Cardiac Surgery in Nonagenarians Following the TAVI/TMVI Era: A Multicenter 23-Year Comparative Analysis.

BACKGROUND: Studies reporting on the outcome of 90-year-old patients undergoing cardiac surgery are scant in literature; and currently, those regarding the implementation of trans-catheter techniques number even fewer. METHODS: We compared patients aged >89 years operated on between 1998 and 2008 at 8 Italian cardiac surgery centers, with patients of the same age operated on between 2009 and 2021. All of the patients were operated on with "open" surgery, with the exclusion of percutaneous valve repair/implantation procedures. RESULTS: The patients of the two groups (group 98-08-127 patients, and group 09-21-101 patients) had comparable preoperative risk factors in terms of the LogEuroSCORE (98-08: 21.3 ± 6.1 vs. 09-21: 20.9 ± 11.1, p = 0.12). There was a considerable difference in the type of surgery (isolated valve, isolated coronary, and combined surgery, 46.5, 38.5, and 15% vs. 52, 13, and 35% in 98-08 and 09-21, respectively, p = 0.01). Analogous operating durations were recorded (cross-clamp time: 98-08: 46 ± 28 min vs. 09-21: 51 ± 28 min, p = 0.06). The number of packed bypasses was lower in 09-21 (1.3 ± 0.6 vs. 2.4 ± 1.2, p = 0.001). In the postoperative period, there was a statistically significant difference in the 30-day survival in favor of the "more recent" patients (98-08: 17 deaths (13.4%) versus 09-21: 6(5.9%); p = 0.001), also confirmed in the subgroups (12.2% vs. 0% in isolated coronary surgery, p < 0.001; and 12.3% vs. 0% in isolated valve surgery, p < 0.001). CONCLUSIONS: Accurate pre-, intra-, and post-operative evaluation/management to reduce biological impacts facilitate significant improvements in the outcomes in nonagenarian patients when compared to the results recorded in previous years.

Sutureless versus transcatheter aortic valve replacement: A multicenter analysis of "real-world" data.

BACKGROUND: Recent data suggested that transcatheter aortic valve replacement (TAVR) may be indicated also for low-risk patients. However, robust evidence is still lacking, particularly regarding valve performance at follow-up that confers a limitation to its use in young patients. Moreover, a literature gap exists in terms of 'real-world' data analysis. The aim of this study is to compare the cost-effectiveness of sutureless aortic valve replacement (SuAVR) versus transfemoral TAVR. METHODS: Prospectively collected data were retrieved from a centralized database of nine cardiac surgery centers between 2010 and 2018. Follow-up was completed in June 2019. A propensity score matching (PSM) analysis was performed. RESULTS: Patients in the TAVR group (n=1002) were older and with more comorbidities than SuAVR patients (n=443). The PSM analysis generated 172 pairs. No differences were recorded between groups in 30-day mortality [SuAVR vs TAVR: n=7 (4%) vs n=5 (2.9%); p=0.7] and need for pacemaker implant [n=10 (5.8%) vs n=20 (11.6%); p=0.1], but costs were lower in the SuAVR group (20486.6±4188€ vs 24181.5±3632€; p<0.01). Mean follow-up was 1304±660 days. SuAVR patients had a significantly higher probability of survival than TAVR patients (no. of fatal events: 22 vs 74; p<0.014). Median follow-up was 2231 days and 2394 days in the SuAVR and TAVR group, respectively. CONCLUSION: The treatment of aortic valve stenosis with surgical sutureless or transcatheter prostheses is safe and effective. By comparing the two approaches, patients who can undergo surgery after heart team evaluation show longer lasting results and a more favorable cost ratio.

Minimally invasive reoperative aortic valve replacement.

The operative mortality associated with repeat heart valve surgery is supposedly higher than the mortality associated with the primary operation. However, controversy still surrounds the risk factors and optimal surgical approach for patients requiring repeat cardiac surgery, particularly for those requiring aortic valve replacements (AVR). While the standard approach generally utilizes full sternotomy and peripheral cannulation, alternative approaches such as minimally invasive sternotomy may play an increasingly important role in this field. This study compares the advantages and disadvantages of a minimally invasive approach in redo AVR with the standard approach, highlighting difficulties and potential solutions.

Plasma phospholipid omega-3 fatty acids and incidence of postoperative atrial fibrillation in the OPERA trial.

BACKGROUND: Long-chain polyunsaturated omega-3 fatty acids (n-3 PUFA) demonstrated antiarrhythmic potential in experimental studies. In a large multinational randomized trial (OPERA), perioperative fish oil supplementation did not reduce the risk of postoperative atrial fibrillation (PoAF) in cardiac surgery patients. However, whether presupplementation habitual plasma phospholipid n-3 PUFA, or achieved or change in n-3 PUFA level postsupplementation are associated with lower risk of PoAF is unknown. METHODS AND RESULTS: In 564 subjects undergoing cardiac surgery between August 2010 and June 2012 in 28 centers across 3 countries, plasma phospholipid levels of eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), and docosahexaenoic acid (DHA) were measured at enrollment and again on the morning of cardiac surgery following fish oil or placebo supplementation (10 g over 3 to 5 days, or 8 g over 2 days). The primary endpoint was incident PoAF lasting ≥ 30 seconds, centrally adjudicated, and confirmed by rhythm strip or ECG. Secondary endpoints included sustained (≥ 1 hour), symptomatic, or treated PoAF; the time to first PoAF; and the number of PoAF episodes per patient. PoAF outcomes were assessed until hospital discharge or postoperative day 10, whichever occurred first. Relative to the baseline, fish oil supplementation increased phospholipid concentrations of EPA (+142%), DPA (+13%), and DHA (+22%) (P < 0.001 each). Substantial interindividual variability was observed for change in total n-3 PUFA (range = -0.7% to 7.5% after 5 days of supplementation). Neither individual nor total circulating n-3 PUFA levels at enrollment, morning of surgery, or change between these time points were associated with risk of PoAF. The multivariable-adjusted OR (95% CI) across increasing quartiles of total n-3 PUFA at enrollment were 1.0, 1.06 (0.60 to 1.90), 1.35 (0.76 to 2.38), and 1.19 (0.64 to 2.20); and for changes in n-3 PUFA between enrollment and the morning of surgery were 1.0, 0.78 (0.44 to 1.39), 0.89 (0.51 to 1.55), and 1.01 (0.58 to 1.75). In stratified analysis, demographic, medication, and cardiac parameters did not significantly modify these associations. Findings were similar for secondary PoAF endpoints. CONCLUSIONS: Among patients undergoing cardiac surgery, neither higher habitual circulating n-3 PUFA levels, nor achieved levels or changes following short-term fish oil supplementation are associated with risk of PoAF.

Upper 'J' ministernotomy versus full sternotomy: an easier approach for aortic valve reoperation.

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) after previous cardiac surgery is usually associated with an increased risk profile. The study aim was to compare the outcome after AVR through an upper 'J' ministernotomy compared to a standard full sternotomy approach in a redo operation. METHODS: A total of 90 patients who underwent reoperative AVR at the authors' institution between October 2007 and January 2012 was retrospectively reviewed. Of these patients, 46 had patent bypass grafts and 44 previously had heart valve replacement or repair. Sixteen patients had endocarditis as the etiology, and 14 had prosthetic valve endocarditis. Of the 90 patients operated on, a minimally invasive upper 'J' ministernotomy was performed in 38, and a full median sternotomy in 52. The median age was 76 years (25th percentile 68.25 years; 75th percentile 79.25 years) for the minimally invasive group, and 73.5 (25th percentile 68 years; 75th percentile 78.75 years) for the full sternotomy group (p = 0.945). No statistically significant differences in terms of body mass index (p = 0.987), left ventricular ejection fraction (p = 0.544) and EuroSCORE (p = 0.162) were found between the two groups. Intraoperative data and postoperative outcomes, in terms of intensive care unit stay, blood loss, transfusions and sternal complications were analyzed. RESULTS: All patients underwent AVR. The median (IQR) cardiopulmonary bypass and cross-clamp times were respectively 67 (28) min and 51 (28) min for the minimally invasive group, and 72 (47) min and 53.5 (28) min for the full sternotomy group (p = 0.686 and p = 0.993). The postoperative ventilation time was significantly less in ministernotomy patients (median 6 versus 8.5 h; p = 0.027). One patient affected by endocarditis died in the minimally invasive group (mortality rate 2.6%). Hospital mortality in the traditional group was 3/52 (5.8%). CONCLUSION: Minimally invasive aortic valve surgery reoperation through an upper 'J' sternotomy proved to be at least as safe as the standard procedure in terms of hospital morbidity and mortality rates.

Sternal wrapping: developments and results.

BACKGROUND: Postoperative sternal wound complications are infrequent events that negatively affect recovery and may have serious consequences. Sternal wrapping, a technique of sternal care, has hemostatic properties without bone wax, and offers mechanical and microbiologic protection. METHODS: From February 1998 to December 2011, 258 patients in 2 Italian institutions underwent various cardiac surgery procedures with sternal wrapping in place, and were followed up for no less then 6 months. RESULTS: Two (0.8%) extremely compromised patients with ischemic sternal osteonecrosis and deep sternal wound infection required a sternal stabilizing procedure. Four (2%) other patients developed sternal wound complications that were treated entirely medically; 3 of them were very trivial, and 1 was an atypical mediastinitis without sternal involvement. Overall, 46.1% of patients (45.3% of isolated coronary artery bypass, 49.3% of isolated on-pump coronary artery bypass, and 18.2% of off-pump coronary artery bypass patients) were transfused. None of the complications was related to sternal wrapping, bleeding from the sternal edge, or sternal wound problems. CONCLUSIONS: Sternal wrapping showed a very low incidence and severity of sternal wound complications, with good prevention of sternal osteomyelitis. Hemostatic properties were satisfactory, with transfusion rates within an acceptable range.

Increased plasma homocysteine predicts arrhythmia recurrence after minimally invasive epicardial ablation for nonvalvular atrial fibrillation.

OBJECTIVE: Minimally invasive epicardial ablation via right minithoracotomy is an emerging option for patients with drug-refractory nonvalvular atrial fibrillation. To guide the development of rational treatment algorithms, factors predisposing to recurrence of arrhythmia need to be quantified and eventually treated. We addressed the association of the plasma levels of homocysteine and the recurrence of atrial fibrillation after minimally invasive ablation. METHODS: We obtained peripheral blood samples from 104 patients at follow-up after arrhythmia surgery; the homocysteine concentration was expressed as micromoles per liter. Prospective follow-up was conducted through electrocardiogram Holter monitoring (average 18.5 ± 5.8 months). Stratified analysis (high vs low homocysteine) was based on the cutoff value for the last quartile of homocysteine concentration (16 µmol/L). Time-to-event and diagnostic performance analyses were performed. RESULTS: The rate of freedom from atrial fibrillation was 89.4% at the end of follow-up. Elevated circulating homocysteine level, persistent type of atrial fibrillation, and increased left atrial dimension independently predicted the recurrence of atrial fibrillation during the follow-up (adjusted Cox regression). Patients with a high homocysteine level were more likely to have atrial fibrillation recurrence (stratified Kaplan-Meier, P < .001). The cutoff value for elevated homocysteine (16 µmol/L) yielded a good diagnostic performance in the prediction of atrial fibrillation recurrence (area under the receiver operating characteristic curve, 0.807). CONCLUSIONS: The homocysteine level measured during the follow-up reliably predicts the risk of recurrence after epicardial ablation of nonvalvular atrial fibrillation via minithoracotomy. Specific treatments to reduce plasma homocysteine could be considered in the future in these patients.

CentriMag venoarterial extracorporeal membrane oxygenation support as treatment for patients with refractory postcardiotomy cardiogenic shock.

We report our experience with the Levitronix CentriMag (Levitronix LLC, Waltham, MA) in the setting of venoarterial extracorporeal membrane oxygenation (ECMO) system support as treatment for postcardiotomy cardiogenic shock. Between January 2007 and August 2011, 14 consecutive adult patients received CentriMag ECMO support after cardiac surgery procedures at our institution. There were nine males (64.3%) and the mean age was 53.1 ± 14.3 years (range: 25-70 years). Cardiac surgery included: n = 6, aortic and/or mitral valve replacement; n = 5, coronary artery bypass grafting (CABG); and n = 3, Bentall procedures. The CentriMag ECMO support was installed centrally in eight patients and peripherally in six. Median duration of support was 5 days (range: 1-55 days). Seven patients were weaned from ECMO (50%), whereas six patients died while on support mainly because of multiple organ failure (42.9%). One patient died on ECMO support after transfer to the referral hub center while waiting for heart transplantation (Htx). Six (42.8%) patients were successfully discharged home. Levitronix CentriMag in ECMO configuration proved to be effective in managing postcardiotomy cardiogenic shock and the results are encouraging. The system was easy to install and manage.

Impact of arterial revascularization in patients undergoing coronary bypass.

BACKGROUND AND AIM: A debate over alternative therapeutic strategies for multivessel coronary disease is currently ongoing. We aimed at analyzing the results of myocardial revascularization with arterial conduits. METHODS: We retrospectively reviewed 10,752 patients undergoing isolated coronary bypass surgery within our hospital's group. Average follow-up was 37.2 months. Through propensity-matching, we generated three groups (3584 patients each) on the basis of the revascularization strategy: use of one mammary artery plus venous grafts, use of two mammary arteries plus venous graft, and total arterial revascularization. RESULTS: Overall operative mortality was 2.8%. Patient-related factors (renal failure, advanced age, recent myocardial infarction, depressed LVEF, diabetes) were identified as predictors of mortality (logistic regression). Although mortality was not statistically different among groups, patients receiving more than one arterial conduit displayed in the long-term better freedom from cardiac death and from adverse cardiac events (repeat revascularization, myocardial infarction, recurrent angina) (Kaplan-Meier analysis). Use of only one arterial conduit, diabetes and depressed LVEF predicted cardiac mortality, and adverse events (Cox regression). No differences in any endpoint emerged among patients receiving two arterial conduit plus venous grafts or total arterial revascularization. CONCLUSIONS: These data strongly support the practice of using two arterial conduits rather than one. The operative and late results of coronary surgery with arterial conduits are optimal and should serve as a current benchmark for the comparison with state-of-the-art percutaneous interventions.

Aortic valve replacement with and without combined coronary bypass grafts in very elderly patients: early and long-term results.

OBJECTIVE: The number of older patients being referred for aortic valve replacement with or without combined coronary bypass grafting (CABG) is increasing. The aim of this study was to evaluate operative risk factors, early and long-term results of isolated aortic valve and aortic valve replacement combined with CABG in octogenarians and nonagenarians. METHODS: In the last 10 years, 285 very elderly patients who underwent aortic valve replacement either alone or in combination with coronary artery bypass grafts were retrospectively studied. The population was divided into two groups; isolated aortic valve replacement was performed in 188 patients (group A) and 97 patients had aortic valve replacement combined with coronary surgery (group B). RESULTS: The overall hospital mortality was 5.3%, without statistical difference between groups. The incidence of low-output syndrome was higher in group B (P = 0.0001). The multivariate analysis for hospital mortality showed that urgency status, ejection fraction (EF) <35%, intra-operative variables such as clamping time, need for intra aortic balloon pump and post-operative variables such as prolonged ventilation, dialysis, post-operative myocardial infarction and re-thoracotomy for bleeding were independent prognostic factors for hospital mortality. The mean follow-up time was 49.03 ± 19 months. Survival at one, three and five years was 97.1 ± 1.8%, 92.2 ± 2.2% and 82.4 ± 3.6% for group A and 97.2 ± 2.0%, 88.4 ± 2.7% and 75.6 ± 3.2% for group B (P = 0.62), respectively. Age, male gender, post-operative myocardial infarction, urgency status, dialysis, low EF, mean aortic gradient were risk factors for the impaired survival. CONCLUSIONS: In our experience, a careful pre-operative evaluation has yielded good surgical results even in older patients with different comorbidities. Associated coronary grafts slightly increase the surgical risk. The role of revascularization on long-term morbidity and mortality is still not clear. It is essential to compare the results of percutaneous and trans-apical aortic valve replacement with the literature results of conventional aortic valve replacement with and without CABG before it can be used as an alternative for very older patients.

Contemporary outcomes of conventional aortic valve replacement in 638 octogenarians: insights from an Italian Regional Cardiac Surgery Registry (RERIC).

OBJECTIVES: Few data exist on contemporary outcomes after conventional aortic valve replacement (AVR) in the elderly. Accordingly, we evaluated contemporary outcomes and identified predictors of reduced survival in a large series of octogenarians undergoing AVR. METHODS: The Regione Emilia Romagna Cardiac Surgery registry (RERIC) database (n = 2 6938) was queried for clinical features, hospital and mid-term outcomes of octogenarians undergoing AVR between 2003 and 2009. Predictors of hospital and mid-term mortality were identified. RESULTS: The study population consisted of 638 patients. NYHA class III-IV, congestive heart failure, cerebrovascular disease, extra-cardiac arteriopathy, mostly exacerbated patients' clinical profile. Mean log-EuroSCORE was 13.0%. Overall hospital mortality and stroke rates were 4.5% and 1.3%, respectively. Other post-operative complications included renal failure (4.9%), intubation time >48 h (3.4%), complete atrio-ventricular block (4.4%). NYHA III-IV (OR = 2.7; CI 95%:1.2-6.7) and CCS III-IV (OR = 3.1; CI 95%:1.1-9.4) emerged as independent predictors of hospital mortality on multivariate analysis. At 6 years, octogenarians' survival rate was similar to the expected survival of the age- and sex-matched regional population. CCS III-IV (HR = 2.1; CI 95%:1.2-4), preoperative creatinine > 2.1 (HR = 2.8; CI 95%:1.4-5.9), extra-cardiac arteriopathy (HR = 1.5; CI 95%:1.1-2.1) and peripheral neurological dysfunction (HR = 3.8; CI 95%:1.4-10.4) emerged as independent risk factors for decreased 6 years' survival. CONCLUSIONS: This study, showing that contemporary outcomes after AVR are excellent, may help to improve treatment decision-making in elderly patients with aortic valve disease.

Hamartoma of mature cardiac myocytes: case report and review of the literature.

Cardiac hamartoma is an extremely rare type of benign cardiac tumour. A 35 year-old female presented with exertional dyspnea, palpitation, dry-cough and chest-tightness. A mass was discovered in the posterior-inferior wall of the left ventricle. A partial resection of the tumour was performed because of partial obstruction of the left ventricular inflow tract. Histological examination was indicative of a rare benign tumour of the heart: hamartoma of mature myocytes. A literature review completes the description.

Aortic valve replacement: results and predictors of mortality from a contemporary series of 2256 patients.

OBJECTIVE: The study's objectives were to evaluate results and identify predictors of hospital and mid-term mortality after primary isolated aortic valve replacement; compare early and mid-term survival of patients aged more than 80 years or less than 80 years; and assess the effectiveness of the logistic European System for Cardiac Operative Risk Evaluation in predicting the risk for hospital mortality in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% who are undergoing aortic valve replacement. METHODS: Data from 2256 patients undergoing primary isolated aortic valve replacement between January 2003 and December 2007 were prospectively collected in a Regional Registry (Regione Emilia Romagna Interventi Cardiochirurgia) and analyzed to estimate hospital and mid-term results. RESULTS: Overall hospital mortality was 2.2%. By multivariate analysis, New York Heart Association III and IV, Canadian Cardiovascular Society III and IV, pulmonary artery pressure greater than 60 mm Hg, dialysis, central neurologic dysfunction, and severe chronic obstructive pulmonary disease emerged as independent predictors of hospital mortality. At 3 years, the survival was 89.3%. The same predictors of hospital mortality plus ejection fraction of 30% to 50% and age more than 80 years emerged as independent risk factors for 3-year mortality. Compared with younger patients, octogenarians had a higher hospital mortality rate (3.72% vs 1.81%; P = .0143) and a reduced 3-year survival (82.3% vs 91.3%; P < .001). Three-year survival of octogenarians was comparable to the expected survival of an age- and gender-matched regional population (P = .157). The observed mortality rate in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% (mean: 22.4%) was 7% (P < .001). CONCLUSIONS: This study provides contemporary data on the characteristics and outcome of patients undergoing first-time isolated aortic valve replacement.

Efficacy of a new oxygenator-integrated fat and leukocyte removal device.

We evaluated the effectiveness of a new oxygenator-integrated device for removing lipid particles and leukocytes from shed mediastinal blood in 20 patients undergoing elective cardiac surgery under cardiopulmonary bypass. Another 20 patients undergoing cardiac surgery without the device served as controls. After filtration with the RemoveLL device, lipid particles, leukocytes, and fats were significantly reduced compared to preoperative levels. In the control group, blood fats and lipid particles at the end of cardiopulmonary bypass were significantly increased compared to preoperative levels. Leukocyte counts at the end of bypass were significantly lower in patients who had the filtration device compared to the control group. Platelets counts and hematocrit changes were not significantly different between the 2 groups.

Operative and middle-term results of cardiac surgery in nonagenarians: a bridge toward routine practice.

BACKGROUND: Age >90 years represents in many centers an absolute contraindication to cardiac surgery. Nonagenarians are a rapidly growing subset of the population posing an expanding clinical problem. To provide helpful information in regard to this complex decision, we analyzed the operative and 5-year results of coronary and valvular surgical procedures in these patients. METHODS AND RESULTS: We retrospectively reviewed 127 patients aged >or=90 years who underwent cardiac surgery within our hospital group in the period 1998 to 2008. Kaplan-Meier and multiple logistic regression analyses were performed. A longer follow-up than most published studies and the largest series published thus far are presented. Mean age was 92 years (range, 90 to 103 years). Mean logistic EuroSCORE was 21.3+/-6.1. Sixty patients had valvular surgery (including 11 valve repairs), 49 patients had coronary artery bypass grafting, and 18 had valvular plus coronary artery bypass grafting surgery (55 left mammary artery grafts implanted). Forty-five patients (35.4%) were operated on nonelectively. Operative mortality was 13.4% (17 cases). Fifty-four patients (42.5%) had a complicated postoperative course. There were no statistically significant differences in the rate and type of complications between patient strata on the basis of type of surgery performed. Nonelective priority predicted a complicated postoperative course. Predictors of operative mortality were nonelective priority and previous myocardial infarction. Kaplan-Meier survival estimates at 5 years were comparable between patient groups on the basis of procedure performed. CONCLUSIONS: Although the rate of postoperative complications remains high, cardiac surgery in nonagenarians can achieve functional improvement at the price of considerable operative and follow-up mortality rates. Cardiac operations in these very elderly subjects are supported if appropriate selection is made and if the operation is performed earlier and electively. Our results should contribute to the development of guidelines for cardiac operations in nonagenarians.

Mini re-sternotomy for aortic valve replacement in patients with patent coronary bypass grafts.

As the population ages, an increasing number of patients with patent coronary grafts will require subsequent aortic valve replacement. Major operative problems include those associated with re-entry and, in particular, damage of the patent grafts. Between January 2007 and October 2008, 10 patients who had previous coronary bypass surgery underwent aortic valve replacement through upper j-shaped mini re-sternotomy. In all patients the previous grafts were patent. The operation was performed with normothermic cardiopulmonary bypass without dissection and temporary closure of the arterial and venous coronary bypass grafts. The mean age was 73.2+/-13.6 years. The patients had a mean of 2.8+/-0.6 bypass grafts. There were no intraoperative complications due to redo ministernotomy and at no time conversion to full re-sternotomy was necessary. No damage to the previous grafts was reported and the incidence of perioperative myocardial infarction was 0%. One patient required a pacemaker implantation for atrio-ventricular block. The in-hospital mortality was 0%. Aortic valve replacement in previous coronary bypass grafting can be performed safely with a mini re-sternotomy. This approach avoids extensive dissection, decreasing the risk of injuries to heart chambers and previous patent coronary grafts with low morbidity and mortality.

Minimally invasive coronary artery bypass grafting using the inferior J-shaped ministernotomy in high-risk patients.

In the last years the population of patients referred for coronary surgery has changed toward a high-risk profile. In selected cases minimally invasive approach could be a good option to reduce mortality and morbidity. Between September 2005 and September 2007, twenty-one consecutive patients underwent minimally invasive bypass surgery using the J-shaped inferior mini-sternotomy approach. All patients had a EuroSCORE higher than 6. The operative mortality was 0%. Conversion to on-pump surgery was not necessary. The mean operation time was 89+/-18 min, the mean ventilation time was 2.4+/-2.2 h, the mean intensive care unit stay was 47.2+/-36.5 h. In four patients a hybrid approach to achieve a complete revascularization was used. After six months from the operation the graft patency was evaluated with the 64-slice computed tomography. In high-risk coronary patients the use of the minimally invasive technique appeared a good option to achieve low morbidity and mortality. Through a mini-sternotomy approach, single- or double-vessel revascularization can be performed safely off-pump even in high-risk patients without compromising the accuracy of the anastomosis. Nevertheless, a further investigation is required to evaluate the long-term results in a larger cohort of patients.

Anomalous systemic arterial supply to the left lung base without sequestration.

Systemic arterial supply from the descending thoracic aorta to the basal segment of the left lower lobe without a pulmonary arterial supply is a rare congenital anomaly within the spectrum of the sequestration lung disease. We report a case of a young man with anomalous systemic arterial supply to a normal left lower lobe referred to our department because of recurrent haemoptysis who underwent a successful left lower lobectomy.

Acute coronary syndrome in a patient with a single coronary artery arising from the right sinus of Valsalva: a case report.

Coronary anomalies can involve origin or distribution of the artery. Most of these anomalies are not clinically important. A single coronary artery arising from the right coronary sinus of Valsalva is an extremely rare anatomic anomaly. Usually coronary artery malformation is associated with other cardiac malformations and the diagnosis is made after birth. More rarely, coronary artery anomalies are an isolated and asymptomatic cardiac malformation.