Impact of Mitral Regurgitation Etiology on Mitral Surgery After Transcatheter Edge-to-Edge Repair: From the CUTTING-EDGE Registry.

BACKGROUND: Although >150,000 mitral TEER procedures have been performed worldwide, the impact of MR etiology on MV surgery after TEER remains unknown. OBJECTIVES: The authors sought to compare outcomes of mitral valve (MV) surgery after failed transcatheter edge-to-edge repair (TEER) stratified by mitral regurgitation (MR) etiology. METHODS: Data from the CUTTING-EDGE registry were retrospectively analyzed. Surgeries were stratified by MR etiology: primary (PMR) and secondary (SMR). MVARC (Mitral Valve Academic Research Consortium) outcomes at 30 days and 1 year were evaluated. Median follow-up was 9.1 months (IQR: 1.1-25.8 months) after surgery. RESULTS: From July 2009 to July 2020, 330 patients underwent MV surgery after TEER, of which 47% had PMR and 53.0% had SMR. Mean age was 73.8 ± 10.1 years, median STS risk at initial TEER was 4.0% (IQR: 2.2%-7.3%). Compared with PMR, SMR had a higher EuroSCORE, more comorbidities, lower LVEF pre-TEER and presurgery (all P < 0.05). SMR patients had more aborted TEER (25.7% vs 16.3%; P = 0.043), more surgery for mitral stenosis after TEER (19.4% vs 9.0%; P = 0.008), and fewer MV repairs (4.0% vs 11.0%; P = 0.019). Thirty-day mortality was numerically higher in SMR (20.4% vs 12.7%; P = 0.072), with an observed-to-expected ratio of 3.6 (95% CI: 1.9-5.3) overall, 2.6 (95% CI: 1.2-4.0) in PMR, and 4.6 (95% CI: 2.6-6.6) in SMR. SMR had significantly higher 1-year mortality (38.3% vs 23.2%; P = 0.019). On Kaplan-Meier analysis, the actuarial estimates of cumulative survival were significantly lower in SMR at 1 and 3 years. CONCLUSIONS: The risk of MV surgery after TEER is nontrivial, with higher mortality after surgery, especially in SMR patients. These findings provide valuable data for further research to improve these outcomes.

Prognostic value of SARS-CoV-2 on patients undergoing cardiac surgery.

OBJECTIVE: To analyze Italian Cardiac Surgery experience during the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) identifying risk factors for overall mortality according to coronavirus disease 2019 (COVID-19) status. METHODS: From February 20 to May 31, 2020, 1354 consecutive adult patients underwent cardiac surgery at 22 Italian Centers; 589 (43.5%), patients came from the red zone. Based on COVID-19 status, 1306 (96.5%) were negative to SARS-CoV-2 (COVID-N), and 48 (3.5%) were positive to SARS-CoV-2 (COVID-P); among the COVID-P 11 (22.9%) and 37 (77.1%) become positive, before and after surgery, respectively. Surgical procedures were as follows: 396 (29.2%) isolated coronary artery bypass grafting (CABG), 714 (52.7%) isolated non-CABG procedures, 207 (15.3%) two associate procedures, and three or more procedures in 37 (2.7%). Heart failure was significantly predominant in group COVID-N (10.4% vs. 2.5%, p = .01). RESULTS: Overall in-hospital mortality was 1.6% (22 cases), being significantly higher in COVID-P group (10 cases, 20.8% vs. 12, 0.9%, p < .001). Multivariable analysis identified COVID-P condition as a predictor of in-hospital mortality together with emergency status. In the COVID-P subgroup, the multivariable analysis identified increasing age and low oxygen saturation at admission as risk factors for in-hospital mortality. CONCLUSION: As expected, SARS-CoV-2 infection, either before or soon after cardiac surgery significantly increases in-hospital mortality. Moreover, among COVID-19-positive patients, older age and poor oxygenation upon admission seem to be associated with worse outcomes.

Right ventricular assessment can improve prognostic value of Euroscore II.

BACKGROUND: The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery. METHODS: This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC <35%, TAPSE <17 mm, and TDI S' <9.5 mm RESULTS: Among the entire cohort, 624 (70%) showed normal RV, 92 (10%) isolated RV dilatation, 154 (17%) isolated RV dysfunction, and 25 (3%) both RV dilatation and dysfunction. Non-surviving patients showed a significantly higher rate of RV alteration at multivariable analysis, RV status was found to be an independent predictor for higher in-hospital mortality beside Euroscore II. CONCLUSIONS: This prospective multicenter observation study shows the importance to assess RV preoperatively and to include both RV function and dimension in a risk score model such as Euroscore II to implement its predictivity, since PH cannot always mirror the status of the right ventricle.

Pseudoaneurysm fistulized into pulmonary artery 13 years after aortic surgery.

Pseudoaneurysm formation some years after aortic root or ascending aorta surgery, complicated by fistula formation through a branch of the pulmonary artery, is a rare condition described only in case reports. We describe a case of this rare complication in a 58-year-old man, which occurred 13 years after aortic surgery and was characterized by a huge pseudoaneurysm of 70 mm that fistulized into the right pulmonary artery, causing a life-threatening situation.

Spontaneous Coronary Artery Dissection after Minimally Invasive Mitral Valve Repair.

Spontaneous coronary artery dissection is a rare condition usually encountered in young women without risk factors for atherosclerotic disease but with tortuous coronary artery or contemporary presence of fibromuscular dysplasia. Sometimes spontaneous coronary dissection occurs in patients with atherosclerotic disease, although without significant epicardial coronary artery stenosis. We report a case of a patient who underwent minimally invasive mitral valve repair, whose initially uneventful postoperative course was complicated by spontaneous coronary artery dissection of the left main causing a life threatening condition. A subsequent emergency sternotomy was required to perform a coronary artery bypass.

Off-pump minimally invasive direct coronary artery bypass in patients with cosmetic prosthesis for pectus excavatum.

Pectus excavatum can be associated with coronary artery diseases that can become difficult to manage in urgent situations. We describe the use of an off-pump minimally invasive direct coronary artery bypass (MIDCAB) through the fourth intercostal space incision in a patient with pectus excavatum and acute coronary syndrome who previously underwent a cosmetic prosthesis implantation. The patient refused any surgical procedure that could compromise the integrity of his cosmetic prosthesis and a left mini-thoracotomy was a good option to avoid the removal of the prosthesis. The preservation of the integrity of the thoracic cage enhanced chest wall stability and pulmonary function and permitted avoidance of inadvertent cardiac structure iatrogenic injuries. MIDCAB was optimal for the exposure of the left internal thoracic artery and the left anterior descending artery. The deformity of the chest should not be considered as an absolute contraindication to off-pump MIDCAB when other surgical options are not viable, even in emergency situations.

Aortic valve replacement in familial hypercholesterolemia: not an ordinary procedure.

Familial hypercholesterolemia is an inherited disorder with incidences of approximately 1:500 and 1:1,000,000 in heterozygous and homozygous form respectively. Affected patients usually show early coronary artery disease and severe aortic root calcification, despite optimization of therapy. We report a case of a 64-year-old woman affected by heterozygous familial hypercholesterolemia which presented dyspnea and anginal symptoms due to a severely calcified aortic root causing valve stenosis and narrowed sinotubular junction. Aortic valve replacement and aortic root enlargement were performed using the Manougian procedure. Even for experiences surgeons, this surgery could prove challenging for this group of patients due to aggressive degenerative tissue calcification of the aortic root, which often presents an extremely calcified aortic valve with a small annulus associated to a narrowed sinotubular junction.

Myocardial infarction and rupture after bronchial artery embolization.

Bronchial artery embolization is a well-known treatment for hemoptysis. Adverse events of this procedure include multiple systemic embolism and infarction. Myocardial infarction has been recently reported during bronchial artery embolization, owing to the presence of a coronary-to-bronchial artery fistula. We report the management of an ischemic left ventricular free wall rupture caused by bronchial artery embolization in a patient with massive hemoptysis, bronchiectasis, and undetected coronary-to-bronchial artery anomalous connection.

Sternal wrapping: developments and results.

BACKGROUND: Postoperative sternal wound complications are infrequent events that negatively affect recovery and may have serious consequences. Sternal wrapping, a technique of sternal care, has hemostatic properties without bone wax, and offers mechanical and microbiologic protection. METHODS: From February 1998 to December 2011, 258 patients in 2 Italian institutions underwent various cardiac surgery procedures with sternal wrapping in place, and were followed up for no less then 6 months. RESULTS: Two (0.8%) extremely compromised patients with ischemic sternal osteonecrosis and deep sternal wound infection required a sternal stabilizing procedure. Four (2%) other patients developed sternal wound complications that were treated entirely medically; 3 of them were very trivial, and 1 was an atypical mediastinitis without sternal involvement. Overall, 46.1% of patients (45.3% of isolated coronary artery bypass, 49.3% of isolated on-pump coronary artery bypass, and 18.2% of off-pump coronary artery bypass patients) were transfused. None of the complications was related to sternal wrapping, bleeding from the sternal edge, or sternal wound problems. CONCLUSIONS: Sternal wrapping showed a very low incidence and severity of sternal wound complications, with good prevention of sternal osteomyelitis. Hemostatic properties were satisfactory, with transfusion rates within an acceptable range.

Pulmonary pseudoaneurysm: uncommon complication after total aortic arch operation.

Pulmonary pseudoaneurysms are an uncommon but life-threatening condition of congenital or acquired cause, most commonly involving the branch pulmonary arteries and generally requiring emergent intervention. We describe a case of postoperative main pulmonary artery pseudoaneurysm after a complex aortic arch procedure, in which thoracic computed tomography provided full information for its definition before surgical correction.

Absorption of carbon dioxide during endoscopic vein harvest.

OBJECTIVES: Carbon dioxide (CO(2)) insufflation was used by some devices for endoscopic vein harvest to create a subcutaneous tunnel and facilitate the vein harvest. In the literature, some cases of CO(2) micro- and macro-embolisms or hypercarbia during this procedure are described. The purpose of this study was to evaluate if the use of an open CO(2) system rather than a sealed system might be associated with different CO(2) absorption during the procedure. METHODS: Patients were randomized into two groups: those patients in the first group were submitted to endoscopic vein harvest using a sealed CO(2) insufflation; in the second group, the harvest was undertaken with an open CO(2) insufflation. Partial pressure of CO(2) in the arterial blood (PaCO(2)) and end-tidal CO(2) (ETCO(2)) was recorded following anaesthesia induction and before the endoscopic procedure (T0), every 10 min during the endoscopic step (T1) and end after 10 min from the CO(2) insufflation termination (T2). RESULTS: A total of 60 patients were enrolled. PaCO(2) increased significantly between T0, T1 and T2 in both groups (P = 0.0001) during the endoscopic harvest, but the PaCO(2) level was significantly higher in the group that used the sealed system (44.5 ± 7.9 vs 39.7 ± 7.9 mmHg) at the end of the procedure (P = 0.01). No significant differences between end-tidal CO(2) measured at the same intervals between groups were detected. CONCLUSIONS: There was a constant increase in the blood gas concentration compared with the basal pre-procedure values. Sealed systems were associated with a significantly higher CO(2) concentration at the end of the procedure compared with the open ones.

[Does cardiac surgery in women carry a higher risk than in men?]. / La cardiochirurgia nella donna: rischio più alto?

Cardiovascular diseases are the leading cause of death in women, and female patients exhibit peculiar features as to symptoms, diagnosis and treatment. This sex difference is also observed in cardiac surgery, with mortality and morbidity being higher in female patients. Whether female gender is an independent variable for mortality still remains controversial. This review summarizes the data available in the literature on cardiac surgery in the female population.

Role of endovascular repair in the management of late pseudo-aneurysms following open surgery for aortic coarctation.

BACKGROUND: Coarctation of the aorta accounts for almost 5% of all congenital cardiac malformations, and it is usually treated by open surgical procedures. Despite the excellent primary results, many patients may develop anastomotic pseudo-aneurysms, associated with considerable morbidity and mortality rates. We investigated the role of endovascular repair as an alternative to open re-do surgery on the descending aorta. METHODS: We retrospectively collected data of 11 consecutive patients who presented with pseudo-aneurysms of the descending aorta following previous surgical repair of congenital aortic coarctation. Nine patients developed a pseudo-aneurysm after patch aortoplasty, while an interposition graft repair was performed in two cases. Seven patients underwent an endovascular repair (26.9 years after the previous open surgery). Four patients with a pseudo-aneurysm after coarctation repair associated with arch hypoplasia underwent conventional open re-operation. RESULTS: No complications or death were observed in the conventional surgical group. Technical success was obtained in all patients who received a stent-graft procedure. More than one stent graft was necessary only in one case. A left carotid-left subclavian artery bypass was performed in three patients. Type II endoleak was detected by angiography in one patient who had previously undergone subclavian re-vascularisation. The median follow-up (FU) was 44.5 months and was 100% complete. Neither re-operations nor complications or deaths occurred during FU. CONCLUSIONS: Endovascular repair of pseudo-aneurysms following open surgery for aortic coarctation is feasible and safe. However, more patients and longer follow-up are necessary to assess the efficacy of this promising less-invasive alternative to open re-do surgery.

Does preoperative degree of aortic insufficiency influence early and midterm results of sparing surgery?

OBJECTIVE: Aortic valve-sparing operations have shown excellent results in patients with aortic root and or ascending aorta aneurysm. Aortic valve regurgitation is frequently detected in these patients as a result of significant dilation of the aortic root.The aim of this study was to assess the impact of preoperative aortic incompetence degree on the early and midterm outcomes of sparing surgery. METHODS: From September 2001 to July 2006, 84 patients with aortic root aneurysm underwent aortic valve-sparing surgery according to the reimplantation technique. Depending on preoperative grade of aortic insufficiency (AI), two groups were identified: 31 patients (study group, SG) with AI grade III-IV and 53 (control group, CG) with AI grade II or less. The Gelweave Valsalva prosthesis was used in 76 patients (90.5%). Intraoperative, perioperative variables and outcomes at follow-up were retrospectively compared between the groups. RESULTS: Patient demographics and types of operations were comparable between groups. Early mortality rates were almost identical in both groups (3.2% SG vs. 5.7% CG; P = 0.961); at follow-up (FU), no patient died in both groups. Grade III-IV AI was similar in both groups early postoperatively (6.4% SG vs. 3.8% CG; P = 0.981) and during follow-up (13.3% vs. 8%; P = 0.755). Reoperaton rate for AI was 3.3% in SG vs. 6% in CG (P = 0.980). CONCLUSIONS: Preoperative degree of aortic regurgitation does not impair the outcomes of the valve-sparing operation which seem to depend on more factors. Early results were affected by the learning curve but midterm outcomes showed a progressive improvement. Patients with satisfactory reconstruction show stable results over time.