Colchicine reduces postoperative atrial fibrillation: results of the Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS) atrial fibrillation substudy.

BACKGROUND: Inflammation and pericarditis may be contributing factors for postoperative atrial fibrillation (POAF), and both are potentially affected by antiinflammatory drugs and colchicine, which has been shown to be safe and efficacious for the prevention of pericarditis and the postpericardiotomy syndrome (PPS). The aim of the Colchicine for the Prevention of the Post-Pericardiotomy Syndrome (COPPS) POAF substudy was to test the efficacy and safety of colchicine for the prevention of POAF after cardiac surgery. METHODS AND RESULTS: The COPPS POAF substudy included 336 patients (mean age, 65.7±12.3 years; 69% male) of the COPPS trial, a multicenter, double-blind, randomized trial. Substudy patients were in sinus rhythm before starting the intervention (placebo/colchicine 1.0 mg twice daily starting on postoperative day 3 followed by a maintenance dose of 0.5 mg twice daily for 1 month in patients ≥70 kg, halved doses for patients <70 kg or intolerant to the highest dose). The substudy primary end point was the incidence of POAF on intervention at 1 month. Despite well-balanced baseline characteristics, patients on colchicine had a reduced incidence of POAF (12.0% versus 22.0%, respectively; P=0.021; relative risk reduction, 45%; number needed to treat, 11) with a shorter in-hospital stay (9.4±3.7 versus 10.3±4.3 days; P=0.040) and rehabilitation stay (12.1±6.1 versus 13.9±6.5 days; P=0.009). Side effects were similar in the study groups. CONCLUSION: Colchicine seems safe and efficacious in the reduction of POAF with the potentiality of halving the complication and reducing the hospital stay.

Right minithoracotomy versus full sternotomy for the aortic valve replacement: preliminary results.

BACKGROUND: Minimally invasive surgery (MIS) for aortic valve replacement (AVR) is going to increase with different techniques described so far. We hereby report the results of AVR through a right minithoracotomy (RM) compared to a median sternotomy (MS). MATERIALS AND METHODS: One hundred patients operated for isolated AVR by the same surgeon (chief of the department) were enrolled and allocated to: MS (group A, 50 patients, 26 females, mean age 69.9 ± 12.4 years). RM (group B, 50 patients, 27 females, mean age 71.6 ± 11.2 years). Mean logistic Euroscores were, respectively, 6.5 ± 4.0 and 8.0 ± 5.9 (p=ns). RESULTS: Mean duration of cardiopulmonary by-pass (CPB) was 62.8 ± 18.3 min in group A and 101.4 ± 35.2 min in group B (p<0.05); cross-clamp was 44.8 ± 13.4 min in group A and 74.6 ± 26.7 min in group B (p<0.05). Thirty-day mortality was 2 (4%) in group A and 0 in group B (p=ns). ICU stay and hospital stay did not significantly differ amongst two groups. The incidence of bleeding was lower in group B, showing a slight reduction of blood transfusions and re-explorations (p=ns). CONCLUSIONS: Our experience shows that RM offers a good 30-day survival and a lower incidence of mediastinitis or osteomyelitis. The risk of insufficient vision or sudden complications is safely managed by enlarging the surgical incision through a transverse sternotomy.

Another step in transcatheter aortic valve implantation: A challenging transcatheter aortic valve implantation procedure in patient with severe peripheral arterial disease.

Approximately 25% of patients undergoing transcatheter aortic valve implantation presents significant peripheral arterial disease. The purpose of this case report was to present a feasible approach for transcatheter heart valve in a patient with peripheral arterial disease where the presence of a subclavian stent jutting in the aortic arch made the delivery system passage a challenging procedure.

Matryoshka procedure for Valve-in-Valve TAVI failure.

Valve-in-valve transcatheter valve implantation (ViV-TAVI) procedures for deteriorated bioprosthesis are an established therapeutic option for high-risk patients. The presence of the fixed sewing ring of the bioprosthesis can hamper appropriate expansion of the TAVI. We present a case of a ViViV-TAVI, as a salvage procedure for acute ViV-TAVI failure.

Colchicine prevents early postoperative pericardial and pleural effusions.

BACKGROUND: No preventive pharmacologic strategies have been proven efficacious for the prevention of postoperative effusions after cardiac surgery. Colchicine is safe and efficacious for the prevention of pericarditis. On this basis, we realized a substudy of the COPPS trial to assess the efficacy and safety of colchicine for the prevention of postoperative pericardial and pleural effusions. METHODS: The COPPS is a multicenter, double-blind, randomized trial, where 360 consecutive patients (mean age 65.7 ± 12.3 years, 66% men), 180 in each treatment arm, were randomized on the third postoperative day to receive placebo or colchicine for 1 month (1.0 mg twice daily for the first day, followed by a maintenance dose of 0.5 mg twice daily in patients ≥70 kg, and halved doses for patients <70 kg). The incidence of postoperative effusions was evaluated in each study group. RESULTS: Despite similar baseline features, colchicine significantly reduced the incidence of postoperative pericardial (12.8% vs 22.8%, P = .019, relative risk reduction 43.9%, no. of patients needed to treat 10) and pleural effusions (12.2% vs 25.6%, P = .002, relative risk reduction 52.3%, no. of patients needed to treat 8). The rate of side effects (only gastrointestinal intolerance) and drug withdrawal was similar in the study groups with a trend toward an increased rate of both events for colchicine. In multivariable analysis, female gender (hazard ratio 1.76, 95% CI 1.03-3.03, P = .040) and pleura incision (hazard ratio 2.58, 95% CI 1.53-4.53, P < .001) were risk factors for postoperative effusions. CONCLUSIONS: Colchicine is safe and efficacious for the primary prevention of postoperative effusions after cardiac surgery.

Transomental titanium plates for sternal osteomyelitis in cardiac surgery.

INTRODUCTION: Wound infection is a devastating complication resulting in a high mortality rate from 7% to 80%. The risk of recurrences depends on the depth and the extension of the infection. We present our experience of omentoplasty using transomental sternal plates. MATERIAL AND METHODS: Five patients (two females, mean age 61.2 ± 8.3 years) had severe osteomyelitis requiring radical sternectomy and omental flap transposition. In three cases (60%), the sternal manubrium was completely removed: in case of upper sternectomy, chest wall stability was achieved without metallic bars; in two cases chest wall stability required the use of three metallic plates for each patient (STRATOS SYSTEM) fixed on the second, third, and fourth ribs. The plates were passed through the omental flap to obtain a partial cover of the devices. RESULTS: No patient had abdominal complications. One patient had postoperative dehiscence of the superficial wound that was treated by VAC therapy for 30 days. The length of hospital stay was 65.2 ± 45.2 days. All patients had complete wound healing and are alive after 24.0 ± 21.4 months. CONCLUSIONS: Omental flap transposition represents a good option in the treatment of sternal osteomyelitis. Partial or total sternal manubrium preservation and fixation are essential for the restoration of sternal stability. The use of transomental titanium plates provides chest wall stabilization when extensive sternal resection is required.

COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS): a multicentre, randomized, double-blind, placebo-controlled trial.

AIMS: No drug has been proven efficacious to prevent the post-pericardiotomy syndrome (PPS), but colchicine seems safe and effective for the treatment and prevention of pericarditis. The aim of the COlchicine for the Prevention of the Post-pericardiotomy Syndrome (COPPS) trial is to test the efficacy and safety of colchicine for the primary prevention of the PPS. METHODS AND RESULTS: The COPPS study is a multicentre, double-blind, randomized trial. On the third post-operative day, 360 patients (mean age 65.7 ± 12.3 years, 66% males), 180 in each treatment arm, were randomized to receive placebo or colchicine (1.0 mg twice daily for the first day followed by a maintenance dose of 0.5 mg twice daily for 1 month in patients ≥70 kg, and halved doses for patients <70 kg or intolerant to the highest dose). The primary efficacy endpoint was the incidence of PPS at 12 months. Secondary endpoint was the combined rate of disease-related hospitalization, cardiac tamponade, constrictive pericarditis, and relapses. Baseline characteristics were well balanced between the study groups. Colchicine significantly reduced the incidence of the PPS at 12 months compared with placebo (respectively, 8.9 vs. 21.1%; P = 0.002; number needed to treat = 8). Colchicine also reduced the secondary endpoint (respectively, 0.6 vs. 5.0%; P = 0.024). The rate of side effects (mainly related to gastrointestinal intolerance) was similar in the colchicine and placebo groups (respectively, 8.9 vs. 5.0%; P = 0.212). CONCLUSION: Colchicine is safe and efficacious in the prevention of the PPS and its related complications and may halve the risk of developing the syndrome following cardiac surgery. ClinicalTrials.gov number, NCT00128427.

Hypothermic cardiac arrest in the homeless: what can we do?

Accidental deep hypothermia with body temperature < 28 degrees C induces high mortality rates for neurological and cardiac complications. Although several reports described successful treatment of hypothermic arrest by extracorporeal membrane oxygenation (ECMO), the field of warming in the homeless is almost completely unquestioned although the malnutrition and the co-morbidities are usually believed as relevant risk factors for poor outcome. This article describes the experience of successful warming by ECMO in two homeless victims of unwitnessed cardiac arrest, who survived without neurological or cardiac complications. In conclusion, this is an initial experience and further research is required, although our results are appreciable in this high risk subset of population.

Aortic valve replacement using a stentless bioprosthesis through right minithoracotomy: an initial experience.

OBJECTIVE: Aortic valve replacement (AVR) is nowadays a safe procedure with low rates of mortality and morbidity, but the necessity for a less invasive approach is going to increase. The use of a stentless prosthesis through right mini-thoracotomy has not yet been described and our experience could be useful for other surgeons. METHODS: From June 2009 until March 2010, seven female patients (mean age 79.9 ± 5.7 years) underwent stentless-AVR for aortic stenosis through a right mini-thoracotomy (RM). The logistic Euroscore was 11.3 ± 6.1, and left ventricular ejection fraction was 60.7 ± 4.5%. In five cases RM was performed through the second intercostal space (ICS); in two cases through the third ICS. The cannulation was in most cases between ascending aorta and femoral vein (5/7). When transverse sternotomy was required (two patients), the right mammary artery was clipped and cut. RESULTS: Extracorporeal circulation time (ECC) was 110 ± 41min and aortic cross clamp was 80 ± 35min. Two patients required transverse sternotomy. The mean bleeding was 484 ± 469ml and the duration of mechanical ventilation was 22.0 ± 12.5h. The ICU stay was 3.3 ± 2.2 days. No in-hospital death was observed. The mean hospital stay was 11.6 ± 5.4 days. CONCLUSION: Right mini-thoracotomy is a safe and applicable approach even in case of AVR using stentless prosthesis. The risk of insufficient surgical exposure or complication may be safely managed, by enlarging the thoracotomy through transverse sternotomy. However, valve implantation could be more difficult than the standard approach and it requires an expert and confident surgeon with a large experience in standard stentless implantation.

[Infero-postero-lateral acute myocardial infarction caused by left ventricular myxoma embolism]. / Infarto miocardico infero-postero-laterale secondario ad embolizzazione di mixoma ventricolare sinistro.

The majority of myxomas are located in the left atrium (75%) followed by the right atrium (20%). In rare cases, myxomas can be found in the ventricles, with 2.5% reported for myxomas in the left ventricle. Systemic emboli, mostly cerebral, occur in two thirds of such patients, while coronary emboli are rare. Here we report a case of left ventricular myxoma causing infero-postero-lateral myocardial infarction, successfully treated by intracoronary thromboaspiration of myxoma embolus.

Prognostic values of soluble CD30 and CD30 gene polymorphisms in heart transplantation.

Pretransplant soluble CD30 (sCD30) is a predictor of kidney graft outcome. Its status as a predictor of heart transplant (HT) outcome has not been established. We have studied this question by assessing sCD30 levels and the number of (CCAT)n repeats of the microsatellite in the CD30 promoter region, which is able alone to repress gene transcription, in the sera of 83 HT patients and 77 of their donors. sCD30 was non-significantly increased in the patients, whereas there were no differences in the CD30 microsatellite allele frequencies. A negative correlation between the number of (CCAT)n and sCD30 levels was evident in the donors. Patients with pretransplant sCD30

Long-term follow-up of stentless prosthesis.

BACKGROUND: Stentless prostheses have an interesting hemodynamic performance when compared to stented prostheses and are recommended in cases of small aortic annulus. MATERIALS AND METHODS: From January 1996 to January 2004, 138 patients suffering from aortic disease, underwent aortic valve replacement. • Group A: 93 patients underwent stentless aortic valve implantation [stentless Biocor (Biocor Industria e Pesguisa Ltda, Belo Horizonte, Brazil) and stentless Sorin (Sorin Group, Saluggia, Italy)]. • Group B: 45 patients underwent stented aortic valve implantation (stented Biocor). Patients were assessed by clinical evaluation and echocardiography after a mean follow up of 124.5 ± 58.2 months. RESULTS: There was a significant difference in terms of time of extracorporeal circulation and aortic cross clamp. The actuarial survival at 4, 8, 12, and 15 years is 77%, 50%, 21%, and 18%, respectively. Freedom from reoperation at 4, 8, 12, and 14 years was 92%, 83%, 73%, and 63%, respectively. Freedom from all events, death, and reoperation at 4, 8, 12, and 14 years was 70%, 39%, 13%, and 8%, respectively. There is no statistical difference among the two groups in terms of actuarial survival, freedom from reoperation, and freedom from re-hospitalization for prosthesis-related causes. DISCUSSION: There was a significantly higher incidence of pacemaker implantation in Group A and the causes are not known. The rate of freedom from reoperation is high in both groups for the patients who remained alive. There was no statistical difference about prosthesis dysfunction between the two groups. The higher incidence of death in Group A cannot be explained by causes related to the prosthesis because there is no difference in terms of causes of death. Rates of reoperation did not differ between the two groups. CONCLUSIONS: The results obtained with stentless prostheses are encouraging even in long-term follow-up.

Partial aortic root remodeling in case of ascending aortic aneurysms.

OBJECTIVE: In degenerative ascending aortic aneurysms (AAAs), the pathological process may extend into the aortic root, causing aortic regurgitation (AR). As often one or two sinuses are involved, ascending aorta replacement should be associated with selected sinus replacement. METHODS: Thirty patients (21 men and 9 women; mean ± SD age, 70.0 ± 10.4) were operated on for ascending aorta and selected sinus replacement. All patients had degenerative AAA with sinotubular junction and partial root dilatation: one or two sinuses of Valsalva were involved. Mild to moderate-severe AR was present in all patients. The mean ± SD logistic EuroSCORE 1 was 15.4 ± 12.5. Twenty patients had ascending aorta replacement associated with noncoronary sinus replacement; 8 patients, associated with both right and noncoronary sinuses; 1 patient, associated with both left and noncoronary sinuses; and 1 patient, associated with left coronary sinus alone. RESULTS: There were no hospital or late deaths. No thromboembolic event or bleeding complications were reported. Postoperative echocardiography did not show significant AR, and computed tomographic scanning revealed a normal positioning of the vascular graft in the ascending aorta. CONCLUSIONS: Remodeling of the sinotubular junction with selected sinus replacement in degenerative AAA is a valuable approach for aortic root remodeling, leading to a significant reduction of AR when the aortic leaflets are normal.

Nuss procedure in adult pectus excavatum: a simple artifice to reduce sternal tension.

Nowadays the Nuss operation represents the standard surgical choice for pectus excavatum repair in children and teenagers. Some concerns have been raised regarding its applicability in adults, as compared with younger patients, in view of the higher rate of complications after surgery. We describe an easy trick that has been performed on a 36-year old man with a moderate pectus excavatum after an unsatisfactory Nuss procedure. It consisted of a T-shaped partial anterior sternotomy, performed after positioning of the stainless steel bar, in order to promote a hinge mechanism of the sternum to reduce the tension over the reinforcement. This procedure was successful with well-controlled postoperative pain and great patient satisfaction. No complications were recorded at 1-year follow-up. In our opinion, this simple trick could represent a valid surgical option for pectus excavatum repair in late adolescents and adults to obviate the occurrence of major sternal tension.

The day when the echocardiographist went mushrooming .

We report a case of partial congenital absence of the pericardium associated with severe aortic stenosis on a bicuspid valve in a 72-year-old man. Diagnosis was based on echocardiography and confirmed with magnetic resonance imaging, and the patient benefited from pericardioplasty and aortic valve replacement.

The 37-year durability of a Björk-Shiley Delrin-disc aortic valve prosthesis.

We report the exceptional longevity of a Björk-Shiley Delrin-disc prosthetic aortic valve that had been implanted in a man who underwent surgical correction of an ascending aortic aneurysm 37 years later. Upon explantation of the valve, the Delrin disc had only shallow abrasion on the ventricular surface, and none on the aortic surface. We discuss the soundness and durability of this valve in our patient, in contrast with its short functional prosthetic life in other patients. The 37-year lifespan of this patient's Björk-Shiley Delrin-disc valve is among the longest reported.

Is total debranching a safe procedure for extensive aortic-arch disease? A single experience of 27 cases.

OBJECTIVE: Thoracic, arch, and proximal descending thoracic aorta diseases are still considered an enormous challenge. The hybrid approach developed in recent years (supra-aortic trunks debranching and thoracic endovascular repair aortic repair; TEVAR) may improve the morbidity and mortality of the population at risk. The aim of this study was to analyze retrospectively our experience in the hybrid treatment of aortic-arch aneurysms and dissections. METHOD: We carried out a retrospective review of 27 patients who required a surgical debranching of the supra-aortic trunks and a TEVAR in the management of the aortic arch and proximal descending thoracic aortic disease. The aortic lesions included 18 degenerative arch-aortic aneurysms, four complicated aortic dissections, two subclavian artery aneurysms, and three penetrating atherosclerotic ulcers. Technical success was achieved in all patients. RESULTS: The 30-day mortality rate was 11.1% (3/27). Mean follow-up was 16.7 months (range, 1-56), and the survival rate was 77.8%. The endoleaks' rate was 3.7% (1/27), due to a stent-graft migration. CONCLUSION: Hybrid approaches may represent an alternative option in the treatment of complex aortic lesions involving the arch and the proximal descending thoracic aorta in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger comparative series.

Preoperative mobilization of bone marrow-derived cells followed by revascularization surgery: early and long-term outcome.

INTRODUCTION: Coronary artery disease (CAD), along with its main complications such as acute myocardial infarction (AMI) and congestive heart failure (CHF), remains a serious worldwide problem and affects many patients despite the improvement of medical treatment. The possibility of the replacement of the infarcted areas by the re-generation of the myocardial cells has been long discussed and the mobilization of the stem cells from bone marrow (BMCs) to the peripheral blood (PB) induced by cytokines, represents a potential pathway to activate the regenerative process. PATIENTS AND METHODS: We describe BMC mobilization and direct/indirect revascularization in 15 patients operated on for coronary artery bypass grafting (CABG) and/or mitral valve surgery and/or ventricular remodeling combined to multiple trans-myocardial punctures (Sen technique) in ungraftable non-viable fibrotic areas. RESULTS: Peak values of circulating BMCs were recorded between day +4 and day +6. We had no in-hospital (0-30 days) mortality. All the patients were discharged from the ICU after a median period of 2 days while the in-hospital length of stay was 10.5+4.2 days (range 7-21) and all patients were discharged in good clinical condition. There were two sudden deaths over the mid-term, at postoperative day (POD) 32 and 45 respectively. CONCLUSIONS: Our study suggests that the combination of BMC mobilization and CABG may be safely performed. However, considering the small series, final conclusions about the benefit of this procedure must await a larger prospective study comparing the role of cytokines alone, myocardial perforation, and the combination of both.

Pulsed or continuous flow in long-term assist devices: a debated topic.

The end-stage cardiomyopathy is an increasing worldwide problem. Cardiac transplantation lacks sufficient donors to treat all patients, and there is thus debate about alternative strategies. The use of left ventricular assist devices for long-term support is increasing with a positive impact on patient survival. Although there is an ongoing debate regarding the risks and benefits of maintaining pulsatile flow during long-term ventricular assist device support, there has been a significant move towards implantation of continuous flow devices due to the lower surgical morbidity and better long-term reliability of these pumps. The following is a review of the literature on continuous and pulsatile flow for long-term support. Starting from the definition of flow, we analyze the current evidence and consider gastrointestinal complications.