Clinical Outcomes of Cryo Nerve Ablation Technique for Pain Management: An Exploratory Study in Patients Undergoing Left Thoracotomy Coronary Artery Bypass Grafting.

Background: To investigate the impact of Cryo Nerve Block with cryoICE™ device utilization, on post-operative pain in patients undergoing isolated coronary artery bypass grafting (CABG) through left thoracotomy. Methods: All consecutive patients undergoing isolated CABG through left thoracotomy between July 2021 and July 2022 from a single surgeon were included in the study. Patients using the cryoICE™ device for nerve block were compared for baseline demographics and pre-operative characteristics with those that did not use the cryoICE™ device. A propensity-adjusted analysis was used to compare the two groups. The primary outcome was degree of incisional pain and numbness. Results: A total of 103 patients underwent isolated CABG through left thoracotomy. After matching, the cryoICE™ device was used for nerve block in 60 patients while the control group included 43 patients. Mean follow-up was 5.7 months. The cryoICE™ device group had a mean value of incisional pain at hospital discharge was 1.5 (scale 0-10) while at follow-up was 0.69 (scale 0-10). Mean values of skin numbness at hospital discharge were 1 (scale 0-10) and 0.57 (scale 0-10) at follow-up. After univariate analysis comparison of cryoICE™ device group (60 patients) versus non-cryoICE™ device group (43 patients), the total in-hospital morphine use was 49% lower in the cryoICE™ versus the non-cryoICE™ cohort (73.8 + 79.37 mg vs 144.1 + 118.99 mg). Conclusions: Good clinical outcomes were observed in patients undergoing isolated left thoracotomy CABG with cryoICE™ utilization, including a very low incidence of post-operative pain, numbness, and hypersensitivity for all comers.

A multidisciplinary case report of multiple myeloma with renal and cardiac involvement: a look beyond amyloidosis.

BACKGROUND: Multiple myeloma (MM) is a malignant neoplasm associated with kidney involvement in nearly half of the patients. Cast nephropathy, monoclonal immunoglobulin deposition disease (MIDD), and light chain (AL) amyloidosis are the most common monoclonal immunoglobulin-mediated causes of renal injury. Cardiac involvement is also present in MM, characterized by restrictive cardiomyopathy generated by light chain deposit or amyloid. Thromboembolic complications such as deep vein thrombosis or pulmonary embolism are also described. CASE PRESENTATION: We present an unusual multidisciplinary case of a woman with a newly diagnosed MM associated with severe proteinuria and high natriuretic peptide. A renal and fat pad biopsy with Congo red staining were performed but amyloid deposition was not discovered. While immunofluorescence on fresh frozen unfixed tissue was not contributory, the immunofluorescence on fixed tissue and electron microscopy revealed the correct diagnosis. During subsequent investigations, two intracardiac right-sided masses and massive pulmonary embolism were also detected. CONCLUSIONS: This case highlights that multiple organ involvement in patients with MM may result from a combination of paraprotein-dependent and -independent factors. Moreover, renal diseases induced by monoclonal gammopathies are a group of complex and heterogeneous disorders. Their subtle presentation and their potential multiorgan involvement require the expertise of a multidisciplinary team able to provide the most appropriate diagnostic and therapeutic assessment.

Successful early surgical treatment of a post-MINOCA ventricular septal defect.

BACKGROUND: Acquired ventricular septal defect (VSD) is a life-threatening condition that occurred after a myocardial infarction (MI). The timing of the intervention remains very debated but it is crucial to choose the right surgical technique to obtain a stable and complete repair. METHODS: We report the case of an acquired VSD that occurred after a MI without obstructions of coronary arteries (MINOCA). The defect was promptly treated with a double patch plus glue sandwich technique. RESULTS: At the end of the procedure, echocardiographic data showed no residual shunt, and no major adverse cardiac and cerebrovascular events were reported during postoperative days or 6 months follow-up. CONCLUSION: Our report suggests that MI's mechanical complications can occur even after a MINOCA.

COVID-19 in patients recovering from cardiac surgery: A surprising mild disease course.

BACKGROUND: We describe the baseline, operative, and postoperative features of a group of 18 patients who contracted the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection in a rehabilitation facility after cardiac surgery, and present some potential explanations for the surprisingly benign course of the COVID-19 in this cohort. METHODS: All patients were operated on an urgent or emergency basis (acute aortic syndrome, 3; refractory heart failure, 12; and endocarditis, 3) during the first lockdown period of the COVID-19 pandemic. The mean age was 70 years, and 12 patients were male. After the diagnosis of COVID-19, patients were treated according to the most recent recommendations. Eleven asymptomatic patients were discharged home or to a COVID-19 hotel and underwent close monitoring. Patients with fever, dyspnea, or a significant rise of the polymerase chain reaction levels were hospitalized, three received antivirals, three azithromicyne, and five hydroxychloroquine. Nasal swabs were repeated on a weekly basis, and all patients were quarantined until the collection of two consecutive negative samples. RESULTS: Diversely from other observations on perioperative COVID-19 reporting mortality rates of 30%-40%, the COVID-19 had a benign course in our cohort: only seven patients required hospitalization, and one required short intensive care unit admission. There were no deaths, and at the latest follow-up, all patients had been discharged home. COMMENT: Our data show that the SARS-CoV2 infection after cardiac surgery may have a benign course. Further studies are needed to investigate the relationship between the timing of the infection, some potentially protective therapies (e.g., anticoagulants), and the course of the COVID-19.

Cardiac arrest in takotsubo syndrome: results from the InterTAK Registry.

AIMS: We aimed to evaluate the frequency, clinical features, and prognostic implications of cardiac arrest (CA) in takotsubo syndrome (TTS). METHODS AND RESULTS: We reviewed the records of patients with CA and known heart rhythm from the International Takotsubo Registry. The main outcomes were 60-day and 5-year mortality. In addition, predictors of mortality and predictors of CA during the acute TTS phase were assessed. Of 2098 patients, 103 patients with CA and known heart rhythm during CA were included. Compared with patients without CA, CA patients were more likely to be younger, male, and have apical TTS, atrial fibrillation (AF), neurologic comorbidities, physical triggers, and longer corrected QT-interval and lower left ventricular ejection fraction on admission. In all, 57.1% of patients with CA at admission had ventricular fibrillation/tachycardia, while 73.7% of patients with CA in the acute phase had asystole/pulseless electrical activity. Patients with CA showed higher 60-day (40.3% vs. 4.0%, P < 0.001) and 5-year mortality (68.9% vs. 16.7%, P < 0.001) than patients without CA. T-wave inversion and intracranial haemorrhage were independently associated with higher 60-day mortality after CA, whereas female gender was associated with lower 60-day mortality. In the acute phase, CA occurred less frequently in females and more frequently in patients with AF, ST-segment elevation, and higher C-reactive protein on admission. CONCLUSIONS: Cardiac arrest is relatively frequent in TTS and is associated with higher short- and long-term mortality. Clinical and electrocardiographic parameters independently predicted mortality after CA.

Impact of Pleural Integrity Preservation After Minimally Invasive Aortic Valve Surgery.

OBJECTIVE: While the benefits of minimally invasive aortic valve surgery compared with standard sternotomy have been widely described, the impact of preservation of pleural integrity (PPI) in minimally invasive surgery is still widely discussed. This study aims to define the role of PPI on postoperative and long-term outcomes after minimally invasive aortic valve replacement (MIAVR). METHODS: All 2,430 consecutive patients undergoing MIAVR (ministernotomy or right anterior minithoracotomy) between 1997 and 2022 were included in the study. Patients were divided into 2 groups: patients with and without PPI. PPI was considered the maintenance of the pleura closed without the need for a chest tube insertion at the end of the surgical procedure. A propensity-matched analysis was used to compare the PPI and not-PPI groups. RESULTS: After propensity matching, 848 patients were included in each group (PPI and not-PPI). The mean age was 70.21 versus 71.42 years, and the mean Society of Thoracic Surgeons predicted risk of mortality was 0.31% versus 0.30% in not-PPI versus PPI, respectively. The mean follow-up time was 147.4 months. Postoperatively, not-PPI versus PPI patients had a longer intensive care unit stay (9.7 vs 17.3 h, P < 0.001) and hospital length of stay (5.2 vs 8.9 days, P < 0.001). The rate of respiratory complications including the incidence of pneumothorax or subcutaneous emphysema, pulmonary atelectasis, and pleural effusion events requiring thoracentesis/drainage was significantly higher in not-PPI versus PPI. The 30-day all-cause mortality was higher in not-PPI versus PPI (0.029 vs 0.010, P = 0.003). Perioperative, short-term, and long-term all-cause mortality was significantly higher in the not-PPI group. CONCLUSIONS: PPI after MIAVR is associated with reduced incidence of postoperative complications, reduced lengths of stay, and improved overall survival compared with not-PPI. Therefore, a MIAVR tailored patient-procedure approach to maintaining the pleura integrity positively impacts short-term and long-term outcomes.

Clinical Outcomes and Cost Analysis in Patients with Heart Failure Undergoing Transcatheter Edge-to-Edge Repair for Mitral Valve Regurgitation.

Objective: To analyze the clinical and cost outcomes of transcatheter edge-to-edge repair (TEER) for mitral regurgitation (MR) in heart failure (HF) patients. Methods: All 162 HF patients undergoing TEER for MR between January 2019 and March 2023 were included. A propensity-adjusted analysis was used to compare 32 systolic vs. 97 diastolic vs. 33 mixed (systolic + diastolic) HF patients. Systolic, diastolic, and mixed HF patients were defined according to AHA guidelines. The primary outcome was the long-term incidence of all-cause death and major adverse cardiovascular and cerebrovascular events (MACCEs, all-cause mortality + stroke + myocardial infarction + repeat intervention). Results: The mean age was 76.3 vs. 80.9 vs. 76 years old, and the mean ejection fraction (EF) was 39.5% vs. 59.8% vs. 39.7% in systolic vs. diastolic vs. mixed HF, respectively. Postoperatively, the diastolic vs. systolic HF group had a higher intensive care unit stay (21 vs. 0 h; HR 67.5 (23.7, 111.4)]; lower ventilation time [2 vs. 2.3 h; HR 49.4 (8.6, 90.2)]; lower EF [38% vs. 58.5%; HR 9.9 (3.7, 16.1)]. In addition, the diastolic vs. mixed HF groups had a lower incidence of EF < 50% (11 vs. 27 patients; HR 6.6 (1.6, 27.3) and a lower use of dialysis (one vs. three patients; HR 18.1 (1.1, 287.3), respectively. At a mean 1.6 years follow-up, all-cause death [HR 39.8 (26.2, 60.5)], MACCEs [HR 50.3 (33.7-75.1)], and new pacemaker implantations [HR 17.3 (8.7, 34.6)] were higher in the mixed group. There was no significant total hospital cost difference among the systolic (USD 106,859) vs. diastolic (USD 91,731) vs. mixed (USD 120,522) HF groups (p = 0.08). Conclusions: TEER for MR evidenced the worst postoperative and follow-up clinical outcomes in the mixed HF group compared to diastolic and systolic HF groups. No total hospital cost differences were observed.

Midterm Clinical Outcomes of Robotic-Assisted Reverse Hybrid Coronary Revascularization: A Single-Center Experience.

Outcomes of robotic-assisted reverse hybrid coronary revascularization (HCR) remain hindered. We aimed to analyze midterm clinical outcomes of robotic-assisted reverse HCR. All consecutive 285 patients who underwent reverse robotic-assisted HCR between September 2005 and July 2021 were included. Reverse HCR comprises percutaneous coronary intervention with stent implantation in non-left anterior descending (LAD) coronary arteries was performed within 30 days before robotic-assisted left internal thoracic artery (LITA) harvesting and LITA-to-LAD manual anastomosis through a 4-cm left minithoracotomy. Dual antiplatelet therapy was not interrupted in any patient. Preoperatively, mean age was 70.2 years (±11.2). Before surgery, 168 patients received 1 stent, 112 patients 2 stents, and 5 patients 3 stents. Intraoperatively, mean operating room time was 5.9 hours (±1); no case was converted to full sternotomy, whereas 9 patients (3.1%) received intraoperative blood product transfusions. Postoperatively, a small incidence of stroke, 1 (0.3%), reoperation for bleeding, 7 (2.4%), blood product transfusions, 48 (16.8%), and hospital stay (4.8 days) was observed. At 30-day follow-up, 1 patient (0.3%) underwent percutaneous coronary intervention with stent on a surgical LITA-LAD anastomosis owing to graft failure. Mean follow-up was 4.2 years. Reported midterm outcomes included all-cause death in 31 patients (10.9%), major adverse cardiovascular and cerebrovascular events in 102 of 285 (35.9%), nonfatal stroke in 2 of 285 (0.7%), myocardial infarction in 17 of 285 (5.9%), and repeat intervention in 50 of 285 patients (17.5%). This single-center study reports effective and safe clinical outcomes at midterm follow-up of reverse HCR procedures for treating multivessel coronary artery disease.

Risk Score for Long-Term Survival and Major Adverse Cardiovascular and Cerebrovascular Events After Coronary Artery Bypass Grafting Surgery.

To develop risk scoring models predicting long-term survival and major adverse cardiovascular and cerebrovascular events (MACCEs), including myocardial infarction and stroke after coronary artery bypass grafting (CABG). All 4,821 consecutive patients who underwent isolated CABG at Lankenau between January 2005 and July 2021 were included. MACCE was defined as all-cause mortality + myocardial infarction + stroke. Variable selection for both outcomes was obtained using a double-selection logit least absolute shrinkage and selection operator with adaptive selection. Model performance was internally evaluated by calibration and accuracy using bootstrap cross-validation. Mortality and MACCEs were compared in patients split into 3 groups based on the predicted risk scores for all-cause mortality and MACCEs. An external validation of our database was performed with 665 patients from the University of Brescia, Italy. Preoperative risk predictors were found to be predictors for all-cause mortality and MACCEs. In addition, being of African-American ethnicity is a significant predictor for MACCEs after isolated CABG. The areas under the curve (AUCs), which measures the discrimination of the models, were 80.4%, 79.1%, 81.3%, and 79.2% for mortality at 1, 2, 3, and 5 years follow-up. The AUCs for MACCEs were 75%, 72.5%, 73.8%, and 72.7% at 1, 2, 3, and 5 years follow-up. For external validation, the AUCs for all-cause mortality and MACCEs at 1, 2, 3, and 5 years were 73.7%, 70.8%, 68.7%, and 72.2% and 72.3%, 68.2%, 65.6%, and 69.6%, respectively. The Advanced (AD) Coronary Risk Score for All-Cause Mortality and MACCE provide good discrimination of long-term mortality and MACCEs after isolated CABG. External validation observed a more AUCs greater than 70%.

Case report: Infective endocarditis after transcatheter aortic valve implantation surgically treated with sutureless prosthesis and ascending aorta replacement.

Infective endocarditis on transcatheter aortic valve implantation (TAVI) represents an increasingly frequent challenge for cardiac surgeons. Patients undergoing TAVI usually have high mortality risk scores and unsuitable anatomy for the traditional surgical approach. Therefore, surgical planning is crucial, albeit sometimes intraoperative findings can be unexpected and arduous. We describe a case of infective endocarditis on TAVI in a patient with a porcelain aorta and "hostile" aortic root surgically treated with Perceval sutureless prosthesis and ascending aorta replacement.

Radial artery harvesting with harmonic scalpel: fully no-touch technique.

The radial artery has been used for decades as an alternative to other arterial bypass graft conduits. Positive long-term patency results and survival benefits have led to an increase in its popularity. The emerging evidence of the need for total arterial myocardial revascularization unleashes the potential of the radial artery as a versatile arterial conduit capable of reaching all coronary targets in a lot of different configurations. In addition, a radial artery graft has proven benefits in terms of graft patency compared with a saphenous venous graft. In this context, multiple randomized clinical trials have repeatedly proven the improved clinical outcomes of radial artery grafts based on 10 years of follow-up; the radial artery graft has also been shown to be a suitable arterial conduit in up to 90% of coronary artery bypass grafting cases. Despite the scientific evidence regarding the benefits of the radial artery graft, most surgeons are still reluctant to use the radial artery in coronary artery bypass graft procedures. Consequently, surgical residents risk not developing solid surgical skills for utilization of the radial artery graft. Safe, easy-to-learn techniques are needed to speed up the learning curve and at the same time lower the complications. In this context, a fully no-touch technique for harvesting the radial artery using a harmonic scalpel can be the right way to introduce young surgeons to this basic but paramount skill.

Severe Refractory Vasoplegic Shock Syndrome after OPCABG Successfully Treated with Hydroxycobalamin: A Case Report and Review of the Literature.

BACKGROUND: Vasoplegic shock syndrome (VSS) after an off-pump coronary artery bypass graft (OPCABG) is an extremely rare condition. Inotropic support is usually the first-line therapy, though it can precipitate several complications or be ineffective. We report the first case of severe refractory VSS after OPCABG successfully treated with hydroxycobalamin. METHODS: A 77-year-old gentleman underwent OPCABG for three vessels coronary artery disease. Preoperative LV ejection fraction was 28%, and the patient before surgery started sacubitril/valsartan titrated, then, at the highest dose. Surgery was uneventful and, by the end of the procedure, TEE showed improved biventricular contractility. RESULTS: The patient was transferred to the ICU without inotropic support, but soon developed hypotension. TEE ruled out pericardial tamponade and confirmed fair contractility. Norepinephrine was titrated to a medium-high dose, vasopressin was started and a Swan-Ganz catheter was placed. SVR was 480 dyn·s·cm-5. Despite aggressive pharmacologic treatment (including methylprednisolone and methylene blue), no improvements were noticed. Ten grams of hydroxycobalamin were administered. One hour later, hemodynamic status re-assessment showed SVR > 800 dyn·s·cm-5. Afterward, vasopressors were gradually reduced. CONCLUSIONS: Our case demonstrated the importance of adequate early treatment in VSS after OPCABG. This case report shows, for the first time, that hydroxycobalamin was effectively used to restore homeostasis.

Does a standard myectomy exist for obstructive hypertrophic cardiomyopathy? From the Morrow variations to precision surgery.

OBJECTIVES: The purpose of this work is to revisit the history of surgical treatment for obstructive hypertrophic cardiomyopathy (oHCM) over the last 60 years, in the light of advancing knowledge of the pathophysiology of obstruction. METHODS: In this narrative review the contribution of the different surgical approaches to the field will be assessed in our personal experience in Florence. RESULTS: Septal myectomy is the treatment of choice in patients with obstructive hypertrophic cardiomyopathy who remain symptomatic despite optimal medical treatment. Over the decades, numerous "theme variations" of the Morrow operation have been proposed, each of them targeting a specific pathophysiological determinant of left ventricular outflow tract obstruction. CONCLUSIONS: Precision surgery in oHCM patients today depends on the ability of the surgeon to combine and master these variations, with the bird's eye view allowed by climbing on the shoulders of giants.

Early and Long-Term Clinical and Echocardiographic Outcomes of Sutureless vs. Sutured Bioprosthesis for Aortic Valve Replacement.

Objective: The goal of this manuscript is to compare clinical and echocardiographic outcomes of patients undergoing aortic valve replacement (AVR) with Perceval sutureless bioprosthesis (SU-AVR) and sutured bioprosthesis (SB). Methods: Following the PRISMA statement, data were extracted from studies published after August 2022 and found in PubMed/MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, SciELO, LILACS, and Google Scholar. The primary outcome of interest was post-procedural permanent pacemaker implantation, and the secondary outcomes were new left bundle branch block (LBBB), moderate/severe paravalvular leak (PVL), valve dislocation (pop-out), need for a second transcatheter heart valve, 30-day mortality, stroke, and echocardiographic outcomes. Results: Twenty-one studies were included in the analysis. When SU-AVR was compared to other SB, mortality ranged from 0 to 6.4% for Perceval and 0 to 5.9% for SB. Incidence of PVL (Perceval 1-19.4% vs. SB 0-1%), PPI (Perceval 2-10.7% vs. SB 1.8-8.5%), and MI (Perceval 0-7.8% vs. SB 0-4.3%) were comparable. In addition, the stroke rate was lower in the SU-AVR group when compared to SB (Perceval 0-3.7% vs. SB 1.8-7.3%). In patients with a bicuspid aortic valve, the mortality rate was 0-4% and PVL incidence was 0-2.3%. Long-term survival ranged between 96.7 and 98.6%. Valve cost analysis was lower for the Perceval valve and higher for sutured bioprosthesis. Conclusions: Compared to SB valves, Perceval bioprosthesis has proved to be a reliable prosthesis for surgical aortic valve replacement due to its non-inferior hemodynamics, implantation speed, reduced cardiopulmonary bypass time, reduced aortic cross-clamp time, and shorter length of stay.

A threatening meteor for cardiac surgeons: anomalous left main coronary origin in type A aortic dissection.

We present the case of a type A aortic dissection originating from the right coronary ostium and an intraoperative diagnosis of the entire coronary artery system originating from a single right-sided coronary ostium.

Emerging Medical Treatment for Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a common myocardial disease characterized by otherwise unexplained left ventricular hypertrophy. The main cause of disabling symptoms in patients with HCM is left ventricular outflow tract (LVOT) obstruction. This phenomenon is multifactorial, determined both by anatomical and functional abnormalities: myocardial hypercontractility is believed to represent one of its major determinants. The anatomical anomalies are targeted by surgical interventions, whereas attenuating hypercontractility is the objective of old and new drugs including the novel class of allosteric myosin inhibitors. This review summarizes the current treatment modalities and discusses the emerging therapeutical opportunities focusing on the recently developed cardiac myosin ATPase inhibitors Mavacamten and CK-274. Novel surgical and interventional approaches are also discussed.

Prognostic relevance of GRACE risk score in Takotsubo syndrome.

BACKGROUND: Takotsubo syndrome is an increasingly recognised cardiac condition that clinically mimics an acute coronary syndrome, but data regarding its prognosis remain controversial. It is currently unknown whether acute coronary syndrome risk scores could effectively be applied to Takotsubo syndrome patients. This study aims to assess whether the Global Registry of Acute Coronary Events (GRACE) score can predict clinical outcome in Takotsubo syndrome and to compare the prognosis with matched acute coronary syndrome patients. METHODS: A total of 561 Takotsubo syndrome patients was included in this prospective registry. According to the GRACE score, the population was divided into quartiles. The primary endpoint was all-cause mortality and the secondary endpoints were cardiocerebrovascular events (a composite of all-cause mortality, cardiovascular death, recurrence of Takotsubo syndrome and stroke). RESULTS: The median GRACE risk score was 139±27. Takotsubo syndrome patients with a higher GRACE risk score mostly have a higher rate of physical triggers and lower left ventricular ejection fraction on admission. During long-term follow-up, all-cause mortality rates were 5%, 11%, 12% and 22%, respectively, in the first, second, third and fourth quartile (P<0.001). After multivariate analysis, the GRACE risk score was found to be a strong predictor of all-cause mortality (odds ratio (OR) 1.68, 95% confidence interval (CI) 1.28-2.20; P=0.001) and cardiocerebrovascular events (OR 1.63, 95% CI 1.26-2.11; P=0.001). Moreover, all-cause mortality in Takotsubo syndrome patients was comparable with the matched acute coronary syndrome cohort. CONCLUSION: In Takotsubo syndrome, the GRACE risk score allows us to predict all-cause mortality and cardiocerebrovascular events at long-term follow-up.

Novel Aspects of Classification, Prognosis and Therapy in Takotsubo Syndrome.

Takotsubo syndrome (TTS) can be considered a transient form of acute heart failure that mimics an acute coronary syndrome. Although many hypotheses have been formulated, the precise physiopathology of TTS remains unknown. TTS is associated with a heterogeneous clinical course, which ranges from benign to poor outcome, comprising life-threatening phenotypes. In the acute phase, TTS patients may experience complications including left ventricular outflow tract obstruction, cardiogenic shock, arrhythmias and thromboembolic events. Furthermore, after the acute episode, physiological abnormalities can persist and some patients continue to suffer cardiac symptoms. To recognise patients at higher risk earlier, many variables have been proposed and risk stratifications suggested. There is no solid evidence regarding specific therapy and the proper management of TTS patients, either in the acute phase or long term. This review describes the current knowledge regarding diagnostic criteria, prognosis and therapy in TTS.