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The meta-analysis by He et al. has the worth to cover, as much as possible, a gap of scientific evidence were conducting a randomized trial appears very complex for ethical and logistical reasons. The authors concluded that mitral valve repair (MVP) provides better-pooled results, both early and late, with respect to mitral valve replacement. However, the superiority of MVP is driven by some single large cohort studies where surgeons had wide experience in the field of MVP for infective endocarditis. This finding is also confirmed by other studies. But if mitral repair produces such a better short- and long-term survival than replacement, why are there no clear indications from consensus and guidelines pushing surgeons toward the pursuit of a reconstructive procedure at almost any cost? We wonder to repair or not to repair, is that really the question? The AATS consensus suggests repairing "whenever possible" but without providing more specific indications. If the two primary goals of surgery are total removal of infected tissues and reconstruction of cardiac morphology, including repair or replacement of the affected valve(s), probably MVP should be performed in case of less extensive tissue detriment by the infection. In more wide valve involvement, MVP may be the choice but only in very expert hands and in Centers with a very large volumes of valve repairing. This decision cannot, therefore, be the result of the choice of an individual but must derive from a careful multidisciplinary discussion to be held in an EndoTeam.
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Endocarditis Bacteriana , Endocarditis , Implantación de Prótesis de Válvulas Cardíacas , Endocarditis/cirugía , Endocarditis Bacteriana/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Válvula Mitral/cirugía , Resultado del TratamientoRESUMEN
Mitral valve regurgitation (MR) is a common valvular disorder occurring in up to 10% of the general population. Mitral valve reconstructive strategies may address any of the components, annulus, leaflets, and chords, involved in the valvular competence. The classical repair technique involves the resection of the prolapsing tissue. Chordal replacement was introduced already in the '60, but in the mid '80, some surgeons started to use expanded polytetrafluoroethylene (ePTFE) Gore-Tex sutures. In the last years, artificial chords have been used also using transcatheter approach such as NeoChord DS 1000 (Neochord) and Harpoon TSD-5. The first step is to achieve a good exposure of the papillary muscles that before approaching the implant of the artificial chords. Then, the chords are attached to the papillary muscle, with or without the use of supportive pledgets. The techniques to correctly implant artificial chords are many and might vary considerably from one center to another, but they can be summarized into three big families of suturing techniques: single, running or loop. Regardless of how to anchor to the mitral leaflet, the real challenge that many surgeons have taken on, giving rise to some very creative solutions, has been to establish an adequate length of the chords. It can be established based on anatomically healthy chords, but it is important to bear in mind that surgeons work on the mitral valve when the heart is arrested in diastole, so this length could fail to replicate the required length in the full, beating heart. Hence, some surgeons suggested techniques to overcome this problem. Herein, we aimed to describe the current use of artificial chords in real-world surgery, summarizing all the tips and tricks.
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Procedimientos Quirúrgicos Cardíacos , Insuficiencia de la Válvula Mitral , Humanos , Válvula Mitral/cirugía , Cuerdas Tendinosas/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Prótesis e Implantes , Politetrafluoroetileno , Resultado del TratamientoRESUMEN
OBJECTIVE: To analyze Italian Cardiac Surgery experience during the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) identifying risk factors for overall mortality according to coronavirus disease 2019 (COVID-19) status. METHODS: From February 20 to May 31, 2020, 1354 consecutive adult patients underwent cardiac surgery at 22 Italian Centers; 589 (43.5%), patients came from the red zone. Based on COVID-19 status, 1306 (96.5%) were negative to SARS-CoV-2 (COVID-N), and 48 (3.5%) were positive to SARS-CoV-2 (COVID-P); among the COVID-P 11 (22.9%) and 37 (77.1%) become positive, before and after surgery, respectively. Surgical procedures were as follows: 396 (29.2%) isolated coronary artery bypass grafting (CABG), 714 (52.7%) isolated non-CABG procedures, 207 (15.3%) two associate procedures, and three or more procedures in 37 (2.7%). Heart failure was significantly predominant in group COVID-N (10.4% vs. 2.5%, p = .01). RESULTS: Overall in-hospital mortality was 1.6% (22 cases), being significantly higher in COVID-P group (10 cases, 20.8% vs. 12, 0.9%, p < .001). Multivariable analysis identified COVID-P condition as a predictor of in-hospital mortality together with emergency status. In the COVID-P subgroup, the multivariable analysis identified increasing age and low oxygen saturation at admission as risk factors for in-hospital mortality. CONCLUSION: As expected, SARS-CoV-2 infection, either before or soon after cardiac surgery significantly increases in-hospital mortality. Moreover, among COVID-19-positive patients, older age and poor oxygenation upon admission seem to be associated with worse outcomes.
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COVID-19 , SARS-CoV-2 , Adulto , Anciano , Puente de Arteria Coronaria , Humanos , PronósticoRESUMEN
OBJECTIVES: T1 mapping (T1-map) and cardiac magnetic resonance feature tracking (CMR-FT) techniques have been introduced for the early detection of interstitial myocardial fibrosis and deformation abnormalities. We sought to demonstrate that T1-map and CMR-FT may identify the presence of subclinical myocardial structural changes in patients with mitral valve prolapse (MVP). METHODS: Consecutive MVP patients with moderate-to-severe mitral regurgitation and comparative matched healthy subjects were prospectively enrolled and underwent CMR-FT analysis to calculate 2D global and segmental circumferential (CS) and radial strain (RS) and T1-map to determine global and segmental native T1 (nT1) values. RESULTS: Seventy-three MVP patients (mean age, 57 ± 13 years old; male, 76%; regurgitant volume, 57 ± 21 mL) and 42 matched control subjects (mean age, 56 ± 18 years; male, 74%) were included. MVP patients showed a lower global CS (- 16.3 ± 3.4% vs. - 17.8 ± 1.9%, p = 0.020) and longer global nT1 (1124.9 ± 97.7 ms vs. 1007.4 ± 26.1 ms, p < 0.001) as compared to controls. Moreover, MVP patients showed lower RS and CS in basal (21.6 ± 12.3% vs. 27.6 ± 8.9%, p = 0.008, and - 13.0 ± 6.7% vs. - 14.9 ± 4.1%, p = 0.013) and mid-inferolateral (20.6 ± 10.7% vs. 28.4 ± 8.7%, p < 0.001, and - 12.8 ± 6.3% vs. - 16.5 ± 4.0%, p < 0.001) walls as compared to other myocardial segments. Similarly, MVP patients showed longer nT1 values in basal (1080 ± 68 ms vs. 1043 ± 43 ms, p < 0.001) and mid-inferolateral (1080 ± 77 ms vs. 1034 ± 37 ms, p < 0.001) walls as compared to other myocardial segments. Of note, nT1 values were significantly correlated with CS (r, 0.36; p < 0.001) and RS (r, 0.37; p < 0.001) but not with regurgitant volume. CONCLUSIONS: T1-map and CMR-FT identify subclinical left ventricle tissue changes in patients with MVP. Further studies are required to correlate these subclinical tissue changes with the outcome. KEY POINTS: ⢠T1 mapping (T1-map) and cardiac magnetic resonance feature tracking (CMR-FT) techniques have been introduced for the early detection of interstitial myocardial fibrosis and deformation abnormalities. ⢠In MVP patients, we demonstrated a longer global nT1 with associated reduced global circumferential (CS) and radial strain (RS) as compared to control subjects. ⢠Among MVP patients, the mid-basal left ventricle inferolateral wall showed longer nT1 with reduced CS and RS as compared to other myocardial segments. Further studies are required to correlate these subclinical tissue changes with the outcome.
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Prolapso de la Válvula Mitral , Adulto , Anciano , Corazón , Humanos , Imagen por Resonancia Cinemagnética , Espectroscopía de Resonancia Magnética , Masculino , Persona de Mediana Edad , Prolapso de la Válvula Mitral/diagnóstico por imagen , Miocardio , Valor Predictivo de las PruebasRESUMEN
It is well known that the left internal mammary artery (LIMA) should be the first conduit of choice. Similarly, especially in patients younger than 70 years, other conduits should be search among arterial grafts, such as right internal mammary artery (RIMA) or radial artery (RA). If the RA can be harvested in the meanwhile of LIMA harvesting without time consuming, it is well established that former one has to be grafted only on presence of a good run-off. One of the main criticisms moved to the use of RIMA are linked to technical difficulties in its harvesting it.
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Arterias Mamarias , Mama , Humanos , Anastomosis Interna Mamario-Coronaria , Arteria RadialRESUMEN
OBJECTIVE: For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches to establish the possible gold standard. METHODS: A systematic search was performed to identify all publications reporting the outcomes of four approaches for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis. RESULTS: There were 31 included studies with 9663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA, and 6.4% RRA; early TR moderate-or-more was 9.6%, 4.8%, 4.6%, and 3.8%; late mortality was 22.5%, 18.2%, 11.9%, and 11.9%; late TR moderate-or-more was 27.9%, 18.3%, 14.3%, and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (-85% vs. no TA; -64% vs. SA; -32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches; however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes. CONCLUSIONS: Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provide more stable FTR across time.
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Anuloplastia de la Válvula Cardíaca , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Tricúspide , Teorema de Bayes , Humanos , Metaanálisis en Red , Resultado del Tratamiento , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
Aims: Thoracic aortic aneurysm (TAA) that progress to acute aortic dissection is often fatal and there is no pharmacological treatment that can reduce TAA progression. We aim to evaluate statins' effects on TAA growth rate and outcomes using a meta-analysis approach. Methods and results: A detailed search related to the effects of statins on TAA was conducted according to PRISMA guidelines. The analyses of statins' effects on TAA growth rate were performed on 4 studies (n = 1850), while the impact on outcomes was evaluated on 3 studies (n = 2,867). Patients under statin treatment showed a reduced TAA growth rate (difference in means = -0.36 cm/year; 95%CI: -0.64, -0.08; p = 0.013) when compared to controls, patients not taking statins. Regarding the outcomes (death, dissection, or rupture of the aorta, and the need for operative repair), statins exhibited a protective effect reducing the number of events (log odds ratio = -0.56; 95%CI: -1.06, -0.05; p = 0.030). In vitro, the anti-fibrotic effect of atorvastatin was tested on vascular smooth muscle cells (VMSC) isolated from patients with TAA. Our results highlighted that, in transforming growth factor beta 1 (TGF-ß1) pro-fibrotic condition, VSMC expressed a significant lower amount of collagen type I alpha 1 chain (COL1A1) when treated with atorvastatin (untreated = +2.66 ± 0.23 fold-change vs. treated = +1.63 ± 0.09 fold-change; p = 0.014). Conclusion: Statins show a protective effect on TAA growth rate and adverse outcomes in patients with TAA, possibly via their anti-fibrotic properties on VSMC. Given the current lack of effective drug treatments for TAA, we believe our findings highlight the need for more in-depth research to explore the potential benefits of statins in this context.
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In recent years the tricuspid is no longer considered the "forgotten valve," but nowadays, specialists focused the treatment of tricuspid regurgitation (TR) especially at the time of left heart valve (LHV) surgery, overlooking the emerging entity of isolated TR. Its incidence appears to be rising along with the higher prevalence of atrial fibrillation (AF), intracardiac devices and intravenous drug users. Hence, the aim of the present review is to summarize the available evidences in terms of natural history, clinical presentation and treatment of isolated TR. Tricuspid regurgitation is commonly classified into primary and secondary etiology. Primary or organic TR is relatively uncommon (10%) and may be due to either acquired or congenital diseases. Conversely, secondary or functional TR, caused by dilatation and flattening of the tricuspid annulus along with increase of leaflet tethering due to the remodeling of the right ventricle (RV) has become in last decade an emerging entity. Secondary TR may be due grade progression after left heart valve surgery, to previous TV surgery failure, RV remodeling or permanent AF. Primary TR causes pure volume overload on initially normal right-sided cardiac chambers. Conversely, RV enlargement is the major finding of secondary TR; RV systolic area, RV spherical index and right atrial area were identiï¬ed as independent factors correlated with TV tethering height. The RV has less muscle mass than the left ventricle, and RV systolic function is therefore more load sensitive. Thus, pulmonary hypertension results in an early fall in RV ejection fraction and associated RV enlargement. An interesting entity is isolated TR related to AF, whose prevalence is estimated to be 14% in recent studies. It is known to cause dilation of the mitral and tricuspid annulus, together with changes in the dynamic mechanisms that govern the variation in area size during the cardiac cycle; as a matter of fact the relative change in TA area was significantly lower in AF (13.5%) than in sinus rhythm (SR) (33.1%). In isolated TR, medical therapy (MT) is indicated only in patients with secondary TR having also severe RV/LV dysfunction or severe pulmonary hypertension. Diuretics are the main MT in case of isolated TR in the presence of right HF in carefully selected candidates, surgery can be performed safely with good long-term survival and it should be considered early at first stages. In the treatment of isolated TR we had two diametrically opposed approaches so far, such as medical therapy, based almost exclusively on diuretics, and surgical therapy. In this scenario, trans-catheter approach is gaining momentum, including repair or replacement treatment. The former sees the use of devices for direct or indirect annuloplasty, or leaflet approximation. The second consists of orthotopic or heterotopic replacement devices (transcatheter tricuspid valve replacement devices). Evidences from randomized studies and longer follow-up will help clarify the best patient selection and treatment strategies.
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We report the case of a 28-year-old Caucasian patient symptomatic for low-threshold angina. Coronary angiography ruled out significant coronary stenosis. He was diagnosed with familial hypercholesterolemia and severe aortic stenosis in a setting of bicuspid valve disease. Preoperative evaluation showed diffuse atheromatous disease and severe calcification of the ascending aorta. The patient was treated by endarterectomy of the ascending aorta, non-coronary sinus enlargement patch and aortic valve replacement. This case report emphasizes the role of aortic valve disease in patients with familial hypercholesterolemia and highlights the complexity of surgical management of this condition.
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Estenosis de la Válvula Aórtica , Enfermedad de la Válvula Aórtica Bicúspide , Calcinosis , Hipercolesterolemia , Hiperlipoproteinemia Tipo II , Masculino , Humanos , Adulto , Enfermedad de la Válvula Aórtica Bicúspide/complicaciones , Hipercolesterolemia/complicaciones , Aorta Torácica , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Calcinosis/complicaciones , Calcinosis/diagnóstico por imagen , Hiperlipoproteinemia Tipo II/complicacionesRESUMEN
BACKGROUND: Thoracic aortic aneurysm (TAA) is a serious condition that affects the aorta, characterized by the dilation of its first segment. The causes of TAA (e.g., age, hypertension, genetic syndromes) are heterogeneous and contribute to the weakening of the aortic wall. This complexity makes treating this life-threatening aortopathy challenging, as there are currently no etiological therapy available, and pharmacological strategies, aimed at avoiding surgical aortic replacement, are merely palliative. Recent studies on novel therapies for TAA have focused on identifying biological targets and etiological mechanisms of the disease by using advanced -omics techniques, including epigenomics, transcriptomics, proteomics, and metabolomics approaches. METHODS: This review presents the latest findings from -omics approaches and underscores the importance of integrating multi-omics data to gain more comprehensive understanding of TAA. RESULTS: Literature suggests that the alterations in TAA mediators frequently involve members of pro-fibrotic process (i.e., TGF-ß signaling pathways) or proteins associated with cell/extracellular structures (e.g., aggrecans). Further analyses often reported the importance in TAA of processes as inflammation (PCR, CD3, leukotriene compounds), oxidative stress (chromatin OXPHOS, fatty acids), mitochondrial respiration and glycolysis/gluconeogenesis (e.g., PPARs and HIF1a). Of note, more recent metabolomics studies added novel molecular markers to the list of TAA-specific detrimental mediators (proteoglycans). CONCLUSION: It is increasingly clear that integrating data from different -omics branches, along with clinical data, is essential as well as complicated both to reveal hidden relevant information and to address complex diseases such as TAA. Importantly, recent progresses in metabolomics highlighted novel potential and unprecedented marks in TAA diagnosis and therapy.
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Differential outcomes between men and women following the treatment of coronary artery disease are currently under investigation. An increasing amount of evidence supports the concept that the differential anatomical features, functional characteristics, and risk factors between the two sexes should be considered in decision making for the therapeutic strategy to adopt in patients with coronary artery disease. Most risk scores have been developed based on predominantly male populations and might not work well for predicting cardiovascular risk in women. Moreover, there are currently no specific recommendations for a differential diagnostic work-up or treatment based on sex. We review and discuss the latest evidence on the outcomes of men and women undergoing treatment of coronary artery disease by means of percutaneous or surgical revascularization.
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Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Humanos , Masculino , Femenino , Enfermedad de la Arteria Coronaria/cirugía , Puente de Arteria Coronaria , Factores Sexuales , Intervención Coronaria Percutánea/efectos adversos , Factores de Riesgo , Resultado del TratamientoRESUMEN
We would like to thank Lin Chen et al. [...].
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The impact of the coronavirus disease-2019 (COVID-19) pandemic forced the governments worldwide to deal with an unprecedented health crisis. The aim of this review is to summarize what happened to cardiac surgery worldwide during the first wave of this pandemic. A literature search was performed to extrapolate key concepts regarding guidelines and reorganization of cardiac surgery wards during COVID-19. Supporting literature was also included to discuss the hot topics related to COVID-19 and cardiac surgery. Hence, both official documents from national scientific societies and single- or multiple-center experiences during the pandemics are reviewed and discussed. In Italy, the first western country hit by the pandemic, two different models were proposed to cope with the need for ICU/ward beds and to reallocate cardiac surgical services: Hub-and-Spoke system ('Hubs', dedicated to perform urgent and nondeferrable surgery, and 'Spokes', turned into COVID centers) and/or a progressive reduction in surgical activity. Worldwide, several guidelines/consensus statements were published, suggesting how to deal with the outbreak. Two different approaches for stratifying surgical indications were proposed: dynamic, based on the number of hospitalized COVID-19 patients; static, based only on the severity of the cardiovascular disease. Moreover, the importance of personal protective equipment was stressed. Several measures should have been adopted to deal with an unprecedented need for healthcare resources allocation to care for COVID-19 patients, putting the healthcare systems under serious stress. Cardiac surgery has, as have most surgical activities, been asked to reduce its own activity, giving priority to emergency and nondeferrable cases.
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COVID-19 , Procedimientos Quirúrgicos Cardíacos , Cirugía Torácica/organización & administración , HumanosRESUMEN
Redo surgeries are becoming more common because of an increased rate of bioprosthesis implantation. We performed a retrospective study on patients who underwent redo replacement of an aortic and/or mitral bioprosthesis between 2005 and 2018 to evaluate intra-hospital mortality and morbidity. Univariate analysis was performed on the propensity score variables to determine predictors of mortality. A total of 180 patients were enrolled in the study: Group A (replacement of aortic bioprosthesis) with 136 patients (75.56%) and group B (replacement of mitral bioprosthesis ± aortic bioprosthesis) with 44 patients (24.44%). NYHA class ≥ 3 and female sex were significantly more common in group B. Cardiopulmonary-bypass time and aortic cross-clamping time in group A and group B were, respectively, 154.95 ± 74.35 and 190.25 ± 77.44 (p = 0.0005) and 115.99 ± 53.54 and 144.91 ± 52.53 (p = 0.0004). Overall mortality was 8.89%. After propensity score adjustment, Group B was confirmed to have an increased risk of death (OR 3.32 CI 95% 1.02−10.88 p < 0.0001), gastrointestinal complications (OR 7.784 CI 95% 1.005−60.282 p < 0.0002) and pulmonary complications (OR 2.381 CI 95% 1.038−5.46 p < 0.0001). At the univariate analysis, endocarditis, cardiopulmonary-bypass and aortic cross clamping time, NYHA class ≥ 3 and urgency setting were significantly associated to death. Intra-hospital outcomes were acceptable regarding mortality and complications. Patients who need redo surgery on mitral bioprosthesis have an increased risk of post-operative pulmonary and gastrointestinal complications and mortality. Therefore the choice of mitral bioprosthesis at time of first surgery should be carefully evaluated.
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AIMS: To compare early and late mortality of acute isolated tricuspid valve infective endocarditis (TVIE) treated with valve repair or replacement. METHODS: Patients who were surgically treated for TVIE from 1983 to 2018 were retrieved from the Italian Registry for Surgical Treatment of Valve and Prosthesis Infective Endocarditis. All the patients were followed up by means of phone interview or calling patient referral physicians or cardiologists. Kaplan-Meier method was used to assess late survival and survival free from TVIE recurrence with log-rank test for univariate comparison. The primary end points were early mortality (30âdays after surgery) and long-term survival free from TVIE recurrence. RESULTS: A total of 4084 patients were included in the registry. Among them, 149 patients were included in the study. Overall, 77 (51.7%) underwent TV repair and 72 (48.3%) TV replacement. Early mortality was 9% (13 patients). Expected early mortality according to EndoSCORE was 12%. The TV repair showed lower mortality and major complication rate (7% and 16%), compared with TV replacement (11% and 25%), but statistical significance was not reached. Median follow-up was 19.1âyears (14.3-23.8). Late deaths were 30 and IE recurrences were 5. No difference in cardiac survival free from IE was found between the two groups after 20âyears (80â±â6% Repair Group vs 59â±â13% Replacement Group, P = 0.3). CONCLUSIONS: Overall results indicate that once surgically addressed, TVIE has a low recurrence rate and excellent survival, apparently regardless of the type of surgery used to treat it.
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Procedimientos Quirúrgicos Cardíacos , Endocarditis Bacteriana , Endocarditis , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Endocarditis/cirugía , Endocarditis Bacteriana/cirugía , Humanos , Resultado del Tratamiento , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugíaRESUMEN
The Commando procedure is challenging, and aims to replace the mitral valve, the aortic valve and the aortic mitral curtain, when the latter is severely affected by pathological processes (such as infective endocarditis or massive calcification). Given the high complexity, it is seldomly performed. We aim to review the literature on early (hospitalization and up to 30 days) and long-term (at least 3 years of follow-up) results. Bibliographical research was performed on PubMed and Cochrane with a dedicated string. Papers regarding double valve replacement or repair in the context of aortic mitral curtain disease were included. The metaprop function was used to assess early survival and complications (pacemaker implantation, stroke and bleeding). Nine papers (540 patients, median follow-up 41 (IQR 24.5-51.5) months) were included in the study. Pooled proportion of early mortality, stroke, pacemaker implant and REDO for bleeding were, respectively 16.2%, 7.8%, 25.1% and 13.1%. The long-term survival rate ranged from 50% to 92.2%. Freedom from re-intervention was as high as 90.9% when the endocarditis was not the first etiology and 78.6% in case of valvular infection (one author had 100%). Freedom from IE recurrences reached 85% at 10 years. Despite the high mortality, the rates of re-intervention and infective endocarditis recurrences following the Commando procedure are satisfactory and confirm the need for an aggressive strategy to improve long-term outcomes.
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OBJECTIVES: The best treatment for rheumatic mitral regurgitation is still under debate. Our goal was to assess the long-term results of mitral repair for rheumatic mitral regurgitation performed in 2 referral centres for mitral repair. METHODS: Patients who underwent mitral valve repair between 1999 and 2009 were selected. Preoperative and postoperative data were prospectively entered into a dedicated database and retrospectively reviewed. Kaplan-Meier estimates were used to analyse long-term survival. Competing risk analysis was performed by calculating the cumulative incidence function for time to recurrence of mitral regurgitation ≥3+, mitral regurgitation ≥2+, mitral reoperation and the combined end point of repair failure (mitral regurgitation ≥ 3+ and/or mean gradient ≥ 10 mmHg and/or mitral valve REDO) with death as a competing risk. RESULTS: A total of 72 patients were included. Mitral calcifications were present in 25 patients (34.7%). Most of the patients (65/72, 90.3%) underwent annuloplasty, and mixes of reparative techniques were used in 21 patients (29.2%). In-hospital mortality was 2.8%. Mean follow-up was 11.6 ± 5.16 (max 19.1 years), 98.6% completed. Survival at 14 years was 70 ± 6.27%. At 14 years, the cumulative incidence function of repair failure was 36.7 ± 6.52%. The presence of severe mitral annulus calcification was an independent predictor of repair failure. CONCLUSIONS: Mitral repair for rheumatic mitral regurgitation is characterized by a high rate of failure in the long term (14 years), particularly in patients with severe annular calcifications. These results call for a very selective approach when considering a repair strategy in this setting, especially in case of unfavourable anatomical conditions.
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Implantación de Prótesis de Válvulas Cardíacas , Anuloplastia de la Válvula Mitral , Insuficiencia de la Válvula Mitral , Cardiopatía Reumática , Estudios de Seguimiento , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Anuloplastia de la Válvula Mitral/efectos adversos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/cirugía , Reoperación , Estudios Retrospectivos , Cardiopatía Reumática/complicaciones , Cardiopatía Reumática/diagnóstico por imagen , Cardiopatía Reumática/cirugía , Resultado del TratamientoRESUMEN
Observational evidence shows that the use of multiple arterial grafts (MAG) is associated with longer postoperative survival and improved clinical outcomes. The current European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines on myocardial revascularization recommend the use of MAG in appropriate patients. However, a significant volume-to-outcome relationship exists for MAG, and lack of sufficient experience is associated with increased operative risk. A stepwise approach to building experience with MAG allows successful implementation of this technique into routine coronary surgery practice.
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Enfermedad de la Arteria Coronaria , Arterias Mamarias , Arterias , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Revascularización Miocárdica , Arteria Radial , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Type A aortic dissection (AAD) is a life-threatening disease with very high mortality. The gold standard treatment is surgical, as medical treatment has been proven to be ineffective. It is still unclear the role of preoperative neurological dysfunction in the prognosis of the patient. Therefore, the choice of performing surgery in patients with neurological symptoms is still left to the surgeon at the time of the diagnosis. The aim of this study is to make a narrative review of the current literature about the management of patients with neurological symptoms in AAD patients. EVIDENCE ACQUISITION: A bibliographical research was performed on PubMed, looking for papers containing the words: "((preoperative neurological symptoms in type a aortic dissection) OR brain injury type A aortic dissection) AND ("2010"[Date - Publication]: "3000"[Date - Publication])". A total of 35 papers were found. EVIDENCE SYNTHESIS: A total of 6 papers were chosen to be reviewed. All of them concluded that even patients with severe neurological symptoms (up to comatose state) had a good chance to recover neurological functions after surgery if treated in the first hours from the onset of symptoms. Interestingly, a hemorrhagic stroke was rarely found. CONCLUSIONS: Preoperative neurological dysfunction have been long considered a contraindication to surgery. Nevertheless, several authors show neurological and survival good results in patients with preoperative neurological dysfunction. They also stress the importance of surgical timing finding in 5 to 10 hours the surgical time limit to improve neurological dysfunction. A preoperative neurological dysfunction could be considered a strong advice towards surgical intervention. It is time to change and consider prompt surgery not only for survival but also for cerebral protection.
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Aneurisma de la Aorta , Disección Aórtica , Sistema Nervioso/fisiopatología , Disección Aórtica/complicaciones , Aneurisma de la Aorta/complicaciones , Humanos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: During the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) pandemic, Northern Italy had to completely reorganize its hospital activity. In Lombardy, the hub-and-spoke system was introduced to guarantee emergency and urgent cardiovascular surgery, whereas most hospitals were dedicated to patients with coronavirus disease 2019 (COVID-19). The aim of this study was to analyse the results of the hub-and-spoke organization system. METHODS: Centro Cardiologico Monzino (Monzino) became one of the four hubs for cardiovascular surgery, with a total of eight spokes. SARS-CoV-2 screening became mandatory for all patients. New flow charts were designed to allow separated pathways based on infection status. A reorganization of spaces guaranteed COVID-19-free and COVID-19-dedicated areas. Patients were also classified into groups according to their pathological and clinical status: emergency, urgent and non-deferrable (ND). RESULTS: A total of 70 patients were referred to the Monzino hub-and-spoke network. We performed 41 operations, 28 (68.3%) of which were emergency/urgent and 13 of which were ND. The screening allowed the identification of COVID-19 (three patients, 7.3%) and non-COVID-19 patients (38 patients, 92.7%). The newly designed and shared protocols guaranteed that the cardiac patients would be divided into emergency, urgent and ND groups. The involvement of the telematic management heart team allowed constant updates and clinical discussions. CONCLUSIONS: The hub-and-spoke organization system efficiently safeguards access to heart and vascular surgical services for patients who require ND, urgent and emergency treatment. Further reorganization will be needed at the end of this pandemic when elective cases will again be scheduled, with a daily increase in the number of operations.