'Goal-directed extracorporeal circulation: transferring the knowledge and experience from daily cardiac surgery to extracorporeal membrane oxygenation'.

Metabolism management plays an essential role in extracorporeal technologies. There are different metabolic management devices integrated to extracorporeal devices; the most commonly used and accepted metabolic target in adult patients is indexed oxygen delivery (280 mL/min/m2) and cardiac index (2.4 L/min/m2), which can be managed independently or according to other metabolic parameters. Extracorporeal membrane oxygenation (ECMO) is a temporary form of life support providing a prolonged biventricular circulatory and pulmonary support for patients experiencing both pulmonary and cardiac failure unresponsive to conventional therapy. The goal-directed perfusion initiative during cardiopulmonary bypass (CPB) reduced the incidence of acute kidney injury after cardiac surgery. On the basis of the available literature, the identified goals to achieve during CPB include maintenance of oxygen delivery > 300 mL O2/min/m2 and reduction in vasopressor use. ECMO and CPB are conceptually similar but differ in many aspects and finality; in particular, they differ in the scientific evidence for metabolic management nadirs. As for CPB, predictive target parameters have been found and consolidated, particularly in terms of acute renal injury and the prevention of anaerobic metabolism, while for ECMO management, a blurred path remains. In this context, we review the strategies for optimal goal-directed therapy during CPB and ECMO, trying to transfer the knowledge and experience from daily cardiac surgery to veno-arterial ECMO.

Gaseous Micro-Embolic Activity and Goal-Directed Perfusion Management in a Closed System for Cardiopulmonary Bypass and Minimally Invasive Extracorporeal Circulation during Coronary Artery Bypass Grafting.

BACKGROUND: Cardiopulmonary bypass (CPB) techniques are becoming minimally invasive in clinical practice. The literature describes various extracorporeal techniques which seek to eliminate air-blood contact and reduce both hemodilution and the contact surface such as in Minimally invasive Extracorporeal Circulation (MiECC) and closed systems for CPB. However, the delivery of micro-embolic activity in the circuit and metabolic activity in terms of oxygen delivery for Goal-Directed Perfusion (GDP) management, in relation to the patient's blood volume and central venous pressure, have never been related and correlated. In this report, we present a cohort study that investigated these aspects between the closed SVR2000 System and modular MiECC (both from Eurosets SRL, Medolla, Italy). MATERIALS AND METHODS: Data were collected retrospectively and used to compare 60 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) surgery by two surgeons using an SVR2000 oxygenator in 30 procedures, with a matched cohort of patients from the same period who underwent isolated CABG surgery by two other surgeons using a modular MiECC in 30 procedures. The primary endpoints collected were data on micro-embolic activity, including the number of gaseous micro-emboli in the circuit during the procedure, the mean maintenance value of oxygen delivery (DO2) and data relating to venous return volume and central venous pressure (CVP). RESULTS: During the CPB procedures, the following values were recorded for the closed SVR2000 and MiECC groups, respectively: the average number of gaseous micro-emboli (GME) in the venous line, 833 ± 23 vs 1221 ± 45 (p = 0.028); GME in the outlet of the pump, 375 ± 45 vs 429 ± 76 (p = 0.89; GME in the arterial line, 189 ± 36 vs 205 ± 27 (p = 0.92), and the volume of GME in the arterial line (mL), 0.32± 12 vs 0.49± 17 (p = 0.93). The mean Indexed Oxygen Delivery (DO2i) during cross-clamp (ml/min/m2) was 319 ±12 vs 278 ±9 (p = 0.0019), respectively. The maximum mean volume of venous return in the soft-shell venous reservoir (ml) was 1801 ±128 vs 824 ±192 (p = 0.038). The mean central venous pressure (CVP) during cross-clamp (mmHg) was 0 ± 2 vs 6 ± 2 (p = 0.019). CONCLUSIONS: In this study, the results in the closed SVR2000 group were not statistically inferior to those in the modular MiECC group in terms of gaseous micro-embolic activity during CPB. Our analysis showed an important reduction of GME delivery in both systems. The closed SVR2000 group showed better management for GDP in terms of DO2i, associated with the flexibility of dynamic volume management and the absence of cavitation and regulation of the rate per minute and pump flow, which were reported in the MiECC group. The SVR2000 and modular MiECC systems were both safe and effective in perioperative practice without iatrogenic problems.

Negative Pressure Wound Therapy: Comparison of Outpatient and Inpatient Approaches.

BACKGROUND: The results of recent studies regarding the efficacy of Negative Pressure Wound Therapy (NPWT) for the prevention of sternal wound infection (SWI) after adult cardiac surgery are not conclusive. METHODS: Data were collected from patients who were operated upon at the GVM Care & Research group in Italy from 2013 to 2021; all patients who required treatment for sternotomy wound infection with Negative Pressure Wound Therapy (NPWT) through WaterLily™ system (Eurosets, Medolla, MO, Italy) were selected. We compared the preoperative risk characteristics, and particularly those that were most strongly associated with possible dehiscence of the wound. A statistical analysis was performed for comparison of the groups. RESULTS: Out of the total 40,267 patients who underwent cardiac surgery with extracorporeal circulation within this time frame, 1,483 (3.68%) required NPWT, including 690 (46.52%) in the HOME group and 793 (53.47%) in the HOSPITAL group (p =0.76). Thirty-nine (5.65%) patients in the HOME group and 37 (4.66%) in the HOSPITAL group required re-treatment for re-dehiscence after secondary closure (p =0.79). CONCLUSIONS: The use of a WaterLily™ system (Eurosets, Medolla, MO, Italy) was safe and effective for the treatment of sternotomy wounds with superficial and deep infections and was associated with a low rate of dehiscence, even when used with discharged and managed outpatient patients.

Evaluation of (Wet) and (Dry) Mediastinal Chest Drainage in Minimally Invasive and Conventional Cardiac Surgery.

BACKGROUND: Drainage of fluid and evacuation of air from the pericardial and pleural spaces after cardiothoracic surgery is necessary to prevent effusion, tamponade, and pneumothorax, and also to detect hemorrhage. For this purpose, negative-pressure drains are placed in the mediastinum and pleural cavities. We compared the efficacy and safety of two systems wet and dry drainage for the management and monitoring of negative pressure and anti-reflux valve safety systems, to promote healing of the pleural and pericardial cavities. METHODS: Two devices for mediastinal chest drainage [Venice PAS (Wet) and Rome PAS (Dry); both Eurosets SRL, Medolla, Italy] were evaluated in terms of safety, efficacy and clinical outcomes in a cohort of 60 patients who underwent elective cardiac surgery procedures. The patients were divided into a minimally invasive cardiac surgery (MICS) group [n=30; mitral valve surgery (MVS) by right anterolateral mini-thoracotomy] and a conventional cardiac surgery (CCS) group [n=30; coronary arterial bypass grafting (CABG) in full sternotomy] at a single institution (Anthea Hospital GVM Care & Research, Bari, Italy). RESULTS: Negative pressure was managed with a target value of -20 cmH2O measured in the chest tube and was related to the device: deviation of ± 1 cmH2O for the Venice PAS (Wet) and 0 cmH2O for the Rome PAS (Dry) in the MICS group; deviation of 1 ± 0.8 cmH2O for the Venice PAS (Wet) and 0.8±0.2 cmH2O for the Rome PAS (Dry) in the CCS group. A constant volumetric air leak meter (VALM) value and the absence of air-leak bubbling were correlated with the absence of air in the pleural cavity and complete pulmonary re-expansion to restore normal respiratory dynamics in the MICS group for both models of chest drainage. The maximum total pericardial blood drained was 1104 ± 302 ml with Venice PAS (Wet) and 1530 ± 230 with Rome PAS (Dry) in the CCS group. There were no reports of cardiac tamponade in either group. CONCLUSIONS: The two mediastinal chest drainage devices [Venice PAS (Wet) and Rome PAS (Dry)] in this study were effective, accurate for measuring the applied negative pressure, and safe in their application after cardiac surgery procedures via minimally invasive and conventional approaches for blood and liquid drainage, prevention of cardiac tamponade, and restoration of normal respiratory dynamics after surgical pneumothorax. Both systems are equipped with anti-reflux valves to prevent air and blood from entering the drainage, and no adverse events were reported.

Cardiopulmonary Bypass Settings for the Prevention of Early Hypotension During CABG.

BACKGROUND: Vasoplegic syndrome is a form of vasodilatory shock that can occur before, during or after cardiopulmonary bypass (CPB). We introduce a strategy to reduce the incidence of early hypotension phenomena during Coronary Artery Bypass Graft (CABG) procedures. MATERIALS AND METHODS: In this prospective cohort study, 100 patients underwent elective CABG with two perioperative CPB settings. The study group (50 patients) was managed with retrograde autologous priming (RAP), 3-minute stepwise for the institution of CPB, and pulsatile flow (PP). The control group (50 patients) was managed without RAP, with the rapid initiation of CPB, and non-pulsatile (NP) flow. The primary endpoints were MAP (mmHg), number of hypotensive phenomena (MAP < 50 mmHg for > 30 sec), the venous return volume on CPB (ml), the cardiac index (L/min/m2), hemoglobin (g/dL), indexed oxygen delivery (DO2i, ml/min/m2), the systemic vascular resistance index (SVRI, dynes s m2/cm5), number of 1-ml boluses of a vasoactive substance (norepinephrine), the positive fluid balance (ml), and the number of red blood cell units for transfusion. RESULTS: During CPB, the mean values in the study and control groups were as follows: MAP, 68± 7 vs 56 ± 7 (p-value, 0.0019); hypotensive phenomena, 3 ± 1 vs 8 ±2 (p-value, 0.019); venous return volume, 840±79 vs 1129 ±123 (p-value, 0.0017); cardiac index, 2.4 ± 0.4 vs 2.7 ±0.2 (p-value, 0.0023); hemoglobin, 9.13 ± 0.29 vs 7.8± 0.23 (p-value, 0.0001); DO2i, 301± 12 vs 276±23 (p-value, 0.0011); SVRI, 1879 ±280 vs 2210 ±140 (p-value, 0.0017); norepinephrine, 1±2 vs 8 ±3 (p-value, 0.0023); positive fluid balance, 750 ±212 vs 1450 ±220 (p-value, 0.005); and total number of red blood cell units for transfusion, 16 ±4.2 vs 27 ± 5.3 (p-value, 0.008). CONCLUSIONS: In this prospective cohort study, during CPB, the study group showed a better preservation of MAP, SVRI, and DO2i, and a reduction of vasoconstrictor use in a CPB setting with the RAP technique, 3-minute stepwise for the initiation of CPB and pulsatile pump flow, compared to the control group. Further studies are needed to validate this perioperative approach to CPB.

Infective Endocarditis After Percutaneous Device Closure of Atrial Septal Defects: Incidence, Diagnosis, and Treatment. Case Report and Literature Review.

Infective endocarditis (IE) on atrial septal defect (ASD) closure devices, while extremely rare, has been reported to be more frequent early after the procedure. We describe a case of late IE after percutaneous closure of patent foramen ovale (PFO). We also performed a literature review on this subject. We reviewed a total of 42,365 patients who were treated with percutaneous devices: 13,916 for ostium secundum (OS) (32%), 24,726 for PFO (58%) and 3,723 for OS+PFO (8%). Among these patients, we identified 50 cases of IE after atrial septal defect device closure (0.001%). In contrast to previous reports, nearly 66% of IE in this setting occurred late, after at least 6 months from the procedure (33/50 patients). A statistical analysis clearly showed that the mean time from the procedure to IE increased in the last five years, probably associated with a change in antiplatelet therapy after ASD closure. Management of IE on an ASD occluder should always be discussed in the setting of a multidisciplinary heart team that includes a cardiologist, cardiac surgeon, and anesthetist. While surgical strategies gave excellent results, conservative management might be considered in cases of small IE vegetations and for patients in good general condition. However, in these cases, the patient must be closely observed with repeated blood and instrumental tests.

Impact of Surgeon Experience and Centre Volume on Outcome After Off-Pump Coronary Artery Bypass Surgery: Results From the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) Registry.

AIM: The aim of this study was to assess the impact of surgeon experience and centre volume on early operative outcomes in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. METHOD: Of 7,352 patients in the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry, 1,549 underwent OPCAB and were included in the present analysis. Using adjusted regression analysis, we compared major early adverse events after procedures performed by experienced OPCAB surgeons (i.e., ≥20 cases per year; n=1,201) to those performed by non-OPCAB surgeons (n=348). Furthermore, the same end points were compared between procedures performed by OPCAB surgeons in high OPCAB volume centres (off-pump technique used in >50% of cases; n=894) and low OPCAB volume centres (n=307). RESULTS: In the experienced OPCAB surgeon group, we observed shorter procedure times (ß -43.858, 95% confidence interval [CI] -53.322 to -34.393; p<0.001), a lower rate of conversion to cardiopulmonary bypass (odds ratio [OR] 0.284, 95% CI 0.147-0.551; p<0.001), a lower rate of prolonged inotrope or vasoconstrictor use (OR 0.492, 95% CI 0.371-0.653; p<0.001), a lower rate of early postprocedural percutaneous coronary interventions (OR 0.335, 95% CI 0.169-0.663; p=0.002), and lower 30-day mortality (OR 0.423, 95% CI 0.194-0.924; p=0.031). In high OPCAB volume centres, we found a lower rate of prolonged inotrope use (OR 0.584, 95% CI 0.419-0.814; p=0.002), a lower rate of postprocedural acute kidney injury (OR 0.382, 95% CI 0.198-0.738; p=0.004), shorter duration of intensive care unit (ß -1.752, 95% CI -2.240 to -1.264; p<0.001) and hospital (ß -1.967; 95% CI -2.717 to -1.216; p<0.001) stays, and lower 30-day mortality (OR 0.316, 95% CI 0.114-0.881; p=0.028). CONCLUSIONS: Surgeon experience and centre volume may play an important role on the early outcomes after OPCAB surgery.

The Evolution of Temperature Management for Cardiac Surgery: A Historical Perspective.

Intraoperative temperature regimen usually is planned preoperatively by a "team." Selecting and understanding the impact of the temperature regimen (normothermia, or mild, moderate, or severe hypothermia) usually are related to the type of cardiac surgery (eg, using circulatory arrest or open-heart surgery). Cardiopulmonary bypass constitutes a challenging situation for monitoring temperature because of the rapid and extraordinary degree of heat transferred through the bypass circuit during heating and cooling. The core compartment undergoes the fastest temperature changes because of the rapid rate of blood reinfused into the organs. In modern cardiac surgery, different types and technologies of heater-cooler devices can be used in clinical practice, thanks to the development process that took its cue from past experiences. In this context, the authors review the role of thermal exchange in cardiac surgery and the progress achieved from first-to-second-generation heater-cooler devices.

Prone Positioning in Postoperative Cardiac Surgery Patients: A Narrative Review.

Limited data are available on the use of the prone position in cardiac surgery. Concerns in performing this maneuver in open cardiac surgery due to the risk of post-sternotomy wound infections and hemodynamic instability do not seem to be supported by existing evidence. Indeed, available data show that prone positioning may improve gas exchange in cardiac surgery patients as well. However, previous studies of prone positioning in this setting were heterogeneous in patient characteristics and outcomes evaluated. As a result, whether prone positioning also may be effective in reducing mortality in patients with postoperative acute respiratory failure, particularly in those who underwent surgery under extracorporeal circulation, remains to be clearly elucidated. The aim of this article is to provide an overview of available literature, which seems to suggest the efficacy of prone positioning, and to make an in-depth analysis of the studies on this topic by evaluating the efficacy of this maneuver on hard endpoints.

Retrograde Autologous Priming for Minimally Invasive Mitral Valve Surgery.

OBJECTIVES: Little is known about the safety and clinical utility of retrograde autologous priming (RAP) in patients undergoing minimally invasive mitral valve surgery. The study authors hypothesized that RAP would increase the oxygen delivery index (DO2i) while decreasing red blood cell transfusion requirements compared to valve surgery without RAP. DESIGN: The study was an observational analysis. SETTING: A single institutional study. PARTICIPANTS: The authors analyzed data from 500 consecutive patients who underwent minimally invasive isolated mitral valve repair from December 31, 2012, to December 31, 2019. INTERVENTION: RAP was performed in 235 patients (47%) prior to the initiation of cardiopulmonary bypass (CPB). MEASUREMENT AND MAIN RESULTS: A continuous monitoring system was used for DO2 management during CPB. The mean arterial pressure was maintained between 55 and 70 mmHg, and the cardiac index was set at 2.4 L/min/m2, with adjustments in accordance with DO2i. The trigger point for red cell blood transfusion during CPB was hemoglobin <7 g/dL. Baseline hematocrit was lower in the RAP group compared to the no-RAP group (33.4 ± 3.6 v 38.1 ± 4.9, respectively; p < 0.001). Both CPB and cross-clamp times were similar between groups. Hematocrit during CPB was significantly higher in the RAP group compared to the no-RAP group (27.6 ± 2.6 v 25.9 ± 5.1, respectively; p < 0.001). RAP was also associated with significantly higher mean DO2i (292 ± 19.5 v 282.9 ± 35.1 mL/min/m2, respectively; p < 0.001) and fewer red blood cells transfusions during the intraoperative and immediate postoperative periods (p < 0.001). CONCLUSIONS: In a minimally invasive mitral valve context, RAP was safe and associated with better DO2i, higher hematocrit, and fewer intraoperative and postoperative red blood cell transfusions.

Postcardiotomy Venoarterial Extracorporeal Membrane Oxygenation With and Without Intra-Aortic Balloon Pump.

OBJECTIVES: To compare the outcomes of patients with postcardiotomy shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) only compared with VA-ECMO and intra-aortic balloon pump (IABP). DESIGN: A retrospective multicenter registry study. SETTING: At 19 cardiac surgery units. PARTICIPANTS: A total of 615 adult patients who required VA-ECMO from 2010 to 2018. The patients were divided into 2 groups depending on whether they received VA-ECMO only (ECMO only group) or VA-ECMO plus IABP (ECMO-IABP group). MEASUREMENTS AND MAIN RESULTS: The overall series mean age was 63 ± 13 years, and 33% were female. The ECMO-only group included 499 patients, and 116 patients were in the ECMO-IABP group. Urgent and/or emergent procedures were more common in the ECMO-only group. Central cannulation was performed in 47% (n = 54) in the ECMO-IABP group compared to 27% (n = 132) in the ECMO-only group. In the ECMO-IABP group, 58% (n = 67) were successfully weaned from ECMO, compared to 46% (n = 231) in the ECMO-only group (p = 0.026). However, in-hospital mortality was 63% in the ECMO-IABP group compared to 65% in the ECMO-only group (p = 0.66). Among 114 propensity score-matched pairs, ECMO-IABP group had comparable weaning rates (57% v 53%, p = 0.51) and in-hospital mortality (64% v 58%, p = 0.78). CONCLUSIONS: This multicenter study showed that adjunctive IABP did not translate into better outcomes in patients treated with VA-ECMO for postcardiotomy shock.

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

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

The influence of metabolic syndrome in heart valve intervention. A multi-centric study.

BACKGROUND: The effect of metabolic syndrome (MetS), defined as insulin resistance along with two or more of: obesity, atherogenic dyslipidaemia and elevated blood pressure, on postoperative complications after isolated heart valve intervention remains controversial. We hypothesized that MetS may negatively influence the postoperative course in these patients. METHODS: Patients from 10 cardiac units who underwent isolated valve intervention (mitral ± $\pm $ tricuspid repair/replacement (mitral valve surgery [MVS]) or surgical aortic valve replacement (SAVR), or transcatheter aortic valve replacement (TAVR) were included. MetS was defined according to the World Health Organization criteria. Primary outcome was in-hospital mortality and overall postoperative length of stay (LOS). Relevant postoperative complications were also recorded. RESULTS: From 2010 to 2019, 17,283 patients underwent valve intervention. The MVS, SVAR, and TAVR accounted for the 39.4%, 48.2%, and 12.3% respectively of the whole. MetS compared to no-MetS was associated to higher mortality in the MVS group (6.5% vs. 2%, p < .001), but not in the SAVR and TAVR group. In both surgical cohorts, MetS was associated with increased complications including red blood cells transfusion, renal failure, mechanical ventilation time, intensive care and overall postoperative LOS (11 (9) vs. 10 (6), p < .001 and 10 (6) versus 10 (5) days, p = .002, MVS and [SAVR]). No differences were found in the TAVR cohort, with similar mortality and complications. CONCLUSION: MetS was associated to more postoperative complications, with higher mortality in the MVS group. In the TAVR cohort, postoperative complications and mortality rate did not differ between patients with and without MetS, however LOS was longer in the MetS group.

A new technique to adjust the length of artificial chordae during mitral anterior leaflet repair.

BACKGROUND: Length measurement of artificial chordae remains a critical step during mitral valve repair (MVr). The aim of this study is to assess the effectiveness of a new length measuring technique. METHODS: All consecutive patients with anterior leaflet prolapse/flail who underwent MVr using the described method between January 2020 and January 2022 at our institution were included in the analysis. Clinical and transesophageal echocardiography data were collected postoperatively and at 1-year follow-up. The primary outcome was freedom from mitral regurgitation (MR). Secondary outcomes were presentation with New York Heart Association (NYHA) class <2 and leaflet coaptation length ≥10 mm. RESULTS: Of 25 patients, 16 (64%) were males. A total of 15 (60%) had isolated anterior leaflet disease, while 10 (40%) had concomitant posterior involvement. Twenty patients with isolated MR (80%) underwent right anterior mini-thoracotomy, while 5 (20%) with associated valvular or coronary disease underwent sternotomy. The median number of chordae implanted was 2 [1-4]. Postrepair intraoperative MR grade was 0 in 23 patients (92%) and 1 in 2 (8%). Thirty-day mortality was 0%. De novo atrial fibrillation was 20%. At follow-up, mortality was 0%. No patients presented with moderate or severe MR. A total of 22 patients (88%) were in NYHA class I, while 3 (12%) in class II. The coaptation length was 11 ± 1 mm. CONCLUSIONS: The short-term outcomes of the described technique are good with adequate leaflet coaptation in all treated patients. Long-term results are needed to assess the stability and durability of this repair technique.

Management algorithms and artificial intelligence systems for cardiopulmonary bypass.

This article introduces management algorithms to support operators in choosing the best strategy for metabolic management during cardiopulmonary bypass using artificial intelligence systems. We developed algorithms for the identification of the optimal way for assessing metabolic parameters. Different management algorithms for extracorporeal procedures interfaced with metabolic monitoring systems already exist on the market and are applied in clinical practice. These algorithms could provide guidance for selecting the best metabolic strategy with the aim at reducing human error and optimizing management.

Radial-Artery or Saphenous-Vein Grafts in Coronary-Artery Bypass Surgery.

BACKGROUND: The use of radial-artery grafts for coronary-artery bypass grafting (CABG) may result in better postoperative outcomes than the use of saphenous-vein grafts. However, randomized, controlled trials comparing radial-artery grafts and saphenous-vein grafts have been individually underpowered to detect differences in clinical outcomes. We performed a patient-level combined analysis of randomized, controlled trials to compare radial-artery grafts and saphenous-vein grafts for CABG. METHODS: Six trials were identified. The primary outcome was a composite of death, myocardial infarction, or repeat revascularization. The secondary outcome was graft patency on follow-up angiography. Mixed-effects Cox regression models were used to estimate the treatment effect on the outcomes. RESULTS: A total of 1036 patients were included in the analysis (534 patients with radial-artery grafts and 502 patients with saphenous-vein grafts). After a mean (±SD) follow-up time of 60±30 months, the incidence of adverse cardiac events was significantly lower in association with radial-artery grafts than with saphenous-vein grafts (hazard ratio, 0.67; 95% confidence interval [CI], 0.49 to 0.90; P=0.01). At follow-up angiography (mean follow-up, 50±30 months), the use of radial-artery grafts was also associated with a significantly lower risk of occlusion (hazard ratio, 0.44; 95% CI, 0.28 to 0.70; P<0.001). As compared with the use of saphenous-vein grafts, the use of radial-artery grafts was associated with a nominally lower incidence of myocardial infarction (hazard ratio, 0.72; 95% CI, 0.53 to 0.99; P=0.04) and a lower incidence of repeat revascularization (hazard ratio, 0.50; 95% CI, 0.40 to 0.63; P<0.001) but not a lower incidence of death from any cause (hazard ratio, 0.90; 95% CI, 0.59 to 1.41; P=0.68). CONCLUSIONS: As compared with the use of saphenous-vein grafts, the use of radial-artery grafts for CABG resulted in a lower rate of adverse cardiac events and a higher rate of patency at 5 years of follow-up. (Funded by Weill Cornell Medicine and others.).

A modified technique for aortic prosthesis implantation after prosthetic valve endocarditis complicated by complex paraannular aortic abscess.

The aim of this study is to describe a modified technique for aortic prosthesis implantation in the sinuses of Valsalva without the use of a patch for aortic annular reconstruction in patients with prosthetic valve endocarditis complicated by aortic abscess. From January 2008 to March 2021, 47 patients underwent aortic valve replacement due to prosthetic aortic valve endocarditis. The new aortic prosthesis was implanted into the sinuses of Valsalva above the abscess left open to drain. The first step consists in passing U-shaped stitches with pledgets through the aortic wall approximately 5-7 mm above the abscess involving the annulus. In the second step, the prosthesis is fixed to the aortic wall. In the third step, a 10 mm wide Teflon strip is positioned along the external course of the aortic wall and U-shaped stitches without pledgets are passed from the outside to the inside to definitively fix the prosthetic annulus to the sinuses of Valsalva. In-hospital mortality was 8.5% (4/47 patients). Mean follow-up was 62 ± 37.7 months. Four patients died (9.3%). Predicted probability of cardiac vs non-cardiac mortality was not statistically significant (p = 0.88). Overall survival probability (freedom from all-cause death) at 3, 7 and 9 years was 97%, 87.5% and 75%, respectively. No patients presented with grade 2 or 3 peri-prosthetic leak, nor had endocarditis. Prosthetic valve endocarditis complicated by complex paraannular aortic abscess can be successfully addressed with good long-term results by using our alternative technique.

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

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

Air, inflammation and biocompatibility of the extracorporeal circuits.

The inflammatory response in cardiac surgery using extracorporeal circulation (ECC) has been widely discussed in the literature with analysis on cytokines released in humans; demonstrating manifold trigger causes. To mitigate this response-mainly linked to the contact and recognition by the blood of a "non-self" surface-many efforts have been made to make the circuits of the extra-corporeal circulation "biomimetics"; trying to emulate the cardio-vascular system. In other words, biomedical companies have developed many biocompatible products in order to reduce the invasiveness of the ECC. One of the techniques used to reduce the contact of blood with "nonself" surfaces is the "coating" of the internal surfaces of the ECC. This can be done with phospholipidic, electrically neutral, and heparin derivates with anticoagulant activity. The coating can be divided into two categories: the "passive coating" with Phosphorylcholine by biomedical companies and the administration of albumin added to the "priming" during the filling of the circuit by the perfusionist. Alternatively, we have the "active" coating: treatment of the internal surfaces in contact with the blood with neutral proteins and heparin. The latter are different according to the production company, but the aim is always to maintain high levels of systemic and local anticoagulation, inactivating the "contact" coagulation between the blood and the surfaces. A recent study demonstrates that the use of an "active coating" is associated with better preservation of the endothelial glycocalyx compared with "passive coating" circuits.

Minimally Invasive Mitral Valve Repair for Standalone Secondary Mitral Regurgitation.

BACKGROUND: Chronic secondary mitral valve regurgitation is associated with a poor prognosis. Yet, in contrast to primary mitral regurgitation, there is no clear evidence that a reduction in regurgitation improves survival. The limited availability of data regarding secondary mitral regurgitation has resulted in a low level of evidence for treatment recommendations. We evaluated the influence of minimally invasive mitral valve annuloplasty on survival, freedom from recurrent regurgitation, and other echocardiographic parameters in patients with "standalone" secondary mitral valve regurgitation. METHODS: The analysis included patients with severe secondary mitral regurgitation, left ventricular function <40%, and persistent symptoms, despite optimal medical therapy. We excluded patients who were eligible for coronary artery revascularisation or cardiac resynchronisation therapy (i.e., not standalone mitral regurgitation). After discharge, patients were scheduled for outpatient clinic follow-up at 1, 3, 6, and 12 months. RESULTS: From 2012 to 2018, 54 consecutive patients underwent minimally invasive mitral valve annuloplasty for severe standalone secondary mitral regurgitation. All patients were discharged with no or trivial residual regurgitation. The mean duration of follow-up was 33.5±16.8 months. Overall survival was 90% at 4 years postprocedure. Freedom from moderate regurgitation or reintervention was 89% at the 4-year follow-up. There was a low incidence of readmission for heart failure and patients showed consistent improvements in left ventricular function and symptoms. CONCLUSIONS: Mitral valve repair with reduction and stabilisation of the annulus may be beneficial for symptomatic patients with secondary stand-alone mitral regurgitation.