Perceval valve-in-valve implant for full root xenograft failure.

Aortic root replacement with a biological conduit results in excellent hemodynamics but has limited durability. We report a series of six patients who underwent successful Perceval-S surgical aortic valve implantation following surgical deterioration of a biological valve composite conduit and discuss the technical details and the importance of appropriate valve sizing for this procedure.

Two innovative aortic bioprostheses evaluated in the real-world setting. First results from a two-center study.

BACKGROUND: The increasing use of biological substitutes for surgical aortic valve replacement (AVR), has led to the development of new bioprostheses with improved hemodynamics and expected durability. METHODS: In this observational retrospective two-center cohort study, two innovative bioprostheses, INSPIRIS Resilia and AVALUS were analyzed. We analyzed early and 2.4-year follow-up results in terms of safety, clinical outcome and hemodynamic performance. RESULTS: From November 2017 to February 2021, 148 patients underwent AVR with INSPIRIS Resilia (N.=74) or AVALUS (N.=74) bioprosthesis. The 30-day and mid-term mortality was comparable (1% vs. 3%, P=0.1 and 7% vs. 4%, P=0.4, respectively). Valve-related mortality was observed in one AVALUS patient. Three (4%) patients of the AVALUS group developed prosthetic endocarditis and two of them died after reoperation. No other cases of prosthetic endocarditis were observed. No cases of structural valve degeneration or significant paravalvular leak were detected at follow-up. Median follow-up peak pressure gradient was 21 vs. 23 mmHg (P=0.4) and the mean pressure gradient was 12 vs. 13 mmHg (P=0.9) for Inspiris and AVALUS, respectively. The effective orifice area (EOA) and indexed EOA were 1.5 cm2 vs. 1.4 cm2 (P=0.4) and 0.8 vs. 0.7 cm2/m2 (P=0.5), respectively. Indexed left ventricular mass regression was -33 vs. -52 g/m2 for the Inspiris and AVALUS groups, respectively, (R2-adjusted =0.14; P<0.01). CONCLUSIONS: INSPIRIS Resilia and AVALUS bioprostheses were reliable with comparable results in safety, clinical outcome and hemodynamic performance. After statistical adjustment, AVALUS was associated with better left ventricular mass reduction. Long-term follow-up would provide definitive comparative results.

Survival and Recurrence of Endocarditis following Mechanical vs. Biological Aortic Valve Replacement for Endocarditis in Patients Aged 40 to 65 Years: Data from the INFECT-Registry.

BACKGROUND: Infective endocarditis (IE) is a serious disease, and in many cases, surgery is necessary. Whether the type of prosthesis implanted for aortic valve replacement (AVR) for IE impacts patient survival is a matter of debate. The aim of the present study is to quantify differences in long-term survival and recurrence of endocarditis AVR for IE according to prosthesis type among patients aged 40 to 65 years. METHODS: This was an analysis of the INFECT-REGISTRY. Trends in proportion to the use of mechanical prostheses versus biological ones over time were tested by applying the sieve bootstrapped t-test. Confounders were adjusted using the optimal full-matching propensity score. The difference in overall survival was compared using the Cox model, whereas the differences in recurrence of endocarditis were evaluated using the Gray test. RESULTS: Overall, 4365 patients were diagnosed and operated on for IE from 2000 to 2021. Of these, 549, aged between 40 and 65 years, underwent AVR. A total of 268 (48.8%) received mechanical prostheses, and 281 (51.2%) received biological ones. A significant trend in the reduction of implantation of mechanical vs. biological prostheses was observed during the study period (p < 0.0001). Long-term survival was significantly higher among patients receiving a mechanical prosthesis than those receiving a biological prosthesis (hazard ratio [HR] 0.546, 95% CI: 0.322-0.926, p = 0.025). Mechanical prostheses were associated with significantly less recurrent endocarditis after AVR than biological prostheses (HR 0.268, 95%CI: 0.077-0.933, p = 0.039). CONCLUSIONS: The present analysis of the INFECT-REGISTRY shows increased survival and reduced recurrence of endocarditis after a mechanical aortic valve prosthesis implant for IE in middle-aged patients.

Contemporary outcomes of cardiac surgery patients supported by the intra-aortic balloon pump.

OBJECTIVES: Although the intra-aortic balloon pump (IABP) has been the most widely adopted temporary mechanical support device in cardiac surgical patients, its use has declined. The current study aimed to evaluate the occurrence and predictors of early mortality and complication rates in contemporary cardiac surgery patients supported by an IABP. METHODS: A multicentre, retrospective analysis was performed of all consecutive cardiac surgical patients receiving perioperative balloon pump support in 8 centres between January 2010 to December 2019. The primary outcome was early mortality, and secondary outcomes were balloon-associated complications. A multivariable binary logistic regression model was applied to evaluate predictors of the primary outcome. RESULTS: The study cohort consisted of 2615 consecutive patients. The median age was 68 years [25th percentile 61, 75th percentile 75 years], with the majority being male (76.9%), and a mean calculated 30-day mortality risk of 10.0%. Early mortality was 12.7% (n = 333), due to cardiac causes (n = 266), neurological causes (=22), balloon-related causes (n = 5) and other causes (n = 40). A composite end point of all vascular complications occurred in 7.2% of patients, and leg ischaemia was observed in 1.3% of patients. The most important predictors of early mortality were peripheral vascular disease [odds ratio (OR) 1.63], postoperative dialysis requirement (OR 10.40) and vascular complications (OR 2.57). CONCLUSIONS: The use of the perioperative IABP proved to be safe and demonstrated relatively low complication rates, particularly for leg ischaemia. As such, we believe that specialists should not be held back to use this widely available treatment in high-risk cardiac surgical patients when indicated.

Cardiac Surgery in Patients With Liver Cirrhosis (CASTER) Study: Early and Long-Term Outcomes.

BACKGROUND: Patients with liver cirrhosis (LC) undergoing cardiac surgery (CS) face perioperative high mortality and morbidity, but extensive studies on this topic are lacking. METHODS: All adult patients with LC undergoing a CS procedure between 2000 and 2017 at 10 Italian Institutions were included in this retrospective cohort study. LC was classified according to preoperative Child-Turcotte-Pugh (CTP) score and Model for End-Stage Liver Disease (MELD) score. Early-term and medium-term outcomes analysis was performed in the overall population and according to CTP classes. RESULTS: The study population included 144 patients (mean age 66 ± 9 years, 69% male). Ninety-eight, 20, and 26 patients were in CTP class A, in early CTP class B (MELD score <12), or advanced CTP class B (MELD score >12), respectively. The main LC etiologies were viral (43%) and alcoholic (36%). Liver-related clinical presentation (ascites, esophageal varices, and encephalopathy) and laboratory values (estimated glomerular filtration rate, serum albumin, and bilirubin, platelet count) significantly worsened across the CTP classes (P = .001). Coronary artery bypass grafting or valve surgery (87% bioprosthesis) were performed in 36% and 50%, respectively. Postoperative complications (especially acute kidney injury, liver complication, and length of stay) significantly worsened in advanced CTP class B (P = .001). Notably, observed mortality was 3-fold or 4-fold higher than the EuroSCORE (European System for Cardiac Operative Risk Evaluation) II-predicted mortality, in the overall population, and in the subgroups. At Kaplan-Meier analysis, 1-year and 5-year cumulative survival in the overall population was 82% ± 3% and 77% ± 4%, respectively. The 5-year survival in CTP class A, early CTP class B, and advanced CTP class B was 72% ± 5%, 68% ± 11%, and 61% ± 10%, respectively (P = .238). CONCLUSIONS: CS outcomes in patients with LC are significantly affected in relation to the extent of preoperative liver dysfunction, but in early CTP classes, medium-term survival is acceptable. Further analysis are needed to better estimate the preoperative risk stratification of these patients.

Sutureless aortic valve replacement in high risk patients neutralizes expected worse hospital outcome: A clinical and economic analysis.

BACKGROUND: Aortic valve replacement (AVR) by sutureless prostheses is changing surgeon options, although which patients benefit most, as well as their possible economic impact is still to be defined. METHODS: Perceval-S prosthesis (LivaNova) is reserved, at the documented Institution, for patients at perceived high surgical risk. This retrospective analysis of outcome and resource consumption compared Perceval with other tissue valves. To clarify the comparison, only patients respecting 'instructions-for- use' of Perceval were reviewed. INCLUSION CRITERIA: > 65 years, +/- coronary artery bypass grafting, patent foramen ovale closure or myectomy. EXCLUSION CRITERIA: bicuspid, combined valve or aortic sur- gery. Costs were calculated per patient on a daily basis including preoperative tests, operating costs (hourly basis), disposables, drugs, blood components and personnel. RESULTS: The sutureless group (SU-AVR) had a higher risk profile than the sutured group (ST-AVR). Cardiopulmonary bypass (CPB) and cross-clamp times were significantly shorter in SU-AVR (isolated AVR: cross-clamp 52.9 ± 12.6 vs. 69 ± 15.3 min, p < 0.001; CPB 79.4 ± 20.3 vs. 92.7 ± 18.2 min, p < 0.001). Hospital mortality was 0.9% in SU-AVR and nil in ST-AVR, p = 0.489; intubation 7 (IQR 5-10.7) and 7 h (IQR 5-9), p = 0.785; intensive care unit 1 (IQR 1-1) and 1 day (IQR 1-1), p = 0.258; ward stay 5.5 (IQR 4-7) and 5 days (IQR 4-6), p = 0.002; pacemaker 5.7% (6/106) and 0.9% (1/109), p = 0.063, respectively. Hospital costs (excluding the prosthesis) were $12,825 (IQR 11,733-15,334) for SU-AVR and $12,386 (IQR 11,217-14,230) in ST-AVR, p = 0.055. CONCLUSIONS: Despite higher operative risks in SU-AVR, hospital mortality, morbidity and resource consumption did not differ. Operative times were shorter with the sutureless device and this improve- ment, along with more frequent ministernotomy, may have improved many postoperative aims.

Sutureless prosthesis for failed small Mitroflow valves: the Perceval-after-Mitroflow procedure.

Because of its favourable haemodynamic characteristics and easy implantability, Mitroflow aortic valve bioprosthesis has been the valve of choice for many surgeons in patients with small aortic annulus. Disappointingly, early structural valve deterioration and high transvalvular gradients have been reported mostly in older patients with small prostheses. Reimplanting a new stented prosthesis sutured in a narrow and damaged annulus is technically challenging and demanding mainly in high-risk patients. Valve-in-valve transcatheter aortic valve implantation has been proposed as a viable option; however, it presents significant limitations because of residual high transprosthetic pressure gradients and risk of coronary occlusion. We report a series of 8 patients, with medium-term follow-up, who underwent successful Perceval-S surgical sutureless aortic implant after the removal of a degenerated small Mitroflow valve. No early mortality occurred, but 1 patient died 4 months postoperatively due to gastrointestinal disease. No major complications occurred. Early and mid-term postoperative pressure gradients were low (mean gradients 13.1 ± 3.3 mmHg and 10.2 ± 3.8 mmHg, respectively). In operable patients with a degenerated Mitroflow valve, these favourable clinical and haemodynamic results suggest that the sutureless solution is a simple, valid and safer alternative to conventional redo valve replacement or to valve-in-valve transcatheter aortic valve implantation.

Mitroflow Aortic Bioprosthesis Failure in Type B Aortic Dissection: Preventive Left Main Stenting in Transapical Transcatheter Aortic Valve Implantation Strategy.

Mitroflow aortic prosthesis dysfunction in case of complex vascular disease is considered a challenging scenario. Because of the high risk for surgical reoperation and the presence of chronic aortic dissection originated from a calcified Kommerel diverticulum, we considered to perform a transapical valve-in-valve transcatheter aortic valve implantation (TAVI) procedure. Myocardial ischemia is a dreadful complication reported in valve-in-valve TAVI procedures, mainly in patients with degenerated Mitroflow aortic bioprostheses. Because of the narrow shape of Valsalva sinuses and the short distance between Mitroflow annulus and left coronary ostium, to overcome the risk of possible Mitroflow leaflets displacement during TAVI expansion thus overlapping coronary ostia, we performed a preventive angioplasty. Then, we implanted a bare metal stent on the left main protruding in the aortic root. At 3 years follow-up the patient was in good clinical conditions.

Impact of prosthesis-patient mismatch on cardiac events and midterm mortality after aortic valve replacement in patients with pure aortic stenosis.

BACKGROUND: Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of the prosthesis being implanted is too small in relation to body size, thus causing abnormally high transvalvular pressure gradients. The objective of this study was to examine the midterm impact of PPM on overall mortality and cardiac events after aortic valve replacement in patients with pure aortic stenosis. METHODS AND RESULTS: The indexed EOA (EOAi) was estimated for each type and size of prosthesis being implanted in 315 consecutive patients with pure aortic stenosis. PPM was defined as an EOAi < or =0.80 cm2/m2 and was correlated with overall mortality and cardiac events. PPM was present in 47% of patients. The 5-year overall survival and cardiac event-free survival were 82+/-3% and 75+/-4%, respectively, in patients with PPM compared with 93+/-3% and 87+/-4% in patients with no PPM (P< or =0.01). In multivariate analysis, PPM was associated with a 4.2-fold (95% CI, 1.6 to 11.3) increase in the risk of overall mortality and 3.2-fold (95% CI, 1.5 to 6.8) increase in the risk of cardiac events. The other independent risk factors were history of heart failure, NHYA class III-IV, severe left ventricular hypertrophy, and absence of normal sinus rhythm before operation. CONCLUSIONS: PPM is an independent predictor of cardiac events and midterm mortality in patients with pure aortic stenosis undergoing aortic valve replacement. As opposed to other risk factors, PPM may be avoided or its severity may be reduced with the use of a preventive strategy at the time of operation.

Time series analysis of physiologic left ventricular reconstruction in ischemic cardiomyopathy.

OBJECTIVE: The history of left ventricular reconstruction has demonstrated that the full spectrum of recoverable physiologic parameters is essential for a good functional result. We report the long-term outcome of a new surgical technique that arranges myocardial fibers in a near-normal disposition, also recovering left ventricular twisting. METHODS: Between May 2006 and October 2013, 29 consecutive patients with previous anterior myocardial infarction and heart failure symptoms underwent physiologic left ventricular reconstruction surgery and coronary revascularization. Patients were examined by means of standard echocardiography and 2-dimensional speckle tracking at 8 time steps until 7 years after surgery. Ten geometric and functional parameters were evaluated at each step and analyzed by the linear mixed model test. RESULTS: Hospital mortality was 0%. The mean percentage of indexed end-diastolic and end-systolic volume reduction was 45.7% and 50.9%, respectively. Ejection fraction and all of the volumes were significantly different in the postoperative period with a steady correction during time. Diastolic parameters were not worsened by surgical reconstruction. Ejection fraction and deceleration time showed a significant improvement during time. Left ventricular torsion increased immediately after the surgical correction from 2.8 ± 4.4 degrees to 8.7 ± 3.9 degrees (P = .02) and was still present 4 years after surgery. CONCLUSIONS: Surgical conduction of ventricular reconstruction should be standardized to achieve the full spectrum of recoverable physiologic parameters. The renewal of ventricular torsion should be pursued as an adjunctive element of ventricular efficiency, mainly in ventricles that work at a critical level in the Frank-Starling relationship and pressure-volume loop.

Determinants of postinfarction remodeling affect outcome and left ventricular geometry after surgical treatment of ischemic cardiomyopathy.

OBJECTIVE: To identify the effects of the time between myocardial infarction and surgery, the site of infarction, mitral involvement on ventricular geometry, and clinical outcome in the treatment of ischemic cardiomyopathy in patients with heart failure. METHODS: Sixty-nine consecutive patients with ischemic cardiomyopathy, indexed end-systolic volume > or =50 mL/m(2), ejection fraction < or =35%, and heart failure underwent surgery 81.9 +/- 100.8 months after myocardial infarction, using different techniques of ventricular restoration. Thirteen geometric parameters were studied pre- and postoperatively. Paired and unpaired t tests and general linear model for multivariate analysis were used to analyze subgroups. Logistic regression and Kaplan-Meier survival curves with pairwise log-rank were used to correlate covariates to clinical outcome. RESULTS: Longer time to surgery and posterior necrosis linearly correlated with higher left ventricular volumes (r(2) =.66) and diameters (r(2) =.40). High grade of mitral regurgitation was always present in posterior infarctions. Hospital mortality was 4.3%. Complicated postoperative course was predicted by mitral surgery (P =.004) and longer time to surgery (P =.04). Survival was significantly lower in the posterior infarction (P =.0002) and mitral surgery (P =.001) subgroups. At a mean follow-up of 1.9 +/- 1.3 years, functional status and geometrical restoration are influenced by the studied covariates. CONCLUSIONS: Longer time to surgery after myocardial infarction, its posterior location, and significant mitral regurgitation can affect left ventricular remodeling, surgical restoration, and clinical outcome in patients with ischemic cardiomyopathy.

Ross procedure for severe congenital aortic regurgitation in a three-month-old patient.

We here describe the case of an infant with severe aortic regurgitation due to a congenital dysplastic aortic valve. Surgical treatment (autograft replacement of the aortic valve) was carried out when the patient was 3 months old. The technical aspects and the results of instrumental examination during follow-up are discussed.

Myectomy-myotomy associated with aortic valve replacement for aortic stenosis: effects on left ventricular mass regression.

BACKGROUND: Left ventricular outflow tract dynamic obstruction may develop after aortic valve replacement for aortic stenosis with a higher mortality and morbidity and may persist until left ventricular mass regression occurs. The aim of this study was to ascertain the effects of myectomy-myotomy on the left ventricular mass and mean wall thickness regression and on left ventricular mass normalization at least 1 year postoperatively. METHODS: A total of 162 patients including 71 with myectomy-myotomy (group I) and 91 without (group II) were studied at pre- and postoperative echocardiography. RESULTS: The relative left ventricular regression, after adjustment by ANCOVA analysis, was significantly greater in group I than in group II (-24.6 +/- 14.7 and -16.8 +/- 17.8%, p = 0.004) and the absolute mean wall thickness regression was greater in group I than in group II (-1.6 +/- 1.3 vs -1.1 +/- 1.6 mm, p = 0.019). Multivariable analysis showed myectomy-myotomy as an independent predictor of left ventricular mass regression. CONCLUSIONS: Myectomy-myotomy may improve left ventricular mass regression after aortic valve replacement for pure aortic stenosis.

Off-pump coronary surgery in a single center experience: from selective to systematic use.

BACKGROUND: The feasibility of the systematic use of the off-pump technique for myocardial revascularization was investigated. METHODS: From September 1997 to June 2001, 1221 isolated coronary artery bypass grafting operations were performed consecutively: 771 (group A) were completed with cardiopulmonary bypass, and 450 (group B) without. Since July 2000 all patients were considered as potential candidates for off-pump coronary artery bypass. In group B, a specific original instrumentation was used for coronary stabilization. RESULTS: The differences in the preoperative data were: a higher age, a higher incidence of chronic obstructive pulmonary disease and a left ventricular ejection fraction < 30% in group B; a higher incidence of critical left main stenosis in group A. More grafts per patient were completed in group A (3.0 +/- 1.4 vs 2.2 +/- 0.9, p < 0.001). The hospital mortality (group A 1.0%, group B 0.7%) and the incidence of perioperative myocardial infarction (group A 2.5%, group B 1.1%) and that of cerebrovascular accidents (group A 1.4%, group B 0.9%) were comparable. Bleeding (610 +/- 370 vs 496 +/- 215 ml, p < 0.001), the transfusion rate (36 vs 19.7%, p < 0.001), the intubation time (13.4 +/- 3.5 vs 8.3 +/- 5 hours, p < 0.001), the intensive care unit stay (1.7 +/- 2.7 vs 1.2 +/- 2.1 days, p < 0.001) and the hospital stay (5.8 +/- 3 vs 5.1 +/- 3.2 days, p < 0.001) were lower in group B. At follow-up, the mortality (2.5 vs 1.1%), the rate of recurrence of angina (2.5 vs 2.0%), and those of re-angiography (4.1 vs 5.3%) and of new revascularization (1.6 vs 1.1%) were similar. The actuarial survival rates were 99.8, 98.6 and 96.3% in group A, and 98.8, 96.7 and 96.7% in group B at 1, 2 and 3 years of follow-up respectively (log rank p = 0.3387). CONCLUSIONS: The increase in the use of off-pump coronary artery bypass up to its systematic empolyment is feasible. The early and intermediate results are satisfactory.

[Off-pump myocardial revascularization in patients with multivessel coronary disease]. / Rivascolarizzazione miocardica senza circolazione extracorporea in pazienti con malattia coronarica multivasale.

BACKGROUND: Some criticisms have been addressed to off-pump coronary surgery technique concerning the possibility of its systematic use with the respect of the completeness of revascularization. We report our experience with off-pump revascularization in patients with multivessel coronary disease. METHODS: Between September 1997 and April 2003, 868 patients with multivessel coronary disease were scheduled for off-pump surgical revascularization. From September 2000, the percentage of patients operated on without cardiopulmonary bypass has been stably > 90%. Fifteen patients (1.7%) had a conversion to cardiopulmonary bypass for anatomical reasons (n = 6) or clinical instability (n = 9). RESULTS: An average of 2.5 +/- 0.8 (range 1-5) anastomoses per patient were completed. Bilateral mammary artery was used in 573 patients (66%); totally arterial revascularization was accomplished in 479 patients (55.2%). In-hospital mortality rate was 0.6% (5 patients). Total incidence of non-fatal postoperative complications (bleeding requiring re-exploration, perioperative myocardial infarction, stroke, new onset of acute renal failure) was 3.5%. Mean postoperative hospital stay was 4.8 +/- 3.8 days. At a mean follow-up of 21.6 +/- 15.6 months (range 1-65 months), the postoperative actuarial survival rates were 97.3, 93.7 and 86.7% at 1, 3 and 5 years postoperatively. Actuarial freedom rates from new revascularization were 98.7, 96.6 and 96.6% at 1, 3 and 5 years postoperatively. CONCLUSIONS: Early- and intermediate-term results of this study demonstrate the feasibility of off-pump revascularization in all patients with multivessel coronary disease, respecting the criterion of complete myocardial revascularization.

[Myocardial revascularization without extracorporeal circulation in patients with multivessel coronary disease]. / Rivascolarizzazione miocardica senza circolazione extracorporea in pazienti con malattia coronarica multivasale.

BACKGROUND: Some criticisms have been addressed to off-pump coronary surgery technique concerning the possibility of its systematic use with the respect of the completeness of revascularization. We report our experience with off-pump revascularization in patients with multivessel coronary disease. METHODS: Between September 1997 and April 2003, 868 patients with multivessel coronary disease were scheduled for off-pump surgical revascularization. From September 2000, the percentage of patients operated on without cardiopulmonary bypass has been stably > 90%. Fifteen patients (1.7%) had a conversion to cardiopulmonary bypass for anatomical reasons (n = 6) or clinical instability (n = 9). RESULTS: An average of 2.5 +/- 0.8 (range 1-5) anastomoses per patient were completed. Bilateral mammary artery was used in 573 patients (66%); totally arterial revascularization was accomplished in 479 patients (55.2%). In-hospital mortality rate was 0.6% (5 patients). Total incidence of non-fatal postoperative complications (bleeding requiring re-exploration, perioperative myocardial infarction, stroke, new onset of acute renal failure) was 3.5%. Mean postoperative hospital stay was 4.8 +/- 3.8 days. At a mean follow-up of 21.6 +/- 15.6 months (range 1-65 months), the postoperative actuarial survival rates were 97.3, 93.7 and 86.7% at 1, 3 and 5 years postoperatively. Actuarial freedom rates from new revascularization were 98.7, 96.6 and 96.6% at 1, 3 and 5 years postoperatively. CONCLUSIONS: Early- and intermediate-term results of this study demonstrate the feasibility of off-pump revascularization in all patients with multivessel coronary disease, respecting the criterion of complete myocardial revascularization.

Home-based versus in-hospital cardiac rehabilitation after cardiac surgery: a nonrandomized controlled study.

BACKGROUND: Exercise rehabilitation after cardiac surgery has beneficial effects, especially on a long-term basis. Rehabilitative programs with telemedicine plus appropriate technology might satisfy the needs of performing rehabilitation at home. OBJECTIVE: The purpose of this study was to compare exercise capacity after home-based cardiac rehabilitation (HBCR) or in-hospital rehabilitation in patients at low to medium risk for early mortality (EuroSCORE 0-5) following cardiac surgery. DESIGN: A quasi-experimental study was conducted. METHODS: At hospital discharge, patients were given the option to decide whether to enroll in the HBCR program. Clinical examinations (electrocardiography, cardiac echo color Doppler, chest radiography, blood samples) of patients in the HBCR group were collected during 4 weeks of rehabilitation, and exercise capacity (assessed using the Six-Minute Walk Test [6MWT]) was assessed before and after rehabilitation. A group of patients admitted to the in-hospital rehabilitation program was used as a comparison group. Patients in the HBCR group were supervised at home by a medical doctor and telemonitored daily by a nurse and physical therapist by video conference. Periodic home visits by health staff also were performed. RESULTS: One hundred patients were recruited into the HBCR group. An equal number of patients was selected for the comparison group. At the end of the 4-week study, the 2 groups showed improvement from their respective baseline values only in the 6MWT. No difference was found in time × group interaction. LIMITATIONS: Because patients self-selected to enroll in the HBCR program and because they were enrolled from a single clinical center, the results of the study cannot be generalized. CONCLUSIONS: In patients who self-selected HBCR, the program was found to be effective and comparable to the standard in-hospital rehabilitative approach, indicating that rehabilitation following cardiac surgery can be implemented effectively at home when coadministered with an integrated telemedicine service.

Perceval sutureless valve in freestyle root: new surgical valve-in-valve therapy.

Aortic root replacement with biological conduit (homograft, autograft, or xenograft) is a valuable tool, but biological valves are often prone to degeneration. Reoperations usually require root removal and repetition of the Bentall procedure to maintain the same orifice area. A less radical option is to limit replacement to the valve. In cases of calcified or very small roots, standard valve implantation cannot be performed, and bailout with a sutureless valve may be a particularly useful option. Here we have described a case of leaflet rupture in a calcified small Freestyle root (Medtronic Inc, Minneapolis, MN) in which we performed a valve-in-valve (V-in-V) procedure with a Perceval-S prosthesis (Sorin Group, Saluggia, Italy).