Continuous Glucose Monitoring System After Coronary Artery Bypass Graft Surgery: A Feasibility Study.

BACKGROUND: Blood glucose level variability has been associated with increased risk of complication in the postoperative setting of cardiovascular surgery. Although interesting for optimization of blood glucose management in this context, continuous blood glucose (CBG) devices can have a limited reliability in this context, in particular because of the use of paracetamol. The aim of this study was to evaluate the reliability of Dexcom G6®, a recently developed continuous glucose monitoring device. METHODS: We performed a prospective, observational, non-randomized, single-centre study comparing Dexcom G6® CBG level monitoring with the standard methods routinely used in this context. The standard blood glucose values were paired to the time corresponding values measured with Dexcom G6®. Agreement between the two methods and potential correlation in case of paracetamol use were calculated. RESULTS: From May 2020 to August 2021, 36 out of 206 patients operated for isolated coronary artery bypass grafting were enrolled; 673 paired blood glucose level were analyzed. Global agreement (ρc) was 0.85 (95% C.I.: 0.84-0.86), intensive care unit agreement was 0.78 (95%C.I.: 0.74-0.82) and ward agreement was 0.91 (95%C.I.: 0.89-0.93). In the diabetic population, it was 0.87 (95%C.I.: 0.85-0.90). When paracetamol was used, the difference was 0.02 mmol/l (95%C.I.: 0.29-0.33). CONCLUSIONS: Dexcom G6® provides good blood glucose level accuracy in the postoperative context of cardiac surgery compared to the standard methods of measurements. The results are particularly reliable in the ward where the need for repeated capillary glucose measurements implies patient discomfort and time-consuming manipulations for the nursing staff.

An Investigation of Metabolic Risk Factors and Gut Microbiota in Unexplained Syncope.

BACKGROUND: The pathogenesis of many syncopal episodes remains unexplained. Intestinal dysbiosis could be involved in the pathophysiological mechanisms of syncope due to its connection with the central nervous system via the microbiota-gut-brain axis. This pilot study aimed to explore the specific cardiometabolic risk factors and gut microbiota in unexplained syncope (US), compared to other types of syncope, to assess their similarity or verify their different origins. METHODS: We studied 86 participants with syncope, who were divided into four groups: an orthostatic syncope group (OH, n = 24), a neuromediated syncope group (NMS, n = 26), a cardiological syncope group (CS, n = 9), and an unexplained syncope group (US, n = 27). We evaluated the anthropometric, clinical, and metabolic characteristics of the four groups; the α- and ß-diversity; and the differences in the abundance of the microbial taxa. RESULTS: The US group had a lower incidence of systolic hypertension at the first visit and a lower frequency of patients with nocturnal hypertension than the CS group. Compared to the OH and NMS groups, the US group had a higher incidence of carotid plaques and greater carotid intima-media thickness, respectively. The microbiota differed significantly between the US and CS groups, but not between the US group and the OH or NMS group. CONCLUSIONS: We observed significant differences in the gut microbiota between CS and US. Future studies are necessary to evaluate the involvement of the gut microbiota in the complex pathogenesis of syncope and whether its analysis could support the interpretation of the pathophysiological mechasnisms underlying some episodes classifiable as US.

Functional hypothalamic amenorrhea: gut microbiota composition and the effects of exogenous estrogen administration.

Functional hypothalamic amenorrhea (FHA) is characterized by estrogen deficiency that significantly impacts metabolic, bone, cardiovascular, mental, and reproductive health. Given the importance of environmental factors such as stress and body composition, and particularly considering the importance of estrogens in regulating the gut microbiota, some changes in the intestinal microenvironment are expected when all of these factors occur simultaneously. We aimed to assess whether the gut microbiota composition is altered in FHA and to determine the potential impact of hormonal replacement therapy (HRT) on the gut microbiota. This prospective observational study included 33 patients aged 18-34 yr with FHA and 10 age-matched healthy control women. Clinical, hormonal, and metabolic evaluations were performed at baseline for the FHA group only, whereas gut microbiota profile was assessed by 16S rRNA gene amplicon sequencing for both groups. All measurements were repeated in patients with FHA after receiving HRT for 6 mo. Gut microbiota alpha diversity at baseline was significantly different between patients with FHA and healthy controls (P < 0.01). At the phylum level, the relative abundance of Fusobacteria was higher in patients with FHA after HRT (P < 0.01), as was that of Ruminococcus and Eubacterium at the genus level (P < 0.05), which correlated with a decrease in circulating proinflammatory cytokines. FHA is a multidimensional disorder that is interconnected with dysbiosis through various mechanisms, particularly involving the gut-brain axis. HRT appears to induce a favorable shift in the gut microbiota in patients with FHA, which is also associated with a reduction in the systemic inflammatory status.NEW & NOTEWORTHY Our study marks the first comprehensive analysis of gut microbiota composition in FHA and the impact of HRT on it, along with biochemical, anthropometric, and psychometric aspects. Our results indicate distinct gut microbiota composition in patients with FHA compared with healthy individuals. Importantly, HRT prompts a transition toward a more beneficial gut microbiota profile and reduced inflammation. This study validates the concept of FHA as a multifaceted disorder interlinked with dysbiosis, particularly involving the gut-brain axis.

Cardiac surgery simulation - part 2: Step-by-step Konno operation in a preclinical model.

This operation is performed on a preclinical model (porcine heart) that has been positioned and fixed inside a plastic mannequin, simulating the human anatomy. This set-up allows surgical operations to be performed at almost the same depth and orientation as in the operating theatre. The preclinical model allows the exact simulation of most of the key movements and steps of major adult and congenital operations. In this case, we replicate the Konno operation. This intervention addresses localized subaortic stenosis involving the left outflow tract or the narrowing of the left ventriculo-aortic junction.

del Nido versus hematic cardioplegia in minimally invasive aortic valve surgery.

BACKGROUND: The quality of a myocardial protection of a single-dose del Nido cardioplegia versus multiple dose blood-based cardioplegia on myocardial injury, outcomes and operative times in patients undergoing minimally invasive aortic valve replacement is basically unreported. METHODS AND RESULTS: Preoperative and post-operative data, as well as technical details from isolated minimally invasive aortic valve replacements, performed using single-dose or multiple-dose cardioplegia were prospectively collected and retrospectively analysed. A total of 110 patients undergoing minimally invasive valve replacements at our institution composed two groups: 55 patients in the blood cardioplegia group (BloCa) and 55 in the del Nido group (DeNiCa). The two-matched groups were comparable in terms of preoperative variables. In the DeNiCa group, there was a statistically significant less need for cardiac defibrillation after aortic cross-clamp release (p < 0.001). Moreover, the BloCa group received intraoperatively more blood transfusions (p = 0.001) and more insulin administration for higher glucose levels (p < 0.001). The BloCa group showed higher intraoperative lactate levels (p = 0.01). Need for post-operative inotropic and vasoactive support, Creatine Kinase-MB levels after 6 and 12 h, onset of post-operative atrial fibrillation and length of stay were similar. No deaths occurred in neither groups. CONCLUSION: Single-dose del Nido cardioplegia in the setting of minimally invasive aortic surgery seems to offer adequate myocardial protection, comparable to multiple dose hematic cardioplegia. It has been documented a lower peri-operative need of defibrillation after cross-clamp release, lactate- and glucose peak values, as well as less blood transfusions compared to blood cardioplegic strategy.

Cardiac surgery simulation: step-by-step Nicks procedure in a preclinical model.

We demonstrate the Nicks operation, one of the posterior aortic root enlargement procedures, on a preclinical model (porcine heart). The goal of this operation is to facilitate the implementation of a suitably sized aortic prosthetic valve. The procedure is performed by making a longitudinal incision through the non-coronary sinus without entering the fibrous body between the aortic valve and the anterior leaflet of the mitral valve and inserting a patch to enlarge the annulus.

Mid-Term Clinical Outcomes and Hemodynamic Performances of Trifecta and Perimount Bioprostheses following Aortic Valve Replacement.

Aims of the Study: We evaluated the clinical outcome and the hemodynamic and freedom from structural valve degeneration of two standard aortic bioprostheses. Methods: Clinical results, echocardiographic findings and follow-up data of patients operated for isolated or combined aortic valve replacement with the Perimount or the Trifecta bioprosthesis were prospectively collected, retrospectively analysed and compared. We weighted all the analyses by the inverse of the propensity of choosing either valves. Results: Between April 2015 and December 2019, 168 consecutive patients (all comers) underwent aortic valve replacement with Trifecta (n = 86) or Perimount (n = 82) bioprostheses. Mean age was 70.8 ± 8.6 and 68.8 ± 8.6 years for the Trifecta and Perimount groups, respectively (p = 0.120). Perimount patients presented a greater body mass index (27.6 ± 4.5 vs. 26.0 ± 4.2; p = 0.022), and 23% of them suffered from angina functional class 2-3 (23.2% vs. 5.8%; p = 0.002). Mean ejection fraction was 53.7 ± 11.9% (Trifecta) and 54.5 ± 10.4% (Perimount) (p = 0.994), with mean gradients of 40.4 ± 15.9 mmHg (Trifecta) and 42.3 ± 20.6 mmHg (Perimount) (p = 0.710). Mean EuroSCORE-II was 7 ± 11% and 6 ± 9% for the Trifecta and Perimount group, respectively (p = 0.553). Trifecta patients more often underwent isolated aortic valve replacement (45.3% vs. 26.8%; p = 0.016) and annulus enlargement (10.5% vs. 2.4%; p = 0.058). All-cause mortality at 30 days was 3.5% (Trifecta) and 8.5% (Perimount), (p = 0.203) while new pacemaker implantation (1.2% vs. 2.5%; p = 0.609) and stroke rate (1.2% vs. 2.5%; p = 0.609) were similar. Acute MACCE were observed in 5% (Trifecta) and 9% (Perimount) of patients with an unweighted OR of 2.22 (95%CI 0.64-7.66; p = 0.196) and a weighted OR of 1.10 (95%CI: 0.44-2.76, p = 0.836). Cumulative survival at 24 months was 98% (95%CI: 0.91-0.99) and 96% (95%CI: 0.85-0.99) for Trifecta and Perimount groups, respectively (log-rank test; p = 0.555). The 2-year freedom from MACCE was 94% (95%CI: 0.65-0.99) for Trifecta and 96% (95%CI: 0.86-0.99) for Perimount (log-rank test; p = 0.759, HR 1.46 (95%CI: 0.13-16.48)) in the unweighted analysis (not estimable in the weighted analysis). During the follow-up (median time: 384 vs. 593 days; p = 0.0001) there were no re-operations for structural valve degeneration. Mean valve gradient at discharge was lower for Trifecta across all valve sizes (7.9 ± 3.2 vs. 12.1 ± 4.7 mmHg; p < 0.001), but the difference did not persist during follow-up (8.2 ± 3.7 mmHg for Trifecta, 8.9 ± 3.6 mmHg for Perimount; p = 0.224); Conclusions: Postoperative outcome and mid-term follow-up were similar. An early better hemodynamic performance was detected for the Trifecta valve but did not persist over time. No difference in the reoperation rate for structural valve degeneration was found.

Cardiac surgery simulation: Step-by-step hemi-Yacoub operation in a preclinical model.

We demonstrate a hemi-Yacoub operation on a preclinical model (porcine heart). It is an alternative remodelling technique for the management of dilatation of the ascending aorta with the involvement of the aortic root, particularly the noncoronary sinus or in case of an aortic dissection. The goal of this operation is to replace selectively the dilated/dissected portion (noncoronary sinus), thereby avoiding replacement of the entire aortic root.

Ten-Year Experience with Transapical and Direct Transaortic Transcatheter Aortic Valve Replacement to Address Patients with Aortic Stenosis and Peripheral Vascular Disease.

Objective: Transcatheter aortic valve replacement (TAVR) through alternative access routes is indicated in patients with severe aortic valve stenosis and diseased peripheral arteries. We analysed and compared the outcome of patients undergoing transapical (TA) and direct transaortic (TAO) TAVR procedures. Methods: Preoperative characteristics, procedural details, and thirty-day outcome of patients undergoing transapical (TA-TAVR group) and direct transaortic (TAO-TAVR group) TAVR procedures were prospectively collected and retrospectively analysed. Results: From March 2012 to March 2022, 81 TA and 82 TAO-TAVR (total: 163 cases) were performed with balloon-expanding (n = 120; 73.6%) and self-expandable (n = 43; 26.4%) valves. The mean age was 79.7 ± 6.2 and 81.9 ± 6.7 years for the TA- and TAO-TAVR groups, respectively (p = 0.032). Females were more represented in the TAO-TAVR group (56% vs. 32%; p = 0.003) while TA-TAVR patients showed a higher prevalence of previous vascular surgery (20% vs. 6%; p = 0.01), previous cardiac surgery (51% vs. 3.6%; p < 0.001), and porcelain aorta (22% vs. 5%; p = 0.001). The mean ejection fraction was 49.0 ± 14.6% (TA) and 53.5 ± 12.2% (TAO) (p = 0.035) while mean gradients were 35.6 ± 13.2 mmHg (TA) and 40.4 ± 16.1 mmHg (TAO) (p = 0.045). The median EuroSCORE-II was 5.0% (IQR: 3.0−11.0) and 3.9% (IQR: 2.5−5.4) for the TA- and TAO-TAVR groups, respectively (p = 0.005). The procedural time was shorter for TA procedures (97 min (IQR: 882−118) vs. 102 min (IQR: 88−129); p = 0.133). Mortality at day 30 was 6% in both groups (p = 1.000); the permanent pacemaker implantation rate was similar (8.6% vs. 9.7%; p = 1.000), and hospital stay was shorter for the TAO group (8 days (IQR: 6−11) vs. 10 days (IQR: 7−13); p = 0.025). Conclusions: Our results show that transapical and direct transaortic TAVR in high-risk patients with diseased peripheral arteries provide satisfactory clinical results with similar thirty-day outcomes.

Cardiac surgery simulation - part 1: Step-by-step David procedure in a preclinical model.

We performed this operation on a preclinical model (porcine heart) that has been positioned and fixed inside a plastic mannequin that simulates the human anatomy. This simulation allows surgical operations to be performed at almost the same depth and orientation at which they would be performed on a patient in an operating room. The preclinical model allows the exact simulation of most of the key movements and steps of major coronary and valve surgery. In this case, we show the salient steps of the David I operation.

Twenty-year experience with skeletonized bilateral internal thoracic arteries for surgical myocardial revascularization. A single center experience.

BACKGROUND AND AIM OF THE STUDY: The mammary artery shows excellent long-term patency and encourages the use of skeletonized bilateral internal thoracic arteries (BITA) for coronary surgery. We analyzed the long-term outcome of patients operated for myocardial revascularization with BITA in a single center. MATERIALS AND METHODS: Clinical data and surgical details of patients undergoing coronary surgery with BITA were prospectively collected and retrospectively analyzed. Selected variables were studied as risk factors for sternal wound complication and a subanalysis of clinical outcome for patients aged 70 years or greater was performed. A long-term follow-up of the study group is provided. RESULTS: From January 2001 to November 2021, 750 patients underwent myocardial revascularization using BITA grafts (mean age: 61 ± 9.5 years; males: 91%) at our institute. Patients with triple-vessel disease were 81%, 15.3% of all procedures were performed off-pump and 3.6% were urgent cases. Hospital mortality was 0.5%. Sternal wound complication was observed in 67 patients (9.0%) with 7 deep sternal wound infections (0.9%). Female gender (odds ratios [OR]: 3.7, p < 0.01), BMI >30 (OR: 1.8, p = 0.04), smoking (OR: 1.8, p = 0.02), and chronic kidney failure (OR: 3.7, p = 0.05) were independent predictors for sternal complications. During a mean follow-up time of 8.7 ± 5.3 years, 34 patients (4.5%) underwent a repeated myocardial revascularization, and there were 89 all-cause deaths (11.9%) and the cumulative survival at 5, 10, 15, and 20 years was 97%, 89%, 76%, and 60% for the whole study group 92%, 74%, 47%, and 43% for the subgroup of elderly patients (mean age: 74 ± 3.5 years). CONCLUSIONS: Use of skeletonized bilateral thoracic arteries shows low-rate of wound infection and good long-term outcome with low risk of repeated revascularizations, regardless of patients' age.

Percutaneous Venous Cannulation for Minimally Invasive Cardiac Surgery: The Safest and Effective Technique Described Step-by-Step.

The current cardiac surgical landscape, with the expansion of minimally invasive operations, ECMO, and some interventional therapies, requires a thorough knowledge of peripheral cannulation techniques. In particular, venous cannulation may appear trivial and complication-free, but this does not reflect the reality. A venous cannulation which is not perfectly performed can lead to serious life-threatening complications in several steps. The technique we describe step by step is the current gold standard in terms of safety and efficacy: from the use of ultrasound for ultrasound-guided puncture to safe advancement of super stiff guidewires by means of a sentinel catheter, and concluding with smooth insertion of the venous cannula over the stiff guidewire up to the SVC. Moreover, a list of bailout maneuvers to solve complications is presented along with a report of institutional clinical experience since the adoption of this technique.

Efficacy of Intraoperative Vein Graft Storage Solutions in Preserving Endothelial Cell Integrity during Coronary Artery Bypass Surgery.

(1) Introduction: Intraoperative preservation solutions for saphenous vein grafts may influence the endothelial structure and increase the risk of graft failure after coronary surgery. The aim of the study was to compare the efficacy of three solutions in maintaining the endothelial cell integrity of venous segments. (2) Methods: We tested the efficacy of physiological saline solution (PSS), heparinized autologous blood (HAB) and DuraGraft® in preserving the endothelium of vein segments by evaluating the degree of endothelial cell apoptosis. Two incubation times (2 and 4 h from harvesting) were used for each solution. The quantification of apoptotic cells was computed as the intensity nuclei/intensity area ratio. (3) Results: After 2 h of ischemia, the degree of apoptosis decreased progressively across the use of DuraGraft, HAB and PSS (p = 0.004), although only the difference between DuraGraft and PSS yielded a statistical significance (p = 0.002). After 4 h, a similar decrease in apoptosis was shown across the three media; however, statistical significance was not reached. The analysis of the elapsed time (2 or 4 h of incubation) showed that this was a relevant factor in maintaining the endothelial structural integrity independently from the storage solution (test for interaction of media and time p = 0.010). (4) Conclusion: Within 2 h of incubation, endothelial structural integrity depended on the incubating medium. DuraGraft better protected the SVG against ischemic-induced apoptosis when compared to saline solution. Prolonged ischemia was associated with extended endothelium damage and none of the studied solutions protected the vein graft.

The Aortic Annulus Stabilization Technique Prevents Paravalvular Leaks after Rapid Deployment Aortic Valve Implantation.

BACKGROUND: Surgical aortic valve replacement with rapid deployment bioprosthesis guarantees good hemodynamic results but carries the risk of paravalvular leaks. To address this issue, an annulus stabilization technique has been recently developed. METHODS: Clinical and hemodynamic parameters from patients treated for aortic valve replacement with the rapid deployment bioprosthesis and a concomitant annulus stabilization technique were prospectively collected and retrospectively analyzed. Echocardiographic data at discharge and at 1-year follow-up were collected and analysed. RESULTS: A total of 57 patients (mean age 74.3 ± 6.1 years) with symptomatic aortic valve stenosis underwent aortic valve replacement with the rapid deployment bioprosthesis and concomitant annulus stabilization technique (mean valve size: 23.8 ± 1.9 mm). Combined procedures accounted for 56.1%. Hospital mortality was 1.8% and a new pacemaker for conduction abnormalities was implanted in 10 patients. The pre-discharge echocardiographic control showed absence of paravalvular leaks of any degree in all patients with mean valve gradient of 9.6 ± 4.0 mmHg. The 1-year echocardiographic control confirmed the good valve hemodynamic (mean gradient of 8.0 ± 2.8 mmHg) and absence of leaks. CONCLUSION: In this preliminary clinical experience, the annulus stabilization technique prevents postoperative paravalvular leaks after rapid deployment aortic valve implantation, up to 1-year postoperatively. Studies on larger series are of paramount importance to confirm the long-term efficacy of this new surgical technique.

Retinal image quality with multifocal, EDoF, and accommodative intraocular lenses as studied by pyramidal aberrometry.

BACKGROUND: To study and compare the clinical optical image quality following implantation with different premium IOLs by analysing the point spread function (PSF) Strehl ratio using a pyramidal wavefront sensor (PWS)-based aberrometer. METHODS: This study included 194 eyes implanted with: (a) 19 AcrySof SA60AT (control group); (b) 19 Miniwell; (c) 24 LENTIS Mplus LS-313 MF30; d) 33 LENTIS Mplus LS-313 MF15; (e) 17 AkkoLens Lumina; (f) 31 AT LISA Tri 839MP; (g) 20 Precizon Presbyopic; (h) 20 AcrySof IQ PanOptix; (i) 11 Tecnis Eyhance. Main outcome measures were PSF Strehl ratio, PSF Strehl ratio excluding second-order aberrations (PSFw2), total root mean square (RMS), low-order aberration (LOA) and high-order aberration (HOA) RMS measured by PWS aberrometer. RESULTS: AT LISA Tri had the highest PSFw2 Strehl ratio at both 3.0- and 4.0-mm pupil size (0.52 ± 0.14 and 0.31 ± 0.10; P < 0.05), followed by SA60AT (0.41 ± 0.11 and 0.28 ± 0.07) and PanOptix (0.4 ± 0.07 and 0.26 ± 0.04). AT LISA Tri was found to provide a significantly better retinal image quality than PanOptix at both 3.0 mm (P < 0.0001) and 4.0 mm (P = 0.004). Mplus MF15 was found to be significantly better than Mplus MF30 at both 3.0 mm (P < 0.0001) and 4.0 mm (P = 0.002). Total RMS, LOA RMS, HOA RMS, PSF Strehl ratio and PSFw2 varied significantly between the studied groups (P < 0.001). CONCLUSIONS: Far distance clinical image quality parameters measured by PWS aberrometer differed significantly according to the technology of the implanted lens. AT LISA Tri, SA60AT and PanOptix showed the highest values of far distance retinal image quality, while the lowest PSFw2 Strehl ratios were displayed by Miniwell, Mplus MF30 and Precizon Presbyopic.

Light scattering in intraocular lenses explanted 15 to 40 years after surgery.

The optical quality of intraocular lenses (IOLs) of different materials that have been implanted from 16 to 44 years in human eyes was studied. The IOLs were explanted due to other causes than loss of transparency. The scattered light from the IOLs was assessed in two angular regimes by using dark field images (for wide angles) and the optical integration method (for narrower angles). No evident differences were found in the scattering intensities processed from the dark images. The explanted lenses presented slightly increased amounts of straylight between 1 and 5.1° when compared to a reference new unused lens.

Early predictors of mortality in refractory cardiogenic shock following acute coronary syndrome treated with extracorporeal membrane oxygenator.

We aimed to analyze the outcome and identify predictors of hospital mortality in patients with refractory cardiac arrest (CA) complicating acute coronary syndromes (ACS) and requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment. Between Jan-2005 and Dec-2019, 51 patients underwent urgent VA-ECMO implantation for CA in ACS. Patients were divided in two groups: "in-hospital" cardiac arrest (IHCA) and "out-of-hospital" cardiac arrest (OHCA). Prospectively collected data were retrospectively analyzed and compared between groups. Predictors for hospital mortality were investigated. IHCA and OHCA patients were 32 (62.7%) and 19 (37.3%), respectively. The groups differed for: male gender (72% vs 95%; p = 0.070), lactate peak level (8.5 ± 4.3vs10.7 ± 2.9; p = 0.023), total elapsed time from CA to VA-ECMO implantation in both groups (p < 0.001) and elapsed time from CA (IHCA group) or hospital arrival (OHCA group) to VA-ECMO implantation (38 min vs 80 min; p = 0.001). At logistic regression analysis, concomitant lactate level greater than 8.0 mmol/L and elapsed time from CA to VA-ECMO ≥ 30 min were predictors of increased mortality (OR 3.9; 95% CI 1.19-12.79; p = 0.025) for the entire population. In-hospital mortality was 60.8% (31/51 patients): 68.4% in OHCA group and 56.2% in IHCA group. No risk factors related to 30-day mortality resulted significant at univariable analysis. When rapidly instituted, VA-ECMO improves survival in patients with refractory cardiac arrest allowing coronary syndrome treatment. The association of an elapsed time from CA to VA-ECMO implantation longer than 30 min and a preoperative lactate peak level over 8.0 mmol/L predict a poor outcome, independently from being IHCA or OHCA.

Extended Depth-of-Field Intraocular Lenses: An Update.

Extended depth-of-focus (EDOF) is a new intraocular lens (IOL) technology in the treatment of presbyopia. In contrast to multifocal (MF) IOLs, EDOF lenses create a single elongated focal point, rather than several foci, to enhance depth of focus. In this way, EDOF IOLs aim to reduce photic phenomena, glare, and halos, which have been reported in MF IOLs. A potential disadvantage is a decrease of retinal image quality if the amount of the aberrations is excessively increased. Frequently, EDOF IOLs are combined with MF optical designs; for this reason, EDOF IOLs are commonly a subject of confusion with optical multifocality concepts. The aim of this article is to clarify what an EDOF IOL is and to discuss the recently reported outcomes with these IOLs. We propose naming lenses that have combined optical designs as "hybrid IOLs."

Risk stratification of severe aortic stenosis according to new guidelines: long term outcomes.

BACKGROUND: Current ESC and ACC/AHA guidelines for the management of valvular heart disease assign a class Ia indication for aortic valve replacement (AVR) only to patients with symptomatic severe aortic valve stenosis and asymptomatic patients with depressed left ventricular ejection fraction (LVEF <50%) or positive exercise test. We examined the long-term outcomes for patients undergoing AVR for aortic stenosis over a 11-year period at our institution compared to current international guidelines for AVR. METHODS: Patients who had undergone isolated AVR for severe aortic valve stenosis between January 2001 and December 2012 were selected. The population was divided into subgroups based on preoperative LVEF (< or ≥50%) and on presence/absence of symptoms (NYHA =I or ≥II, respectively). RESULTS: We identified 607 patients with a median follow-up (FU) time of 5.75 years (IQR 3.24-8.00 years). The presence of symptoms did not have a significant impact on cardiovascular mortality (P=0.201). Patients with LVEF <50% displayed a higher long-term cardiovascular mortality rate (P=0.015). Multivariate analysis showed that preserved LVEF was a protective factor for asymptomatic patients (P=0.021), while preoperative LVEF did not affect the mortality rate in symptomatic patients (HR 0.88; 95% CI, 0.54-1.44). Correspondingly, asymptomatic patients with reduced LVEF were found to be at a higher risk of long-term mortality compared to the other groups (P=0.011). The only other independent risk factor for death was age (HR 6.46; 95% CI, 2.22-18.76). CONCLUSIONS: According to our data, current international class I indications for symptomatic patients ensure good long-term survival, while class I indications for asymptomatic patients with reduced LVEF are associated with poor long-term survival. Our results suggest that early surgery should also be considered also for asymptomatic patients with preserved LVEF, particularly in cases of very low operative risk.