Early paravalvular leak after conventional mitral valve replacement: A single-center analysis.

INTRODUCTION: Paravalvular leak (PVL) is a well-recognized complication after mitral valve replacement (MVR). However, there are only a few studies analyzing leak occurrence and postoperative results after surgical MVR. The aim of this study was to assess the rate and determinants of early mitral PVL and to evaluate the impact on survival. METHODS: We performed a retrospective analysis involving patients who underwent MVR from January 2012 to December 2019 at our Institution. Postoperative transthoracic echocardiography evaluation was done for all subjects before hospital discharge. Multivariable analysis was carried out by constructing a logistic regression model to identify predictors for PVL occurrence. RESULTS: Four hundred ninety-four patients were enrolled. Operative mortality was 4.9%. Early mitral PVL was found in 16 patients (3.2%); the majority were mild (75%). Leaks occurred more frequently along the posterior segment of the mitral valve annulus (62.5%). Only one individual with moderate-to-severe PVL underwent reoperation during the same hospital admission. Multivariable analysis revealed that preoperative diagnosis of infective endocarditis was the only factor associated with early leak after MVR (odds ratio: 4.96; 95% confidence interval: 1.45-16.99; p = .011). Overall mortality at follow-up (mean follow-up time: 4.7 [SD: 2.5] years) was 19.6% and favored patients without early mitral PVL. CONCLUSION: The incidence of early PVL after MVR is low. PVL is usually mild and develop more frequently along the posterior segment of the mitral valve annulus. Preoperative diagnosis of infective endocarditis increases the risk of PVL formation.

Catheter ablation of atrial tachycardias after mitral valve surgery: A systematic review and meta-analysis.

INTRODUCTION: Data regarding catheter ablation (CA) of atrial tachycardias (ATs) occurring after mitral valve surgery (MVS) are scarce. The aim of this study was to assess the safety and efficacy of CA of ATs in this surgical population through a systematic review of the literature and meta-analysis. METHODS: A systematic search on PubMed/MEDLINE, EMBASE, and Web of Science was performed considering patients undergoing CA for ATs occurring after MVS. Periprocedural thromboembolic and hemorrhagic complications were assessed. The acute success and maintenance of sinus rhythm (SR) at a mid (<24 months) and long-term follow-up (FU) after CA were investigated along with the burden of arrhythmic recurrence at FU. RESULTS: Fourteen studies for a total of 227 patients were considered. Three-dimensional (3D) mapping systems were used in all studies. Only two major bleedings were recorded with a pooled estimate of periprocedural major complications of 0%. The acute success after CA was 95% with a clear improvement over time. Although maintenance of SR was 71% at a midterm FU, long-term efficacy was as low as 47% due to an increased burden of atrial fibrillation (AF) recurrence despite multiple procedures/patient. CONCLUSION: In this meta-analysis, CA of postsurgical ATs after MVS proved safe and effective but with still a significant burden of AF recurrence at more than 24 months of FU due to a progressive atrial substrate deterioration. The improvement of procedural success over time might suggest a learning curve in optimizing the use of 3D mapping systems.

Right ventricular assessment can improve prognostic value of Euroscore II.

BACKGROUND: The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery. METHODS: This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC <35%, TAPSE <17 mm, and TDI S' <9.5 mm RESULTS: Among the entire cohort, 624 (70%) showed normal RV, 92 (10%) isolated RV dilatation, 154 (17%) isolated RV dysfunction, and 25 (3%) both RV dilatation and dysfunction. Non-surviving patients showed a significantly higher rate of RV alteration at multivariable analysis, RV status was found to be an independent predictor for higher in-hospital mortality beside Euroscore II. CONCLUSIONS: This prospective multicenter observation study shows the importance to assess RV preoperatively and to include both RV function and dimension in a risk score model such as Euroscore II to implement its predictivity, since PH cannot always mirror the status of the right ventricle.

Hyperlactatemia during cardiopulmonary bypass: risk factors and impact on surgical results with a focus on the long-term outcome.

INTRODUCTION: Lactate, a product of anaerobic metabolism, is a biomarker and indicator for tissue hypoperfusion and oxygen debt. An elevated blood lactate level has been associated with poor outcome in many clinical conditions, including cardiac surgery. Nevertheless, debate exists regarding which blood lactate concentration is most indicative of poor outcomes. We evaluate the impact of hyperlactatemia, defined as a peak arterial blood concentration ⩾2.0 mmol/L during cardiopulmonary bypass, on surgical results with a focus on long-term outcome. METHODS: We reviewed 1,099 consecutive adult patients who underwent cardiac surgery on pump. The patients were divided into two groups based on the presence or not of hyperlactatemia. Pre- and intraoperative risk factors for hyperlactatemia were identified, and the postoperative outcome of patients with or without hyperlactatemia was compared. RESULTS: Hyperlactatemia was present in 372 patients (33.8%). Factors independently associated with hyperlactatemia were urgent/emergency procedure, cardiopulmonary bypass duration and aortic cross-clamp time. Patients with hyperlactatemia had significantly higher rate of prolonged mechanical ventilation time, in-hospital stay and requirement of inotropes and intra-aortic balloon pump support (p < 0.001). Operative (30-day) mortality was higher in the group of patients with hyperlactatemia (7.8% vs. 1.1%; p < 0.001). Kaplan-Meier curve showed worse long-term survival (mean follow-up: 4.02 ± 1.58 years) in patients with hyperlactatemia. CONCLUSION: Hyperlactatemia during cardiopulmonary bypass has a significant association with postoperative morbidity and mortality. Correction of risk factors for hyperlactatemia, together with prompt detection and correction of this condition, may control complications and improve outcome.

Safety and efficacy of biatrial vs left atrial surgical ablation during concomitant cardiac surgery: A meta-analysis of clinical studies with a focus on the causes of pacemaker implantation.

INTRODUCTION: The latest STS guidelines recommend concomitant atrial fibrillation (AF) ablation not only during mitral surgery (Class IA) but also during other-than-mitral cardiac surgery procedures (Class IB) in patients with preoperative AF. Conventional Cox-Maze III/IV procedures are performed on both atria (BA), but several studies reported excellent results with left atrial only (LA) ablations: the scope of this study is to compare the safety and efficacy of BA vs LA approach. METHODS AND RESULTS: Pubmed, Scopus, and WOS were searched from inception to November 2018: 28 studies including 7065 patients and comparing the performance of BA vs LA approaches were identified: of these, 16 (57.1%) enrolled exclusively patients with non-paroxysmal AF forms, 10 (35.7%) focused on mitral surgery as main procedure, and 16 (57.1%) regarded patients undergone Cox-Maze with radiofrequency. The 6- and 12-months prevalence of sinus rhythm were higher in the BA group (OR, 1.37, CI, 1.09-1.73, P = .008 and OR, 1.37, CI, 0.99-1.88, P = .05 respectively). Permanent pacemaker (PPM) implantation (OR, 1.85, CI, 1.38-2.49, P < .0001) and reopening for bleeding (OR, 1.70, CI, 1.05-2.75, P = .03) were higher in the BA group. Among patients undergone PPM implantation, BA group had a significantly higher risk of sinoatrial node dysfunction (OR, 3.01, CI, 1.49-6.07, P = .002). CONCLUSIONS: Concomitant BA ablation appears superior to LA ablation in terms of efficacy but is associated with a higher risk of bleeding and of PPM implantation, more frequently due to sinoatrial node dysfunction. LA approach should be preferable in patients with a higher risk of bleeding or with perioperative risk factors for PPM implantation.

Whole body perfusion in patients undergoing frozen elephant trunk for type A acute aortic dissections.

The Frozen Elephant Trunk (FET) can be adopted in selected type A acute aortic dissections (TAAAD). During FET, a prolonged distal circulatory arrest exposes the spine and visceral organs to potential ischemic injuries. Antegrade distal aortic perfusion (ADAP) could minimize this risk: we describe the technical aspects of the simultaneous use of antegrade cerebral perfusion (ACP) and ADAP achieving a "Whole Body Perfusion" (WBP) during FET.

Safety and efficacy of prothrombin complex concentrate as first-line treatment in bleeding after cardiac surgery.

BACKGROUND: Bleeding after cardiac surgery requiring surgical reexploration and blood component transfusion is associated with increased morbidity and mortality. Although prothrombin complex concentrate (PCC) has been used satisfactorily in bleeding disorders, studies on its efficacy and safety after cardiopulmonary bypass are limited. METHODS: Between January 2005 and December 2013, 3454 consecutive cardiac surgery patients were included in an observational study aimed at investigating the efficacy and safety of PCC as first-line coagulopathy treatment as a replacement for fresh frozen plasma (FFP). Starting in January 2012, PCC was introduced as solely first-line treatment for bleeding following cardiac surgery. RESULTS: After one-to-one propensity score-matched analysis, 225 pairs of patients receiving PCC (median dose 1500 IU) and FFP (median dose 2 U) were included. The use of PCC was associated with significantly decreased 24-h post-operative blood loss (836 ± 1226 vs. 935 ± 583 ml, p < 0.0001). Propensity score-adjusted multivariate analysis showed that PCC was associated with significantly lower risk of red blood cell (RBC) transfusions (odds ratio [OR] 0.50; 95% confidence interval [CI] 0.31-0.80), decreased amount of RBC units (ß unstandardised coefficient -1.42, 95% CI -2.06 to -0.77) and decreased risk of transfusion of more than 2 RBC units (OR 0.53, 95% CI 0.38-0.73). Patients receiving PCC had an increased risk of post-operative acute kidney injury (AKI) (OR 1.44, 95% CI 1.02-2.05) and renal replacement therapy (OR 3.35, 95% CI 1.13-9.90). Hospital mortality was unaffected by PCC (OR 1.51, 95% CI 0.84-2.72). CONCLUSIONS: In the cardiac surgery setting, the use of PCC compared with FFP was associated with decreased post-operative blood loss and RBC transfusion requirements. However, PCC administration may be associated with a higher risk of post-operative AKI.

Predictive factors of long-term survival in the octogenarian undergoing surgical aortic valve replacement: 12-year single-centre follow-up.

The improvement of life expectancy created more surgical candidates with severe symptomatic aortic stenosis and age >80. Therefore, the main objective of this observational, retrospective single-centre study is to compare the long-term survival of octogenarians that have undergone surgical aortic valve replacement (AVR) to the survival of the general population of the same age and to establish whether any perioperative characteristics can anticipate a poor long-term result, limiting the prognostic advantage of the procedure at this age. From 2000 to 2014, 264 octogenarians underwent AVR at our institution. Perioperative data were retrieved from our institutional database and patients were followed up by telephonic interviews. The follow-up ranged between 2 months and 14.9 years (mean 4.1 ± 3.1 years) and the completeness was 99.2 %. Logistic multivariate analysis and Cox regression were respectively applied to identify the risk factors of in-hospital mortality and follow-up survival. Our patient population ages ranged between 80 and 88 years. Isolated AVR (I-AVR) was performed in 136 patients (51.5 %) whereas combined AVR (C-AVR) in 128 patients (48.5 %). Elective procedures were 93.1 %. Logistic EuroSCORE was 15.4 ± 10.6. In-hospital mortality was 4.5 %. Predictive factors of in-hospital mortality were the non-elective priority of the procedure (OR 5.7, CI 1.28-25.7, p = 0.02), cardiopulmonary bypass time (OR 1.02, CI 1.01-1.03, p = 0.004) and age (OR 1.36, CI 1.01-1.84, p = 0.04). Follow-up survival at 1, 4, 8 and 12 years was 93.4 % ± 1.6 %, 72.1 % ± 3.3 %, 39.1 % ± 4.8 % and 20.1 % ± 5.7 %, respectively. The long-term survival of these patients was not statistically different from the survival of an age/gender-matched general population living in the same geographic region (p = 0.52). Predictive factors of poor long-term survival were diabetes mellitus (HR 1.55, CI 1.01-2.46, p = 0.05), preoperative creatinine >200 µmol/L (HR 2.07, CI 1.21-3.53, p = 0.007) and preoperative atrial fibrillation (HR 1.79, CI 1.14-2.80, p = 0.01). In our experience, AVR can be safely performed in octogenarians. After a successful operation, the survival of these patients returns similar to the general population. Nevertheless, the preoperative presence of major comorbidities such as diabetes mellitus, renal dysfunction and atrial fibrillation significantly impact on long-term results.

The beneficial effects of TAVI in mitral insufficiency.

BACKGROUND: Previous studies have suggested that concomitant mitral regurgitation (MR) is a risk factor for acute transcatheter aortic valve implantation (TAVI) failure, but may improve afterwards. Aim of this study was to assess the prevalence, clinical meaning and modifications of MR in patients undergoing TAVI. METHODS: In a retrospective, two-center (Potenza-San Carlo and Roma- San Camillo) study, from January 2010 to June 2014 we enrolled 165 consecutive patients (age =80 ± 5 years, 74 males, Ejection Fraction 51 ± 9 %) referred for TAVI with either Medtronic Core-ReValving System (in 114 patients, 69%) or balloon-expandable Edwards SAPIEN/SAPIEN XT (in 51 patients, 31%). All patients underwent TTE and TEE assessment of MR (from 1, mild to 4 = severe according to ESC latest guidelines) with core lab reading by a single observer blinded to patient identity and status. Assessment was performed at baseline (24 h prior to intervention) and at 1, 6, 12 and 24 months. RESULTS: Mild-to-Moderate MR (grade 1-2) was present in 137 patients and Moderate-to-Severe MR (grade 3-4) was present in 28 patients. No significant differences were seen comparing perioperative mortality and morbidity between the two groups. In the group of preoperative MR grade 3-4 the mean decrease from MR pre-TAVI to MR at 1 month post-TAVI was 0.464 (p < 0.0001) and this improvement was persistent at 6 months (p < 0.0001) and at 12 months (p < 0.0001), with partial benefit loss at 1 and 2 years. The mean difference from Left Atrial volume post-TAVI at 1 month was 16.5 ml (p < 0.0001) and this improvement was persistent at 12 months 12.12 ml (p < 0.0001). CONCLUSIONS: TAVI effectively treats the aortic valve but as a beneficial by product also ameliorates concomitant MR. The presence of moderate-to-severe MR does not increase the acute risk of failure of TAVI. In successful procedures, the MR improves immediately and persistently.

[Single-center retrospective observational study on predictors of residual mitral regurgitation 1 year after MitraClip® implantation]. / Studio osservazionale retrospettivo monocentrico sui predittori di insufficienza mitralica residua a 1 anno dall'impianto di MitraClip®.

BACKGROUND: The extent of residual mitral regurgitation (MR) (1+ vs ≥2+) has a notable impact on the outcome of MitraClip (MC) repair of significant functional MR. In this retrospective single-center study, we evaluated the predictors of MI ≥2+ at 1 year in one of our case series. METHODS: Overall, 58 patients with moderate severe functional MR underwent MC implantation; of these, 48 patients had instrumental clinical follow-up for 1 year. RESULTS: At 1 year, 10 patients died (mortality 17.2%). In the remaining 48 patients, the incidence of rehospitalization was 8.3%, and the incidence of MR grade 1+ and ≥2+ was 54.1% (n = 26) and 45.9% (n = 22), respectively. In patients with MR ≥2+, clinical and instrumental outcomes were worse than in patients with MR 1+. The height of the posterior leaflet and the extent of immediate postprocedural MR were independent predictors of MR ≥2+. CONCLUSIONS: Percutaneous repair with MC of moderate/severe functional MR has favorable 1-year outcomes in terms of mortality and rehospitalizations. The best results are achieved in patients with residual MR 1+. Echocardiographic parameters are independent predictors of residual MR ≥2+.

Platelet Reduction after Transcatheter Aortic Valve Implantation: Results from the PORTRAIT Study.

Background: An unexplained condition that follows transcatheter aortic valve implantation (TAVI) is platelet count reduction (PR). According to published research, patients with balloon-expandable valves (BEVs) had a greater PR than those with self-expandable valves (SEVs). Objectives: The purpose of this study was to investigate the incidence and clinical effects of PR following TAVI. Methods: In total, 1.122 adult TAVI patients were enrolled. Propensity score matching was carried out in a 1:1 ratio between patients with BEVs and those with SEVs. The analysis included changes in platelet count, in-hospital mortality, and early postoperative adverse events. Results: Notably, 632 patients were matched (BEV:316; SEV:316). All patients' post-procedural platelet counts changed according to a parabolic curve, using a mixed regression model for repeated analyses (estimate = -0.931; standard error = 0.421; p = 0.027). The platelet count varied comparably in patients with BEVs and SEVs (estimate = -4.276, standard error = 4.760, p = 0.369). The average time for obtaining the nadir platelet count value was three days after implantation (BEV: 146 (108-181) vs. SEV: 149 (120-186); p = 0.142). Overall, 14.6% of patients (92/632) had post-procedural platelet count <100,000/µL. There was no difference between the two prosthesis types (BEV:51/316; SEV:41/316; p = 0.266). Thrombocytopenia was found to be significantly linked to blood product transfusions, lengthier stays in the intensive care unit and hospital, and in-hospital mortality. Conclusions: TAVI, irrespective of the type of implanted valve, is linked to a significant but temporary PR. Thrombocytopenia increases the risk of serious complications and in-hospital death in TAVI patients. To explore and clarify the causes and associated effects, further prospective research is necessary.

Surgical repair of left ventricular free-wall rupture complicating acute myocardial infarction: a single-center 30 years of experience.

Background: Left ventricular free-wall rupture (LVFWR) is a catastrophic complication of acute myocardial infarction (AMI). Historically, cardiac surgery is considered the treatment of choice. However, because of the rarity of this entity, little is known regarding the efficacy and safety of surgical treatment for post-infarction LVFWR. The aim of this study was to report a single-center experience in this field over a period of 30 years. Methods: Patients who developed LVFWR following AMI and underwent surgical repair at our Institution from January 1990 to December 2019 were considered. The primary end-point was in-hospital morality rate; secondary outcomes were long-term survival and postoperative complications. Multivariate analysis was carried out by constructing a logistic regression model to identify risk factors for early mortality. Results: A total of 35 patients were enrolled in this study. The mean age was 68.9 years; 65.7% were male. The oozing type of LVFWR was encountered in 29 individuals, and the blowout type in 6 subjects. Sutured repair was used in 77.1% of patients, and sutureless repair in the remaining cases. The in-hospital mortality rate was 28.6%. Low cardiac output syndrome was the main cause of postoperative death. Multivariable analysis identified age >75 years at operation, preoperative cardiac arrest, concurrent ventricular septal rupture (VSR) as independent predictors of in-hospital death. Follow-up was complete in 100% of patients who survived surgery (mean follow-up: 9.3 ± 7.8 years); among the survivors, 16 patients died during the follow-up with a 3-year and 12-year overall survival rate of 82.5% and 55.2%, respectively. Conclusions: Surgical treatment of LVFWR following AMI is possible with acceptable in-hospital mortality and excellent long-term results. Advanced age, concurrent VSR and cardiac arrest at presentation are independent risk factors of poor early outcome.

Platelet Reduction after Aortic Bioprosthesis Implantation: Results from the PORTRAIT Study.

Background: Platelet count reduction (PR) is a common but unclear phenomenon that occurs after aortic bioprosthesis valve implantation (bio-AVR). This study aimed to investigate the occurrence and clinical impact of PR in patients receiving stented, rapid deployment (RDV), or stentless bioprostheses. Methods: 1233 adult bio-AVR patients were enrolled. Platelet count variation, early post-operative adverse events, and in-hospital mortality were analysed. Results: 944 patients received a stented valve, an RDV was implanted in 218 patients, and 71 patients had a stentless bioprosthesis. In all groups, the platelet count at discharge was lower than the baseline values (p < 0.001). The percentage of PR was 27% in the stented group, 56% in the RDV group, and 55% in the stentless group. A higher platelet reduction, reaching the minimum platelet value, was observed in the RDV (mean: -30.84, standard error (SE): 5.91, p < 0.001) and stentless (mean: 22.54, SE: 9.10, p = 0.03) groups compared to the stented group. A greater PR occurred as the size of the bioprosthesis increased in RDV (p = 0.01), while platelet count variation was not directly proportional to the stented bioprosthesis size (p < 0.001). PR was not affected by cardiopulmonary bypass (mean: -0.00, SE: 0.001, p = 0.635) or cross-clamp (mean: -0.00, SE: 0.002, p = 0.051) times in any of the groups. RDV subjects experienced more in-hospital adverse events. PR was found to be associated with ischemic strokes in the overall population. Conclusions: Bio-AVR is associated with significant but transient PR. RDV patients more likely experience significant PR and related adverse clinical events. PR is associated with ischemic strokes, regardless of the bioprosthesis type.

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.

A biocompatible cardiopulmonary bypass strategy to reduce hemostatic and inflammatory alterations: a randomized controlled trial.

OBJECTIVE: Cardiopulmonary bypass (CPB) systems without a venous reservoir rarely are adopted clinically. The effects of a biocompatible CPB system with a venous reservoir were evaluated on the activation of the coagulation and inflammatory systems. DESIGN: A prospective, randomized controlled trial. SETTING: A university hospital (single center). PARTICIPANTS: Eighty-three coronary artery bypass graft (CABG) surgery patients were assigned to the Physio group (closed venous reservoir, phosphorylcholine coating, and no cardiotomy suction) or the Standard group (open, noncoated, and cardiotomy suction used). METHODS: Blood samples were obtained at 6 different time points before, during, and after surgery. Nuclear factor-kB (NF-κB) was evaluated before surgery and 2 and 24 hours after surgery. Myocardial damage was evaluated measuring cardiac troponin I. MEASUREMENTS AND MAIN RESULTS: Interleukin (IL)-6 (a marker of inflammation), prothrombin fragment 1-2 (PF-1.2, a marker of thrombin generation), plasmin-antiplasmin complex (PAP, a marker of fibrinolysis), and platelet factor 4 (PF4, a marker of platelet activation) were measured. The DNA binding activity of proinflammatory transcription factor NF-κB was quantified in the isolated lymphomonocyte cells. Surgery caused changes of all plasma biomarkers. This reaction was attenuated strongly in the Physio group; PF-1.2, PAP, and PF4 all were decreased significantly. In the Physio group, a significantly lower cardiac troponin I release was observed postoperatively. After surgery, NF-κB activity was reduced in the Physio group although this difference was not statistically significant. CONCLUSIONS: A multimodal strategy using a closed and phosphorylcholine-coated CPB circuit together with the avoidance of cardiotomy suction reduced activation of the coagulation and fibrinolytic systems intraoperatively, although these changes did not persist postoperatively. However, no difference in clinical outcome was appreciated on a larger scale.

Similar outcome of tricuspid valve repair and replacement for isolated tricuspid infective endocarditis.

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 (30 days 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 19.1 years (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 20 years (80 ±â€Š6% Repair Group vs 59 ±â€Š13% 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.

Protective effects of steroids in cardiac surgery: a meta-analysis of randomized double-blind trials.

OBJECTIVE: Cardiac surgery and cardiopulmonary bypass (CPB) induce an acute inflammatory response contributing to postoperative morbidity. The use of steroids as anti-inflammatory agents in surgery using CPB has been tested in many trials and has been shown to have good anti-inflammatory effects but no clear clinical advantages for the lack of an adequately powered sample size. The aim of this study was to evaluate the effects of steroid treatment on mortality and morbidity after cardiac surgery. DESIGN: A systematic meta-analysis of randomized double-blind trials (RDBs). SETTING: A university hospital. PARTICIPANTS: Adult patients who underwent cardiac surgery. MEASUREMENTS AND MAIN RESULTS: A trial search was performed through PubMed and Cochrane databases from 1966 to January 2009. Among 104 clinical trials reviewed, 31 RDB trials (1,974 patients) were considered suitable to be analyzed. A quality assessment of the trials was performed using the Jadad score. The types of steroid used in these trials were methylprednisolone (51.4%), dexamethasone (34.3%), hydrocortisone (5.7%), prednisolone (2.9%), or a combination of methylprednisolone and dexamethasone (5.7%). Steroid prophylaxis provided a protective effect preventing postoperative atrial fibrillation (odds ratio = 0.56; confidence interval [CI] 0.44-0.72, p < 0.0001), reducing postoperative blood loss (mean difference = -204.2 mL; CI from -287.4 to -121 mL; p < 0.0001), and reducing intensive care unit (mean difference = -6.6 hours; CI from -10.5 to -2.7 hours, p = 0.0007) and overall hospital stay (mean difference = -0.8 days; CI from -1.4 to -0.2 days, p = 0.01). Steroid prophylaxis had no effect on postoperative mortality, mechanical ventilation duration, re-exploration for bleeding, and postoperative infection. CONCLUSIONS: A systematic review of RDB trials reveals that steroid prophylaxis may reduce morbidity after cardiac surgery and does not increase the risk of postoperative infections.

Ablation of atrial tachycardia in the setting of prior mitral valve surgery.

BACKGROUND: Data regarding catheter ablation of post-surgical atrial tachycardia occurring after mitral valve surgery are scarce. Through a search of the literature, this study aimed to assess the feasibility of catheter ablation and the characteristics of atrial arrhythmias ablated in these patients. METHODS: Studies assessing the main procedure parameters and the electrophysiologic findings of the investigated atrial tachycardia were selected. The electrophysiologic mechanism (focal vs. re-entrant arrhythmias), site of arrhythmia origin (left atrium vs. right atrium) and their anatomic correlation with specific surgical access and/or prior Cox-Maze IV procedure were all addressed. RESULTS: Eleven studies including 206 patients undergoing catheter ablation of 297 post-surgical arrhythmia morphologies occurring after mitral valve surgery were considered. Major complications were observed in 2 patients only (0.9%). Restoration of sinus rhythm was achieved in 96% of patients. Macro-reentrant arrhythmia was mostly observed (90.4%) with a non-negligible proportion of focal arrhythmia (9.6%). Left-sided arrhythmia was common (54.4%,) but cavotricuspid isthmus-dependent arrhythmia was frequently reported (33%). Although specific atriotomies showed trends towards peculiar locations of the investigated arrhythmia, Cox-Maze IV procedure was the only independent predictor for left-sided arrhythmia (OR=17.3; 95% CI 7.2-41.2; P<0.0001). CONCLUSIONS: Catheter ablation of post-surgical arrhythmia occurring after mitral valve surgery is feasible, and, in this setting, the vast majority of the arrhythmia morphologies are based on macro-reentry and in about one third of cases show cavotricuspid isthmus-dependent arrhythmia. Prior Cox-Maze-IV associated with mitral valve surgery is an independent predictor of left-sided arrhythmia possibly due to non-transmural surgical lesions.

Early Aortic Paravalvular Leak After Conventional Cardiac Valve Surgery: A Single-Center Experience.

BACKGROUND: Paravalvular leak (PVL) is a well-known complication after aortic valve replacement (AVR). Although some studies have described the incidence of postoperative aortic PVL, there are conflicting data about the predictive factors and a paucity of evidence regarding their time course and impact on survival. METHODS: Data were collected from patients who underwent surgical AVR at Circolo Hospital in Varese, Italy from January 2014 to December 2017. A transthoracic echocardiogram (TTE) was performed in all patients before hospital discharge. Additionally, a second TTE was obtained during postoperative follow-up in subjects with early aortic PVL. RESULTS: A total of 514 patients were enrolled in the study. At hospital discharge, aortic PVL was present in 60 patients (11.7%); the majority (78.3%) of the PVLs were mild. Multivariate logistic regression analysis identified smaller body surface area, female sex, and operating surgeon as the strongest predictors of early aortic PVL. Follow-up TTE was available for 50 patients (83.3%). Median time from the date of surgery to follow-up TTE was 2.2 years (0.4 to 4 years). Most aortic PVLs remained unchanged (50%) or disappeared (36%) over time. Only 2 patients (4%) had a progression of the leak. Overall, mortality was 8.4% (43 of 514). Survival was negatively affected by the presence of residual, mild to moderate, or moderate aortic PVL. CONCLUSIONS: Aortic PVL is not uncommon after standard AVR. Operating surgeon, smaller body surface area, and female sex are risk factors for the development of this complication. These leaks are usually mild and generally have a benign course. However, the presence of mild to moderate or more severe aortic PVL may influence postoperative survival.

Surgery for Bentall endocarditis: short- and midterm outcomes from a multicentre registry.

OBJECTIVES: Endocarditis after the Bentall procedure is a severe disease often complicated by a pseudoaneurysm or mediastinitis. Reoperation is challenging but conservative therapy is not effective. The aim of this study was to assess short- and midterm outcomes of patients reoperated on for Bentall-related endocarditis. METHODS: Seventy-three patients with Bentall procedure-related endocarditis were recorded in the Italian registry. The mean age was 57 ± 14 years and 92% were men; preoperative comorbidities included hypertension (45%), diabetes (12%) and renal failure (11%). The logistic EuroSCORE was 25%; the EuroSCORE II was 8%. RESULTS: Preoperatively, 12% of the patients were in septic shock; left ventricular-aortic discontinuity was present in 63% and mitral valve involvement occurred in 12%. The most common pathogens were Staphylococcus aureus (22%) and Streptococci (14%). Reoperations after a median interval of 30 months (1-221 months) included a repeat Bentall with a bioconduit (41%), a composite mechanical (33%) or biological valved conduit (19%) and a homograft (6%). In 1 patient, a heart transplant was required (1%); in 12%, a mitral valve procedure was needed. The hospital mortality rate was 15%. The postoperative course was complicated by renal failure (19%), major bleeding (14%), pulmonary failure (14%), sepsis (11%) and multiorgan failure (8%). At multivariate analysis, urgent surgery was a risk factor for early death [hazard ratio 20.5 (1.9-219)]. Survival at 5 and 8 years was 75 ± 6% and 71 ± 7%, with 3 cases of endocarditis relapse. CONCLUSIONS: Surgery is effective in treating endocarditis following the Bentall procedure although it is associated with high perioperative mortality and morbidity rates. Endocarditis relapse seems to be uncommon.