Combined Treatment With Carotid Endoarterectomy and Coronary Artery Bypass Grafting: A Single-Institutional Experience in 222 Patients.

INTRODUCTION: Carotid atherosclerotic disease is a known independent risk factor of post operative stroke after coronary artery bypass grafting (CABG). The best management of concomitant coronary artery disease and carotid artery disease remains debated. Current strategies include simultaneous carotid endoarterectomy (CEA) and CABG, staged CEA followed by CABG, staged CABG followed by CEA, staged transfemoral carotid artery stenting (TF-CAS) followed by CABG, simultaneous TF-CAS and CABG and transcarotid artery stenting. METHODS: We report our experience based on a cohort of 222 patients undergoing combined CEA and CABG surgery who come to our observation from 2004 to 2020. All patients with >70% carotid stenosis and severe multivessel or common truncal coronary artery disease underwent combined CEA and CABG surgery at our instituion. 30% of patients had previously remote neurological symptoms or a cerebral CT-scan with ischemic lesions. Patients with carotid stenosis >70%, either asymptomatic or symptomatic, underwent CT-scan without contrast media to assess ischemic brain injury, and in some cases, if necessary, CT-angiography of the neck and intracranial vessels. RESULTS: The overall perioperative mortality rate was 4.1% (9/222 patients). Two patients (.9%) had periprocedural ipsilateral transient ischemic attack (TIA) which completely resolved by the second postoperative day. Two patients (.9%) had an ipsilateral stroke, while 7 patients (3.2%) had a stroke of the controlateral brain hemisphere. Two patients (.9%) patients were affected by periprocedural coma caused by cerebral hypoperfusion due to perioperative heart failure. There were no statistically significant differences between patients in Extracorporeal Circulation (ECC) and Off-pump patients in the onset of perioperative stroke. CONCLUSION: Our experience reported that combined surgical treatment of CEA and CABG, possibly Off-Pump, is a feasible treatment procedure, able to minimize the risk of post-operative stroke and cognitive deficits.

Effects of Sodium-Glucose Transporter 2 Inhibitors (SGLT2-I) in Patients With Ischemic Heart Disease (IHD) Treated by Coronary Artery Bypass Grafting via MiECC: Inflammatory Burden, and Clinical Outcomes at 5 Years of Follow-Up.

Introduction: Minimally invasive extracorporeal circulation (MiECC) reduced inflammatory burden, leading to best clinical outcomes in patients treated with coronary artery bypass grafting (CABG). Despite this, the patients with type 2 diabetes mellitus (T2DM) vs those without T2DM (non-T2DM) have a worse prognosis, caused by over-inflammation and modulated by sodium-glucose transporter 2 receptors. However, we evaluated the inflammatory burden and clinical outcomes in non-T2DM vs T2DM patients under sodium-glucose transporter 2 inhibitors (SGLT2-I users) vs non-SGLT2-I users at 5 years of follow-up post-CABG via MiECC. Materials and methods: In a multicenter study, we screened consecutive patients with indications to receive CABG. The study endpoints were the inflammatory burden (circulating serum levels of tumor necrosis factor-alpha (TNF-α), interleukin 1 and 6 (IL-1 and IL-6), C-reactive protein (CRP), and leucocytes count) and the clinical outcomes at follow-up of 5 years in non-T2DM vs SGLT2-I users, in non-T2DM vs non-SGLT2-I users, and SGLT2-I users vs non-SGLT2-I users. Results: At baseline, and at one year and 5 years of follow-up, the non-T2DM vs SGLT2-I users, non-T2DM vs non-SGLT2-I users, and SGLT2-I users vs non-SGLT2-I users had the lowest values of IL-1, IL-6, and TNF-α (p < 0.05). At one year of follow-up, SGLT2-I users vs non-T2DM and non-SGLT2-I users vs non-T2DM users had a higher rate of all deaths, cardiac deaths, re-myocardial infarction, repeat revascularization, and stroke, and of the composite endpoint (p < 0.05). In a multivariate Cox regression analysis, the composite endpoint was predicted by IL-1 [2.068 (1.367-3.129)], TNF-α [1.989 (1.081-2.998)], and SGLT2-I [0.504 (0.078-0.861)]. Conclusion: In T2DM patients, the SGLT2-I significantly reduced the inflammatory burden and ameliorated clinical outcomes at 5 years of follow-up post-CABG via MiECC.

Intramural haematoma of the thoracic aorta: A case series.

We reported four cases of intramural haematoma of the descending thoracic aorta. Four patients, aged 55-82 years, hypertensive, were transferred from the emergency room of other hospitals due to the appearance of epigastric pain and left thorax pain. All patients underwent computed tomography angiography reporting the presence of intramural haematoma. Three patients underwent a drug therapy to maintain a controlled hypotension. A computed tomography revaluation was performed documenting (1) an increase in the thickness of the intramural haematoma, (2) the appearance of a penetrating ulcer within the haematoma and (3) the appearance of several penetrating lesions throughout the thoracic aorta. Patients required the placement of one or two thoracic aorta endoprosthesis. For the fourth patient, the hyperdense appearance of the intramural haematoma and the presence of pleural effusion suggested an urgent treatment intervention. All patients underwent a placement of cerebrospinal fluid catheter and drainage before treatment. All patients were treated with endovascular intervention with 100% technical success and absence of migration or retrograde type A dissection. There were no complications related to femoral surgical access or access routes. Perioperative mortality was null; no patient had paraplegia. No strokes, transient ischemic attack or perioperative myocardial infarction were observed. The average hospitalization was 5 days. After 3 months, angio-computed tomography reported for all patients a complete reabsorption of the intramural haematoma and a complete exclusion of the penetrating ulcer of the aortic wall present at the time of the intervention. There have been no cases of distant thoracic aortic tears. Endovascular treatment must be considered the preeminent treatment for thoracic aortic haematoma. Best timing to perform the endovascular procedure depends on the patient clinical picture and on stability of hemodynamic parameters.

The secret life of the mitral valve.

In secondary mitral regurgitation, the concept that the mitral valve (MV) is an innocent bystander, has been challenged by many studies in the last decades. The MV is a living structure with intrinsic plasticity that reacts to changes in stretch or in mechanical stress activating biohumoral mechanisms that have, as purpose, the adaptation of the valve to the new environment. If the adaptation is balanced, the leaflets increase both surface and length and the chordae tendineae lengthen: the result is a valve with different characteristics, but able to avoid or to limit the regurgitation. However, if the adaptation is unbalanced, the leaflets and the chords do not change their size, but become stiffer and rigid, with moderate or severe regurgitation. These changes are mediated mainly by a cytokine, the transforming growth factor-ß (TGF-ß), which is able to promote the changes that the MV needs to adapt to a new hemodynamic environment. In general, mild TGF-ß activation facilitates leaflet growth, excessive TGF-ß activation, as after myocardial infarction, results in profibrotic changes in the leaflets, with increased thickness and stiffness. The MV is then a plastic organism, that reacts to the external stimuli, trying to maintain its physiologic integrity. This review has the goal to unveil the secret life of the MV, to understand which stimuli can trigger its plasticity, and to explain why the equation "large heart = moderate/severe mitral regurgitation" and "small heart = no/mild mitral regurgitation" does not work into the clinical practice.

Surgical mitral plasticity for chronic ischemic mitral regurgitation.

BACKGROUND AND AIM OF THE STUDY: The outcome of mitral valve (MV) repair for chronic ischemic mitral regurgitation (IMR) is suboptimal, due to the high recurrence rate of moderate or severe mitral regurgitation (MR) during follow-up. The MV adapts to new MR increasing its area to cover the enlarged annular area (mitral plasticity). As this process is often incomplete, we aimed to evaluate if augmenting the anterior leaflet (AL) and cutting the second-order chords (CC) together with restrictive mitral annuloplasty, a strategy we call "surgical mitral plasticity," could improve the midterm results of MV repair for IMR. MATERIALS AND METHODS: From November 2017 to October 2019, 22 patients with chronic IMR underwent surgical mitral plasticity. Mean age was 73 ± 7 years and six were female. Mean ejection fraction was 32% ± 11%, IMR grade was moderate in 10 and severe in 12. Mean clinical and echocardiographic follow-up was 12 ± 6 months. RESULTS: There was no early death, and one patient died 6 months after surgery. Ejection fraction improved from 32% ± 15% to 40% ± 6% (P = .031). IMR was absent or mild in all patients, and none showed recurrent moderate or more IMR. Tenting area decreased significantly from 2.5 ± 0.5 to 0.5 ± 0.3 cm² and coaptation length increased from 1.9 ± 0.7 to 7.8 ± 1.6 mm. All patients were in New York Heart Association class I or II. CONCLUSIONS: Mitral plasticity, if uncomplete, is ineffective in preventing IMR to become significant. Surgical mitral plasticity, by completing incomplete process of MV adaptation, has a strong rationale, which however needs to be validated with longer follow-up.

Association of tethering of the second-order chords and prolapse of the first-order chords of the anterior leaflet: A risk factor for early and late repair failure.

BACKGROUND AND AIM: Second-order chord tethering of the anterior leaflet is a risk factor for failure of posterior leaflet prolapse repair. MATERIALS AND METHODS: We describe two cases of second-order chord tethering of the anterior leaflet associated with severe mitral regurgitation due to prolapse or chordal rupture of the anterior leaflet, causing early and late failure of repair. RESULTS: We described two cases where this phenomenon happened. CONCLUSIONS: Our cases demonstrate that the second-order chords of the prolapsing AL can be tethered and that this aspect should be carefully evaluated before surgery, as it can progress over time, affecting the results of surgical repair.

Modulation of SERCA in Patients with Persistent Atrial Fibrillation Treated by Epicardial Thoracoscopic Ablation: The CAMAF Study.

OBJECTIVES: To evaluate atrial fibrillation (AF) recurrence and Sarcoplasmic Endoplasmic Reticulum Calcium ATPase (SERCA) levels in patients treated by epicardial thoracoscopic ablation for persistent AF. BACKGROUND: Reduced levels of SERCA have been reported in the peripheral blood cells of patients with AF. We hypothesize that SERCA levels can predict the response to epicardial ablation. METHODS: We designed a prospective, multicenter, observational study to recruit, from October 2014 to June 2016, patients with persistent AF receiving an epicardial thoracoscopic pulmonary vein isolation. RESULTS: We enrolled 27 patients. Responders (n = 15) did not present AF recurrence after epicardial ablation at one-year follow-up; these patients displayed a marked remodeling of the left atrium, with a significant reduction of inflammatory cytokines, B type natriuretic peptide (BNP), and increased levels of SERCA compared to baseline and to nonresponders (p < 0.05). Furthermore, mean AF duration (Heart rate (HR) 1.235 (1.037-1.471), p < 0.05), Left atrium volume (LAV) (HR 1.755 (1.126-2.738), p < 0.05), BNP (HR 1.945 (1.895-1.999), p < 0.05), and SERCA (HR 1.763 (1.167-2.663), p < 0.05) were predictive of AF recurrence. CONCLUSIONS: Our data indicate for the first time that baseline values of SERCA in patients with persistent AF might be predictive of failure to epicardial ablative approach. Intriguingly, epicardial ablation was associated with increased levels of SERCA in responders. Therefore, SERCA might be an innovative therapeutic target to improve the response to epicardial ablative treatments.

Effects of Alpha Lipoic Acid on Multiple Cytokines and Biomarkers and Recurrence of Atrial Fibrillation Within 1 Year of Catheter Ablation.

Catheter ablation (CA) is a procedure commonly used to restore sinus rhythm in patients with atrial fibrillation (AF). However, AF recurrence after CA remains a relevant clinical issue. We tested the effects of an oral antioxidant treatment (alpha lipoic acid [ALA]) on AF recurrence post-CA. Patients with paroxysmal AF have been enrolled in a randomized, prospective, double-blind, controlled placebo trial. After CA, patients have been randomly assigned to receive ALA oral supplementation (ALA group) or placebo (control group) and evaluated at baseline and after a 12-month follow-up: 73 patients completed the 12-month follow-up (ALA: 33 and control: 40). No significant difference has been detected between the 2 groups at baseline. Strikingly, 1 year after CA, ALA therapy significantly reduced serum markers of inflammation. However, there was no significant difference in AF recurrence events at follow-up comparing ALA with placebo group. Multivariate analysis revealed that the only independent prognostic risk factor for AF recurrence after CA is age. In conclusion, ALA therapy reduces serum levels of common markers of inflammation in ablated patients. Nevertheless, ALA does not prevent AF recurrence after an ablative treatment.

Novel apical coring device for apicoaortic conduit insertion to treat off-pump aortic stenosis, coronary disease, and lung cancer.

The surgical treatment of concomitant cardiac disease and lung cancer represents a challenge. We report the case of a 66-year-old high-risk female patient with severe aortic stenosis as well as severely impaired left ventricular function associated with coronary artery disease involving the left anterior descending artery complicated from a severe functional mitral regurgitation in which an early-stage non-small cell carcinoma was incidentally discovered during workup. Because of the possibility of potential negative impact of cardiopulmonary bypass on the cancer prognosis and the severe impairment of systolic function of the left ventricle that impeded the treatment of lung cancer as the first step of such a complex treatment, we planned to treat all the diseases in a single-stage procedure. Using an automated delivering system composed of a ventricular connector (Correx AVB; Correx, Inc, Waltham, MA USA), we were able to perform an apicoaortic bypass as well as a left anterior descending revascularization using the left internal thoracic artery, both on a beating heart without the aid of cardiopulmonary bypass and a three-segmentectomy of the left upper lobe with the removal of paraaortic nodes. Six months postoperatively, she was asymptomatic with a noticeable increase of systolic function, a mild mitral incompetence, and no appearance of tumor recurrence. To the best of our knowledge, this is the first case described in the literature in which three major problems involving cardiac valves, coronary arteries, and the lung have been treated in one stage without cardiopulmonary bypass.

Implantation of a new mitral ring, adjustable during follow-up: a simplified technique.

Mitral valve repair for ischaemic mitral incompetence has a 10% rate of failure at ten year follow-up. Progressive annular dilation could play an important role. We have implanted the enCor(SQ)(TM) mitral valve repair system. This system can be downsized during follow-up with the appropriate activation via the lead passed through the left atrium suture line, in order to restore mitral leaflet coaptation.

Pseudoaneurysm after patch-free carotid bifurcation endarterectomy: a case report.

The purpose of this report is to present the case of a 59-year-old man affected by multivessel coronary artery disease and sterile pseudoaneurysm of the right carotid bifurcation presenting as a pulsating neck mass 1 month after patch-free carotid endarterectomy. The surgical approach included median sternotomy and incision parallel to the anterior margin of the right sternocleidomastoid muscle. The pseudoaneurysm was excised after control of the brachiocefalic trunk and insertion of a Pruit-Inahara shunt, and the carotid vessels were directly sutured without using any prosthetic or autologous material. Concomitant coronary bypass grafting was performed. The postoperative course was uneventful and there was no evidence of recurrence of pseudoaneurysm at 6-month follow-up. On the basis of this experience and of pertinent literature, the options for the management of such rare entities are discussed.

Evaluation of less invasive method for saphenous vein harvest in patients with type II diabetes.

BACKGROUND: Diabetes mellitus is an established risk factor for leg wound healing complications after great saphenous vein harvest. Leg healing complications occur in 1-25% of coronary artery bypass graft patients, and are often underestimated. PATIENTS AND METHODS: The records of 230 patients enrolled in a prospective trial to evaluate a minimally invasive approach compared with conventional longitudinal harvest were reviewed. Of 100 patients with diabetes, 49 had undergone minimally invasive harvest (group A). Forty-nine patients from the pool without diabetes who underwent minimally invasive harvest were selected using propensity scoring analysis (group B), and 46 diabetic patients operated using a conventional technique (group C) were matched to group A patients. Ninety-five patients with and 49 without diabetes finally entered the study. The quality of leg wound healing was quantified by ASEPSIS score by two independent surgeons in a blinded manner. The occurrence of complications was compared between groups. RESULTS: Fewer leg wound healing complications occurred in diabetic patients in the minimally invasive compared with the conventional group (P < 0.0001). Rates of complications were comparable among diabetic and non-diabetic patients operated using the minimally invasive technique. The intraoperative flow of vein grafts obtained by the minimally invasive technique was comparable to that of veins harvested using the conventional technique. CONCLUSION: These data suggest that postoperative leg wound morbidity can be significantly attenuated by the adoption of a less invasive approach, even in high-risk patients with diabetes. The advantages are not offset by the co-existence of other cardiovascular risk factors or by a long history of diabetes.

Open clip-free radial artery harvesting with the harmonic shears.

BACKGROUND: The Ultracision Harmonic Scalpel is associated with several advantages in radial artery (RA) harvesting. It allows fewer hemostatic clips to close the collateral branches, less thermal injury of the conduit, and reduced time of harvesting in comparison with the conventional RA harvesting technique with electrocautery and hemostatic clips. We recently started open RA harvesting with the harmonic shears (HSH). In this study, we aimed at evaluating the feasibility of this simplified ultrasonically activated harvesting technique, and report the results of RA harvesting with HSH. METHODS: The RA harvesting with HSH was performed in 20 patients operated on for myocardial revascularization from July 2004 to December 2005. RESULTS: The harvest of the RA was completed in little time, without any complication. Neither bleeding from the collateral branches nor spasm alongside the entire length of the RA was observed. No bleeding occurred from the muscles of the forearm. CONCLUSION: This technique of RA harvesting with HSH is impressive in terms of short time of harvest, complete absence of clips for the collateral branches, and no thermal injury of the conduit.

The "button inside" technique for the aortic root replacement: a modified button technique.

Modified button technique for reattachment of coronary arteries in the aortic root replacement is reported. Anastomosis of the coronary buttons is performed from the inside of the composite valve graft previously including the coronary buttons in the composite valve graft. Reduced tension is present between coronary arteries and the composite valve graft once the heart is beating and the systemic pressure is increasing. In this way coronary buttons are reinforced directly by the composite aortic wall graft prosthesis. The coronary ostia are perfused with lower tension at the site of the coronary anastomoses. No bleeding from the suture line of the coronary buttons occurs using this new surgical approach.

[Two cardiac tumors with left ventricular location: myxoma and papillary fibroelastoma]. / Due rari casi di tumori cardiaci in sede ventricolare sinistra: mixoma ventricolare e fibroelastoma papillare.

We report 2 clinical cases of cardiac tumors, myxoma and papillary fibroelastoma, with unusual ventricular location. The clinical manifestations of these entities are not well described. Usually the patients are asymptomatic even if they have a high risk for cardiac and systemic embolic events so that these neoplasms are recognized during life more often in patients evaluated for embolic events of unclear pathology. The routine use of echocardiography has increased the detection of these tumors in living patients. In the surgical treatment, the approach should allow minimal manipulation of the tumors, inspection of all four cardiac chambers to overlook if tumors are multifocal and provide adequate exposure for complete resection. In our experience, we used two surgical approaches, via the left ventricle and via the aortic valve.

[Repair of post-infarct left ventricular rupture with pericardial patch]. / Tecnica di riparazione della rottura della parete libera del ventricolo postinfartuale con "patch" di pericardio.

The devolpment of a left ventricular rupture after myocardial infarction is not a rare complication. We report a case of 70-year-old male patient with clinical and instrumental signs of cardiac tamponade after left ventricular rupture. We repaired this lesion with pericardial patch and biological Glue without extracorporeal circulation and sutureless.

[Repair technique of post-infarction ventricular free wall rupture with pericardial patch]. / Tecnica di riparazione della rottura della parete libera del ventricolo postinfartuale con "patch" di pericardio.

The development of a left ventricular rupture after myocardial infarction is not a rare complication. We report a case of 70-year-old male patient with clinical and instrumental signs of cardiac tamponade after left ventricular rupture. We repaired this lesion with pericardial patch and biological Glue without extracorporeal circulation and sutureless.