Early Versus Late Tracheostomy in Cardiac Surgical Patients: A 12-Year Single Center Experience.

OBJECTIVES: To evaluate whether early tracheostomy is associated with better outcomes in mechanical ventilation-dependent patients after cardiac surgery compared with a late tracheostomy. DESIGN: Retrospective, observational study. SETTING: Cardiac surgical intensive care unit (ICU) of a tertiary care center. PARTICIPANTS: All patients who underwent tracheostomy after cardiac surgery between 2004 and 2015 were subdivided into the following 2 groups according to the timing of tracheostomy: "early" if the tracheostomy was performed before the 14th postoperative day and "late" from the 14th postoperative day onward. INTERVENTIONS: Early versus late tracheostomy. MEASUREMENTS AND MAIN RESULTS: During the study period, 112 of 5,148 patients (2.2%) underwent tracheostomy after cardiac surgery. Early tracheostomy was performed in 62 patients, and 50 patients underwent late tracheostomy. Both groups of patients were similar in terms of preoperative and intraoperative characteristics, perioperative risk, and postoperative complications. Patients in the early group had a significantly shorter ventilation time (31.3 ± 23.6 v 39.4 ± 22.4 d; p = 0.034), shorter ICU stay (37.7 ± 21.7 v 46.4 ± 25 d; p = 0.025), and a shorter hospital stay (53.4 ± 29.3 v 66.8 ± 38.5 d; p = 0.020). There were no intergroup differences in weaning rates and in-hospital, 3-month, and 1- and 2-year mortality. CONCLUSIONS: In this study, early tracheostomy after cardiac surgery in patients requiring prolonged mechanical ventilation was associated with a shorter ventilation time and ICU and hospital stay, but did not result in a lower in-hospital and long-term mortality rate.

Nine years' experience with the chordal cutting technique in ischemic mitral regurgitation.

OBJECTIVES: The optimal surgical management of chronic ischemic mitral regurgitation has not yet been clearly defined. Among the various approaches proposed, the excision of strut (or main) chordae, along with complete annuloplasty to relieve tethering, has been the one preferred by our institution to treat this particular subset of mitral disease. METHODS: Between October 2004 and May 2013, 11 patients underwent surgery for chronic ischemic mitral regurgitation. RESULTS: There was no perioperative death. No patient was lost to follow-up. There was one late death due to respiratory failure three years after the operation, and one patient received a ventricular assist device ten months after surgery. The remaining patients are all alive with residual trivial-to-mild regurgitation. CONCLUSION: Chordal cutting associated with complete annuloplasty may be a good surgical option in chronic ischemic mitral regurgitation.

Cardiac surgery practice during the COVID-19 outbreak: a multicentre national survey.

OBJECTIVES: Healthcare systems worldwide have been overburdened by the coronavirus disease 2019 (COVID-19) outbreak. Accordingly, hospitals had to implement strategies to profoundly reshape both non-COVID-19 medical care and surgical activities. Knowledge about the impact of the COVID-19 pandemic on cardiac surgery practice is pivotal. The goal of the present study was to describe the changes in cardiac surgery practices during the health emergency at the national level. METHODS: A 26-question web-enabled survey including all adult cardiac surgery units in Italy was conducted to assess how their clinical practice changed during the national lockdown. Data were compared to data from the corresponding period in 2019. RESULTS: All but 2 centres (94.9%) adopted specific protocols to screen patients and personnel. A significant reduction in the number of dedicated cardiac intensive care unit beds (-35.4%) and operating rooms (-29.2%), along with healthcare personnel reallocation to COVID departments (nurses -15.4%, anaesthesiologists -7.7%), was noted. Overall adult cardiac surgery volumes were dramatically reduced (1734 procedures vs 3447; P < 0.001), with a significant drop in elective procedures [580 (33.4%) vs 2420 (70.2%)]. CONCLUSIONS: This national survey found major changes in cardiac surgery practice as a response to the COVID-19 pandemic. This experience should lead to the development of permanent systems-based plans to face possible future pandemics. These data may effectively help policy decision-making in prioritizing healthcare resource reallocation during the ongoing pandemic and once the healthcare emergency is over.

Repair of posterior left ventricular aneurysm through transatrial approach.

Repair of posterior left ventricular ischemic aneurysms implies an extracardiac approach to reshape the ventricular geometry frequently associated with mitral surgery. A transatrial technique was described for lesions following mitral surgery or for subvalvular idiopathic cases. A transmitral approach was used for ischemic or traumatic pseudoaneurysm. We describe a case of postinfarction posterior true aneurysm with associated mitral incompetence. Both lesions were treated through an intracardiac approach. The posterior mitral leaflet was detached posteriorly to close the aneurysm with a patch, and the valve replaced sparing all subvalvular apparatus. This technique seems to be safe and allows to treat both lesions avoiding ventriculotomy.

Obstruction of the tricuspid valve orifice by a huge right atrial myxoma associated with the Carney complex: a case report.

Carney complex (CNC) is an inherited autosomal dominant disorder associated with multiple neoplasms. Myxomas associated with CNC differ from their sporadic forms because the former usually develop at a younger age and they may be multicentric and have a tendency to recur. Furthermore, their localization may be atypical. We report the case of a 57-year-old man, with a huge right atrial myxoma obstructing the tricuspid valve orifice. A diagnosis of CNC was established by genetic analysis. The importance of early diagnosis and an adequate follow-up is emphasized.

Effect of revascularizing viable myocardium on left ventricular diastolic function in patients with ischaemic cardiomyopathy.

AIMS: In patients with ischaemic left ventricular (LV) dysfunction and viable myocardium, revascularization improves systolic function. Diastolic dysfunction is also present in such patients; however, whether revascularization improves diastolic function also is largely unknown. METHODS: Twenty-six patients with chronic ischaemic cardiomyopathy [ejection fraction (EF) 32 +/- 6%, wall motion score index (WMSI) 2.45 +/- 0.33] and viable myocardium (low-dose dobutamine echocardiography) were examined at baseline and > or =4 months after revascularization. Diastolic function was assessed by transmitral pulsed-wave Doppler and tissue Doppler imaging (TDI) at the mitral annulus. RESULTS: At baseline, 62% of patients showed non-restrictive filling (non-RF) pattern, and 38% restrictive filling (RF) pattern. After revascularization, along with improvement in systolic function (EF 43 +/- 10%, WMSI 1.78 +/- 0.47, P = 0.0002 for both), diastolic filling improved in most patients, with only three patients still exhibiting RF pattern (P = 0.016); furthermore, E' velocity increased (32 +/- 42%, P = 0.0028) and E/E' decreased (-19 +/- 31%, P = 0.0378) compared with baseline. Left ventricular filling pressure also decreased, from 17.5 +/- 6.8 to 13.1 +/- 6.5 mmHg (P = 0.005). Improvement of diastolic function by TDI was related to the extent of viability at baseline (P = 0.0098) and to LV reverse remodelling after revascularization (P = 0.0092). CONCLUSION: In patients with ischaemic cardiomyopathy, LV diastolic filling may largely improve after revascularization. Improvement of diastolic dysfunction is related to the amount of viable tissue and it may represent an additional advantage of revascularizing dyssinergic but viable myocardium.

Post-traumatic Aortopulmonary Fistula after Bentall Procedure.

Pseudoaneurysm complicated by aortopulmonary fistula (APF) after a Bentall procedure is extremely rare but potentially fatal, so timely diagnosis and treatment are critical. We present a subacute case of a post-traumatic APF which has had initial aspecific symptoms and later an acute worsening heart failure with chest pain not responding to medical treatment and requiring emergency surgery.

Short-term hemodynamic performance of the Sorin Freedom SOLO stentless valve.

BACKGROUND AND AIM OF THE STUDY: The new Sorin Freedom SOLO pericardial stentless valve is designed for supra-annular implantation, and requires only one running suture. It can be implanted with a short cross-clamp time, and is designed to offer the same hemodynamic advantages of other stentless valves. The study aim was to evaluate the prospective postoperative and two-month follow up hemodynamic performance of this bioprosthesis. METHODS: Thirty patients (13 males, 17 females; mean age 75.6 +/- 6.21 years) with severe aortic stenosis underwent valve replacement with the Sorin Freedom SOLO stentless valve. All patients underwent transthoracic echocardiography before surgery, before hospital discharge, and at two months' follow up. The peak and mean transprosthetic gradients, telediastolic and telesystolic diameters, septal and posterior wall thicknesses, total and indexed ventricular mass volume and left ventricular ejection fraction were evaluated. RESULTS: Both, the transprosthetic peak gradient and mean gradient decreased significantly during the first two months (p < 0.05 and p < 0.001, respectively). The telediastolic diameter was significantly reduced between preoperative evaluation and follow up (p < 0.05). The interventricular septum thickness was decreased significantly after two months (p <0.001), as was the posterior wall thickness, albeit to a lesser degree (p < 0.05). Both, total and indexed ventricular mass volume showed a significant regression at the two months follow up (p < 0.001). CONCLUSION: The Sorin Freedom SOLO stentless valve shows good hemodynamic performance, with an early and highly progressive left ventricular remod eling. If these data are confirmed in future studies, the SOLO prosthesis might represent a safe alternative to the use of conventional stentless valves.

Cardiac tamponade caused by a migrating sewing needle.

: Penetrating injuries of the heart caused by migrating needles have been rarely described. They usually occur accidentally or are self-inflicted in the setting of an underlying psychiatric disorder. We present an unusual case of cardiac tamponade caused by a sewing needle that migrated to the heart from the chest wall through the lung. The lesions were successfully repaired through a median sternotomy without cardiopulmonary bypass. The pathophysiological mechanism and the pertinent literature are briefly analysed.

Platypnea-orthodeoxia induced by fenestrated atrial septal aneurysm.

Platypnea-orthodeoxia is a peculiar syndrome characterized by a right-to-left shunt, which occurs in the upright position. The diagnosis is made by contrast transesophageal echocardiography, paying attention to include contrast visualization in the orthostatic decubitus. The association of this syndrome with a fenestrated atrial septal aneurysm is rare and probably underlies a peculiar and also rare mechanism of shunting in presence of normal pulmonary pressure. We report of a case of a 58-year-old man with a fenestrated atrial septal aneurysm and platypnea-orthodeoxia syndrome treated by surgical closure of the atrial defect.

[Risk evaluation in coronary surgery: a single center experience using the EuroSCORE]. / Valutazione del rischio in chirurgia coronarica: esperienza di un centro con il sistema EuroSCORE.

BACKGROUND: One of the most utilized systems for risk stratification in cardiac surgery is the EuroSCORE. It considers some risk factors that should influence the surgical risk. The aim of this study was to evaluate if our results, related to isolated coronary artery bypass surgery, are well predictable by this system and which are the parameters statistically significant for hospital mortality. METHODS: From January 1, 2002 to April 30, 2004, 724 patients underwent isolated myocardial revascularization. All risk factors considered for the EuroSCORE system evaluation and the EuroSCORE value itself were analyzed to assess their significance to predict surgical risk. Univariate statistical analysis was performed with the Student's t-test for quantitative variables and the chi2 in contingency tables for categorical variables. Logistic regression was used for multivariate analysis. RESULTS: Cumulative operative mortality was 3.7% (27 patients). The EuroSCORE value, age, critical preoperative state, emergency and low ejection fraction were all statistically significant risk factors for hospital mortality. Multivariate analysis excluded only the critical preoperative state. The analysis of contingency tables showed that the surgical risk was statistically significant above the age of 75 years. The same analysis revealed that the mortality rate was statistically different in the three groups and it showed that the system could over-estimate mortality at lower EuroSCOREs and under-estimate mortality at higher EuroSCOREs. CONCLUSIONS: This study confirms the value of the EuroSCORE for risk stratification in this group of patients. The most important parameters considered for its calculation confirmed their predictive value. This model allows a reliable quality control of our surgical practice.

Metachronous cardiac and cerebral sarcomas: case report with focus on molecular findings and review of the literature.

Although multiple primary malignancies are relatively rare, they have increased in frequency over the last decades, partly because of advances in diagnosis and therapy. This report describes for the first time the case of a patient with past occupational exposure to asbestos and no family history of cancer who developed 2 rare primary malignancies: a cardiac sarcoma and a gliosarcoma 11 months later. Molecular-cytogenetic studies did not identify common lesions to these 2 rare metachronous sarcomas. The gliosarcoma was associated with monosomy 10 and underlying PTEN monoallelic loss, which has been recurrently observed. In the cardiac sarcoma, MDM2 amplification and CDKN2AB/9p21 biallelic deletion suggested intimal sarcoma. No causal relationship was found between cardiac sarcoma and asbestos exposure, although MDM2 abnormalities were linked to malignant mesothelioma.

[Surgical myocardial revascularization in patients over and under 70 years of age: results and prognostic factors]. / Rivascolarizzazione miocardica chirurgica nei pazienti di età superiore ed inferiore a 70 anni: risultati e fattori prognostici.

BACKGROUND: The increase in mean age has made older patients candidates to myocardial revascularization. This study is focused to evaluate hospital mortality and major postoperative complications in two groups of patients < or = 70 or > 70 years. The possible confounder effect of other important risk factors has been studied in multivariate models. METHODS: From January 1 to December 31, 2002, 228 patients < or = 70 years (group A) and 116 patients > 70 years (group B) underwent isolated myocardial revascularization. We analyzed the incidence of hospital mortality, cardiac failure, postoperative bleeding, major arrhythmias, atrial fibrillation, respiratory failure, renal failure, sternal infection, stroke, transient ischemic attack, total neurological complications, and number of patients with at least one of these complications. Univariate statistical analysis was used to compare this two groups and multivariate analysis to adjust for four known important risk factors, i.e. sex, diabetes, ejection fraction < 0.40, and off-pump surgical technique. RESULTS: Hospital mortality was statistically higher in group B than in group A (7.8 vs 1.7%, p < 0.05). The incidence of cardiac failure, although higher in group B, was not statistically significant. Multivariate analysis confirmed low ejection fraction as the only statistical risk factor for low cardiac output (p < 0.05). Atrial fibrillation was statistically higher in group B (p < 0.05). No difference was found for all other complications considered. Age, low ejection fraction and the use of cardiocirculatory bypass at multivariate analysis were statistically significant risk factors for the incidence of at least one postoperative event. CONCLUSIONS: Myocardial revascularization in patients > 70 years has a higher mortality and morbidity. At multivariate analysis, low ejection fraction is also confirmed as a significant risk factor for low cardiac output and total morbidity. At the same time, the technical option of "beating heart" myocardial revascularization seems to achieve better results and probably it should be used more extensively in this group of patients.

Levosimendan may improve weaning outcomes in venoarterial ECMO patients.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support in patients with refractory cardiogenic shock, allowing time for cardiac recovery. Levosimendan is a calcium sensitizer with inotropic and vasodilatory effects used in the treatment of severe heart failure. It does not increase myocardial oxygen consumption. Its maximum hemodynamic response is seen 24-48 h after stopping infusion, but its effects can persist for 7-9 d owing to active metabolites. We sought to investigate whether the use of levosimendan improves weaning outcomes in patients on VA-ECMO. Six consecutive patients with cardiogenic shock were placed on femorofemoral VA-ECMO support and received levosimendan 24 h before the planned weaning (group A). As control group (group B), we retrospectively reviewed the VA-ECMO implanted at our institution before the introduction of the levosimendan protocol. These patients received only traditional inotropes. The weaning rate was 83.33% in group A and 27.3% in group B. The survival rate was 66.66% and 36.4%, respectively. In group A, three of six patients (50%) required inotropic/vasopressor support after ECMO cessation, while in group B 11 of 11 patients (100%) required support. In our case series, pretreatment with levosimendan seems to facilitate weaning from VA-ECMO, reducing the need for high-dose inotropes.

[Single cardiac metastasis from colorectal cancer: an unusual localization]. / Singola metastasi cardiaca da adenocarcinoma intestinale: una rara localizzazione.

Metastasis to the heart from malignancy is a frequent but underestimated event. Tumors that are located in the mediastinum, such as pleural mesothelioma, are more frequently associated with cardiac colonization. Few reports have described metastasis from colon adenocarcinoma, which usually colonizes liver and lungs. Moreover, intracardiac localization is more common for primary cardiac neoplasms than for metastasis. We present an unusual case of a patient operated for colon adenocarcinoma who exhibited a single intracardiac secondary localization. Although the mass was huge, the patient was completely asymptomatic. Strict oncologic follow-up facilitates an early identification of the lesion, which could then be promptly resected.

[Case report of a patient on extracorporeal memebrane oyxgenation for cardiogenic shock not suitable for weaning in a peripheral center. Just a "problem" or is it feasible a treatment before patient transfer to a Hub center?]. / Paziente in ossigenazione extracorporea a membrana per shock cardiogeno non svezzabile in un centro periferico. Solo un "problema" o è possibile un trattamento prima del trasferimento ad un centro Hub?

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is the treatment of choice for cardiogenic shock unresponsive to inotropes or intra-aortic balloon pumping. It provides a temporary mechanical circulatory support and blood oxygenation allowing time for cardiac recovery. If this is not the case, the patient may become suitable for heart transplantation or left ventricular assist device (LVAD) implantation and must be transferred to a referral center. In this setting, patient transport is asscociated with high risk and it is also difficult from a logistic point of view. We describe a relatively simple method to switch the assistance from VA ECMO to LVAD. Through a left minithoracotomy an apical cannula is inserted into the left ventricle and then connected to the venous return of ECMO. The progressive clamping of ECMO venous cannula transforms the circuit from VA ECMO to a LVAD. In fact, if the switching procedure is succesfully accomplished, the left ventricle is drained, and thus unloaded, through the apical cannula while the blood to systemic circulation is provided from the femoral artery cannula. In this final setting, the oxygenator can be removed and the patient extubated, allowing an easier and less hazardous transfer to a heart transplantation center.

[Rare endocarditis due to Abiotrophia defectiva. Case report and literature review]. / Rara endocardite da Abiotrophia defectiva. Presentazione di un caso e revisione della letteratura.

Endocarditis by Abiotrophia defectiva is rare but associated with high rates of complications and mortality. The microbiological identification is challenging. Two cases without preexisting valvulopathy and one case with mitral-aortic involvement are described in the literature. A case of this subacute form of endocarditis, with normal mitral and aortic valves, is reported. Surgery was necessary, and mitral repair and aortic homograft implantation were performed with good 3-month results. In case of subacute endocarditis, especially when etiology is difficult to detect, Abiotrophia defectiva should be suspected.

Postinfarction septal dissection and rupture evolved as an inferobasal pseudoaneurysm: a specific anatomical pattern.

In rare cases of posterior myocardial infarction, septal rupture is the consequence of a dissecting interventricular hematoma that evolves as a fibrotic septal chamber with two separate communications, towards left and right ventricle. This unusual anatomical pattern is generally unsuspected and described as a normal interventricular defect associated with a basal left ventricular aneurysm or pseudoaneurysm. We present a case where echocardiography and ventricular angiography did not detect this situation. As surgical implications are important, this peculiar anatomical pattern should be suspected especially in patients with asymptomatic postinfarction posterior septal rupture or in those with minimal clinical impairment.

Is lower limb venous drainage during peripheral extracorporeal membrane oxygenation necessary?

Extracorporeal membrane oxygenation (ECMO) is becoming a gold standard in acute heart failure, not responsive to inotrops and intra-aortic balloon contrapulsation. This diffusion is due to the possibility to implant it through peripheral cannulation and to perform long-time assistance. Nevertheless, this technique implies some problems concerning inferior limb perfusion. It is widely accepted that arterial distal cannulation and perfusion of the limb is mandatory, especially for long periods of assistance; but the necessity to implant a distal venous drainage is still discussed. We would like to present our experience on peripheral ECMO where we could avoid venous distal drainage uneventfully.