Progression of the ascending aorta diameter after surgical or transcatheter bicuspid aortic valve replacement.

OBJECTIVES: Ascending aorta dilatation in patients with bicuspid aortic valve is related both to genetic and haemodynamic factors. Aim of this study is to compare late progression of ascending aorta dilatation in bicuspid aortic valve patients undergoing surgical aortic valve replacement (SAVR) vs transcatheter aortic valve implantation (TAVI). METHODS: Data of 189 consecutive patients who underwent aortic valve replacement for severe bicuspid aortic valve stenosis were prospectively collected. Patients who underwent SAVR were compared to patients who underwent TAVI. Indication to the procedure was validated by the institutional Heart Team. Aortic diameters were evaluated by transthoracic echocardiogram. Differences between preoperative and long-term follow-up ascending aorta diameters were compared in the two groups. RESULTS: Between January 2015 and December 2021, 143(76%) patients underwent SAVR and 46(24%) patients underwent TAVI. At 4.6 (Standard Deviation, SD 1.7) years follow-up, patients in the TAVI group showed significantly lower survival (P = 0.00013) and event-free survival (P < 0.0001). Ascending aorta diameter progression was lower in surgical compared to transcatheter patients, 0.95(0.60,1.30) mm vs 1.65(0.67, 2.63) mm, P = 0.02. Ascending aorta diameter progression indexed for body surface area and height, was lower in the surgical group: 0.72(0.38,1.05) mm/m2 vs 1.05(0.39,1.71) mm/m2 P = 0.02, and 0.59(0.36,0.81) mm/m vs 1.11(0.44,1.78) mm/m, P = 0.001, respectively. At multivariable linear regression analysis transcatheter procedure, baseline aortic diameter, and paravalvular leak were significantly associated with increased postoperative ascending aorta dilatation. CONCLUSIONS: Bicuspid aortic valve patients who underwent SAVR, showed significantly less long-term ascending aorta diameter progression than patients who underwent transcatheter procedure.

Outcomes of Minimally Invasive Aortic Valve Replacement in Obese Patients: A Propensity-Matched Study.

INTRODUCTION: Obese patients are at risk of complications after cardiac surgery. The aim of this study is to investigate safety and efficacy of a minimally invasive approach via upper sternotomy in this setting. METHODS: We retrospectively reviewed 203 obese patients who underwent isolated, elective aortic valve replacement between January 2014 and January 2023 - 106 with minimally invasive aortic valve replacement (MIAVR) and 97 with conventional aortic valve replacement (CAVR). To account for baseline differences, a propensity-matching analysis was performed obtaining two balanced groups of 91 patients each. RESULTS: The 30-day mortality rate was comparable between groups (1.1% MIAVR vs. 0% CAVR, P=0.99). MIAVR patients had faster extubation than CAVR patients (6 ± 2 vs. 9 ± 2 hours, P<0.01). Continuous positive airway pressure therapy was less common in the MIAVR than in the CAVR group (3.3% vs. 13.2%, P=0.03). Other postoperative complications did not differ significantly. Intensive care unit stay (1.8 ± 1.2 vs. 3.2 ± 1.4 days, P<0.01), but not hospital stay (6.7 ± 2.1 vs. 7.2 ± 1.9 days, P=0.09), was shorter for MIAVR than for CAVR patients. Follow-up survival was comparable (logrank P-value = 0.58). CONCLUSION: MIAVR via upper sternotomy has been shown to be a safe and effective option for obese patients. Respiratory outcome was promising with shorter mechanical ventilation time and reduced need for post-extubation support. The length of stay in the intensive care unit was reduced. These advantages might be important for the obese patient to whom minimally invasive surgery should not be denied.

Outcomes of Minimally Invasive Aortic Valve Replacement in Obese Patients: A Propensity-Matched Study

ABSTRACT Introduction: Obese patients are at risk of complications after cardiac surgery. The aim of this study is to investigate safety and efficacy of a minimally invasive approach via upper sternotomy in this setting. Methods: We retrospectively reviewed 203 obese patients who underwent isolated, elective aortic valve replacement between January 2014 and January 2023 - 106 with minimally invasive aortic valve replacement (MIAVR) and 97 with conventional aortic valve replacement (CAVR). To account for baseline differences, a propensity-matching analysis was performed obtaining two balanced groups of 91 patients each. Results: The 30-day mortality rate was comparable between groups (1.1% MIAVR vs. 0% CAVR, P=0.99). MIAVR patients had faster extubation than CAVR patients (6 ± 2 vs. 9 ± 2 hours, P<0.01). Continuous positive airway pressure therapy was less common in the MIAVR than in the CAVR group (3.3% vs. 13.2%, P=0.03). Other postoperative complications did not differ significantly. Intensive care unit stay (1.8 ± 1.2 vs. 3.2 ± 1.4 days, P<0.01), but not hospital stay (6.7 ± 2.1 vs. 7.2 ± 1.9 days, P=0.09), was shorter for MIAVR than for CAVR patients. Follow-up survival was comparable (logrank P-value = 0.58). Conclusion: MIAVR via upper sternotomy has been shown to be a safe and effective option for obese patients. Respiratory outcome was promising with shorter mechanical ventilation time and reduced need for post-extubation support. The length of stay in the intensive care unit was reduced. These advantages might be important for the obese patient to whom minimally invasive surgery should not be denied.

The multidisciplinary Heart Team approach for patients with cardiovascular disease: a step towards personalized medicine.

AIMS: Despite general agreement on the benefits of the Heart Team approach for patients with cardiac diseases, few data are available on its real impact on the decision-making process. The aim of the study is to define the evolution over time of the level of agreement with the systematic discussion of patients in the Heart Team and to evaluate the adherence to the Heart Team recommendations and the impact of the Heart Team on the clinical outcome of the patients. METHODS: In 2015--2016, an experienced cardiac surgeon and a cardiologist independently reviewed clinical data of a series of 100 patients (Group 1, G1) and subsequently for each patient recommended treatment (surgical, percutaneous, hybrid or medical therapy) or further diagnostic investigations. The next day, each case was discussed by the Hospital Heart Team. The Heart Team recommendation, the subsequent treatment received by the patient and the in-hospital outcome were recorded. The same study procedure was repeated in 2017 in a second (G2) and in 2018 in a third (G3) group, both of them including 100 patients. RESULTS: Complete agreement in treatment selection by the cardiac surgeon, cardiologist and the Heart Team was observed in 43% of cases in G1 and in 70% and 68% in G2 and G3, respectively (G1 vs. G2: P  < 0.001, G1 vs. G3: P  = 0.01, G2 vs. G3: P  = 0.30). Agreement was less frequent in patients with a higher risk profile and in patients with aortic valve stenosis. The Heart Team decision was implemented in 95% of cases with a 30-day mortality of 0.67%. CONCLUSION: Agreement in treatment selection among the cardiac surgeon, cardiologist and Heart Team appears to be low in the initial experience. Subsequently, it seems to steadily increase over time up to a limit, when it reaches a plateau of stable results. Heart Team clinical cases discussion, based on both guidelines and multidisciplinary experience, represents a key step in defining the best patient treatment pathway, potentially improving the decision-making process and clinical results.

Comparison of De-Kay repair versus De Vega suture for functional tricuspid regurgitation: a preliminary experience.

BACKGROUND: In patients undergoing mitral valve surgery, restrictive suture annuloplasty (De Vega) for less-than-severe functional tricuspid regurgitation has been proven to be safe and effective. The aim of this study is to determine whether the adjunct of the plication of the posterior tricuspid leaflet with the same running suture (bicuspidized De Vega or "De Kay") is equally safe and effective. METHODS: Single center, retrospective study on patients submitted to suture repair of the tricuspid valve during mitral valve surgery, with either conventional or De Kay, between January 2014 and December 2020. Comparison was based on degree of residual tricuspid valve regurgitation and right ventricular assessment at discharge. RESULTS: Over the course of the study period, 255 patients undergoing mitral valve surgery had a dilated (>40 mm or >20 mm/m2) tricuspid valve annulus, with less-than-severe tricuspid regurgitation. Conventional De Vega was employed in 166 patients (65.1%) and De Kay in the remaining 89 (34.9%). At discharge the adjunct of postero-septal commissure plication has similar outcomes to the classic De Vega repair. It seems to preserve right ventricular function. CONCLUSIONS: De Kay repair guarantees the same tricuspidal regurgitation reduction as compared with conventional De Vega early after surgery.

MINOCA Associated with a Myocardial Bridge: Pathogenesis, Diagnosis and Treatment.

Myocardial bridging (MB) is the most frequent congenital coronary anomaly characterized by a segment of an epicardial coronary artery that passes through the myocardium. MB is an important cause of myocardial ischemia and is also emerging as a possible cause of myocardial infarction with non-obstructed coronary arteries (MINOCA). There are multiple mechanisms underlying MINOCA in patients with MB (i.e., MB-mediated increased risk of epicardial or microvascular coronary spasm, atherosclerotic plaque disruption and spontaneous coronary artery dissection). The identification of the exact pathogenetic mechanism is crucial in order to establish a patient-tailored therapy. This review provides the most up-to-date evidence regarding the pathophysiology of MINOCA in patients with MB. Moreover, it focuses on the available diagnostic tools that could be implemented at the time of coronary angiography to achieve a pathophysiologic diagnosis. Finally, it focuses on the therapeutic implications associated with the different pathogenetic mechanisms of MINOCA in patients with MB.

The metaverse in medicine.

The metaverse is an alternative digital world, accessed by means of dedicated audiovisual devices. In this parallel world, various forms of artificial intelligence meet, including individuals in the form of digital copies of real people (avatars), able to interact socially. Metaverse in medicine may be used in many different ways. The possibility to perform surgery at a distance of thousands of miles separating the patient from the surgeon, who could have also the possibility to visualize in real-time patient's clinical data, including diagnostic images, obviously is very appealing. It would be also possible to perform medical treatments and to adopt pharmacological protocols on human avatars clinically similar to the patients, thus observing treatment effects in advance and significantly reducing the clinical trials duration. Metaverse may reveal an exceptional educational tool, offering the possibility of interactive digital lessons, allowing to dissect and to study an anatomical apparatus in detail, to navigate within it, not only to study, but also to see the evolution of the pathological process, and to simulate in advance surgical or medical procedures on virtual patients. However, while artificial intelligence is now an established reality in the clinical practice, the metaverse is still in its initial stages, and to figure out its potential usefulness and reliability, further developments are expected.

The Sodium-Glucose Co-Transporter-2 (SGLT2) Inhibitors Reduce Platelet Activation and Thrombus Formation by Lowering NOX2-Related Oxidative Stress: A Pilot Study.

Sodium−glucose co-transporter-2 inhibitors or gliflozins, the newest anti-hyperglycemic class, induce cardioprotective benefits in patients with type 2 diabetes (T2D). As platelet activation and oxidative stress play a key role in atherothrombotic-related complications, we hypothesized that gliflozins might modulate oxidative stress, platelet activation and thrombus formation. We performed an interventional open-label single-arm before-after study in 32 T2D patients on top of their ongoing metformin therapy. The population was divided into two groups: treatment with GLP-1 receptor agonists (GLP-1RA, Group A) and gliflozins (Group B). Oxidative stress, platelet activation and thrombus growth were assessed before and after 15 days of treatment. Compared to the baseline, gliflozins treatment significantly decreased sNOX2-dp (−45.2%, p < 0.001), H2O2 production (−53.4%, p < 0.001), TxB2 (−33.1%, p < 0.001), sP-selectin (−49.3%, p < 0.001) and sCD40L levels (−62.3%, p < 0.001) as well as thrombus formation (−32%, p < 0.001), whereas it potentiated anti-oxidant power (HBA, +30.8%, p < 0.001). Moreover, a significant difference in oxidative stress, platelet activation and thrombus formation across groups A and B was found. In addition, an in vitro study on stimulated platelets treated with gliflozins (10−30 µM) showed a reduction in oxidative stress, platelet activation and thrombus growth. Our results showed that gliflozins have antiplatelet and antithrombic activity related to an NOX2 down-regulation, suggesting a new mechanism responsible for cardiovascular protection.

Natural Activators of Autophagy Increase Maximal Walking Distance and Reduce Oxidative Stress in Patients with Peripheral Artery Disease: A Pilot Study.

Trehalose, spermidine, nicotinamide, and polyphenols have been shown to display pro-autophagic and antioxidant properties, eventually reducing cardiovascular and ischemic complications. This study aimed to investigate whether a mixture of these components improves maximal walking distance (MWD) in peripheral artery disease (PAD) patients. Nitrite/nitrate (NOx), endothelin-1, sNOX2-dp, H2O2 production, H2O2 break-down activity (HBA), ATG5 and P62 levels, flow-mediated dilation (FMD), and MWD were evaluated in 20 PAD patients randomly allocated to 10.5 g of mixture or no-treatment in a single-blind study. The above variables were assessed at baseline and 60 days after mixture ingestion. Compared with baseline, mixture intake significantly increased MWD (+91%; p < 0.01) and serum NOx (+96%; p < 0.001), whereas it significantly reduced endothelin-1 levels (−30%, p < 0.01). Moreover, mixture intake led to a remarkable reduction in sNOX2dp (−31%, p < 0.05) and H2O2 (−40%, p < 0.001) and potentiated antioxidant power (+110%, p < 0.001). Finally, mixture ingestion restored autophagy by increasing ATG5 (+43%, p < 0.01) and decreasing P62 (−29%, p < 0.05). No changes in the above-mentioned variables were observed in the no-treatment group. The treatment with a mixture of trehalose, spermidine, nicotinamide, and polyphenols improves MWD in PAD patients, with a mechanism possibly related to NOX2-mediated oxidative stress downregulation and autophagic flux upregulation. Clinical Trial Registration unique identifier: NCT04061070.

Usability, performance and safety of a new device for degenerative mitral regurgitation: in vivo chronic evaluation.

OBJECTIVES: This study aimed to evaluate the usability, performance and safety of an innovative mitral valve device in the chronic setting characterized by an intraventricular bridge, which enables artificial chordae anchoring and/or direct posterior leaflet fixation. METHODS: Ten female sheep were employed and underwent device implantation. Any interference of the device with leaflet motion, ease of device use, correct chordae length estimation and implantation were evaluated. Post-procedural valve competence and device performance were verified by periodic postoperative echocardiograms and laboratory examinations. Following euthanasia, gross anatomy and histology evaluation of the hearts and valves were performed to detect tissue abnormalities and inflammation reaction related to the device. RESULTS: The procedure was successfully completed in all 10 sheep. Lengths of the 2 chordae implanted were 23 (21.5-24) mm and 23 (22.5-24) mm. The time required to suture both pairs of the artificial chordae was 2.7 ± 0.7 min. At the 3-month follow-up, left ventricular function was normal. The transvalvular peak pressure gradient was 9 (7.5-10) and the mean gradient was 4 (3.5-4) mmHg. Upon necropsy and histological evaluation, no damage to left ventricle wall, valve leaflets, chordae and papillary muscles and absence of thrombus formation and inflammatory reaction were observed. Radiological images showed neither fracture of the device nor calcifications. Laboratory tests showed no signs of haemolysis. CONCLUSIONS: In vivo late tests confirmed the ease of correct chordal length estimation prior to implantation, short operative time and usability in flailed anterior leaflet repair. The absence of negative impact of the device on mitral leaflets motion, function and structure and successful repair might suggest that the device would be useful in complex degenerative mitral disease.

[Cardiac glomus tumor: An unusual localization of pericytic (perivascular) tumor]. / Tumeur glomique intracardiaque : une tumeur péricytaire (périvasculaire) de localisation inhabituelle.

Glomus tumor are rare mesenchymal neoplasm, belonging to the pericytic (perivascular) tumor family, witch recent molecular characterization has allowed highlight recurrent molecular abnormalities. In fact, glomus tumor involves frequent MIR143-NOTCH gene fusion whereas others pericytic tumor (myopericytoma and myofibroma) involve mutations of PDGFRB gene. Glomus tumor are usually developed in superficial localization. However visceral locations have been described. Cardiac location is exceptional with only one case reported in literature. Here, we report the case of cardiac glomus tumor (glomangiomyoma) developed in the left ventricle in a 34 year-old patient, diagnosed after chest pain. The length of tumor was 4cm in greatest dimension. Histologically, the tumor concerned both round glomus cells and smooth muscle cells with prominent branching thin-walled vessels. By immunohistochemistry, these two contingents exhibited diffuse expression of smooth muscle actin and heterogeneous expression of H-caldesmone whereas cytokeratins, melanocytic markers and chomogranine were negative. Next Generation molecular analysis using RNA sequencing highlighted the characteristic MIR143-NOTCH gene fusion witch supports the diagnosis of glomus tumor. In this observation, we recall histological and immunohistochemistry features of glomus tumor and we make a synthesis concerning the molecular data recently described in sporadic glomus tumor.

A new device to treat mitral valve regurgitation: a proof of concept in bench test study.

Mitral valve repair is typically performed by implanting a ring-like device at the valve annulus to reshape the annulus and to improve leaflet coaptation. In most cases, some additional procedures are needed, including leaflet resection and artificial chordae implantation. However, artificial chordae implantation could be technically challenging and postoperative left ventricular remodeling could increase the risk of recurrent mitral regurgitation. We propose an innovative annular device made of chromo-cobalt, finalized not only to reshape the annulus but also to enable anchoring of leaflets to a fixed intraventricular structure. Durability evaluation of the device was tested by applying eight radial force vectors equally spaced along the ring and related fatigue analysis. To evaluate the efficacy of the mitral valvuloplasty using the tested ring, the device was implanted in five adult swine hearts. Functional analysis of the ring was performed by measuring left ventricular pressure and fluid volume loss, following implantation in normal and dysfunctional mitral valve leaflets. Both fatigue and functional analysis showed satisfactory and promising results in terms of durability and efficacy of mitral valve repair. Because of its favorable durability and functional characteristics this device appears promising and provides good results in terms of valve competence, thus avoiding both manipulations of papillary muscles and interference in left ventricular hemodynamics. However, an in vivo test is mandatory to fully understand the impact of the device on subvalvular apparatus.

Psychological Effects of Skin Incision Size in Minimally Invasive Valve Surgery Patients.

OBJECTIVE: Clinical benefits of minimally invasive cardiac valve surgery (MIVS) have been reported. Improved postoperative mental status was never analyzed with dedicated psychological tests. In the present study we intend to investigate potential benefits of MIVS for patient psychological well-being, with special attention to the relevance of the patient perception of the chest surgical scar, of the self body image and cosmetic aspects. METHODS: Between 2016 and 2017, 87 eligible patients, age 66.5 ± 14.5 years, operated on for heart valve surgery, underwent either conventional full sternotomy (CS; n = 48) or MIVS by V-shape hemi-sternotomy approach (n = 39). Before selection of the surgical approach, patients had undergone preoperative evaluation of their psychological status using Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory Form Y (STAI-Y), and EuroQol-5D (EQ-5D) psychological tests. Six months postoperatively, patients filled in dedicated questionnaires to assess their psychological status, quality of life, and subjective perception, thus repeating the above-mentioned tests and adding the Body Image Questionnaire (BIQ) and Patient and Observer Scar Assessment Scale (POSAS) v2.0 tests for scar-healing process evaluation. RESULTS: No patient died during the study.The 4 post-test scales of psychological well-being (BDI-II P = 0.04, STAI-Y P = 0.04, 2 indices of EQ-5D P = 0.03, P = 0.01) showed significant differences between the MIVS group and CS group, with MIVS-small incision patients having lower level of depression and anxiety symptoms and better quality of life. Mean score differences of scar perception (BIQ and POSAS v2.0) were significant, with MIVS patients having evaluated the scar quality significantly better than CS patients. CONCLUSIONS: MIVS appears associated with significant esthetical and related psychological benefits, as documented by technical tests. These findings should be considered when selecting the most appropriate technique for heart valve surgery.

The extended heart: cardiac surgery serving more hospitals.

The Heart Team is becoming ever more central in delivering cardiovascular care, embodying a modern aspect of medical practice, designed to place the patient at the 'center' of a team with different specialists, all contributing to the definition of the most appropriate therapeutic actions. We prospectively analyzed 200 consecutive patients (2015-2017). Patients were evaluated independently by a cardiologist and a cardiac surgeon, each deciding the most appropriate therapeutic action. At a later time, the same patient, was evaluated by the Heart Team. For the first 100 patients the rate of concurrence between cardiologist and cardiac surgeon as well as among each specialist and the Heart Team, was relatively low (51 and 42% respectively). For the following 100 patients the concurrence rate was significantly higher (75 and 70% respectively). The systematic and collegial discussion of the patients in the contest of the Heart Team, steered toward an evolution of each specialist in the group settings. The Electronic Heart Team (e-Heart Team) employing video conference support, applied to the first 65 patients with promising results, represent a further advancement in the delivery of care, by reducing the distance from the 'Hub' center, and the specialist in the 'Spoke' facility, who from simple source of the patient, now becomes an essential part of the therapeutic decision process. The Heart Team environment can deeply affect patients management and improve treatment results, by sharing the expertise and overcoming the limitations of the individual disciplines, thus reaching the common goal of the patient's best available treatment.

Left ventricular unloading during extracorporeal membrane oxygenation - Impella versus atrial septal defect: A simulation study.

BACKGROUND: Atrial septal defect and Impella have been proposed for left ventricular unloading in venoarterial extracorporeal membrane oxygenation patients. This work aims at evaluating the haemodynamic changes in venoarterial extracorporeal membrane oxygenation patients after Impella implantation or atrial septal defect realization by a simulation study. METHODS: A lumped parameter model of the cardiovascular system was adapted to this study. Atrial septal defect was modelled as a resistance between the two atria. Venoarterial extracorporeal membrane oxygenation and Impella were modelled starting from their pressure-flow characteristics. The baseline condition of a patient undergoing venoarterial extracorporeal membrane oxygenation was reproduced starting from haemodynamic and echocardiographic data. The effects of different atrial septal defect size, Impella and venoarterial extracorporeal membrane oxygenation support were simulated. RESULTS: Impella caused an increment of mean arterial pressure up to 67%, a decrement in mean pulmonary arterial pressure up to 8%, a decrement in left ventricular end systolic volume up to 11% with a reduction up to 97% of left ventricular cardiac output. Atrial septal defect reduces left atrial pressure (19%), increases right atrial pressure (22%), increases mean arterial pressure (18%), decreases left ventricular end systolic volume (11%), increases right ventricular volume (33%) and decreases left ventricular cardiac output (55%). CONCLUSION: Impella has a higher capability in left ventricular unloading during venoarterial extracorporeal membrane oxygenation in comparison to atrial septal defect with a lower right ventricular overload.

Improved Patient Recovery With Minimally Invasive Aortic Valve Surgery: A Propensity-Matched Study.

OBJECTIVE: Despite conflicting evidence available, minimally invasive aortic valve replacement (MIAVR) is increasingly used as an alternative to full sternotomy. We sought to compare early outcomes of aortic valve replacement through a full sternotomy (conventional aortic valve replacement [CAVR]) and upper ministernotomy (MIAVR). METHODS: We analyzed 297 patients having undergone primary, elective, isolated MIAVR or CAVR between January 2014 and June 2018. Following propensity score matching, 120 patients remained in each group. RESULTS: MIAVR required longer bypass (93 ± 26 vs 81 ± 24 minutes, P < 0.01) and operative times (214 ± 39 vs 182 ± 37 minutes, P < 0.01). However, aortic cross-clamp times were comparable (57 ± 17 vs 54 ± 14 minutes for MIAVR and CAVR, respectively, P = 0.14). MIAVR had less 24-hour blood loss (253 ± 204 vs 323 ± 296 mL, P = 0.03), less red blood cells transfusions [1.4 packs (1.1 o 1.9) vs 2.1 packs (1.8 to 2.7), P = 0.01], and shorter assisted ventilation time (7.1 ± 3.3 vs 9.7 ± 3.8 hours, P < 0.01) when compared to CAVR. These results led to significantly shorter intensive care unit and hospital stays for MIAVR patients (2.5 ± 1.3 vs 3.4 ± 1.1 days, P < 0.01 and 6.9 ± 4.1 vs 8.2 ± 4.8 days, P = 0.03, respectively). Thirty-day mortality and clinical outcomes did not differ significantly among groups. CONCLUSIONS: MIAVR through upper ministernotomy was shown to be as safe and reliable as CAVR. Patient recovery time was improved by shortening mechanical ventilation and reducing blood loss and transfusions. These results may be significant for high-risk patients undergoing aortic valve surgery.

Sutureless aortic valve replacement in high risk patients neutralizes expected worse hospital outcome: A clinical and economic analysis.

BACKGROUND: Aortic valve replacement (AVR) by sutureless prostheses is changing surgeon options, although which patients benefit most, as well as their possible economic impact is still to be defined. METHODS: Perceval-S prosthesis (LivaNova) is reserved, at the documented Institution, for patients at perceived high surgical risk. This retrospective analysis of outcome and resource consumption compared Perceval with other tissue valves. To clarify the comparison, only patients respecting 'instructions-for- use' of Perceval were reviewed. INCLUSION CRITERIA: > 65 years, +/- coronary artery bypass grafting, patent foramen ovale closure or myectomy. EXCLUSION CRITERIA: bicuspid, combined valve or aortic sur- gery. Costs were calculated per patient on a daily basis including preoperative tests, operating costs (hourly basis), disposables, drugs, blood components and personnel. RESULTS: The sutureless group (SU-AVR) had a higher risk profile than the sutured group (ST-AVR). Cardiopulmonary bypass (CPB) and cross-clamp times were significantly shorter in SU-AVR (isolated AVR: cross-clamp 52.9 ± 12.6 vs. 69 ± 15.3 min, p < 0.001; CPB 79.4 ± 20.3 vs. 92.7 ± 18.2 min, p < 0.001). Hospital mortality was 0.9% in SU-AVR and nil in ST-AVR, p = 0.489; intubation 7 (IQR 5-10.7) and 7 h (IQR 5-9), p = 0.785; intensive care unit 1 (IQR 1-1) and 1 day (IQR 1-1), p = 0.258; ward stay 5.5 (IQR 4-7) and 5 days (IQR 4-6), p = 0.002; pacemaker 5.7% (6/106) and 0.9% (1/109), p = 0.063, respectively. Hospital costs (excluding the prosthesis) were $12,825 (IQR 11,733-15,334) for SU-AVR and $12,386 (IQR 11,217-14,230) in ST-AVR, p = 0.055. CONCLUSIONS: Despite higher operative risks in SU-AVR, hospital mortality, morbidity and resource consumption did not differ. Operative times were shorter with the sutureless device and this improve- ment, along with more frequent ministernotomy, may have improved many postoperative aims.

Delayed massive subcutaneous emphysema following Robicsek closure.

A surgical procedure may lead to unusual and unexpected clinical scenario. Good medical practice should always keep it in mind. So, a broken sternal steel wire was the rare cause of massive emphysema.