STEMI or not STEMI? A multimodality imaging approach to a challenging intracardiac mass with a tricky presentation.

Cardiac tumors, due to the various clinical scenarios and their histological subtypes, are still challenging for clinicians. They are differentiated into primary and secondary. The latest are more common and are usually lung and breast cancers, melanomas, and lymphoma metastasis. We present a case of a 73-year-old woman, with a history of breast cancer 10 years earlier, admitted to Cath lab for an elevation of the ST-segment of the electrocardiogram, myocardial infarction. Echocardiogram showed a curious abnormality in the myocardial wall. Thanks to a multimodality imaging strategy, including contrast-enhanced echocardiography and cardiac magnetic resonance, characterization of the underlying pathology was clear and, thus, the appropriate management and therapy.

This is the case of a cardiac metastatic tumor, whose certain diagnosis can only be made by myocardial biopsy ­ an invasive sample of heart tissue ­ unfortunately not available in our case. Alternatively, we puzzled data from two second-level imaging techniques: contrast-enhanced cardiac ultrasound and cardiac magnetic resonance, which allowed us to better evaluate the nature of this cardiac mass. The former gave information about its blood supply, the latter gave information about tissue characterization. In this paper, we show how a complete integration of data from clinical and a stepwise multimodality imaging-based approach may allow a diagnosis in a complex clinical case.

Evolocumab Treatment in Dyslipidemic Patients Undergoing Coronary Artery Bypass Grafting: One-Year Safety and Efficacy Results.

Background: The inhibition of PCSK9 lowered LDL cholesterol levels, reducing the risk of cardiovascular events. However, the effect on patients who have undergone surgical myocardial revascularization has not yet been evaluated. Methods: From January 2017 to December 2022, 180 dyslipidemic patients who underwent coronary artery bypass were included in the study. Until December 2019, 100 patients optimized therapy with statin ± ezetimibe (SG). Since January 2020, 80 matched patients added treatment with Evolocumab every 2 weeks (EG). All 180 patients were followed-up at 3 and 12 months, comparing outcomes. Results: The two groups are homogenous. At 3 months and 1 year, a significant decrease in the parameter mean levels of LDL cholesterol and total cholesterol is detected in the Evolocumab group compared to the standard group. No mortality was detected in either group. No complications or drug discontinuation were recorded. In the SG group, five patients (5%) suffered a myocardial infarction during the 1-year follow-up. In the EG group, two patients (2.5%) underwent PTCA due to myocardial infarction. There is no significant difference in overall survival according to the new treatment (p-value = 0.9), and the hazard ratio is equal to 0.94 (95% C.I.: [0.16-5.43]; p-value = 0.9397). Conclusions: The use of Evolocumab, which was started immediately after coronary artery bypass graft surgery, significantly reduced LDL cholesterol and total cholesterol levels compared to statin treatment alone and is completely safe. However, at one year of follow-up, this result did not have impact on the reduction in major clinical events.

Neurological Disorders in Takotsubo Syndrome: Clinical Phenotypes and Outcomes.

BACKGROUND: Neurological disorders as a risk factor for Takotsubo syndrome (TTS) are not well characterized. The aim of the study was to evaluate TTS-associated neurological phenotypes and outcome. METHODS AND RESULTS: Patients with TTS enrolled in the international multicenter GEIST (German Italian Spanish Takotsubo) registry were analyzed. Prevalence, clinical characteristics, and short- and long-term outcomes of patients with TTS were recorded. A subgroup analysis of the 5 most represented neurological disorders was performed. In total, 400 (17%) of 2301 patients had neurological disorders. The most represented neurological conditions were previous cerebrovascular events (39%), followed by neurodegenerative disorders (30.7%), migraine (10%), epilepsy (9.5%), and brain tumors (5%). During hospitalization, patients with neurological disorders had longer in-hospital stay (8 [interquartile range, 5-12] versus 6 [interquartile range, 5-9] days; P<0.01) and more often experienced in-hospital complications (27% versus 16%; P=0.01) mainly driven by cardiogenic shock and in-hospital death (12% versus 7.6% and 6.5% versus 2.8%, respectively; both P<0.01). Survival analysis showed a higher mortality rate in neurological patients both at 60 days and long-term (8.8% versus 3.4% and 23.5% versus 10.1%, respectively; both P<0.01). Neurological disorder was an independent predictor of both the 60-day and long-term mortality rate (odds ratio, 1.78 [95% CI, 1.07-2.97]; P=0.02; hazard ratio, 1.72 [95% CI, 1.33-2.22]; both P<0.001). Patients with neurodegenerative disorders had the worst prognosis among the neurological disease subgroups, whereas patients with TTS with migraine had a favorable prognosis (long-term mortality rates, 29.2% and 9.7%, respectively). CONCLUSIONS: Neurological disorders identify a high-risk TTS subgroup for enhanced short- and long-term mortality rate. Careful recognition of neurological disorders and phenotype is therefore needed.

Safety and Efficacy of PCSK9 Inhibitors in Patients with Acute Coronary Syndrome Who Underwent Coronary Artery Bypass Grafts: A Comparative Retrospective Analysis.

Background. The in-hospital reduction in low-density lipoprotein cholesterol (LDL-C) levels following acute coronary syndrome (ACS) is recommended in the current clinical guidelines. However, the efficacy of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors in those patients undergoing coronary artery bypass graft (CABG) has never been demonstrated. Methods. From January 2022 to July 2023, we retrospectively analyzed 74 ACS patients characterized by higher LDL-C levels than guideline targets and who underwent coronary bypass surgery. In the first period (January 2022-January 2023), the patients increased their statin dosage and/or added Ezetimibe (Group STEZE, 43 patients). At a later time (February 2023-July 2023), the patients received not only statins and Ezetimibe but also Evolocumab 140 mg every 2 weeks starting as early as possible (Group STEVO, 31 patients). After one and three months post-discharge, the patients underwent clinical and laboratory controls with an evaluation of the efficacy lipid measurements and every adverse event. Results. The two groups did not differ in terms of preoperative risk factors and Euroscore II (STEVO: 2.14 ± 0.75 vs. STEZE: 2.05 ± 0.6, p = 0.29). Also, there was no difference between the groups in terms of ACS (ST-, Instable angina, or NSTE) and time of symptoms onset regarding total cholesterol, LDL-C, and HDL-C trends from the preprocedural period to 3-month follow-up, but there was a more significant reduction in LDL-C and total cholesterol in the STEVO group (p = 0.01 and p = 0.04, respectively) and no difference in HDL-C rise (p = 0.12). No deaths were reported. In three STEZE group patients, angina recurrence posed the need for percutaneous re-revascularization. No STEVO patients developed significant adverse events. The statistical difference in these serious events, 7% in STEZE vs. 0% in STEVO, was not significant (p = 0.26). Conclusions. Evolocumab initiated "as soon as possible" in ACS patients submitted to CABG with high-intensity statin therapy and Ezetimibe was well tolerated and resulted in a substantial and significant reduction in LDL-C levels at discharge, 1 month, and 3 months. This result is associated with a reduction but without a statistical difference between groups.

Emergent Conversion to Open Heart Surgery during Transcatheter Aortic Valve Implantation: The Presence of a Rescue Team Improves Outcomes.

OBJECTIVE: Transcatheter aortic valve implant (TAVI) is the gold standard for the high-surgical-risk group of patients with aortic valve disease and it is an alternative to surgery in patients at intermediate risk. Lethal complications can occur, and many of these are manageable only with emergent conversion to open heart surgery. We retrospectively evaluate the outcome of all patients undergoing TAVI in our departments and the impact of a complete cardiac rescue team to reduce 30-day mortality. METHODS: Data from all patients undergoing TAVI between January 2020 and August 2023 in our center were analyzed. An expert complete rescue was present in catheter laboratory. Primary outcomes were in-hospital and at 30-day mortality and evaluation of all cases needed for emergent conversion to open heart surgery. RESULTS: 825 patients were enrolled. The total mortality was 19/825 (2.3%). Eleven of the total patients (1.3%) required emergent conversion to open heart surgery. Among them, eight were alive (73%), with a theoretical decrease of 0.98% in overall mortality. CONCLUSIONS: surgical treatment is rare during TAVI. The presence of an expert complete rescue team as support means an increase in survival. Surgery must be used only to restore circulatory and to treat complication while percutaneous approaches should complete the procedure.

How many clues make an evidence? An unusual case of aborted cardiac arrest due to mitral valve prolapse.

There is an increasing awareness on the association between mitral valve prolapse (MVP) and sudden cardiac death. Mitral annular disjunction (MAD) is a phenotypic risk feature that can help in risk stratification. We present a case of a 58-year-old woman who experienced an out-of-hospital cardiac arrest caused by ventricular fibrillation interrupted by a direct current shock. No coronary lesions were documented. Echocardiogram showed myxomatous MVP. Nonsustained ventricular tachycardia have been registered during hospital stay. Interestingly, cardiac magnetic resonance revealed MAD and a late gadolinium enhancement area in inferior wall. Finally, a defibrillator has been implanted. For arrhythmic risk stratification of MVP with MAD, multimodality imaging is the diagnostic tool to find out the disease behind many cardiac arrests of unknown cause.

Minimally invasive mitral valve reconstruction: Is it an "all-comers" procedure?

BACKGROUND AND AIM OF THE STUDY: The debate on the usefulness of the minimally invasive approach in mitral valve surgery is still open. The aim of this study is to describe a single-center case series of all comers undergoing minimally invasive mitral valve reconstruction. METHODS: From 2010 to 2019, all the data recorded in the medical records of 893 consecutive patients undergoing mitral valve reconstruction through a right mini-thoracotomy were retrospectively collected. All patients were contacted by telephone for remote evaluation and integration of echocardiographic information on surgical results. RESULTS: Mean age was 62.2 ± 14.5; 447 (50%) were female and mean log EuroSCORE was 2.5 ± 2.8%. At a mean follow-up of 4.1 ± 2.2 years (median 3.9), a total of 24 deaths (2.68%) were recorded. Twenty-four patients required rehospitalization for cardiac causes, 13 (1.4%) patients had at least moderate mitral insufficiency on follow-up echocardiography and, of these, seven patients underwent reoperation (0.8%). The cumulative hazard showed that 8.3% of patients experienced at least one event at 5 years. NYHA class improved significantly with 874 patients in NYHA class I, 13 in NYHA class II, 6 in NYHA class III, and 0 in NYHA class IV at last follow-up (p < .001 from baseline as reference point). CONCLUSIONS: In a high-volume center, mitral valve surgery using a minimally invasive approach is a feasible treatment option for all-comers and is associated with excellent results that are maintained at clinical and echocardiographic follow-up.

Minimally invasive extracorporeal circulation in end-stage coronary artery disease patients undergoing myocardial revascularization.

BACKGROUND: Patients with coronary artery disease and concomitant heart failure (left ventricular ejection fraction < 35%) requiring myocardial revascularization are at risk of poor long-term prognosis and higher mortality. The benefits of minimally invasive extracorporeal circulation (MiECC), particularly in end-stage coronary artery disease patients undergoing myocardial revascularization, have not been completely described. MATERIALS AND METHODS: In this single-centre control study, 60 end-stage coronary artery disease patients undergoing isolated coronary artery bypass grafting (CABG) were included. Patients were divided into two groups of 30 patients each undergoing CABG using MiECC or conventional extracorporeal circulation (cECC). RESULTS: In the MiECC group, oxygen delivery index (DO2i) was 305 mL/min/m2 in relation to indexed oxygen extraction ratio (O2ERi) 21.5%, whereas in the cECC group DO2i was 288 mL/min/m2 in relation to O2ERi 25.6% (p = 0.037). Lactate levels > 3 mmol/L were reported in 7 MiECC patients vs 20 cECC patients (p = 0.038), with blood glucose peak. Mean nadir hemoglobin values during cardiopulmonary bypass (CPB) were 9.7 g/dL in the MiECC group vs 7.8 g/dL in the cECC group (p = 0.044). Cardiac index during CPB was 2.4 L/min/m2 in both groups. Red blood cell units administered were 8 vs 21 units in the MiECC vs cECC group (p = 0.022). A glycemic peak was recorded in 7 patients of the MiECC group and in 20 patients of the cECC group (p = 0.037). CONCLUSION: In end-stage coronary artery disease, the MiECC technique was associated with a higher DO2i compared to cECC. MiECC patients showed a significant reduction in red blood cell unit administration and peak intraoperative lactate levels, which correlated with better postoperative outcome.

Long-term outcomes of pericardial strip versus prosthetic ring annuloplasty for secondary tricuspid regurgitation by a minimally invasive approach.

BACKGROUND: This study was conducted to compare the outcomes of prosthetic ring versus autologous pericardial strip for the treatment of functional tricuspid regurgitation during left-sided valve surgery by minimally invasive approach. METHODS: From January 2008 and July 2016, autologous pericardial strip (group P-TAP) was used in 109 patients, and prosthetic ring (group R-TAP) in 115 patients. The primary outcomes were long-term overall survival, development of patch degeneration, and significant tricuspid regurgitation recurrence. The second outcome was the assessment of right ventricular functional parameters. RESULTS: Operative mortality was 1 case (0.9%) in the R-TAP group. At the time of hospital discharge only one patient (0.9%) in the R-TAP group had grade III+ tricuspid regurgitation, and none had grade IV+. Mean follow-up was 94.1 ± 24.5 months. Mild and moderate tricuspid regurgitation recurrence was 3.7% and 4.5% (P-TAP vs. R-TAP groups, p = 0.99). Severe regurgitation was observed in 1.8% of cases only in the R-TAP group (p = 0.49). There were no reoperations. Late mortality was 3.7% and 5.4% (P-TAP vs. R-TAP groups, p = 0.75). Freedom from death, all causes, were comparable among groups (log-rank p = 0.45). There were no statistically significant differences between two groups in TAPSE, left ventricular end-diastolic diameter, left ventricular ejection fraction, and left atrial diameter. CONCLUSIONS: Tricuspid annuloplasty using an autologous pericardial strip in patients undergoing minimally invasive surgery is associated to similar long results (survival, late tricuspid regurgitation, and functional echocardiographic parameters) than annuloplasty with a prosthetic ring. In particular, the pericardial strip over time does not develop any degeneration or retraction.

Minimally invasive approaches to primary cardiac tumors: A systematic review and meta-analysis.

OBJECTIVE: Cardiac tumors are rare conditions. The vast majority of them are benign yet they may lead to serious complications. Complete surgical resection is the gold standard treatment and should be performed as soon as the diagnosis is made. Median sternotomy (MS) is the standard approach and provides excellent early outcomes and durable results at follow-up. However, minimally invasive (MI) is gaining popularity and its role in the treatment of cardiac tumors needs further clarification. METHODS: A systematic literature review identified 12 candidate studies; of these, 11 met the meta-analysis criteria. We analyzed outcomes of 653 subjects (294 MI and 359 MS) with random effects modeling. Each study was assessed for heterogeneity. The primary endpoints were mortality at follow-up and tumor relapse. Secondary endpoints included relevant intraoperative and postoperative outcomes; tumor size was also considered. RESULTS: There were no significant between-group differences in terms of late mortality (incidence rate ratio [IRR]: MI vs. MS, 0.98 [95% confidence interval [CI]: 0.25-3.82], p = .98). Few relapses (IRR: 1.13; CI: 0.26-4.88; p = .87) and redo surgery (IRR: 1.92; 95% CI: 0.39-9.53; p = .42) were observed in both groups; MI approach resulted in prolonged operation time but that did not influence the clinical outcomes. Tumor size did not significantly differ between groups. CONCLUSION: Both MI and MS are associated with excellent early and late outcomes with acceptable survival rate and low incidence of recurrences. This study confirms that cardiac tumor may be approached safely and radically with a MI approach.

Fibonacci's Golden Ratio-An Innovative Approach to the Design and Management of Extra-Corporeal Circulation.

Technological advances in the field of extracorporeal circulation (ECC) over the past decade have led to numerous methods for monitoring metabolism and coagulation during cardiopulmonary bypass (CPB), as well as materials with improved biocompatibility, which has reduced the risk associated with cardiopulmonary bypass. However, ECC is still predominantly based on a traditional design that involves the use of roller pumps. This exposes the patient to a variety of pathophysiological consequences, both intra- and postoperative, such as postoperative cognitive disorders, hemolysis and hemodilution, systemic inflammation and changes in coagulation. This article describes the advantages of an ECC circuit inspired by the Fibonacci Golden Ratio, which does not use a roller pump, in a prospective study on patients undergoing elective cardiac surgery, compared to conventional ECC. During CPB, echocardiography was used to estimate the quality of fluid dynamics in the extracorporeal circuit and the patient's arterial vessels, a DO2 management system was used to evaluate metabolism, and an electronic system was used to determine gaseous microemboli (GME) counts. Fibonacci ECC offered superior intraoperative fluid dynamics, reduced the production of and improved the elimination of GME, and improved intraoperative metabolism, particularly with regard to oxygen delivery and extraction. The improvements in fluid dynamics and metabolic variables were associated with a reduction in the incidence of pathophysiological events compared to the conventional system, particularly regarding transitory cognitive disorders, and a shorter stay in intensive care.

Time-dependent benefits of pre-treatment with new oral P2Y12 -inhibitors in patients addressed to primary PCI for acute ST-elevation myocardial infarction.

OBJECTIVES: The aim of this observational study was to determine the benefits of the novel, orally delivered P2Y12 -inhibitors (Is) in terms of angiographic endpoints and in relation to the time of the loading dose (LD) administration. BACKGROUND: The goal of ST-elevation myocardial infarction (STEMI) treatment is timely reperfusion. The P2Y12 -Is prasugrel and ticagrelor have improved the angiographic outcome of primary percutaneous coronary intervention (pPCI) and patients' prognosis. However, their onset of action is impaired in STEMI and delayed by their oral administration. METHODS: The 328 eligible patients with STEMI consecutively referred for pPCI were divided into three groups depending on the interval of "P2Y12 -I LD administration-to-balloon time": Group 2 included patients that received P2Y12 -I LD at least 60 min prior to pPCI, Group 1 within 60 min prior to pPCI, and Group 0 at the moment of pPCI. Angiographic, clinical, and biochemical parameters were evaluated. Pre- and post-pPCI TIMI flow grade (TFG) and ST resolution (STR) were used as outcome measures to determine efficacy and optimal timing of pretreatment. RESULTS: Pre-pPCI TFG improved with increasing P2Y12 -I LD administration-to-balloon time; pre-PCI TFG 0/1 was 74.5% in Group 0, 65.5% in Group 1 and 54.9% in Group 2 (P < 0.002). Post-pPCI TFG 3 results also differed significantly between the three groups: 85.2% in Group 0, 88.1% in Group 1, 97.6% in Group 2 (P < 0.013). ST resolution rates were also positively associated with longer pretreatment intervals. CONCLUSIONS: This observational study suggests that the angiographic benefit of P2Y12 -I administration is time-dependent: longer pretreatment improves coronary reperfusion in terms of pre- and post-pPCI TFG and STR.

Hybrid three-stage repair of mega aorta with Lupiae technique: tips and tricks.

Mega aorta syndrome (MAS) poses a complex clinical challenge: the involvement of the ascending aorta, aortic arch, descending thoracic and abdominal aorta with extension below the origin of renal arteries requires almost total replacement of the aorta. The modality of treatment remains still controversial. Different aortic debranching techniques have been developed to re-route the origin of epiaortic and visceral vessels and achieve an optimal landing zone for implantation of subsequent endovascular grafts. We illustrate the Lupiae technique as a further evolution of the aortic debranching and hybrid repair of a mega aorta. It was developed with the purpose to exclude a very long segment of diseased aorta by implanting two or more endoprostheses between two surgically-generated landing zones. We describe a series of 27 patients treated by this hybrid three-stage mega-aorta repair; the tips and tricks discussed here facilitate a safe and effective procedure, enable treatment of frail patients and help to avoid life-threatening complications.

STEMI and NSTEMI ACS in a 30-Year-Old Patient: An Extremely Rare Complication of a Left Atrial Myxoma.

Primary cardiac tumors are a rare entity whose incidence in the general population ranges from 0.0017% to 0.28%. Myxomas represent nearly half of all primary benign cardiac tumors and they prevalently affect female patients. Embolic manifestation is rare with a reported incidence of 0.06%.We present the case of a 30-year-old male patient with acute anterolateral infarction caused by total occlusion of the left anterior descending artery as a consequence of a left atrial myxoma embolization. Urgent surgical resection of the mass didn't avoid early recurrence of atrial myxoma, whose second presentation was again myocardial infarction.This case alerts physicians to "unusual" myocardial infarction patients, when atherosclerotic pathogenesis appears unlikely. In these cases early echocardiographic evaluation should be mandatory and atrial myxoma should be considered among the possible causes. Complete surgical resection is the only effective therapeutic option to improve prognosis; the chance of tumor recurrence should dictate careful research for additional myxomas during surgery and stricter follow-up planning.

Three-year results of repaired Barlow mitral valves via right minithoracotomy versus median sternotomy in a randomized trial.

OBJECTIVES: To clarify whether the results of repair of a complex mitral lesion (Barlow valve) at the intermediate-term follow-up are independent of the mode of surgical access [minithoracotomy vs. median sternotomy (MS)]. METHODS: In a prospective randomized study of mitral repair for Barlow disease using either a minimally invasive (MI) approach or MS, we achieved an average follow-up of 3 years (echocardiography, physical examination and quality of life). Mitral repair was achieved with polytetrafluoroethylene chordal implantation for both leaflets. RESULTS: Both groups included 80 patients. Mechanical ventilation time and intensive care unit and hospital stay were shorter in the MI group (p = 0.01, p = 0.013 and p = 0.02, respectively). During the follow-up, 5 patients in each group (6.25%) displayed mild mitral regurgitation, while 2 patients in each group (2.5%) developed recurrent regurgitation graded as at least moderate/severe. The rate of mitral reoperation was 2.5% in the MI group and 1.25% in the MS group (p = 0.9). The overall follow-up mortality was 3.75% in both the MI and the MS groups. CONCLUSIONS: The 3-year results of repair of Barlow valves were satisfactory irrespective of the approach used to repair the valve. The advantages of MI surgery can be achieved in patients with mitral Barlow disease without concerns over the durability of repair.

Increased plasma homocysteine predicts arrhythmia recurrence after minimally invasive epicardial ablation for nonvalvular atrial fibrillation.

OBJECTIVE: Minimally invasive epicardial ablation via right minithoracotomy is an emerging option for patients with drug-refractory nonvalvular atrial fibrillation. To guide the development of rational treatment algorithms, factors predisposing to recurrence of arrhythmia need to be quantified and eventually treated. We addressed the association of the plasma levels of homocysteine and the recurrence of atrial fibrillation after minimally invasive ablation. METHODS: We obtained peripheral blood samples from 104 patients at follow-up after arrhythmia surgery; the homocysteine concentration was expressed as micromoles per liter. Prospective follow-up was conducted through electrocardiogram Holter monitoring (average 18.5 ± 5.8 months). Stratified analysis (high vs low homocysteine) was based on the cutoff value for the last quartile of homocysteine concentration (16 µmol/L). Time-to-event and diagnostic performance analyses were performed. RESULTS: The rate of freedom from atrial fibrillation was 89.4% at the end of follow-up. Elevated circulating homocysteine level, persistent type of atrial fibrillation, and increased left atrial dimension independently predicted the recurrence of atrial fibrillation during the follow-up (adjusted Cox regression). Patients with a high homocysteine level were more likely to have atrial fibrillation recurrence (stratified Kaplan-Meier, P < .001). The cutoff value for elevated homocysteine (16 µmol/L) yielded a good diagnostic performance in the prediction of atrial fibrillation recurrence (area under the receiver operating characteristic curve, 0.807). CONCLUSIONS: The homocysteine level measured during the follow-up reliably predicts the risk of recurrence after epicardial ablation of nonvalvular atrial fibrillation via minithoracotomy. Specific treatments to reduce plasma homocysteine could be considered in the future in these patients.

Impact of arterial revascularization in patients undergoing coronary bypass.

BACKGROUND AND AIM: A debate over alternative therapeutic strategies for multivessel coronary disease is currently ongoing. We aimed at analyzing the results of myocardial revascularization with arterial conduits. METHODS: We retrospectively reviewed 10,752 patients undergoing isolated coronary bypass surgery within our hospital's group. Average follow-up was 37.2 months. Through propensity-matching, we generated three groups (3584 patients each) on the basis of the revascularization strategy: use of one mammary artery plus venous grafts, use of two mammary arteries plus venous graft, and total arterial revascularization. RESULTS: Overall operative mortality was 2.8%. Patient-related factors (renal failure, advanced age, recent myocardial infarction, depressed LVEF, diabetes) were identified as predictors of mortality (logistic regression). Although mortality was not statistically different among groups, patients receiving more than one arterial conduit displayed in the long-term better freedom from cardiac death and from adverse cardiac events (repeat revascularization, myocardial infarction, recurrent angina) (Kaplan-Meier analysis). Use of only one arterial conduit, diabetes and depressed LVEF predicted cardiac mortality, and adverse events (Cox regression). No differences in any endpoint emerged among patients receiving two arterial conduit plus venous grafts or total arterial revascularization. CONCLUSIONS: These data strongly support the practice of using two arterial conduits rather than one. The operative and late results of coronary surgery with arterial conduits are optimal and should serve as a current benchmark for the comparison with state-of-the-art percutaneous interventions.

Long-term results of ablation for isolated atrial fibrillation through a right minithoracotomy: toward a rational revision of treatment protocols.

OBJECTIVE: Despite continued technical improvements, results of transcatheter radiofrequency ablation of atrial fibrillation may be suboptimal in some patient subgroups. Short-term follow-up of minimally invasive epicardial ablation of isolated atrial fibrillation has been encouraging. METHODS: One hundred four patients with drug-refractory isolated atrial fibrillation underwent minimally invasive surgical ablation through right 3- to 4-cm minithoracotomy by isolation of pulmonary veins and were followed-up for an average of 17 months. Previous failed transcatheter ablation was not a criterion for this procedure. Antiarrhythmic drugs were continued until postoperative month 6, despite demonstration of stable sinus rhythm. RESULTS: The procedure was confirmed to be safe (1 case of procedure-related morbidity, no operative deaths) and effective (89% overall freedom from recurrent arrhythmia at follow-up, 96% freedom from paroxysmal atrial fibrillation, 80% freedom from persisting type atrial fibrillation). Results tended to improve with the expansion of the surgical experience. Cox hazard regression and Kaplan-Meier analysis identified persisting type atrial fibrillation and enlarged left atrium as the major predictors of recurrent atrial fibrillation at follow-up. Health-related quality of life was confirmed to be improved at the end of the follow-up relative to baseline in most Medical Outcomes Study 36-Item Short-Form Health Survey domains. CONCLUSIONS: Minimally invasive epicardial ablation of isolated atrial fibrillation yields stable, gradually improving results. Earlier surgical referral is justifiable after careful cardiologic work-up. To define the relative roles of minimally invasive ablation and transcatheter ablation, which may be considered in the future as alternative therapies, a randomized trial to compare these procedures is advisable.

Minimally invasive radiofrequency ablation of lone atrial fibrillation by monolateral right minithoracotomy: operative and early follow-up results.

BACKGROUND: Although an increasing number of symptomatic patients with atrial fibrillation (AF) are being treated with percutaneous radiofrequency ablation, the actual long-term success rate of this procedure remains uncertain. The increasing availability of minimally invasive techniques has made surgery progressively more appealing, especially because of its superior capacity to create transmural lesions. METHODS: In a group of 46 patients with paroxysmal or persistent "lone" AF, who were refractory to medical treatment or had arrhythmia recurrences after a transcatheter procedure, we performed epicardial radiofrequency ablation by a minimally invasive, monolateral thoracoscopic approach. Mean operative time was 85 +/- 35 minutes, and intensive care unit and hospital stays were, respectively, 18.7 +/- 5.1 hours and 4.1 +/- 1.4 days. There were no deaths and only 1 serious complication due to severe bleeding requiring conversion to median sternotomy. RESULTS: At the 6-month follow-up (Holter monitoring), 40 patients (87%) were in stable sinus rhythm. Of the 6 recurrences that we observed, 5 occurred in patients with persistent AF and 1 in a patient with paroxysmal AF (p < 0.01). CONCLUSIONS: Minimally invasive monolateral thoracoscopic radiofrequency ablation is safe and apparently effective. If these findings are confirmed on larger populations followed for longer periods, this procedure may become a viable proposal for treating refractory lone AF.

Operative and middle-term results of cardiac surgery in nonagenarians: a bridge toward routine practice.

BACKGROUND: Age >90 years represents in many centers an absolute contraindication to cardiac surgery. Nonagenarians are a rapidly growing subset of the population posing an expanding clinical problem. To provide helpful information in regard to this complex decision, we analyzed the operative and 5-year results of coronary and valvular surgical procedures in these patients. METHODS AND RESULTS: We retrospectively reviewed 127 patients aged >or=90 years who underwent cardiac surgery within our hospital group in the period 1998 to 2008. Kaplan-Meier and multiple logistic regression analyses were performed. A longer follow-up than most published studies and the largest series published thus far are presented. Mean age was 92 years (range, 90 to 103 years). Mean logistic EuroSCORE was 21.3+/-6.1. Sixty patients had valvular surgery (including 11 valve repairs), 49 patients had coronary artery bypass grafting, and 18 had valvular plus coronary artery bypass grafting surgery (55 left mammary artery grafts implanted). Forty-five patients (35.4%) were operated on nonelectively. Operative mortality was 13.4% (17 cases). Fifty-four patients (42.5%) had a complicated postoperative course. There were no statistically significant differences in the rate and type of complications between patient strata on the basis of type of surgery performed. Nonelective priority predicted a complicated postoperative course. Predictors of operative mortality were nonelective priority and previous myocardial infarction. Kaplan-Meier survival estimates at 5 years were comparable between patient groups on the basis of procedure performed. CONCLUSIONS: Although the rate of postoperative complications remains high, cardiac surgery in nonagenarians can achieve functional improvement at the price of considerable operative and follow-up mortality rates. Cardiac operations in these very elderly subjects are supported if appropriate selection is made and if the operation is performed earlier and electively. Our results should contribute to the development of guidelines for cardiac operations in nonagenarians.