A 20-year experience in cardiac tumors: a single center surgical experience and a review of literature.

INTRODUCTION: Cardiac tumors are rare and heterogeneous entities which still remain a diagnostic and therapeutic challenge. The treatment for most cardiac tumors is prompt surgical resection. We sought to provide an overview of surgical results from a series of consecutive patients treated at our tertiary care center during almost a 20-year experience. METHODS AND RESULTS: In this single center study, 55 consecutive patients with diagnosis of cardiac tumor underwent surgical treatment from January 2002 to April 2021. Of these, 23 (42%) were male and the mean age was 62 ±â€Š12 years. Fifteen (27%) patients were symptomatic at the time of the diagnosis, mostly for dyspnea and palpitations. The most frequent benign cardiac tumor was myxoma (32; 58%), occurring mainly in the left atrium (31; 97%). Pleomorphic sarcoma was the most frequent primary malignant cardiac tumor (4; 7%), mainly located in the ventricles (1; 25% in the left ventricle; 2; 50% in the right ventricle). In all cases of benign tumors surgery was successful with no relapses. Two (50%) pleomorphic sarcomas showed subsequent relapses. After a median follow-up of 44 months, 15 (27%) patients died. Although malignant tumors presented a limited survival, benign tumors showed a very good prognosis. CONCLUSION: Cardiac tumors require a multidisciplinary approach to guarantee a prompt diagnosis and appropriate treatment. In our surgical experience, outcome after surgery of benign tumors was excellent, while malignant tumors had poor prognosis despite radical surgery.

Surgical management and outcomes in patients with acute type A aortic dissection and cerebral malperfusion.

Objective: The study objective was to evaluate the surgical results in patients with acute type A aortic dissection and cerebral malperfusion. Methods: From 2000 to 2019, 234 patients with type A aortic dissection and cerebral malperfusion were stratified into 3 groups: 50 (21%) with syncope (group 1), 152 (65%) with persistent loss of focal neurological function (group 2), and 32 (14%) with coma (group 3). Results were evaluated and compared by univariable and multivariable analyses. Results: Median age was higher in group 1, and incidence of cardiogenic shock was higher in group 3. The femoral artery was the most common cannulation site, whereas the axillary artery was used in 18% of group 1, 30% of group 2, and 25% of group 3 patients (P = .337). Antegrade cerebral perfusion was performed in more than 80% of patients, and ascending aorta/arch replacement was performed in 40% of group 1, 27% of group 2, and 31% of group 3 (P = .21). In-hospital mortality was 18% in group 1, 27% in group 2, and 56% in group 3 (P = .001). Survival at 5 years is 57.0% in group 1, 57.7% in group 2, and 38.7% in group 3 (P = .0005). On multivariable analysis, age, cardiopulmonary bypass time, and group 3 versus group 2 were independent risk factors for mortality, whereas axillary cannulation was a protective factor. Conclusions: Patients with aortic dissection and cerebral malperfusion without preoperative coma showed acceptable mortality, and those with coma had a high in-hospital mortality regardless of the type of brain protection. Overall axillary artery cannulation appeared to be a protective factor.

Gender-related presentation, surgical treatment, outcome and failure to rescue after surgery for type A aortic dissection: results from a multicentre registry.

OBJECTIVES: Reports on gender-related differences in perioperative characteristics and the outcome after surgery for type A acute aortic dissection are contradictory. METHODS: Perioperative characteristics, outcome and overall or itemized failure-to-rescue rates were collected retrospectively and dichotomized by gender in patients operated on at 5 referral institutions. A propensity score matched analysis was performed to compared males and females with similar preoperative risk profiles. Multivariable analysis assessed gender-related predictors of 30-day mortality. RESULTS: A total of 1271 patients were collected. Females (on average, 63 years old) developed type A acute aortic dissection, with differences in clinical presentation (number of intimal tears, thoracic pain at the onset of symptoms). Female-reported characteristics included lower frozen elephant trunk and elephant trunk procedures, higher femoral perfusion, retrograde cerebral perfusion and retrograde cardiopulmonary bypass restart after deep hypothermic circulatory arrest (P < 0.05). The 30-day mortality was 19.8%, without a gender-related difference (P = 0.37). No substantial differences in hospital outcome and in items related to failure to rescue were reported. A total of 256 propensity score matched pairs of males and females were investigated. Previous differences in surgical techniques and strategies were still confirmed; however, a higher incidence of postoperative permanent coma (P = 0.02) was reported in the female population. CONCLUSIONS: Different surgical techniques and operative strategies were used on the 2 genders, with a lower complexity in females. However, there were no differences in hospital outcome between genders, except for the higher incidence of coma in female patients.

A case of primary cardiac sarcoma with an acute presentation: The role of multimodality imaging.

The case highlights the value of contrast echocardiography in raising clinical suspicion of malignancy, allowing a diagnostic work-up and the treatment of the primitive heart tumors.

Cardiac surgery practice during the COVID-19 outbreak: a multicentre national survey.

OBJECTIVES: Healthcare systems worldwide have been overburdened by the coronavirus disease 2019 (COVID-19) outbreak. Accordingly, hospitals had to implement strategies to profoundly reshape both non-COVID-19 medical care and surgical activities. Knowledge about the impact of the COVID-19 pandemic on cardiac surgery practice is pivotal. The goal of the present study was to describe the changes in cardiac surgery practices during the health emergency at the national level. METHODS: A 26-question web-enabled survey including all adult cardiac surgery units in Italy was conducted to assess how their clinical practice changed during the national lockdown. Data were compared to data from the corresponding period in 2019. RESULTS: All but 2 centres (94.9%) adopted specific protocols to screen patients and personnel. A significant reduction in the number of dedicated cardiac intensive care unit beds (-35.4%) and operating rooms (-29.2%), along with healthcare personnel reallocation to COVID departments (nurses -15.4%, anaesthesiologists -7.7%), was noted. Overall adult cardiac surgery volumes were dramatically reduced (1734 procedures vs 3447; P < 0.001), with a significant drop in elective procedures [580 (33.4%) vs 2420 (70.2%)]. CONCLUSIONS: This national survey found major changes in cardiac surgery practice as a response to the COVID-19 pandemic. This experience should lead to the development of permanent systems-based plans to face possible future pandemics. These data may effectively help policy decision-making in prioritizing healthcare resource reallocation during the ongoing pandemic and once the healthcare emergency is over.

Risk stratification tool for all surgical site infections after coronary artery bypass grafting.

OBJECTIVE: To develop a risk score for surgical site infections (SSIs) after coronary artery bypass grafting (CABG). DESIGN: Retrospective study. SETTING: University hospital. PATIENTS: A derivation sample of 7,090 consecutive isolated or combined CABG patients and 2 validation samples (2,660 total patients). METHODS: Predictors of SSIs were identified by multivariable analyses from the derivation sample, and a risk stratification tool (additive and logistic) for all SSIs after CABG (acronym, ASSIST) was created. Accuracy of prediction was evaluated with C-statistic and compared 1:1 (using the Hanley-McNeil method) with most relevant risk scores for SSIs after CABG. Both internal (1,000 bootstrap replications) and external validation were performed. RESULTS: SSIs occurred in 724 (10.2%) cases and 2 models of ASSIST were created, including either baseline patient characteristics alone or combined with other perioperative factors. Female gender, body mass index >29.3 kg/m2, diabetes, chronic obstructive pulmonary disease, extracardiac arteriopathy, angina at rest, and nonelective surgical priority were predictors of SSIs common to both models, which outperformed (P < .0001) 6 specific risk scores (10 models) for SSIs after CABG. Although ASSIST performed differently in the 2 validation samples, in both, as well as in the derivation data set, the combined model outweighed (albeit not always significantly) the preoperative-only model, both for additive and logistic ASSIST. CONCLUSIONS: In the derivation data set, ASSIST outperformed specific risk scores in predicting SSIs after CABG. The combined model had a higher accuracy of prediction than the preoperative-only model both in the derivation and validation samples. Additive and logistic ASSIST showed equivalent performance.

Bacterial colonization of explanted non-endocarditis cardiac valves: evidence and characterization of the valvular microbiome.

Bacterial colonization has been already demonstrated in heart valve tissues of patients without cardiovascular infections. However, the evidence of a valvular microbiome is still scarce. The next-generation sequencing method was carried out on 34 specimens of aortic (n = 20) and mitral valves (n = 14) explanted from 34 patients having neither evidence nor history of infectious diseases, particularly infective endocarditis. While no bacteria were demonstrated using standard culture methods, bacterial deoxyribonucleic acid (DNA) sequences were found using next-generation sequencing in 15/34 (44%) cases. Escherichia coli was present in 6 specimens and was the most frequently identified bacterium. There was a trend towards a higher rate of bacterial DNA positivity in specimens of calcific valves than in those of non-calcific valves (10/17 vs 5/17, P = 0.17). Based on a quantitative test, E. coli accounted for 0.7% ± 1% in calcific valvular tissue and 0.3% ± 0.3% in non-calcific valvular tissue (P = 0.2), and for 11% ± 27% in the valvular tissue of diabetic patients and 0.3% ± 1% in the valvular tissue of non-diabetic patients (P = 0.08). Detection of bacterial DNA in non-endocarditis valvular tissues could be a relatively common finding. There could be an association between the valvular microbiome and certain models of valve degeneration and common metabolic disorders.

Isolated left atrial cryoablation of atrial fibrillation in conventional mitral valve surgery.

BACKGROUND: Recent trends of surgery for atrial fibrillation (AF) are towards more safe and effective energy sources, as well as to simplified sets of atrial lesions. METHODS: One hundred eighteen (mean age, 67.4 ± 9.2 years) selected patients with paroxysmal/persistent AF and mitral valve (MV) disease underwent cryoablation of AF combined with conventional (not via mini-thoracotomy) MV surgery; the lesion set was limited to only the left atrium. Multivariable analyses identified predictors of cardiac rhythm at hospital discharge and follow-up. RESULTS: There were 7 (5.9%) hospital deaths; 33 (28%) patients were discharged on AF. Higher values of preoperative left atrial volume index (odds ratio [OR] = 1.07, 95% confidence interval [95%CI]: 1.01-1.13) and mixed etiology of MV disease (OR = 4.19, 95%CI: 1.23-14.2) were predictors of hospital discharge on AF. Seventy-four (66.7%) patients were on stable sinus rhythm at follow-up (median period, 6.6 years); the 1, 5, and 10-year nonparametric estimates of adjusted freedom from AF were 98.1%, 89.2% and 45.6%, respectively. Higher values of preoperative systolic pulmonary artery pressure (hazard ratio [HR] = HR = 1.04, 95%CI: 1.01-1.08) and AF at hospital discharge (HR = 4.14, 95%CI: 1.50-11.4) were predictors of AF at follow-up. CONCLUSIONS: During conventional MV surgery, a cryo-lesion set limited to only the left atrium may give good, immediate and long-term results. Left atrial dilation and mixed etiology of MV disease were predictors of hospital discharge on AF. Preoperative pulmonary hypertension and AF at discharge combined with an increased risk of AF at follow-up.

Impact of a natural versus commercial enteral-feeding on the occurrence of diarrhea in critically ill cardiac surgery patients. A retrospective cohort study.

BACKGROUND: Diarrhea is an important complication in critically ill patients undergoing enteral feeding. The occurrence of diarrhea may lead to systemic and local complications and negatively impacts on nursing workload and patient's wellbeing. An enteral feeding based on blenderized natural food could be beneficial in reducing the risk of diarrhea. No study has compared natural and commercial enteral feedings in critically ill cardiac surgery patients. OBJECTIVE: The aim of this study was to compare the risk of diarrhea occurrence in two cohorts of patients fed a blenderized natural food diet or commercial enteral feeding preparations, respectively. DESIGN: Retrospective cohort study. SETTING: Cardiac-Surgery Intensive Care Unit of a University Hospital. PARTICIPANTS: Two-hundred and fifteen patients admitted to the postoperative cardiac surgery intensive care unit were included, 103 fed blenderized natural enteral feeding and 112 fed commercial formulas. METHODS: Commercial enteral formulas were delivered by continuous pump administration, while natural enteral feeding by bolus 3 times per day. Diarrhea was documented in the presence of three or more evacuations of loose or watery stool (or an amount above 250 ml) per day. The presence of diarrhea was recorded daily from the beginning to the end of the enteral feeding, up to a maximum of 8 days. The unadjusted time to the first event of diarrhea between the two enteral feeding groups was compared. Adjusted comparison was then performed by fitting a multivariable Cox Proportional-Hazards model, adjusted for potential confounders for diarrhea occurrence (i.e. administration of inotropes, vasopressors, prokinetics, antibiotics, oral nutritional supplements, antifungal agents, sedatives, opioids, probiotics, laxatives). RESULTS: In unadjusted survival analysis the probability of diarrhea was significantly lower in the natural enteral feeding group (log rank test: p = 0.023). In the multivariable model patients in natural enteral feeding cohort showed a non-significant trend towards an almost halved risk of experiencing diarrhea (hazard ratio: 0.584; 95% confidence interval: 0.335-1.018; p = 0.058) compared to those fed commercial enteral feeding. CONCLUSIONS: Administration of a blenderized diet based on natural food for enteral feeding can reduce the incidence of diarrhea in cardiac surgery critically ill patients. This strategy may reduce the risk of diarrhea-associated malnutrition and systemic and local complications, also having a positive impact on nursing workload and patient wellbeing.

Preoperative risk stratification of deep sternal wound infection after coronary surgery.

OBJECTIVE: To develop a risk score for deep sternal wound infection (DSWI) after isolated coronary artery bypass grafting (CABG). DESIGN: Multicenter, prospective study. SETTING: Tertiary-care referral hospitals. PARTICIPANTS: The study included 7,352 patients from the European multicenter coronary artery bypass grafting (E-CABG) registry. INTERVENTION: Isolated CABG. METHODS: An additive risk score (the E-CABG DSWI score) was estimated from the derivation data set (66.7% of patients), and its performance was assessed in the validation data set (33.3% of patients). RESULTS: DSWI occurred in 181 (2.5%) patients and increased 1-year mortality (adjusted hazard ratio, 4.275; 95% confidence interval [CI], 2.804-6.517). Female gender (odds ratio [OR], 1.804; 95% CI, 1.161-2.802), body mass index ≥30 kg/m2 (OR, 1.729; 95% CI, 1.166-2.562), glomerular filtration rate <45 mL/min/1.73 m2 (OR, 2.410; 95% CI, 1.413-4.111), diabetes (OR, 1.741; 95% CI, 1.178-2.573), pulmonary disease (OR, 1.935; 95% CI, 1.178-3.180), atrial fibrillation (OR, 1.854; 95% CI, 1.096-3.138), critical preoperative state (OR, 2.196; 95% CI, 1.209-3.891), and bilateral internal mammary artery grafting (OR, 2.088; 95% CI, 1.422-3.066) were predictors of DSWI (derivation data set). An additive risk score was calculated by assigning 1 point to each of these independent risk factors for DSWI. In the validation data set, the rate of DSWI increased along with the E-CABG DSWI scores (score of 0, 1.0%; score of 1, 1.8%; score of 2, 2.2%; score of 3, 6.9%; score ≥4: 12.1%; P < .0001). Net reclassification improvement, integrated discrimination improvement, and decision curve analysis showed that the E-CABG DSWI score performed better than other risk scores. CONCLUSIONS: DSWI is associated with poor outcome after CABG, and its risk can be stratified using the E-CABG DSWI score. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT02319083.

Pericardiectomy for constrictive pericarditis: a risk factor analysis for early and late failure.

Predictors of early and late failure of pericardiectomy for constrictive pericarditis (CP) have not been established. Early and late outcomes of a cumulative series of 81 (mean age 60 years; mean EuroSCORE II, 3.3%) consecutive patients from three European cardiac surgery centers were reviewed. Predictors of a combined endpoint comprising in-hospital death or major complications (including multiple transfusion) were identified with binary logistic regression. Non-parametric estimates of survival were obtained with the Kaplan-Meier method. Predictors of poor late outcomes were established using Cox proportional hazard regression. There were 4 (4.9%) in-hospital deaths. Preoperative central venous pressure > 15 mmHg (p = 0.005) and the use of cardiopulmonary bypass (p = 0.016) were independent predictors of complicated in-hospital course, which occurred in 29 (35.8%) patients. During follow-up (median, 5.4 years), preoperative renal impairment was a predictor of all-cause death (p = 0.0041), cardiac death (p = 0.0008), as well as hospital readmission due to congestive heart failure (p = 0.0037); while partial pericardiectomy predicted all-cause death (p = 0.028) and concomitant cardiac operation predicted cardiac death (p = 0.026), postoperative central venous pressure < 10 mmHg was associated with a low risk both of all-cause and cardiac death (p < 0.0001 for both). Ten-year adjusted survival free of all-cause death, cardiac death, and hospital readmission were 76.9%, 94.7%, and 90.6%, respectively. In high-risk patients with CP, performing pericardiectomy before severe constriction develops and avoiding cardiopulmonary bypass (when possible) could contribute to improving immediate outcomes post-surgery. Complete removal of cardiac constriction could enhance long-term outcomes.

Validation and Performance Comparison of Two Scoring Systems Created Specifically to Predict the Risk of Deep Sternal Wound Infection after Bilateral Internal Thoracic Artery Grafting.

Background: The Gatti and the bilateral internal mammary artery (BIMA) scores were created to predict the risk of deep sternal wound infection (DSWI) after bilateral internal thoracic artery (BITA) grafting. Methods: Both scores were evaluated retrospectively in two consecutive series of patients undergoing isolated multi-vessel coronary surgical procedures-i.e., the Trieste (n = 1,122; BITA use, 52.1%; rate of DSWI, 5.7%) and the Besançon cohort (n = 721; BITA use, 100%; rate of DSWI, 2.5%). Baseline patient characteristics were compared between the two validation samples. For each score, the accuracy of prediction and predictive power were assessed by the area under the receiver-operating characteristic curve (AUC) and the Goodman-Kruskal gamma coefficient, respectively. Results: There were significant differences between the two series in terms of age, gender, New York Heart Association functional class, chronic lung disease, left ventricular function, surgical priority, and the surgical techniques used. In the Trieste series, accuracy of prediction of the Gatti score for DSWI was higher than that of the BIMA score (AUC, 0.729 vs. 0.620, p = 0.0033). The difference was not significant, however, in the Besançon series (AUC, 0.845 vs. 0.853, p = 0.880) and when only BITA patients of the Trieste series were considered for analysis (AUC, 0.738 vs. 0.665, p = 0.157). In both series, predictive power was at least moderate for the Gatti score and low for the BIMA score. Conclusions: The Gatti and the BIMA scores seem to be useful for pre-operative evaluation of the risk of DSWI after BITA grafting. Further validation studies should be performed.

Bilateral Internal Thoracic Artery Grafting Concomitant With Other Cardiac Operations　- Insights From a European Multicenter Retrospective Study on 1,123 Consecutive Patients.

BACKGROUND: The use of bilateral internal thoracic artery (BITA) grafting concomitant with other cardiac operations is regarded as a risky strategy and the long-term advantages of BITA use remain unproven.Methods and Results:Pooled results from 3 series of patients (totaling 1,123 patients; mean age, 71.3 years; mean EuroSCORE II, 7.4%) undergoing combined coronary surgery using BITA were reviewed. Predictors of immediate and long-term adverse outcomes were identified by multivariable analyses. In-hospital and 30-day mortality was 7.9% and 6.3%, respectively. Diabetes on insulin (P=0.045), severe renal impairment (P<0.0001), extracardiac arteriopathy (P=0.0058), New York Heart Association class III-IV (P=0.017), recent myocardial infarction (P=0.0009), left ventricular dysfunction (P=0.0054), pulmonary hypertension (P=0.0016), active infective endocarditis (P=0.0011), and prolonged cross-clamp time (P=0.04) were predictors of in-hospital death. Multiple transfusions (27.3%), prolonged mechanical ventilation or reintubation (16.7%), acute kidney injury (11.5%), and sternal wound infections (10.4%) were relevant postoperative complications. Any neurological dysfunction occurred in 5.4% of cases. Median follow-up was 4.2 years. Female sex, chronic dialysis, extracardiac arteriopathy, and left ventricular dysfunction were predictors of both cardiac/cerebrovascular death and major adverse cardiac/cerebrovascular events (MACCE). The 10-year adjusted survival free of cardiac/cerebrovascular death, cerebrovascular accident after discharge, and MACCE was 84.2%, 94.8% and 54.6%, respectively. CONCLUSIONS: BITA grafting concomitant with other cardiac operations may be performed with satisfactory results. Long-term outcomes mostly depend on sex, preoperative comorbidities, and baseline cardiac function.

Modified Bentall procedure: Mechanical vs biological valved conduits in patients older than 65 years.

BACKGROUND: The modified Bentall procedure is still the treatment of choice for patients requiring combined replacement of the ascending aorta and aortic valve. We compared the long-term outcome of patients >65 years of age undergoing Bentall procedure with biological vs mechanical valved conduits in a multi institutional study. METHODS: A total of 282 patients, undergoing a Bentall operation (January 1994-May 2015), with a biological (Group 1, 173 patients) or a mechanical (Group 2, 109 patients) conduit were reviewed, the primary outcome being analysis of late survival and freedom from major adverse events. RESULTS: Hospital mortality was 5% (9 patients) and 2% (2 patients) for Group 1 and Group 2 (p = 0.2). Median follow-up was 77 months (range Q1-Q3: 49-111) for Group 1 vs 107 months (range Q1-Q3: 63-145) for Group 2 (p < 0.001). A not statistically significant advantage in late survival was found in patients receiving mechanical valved conduits (36% for Group 1 vs 58% for Group 2 at 12 years; p = 0.09), although freedom from major adverse events was similar between the 2 groups (33% in Group 1 vs 50% in Group 2 at 12 years; p = 0.3). CONCLUSIONS: In conclusion, mechanical-valved conduits employed for the modified Bentall procedure show a trend towards an improved late survival in patients ≥65 years of age and particularly in those between 65 and 75 years, despite a higher incidence of major adverse events. Our results indicate the need for specific guidelines to better define the ideal age limit for each type of valved conduit.

Risk scores and surgery for infective endocarditis: in search of a good predictive score.

Objectives: To evaluate scoring systems that have been created to predict the risk of death post-surgery in infective endocarditis (IE). Design: Eight scores - (1) The Society of Thoracic Surgery (STS) risk score for IE, (2) De Feo score, (3) PALSUSE score (prosthetic valve, age ≥70, large intracardiac destruction, Staphylococcus spp, urgent surgery, sex [female], EuroSCORE ≥10), (4) ANCLA score (anemia, New York Heart Association class IV, critical state, large intracardiac destruction, surgery of thoracic aorta), (5) Risk-Endocarditis Score (RISK-E), (6) score for heart valve or prosthesis IE (EndoSCORE), and (7,8) Association pour l'Étude et la Prévention de l'Endocadite Infectieuse (AEPEI) score I and II - were evaluated in 324 (mean age, 61.8 ± 14.6 years) consecutive patients having IE and undergoing cardiac operation (1999-2018, Regione Autonoma Friuli-Venezia Giulia, Italy). Results: There were 45 (13.9%) in-hospital deaths. Despite many differences on the number and the type of variables, all the investigated scores showed good goodness-of-fit (Hosmer-Lemeshow test, p ≥.28). For five scores, accuracy of prediction (receiver-operating characteristic curve analysis) was good (ANCLA score) or fair (STS risk score for IE, PALSUSE score, AEPEI score I and II). When compared one-to-one (Hanley-McNeil method), accuracy of prediction of ANCLA score was higher than all of other risk scores except for AEPEI score I (p = .077). Conclusions: Five of eight scores that were evaluated in this study showed satisfactory performance in predicting in-hospital mortality following surgery for IE. The ANCLA score should be preferred.

Safe cross-clamp time using Custodiol®-histidine-tryptophan-ketoglutarate cardioplegia in the adult.

INTRODUCTION: Safe cross-clamp time using single-dose Custodiol®-histidine-tryptophan-ketoglutarate cardioplegia has not been established conclusively. METHODS: Immediate post-operative outcomes of 1,420 non-consecutive, cardiac surgery patients were reviewed retrospectively. Predictors of a combined endpoint made of in-hospital mortality and any major complication post-surgery were found with the multivariable method. Analysis of variance was used to evaluate the impact of cross-clamp time on most relevant complications. Discriminatory power and cut-off value of cross-clamp time were established for in-hospital mortality and each of the major complications (receiver operating characteristic curve analysis). A comparative analysis (with propensity matching) with multidose cold blood cardioplegia on in-hospital mortality post-surgery was performed in non-coronary surgery patients. RESULTS: Coronary, aortic valve and mitral valve surgery and surgery on thoracic aorta were performed in 45.4%, 41.9%, 49.5%, 20.6% of cases, respectively. In-hospital mortality and the rate of any major complication post-surgery were 6.5% and 41.9%, respectively. Cross-clamp time had significant impact on in-hospital mortality and almost all major post-operative complications, except neurological dysfunctions (p = 0.084), myocardial infarction (p = 0.12) and mesenteric ischaemia (p = 0.85). Areas under the receiver operating characteristic curve and the optimal cut-off values for in-hospital mortality and any major complication were of 0.657, 0.594, >140 and >127 minutes, respectively. Comorbidities-adjusted odds ratio for any major complication of cross-clamp time <127 minutes was 1.86 (p < 0.0001). Despite similar in-hospital mortality (p = 0.57), there was an earlier significant increase of mortality in Custodiol-HTK than in multidose cold blood propensity-matched, non-coronary surgery patients. CONCLUSIONS: The use of Custodiol-HTK cardioplegia is associated with a low risk of serious post-operative complications provided that cross-clamp time is of 2 hours or less.

Early and Late Survival of On-Pump Cardiac Surgery Patients Formerly Affected by Lymphoma.

BACKGROUND: Survival after cardiac surgery of patients formerly affected by lymphoma has not been well defined. METHODS: Forty-five consecutive patients having prior Hodgkin's (HL patients, n=26) or non-Hodgkin's lymphoma (non-HL patients, n=19) underwent on-pump cardiac surgery at the authors' institution (2001-2016). Ischaemic, valvular, and ischaemic plus valvular heart disease were present in 14, 13, and 18 patients, respectively. Concomitant aortic disease was treated in three cases. The expected operative risk was calculated by the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II. The 10-year survival was estimated by the Kaplan-Meier method and the Charlson Comorbidity Index (CCI). The Cox proportional-hazards regression was used to evaluate the effect of some risk factors on survival. RESULTS: With respect to non-HL patients, HL patients were younger (mean age, 52.5 vs. 64.7 years, p=0.0017) and underwent cardiac surgery later after lymphoma occurrence (median gap, 21.5 vs. 9.6 years, p=0.0079). No other intergroup differences as baseline characteristics, risk profiles (median EuroSCORE II, 2.3% vs. 3%, p=0.78), and in-hospital mortality (7.7% vs. 10.5%, p=0.99) were found. Older age, severe left ventricular dysfunction, and HL history were predictors of cardiac or cerebrovascular death (p<0.1). The 10-year, crude (40.4%) and adjusted (39.1%) nonparametric estimates of survival were lower than the expected survival by CCI (77.5%, p<0.0001). The 10-year nonparametric estimate of freedom from malignancy was 66.3%. CONCLUSIONS: Immediate and long-term survival after on-pump cardiac surgery of patients formerly affected by lymphoma were worse than expected, according to universally used predictive scoring systems. There was an increased risk of malignant tumour.

Clinical Validation of a Coronary Surgery Technique That Minimizes Aortic Manipulation.

BACKGROUND: To minimize aortic manipulation and maximize use of arterial conduits are aims of modern coronary surgery. METHODS: From March 2012 to October 2016, 890 consecutive patients with multivessel coronary disease underwent isolated coronary operations using both internal thoracic arteries (ITAs). In 205 (23%; mean age, 67.6 ± 9.2 years), the right ITA was proximally transected and used as a free graft, while its in situ stump was elongated with a saphenous vein graft. The new arteriovenous I conduit was directed to the inferolateral cardiac wall. Operative data and early outcomes of these patients (I group) were compared with the remaining 685 patients (control [C] group). Early and late outcomes were also compared in 184 pairs identified with propensity score matching. RESULTS: Between the I and C groups there was no significant difference in expected operative risk (European System for Cardiac Operative Risk Evaluation II, p = 0.28), although diseased ascending aorta (p < 0.0001) and critical preoperative state (p = 0.027) were more frequent in the I group. Despite a higher number of coronary anastomoses (mean, 4 ± 0.9 vs 3.7 ± 1, p < 0.0001), cardiopulmonary bypass time was shorter in the I group both in overall (86.7 ± 23.7 vs 105.7 ± 34.2 minutes, p < 0.0001) and matched series (86.8 ± 24.1 vs 108.8 ± 31.9 minutes, p < 0.0001). In-hospital mortality (1% vs 1.9%, p = 0.54) and the rates of postoperative complications were similar. During the follow-up period, no intergroup difference was found in matched patients in the nonparametric estimates of freedom from all-cause death (p = 0.39) and major adverse cardiac and cerebrovascular events (p = 0.44). CONCLUSIONS: Surgery using this arteriovenous I conduit is safe, minimizes aortic manipulation, shortens cardiopulmonary bypass time, and aids complete revascularization.

The fate of patients having deep sternal infection after bilateral internal thoracic artery grafting in the negative pressure wound therapy era.

BACKGROUND: Late survival of patients having deep sternal wound infection (DSWI) after bilateral internal thoracic artery (BITA) grafting is largely unexplored. METHODS: Outcomes of 3391 consecutive BITA patients were reviewed retrospectively. Patients with DSWI after surgery (n = 142, 4.2%) were compared with those having no sternal complications (n = 3177). Predictors of DSWI and of mortality during the follow-up period were found with negative-binomial and Cox proportional-hazards regression, respectively. One-to-one propensity score-matched analysis, which considered simultaneously baseline patient characteristics, operative data, and postoperative complications was performed. The resulting matched pairs were compared for non-parametric estimates of late survival. The same comparison was performed in matched pairs having no major complications (except DSWI) early after surgery. RESULTS: In-hospital mortality was higher in DSWI cohort than in patients having no sternal complications (5.6% vs. 1.8%, p = 0.0035). Almost all of postoperative complications were more frequent in DSWI patients. Female sex, obesity, chronic lung disease, renal impairment, extracardiac arteriopathy, congestive heart failure, and urgent/emergency priority were predictors of DSWI common to two DSWI risk models that were developed. DSWI was independent predictor of reduced late survival (multiple covariates-adjusted hazard ratio [HR], 1.91, p < 0.0001). The propensity matching resulted in 135 pairs with same in-hospital mortality (5.2%). Estimates of freedom from all-cause death were lower in DSWI cohort (HR, 1.92, p < 0.0001), even when only pairs (n = 59) having no major postoperative complications (except DSWI) were considered (HR, 1.84, p = 0.026). CONCLUSIONS: DSWI after BITA use seems to reduce late survival even after adjusting for baseline patient characteristics and concomitant postoperative complications.