLUSIONS: Pericardium plays an important role in various cardiac and aortic pathologies. Tissues resistant to fibrosis and calcification to be used as patch material are the ideal solution for more successful cardiac reconstruction procedures and will hopefully be provided by the ongoing research.

Blood cysts of the cardiac valves in adults: Review and analysis of published cases.

BACKGROUND AND AIM: Blood cysts of cardiac valves are generally seen in newborns and infants and very rarely in adults. Although in most cases they are incidental findings they may be associated to severe cardiac or systemic complications. This study analyzes incidence, presentation, and treatment of valvular blood cysts in adults. METHODS: A review of the pertinent literature through a search mainly on PubMed and Medline was performed. RESULTS: In patients ≥18 years of age, our search disclosed 54 patients with mitral blood cysts (mean age, 48 ± 18 years), 9 with a tricuspid valve cyst (mean age, 67 ± 15 years), 3 with a blood cyst on the pulmonary valve (age 31, 43, and 44 years), and 1 aortic valve cyst in a 22-year-old man. Most patients were asymptomatic while stroke, syncope, or myocardial infarction occurred in six patients with a mitral valve cyst. Blood cysts were removed surgically in 70% of patients with a mitral cyst, in 55% with a tricuspid cyst, and in all those with a pulmonary or aortic cyst. At histology, the cyst wall was composed mainly by fibrous tissue and with the inner surface lined with typical endothelium. CONCLUSIONS: Blood cysts of cardiac valves are rare in adults but may cause life-threatening complications, particularly when located on the mitral valve. For such reason, surgical removal appears advisable, with low-risk procedures. Widespread use of multimodality imaging techniques will most likely increase the number of valvular blood cysts diagnosed also in adults.

Endothelial Progenitor Cells: An Appraisal of Relevant Data from Bench to Bedside.

The mobilization of endothelial progenitor cells (EPCs) into circulation from bone marrow is well known to be present in several clinical settings, including acute coronary syndrome, heart failure, diabetes and peripheral vascular disease. The aim of this review was to explore the current literature focusing on the great opportunity that EPCs can have in terms of regenerative medicine.

An Integrated Approach for Treatment of Acute Type A Aortic Dissection.

Background and objective: We reviewed a single-institution experience to verify the impact of surgery during different time intervals on early and late results in the treatment of patients with type A acute aortic dissection (A-AAD). Materials and Methods: From 2004 to 2021, a total of 258 patients underwent repair of A-AAD; patients were equally distributed among three periods: 2004-2010 (Era 1, n = 90), 2011-2016 (Era 2, n = 87), and 2017-2021 (Era 3, n = 81). The primary end-point was to assess whether through the years changes in indications, surgical strategies and techniques and increasing experience have influenced early and late outcomes of A-AAD repair. Results: Axillary artery cannulation was almost routinely used in Eras 2 (86%) and 3 (91%) while one femoral artery was mainly cannulated in Era 1 (91%) (p < 0.01). Retrograde cerebral perfusion was predominantly used in Era 1 (60%) while antegrade cerebral perfusion was preferred in Eras 2 (94%,) and 3 (100%); (p < 0.01). There was a significant increase of arch replacement procedures from Era 1 (11%) to Eras 2 (33%) and 3 (48%) (p < 0.01). A frozen elephant trunk was mainly performed in Era 3. Hospital mortality was 13% in Era 1, 11% in Era 2, and 4% in Era 3 (p = 0.07). Actuarial survival at 3 years is 74%, in Era 1, 78% in Era 2, and 89% in Era 3 (p = 0.05). Conclusions: With increasing experience and a more aggressive approach, including total arch replacement, repair of A-AAD can be performed with low operative mortality in many patients. Patient care and treatment by a specific team organization allows a faster diagnosis and referral for surgery allowing to further improve early and late outcomes.

Donor-recipient age interaction and the impact on clinical results after heart transplantation.

To evaluate the impact of donor-recipient age matching on clinical outcomes after heart transplantation, a total of 509 patients (January 1990-December 2018, mean follow-up 111 ± 80 months) were stratified into 4 groups (young-R/young-D, young-R/old-D, old-R/young-D, old-R/old-D) according to the recipient (young-R < 60, old-R ≥ 60 years) and the donor (young-D < 50, old-D ≥ 50 years) age. No difference was found among 30-day mortality (P = .11) and postoperative complications between groups. Both unadjusted and adjusted survival was significantly higher for group young-R/young-D than that of other groups, in which survival was similar [adjusted HR for mortality of 2.0(1.2-3.4), 2.1(1.4-3.8) and 2.5(1.6-4.1) for groups old-R/young-D, young-R/old-D, old-R/old-D, respectively]. Compared to other groups, the incidence of grade ≥ 2 CAV was significantly lower in old-R/young-D group [adjusted HR 0.4(0.2-0.7)]. Among young recipients, the rate of acute grade ≥ 2 rejection episodes was higher in those receiving an old donor graft (P = .04). Old recipient groups were more affected by neoplasms and severe renal failure than young recipient groups (P < .01). Employment of hearts from donors ≥50 years of age adversely affects survival in recipients <60 years of age but does not influence outcomes in older recipients. Also, donor and recipient ages seem to have opposite effects on incidence of rejections and CAV of high grade.

Durability of the Mitroflow Pericardial Prosthesis: Influence of Patient-Prosthesis Mismatch and New Anticalcification Treatment.

BACKGROUND: The Mitroflow pericardial bioprosthesis (MPB) has been recently associated with a high incidence of early structural failures, questioning its validity as cardiac valve substitute. We have therefore reviewed our experience with this device. MATERIALS AND METHODS: A total of 398 patients with a mean age of 75 ± 7 years (58% above the age of 75 years) had aortic valve replacement with a Mitroflow prosthesis (2005-2015). Most patients had calcific aortic stenosis (86%) and were in sinus rhythm (89%). Mean EuroSCORE II was 5.5 ± 6.2. Mean follow-up was 4 ± 2 years (range: 4 months to 10 years), which was 100% complete. RESULTS: Hospital mortality was 6.5%; at discharge, 25% of patients had a moderate patient-prosthesis mismatch and none had a severe mismatch. Cumulative incidence of structural valve deterioration in the entire series was 2% (95% confidence interval [CI]: 1-4) at 5 years and 7% (95% CI: 4-14) at 8 years. Significant factors influencing MPB durability were age ≤ 65 years (p < 0.001) and the presence of patient-prosthesis mismatch (p = 0.01). No cases of structural valve deterioration were observed in patients with the new prosthetic model incorporating an anticalcification treatment the first 4 years of follow-up. CONCLUSIONS: The Mitroflow prosthesis has shown satisfactory results in the first decade of use. Durability appears adversely influenced by patient age and patient-prosthesis mismatch. Thus, a careful valve size selection and implantation in patients >65 years of age appears to be associated with excellent valve durability in the aortic position. Whether the new anticalcification treatment will provide a more durable prosthesis must be verified at a longer follow-up.

Extra-anatomical splanchnic revascularization for hybrid treatment of thoracoabdominal aortic aneurysms.

Treatment of thoracoabdominal aortic aneurysms with endovascular or conventional surgical techniques is burdened by high risk in older patients. Furthermore, the standard hybrid approach might be not feasible in case of severe atherosclerotic disease of the peripheral vessels. This report describes an alternative hybrid procedure which consists of an innovative mini-invasive thoracic approach combined with laparotomy to perform antegrade revascularization of the visceral arteries from the ascending aorta, followed by endovascular treatment.

Aortic arch aneurysm and Kommerell's diverticulum: Repair with a single-stage hybrid approach.

Kommerell's diverticulum is a rare congenital anomaly, consisting in aneurysmal dilatation at the origin of an aberrant subclavian artery. Depending on concomitant anatomical characteristics, different endovascular and open surgical procedures have been proposed. The following report describes the first single-stage hybrid repair of a type I Kommerell's diverticulum associated with an aortic arch aneurysm and anomalous origin of the brachiocephalic vessels by total aortic arch replacement with a composite frozen elephant trunk prosthesis and endovascular treatment of the right subclavian artery. This hybrid procedure may represent an alternative to more challenging open repairs when totally endovascular approach is unfeasible.

Acute aortic dissection and pregnancy: Review and meta-analysis of incidence, presentation, and pathologic substrates.

OBJECTIVES: Pregnancy has been recognized as a predisposing factor for acute aortic dissection (AAD) although its occurrence is quite rare. Currently, no trial and few prospective studies exist about this catastrophic event. The present review and meta-analysis aims to update information on clinical presentation, potential risk factors, treatment, and outcome of acute dissection during pregnancy and puerperium. METHODS: A comprehensive search of three databases was performed to identify all patients reported in articles published from January 1987. A proportional single-arm meta-analysis with random-effects model was used to pool these variables: risk factors, pregnancy/postpartum occurrence, surgical characteristics, and outcomes. RESULTS: A total of 11 reports and 85 patients with pregnancy-related AAD were available for this study. The prevalence of connective tissue disorders was 62%, Marfan syndrome being the most common. Out of 76 patients, 46 (61%) had dissection during pregnancy and 30 (39%) during puerperium; 40% of events occurred in primigravidae and 60% in multigravidae. Type A and type B dissection occurred in 67% vs 33% of patients. Surgery was performed in 73% of cases with a maternal and fetal mortality of 23% and 27%, respectively. CONCLUSIONS: Throughout pregnancy, AAD is quite rare but fatal, especially in Marfan and Loeys-Dietz syndromes, while isolated bicuspid aortic valve is not a risk factor. Even in Marfan syndrome, pathogenesis and evolution of the disease are still unclear. Occurrence of dissection also during puerperium indicates the need for continuous counselling and aortic size monitoring in women at-risk.

Excellent Durability of the Mosaic Porcine Aortic Bioprosthesis at Extended Follow Up.

BACKGROUND: Biological prostheses are widely employed for aortic valve replacement (AVR). The study aim was to evaluate the performance of the Mosaic porcine bioprosthesis in the aortic position over two decades. METHODS: Between November 1995 and December 2016, a total of 254 patients (194 males, 60 females; mean age 74 ± 9 years) underwent AVR with a Mosaic bioprosthesis at the authors' institution. Among the patients, 14% were aged ≥80 years and 86% had pure or prevalent calcific aortic stenosis. Preoperatively, the mean NYHA functional class was 2.5 ± 1.0. RESULTS: Overall hospital mortality was 5%. A total of 107 late deaths occurred, but only 15 were valve-related (0.72 ± 0.19% per patient-year). Actuarial survival at 15 years was 34 ± 7%. Fourteen embolic episodes occurred, with no cases of bioprosthetic thrombosis; freedom from thromboemboli was 88 ± 4% at 15 years. Eight cases of endocarditis occurred, with a freedom of 95 ± 2% at 15 years. Structural valve deterioration (SVD) was observed in four patients, all of whom were successfully reoperated. Freedom from SVD was 97 ± 2% at 15 years and 96 ± 2% at 20 years. At the last follow up, 23 mm and 25 mm prostheses showed mean gradients of 17 ± 6 mmHg and 15 ± 4 mmHg, respectively. A significant reduction in left ventricular mass was noted in patients with aortic stenosis. CONCLUSIONS: The Mosaic bioprosthesis has shown excellent durability over two decades of clinical use, with a negligible incidence of valve degeneration and need for reoperation. Thus, it may be considered a valid option for AVR, especially in elderly patients.

Cell differentiation in cardiac myxomas: confocal microscopy and gene expression analysis after laser capture microdissection.

Cardiac myxomas are rare tumors with a heterogeneous cell population including properly neoplastic (lepidic), endothelial and smooth muscle cells. The assessment of neoplastic (lepidic) cell differentiation pattern is rather difficult using conventional light microscopy immunohistochemistry and/or whole tissue extracts for mRNA analyses. In a preliminary study, we investigated 20 formalin-fixed and paraffin-embedded cardiac myxomas by means of conventional immunohistochemistry; in 10/20 cases, cell differentiation was also analyzed by real-time RT-PCR after laser capture microdissection of the neoplastic cells, whereas calretinin and endothelial antigen CD31 immunoreactivity was localized in 4/10 cases by double immunofluorescence confocal microscopy. Gene expression analyses of α-smooth muscle actin, endothelial CD31 antigen, alpha-cardiac actin, matrix metalloprotease-2 (MMP2) and tissue inhibitor of matrix metalloprotease-1 (TIMP1) was performed on cDNA obtained from either microdissected neoplastic cells or whole tumor sections. We found very little or absent CD31 and α-Smooth Muscle Actin expression in the microdissected cells as compared to the whole tumors, whereas TIMP1 and MMP2 genes were highly expressed in both ones, greater levels being found in patients with embolic phenomena. α-Cardiac Actin was not detected. Confocal microscopy disclosed two different signals corresponding to calretinin-positive myxoma cells and to endothelial CD31-positive cells, respectively. In conclusion, the neoplastic (lepidic) cells showed a distinct gene expression pattern and no consistent overlapping with endothelial and smooth muscle cells or cardiac myocytes; the expression of TIMP1 and MMP2 might be related to clinical presentation; larger series studies using also systematic transcriptome analysis might be useful to confirm the present results.