Surgical revascularization for stable coronary syndrome: the ISCHEMIA trial versus a single-centre matched population-a real-world analysis of patients undergoing surgical revascularization.

OBJECTIVES: The aim of this study was to test if the current general practice of surgical revascularization is comparable to the setting of International Study of Comparative Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial and to evaluate the comparative risk of cardiovascular events or death after coronary artery bypass grafting. METHODS: We selected patients undergoing surgical revascularization and matching ISCHEMIA inclusion criteria. Chronic coronary syndrome patients were included if diagnosis of myocardial ischaemia by functional testing and coronary artery disease at angiography were detected. The primary end point was a composite of cardiovascular death, myocardial infarction, rehospitalization for unstable angina, heart failure and resuscitated cardiac arrest. Secondary end points were death by any cause, cardiovascular death, myocardial infarction and rehospitalization. RESULTS: Among 353 patients, the primary outcome occurred in 62 (17.6%) patients. At 6 months, cumulative event-free survival was 97%, at 1 year 96%, at 5 years 89% and at 10 years 80%. Cumulative risk of the primary composite outcome at 5 years was 11%, 18% in the conservative arm of ISCHEMIA and 16% in the revascularization arm of ISCHEMIA (P < 0.001). Risk of myocardial infarction at 5 years was 7% in surgical patients and 12% and 10% in the conservative and invasive arms of the trial, respectively (P < 0.001). CONCLUSIONS: Long-term results in surgical patients treated for chronic coronary syndromes showed that ISCHEMIA trial findings are not transferable in a 'real-world' scenario and have not changed previous medical practice. A patient-tailored approach, especially with diabetes and reduced left ventricle function, offers the best results in patients with stable coronary artery disease.

Prognostic value of SARS-CoV-2 on patients undergoing cardiac surgery.

OBJECTIVE: To analyze Italian Cardiac Surgery experience during the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) identifying risk factors for overall mortality according to coronavirus disease 2019 (COVID-19) status. METHODS: From February 20 to May 31, 2020, 1354 consecutive adult patients underwent cardiac surgery at 22 Italian Centers; 589 (43.5%), patients came from the red zone. Based on COVID-19 status, 1306 (96.5%) were negative to SARS-CoV-2 (COVID-N), and 48 (3.5%) were positive to SARS-CoV-2 (COVID-P); among the COVID-P 11 (22.9%) and 37 (77.1%) become positive, before and after surgery, respectively. Surgical procedures were as follows: 396 (29.2%) isolated coronary artery bypass grafting (CABG), 714 (52.7%) isolated non-CABG procedures, 207 (15.3%) two associate procedures, and three or more procedures in 37 (2.7%). Heart failure was significantly predominant in group COVID-N (10.4% vs. 2.5%, p = .01). RESULTS: Overall in-hospital mortality was 1.6% (22 cases), being significantly higher in COVID-P group (10 cases, 20.8% vs. 12, 0.9%, p < .001). Multivariable analysis identified COVID-P condition as a predictor of in-hospital mortality together with emergency status. In the COVID-P subgroup, the multivariable analysis identified increasing age and low oxygen saturation at admission as risk factors for in-hospital mortality. CONCLUSION: As expected, SARS-CoV-2 infection, either before or soon after cardiac surgery significantly increases in-hospital mortality. Moreover, among COVID-19-positive patients, older age and poor oxygenation upon admission seem to be associated with worse outcomes.

Extracorporeal Membrane Oxygenation for COVID-19 Respiratory Distress Syndrome: An Italian Society for Cardiac Surgery Report.

An increased need of extracorporeal membrane oxygenation (ECMO) support is going to become evident as treatment of SARS-CoV-2 respiratory distress syndrome. This is the first report of the Italian Society for Cardiac Surgery (SICCH) on preliminary experience with COVID-19 patients receiving ECMO support. Data from 12 Italian hospitals participating in SICCH were retrospectively analyzed. Between March 1 and September 15, 2020, a veno-venous (VV) ECMO system was installed in 67 patients (94%) and a veno-arterio-venous ECMO in four (6%). Five patients required VA ECMO after initial weaning from VV ECMO. Thirty (42.2%) patients were weaned from ECMO, while 39 (54.9%) died on ECMO, and six (8.5%) died after ECMO removal. Overall hospital survival was 36.6% (n = 26). Main causes of death were multiple organ failure (n = 14, 31.1%) and sepsis (n = 11, 24.4%). On multivariable analysis, predictors of death while on ECMO support were older age (p = 0.048), elevated pre-ECMO C-reactive protein level (p = 0.048), higher positive end-expiratory pressure on ventilator (p = 0.036) and lower lung compliance (p = 0.032). If the conservative treatment is not effective, ECMO support might be considered as life-saving rescue therapy for COVID-19 refractory respiratory failure. However warm caution and thoughtful approaches for timely detection and treatment should be taken for such a delicate patients population.

Sternal Wound Complications: Results of Routine Use of Negative Pressure Wound Therapy.

INTRODUCTION: Negative pressure wound therapy (NPWT) has significantly improved outcomes in individuals with superficial and deep sternal wound dehiscence (SWD). We report our experience with NPWT to evaluate factors influencing effectiveness, duration of treatment and postoperative hospital stay. METHODS: We reviewed 92 patients with postoperative SWD following a median sternotomy. Patients were divided into 2 groups: those with a superficial SWD (Group 1; 72, 78%) and those with a deep SWD (Group 2; 20, 28%). Group 1 was further divided into 3 subgroups based on NPWT duration. RESULTS: In both groups, none of the preoperative characteristics examined showed a significant association with longer NPWT duration. In Group 2, there was a trend for postoperative bleeding and neurological complications to be associated with longer treatment duration. In the entire series, staph infection resulted a weak predictor of NPWT duration. In each Group 1 subgroup and in Group 2, treatment days were compared with duration of hospitalization until discharge. Mean post-NPWT hospital stay was 6 days in subgroup 1, 12 days in subgroup 2 and 20 days in subgroup 3 (P<0.0001). At a median 3-year follow-up, there were 4 late deaths, none related to wound complications. No cases of SWD recurrence were observed. CONCLUSION: Our results confirm the effectiveness of NPWT in SWD management, while excessive treatment duration might have a negative impact on the length of hospital stay. Further studies are needed to define an optimal use of NPWT protocol.

Sternal wound complications: results of routine use of negative pressure wound therapy

Abstract Introduction: Negative pressure wound therapy (NPWT) has significantly improved outcomes in individuals with superficial and deep sternal wound dehiscence (SWD). We report our experience with NPWT to evaluate factors influencing effectiveness, duration of treatment and postoperative hospital stay. Methods: We reviewed 92 patients with postoperative SWD following a median sternotomy. Patients were divided into 2 groups: those with a superficial SWD (Group 1; 72, 78%) and those with a deep SWD (Group 2; 20, 28%). Group 1 was further divided into 3 subgroups based on NPWT duration. Results: In both groups, none of the preoperative characteristics examined showed a significant association with longer NPWT duration. In Group 2, there was a trend for postoperative bleeding and neurological complications to be associated with longer treatment duration. In the entire series, staph infection resulted a weak predictor of NPWT duration. In each Group 1 subgroup and in Group 2, treatment days were compared with duration of hospitalization until discharge. Mean post-NPWT hospital stay was 6 days in subgroup 1, 12 days in subgroup 2 and 20 days in subgroup 3 (P<0.0001). At a median 3-year follow-up, there were 4 late deaths, none related to wound complications. No cases of SWD recurrence were observed. Conclusion: Our results confirm the effectiveness of NPWT in SWD management, while excessive treatment duration might have a negative impact on the length of hospital stay. Further studies are needed to define an optimal use of NPWT protocol.

Durability of the Mitroflow Pericardial Prosthesis: Influence of Patient-Prosthesis Mismatch and New Anticalcification Treatment.

BACKGROUND: The Mitroflow pericardial bioprosthesis (MPB) has been recently associated with a high incidence of early structural failures, questioning its validity as cardiac valve substitute. We have therefore reviewed our experience with this device. MATERIALS AND METHODS: A total of 398 patients with a mean age of 75 ± 7 years (58% above the age of 75 years) had aortic valve replacement with a Mitroflow prosthesis (2005-2015). Most patients had calcific aortic stenosis (86%) and were in sinus rhythm (89%). Mean EuroSCORE II was 5.5 ± 6.2. Mean follow-up was 4 ± 2 years (range: 4 months to 10 years), which was 100% complete. RESULTS: Hospital mortality was 6.5%; at discharge, 25% of patients had a moderate patient-prosthesis mismatch and none had a severe mismatch. Cumulative incidence of structural valve deterioration in the entire series was 2% (95% confidence interval [CI]: 1-4) at 5 years and 7% (95% CI: 4-14) at 8 years. Significant factors influencing MPB durability were age ≤ 65 years (p < 0.001) and the presence of patient-prosthesis mismatch (p = 0.01). No cases of structural valve deterioration were observed in patients with the new prosthetic model incorporating an anticalcification treatment the first 4 years of follow-up. CONCLUSIONS: The Mitroflow prosthesis has shown satisfactory results in the first decade of use. Durability appears adversely influenced by patient age and patient-prosthesis mismatch. Thus, a careful valve size selection and implantation in patients >65 years of age appears to be associated with excellent valve durability in the aortic position. Whether the new anticalcification treatment will provide a more durable prosthesis must be verified at a longer follow-up.

Early aortic dissection after aortic valve replacement with a Perceval sutureless bioprosthesis.

We report a patient who developed ascending aorta dissection after aortic valve replacement with a Perceval sutureless pericardial bioprosthesis, a previously not reported complication with this device. At reoperation, the intimal tear was located at the aortotomy suture line; the tips of the nitinol stent were far from the aortic lesion which therefore was not attributable to the presence of this specific prosthetic model. Nevertheless, a previous report of aortic dissection due to erosion of the aortic wall by the strut of a transcatheter prosthesis may raise the suspicion that such complication could also occur with sutureless prostheses of similar design.

Excellent Durability of the Mosaic Porcine Aortic Bioprosthesis at Extended Follow Up.

BACKGROUND: Biological prostheses are widely employed for aortic valve replacement (AVR). The study aim was to evaluate the performance of the Mosaic porcine bioprosthesis in the aortic position over two decades. METHODS: Between November 1995 and December 2016, a total of 254 patients (194 males, 60 females; mean age 74 ± 9 years) underwent AVR with a Mosaic bioprosthesis at the authors' institution. Among the patients, 14% were aged ≥80 years and 86% had pure or prevalent calcific aortic stenosis. Preoperatively, the mean NYHA functional class was 2.5 ± 1.0. RESULTS: Overall hospital mortality was 5%. A total of 107 late deaths occurred, but only 15 were valve-related (0.72 ± 0.19% per patient-year). Actuarial survival at 15 years was 34 ± 7%. Fourteen embolic episodes occurred, with no cases of bioprosthetic thrombosis; freedom from thromboemboli was 88 ± 4% at 15 years. Eight cases of endocarditis occurred, with a freedom of 95 ± 2% at 15 years. Structural valve deterioration (SVD) was observed in four patients, all of whom were successfully reoperated. Freedom from SVD was 97 ± 2% at 15 years and 96 ± 2% at 20 years. At the last follow up, 23 mm and 25 mm prostheses showed mean gradients of 17 ± 6 mmHg and 15 ± 4 mmHg, respectively. A significant reduction in left ventricular mass was noted in patients with aortic stenosis. CONCLUSIONS: The Mosaic bioprosthesis has shown excellent durability over two decades of clinical use, with a negligible incidence of valve degeneration and need for reoperation. Thus, it may be considered a valid option for AVR, especially in elderly patients.

Surgical Treatment of Annuloaortic Ectasia - Replace or Repair?

BACKGROUND: Patients with annuloaortic ectasia may be surgically treated with modified Bentall or David I valve-sparing procedures. Here, we compared the long-term results of these procedures. METHODS: A total of 181 patients with annuloaortic ectasia underwent modified Bentall (102 patients, Group 1) or David I (79 patients, Group 2) procedures from 1994 to 2015. Mean age was 62 ± 11 years in Group 1 and 64 ± 16 years in Group 2. Group 1 patients were in poorer health, with a lower ejection fraction and higher functional class. RESULTS: Early mortality was 3% in Group 1 and 2.5% in Group 2. Patients undergoing a modified Bentall procedure had a higher incidence of thromboembolism and hemorrhage, whereas those undergoing a David I procedure had a higher incidence of endocarditis. Actuarial survival was 70 ± 6% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. Actuarial freedom from reoperation was 97 ± 2% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. In Group 2, freedom from procedure-related reoperations was 98 ± 2% at 10 years. At last follow-up, no cases of moderate or severe aortic regurgitation were observed. CONCLUSIONS: The modified Bentall and David I procedures showed excellent early and late results. The modified Bentall procedure with a mechanical conduit was associated with thromboembolic and hemorrhagic complications, whereas the David I procedure was associated with unexplained occurrences of endocarditis. Thus, the David I procedure appears to be safe, reproducible, and capable of achieving stable aortic valve repair and is therefore our currently preferred solution for patients with annuloaortic ectasia. However, the much shorter follow-up for David I patients limits the strength of our comparison between the two techniques.

The Modified Bentall Procedure: A Single-Institution Experience in 249 Patients with a Maximum Follow Up of 21.5 Years.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the long-term clinical outcomes of the modified Bentall procedure (MBP) with a mechanical conduit. METHODS: Between 1993 and 2014, a total of 249 patients (mean age 62 ± 12 years; range: 25-87 years) underwent a MBP at the authors' institution. The main indication was annuloaortic ectasia in 102 patients (41%), followed by acute aortic dissection in 82 patients (33%); moderate to severe aortic regurgitation was present in 79% of cases. A bicuspid aortic valve was found in 17% of patients, and Marfan syndrome in 7%. The mean NYHA functional class was 2.5 ± 1.1. Concomitant procedures were performed in 36 patients (14%). The mean follow up was 8.7 ± 5.0 years (range: 0.3-21.5 years) and was 99% complete. The total follow up was 6.475 patient-years (pt-yr). RESULTS: Operative mortality was 3% in elective cases. Age, prolonged cardiopulmonary bypass times and mechanical ventilation >96 h were independent risk factors for early mortality. Actuarial survival at 15 and 20 years was 62% and 60%, respectively. Risk factors for late mortality were age and emergency operation. Actuarial freedom from thromboembolism (linearized incidence 0.93%/pt-yr) was 82% at 15 years, and 74% at 20 years. Seven patients required reoperation (0.38%/pt-yr), with an actuarial freedom from reoperation of 91% at 15 years and 87% at 20 years. The incidence of overall valve-related complications was 0.32%/pt-yr, with actuarial freedoms of 94% at 15 and 20 years. CONCLUSIONS: The MBP has shown excellent long-term results with a low incidence of procedure-related complications up to 20 years postoperatively. For this reason, it is considered to be a valid option for the treatment of aortic root disease, whenever valvesparing procedures are not indicated.

Nuss procedure in adult pectus excavatum: a simple artifice to reduce sternal tension.

Nowadays the Nuss operation represents the standard surgical choice for pectus excavatum repair in children and teenagers. Some concerns have been raised regarding its applicability in adults, as compared with younger patients, in view of the higher rate of complications after surgery. We describe an easy trick that has been performed on a 36-year old man with a moderate pectus excavatum after an unsatisfactory Nuss procedure. It consisted of a T-shaped partial anterior sternotomy, performed after positioning of the stainless steel bar, in order to promote a hinge mechanism of the sternum to reduce the tension over the reinforcement. This procedure was successful with well-controlled postoperative pain and great patient satisfaction. No complications were recorded at 1-year follow-up. In our opinion, this simple trick could represent a valid surgical option for pectus excavatum repair in late adolescents and adults to obviate the occurrence of major sternal tension.

A composed graft for subclavian artery reconstruction in case of redo surgery for aortic coarctation.

We report the case of a 66-year-old woman admitted to the intensive care unit (ICU) for ongoing dyspnea and hemoptoe. She was operated upon in 1979 for aortic coarctation by the interposition of a 14 mm Dacron prosthesis from the left subclavian artery to descending aorta. Clinical evaluation performed over the years was normal with no signs of cardiac failure or prosthesis malfunctioning. The computed tomography scans (CT) showed a progressive increase of the descending aorta diameters and the onset of a pseudo-aneurysm of 50 mm in diameter. Patient was re-operated through a median sternotomy enlarged by a left thoracotomy and intra-operative findings revealed the pseudo-aneurysm originating from a dehiscence of the proximal suture. In order to allow a safe reconstruction of the dilated subclavian artery, a T-shaped composed graft was confectioned and then sutured to the descending aorta and the subclavian artery, respectively. Post-operative course was uneventful and three months CT scan showed a normal position of the composed graft.

Reduction in platelet count after aortic valve replacement: comparison of three bioprostheses.

BACKGROUND AND AIM OF THE STUDY: Concerns have recently been raised regarding postoperative decreases in platelet count (PC) after aortic valve replacement (AVR) with the Sorin Freedom Solo (SFS) stentless bioprosthesis. In order to assess the relevance and the clinical impact of this phenomenon, variations in PC were monitored in patients with SFS valves, and compared to changes of PC in patients after AVR with two other bioprostheses, the Medtronic Mosaic (MOS) porcine valve and the Sorin Mitroflow (MIT) pericardial valve. METHODS: Three groups of patients (25 in each group) who had undergone AVR with a biological prosthesis were compared. The patients were similar in terms of their preoperative characteristics, including mean age, NYHA functional class, risk factors, EuroSCORE, and mean PC. The PC was monitored on postoperative days 1, 3, and 5, and again at discharge. Thrombocytopenia was considered to be 'present' when the PC was < 150,000/microl, and 'severe' when the PC was < 30,000/microl. RESULTS: No significant inter-group differences were observed in the duration of extracorporeal circulation or cross-clamp times. The mean postoperative PCs for MOS valves were 154,000 +/- 56,000/microl, 154,000 +/- 54,000/microl, 161,000 +/- 85,000/microl, and 228,000 +/- 95,000/microl at days 1,3, and 5, and at discharge, respectively. For MIT valves, these values were 126,000 +/- 37,000/microl, 113,000 +/- 38,000/microl, 130,000 +/- 46,000/microl, and 170,000 +/- 50,000/microl, respectively. For SFS valves, the values were 99,000 +/- 27,000/microl, 67,000 +/- 9000/microl, 78,000 +/- 54,000/microl, and 96,000 +/- 32,000/microl, respectively. Severe thrombocytopenia was never observed in any patient. A significant decrease in PC occurred with SFS when compared to MOS valves (on days 1, 3, 5, and at discharge, p < 0.001) and to MIT valves (on days 3, 5, and at discharge, p < 0.005). Multivariate analysis showed older age (p = 0.001) and the SFS valve (p = 0.0002) to be incremental risk factors for developing severe or moderate thrombocytopenia after AVR. CONCLUSION: A reduction in PC occurred with all bioprostheses on postoperative day 1, while a significant reduction in PC was continued for SFS valves on postoperative days 3 and 5, when compared to MOS and MIT valves. A normalization of PC at discharge was observed only with MOS valves. Thrombocytopenia after AVR with biological prostheses was not associated with any major postoperative complication.

Lipid insudation as a cause of structural failure of a stentless pericardial bioprosthesis.

The Sorin Pericarbon Freedom (SPF) valve is a stentless bioprosthesis made from bovine pericardium, with a peculiar design aimed at preventing the mechanical failures observed with old models of stented pericardial bioprostheses. Herein, the case is described of a patient who presented with severe regurgitation of a SPF six years after aortic valve replacement, caused by commissural dehiscence. Both, microradiographic and histologic investigations, revealed mild calcific deposits and massive lipid infiltration, thus confirming that a patient-related mechanism such as 'atheromasia' can account for structural valve deterioration also in recipients of pericardial bioprostheses.

Aortic valve replacement with the Medtronic Mosaic bioprosthesis: a 13-year follow-up.

BACKGROUND: This study evaluated the long-term clinical performance of the Mosaic bioprosthesis (Medtronic Inc, Minneapolis, MN) after aortic valve replacement. METHODS: From 1995 to 2008, 178 patients (48 women; mean age, 74±6 years) had aortic valve replacement. Mean functional class was 2.3±0.5, and 157 patients (88%) were in sinus rhythm. Prosthetic sizes were 23 mm in 98 patients and 25 mm in 66. Follow-up was completed in December 2009 with a cumulative duration of 1,015 patient/years (mean, 5.7±3.5 years, maximum, 13.7 years). RESULTS: Early mortality was 4%, none being valve-related; of 38 late deaths 7 were valve-related. Actuarial survival at 13 years was 48%±8%. Mean functional class of current survivors was 1.2±0.6. Six embolic episodes occurred and four cases of endocarditis, with respective actuarial freedom of 92%±5% for embolism and 97%±2% for endocarditis at 13 years. Four patients required reoperations for endocarditis and 2 for structural deterioration. Actuarial freedom from structural deterioration and from reoperation for all causes was 89%±7% and 86%±7% at 13 years, with an actuarial freedom from prosthesis-related deaths of 86%±5%. Results of echocardiographic evaluation at 1 year were mean peak gradient, 20±6 mm Hg and mean effective orifice area index, 1.07±0.21 cm2/m2 for size 23 mm and 22±6 mm Hg and 1.11±0.26 cm2/m2 for size 25 mm; at 10 years, mean peak gradient and mean effective orifice area index were 28±13 mm Hg and 1.01±0.19 cm2/m2 for size 23 mm and 26±8 mm Hg and 1.08±0.18 cm2/m2 for size 25 mm. CONCLUSIONS: The Mosaic bioprosthesis showed good overall performance, with low incidence of structural valve deterioration and hemodynamic stability in the long-term. Expected increased durability of this device should be verified at longer follow-up intervals.

Total calcification of an aortic homograft used as aortic root replacement.

A 66-year-old man presented with total calcification of a homograft used as aortic root replacement approximately 10 years previously. Reoperation consisted of complete dissection of the homograft and en-bloc replacement with a mechanical conduit. Despite careful dissection the right coronary ostium was disrupted requiring reconstruction by interposition of a saphenous vein segment. Reoperation for failure of homografts used as aortic root replacement represents a major technical challenge.