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.

Early failure of tricuspid annuloplasty. Should we repair the tricuspid valve at an earlier stage? The role of right ventricle and tricuspid apparatus.

BACKGROUND: We sought to identify subgroups of patients at a higher probability of tricuspid annuloplasty (TAP) failure early after surgery. METHODS: From May 2009 to December 2015, 688 patients undergoing TAP for functional tricuspid regurgitation (FTR) at a single institution were included in the study. In all patients, a complete transthoracic echocardiographic evaluation of right ventricle (RV) and tricuspid valve (TV) apparatus was collected. RESULTS: Twenty-six patients (3.8%) died within the first 30 days of surgery. Residual TR after TAP was recorded in 85 (12.4%), moderate in 80 (11.7%) and severe in 5 (0.7%). Preoperative TV apparatus remodeling was associated with residual TR; in particular, the following cutoffs were identified: TV coaptation depth ≥6.5 mm, tenting area ≥0.85 cm2 , and tricuspid annulus ≥35 mm. The entire cohort was stratified in three subsets: patients having preoperative mild/moderate TR without preoperative TV apparatus and/or RV remodeling (n = 178); patients having mild/moderate TR with TV apparatus and/or RV remodeling (n = 317); patients with severe TR regardless of TV apparatus and/or RV remodeling (n = 193). Residual TR was 2.8%, 10.4%, and 24.3%, respectively (P < 0.001). At multivariable analysis, patients showing preoperative mild/moderate TR with TV apparatus and/or RV remodeling as well as patients with severe TR were at significantly higher risk for early failure. No difference was found regarding the type of TV repair performed. CONCLUSIONS: Prophylactic TAP should be encouraged among surgeons even earlier than guidelines recommend, and decision-making for the treatment of low-grade FTR at the time of left-sided valve surgery should take into consideration not only annular size but also tethering severity and RV dilatation.

What is the best graft to supplement the bilateral internal thoracic artery to the left coronary system? A meta-analysis.

This meta-analysis was designed to assess the effect of the use of arterial conduits (ACs) versus great saphenous vein (GSV) grafts as a third conduit for revascularization of the right coronary artery system, in addition to the bilateral internal mammary artery on the left coronary artery. PubMed and OVID's version of MEDLINE were searched from January 2000 to September 2017 for relevant publications. The primary end point was the long-term mortality rate. The secondary end point was early mortality, defined as either in-hospital death or death within 30 days after the operation. Meta-regression was used to evaluate the effect of female gender and diabetes on the primary and secondary outcomes. A total of 10 studies (4121 patients) were selected for the systematic review and meta-analysis comparing ACs (1619) versus the GSV (2502), 6 (2548) comparing the GSV (2548) versus the right gastroepiploic artery (1023) and 5 comparing the GSV (2548) versus the radial artery (596). The pooled analysis did not show any difference between ACs and the GSV in terms of long-term mortality rates [hazard ratio (HR) = 0.75, 95% confidence interval (CI) = 0.56-1.01; P = 0.061]. When using the leave-one-out analysis, after the exclusion of 1 study (outlier), ACs were significantly associated with lower long-term mortality rates (HR = 0.67, 95% CI = 0.54-0.83; P < 0.001). When the results were stratified according to the type of study, no differences with regard to long-term results were found between ACs and the GSV, either in the pooled analysis of the 6 propensity score-matched studies (HR = 0.69, 95% CI = 0.43-1.08; P = 0.107) or in the pooled analysis of the 4 non-propensity score-matched studies (HR = 0.88, 95% CI = 0.62-1.23; P = 0.438). Again, when the outlier was excluded, the pooled analysis of the propensity score-matched studies confirmed that ACs were associated with lower long-term mortality rates (HR = 0.58, 95% CI = 0.43-0.80; P < 0.001). Comparisons between the GSV and either the right gastroepiploic artery or the radial artery showed similar results. No publication bias was found. This meta-analysis is the first to compare the GSV to the radial artery and the right gastroepiploic artery for right coronary artery grafting in patients receiving a bilateral internal mammary artery to left coronary artery. The choice of a third AC seems to be preferable in order to achieve better long-term survival.

Surgical treatment of isolated tricuspid valve infective endocarditis: 25-year results from a multicenter registry.

BACKGROUND: To assess early and late mortality in patients with isolated acute tricuspid valve infective endocarditis (TVIE) using data from a multicenter registry. METHODS: From 1983 to 2018, isolated acute TVIE was surgically treated in 157 (3.8%) patients [mean age 47 ±â€¯16 years (range 15-86 years), 25% females]. Of these, 142 (90%) had native tricuspid regurgitation, 7 (5%) native tricuspid valve (TV) steno-regurgitation, and 8 (5%) prosthetic TVIE. Intravenous drug use (IVDU) was recorded in 38% of patients, infection involved cardiac implantable electronic device leads in 21%, and vascular catheters for dialysis in 1%; in the remaining cases, the cause was unknown. The primary endpoint was in-hospital outcome, long-term freedom from recurrence and overall survival. RESULTS: Overall, 77 (49%) patients underwent TV repair, 72 (46%) TV replacement, and 8 (5%) prosthetic TV replacement. Early mortality was 11% (n = 17). Expected early mortality according to EndoSCORE was 12%, with age (odds ratio 1.06) and redo (odds ratio 6.64) as risk factors. Late deaths occurred in 31 patients and TVIE recurrences in 4. Survival rates at 10, 20, and 25 years were 66%, 60%, and 44%, respectively. Risk factors were age [hazard ratio (HR) 1.06], mycotic TVIE (HR 4.2), IVDU (HR 4.90), infected prosthesis replacement (HR 4.4), and presence of cardiac implantable electronic device leads (HR 3.0). No significant difference was found in valve repair vs. replacement and in IVDUs vs. non-IVDUs. CONCLUSIONS: Patients with isolated acute TVIE undergoing surgical treatment show acceptable early and late outcomes. TVIE recurrence was low, and repair of the affected valve does not seem to confer any advantage either at early or long term up to 25 years.

Recombinant activated factor VII is associated with postoperative thromboembolic adverse events in bleeding after coronary surgery.

OBJECTIVES: To evaluate the impact of recombinant activated factor VII (rFVIIa) administration on thromboembolic adverse events (TAEs) in coronary artery bypass grafting (CABG) surgery patients showing postoperative bleeding. METHODS: From January 2004 to May 2015, 180 CABG surgery patients with postoperative bleeding were included in the study. All patients were managed conservatively and 81 (45%) also received rFVIIa. RESULTS: Ten patients developed new TAEs (5.6%), 15 (8.3%) were re-explored, 4 (2.2%) had postoperative dialysis and 6 (3.3%) died by day 30 postoperation. Among those with TAEs, 7 experienced cerebrovascular accidents, 2 had myocardial infarction and 1 had pulmonary embolism. A multivariable regression model confirmed rFVIIa as the only independent factor associated with the development of TAEs (odds ratio 6.19, 95% confidence interval 1.197-31.996; P = 0.0296). Fifteen (8.3%) patients were re-explored for bleeding according to our management protocol. No variables to predict the need for re-exploration were identified by the regression model. Chest tube output was statistically significantly lower in patients who received rFVIIa from 3 h [1.9 (Q1-Q3 1.7-2.1) ml/kg/h vs 3.2 (Q1-Q3 3-3.4) ml/kg/h, P = 0.000] through to 12 h after admission [0.6 (Q1-Q3 0.5-0.6) ml/kg/h vs 0.7 (Q1-Q3 0.6-0.9) ml/kg/h, P = 0.000]. CONCLUSIONS: rFVIIa for the treatment of post-CABG bleeding resulted in increased incidence of TAEs in spite of rapid control of bleeding. Hence, rFVIIa should only be used for selected patients and with extreme caution.

Clinical profile of patients with heart failure can predict rehospitalization and quality of life.

BACKGROUND: The aim of this retrospective study was to identify clinical, humoral and echocardiographic variables predicting rehospitalization and poor quality of life (QOL) in patients with reduced or mid-range ejection fraction heart failure. METHODS: From 2009 to 2012, 310 patients were admitted having signs and symptoms of heart failure with reduced ejection fraction. All the patients were followed by phone, calling the patients or the referring general practitioner. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used as the instrument to evaluate QOL: MLHFQ less than 24 is a good QOL, 24-45 is moderate QOL and more than 45 is poor QOL. The primary event was poor QOL and/or rehospitalization at 4 years. RESULTS: Seventy-nine patients died at median time of 21 months; 4-year survival was 72 ±â€Š3%. Rehospitalization due to heart failure was recorded in 60 cases. Among 231 survivors, MLHFQ score was good in 99 (42%), moderate in 50 (21%) and poor in 88 (37%). Four-year freedom from death, poor QOL or rehospitalization was 51 ±â€Š3%. Multivariable analysis identified the following risk factors: heart rate at discharge at least 70 bpm, ischemic heart disease, atrial fibrillation, hypercholesterolemia, chronic pulmonary disease, N-terminal pro brain natriuretic peptide at discharge, severe tricuspid regurgitation and mitral regurgitation more than moderate. CONCLUSION: Clinical, laboratory and echocardiographic profile is crucial to predict long-term QOL of patients admitted for heart failure.

Additive and independent prognostic role of abnormal right ventricle and pulmonary hypertension in mitral-tricuspid surgery.

OBJECTIVE: To evaluate the additive and independent prognostic value of abnormal right ventricle (aRV) and pulmonary hypertension (PH) in patients undergoing mitral-tricuspid surgery. METHODS: From January 2009 to December 2012, 541 patients underwent mitro-tricuspid surgery. The entire cohort was divided into 6 subgroups: 63 cases had normal RV and no PH (Group A), 180 normal RV but moderate PH (Group B), 101 normal RV but severe PH (Group C), 15 abnormal RV and no-PH (Group D), 86 abnormal RV and moderate PH (Group E) and 96 abnormal RV and severe PH (Group F). RESULTS: Forty-two (7.8%) patients died in hospital due to any cause: 1.6% in group A, 3.9% in group B, 8.9% in group C, 13.3% in group D, 9.3% in group E, 15.6% in group E, p = 0.005. Among 78 patients with no-PH, mortality was significantly higher in patients with aRV (1.6%vs 13.3%. p = 0.03). Among 344 patients with normal RV, mortality was significantly higher in patients with severe PH (1.6% vs 3.9% vs 8.9%. p = 0.03). Comparing the presence of both abnormal RV and severe PH with the remaining patients, mortality was significantly higher in the first group (15.6% 6.1%, p = 0.004). Multivariable analysis confirmed either the independent or the additive role of RV and PH. CONCLUSIONS: In patients undergoing mitral-tricuspid valve surgery, the presence of either RV dysfunction/dilatation or severe pulmonary hypertension, might play an independent prognostic role for mortality. The worst scenario is surely the contemporary presence of both conditions.

Anaortic coronary surgery using the Π-circuit is associated with a low incidence of perioperative neurological complications.

OBJECTIVES: Our goal was to compare the observed and the expected rates of postoperative cerebrovascular accidents (CVA) in a large cohort of consecutive patients undergoing off-pump coronary artery bypass grafting (CABG) using the ∏-circuit as a no-touch technique. METHODS: From January 2001 to May 2016, 3081 patients were consecutively submitted to an off-pump CABG operation using the ∏-circuit. A CVA was defined as a neurological deficit, lasting less (transient ischaemic attack) or more (stroke) than 24 h, diagnosed by a neurologist and confirmed by a computed tomography or magnetic resonance imaging scan of the brain. The primary end point was to compare the observed and the expected rates of CVAs; the latter was obtained using the Society of Thoracic Surgeons' calculator. The secondary end point was to compare the observed and the expected mortality rates using the Society of Thoracic Surgeons' calculator and the prevalence of postoperative complications. Moreover, we identified some subgroups at higher risk. RESULTS: The postoperative rate of CVAs was 0.5% (14 cases): 2 (0.1%) were transient ischaemic attacks and 12 (0.4%) were strokes. The mean expected CVA rate (1.6%) was significantly higher than the observed rate (P < 0.001). None of patients who experienced postoperative CVAs died. The observed mortality was 1.3% (40 patients) vs the expected mortality (2.6%), which was significantly higher (P < 0.001). Multivariable analysis identified age >70 years old, diabetes, extracardiac vasculopathy and chronic renal failure as risk factors for postoperative CVAs. However, in all the subgroups of risk, except for those with chronic renal failure, the use of the ∏-circuit was associated with a low rate of CVAs. CONCLUSIONS: The ∏-circuit should be included as a possible choice among no-touch techniques. The observed rate of CVAs of 75% is lower than the expected rate.

Intraoperative graft verification in coronary surgery.

Transit-time flow measurement (TTFM) is a reliable method to check the graft function intraoperatively in coronary surgery. The given parameters are: Mean Graft Flow (MGF); Pulsatility Index (PI) and Insufficiency Ratio (%BF). Some cutoffs of these parameters have been identified as predictors for unfair 1-y clinical outcome: mean graft flow (MGF) less than 20 ml/min and high pulsatility index greater than 5. Other cutoffs have been found as related to postoperative angiography: MGF 15 ml/min or less and pulsatility index at least 3 (sensitivity 94%; specificity 61%); MGF less than 15 ml/min and pulsatility index greater than 3 for left coronary artery or pulsatility index greater than 5 for right coronary artery (sensitivity 96%; specificity 77%); MGF 15 ml/min or less and pulsatility index at least 5.1 left coronary artery (sensitivity 98%; specificity 26%). Hence, with the need to improve the diagnostic accuracy of TTFM, high-resolution epicardic coronary ultrasound module has been added to graft flow evaluation providing 2D ultrasound imaging (either in short-axis or long-axis) and color-flow mapping, allowing an accurate morphological evaluation of body graft and anastomosis. An intraoperative method aimed to verify coronary grafts should be easy to handle, not time consuming, minimally invasive, easily meaningful and relatively cheap; in addition, it should offer objective parameters more than qualitative criteria. We herein report the results of our experience with intraoperative graft verification with TTFM and high-resolution imaging along with a systematic review of the literature in this field with the aim to provide a road map to be followed.

Intraoperative imaging to detect coronary stenosis in no-angiography patients.

Sometimes, patients scheduled for cardiac operations other than coronary artery bypass may be unsuitable for preoperative coronary angiography. We routinely use intraoperative high-resolution epicardial ultrasound to select the proper target for the graft and to check graft anastomosis integrity. We describe 3 patients who could not undergo preoperative coronary angiography for different reasons. In all cases, we discovered significant stenosis in the left anterior descending coronary artery, which required bypass grafting. Intraoperative verification by transit-time flow measurements confirmed the significant stenosis detected by imaging.

The Dark Side of the Moon: The Right Ventricle.

The aim of this review article is to summarize current knowledge of the pathophysiology underlying right ventricular failure (RVF), focusing, in particular, on right ventricular assessment and prognosis. The right ventricle (RV) can tolerate volume overload well, but is not able to sustain pressure overload. Right ventricular hypertrophy (RVH), as a response to increased afterload, can be adaptive or maladaptive. The easiest and most common way to assess the RV is by two-dimensional (2D) trans-thoracic echocardiography measuring surrogate indexes, such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tissue Doppler velocity of the lateral aspect of the tricuspid valvular plane. However, both volumes and function are better estimated by 3D echocardiography and cardiac magnetic resonance (CMR). The prognostic role of the RV in heart failure (HF), pulmonary hypertension (PH), acute myocardial infarction (AMI), and cardiac surgery has been overlooked for many years. However, several recent studies have placed much greater importance on the RV in prognostic assessments. In conclusion, RV dimensions and function should be routinely assessed in cardiovascular disease, as RVF has a significant impact on disease prognosis. In the presence of RVF, different therapeutic approaches, either pharmacological or surgical, may be beneficial.

A Novel Technique to Reconstruct Tricuspid Valve Anterior Leaflet in Massive Endocarditis.

Tricuspid valve (TV) endocarditis is a common complication in intravenous drug addicts. In case of TV replacement, the main issue is the high risk of new endocarditis on TV prosthesis. On November 2014, a 44 year-old male patient with a history of intravenous drug addiction was referred for TV endocarditis owing to Staphylococcus aureus and severe regurgitation complicated by pulmonary embolism and heart failure. Preoperative echocardiography showed a large vegetation of the anterior leaflet (1.95 × 0.92 cm) covering a huge hole in the leaflet itself. Herein, a novel technique for the treatment of massive endocarditis of the TV is described. Complete anterior leaflet reconstruction was achieved with a huge equine pericardium patch along with native chordae tendinae reimplantation onto the free edge of the patch. Finally, a ring annuloplasty was performed to stabilize the valve reconstruction. The postoperative course was uneventful with evidence of trivial tricuspid regurgitation and no signs of IE recurrence. Complete reconstruction of the anterior leaflet with a patch of xenopericardium and native chordae tendinae reimplantation might be an alternative technique to TV replacement.

Corticosteroid prophylaxis for fetal immaturity in a pregnant patient with atrial myxoma.

We report a case of a woman at 32nd gestational week, admitted for resting dyspnea, showing left atrial (LA) myxoma. Cardiac myxomas are the most common primary benign tumors of the heart. The incidence of cardiac myxomas diagnosed in pregnancy is extremely low. In the present case, cesarean delivery and concomitant surgical resection of LA myxoma were both delayed after corticosteroid prophylaxis in order to reduce neonatal cerebral, intestinal, and pulmonary complications. .

From bench to bedside: Can the improvements in left ventricular assist device design mitigate adverse events and increase survival?

OBJECTIVE: In vitro tests demonstrated that the new cone-bearing configuration of the Jarvik 2000 (Jarvik Heart Inc, New York, NY) left ventricular assist device exhibits better hydraulic efficiency than the previous pin-bearing design. We investigated the long-term outcomes of patients who received the Jarvik 2000 left ventricular assist device, depending on bearing design. METHODS: A retrospective review of prospectively collected data from 18 centers included in the Italian Registry was performed. From May 2008 to September 2013, 99 patients with end-stage heart failure were enrolled. Patients were divided into 2 groups according to their Jarvik 2000 suspending mechanism: Group pin included patients with pin bearings (May 2008 to June 2010), and group cone included patients with newer cone bearings (July 2010 to September 2013). The 2 groups did not differ significantly in terms of baseline characteristics. RESULTS: A total of 30 of 39 patients (group pin) and 46 of 60 patients (group cone) were discharged. During follow-up, 6 patients underwent transplantation, and in 1 patient the left ventricular assist device was explanted. The cumulative incidence competing risk of the entire cohort for noncardiovascular-related death was 28% (20%-40%); the cumulative incidence competing risk for cardiovascular-related death was 56% (42%-73%): 71% in group pin versus 26% in group cone (P = .034). The multivariate analyses confirmed that the pin-bearing design was a risk factor for cardiovascular death, along with Interagency Registry for Mechanically Assisted Circulatory Support class. Right ventricular failures and ischemic and hemorrhagic strokes were significantly higher in group pin. CONCLUSIONS: Patients with the new pump configuration showed a better freedom from cardiovascular death and lower incidence of fatal stroke and right ventricular failure. Further studies are needed to prove the favorable impact of pump-enhanced fluid dynamics on long-term results.

Cor-Knot automated fastener to facilitate Corex aortic valve bypass implantation.

Herein we describe the use of an automated suture fastener (Cor-Knot), recently proposed for valvular surgery, in cases of aortic valve bypass with a Correx apical connector. This surgical option aims to control suture tension, avoid muscular tears, and standardize and simplify the implantation technique. We report the first 5 cases operated on using the new suturing technique.