Fungal Endocarditis Due to Aspergillus oryzae: The First Case Reported in the Literature.

Infective endocarditis (IE) is a severe disease with high mortality and morbidity. Prosthetic valve endocarditis is a life-threatening complication which can occur in less than 10% of patients with valve prosthesis. A fungal etiology of IE is rare and accounts for only 2-4% of all case of endocarditis, but is associated with a higher mortality and morbidity. Herein is reported the first case of fungal endocarditis of aortic valve prosthesis due to Aspergillus oryzae in a 67-year-old caucasian man who nine years previously underwent mitral and aortic valve replacement with mechanical prostheses, and tricuspid annuloplasty for acute IE due to Enterococcus spp. Seven months previously, the patient also underwent a redo cardiac procedure to replace a mitral valve prosthesis with a new mechanical device due to a leakage. Aspergillus oryzae showed impressive growth with strong and unexpected virulence in both local and systemic settings.

Growth properties of cardiac stem cells are a novel biomarker of patients' outcome after coronary bypass surgery.

BACKGROUND: The efficacy of bypass surgery in patients with ischemic cardiomyopathy is not easily predictable; preoperative clinical conditions may be similar, but the outcome may differ significantly. We hypothesized that the growth reserve of cardiac stem cells (CSCs) and circulating cytokines promoting CSC activation are critical determinants of ventricular remodeling in this patient population. METHODS AND RESULTS: To document the growth kinetics of CSCs, population-doubling time, telomere length, telomerase activity, and insulin-like growth factor-1 receptor expression were measured in CSCs isolated from 38 patients undergoing bypass surgery. Additionally, the blood levels of insulin-like growth factor-1, hepatocyte growth factor, and vascular endothelial growth factor were evaluated. The variables of CSC growth were expressed as a function of the changes in wall thickness, chamber diameter and volume, ventricular mass-to-chamber volume ratio, and ejection fraction, before and 12 months after surgery. A high correlation was found between indices of CSC function and cardiac anatomy. Negative ventricular remodeling was not observed if CSCs retained a significant growth reserve. The high concentration of insulin-like growth factor-1 systemically pointed to the insulin-like growth factor-1-insulin-like growth factor-1 receptor system as a major player in the adaptive response of the myocardium. hepatocyte growth factor, a mediator of CSC migration, was also high in these patients preoperatively, as was vascular endothelial growth factor, possibly reflecting the vascular growth needed before bypass surgery. Conversely, a decline in CSC growth was coupled with wall thinning, chamber dilation, and depressed ejection fraction. CONCLUSIONS: The telomere-telomerase axis, population-doubling time, and insulin-like growth factor-1 receptor expression in CSCs, together with a high circulating level of insulin-like growth factor-1, represent a novel biomarker able to predict the evolution of ischemic cardiomyopathy following revascularization.

Restricted T-Cell Repertoire in the Epicardial Adipose Tissue of Non-ST Segment Elevation Myocardial Infarction Patients.

Aims: Human epicardial adipose tissue, a dynamic source of multiple bioactive factors, holds a close functional and anatomic relationship with the epicardial coronary arteries and communicates with the coronary artery wall through paracrine and vasocrine secretions. We explored the hypothesis that T-cell recruitment into epicardial adipose tissue (EAT) in patients with non-ST segment elevation myocardial infarction (NSTEMI) could be part of a specific antigen-driven response implicated in acute coronary syndrome onset and progression. Methods and Results: We enrolled 32 NSTEMI patients and 34 chronic coronary syndrome (CCS) patients undergoing coronary artery bypass grafting (CABG) and 12 mitral valve disease (MVD) patients undergoing surgery. We performed EAT proteome profiling on pooled specimens from three NSTEMI and three CCS patients. We performed T-cell receptor (TCR) spectratyping and CDR3 sequencing in EAT and peripheral blood mononuclear cells of 29 NSTEMI, 31 CCS, and 12 MVD patients. We then used computational modeling studies to predict interactions of the TCR beta chain variable region (TRBV) and explore sequence alignments. The EAT proteome profiling displayed a higher content of pro-inflammatory molecules (CD31, CHI3L1, CRP, EMPRINN, ENG, IL-17, IL-33, MMP-9, MPO, NGAL, RBP-4, RETN, VDB) in NSTEMI as compared to CCS (P < 0.0001). CDR3-beta spectratyping showed a TRBV21 enrichment in EAT of NSTEMI (12/29 patients; 41%) as compared with CCS (1/31 patients; 3%) and MVD (none) (ANOVA for trend P < 0.001). Of note, 11/12 (92%) NSTEMI patients with TRBV21 perturbation were at their first manifestation of ACS. Four patients with the first event shared a distinctive TRBV21-CDR3 sequence of 178 bp length and 2/4 were carriers of the human leukocyte antigen (HLA)-A*03:01 allele. A 3D analysis predicted the most likely epitope able to bind HLA-A3*01 and interact with the TRBV21-CDR3 sequence of 178 bp length, while the alignment results were consistent with microbial DNA sequences. Conclusions: Our study revealed a unique immune signature of the epicardial adipose tissue, which led to a 3D modeling of the TCRBV/peptide/HLA-A3 complex, in acute coronary syndrome patients at their first event, paving the way for epitope-driven therapeutic strategies.

Assessment of the position of retrograde cardioplegia catheter: comparison of hemodynamic versus manual evaluation in a prospective randomized trial.

OBJECTIVE: To evaluate a hemodynamic method for the assessment of the position of the retrograde cardioplegia catheter (RCC) versus conventional Manual Assessment. METHODS: We randomized 200 patients undergoing aortic valve surgery to Manual (n = 101) or Hemodynamic Assessment (n = 99). In the Hemodynamic group a 25% pressure increase at the tip of the RCC when a fistula with the ascending aorta was created via a luer-lock was considered indicative of correct RCC placement. Transesophageal echocardiography was used as a comparison evaluation method. RESULTS: The Hemodynamic and Manual Assessment considered the RCC positioning successful in 89.9% versus 85.1% of cases. Echocardiography confirmed these results in Hemodynamic group but revealed 23 cases of misrecognized incorrect placement in the Manual group (p < 0.0001). Manual maneuvers resulted in 18 cases of secondary displacement and 19 cases of hemodynamic instability (p < 0.0001). CONCLUSIONS: The Hemodynamic Method is quantitative, reproducible, highly reliable, and safer than palpation in the posterior atrioventricular groove.

Systematic bilateral internal mammary artery grafting: lessons learned from the CATHolic University EXtensive BIMA Grafting Study.

OBJECTIVES: Despite claims of feasibility, to date no study has examined the effect of systematic bilateral internal mammary artery (BIMA) use in a large cohort of real-world unselected patients. The CATHolic University EXtensive BIMA Grafting Study (CATHEXIS) registry was designed to assess the feasibility and safety of systematic BIMA grafting. METHODS: The CATHEXIS was a single-centre, prospective, observational, propensity-matched study. The study was supposed to include 2 arms of 500 patients each: a prospective arm and a retrospective arm. The prospective arm included almost all patients referred for coronary artery bypass grafting (CABG) at our institution after the start of the CATHEXIS with very few exceptions. BIMA would have been used in all these patients. The retrospective arm included patients submitted to CABG before the start of the CATHEXIS and propensity matched to the prospective group (average BIMA use 50%; the radial artery was extensively used). Safety analyses were scheduled after enrolment of 200, 300 and 400 BIMA patients. RESULTS: After the first 226 patients, the BIMA use percentage was 88.5% (200 of 226). In 178 (89%) patients, mammary arteries were used as Y graft. Postoperative mortality was 2%, and incidence of perioperative myocardial infarction, graft failure and sternal complications were 3.5%, 3% and 5.5%, respectively. No perioperative stroke occurred. The incidence of major adverse cardiac events (particularly graft failure and sternal complications) in the BIMA arm were significantly higher than those in the propensity-matched cohort; the study was stopped for safety. CONCLUSIONS: In a real world setting the systematic use of BIMA was associated with a higher incidence of perioperative adverse events (particularly sternal complications). Individualization of the revascularization strategy and use of alternative arterial conduits are probably preferable to systematic use of BIMA.

Myocardial apoptosis predicts postoperative course after aortic valve replacement in patients with severe left ventricular hypertrophy.

BACKGROUND AND AIM OF THE STUDY: Myocardial apoptosis has been implicated in heart failure and post-infarct remodeling. In some patients with severe aortic stenosis, delayed valvular replacement is associated with a poor in-hospital outcome. The study aim was to evaluate the impact of cardiomyocyte apoptosis on the postoperative course after aortic valve replacement (AVR) for severe aortic stenosis. METHODS: During elective AVR, myocardial biopsies were obtained from the left ventricle of 11 patients with severe left ventricular hypertrophy (LVH), and the samples analyzed for apoptosis. RESULTS: The mean apoptotic rate was 10.4 +/- 3.7 per thousand. (range: 5-16 per thousand). The apoptotic rate correlated directly with preoperative NYHA functional class, duration of intensive care unit (ICU) stay, number of days of postoperative acute renal insufficiency, and serum level of troponin T at 24 h; the apoptotic rate correlated inversely with cardiac index at 24 h postoperatively. At multivariate analysis, the apoptotic rate and left ventricular mass index were independent predictors of prolonged ICU stay. The apoptotic rate and duration of cardiopulmonary bypass were predictive of the duration of postoperative acute renal insufficiency. CONCLUSION: The study results showed an association between myocardial apoptosis and postoperative outcome in patients with severe LVH submitted for AVR. Non-invasive correlates of apoptosis may be introduced as a means of identifying patients at a higher operative risk, and may help in the evaluation of asymptomatic patients with severe aortic stenosis. Anti-apoptotic strategies before and during surgery would possibly ameliorate the surgical results.

Prosthetic valve endocarditis: predictors of early outcome of surgical therapy. A multicentric study.

OBJECTIVES: Prosthetic valve endocarditis (PVE) is an uncommon yet dreadful complication in patients with prosthetic valves that requires a distinct analysis from native valve endocarditis. The present study aims to investigate independent risk factors for early surgical outcomes in patients with PVE. METHODS: A retrospective cohort study was conducted in 8 Italian Cardiac Surgery Units from January 2000 to December 2013 by enrolling all PVE patients undergoing surgical treatment. RESULTS: A total of 209 consecutive patients were included in the study. During the study period, the global rate of surgical procedures for PVE among all operations for isolated or associated valvular disease was 0.45%. Despite its rarity this percentage increased significantly during the second time frame (2007-2013) in comparison with the previous one (2000-2006): 0.58% vs 0.31% (P < 0.001). Intraoperative and in-hospital mortality rates were 4.3% and 21.5%, respectively. Logistic regression analysis identified the following factors associated with in-hospital mortality: female gender [odds ratio (OR) = 4.62; P < 0.001], shock status (OR = 3.29; P = 0.02), previous surgical procedures within 3 months from the treatment (OR = 3.57; P = 0.009), multivalvular involvement (OR = 8.04; P = 0.003), abscess (OR = 2.48; P = 0.03) and urgent surgery (OR = 6.63; P < 0.001). CONCLUSIONS: Despite its rarity, PVE showed a significant increase over time. Up to now, in-hospital mortality after surgical treatment still remains high (>20%). Critical clinical presentation and extension of anatomical lesions are strong preoperative predictors for poor early outcome.

Epicardial adipose tissue microbial colonization and inflammasome activation in acute coronary syndrome.

BACKGROUND: Epicardial adipose tissue (EAT) has a close functional and anatomic relationship with epicardial coronary arteries. Accumulating evidence suggests that host microbiome alterations may play a role in several inflammatory/immune disorders, triggering a robust proinflammatory response also involving interleukin-1ß (IL-1ß) and the NALP3 inflammasome. In the current study, we explore the hypothesis that in patients with non-ST elevation acute coronary syndrome (ACS), EAT contains potentially pro-atherosclerotic bacteria that might elicit inflammasome activation. METHODS: EAT samples were obtained during coronary artery bypass grafting from ACS (n=18) and effort stable angina (SA; n=16) patients, and as controls, from patients with angiographically normal coronary arteries undergoing surgery for mitral insufficiency (MVD; n=13). In all patients, NALP3 and proIL-1ß mRNA expressions were evaluated with qRT-PCR. In 3 patients from each group, EAT microbiota composition was determined using next-generation sequencing technologies. RESULTS: In EAT, mRNA expression of both NALP3 and pro-IL1ß was significantly higher in ACS than in SA and MVD (P=0.028 and P=0.005, respectively). A broad range of bacterial species (n=76) was identified in both ACS and SA, with different predominant species. In contrast, microbial DNA was barely observed in MVD. CONCLUSIONS: Our study demonstrated the presence of bacterial DNA directly into EAT, surrounding diseased coronary arteries, of patients with ACS. Furthermore, ACS is associated with NALP3/inflammasome pathway activation in EAT. Our data suggest that the EAT environment is susceptible to microbial colonization that might stimulate a proinflammatory response. These findings add new elements to the pathogenesis of ACS and suggest novel therapeutic targets.

Ten-year Echo-Doppler evaluation of forearm circulation following radial artery removal for coronary artery bypass grafting.

OBJECTIVE: To investigate the chronic consequences of radial artery removal for coronary artery bypass surgery on the forearm circulation. METHODS: Thirty-nine patients submitted to radial artery removal for coronary artery bypass were submitted to serial Echo-Doppler evaluation of the flow and morphology of the forearm arteries until 10 years follow-up. RESULTS: The peak systolic velocity of the ulnar artery of the operated side was significantly higher than the control site. The intima-media thickness of the ulnar artery was always significantly higher on the operated side, and this difference reached statistical significance at 10 years follow-up. There was a significantly higher prevalence of atherosclerotic plaques in the ulnar artery (UA) of the operated versus control arm (11/39 vs 0/39; p=0.005). CONCLUSIONS: Radial artery removal for coronary artery bypass surgery leads to a chronic increase in ulnar flow accompanied by increased intima-media thickness and accelerated atherosclerotic disease. These findings may have potentially important implications for surgical indications and patients management.

Radial Artery as a Coronary Artery Bypass Conduit: 20-Year Results.

BACKGROUND: There is a lack of evidence for the choice of the second conduit in coronary surgery. The radial artery (RA) is a possible option, but few data on very-long-term outcomes exist. OBJECTIVES: This study describes 20-year results of RA grafts used for coronary artery bypass grafting and the effects of RA removal on forearm circulation. METHODS: We report the results of the prospective 20-year follow-up of the first 100 consecutive patients who received the RA as a coronary bypass conduit at our institution. RESULTS: Follow-up was 100% complete. There were 64 deaths, 23 (35.9%) from cardiovascular causes. Kaplan-Meier 20-year survival was 31%. Of the 36 survivors, 33 (91.6%) underwent RA graft control at a mean of 19.0 ± 2.5 years after surgery. The RA was found to be patent in 24 cases (84.8% patency). In the overall population, probability of graft failure at 20 years was 19.0 ± 0.2% for the left internal thoracic artery (ITA), 25.0 ± 0.2% for the RA, and 55.0 ± 0.2% for the saphenous vein (p = 0.002 for RA vs. saphenous vein, 0.11 for RA vs. ITA, and p < 0.001 for ITA vs. saphenous vein). Target vessel stenosis >90%, but not location of distal anastomosis, significantly influenced long-term RA graft patency. No patients reported hand or forearm symptoms. The ulnar artery diameter was increased in the operated arm (2.44 ± 0.43 mm vs. 2.01 ± 0.47 mm; p < 0.05) and correlated with the peak systolic velocity of the second palmar digital artery (Pearson coefficient: 0.621; p < 0.05). CONCLUSIONS: The 20-year patency rate of RA grafts is good, and not inferior to the ITA, especially when the conduit is used to graft a vessel with >90% stenosis. RA harvesting does not lead to hand or forearm symptoms, even at a very-long-term follow-up.

Long-term results of the radial artery used for myocardial revascularization.

BACKGROUND: No information is available on the long-term results of radial artery (RA) grafts used as coronary artery bypass conduits. METHODS AND RESULTS: In this report, we describe the long-term (105+/-9 months) angiographic results of a series of 90 consecutive patients in whom the RA was used as a coronary artery bypass conduit directly anastomosed to the ascending aorta. The long-term patency and perfect patency rates of the RA were 91.6% and 88%, respectively, versus 97.5% and 96.3% for internal thoracic artery grafts. The severity of stenosis of the target vessel clearly influenced long-term RA patency, whereas location of the target vessel and long-term use of calcium channel blockers did not influence angiographic results. Preserved endothelial function and absence of flow-limiting, fibrous, intimal hyperplasia were also documented. CONCLUSIONS: Ten years after surgery, RA grafts have excellent patency and perfect patency rates. Appropriate surgical technique and correct indication are the key factors for long-term RA patency.

Risks of using internal thoracic artery grafts in patients in chronic hemodialysis via upper extremity arteriovenous fistula.

BACKGROUND: In patients in chronic hemodialysis via upper extremity arteriovenous fistula in whom ipsilateral internal thoracic artery graft was used for myocardial revascularization, hemodynamic interference between the fistula and the graft during dialysis can be hypothesized. METHODS AND RESULTS: In 5 patients undergoing chronic hemodialysis via upper extremity arteriovenous fistula, ipsilateral to an internal thoracic to left anterior descending graft mammary flow was studied by means of transthoracic echo-color Doppler at baseline and during hemodialysis. Flow in the contralateral mammary artery was used as control. Transthoracic echocardiography was performed in concomitance with flow evaluation to assess eventual modifications of left ventricular segmental wall motion. Immediately after hemodialysis pump start there was a marked reduction of peak systolic and end-diastolic velocities and time average mean velocity and flow in the ITA ipsilateral to the fistula, whereas no substantial hemodynamic modification was evident in the contralateral artery. Dialysis-induced reduction of ipsilateral ITA flow was accompanied by evidence of hypokinesia of the anterior left ventricular wall. Three cases also experienced clinical angina. CONCLUSIONS: Hemodynamically evident flow steal and consequent myocardial ischemia develop during hemodialysis in patients with upper extremity arteriovenous fistula and ipsilateral internal thoracic artery to coronary graft. These data have major implications for patients' management, both for nephrologists and cardiac surgeons.

Is postoperative calcium channel blocker therapy needed in patients with radial artery grafts?

BACKGROUND: Chronic calcium channel blocker therapy has traditionally been considered necessary in patients carrying a radial artery graft, even in the absence of objective data to support it. This report was conceived to evaluate the angiographic and clinical effects of calcium channel blocker therapy during the first postoperative year. PATIENTS AND RESULTS: A total of 100 consecutive patients who received a radial artery graft at our institution were randomly assigned to receive (n = 53) or not receive (n = 47) calcium channel blocker therapy with oral diltiazem 120 mg/daily started in the early postoperative period. At 1-year follow-up, all patients were reassessed clinically and by Tl 201 myocardial scintigraphy, and 83 of them underwent control angiography. In 12 cases we also evaluated the response of the radial artery to the endovascular infusion of serotonin. No difference in terms of clinical outcome, scintigraphic results, and patency rate was found between patients who received or did not receive calcium channel blocker therapy. Endovascular serotonin infusion evoked an evident spastic reaction of radial artery grafts, not attenuated by calcium channel blocker therapy. CONCLUSION: Calcium channel blocker therapy started immediately after surgery and continued for the first postoperative year does not affect radial artery graft patency and clinical and scintigraphic outcomes. On the basis of these data, the prophylactic use of calcium channel blocker therapy in patients with radial artery grafts seems unsubstantiated.

Late reoperations after acute aortic dissection repair: Single-center experience.

BACKGROUND: After repair of acute type A aortic dissection, aortic complications can develop, and reoperations might be necessary. In our retrospective study, we wanted to assess early and late outcomes in this cohort of patients. METHODS: From September 2005 to July 2012, 21 consecutive patients previously operated on for acute type A aortic dissection underwent 27 redo aortic surgical procedures. Indications for redo procedures were: enlargement of the false lumen in the residual aorta (18 events), severe aortic regurgitation with or without aortic root dilatation (8 events), suture dehiscence and pseudoaneurysm at the proximal or distal aortic graft anastomosis (5 events) or at the coronary button anastomosis in patients who previously underwent a Bentall procedure (1 patient). In all cases, total or partial cardiopulmonary bypass was used. Hypothermic cardiocirculatory arrest was needed in 22 (81%) procedures. RESULTS: Hospital mortality was 3.7% (1/27), reexploration for bleeding and paraplegia rates were 7.4% and 7.4%, respectively. Marfan patients received 3.2 procedures per patient vs. 1.5 in non-Marfan patients (p < 0.01). At a mean follow-up of 6.5 years, 2 aortic events occurred: 1 aortic death, and 1 additional aortic redo surgery. CONCLUSIONS: When procedures are carried out on elective basis, redo aortic surgery can be performed in all segments of the aorta with good early and late outcomes. Close lifelong clinical and radiological follow-up is mandatory. After repair of acute type A aortic dissection, Marfan patients are more prone to develop late complications, with a more rapid evolution.

Composite Y internal thoracic artery-saphenous vein grafts: short-term angiographic results and vasoreactive profile.

BACKGROUND: The angiographic patency of composite Y internal thoracic artery-saphenous vein grafts has not been investigated in detail. METHODS: Twenty-five patients who received composite Y internal thoracic artery-saphenous vein grafts had control angiography and vasoactive challenges with serotonin, acetylcholine, and isosorbide dinitrate at a mean of 2.5 +/- 1.2 years after surgery. RESULTS: The perfect patency rate of composite Y internal thoracic artery-saphenous vein grafts was 72% (18/25). The distal portion of the internal thoracic artery was stringed in 4 patients and occluded in 2. The saphenous branch of the composite Y internal thoracic artery-saphenous vein grafts was found patent in all patients except 1. No failures were reported in the proximal tract of the internal thoracic artery. The distal tract of the internal thoracic artery showed reduced capacity of endothelium-mediated relaxation. CONCLUSION: The short-term patency of composite Y internal thoracic artery-saphenous vein grafts is suboptimal and markedly influenced by distal runoff and native flow competition.

Effect of surgical revascularization of a right coronary artery tributary of an infarcted nonischemic territory on the outcome of patients with three-vessel disease: a prospective randomized trial.

BACKGROUND: We evaluated the in-hospital and long-term effects of surgical grafting of a dominant graftable right coronary artery tributary of an infarcted nonischemic territory in patients with triple-vessel disease who were undergoing coronary artery bypass grafting. METHODS: Of 303 consecutive patients undergoing coronary artery bypass grafting with 3-vessel coronary disease and a dominant right coronary artery tributary of an infarcted nonischemic territory, 154 were randomized to right coronary artery revascularization and 149 to no right coronary artery grafting. In all cases, standard on-pump surgical myocardial revascularization was performed. RESULTS: Overall hospital mortality was 2 of 154 versus 1 of 149 (P =.97); no difference in in-hospital outcome was observed between the 2 groups. At follow-up, cardiac event-free survival was 84 of 152 in the right coronary artery grafting series and 62 of 148 in the non-right coronary artery grafting group (P =.20). However, when the analysis was limited to surviving patients without new scintigraphic evidence of ischemia (to avoid confounding factors derived from ischemia in the left coronary system or right coronary artery graft malfunction), we found that patients who received a right coronary artery graft had fewer cardiac events, a lower incidence of arrhythmia, and less left ventricular dilatation than did the non-right coronary artery revascularized series. CONCLUSIONS: Surgical grafting of a right coronary artery tributary of an infarcted nonischemic territory in patients with 3-vessel coronary artery disease submitted to coronary artery bypass grafting improved late electric stability, ventricular geometry, and event-free survival but did not affect in-hospital or 10-year survival.

Early and late arrhythmias in patients in preoperative sinus rhythm submitted to mitral valve surgery through the superior septal approach.

BACKGROUND: It has been hypothesized that the use of the superior septal approach to the mitral valve can lead to postoperative loss of sinus rhythm. This study was undertaken to evaluate the early and mid-term alterations of the cardiac rhythm in patients with preoperative sinus rhythm (SR) submitted to mitral valve surgery through the superior septal approach. METHODS: Seventy-five cases in preoperative SR submitted to primary isolated mitral valve surgery through the superior septal approach constitute the study population. All patients underwent 12-lead electrocardiography on admission, every day after surgery until discharge and every year during the follow-up period. RESULTS: On admission in the intensive care unit, 46 cases maintained their preoperative rhythm, whereas 18 developed a junctional rhythm (JR) and 7 had a first- or second-degree atrio-ventricular block (AVB). Four cases arrived in the unit in atrial fibrillation (AF). On the first postoperative day, these proportions were substantially unchanged, with the only exception being a slight increase in the number of patients in AF. The day before discharge, only 35 of the 74 surviving cases maintained the preoperative SR, whereas 13 developed AF, 10 were in JR, and 16 were in AVB. During the follow-up period (mean, 26 +/- 14 months), the majority of cases (47/74) regained SR; 11 patients had AVB, 3 were in JR, and the remaining 13 were in AF. CONCLUSIONS: The use of the superior septal approach for mitral valve procedures in patients in preoperative SR is associated with minor, transient cardiac rhythm disturbances.

High risk coronary artery bypass patient: incidence, surgical strategies, and results.

BACKGROUND: To describe our experience in the treatment of high risk coronary artery bypass patients and compare patients assigned to on-pump or off-pump surgery. METHODS: During a 42-month period 306 high risk (Euroscore > 5) coronary artery bypass patients were consecutively treated at our institution. On the basis of the coronary anatomy and possibility of achieving a complete revascularization, 197 patients were assigned to off-pump and 109 to on-pump operation. Overall mortality was 6.2% (19 of 306 patients). RESULTS: Although patients treated off-pump had a better cardiac status, no clinical advantages related to the avoidance of cardiopulmonary bypass were found in the overall population. Off-pump patients had more early and late cardiac complications, whereas patients operated on-pump exhibited an higher incidence of postoperative systemic organ dysfunction. Off-pump surgery improved in-hospital outcome only in the subset of patients at highest risk. CONCLUSIONS: Avoidance of cardiopulmonary bypass does not confer significant clinical advantages in all high risk coronary patients; instead, there are particular subsets of patients in whom beating heart surgery can be particularly indicated and others for whom on-pump revascularization appears a better solution. Adaptation of the operation to the single patient is probably the way to improve outcome.