The Role of Microbes in Surgical Decision Making for Infective Endocarditis: Mitral Valve Repair or Replacement?

BACKGROUND: The benefits of mitral repair versus replacement for endocarditis are inconclusive. This study compares outcomes of patients with infective endocarditis undergoing mitral valve repair versus replacement and investigates the impact of microbial etiology. METHODS: All 251 patients undergoing mitral valve surgery for active endocarditis between 2010 and 2023 were enrolled, 180 (71.7%) replacement and 71 (28.3%) repair. To adjust for imbalances, inverse probability of treatment weighting was applied and 187 patients were obtained. RESULTS: The analysis between groups, following the application of inverse probability of treatment weighting, showed no statistically significant differences across all considered outcomes. Early and late death was observed respectively in 6 (8.5%) and 11 (15.5%) patients in the repair group versus 24 (13.3%) and 45 (25.0%) in the replacement group without statistical significance (p = 0.221 and p = 0.446). Relapse occurred in six patients (8.5%) in the repair group after a median time of 4.0 months and in six (3.3%) in the replacement after 6.9 months (p = 0.071). CONCLUSIONS: Surgical strategy in mitral endocarditis has no effect on major postoperative complications, mortality, or medium/long-term survival. Staphylococcus aureus and Coagulase-negative Staphylococci represent a risk for early mortality and relapse. However, mitral valve repair for endocarditis can be pursued when it ensures the complete eradication of all infected tissue, particularly in cases caused by Streptococcus infection, in young patients, and after a minimum of 18 days of antibiotic therapy.

Case report: pseudoaneurysm of left ventricle secondary to infective endocarditis complicated by cardiac rupture-a multimodality imaging approach.

Background: Pseudoaneurysm (PSA) of the left ventricle (LV) is a rare peri-annular complication of infective endocarditis (IE), and it is associated with high risk of free wall rupture. The diagnosis is challenging because the exact incidence and the pathogenesis are still unclear. Case summary: A 69-year-old lady underwent prosthetic mitral valve replacement for IE secondary to Staphylococcus aureus sepsis complicated by multiple embolizations. In the post-operative period, the patient developed persistent low-grade fever with negative blood culture. Transoesophageal echocardiography (TOE) revealed complete posterior valve detachment and a PSA sac arising from the antero-lateral commissure; the colour flow Doppler showed massive mitral regurgitation. Thoracic computed tomography (CT) scan confirmed the echo data and the exact localization of the cardiac rupture. The patient underwent reoperation, a pericardial patch was sutured to exclude the PSA sac, and a mechanical prosthesis valve was finally implanted. A follow-up TOE revealed the exclusion of the PSA; two leakages with mild peri-valvular mitral regurgitation were found, with no haemodynamic impact. Discussion: In our case, the patient developed a PSA of the LV as a consequence of peri-annular extension of IE on the mitral valve. Pseudoaneurysm is a potentially lethal complication, if not promptly treated. Multimodality imaging including echocardiography and CT scan is recommended, in order to plan surgery ad hoc.

Surgical Treatment of Active Endocarditis Pre- and Post-COVID-19 Pandemic Onset.

BACKGROUND: Despite advanced diagnosis and treatment, infective endocarditis (IE) is a potentially life-threatening condition. The impact of COVID-19 on the diagnosis and outcome of the surgical treatment of IE is uncertain. The aim of this study was to analyze the incidence, characteristics, and outcomes of surgically treated IE before and after the COVID-19 pandemic. METHODS: This study retrospectively analyzed the data of 535 patients who underwent valve surgical procedures for IE between January 2010 and December 2022 in a single cardiac surgery center. Patients were divided into two groups depending on the date of their operation: before (n = 393) and after (n = 142) COVID-19 onset. In order to balance the groups, inverse probability of treatment weighting (IPTW) calculated from the propensity score (PS) was applied. Weighted univariate logistic regressions were reported for outcomes; weights were derived from IPTW. Interrupted time series analysis (ITSA) according to Linden's method was used to evaluate the changes in the manifestation of IE after 11 March 2020. RESULTS: Patients from the post-COVID-19 cohort (after 11 March 2020) had a greater number of comorbidities such as diabetes (29.6% vs. 16.3% p = 0.001), hypertension (71.1% vs. 59.5% p = 0.015), and preoperative kidney injury requiring dialysis (9.2% vs. 2.5% p = 0.002), but the median additive and logistic EuroSCORE were not statistically different. In the post-COVID-19 group, we observed a greater prevalence of Staphylococcus aureus-related endocarditis (24.5% vs. 15.4% p = 0.026), a consequent reduction in Staphylococcus non aureus-related endocarditis (12.2% vs. 20.1% p = 0.048), and a decrease in aortic valve replacements (43.0% vs. 53.9%), while the number of mitral valve replacements and repair was greater (21.1% vs. 15.0% and 6.3% vs. 4.3%, respectively). No differences were found in the two groups concerning early death, death, or relapse at 1 year after surgery. Data obtained by multivariable analysis identified preoperative renal dysfunction requiring dialysis as the only common risk factor for early mortality via stratifying by time periods in analysis. CONCLUSIONS: The incidence of surgically treated IE significantly increases after the COVID-19 pandemic with a higher incidence of mitral valve involvement with respect to the aortic valve. Although a delay in surgical timing occurred during the COVID-19 pandemic, data in terms of mortality and outcomes were largely unaffected.

Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement.

BACKGROUND: Nowadays, one of the main goals of aortic valve surgery is to reduce the biological impact, mortality, and complications. It is well-known that long operative times in terms of the extracorporeal circulation, but above all, of the aortic cross-clamp time (ACC), represent a risk factor for mortality in patients undergoing cardiac surgery. In order to shorten the aortic cross-clamp time, many technological improvements, such as sutureless prostheses, have been introduced, but their actual effectiveness has not been proven yet. The aim of this study was to assess the 30-day outcomes of patients undergoing aortic valve replacement surgery, focusing on the ACC length. METHODS: All 3139 patients undergoing aortic valve replacement between January 2013 and July 2022 at our institution were enrolled. The data were retrospectively collected and the baseline characteristics and intraoperative variables were recorded. In order to adjust the results according to the differences in the baseline characteristics, propensity score matching was performed and four groups of 351 patients were obtained based on the first, second, third, and fourth quartile of the ACC time. RESULTS: The patient population included 132 redo surgeries (9.4%) and 61 cases of active endocarditis (4.3%), with an overall median EuroSCORE II of 1.8 (IQR 1.2-3.1). An increase across the groups was observed in terms of the acute kidney failure (p < 0.001) incidence, the number of blood transfusions (p = 0.022), prolonged hospital stays (p < 0.001), the and respiratory failure (p < 0.001) incidence. A p of < 0.1 was found for the 30-day mortality (p = 0.079). The predictors of an early 30-day mortality were standard full sternotomy (OR 2.48, 95% CI 1.14-5.40, p = 0.022), EuroSCORE II (OR 1.10, 95% CI 1.05-1.16, p < 0.001), and a trend for a longer ACC time (Q4 vs. Q1: OR 2.62, 95% CI 0.89-7.68, p = 0.080). CONCLUSIONS: Shortening the operative times resulted in marked improvements of the patients' outcomes. The combined use of minimally invasive approaches and sutureless aortic valve prostheses allows for a lower 30-day events rate. New technologies should be assessed to obtain the best results with the least risk.

Periareolar approach in female patients undergoing mitral and tricuspid valve surgery: An almost invisible surgical access.

BACKGROUND AND AIM OF THE STUDY: Periareolar minithoracotomy represents an interesting option in minimally invasive cardiac surgery and it is our preferred approach for women. Our aim is to assess the results in female patients, in terms of nipple postoperative pain, local sensitivity, and eventual alterations in mammography after surgery. METHODS: Fifty-seven female patients underwent periareolar incision, as minithoracotomy approach, from December 2018 to December 2021. Their mean age was 56 ± 12 years, their body mass index was 22.5 ± 4.8; their surgery was elective in 93%, with mean Euroscore II about 2 ± 1.3. RESULTS: Of 57 patients, 87.7% (50 patients) underwent mitral valve repair, whose six with associated procedures; 8.8% (five patients) underwent mitral valve replacement whose two with tricuspid annuloplasty associated and 3.5% (two patients) had isolated tricuspid surgery. The cardiopulmonary bypass and aortic cross-clamp time were 123.2 ± 30.2 and 101.3 ± min respectively. There were no conversions to either full sternotomy or larger thoracotomy approach. There were no in-hospital and follow-up deaths. No strokes or wound infections were observed. Mean follow-up was 16± 9 months. Within the investigated follow-up, 100% of the patients were satisfied with the esthetic result, no remarkable postoperative pain was reported, two patients had slight hyposensitivity in the nipple area. About 50% IThad mammography as prevention screening after surgery and no abnormalities were found. CONCLUSIONS: Periareolar minithoracotomy is a feasible surgical option in female patients, with excellent healing and cosmetic results and preserving the tissues of the mammary gland.

Impact of comorbidities on older patients undergoing open heart surgery.

BACKGROUND: The number of elderly patients undergoing cardiac surgery is increasing. Age greater than 80 years has been identified as a strong independent risk factor for shortand long-term survival. The current study is aimed to identify the impact of preoperative comorbidities on early and late outcomes in older patients undergoing cardiac surgery. METHODS: Baseline characteristics, procedurals and postoperative complications of all patients undergoing cardiac surgery at our institution are collected. The current analysis is focused on patients aged at least 80 years at the time of intervention and treated from January 2010 to December 2019. RESULTS: In-hospital mortality resulted as 6.3%. Redo intervention [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.13-5.48], chronic obstructive pulmonary disease (COPD) (OR 2.99, 95% CI 1.75-5.12) and peripheral arterial disease (PAD) (OR 2.23, 95% CI 1.30-3.81) were independent baseline predictors of outcome in the multivariate analysis. Prolonged extracorporeal circulation time, need for transfusion and prolonged intubation time strongly and independently predicted in-hospital mortality. During a mean follow-up of 3.6 years 34.3% of patients died and unplanned admission (HR 1.33, 95% CI 1.05-1.67), NYHA class III-IV (HR 1.35, 95% CI 1.12-1.64), diabetes (HR 1.27, 95% CI 1.01-1.59), COPD (HR 1.60, 95% CI 1.25-2.04) and PAD (HR 1.32, 95% CI 1.03-1.71) resulted as independent predictors of all-cause death. CONCLUSION: Cardiac surgery is feasible in octogenarians, with an acceptable risk of mortality. Chronological age itself should not be the main determinant of choice while referring patients for cardiac surgical intervention. Comorbidities such as COPD, PAD and diabetes need to be taken into account for risk stratification.

Biological Characterization of Human Autologous Pericardium Treated with the Ozaki Procedure for Aortic Valve Reconstruction.

BACKGROUND: The Ozaki procedure is an innovative surgical technique aiming at reconstructing aortic valves with human autologous pericardium. Even if this procedure is widely used, a comprehensive biological characterization of the glutaraldehyde (GA)-fixed pericardial tissue is still missing. METHODS: Morphological analysis was performed to assess the general organization of pericardium subjected to the Ozaki procedure (post-Ozaki) in comparison to native tissue (pre-Ozaki). The effect of GA treatment on cell viability and nuclear morphology was then investigated in whole biopsies and a cytotoxicity assay was executed to assess the biocompatibility of pericardium. Finally, human umbilical vein endothelial cells were seeded on post-Ozaki samples to evaluate the influence of GA in modulating the endothelialization ability in vitro and the production of pro-inflammatory mediators. RESULTS: The Ozaki procedure alters the arrangement of collagen and elastic fibers in the extracellular matrix and results in a significant reduction in cell viability compared to native tissue. GA treatment, however, is not cytotoxic to murine fibroblasts as compared to a commercially available bovine pericardium membrane. In addition, in in vitro experiments of endothelial cell adhesion, no difference in the inflammatory mediators with respect to the commercial patch was found. CONCLUSIONS: The Ozaki procedure, despite alteration of ECM organization and cell devitalization, allows for the establishment of a noncytotoxic environment in which endothelial cell repopulation occurs.

Pacemaker need after sutureless aortic valve replacement: the role of the learning curve.

AIM: Aortic valve replacement (AVR) using sutureless prosthesis is a reasonable alternative in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. Actually, excellent performances have been demonstrated in hemodynamic outcomes and safety, but some questions remain open regarding long-term durability and the need for postoperative pacemaker implantation. METHODS: Between January 2014 and August 2019, all 436 patients [male 40.6%, median age 78 years interquartile range (73-82)] treated with sutureless AVR with a Perceval prosthesis were included in our analysis. RESULTS: The univariate logistic regression showed previous aortic valve surgery [P = 0.028; odds ratio (OR) 3.248], dialysis (P = 0.036; OR 6.435), renal insufficiency (P = 0.021; OR 2.75), EuroSCORE II (P = 0.016; OR 1.051) and year of operation (P < 0.01; OR 0.658) as factors associated with the development of atrioventricular type II or type III block or junctional block requiring pacemaker implantation. The overall incidence of pacemaker implantation after sutureless AVR was 7.1% in the current study, but it dropped to 3.8 and 4.7%, respectively, in 2018 and 2019. CONCLUSION: The Perceval aortic valve is associated with encouraging postoperative results. The incidence of pacemaker implantation is strictly linked to the surgeons' experience, decreasing year by year after an adequate sizing, reaching a percentage comparable with sutured valve.

Asymptomatic giant circumflex aneurysm in patient with a cisplatin treatment history.

We report a case of 62-years-old man with a previous history of squamocellular tumour at the jaw treated with cisplatin chemotherapy. Six years after the chemotherapy, a transthoracic echocardiography showed a large left atrial lateral wall mass causing mitral stenosis. The thoracic computed tomography angiography (CTA) scan confirmed the mass (66x88mm) with contrast enhancement and the coronary angiography defined it as a giant left circumflex aneurysm. The aneurysm was resected and bypass graft performed. The aetiology and the technique used to treat this aneurysm are worthy to be described.

Minimally invasive aortic valve surgery in obese patients: Can the bigger afford the smaller?

BACKGROUND: Ministernotomy and right minithoracotomy are well-known minimally invasive approaches for aortic valve replacement (AVR); however, controversial opinions exist for their utilization in obese patients. The aim of this study is to check a potential positive role of minimally invasive surgery in this population. METHODS: From January 2010 to November 2019, 613 obese patients (defined by a body mass index ≥30) underwent isolated AVR at our institution. Surgical approach included standard median sternotomy (176 patients), partial upper sternotomy (271 patients), or right anterior minithoracotomy (166 patients). Intra- and postoperative data were retrospectively collected. RESULTS: Patients treated with minimally invasive approaches had shorter cardiopulmonary bypass time (p = .012) and aortic cross-clamp time (p = .022), mainly due to the higher utilization of sutureless valve implantation. They also presented advantages in terms of reduced postoperative ventilation time (p = .010), incidence of wound infection (p = .009), need of inotropic support (p = .004), and blood transfusion (p = .001). The univariable logistic regression showed the traditional full sternotomy approach as compared with ministernotomy (p = .026), active smoking (p = .009), peripheral vascular disease (p = .003), ejection fraction (p = .026), as well Logistic European system for cardiac operative risk evaluation (EuroSCORE; p = .015) as factors associated with hospital mortality. The multivariable logistic regression adjusted for the logistic EuroSCORE revealed that surgical approaches do not influence hospital mortality. CONCLUSIONS: Obese patients with severe aortic valve pathology can be treated with minimally invasive approaches offering a less biological insult and reduced postoperative complications, but without impact on hospital mortality.

Radial artery supply to the left mammary artery in a redo coronary bypass.

BACKGROUND: Single-inflow coronary bypass through left internal thoracic artery and Y graft is effective in myocardial revascularization, but left sublavian diseases may affect its safety. AIM OF THE STUDY: To assess that, in presence of a composite Y graft, issues involving the origin of the left internal thoracic artery are relatively easy to manage, even in reoperations. METHODS: A critical stenosis of the subclavian artery involving the origin of a bilateral internal thoracic artery Y graft was bypassed using a free radial artery graft. RESULTS: Bypass was performed between the left thoracic artery and the ascending aorta, off-pump and with excellent results. CONCLUSIONS: In consideration of the excellent long term results of total arterial revascularization, radial artery is a feasible graft option, even in case of a composite Y graft in place.

Full Sternotomy, Hemisternotomy, and Minithoracotomy for Aortic Valve Surgery: Is There a Difference?

BACKGROUND: This study compared perioperative results and mortality rates of different approaches to perform aortic valve replacement (AVR), describing predictors favoring one approach over the others. METHODS: All patients who underwent AVR were enrolled. The choice of the approach was left to surgeon's preference. Data were retrospectively collected, and the major baseline characteristics (including age, sex, body mass index, creatinine clearance, preoperative condition, cardiovascular risk factors, functional status, and left ventricular ejection fraction, etc.) and intraoperative variables were recorded. To adjust for differences in baseline characteristics between the study groups, a propensity score matching was performed. Linear and logistic regression analyses were performed. RESULTS: Partial upper hemisternotomy was performed in 820 patients (43%), right anterior minithoracotomy in 488 (26%), and median sternotomy in 599 (31%). After propensity score matching, three groups of 377 patients were obtained. Cardiopulmonary bypass and cross-clamp times were shorter in the right anterior minithoracotomy group than in the median sternotomy and partial upper hemisternotomy groups (p < 0.001). No significant differences in in-hospital mortality were observed (p = 0.9). Renal failure (odds ratio, 5.4; 95% confidence interval, 2.3 to 11.4; p < 0.0001), extracardiac arteriopathy (odds ratio, 2.9; 95% confidence interval, 1.1 to 6.7; p = 0.017), and left ventricular ejection fraction (odds ratio, 0.96; 95% confidence interval, 0.93 to 0.99; p = 0.009) emerged as independent predictors of in-hospital mortality. CONCLUSIONS: Minimal-access isolated aortic valve surgery is a reproducible, safe, and effective procedure with similar outcomes and operating times compared with conventional sternotomy.

Right anterior mini-thoracotomy vs. conventional sternotomy for aortic valve replacement: a propensity-matched comparison.

BACKGROUND: Right anterior mini-thoracotomy (MIAVR) is a promising technique for aortic valve replacement. We aimed at comparing its outcomes with those obtained in a propensity-matched group of patients undergoing sternotomy at our two high-volume centers. METHODS: Main clinical and operative data of patients undergoing aortic valve replacement between January 2010 and May 2016 were retrospectively collected. A total of 678 patients were treated with a standard full sternotomy approach, while MIAVR was performed in 502. Propensity score matching identified 363 patients per each group. RESULTS: In-hospital mortality was not significantly different between the propensity-matched groups (1.7% in MIAVR patients vs. 2.2% in conventional sternotomy patients; P=0.79). No significant difference in the incidence of major post-operative complications was observed. Post-operative ventilation times (median 7, range 5-12 hours in MIAVR patients vs. median 7, range 5-12 in conventional sternotomy patients; P=0.72) were not significantly different between the two groups. Cardiopulmonary bypass time (61.0±21.0 vs. 65.9±24.7 min in conventional sternotomy group; P<0.01) and aortic cross-clamping time (48.3±16.7 vs. 53.2±19.6 min in full sternotomy group; P<0.01) were shorter in MIAVR group. EuroSCORE (OR 1.52, 95% CI, 1.12-2.06; P<0.01) was found to be the only independent predictor of intra-hospital mortality in the whole propensity-matched population. CONCLUSIONS: Our experience shows that mini-access isolated aortic valve surgery is a reproducible, safe and effective procedure with similar outcomes and no longer operative times compared to conventional sternotomy.

Minimally invasive reoperative aortic valve replacement.

The operative mortality associated with repeat heart valve surgery is supposedly higher than the mortality associated with the primary operation. However, controversy still surrounds the risk factors and optimal surgical approach for patients requiring repeat cardiac surgery, particularly for those requiring aortic valve replacements (AVR). While the standard approach generally utilizes full sternotomy and peripheral cannulation, alternative approaches such as minimally invasive sternotomy may play an increasingly important role in this field. This study compares the advantages and disadvantages of a minimally invasive approach in redo AVR with the standard approach, highlighting difficulties and potential solutions.

Upper 'J' ministernotomy versus full sternotomy: an easier approach for aortic valve reoperation.

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) after previous cardiac surgery is usually associated with an increased risk profile. The study aim was to compare the outcome after AVR through an upper 'J' ministernotomy compared to a standard full sternotomy approach in a redo operation. METHODS: A total of 90 patients who underwent reoperative AVR at the authors' institution between October 2007 and January 2012 was retrospectively reviewed. Of these patients, 46 had patent bypass grafts and 44 previously had heart valve replacement or repair. Sixteen patients had endocarditis as the etiology, and 14 had prosthetic valve endocarditis. Of the 90 patients operated on, a minimally invasive upper 'J' ministernotomy was performed in 38, and a full median sternotomy in 52. The median age was 76 years (25th percentile 68.25 years; 75th percentile 79.25 years) for the minimally invasive group, and 73.5 (25th percentile 68 years; 75th percentile 78.75 years) for the full sternotomy group (p = 0.945). No statistically significant differences in terms of body mass index (p = 0.987), left ventricular ejection fraction (p = 0.544) and EuroSCORE (p = 0.162) were found between the two groups. Intraoperative data and postoperative outcomes, in terms of intensive care unit stay, blood loss, transfusions and sternal complications were analyzed. RESULTS: All patients underwent AVR. The median (IQR) cardiopulmonary bypass and cross-clamp times were respectively 67 (28) min and 51 (28) min for the minimally invasive group, and 72 (47) min and 53.5 (28) min for the full sternotomy group (p = 0.686 and p = 0.993). The postoperative ventilation time was significantly less in ministernotomy patients (median 6 versus 8.5 h; p = 0.027). One patient affected by endocarditis died in the minimally invasive group (mortality rate 2.6%). Hospital mortality in the traditional group was 3/52 (5.8%). CONCLUSION: Minimally invasive aortic valve surgery reoperation through an upper 'J' sternotomy proved to be at least as safe as the standard procedure in terms of hospital morbidity and mortality rates.

CentriMag venoarterial extracorporeal membrane oxygenation support as treatment for patients with refractory postcardiotomy cardiogenic shock.

We report our experience with the Levitronix CentriMag (Levitronix LLC, Waltham, MA) in the setting of venoarterial extracorporeal membrane oxygenation (ECMO) system support as treatment for postcardiotomy cardiogenic shock. Between January 2007 and August 2011, 14 consecutive adult patients received CentriMag ECMO support after cardiac surgery procedures at our institution. There were nine males (64.3%) and the mean age was 53.1 ± 14.3 years (range: 25-70 years). Cardiac surgery included: n = 6, aortic and/or mitral valve replacement; n = 5, coronary artery bypass grafting (CABG); and n = 3, Bentall procedures. The CentriMag ECMO support was installed centrally in eight patients and peripherally in six. Median duration of support was 5 days (range: 1-55 days). Seven patients were weaned from ECMO (50%), whereas six patients died while on support mainly because of multiple organ failure (42.9%). One patient died on ECMO support after transfer to the referral hub center while waiting for heart transplantation (Htx). Six (42.8%) patients were successfully discharged home. Levitronix CentriMag in ECMO configuration proved to be effective in managing postcardiotomy cardiogenic shock and the results are encouraging. The system was easy to install and manage.

"Community projects" in Modena (Italy): promote regular physical activity and healthy nutrition habits since childhood.

Lack of exercise and unhealthy diets are two of the most important risk factors to develop overweight, obesity and other chronic diseases. The school plays a key role in the promotion of lifelong healthy habits in children and their families. Every intervention at school level will need to be matched by changes in the social and cultural context so that the benefits can be sustained and enhanced in the community. We promoted healthy nutrition and a regular physical activity in schools and in local communities, through multifaceted interventions, which involved more than 10,000 children and about 100,000 adults.

Efficacy of a new oxygenator-integrated fat and leukocyte removal device.

We evaluated the effectiveness of a new oxygenator-integrated device for removing lipid particles and leukocytes from shed mediastinal blood in 20 patients undergoing elective cardiac surgery under cardiopulmonary bypass. Another 20 patients undergoing cardiac surgery without the device served as controls. After filtration with the RemoveLL device, lipid particles, leukocytes, and fats were significantly reduced compared to preoperative levels. In the control group, blood fats and lipid particles at the end of cardiopulmonary bypass were significantly increased compared to preoperative levels. Leukocyte counts at the end of bypass were significantly lower in patients who had the filtration device compared to the control group. Platelets counts and hematocrit changes were not significantly different between the 2 groups.