Leadless Pacemaker Infection Risk in Patients with Cardiac Implantable Electronic Device Infections: A Case Series and Literature Review.

(1) Background: Leadless pacemakers (LPs) have been proposed as a reimplantation strategy in pacing-dependent patients undergoing cardiac implantable electronic device (CIED) extraction for infection. In this study, we analysed the risk of LP infection when this device is implanted before lead extraction. (2) Methods: This was a retrospective study including patients who underwent LP implantation between 2017 and 2022. Patients were divided in two groups according to whether LP was implanted following CIED extraction for infection (Group 1) or other indications (Group 2). The primary aim was to describe the risk of LP infection. (3) Results: We included in this study 49 patients with a median age of 81 [20-94] years, mostly males (36, 73%). In Group 1 patients, 17 cases (85%) showed systemic CIED infections, and 11 (55%) had positive lead cultures. Most Group 1 cases (n = 14, 70%) underwent one stage of LP implantation and CIED extraction. Mortality rate during follow-up was 20% (nine patients). Patients were followed up for a median of 927 [41-1925], days and no cases of definite or suspected LP infections were identified. (4) Conclusions: The risk of LP infection was extremely low. LP appears as a potential option for reimplantation in this setting and should be considered in pacing-dependent patients at a high risk of CIED infection recurrence.

The impact of dual antiplatelet therapy administration on the risk of bleeding complications during coronary artery bypass surgery.

INTRODUCTION: Dual antiplatelet therapy reduces the risk of cardiovascular death, myocardial infarction and recurrence of adverse ischemic events in patients affected by acute coronary syndromes, but in patients urgently needing coronary artery surgery it can increase the risk of severe perioperative bleeding complications. AIM: We evaluated the impact of dual antiplatelet therapy (DAPT) based on acetylsalicylic acid plus clopidogrel or ticagrelor in patients undergoing coronary artery bypass grafting (CABG). MATERIAL AND METHODS: Three hundred and thirty-three patients underwent coronary artery bypass grafting with DAPT discontinuation > 72 hours or 3-4 days (group A, n = 159), 48-72 hours or 2-3 days (group B, n = 126), < 24 hours or 0-1 day (group C, n = 24) prior to CABG. RESULTS: Operative mortality was 1.87% (group A), 0.79% (group B), absent (group C). The incidence of mediastinal re-exploration was 1.25% or 2 patients (group A), 1.59% or 2 patients (group B), 8.33% or 4 patients (group C) (p = 0.01). Group C showed postoperatively a greater incidence of a blood loss greater than 500 ml at 6 hours and a blood loss from chest tube drainages significantly higher at 6 and 24 hours (p < 0.01). Multivariate analysis showed that ongoing ticagrelor intake in group C (HR = 42.4; p = 0.02) and group C (HR = 6.9; p = 0.04) were the only independent predictors of surgical re-exploration. In group C, surgical re-exploration was 2.56% or 1/39 patients taking clopidogrel, 33.3% or 3/9 patients taking ticagrelor (p = 0.002). CONCLUSIONS: Dual antiplatelet therapy ongoing until 1 day or 24 hours before CABG showed a significantly increased risk of bleeding complications in comparison with its discontinuation at 2-3 and > 3-4 days before, respectively. Major blood loss and surgical re-exploration were not associated with increased risk of operative all-cause or bleeding-related mortality. As expected, taking ticagrelor compared with clopidogrel in the short interval confers a higher risk of bleeding complications.

Surgical "elephant trunk" arch replacement with a branched arch prosthesis: two alternative operative techniques.

INTRODUCTION: Elephant trunk repair of the aortic arch cannot be performed with a branched prosthesis. AIM: We conceived two different modifications of the original technique to perform an arch replacement with a branched graft, while arranging an adequate landing zone for a subsequent thoracic endovascular aortic repair, without the need of dedicated material. MATERIAL AND METHODS: Eight consecutive patients underwent arch replacement with one of our techniques. Five were emergency patients with acute aortic dissection, and 3 suffered chronic expansive disease. The "modified elephant trunk" includes a separate anastomosis of an endo-luminal prosthetic segment in the descending aorta. Subsequently, the branched arch prosthesis is anastomosed to the distal aortic stump with the attached trunk. In the "prophylactic debranching", a tail is left on the distal end of the arch prosthesis, so that the branches for the supra-aortic vessels will remain displaced proximally, allowing a "zone 1" available for landing. RESULTS: Three patients experienced transient cerebral deficits (1 transient ischemic attack and post-operative delirium in 2 cases), 1 required re-operation for bleeding and 2 needed prolonged intubation. One died of multi-organ failure. CONCLUSIONS: Both techniques proved to be easily reproducible, and allow an adequate landing zone for a subsequent endovascular procedure, while retaining the advantages of using a tetra-furcated prosthesis. They are a viable alternative when a hybrid prosthesis cannot be implanted.

A Novel Endosurgical Prosthesis to Treat Thoracoabdominal Aortic Aneurysm in Complex Anatomy or Emergency Settings.

BACKGROUND: Despite improvements in operative techniques, open thoracoabdominal aortic aneurysm (TAAA) repair is complex and characterized by high mortality and morbidity rate. Less invasive techniques have been developed since 2005 for the treatment of TAAA. Unfortunately, many of these devices require custom fabrication, resulting in delay of many weeks until treatment can be delivered but crucial in critical emergency cases. We present a novel hybrid endovascular and surgical prosthesis, which was tested on five pigs, with the aim of reducing the barrier issues of endovascular therapy in such particular cases. METHODS: The principal characteristic of the proposed hybrid endovascular prosthesis is to combine a proximal and distal stented zones and, in between, a classical surgical blood tied Dacron prosthesis. The device was tested in five pigs where feasibility of implantation and acute postoperative outcomes were evaluated, including bleeding, bowel ischemia, renal function, and peripheral blood perfusion. RESULTS: In all cases, following laparotomy, the endoprosthesis was successfully implanted under fluoroscopy and the surgical prosthesis zone could be easily detected by the radio-opaque markers. No major bleeding or cardiac events occurred throughout preparation and implantation. One hour after prosthesis implantation and surgical anastomoses of all vessels were completed, normal urine output was registered, and no acidosis was detected. CONCLUSIONS: This novel graft has shown ease of endoprosthesis and visceral vessels implantation without the need of thoracotomy or extracorporeal circulation and may be useful in an emergency setting or high risk and complex anatomy TAAA unsuitable for traditional endovascular aneurysm repair, or to avoid an excess waiting time for a "custom made" prosthesis. The great adaptability of this "hybrid" prosthesis in complex anatomy for the majority of TAAA could be important in high-risk patients and in some difficult situations, such as a high risk of imminent rupture.

Clinical outcome and hemodynamic performance of St. Jude Trifecta aortic prosthesis: short-term follow-up and risk factors analysis.

BACKGROUND: We retrospectively analysed the short-term outcome of the third-generation St. Jude Trifecta aortic prosthesis. METHODS: Between December 2014 and December 2017, 177 patients (mean age 75.1±6.8 years, 95 males, 82 females) underwent aortic valve replacement with a St. Jude Trifecta aortic prosthesis and were followed up to 27±9 months. Preoperatively 92 patients (52.0%) were in NYHA class III-IV, EuroSCORE II was 3.2%±2.1%. RESULTS: Trifecta sizes implanted were 19 mm (n=46) (26%), 21 mm (n=69) (39%), 23 mm (n=46) (26%), 25 mm (n=16) (9%). Concomitant coronary artery bypass grafting was performed in 60 patients (34.0%). Operative mortality was 3.4% (1.7% for isolated aortic valve replacement versus 6.7% for combined aortic valve replacement and coronary artery bypass grafting) (P=0.084). The only independent predictor of mortality was the need for the mechanical ventilation greater than 24 hours (P=0.037); recently occurring myocardial infarction was risk factor for mortality at the univariate analysis only (P=0.013). Three-year survival was 84%±6%, freedom from cardiac death 98%±1%, freedom from prosthetic endocarditis 97%±1%. No thromboembolisms or structural valve degeneration were observed. Patient-prosthesis mismatch (PPM) was absent in 126 patients (71.2%), mild-to-moderate in 32 (18.1%), moderate in 19 (10.7%), severe in no any patient. Follow-up echocardiography showed an average mean and peak trans-aortic valve gradients reduction more than 70% in comparison with preoperative value (P<0.0001), and a significant regression of left ventricular hypertrophy (P<0.0001). Moderate PPM did not negatively affect survival. Concomitant severe coronary artery disease was found as an independent predictor of reduced survival (72%±12% versus 86%±6%) (P=0.015). CONCLUSIONS: Trifecta aortic prosthesis seems to provide very favourable clinical outcome and hemodynamic performance. At three years, survival was negatively affected by severe coronary artery disease detected at the time of operation. During short-term follow-up, no early structural valve degeneration was been observed. Due to low incidence of PPM and low peak and mean trans-prosthetic aortic valve gradients, third generation Trifecta aortic prosthesis should be considered as one of the best options in the setting of the aortic valve replacement surgery. However, a long-term follow-up is mandatory to confirm the early promising data.

Influence of Body Mass Index on Outcomes of Patients Undergoing Surgery for Acute Aortic Dissection: A Propensity-Matched Analysis.

To determine whether body mass index ≥30 kg/m2 affects morbidity and mortality rates in patients undergoing surgery for type A acute aortic dissection, we conducted a retrospective study of 201 patients with type A dissection. Patients were divided into 2 groups according to body mass index (BMI): nonobese (BMI, <30 kg/m2; 158 patients) and obese (BMI, ≥30 kg/m2; 43 patients). Propensity score matching was used to reduce selection bias. The overall mortality rate was 19% (38/201 patients). The perioperative mortality rate was higher in the obese group, both in the overall cohort (33% vs 15%; P=0.01) and in the propensity-matched cohort (32% vs 12%; P=0.039). In the propensity-matched cohort, patients with obesity had higher rates of low cardiac output syndrome (26% vs 6%; P=0.045) and pulmonary complications (32% vs 9%; P=0.033) than those without obesity. The overall 5-year survival rates were 52.5% ± 7.8% in the obese group and 70.3% ± 4.4% in the nonobese group (P=0.036). In the propensity-matched cohort, the 5-year survival rates were 54.3% ± 8.9% in the obese group and 81.6% ± 6.8% in the nonobese group (P=0.018). Patients with obesity (BMI, ≥30 kg/m2) who underwent surgery for type A acute aortic dissection had higher operative mortality rates and an increased risk of low cardiac output syndrome, pulmonary complications, and other postoperative morbidities than did patients without obesity. Additional extensive studies are needed to confirm our findings.

Mitral Valve Repair with a Semi-Rigid C-Band Annuloplasty Ring in Ischemic Mitral Regurgitation: Still a Viable Surgical Option?

BACKGROUND: Ischemic mitral valve regurgitation (IMR) develops in approximately 10% of patients after myocardial infarction. Surgical management of IMR is controversial, as many series have failed to demonstrate the superiority of mitral valve repair (MVRep) over mitral valve replacement (MVR) in IMR. Moreover, in the setting of MVRep, the choice of ring type is the subject of much debate. The study aim was to evaluate the results of MVRep in IMR with the use of a semi-rigid incomplete C-ring. METHODS: Between January 2006 and May 2014, a total of 105 patients (79 males, 26 females; mean age 69 ± 8 years) underwent surgical MVRep using a semi-rigid incomplete ring (median size 30 mm) during coronary artery bypass grafting (CABG) to treat IMR. The patients' mean logistic EuroSCORE was 14 ± 12, and the preoperative left ventricular ejection fraction was 43 ± 11%. The mean duration of follow up was 48 ± 31 months, and was 100% complete. RESULTS: In-hospital mortality was 6.6% (n = 7). The main predictor of in-hospital mortality was cardiopulmonary bypass time (p <0.05). Echocardiography performed at discharge showed moderate mitral regurgitation (MR) in only one patient, and significant reductions in left ventricular end-diastolic diameter (p <0.0001) and MR grade (p <0.0001). After seven years, freedom from all-cause death was 73 ± 9%, while freedoms from recurrence of MR grade ≥2 and NYHA class >II were 95 ± 3% and 89 ± 4%, respectively. Freedom from reintervention was 100%. CONCLUSIONS: Despite the adverse prognosis of IMR, the present study demonstrated the effectiveness and durability of mitral valve repair with the use of a semi-rigid ring, as a concomitant procedure to CABG, showing good results in terms of recurrence of MR and event-free survival at mid-term follow up.

Cold crystalloid versus warm blood cardioplegia in patients undergoing aortic valve replacement.

BACKGROUND: Myocardial protection techniques during cardiac arrest have been extensively investigated in the clinical setting of coronary revascularization. Fewer studies have been carried out of patients affected by left ventricular hypertrophy, where the choice of type and temperature of cardioplegia remain controversial. We have retrospectively investigated myocardial injury and short-term outcome in patients undergoing aortic valve replacement plus or minus coronary artery bypass grafting with using cold crystalloid cardioplegia (CCC) or warm blood cardioplegia (WBC). METHODS: From January 2015 to October 2016, 191 consecutive patients underwent aortic valve replacement plus or minus coronary artery bypass grafting in normothermic cardiopulmonary bypass. Cardiac arrest was obtained with use of intermittent antegrade CCC group (n=32) or WBC group (n=159), according with the choice of the surgeon. RESULTS: As compared with WBC group, in CCC group creatine-kinase-MB (CK-MB), cardiac troponin I (cTnI), aspartate aminotransferase (AST) release, and their peak levels, were lower during each time points of evaluation, with the greater statistically significant difference at time 0 (P<0.05, for all comparisons). A time 0, CK-MB/CK ratio >10% was 5.9% in CCC group versus 7.8% in WBC group (P<0.0001). At time 0 CK-MB/CK ratio >10% in patients undergoing isolated aortic valve replacement was 6.0% in CCC group versus 8.0% in WBC group (P<0.01). No any difference was found in perioperative myocardial infarction (0% versus 3.8%), postoperative (PO) major complications (15.6% versus 16.4%), in-hospital mortality (3.1% versus 1.3%). CONCLUSIONS: In aortic valve surgery a significant decrease of myocardial enzymes release is observed in favor of CCC, but this difference does not translate into different clinical outcome. However, this study suggests that in presence of cardiac surgical conditions associated with significant left ventricular hypertrophy, i.e., the aortic valve disease, a better myocardial protection can be achieved with the use of a cold rather than a warm cardioplegia. Therefore, CCC can be still safely used.

An Unexpected Risk Factor for Early Structural Deterioration of Biological Aortic Valve Prostheses.

BACKGROUND: An alarming rate of early failure has been recently reported for the LivaNova (previously Sorin) Mitroflow (LivaNova, London, UK) bioprosthesis. Here, we aimed at verifying if this possible underperformance is confirmed in a large, single-center experience and identifying the risk factors associated with early deterioration. METHODS: In all, 459 Mitroflow valves have been implanted from July 2009 to December 2013 (patients' mean age 73 years; 204 women). Surviving patients have undergone yearly clinic and echocardiographic follow-up. Dysfunction was defined as moderate if the mean gradient was more than 30 mm Hg or severe if it exceeded 40 mm Hg. The population was divided on the basis of a dimensional mismatch, the model of the prosthesis (LX or DL: follow-up to 4 years), and patient's age at the time of implantation. RESULTS: Cumulative freedom from moderate valve dysfunction was 81% ± 3% at 60 months. It was lower with patient-prosthesis mismatch (71% ± 5% versus 92% ± 3%; p = 0.0065) and with the more recent DL model (at 42 months: 78% ± 6% versus 96% ± 2%; p < 0.0001). Cumulative freedom from severe dysfunction was 93% ± 2% at 5 years. Again, it was inferior among patients with a mismatch (86% ± 4% versus 100%; p = 0.0013) and for the DL model (42 months: 92.5% ± 3% versus 98.5% ± 1%; p = 0.0309). Smaller prostheses showed higher rates of early degeneration. CONCLUSIONS: The LivaNova Mitroflow valve appears to be prone to early deterioration. Smaller size prostheses should be used cautiously and avoided with patient-prosthesis mismatch. The DL model anticalcification treatment seems unable to prevent early degeneration, and possibly contributes to even earlier failure.

Coronary endarterectomy: an old tool for patients currently operated on with coronary artery bypass grafting. Long-term results, risk factor analysis.

AIM: Coronary endarterectomy (CE) may provide a useful adjunctive technique to coronary artery bypass grafting (CABG) in patients with diffuse coronary artery disease. Nevertheless, the incidence of complications still remains high, long-term results remain unclear, and no risk factors for late mortality have been completely described yet. MATERIAL AND METHODS: We retrospectively reviewed 90 consecutive patients (67 ±8.2 years) undergoing isolated CABG in association with CE between 2006 and 2013. Mean follow-up was 75.1 ±36.2 months (median: 84 months) and it was 100% complete (6755/6755 patient-months). RESULTS: Operative mortality was 4.4%, the incidence of perioperative myocardial infarction was 11%. Ten-year survival was 83.3 ±4.1%, freedom from cardiac death 92.7 ±2.9%, and freedom from major adverse cardiac and cerebrovascular events 58.2 ±10.2%. Independent predictors of late mortality were age older than 70 years at time of the surgery (p = 0.018) and chronic obstructive pulmonary disease (p = 0.036). Ten-year freedom from cardiac death was better after CE on the left descending coronary artery (LAD) (93.2 ±3.3%) in comparison to CE not on the LAD (74.6 ±10.2%), although this difference did not reach statistical significance (p = 0.102). CONCLUSIONS: Although the incidence of perioperative myocardial infarction continues to be not negligible, in the presence of diffusely diseased coronary artery vessels CE associated with CABG appears to be a feasible adjunctive surgical tool, conferring satisfactory early and long-term outcomes. Coronary endarterectomy on the LAD confers a high probability of freedom from late cardiac death. Patients older than 70 years and those affected by a primary respiratory disease represent a new challenge on which to focus attention due to the increased risk of late death.

Bicuspid aortic root spared during ascending aorta surgery: an update of long-term results.

BACKGROUND: Bicuspid aortic valve (BAV) aortopathy is well known in literature even if only few data exist regarding isolated supra-coronary aneurysm with normally functioning valve and root. Aim of this study is to clarify the long-term fate of bicuspid aortic root spared at the time of ascending aorta surgery. METHODS: We identified forty-seven patients (mean age, 57±11 y; range, 35-81 y, 31 males) who were treated by means of supracoronary aortic replacement in presence of normally functioning BAV and not significantly enlarged sinues of Valsalva. Clinical follow-up (mean 93±50 months; range, 21-207) was 98.9% complete. RESULTS: Freedom from cardiac death at 5- and 10-year was 95%±5% and 83%±16%. Three surviving patients required reoperation for the development of aortic insufficiency [2 cases treated by aortic valve replacement (AVR)] or for progression of aortic stenosis (AS) [1 case treated by transcatheter aortic valve implantation (TAVI)]. Freedom from new procedure on aortic valve was 100% and 94.4%±5.6% at 5- and 10-year. Composite event-free survival at 5- and 9-year was 82%±18% and 69%±30%. CONCLUSIONS: Although in the setting of a BAV, aortic root integrity seems to remain stable during long term follow up with low rate of reoperation and occurrence of new adverse event.

Can Perceval sutureless valve reduce the rate of patient-prosthesis mismatch?†.

OBJECTIVES: The aim of this study is to compare the theoretical incidence of patient-prosthesis mismatch (PPM) in patients undergoing a sutureless or a sutured aortic valve replacement using an exact statistical matching. METHODS: Between May 2012 and March 2016, 65 patients with severe symptomatic aortic stenosis underwent a sutureless aortic valve replacement with the Perceval bioprosthesis in 2 centres. Moreover, 177 aortic valve replacements with conventional sutured bioprosthesis were performed between August 2003 and September 2015. Perceval and sutured patients were 1:1 exactly matched for sex and body surface area (BSA), resulting in 62 couples (sutureless: BSA 1.77 ± 0.16 m 2 , female 62.9% vs sutured: BSA 1.77 ± 0.15 m 2 , female 62.9%). RESULTS: After matching, the indexed effective orifice area was 1.50 ± 0.18 cm 2 /m 2 and 0.81 ± 0.19 cm 2 /m 2 in the sutureless and the sutured group, respectively ( P < 0.001). No PPM occurred in patients who received a Perceval bioprosthesis ( n = 62). In the sutured group ( n = 62), 38 patients (61.3%) developed a PPM, which was moderate in 41.9% ( n = 26) and severe in 19.4% ( n = 12) ( P < 0.001). CONCLUSIONS: The indexed effective orifice area of the sutureless group was significantly larger than in the sutured one. The incidence of PPM with the conventional sutured biprosthesis was 61.3%, while it decreases to 0% in the sutureless group. No PPM was reported in the sutureless valve group. Therefore, the Perceval sutureless valve provides larger effective orifice areas compared to the sutured conventional bioprosthesis and could be considered as a good option to reduce the risk of a PPM.

Long-Term Results of Aortic Root Surgery in Marfan Syndrome Patients: A Single-Center Experience.

BACKGROUND AND AIM OF THE STUDY: The study aim was to compare long-term results of Marfan syndrome (MFS) patients affected by aortic root disease undergoing aortic root replacement with the Bentall or David operation. METHODS: Since 1994, a total of 59 patients has been followed at the authors' Marfan Center, having undergone either a Bentall operation (Bentall group, n = 30) or a David operation (David group, n = 29). RESULTS: No operative mortality was recorded. After 20 years (mean follow up 97 ± 82 months; range 1 to 369 months) no prosthesis-related major bleeding or thromboembolic events had been observed; the 20-year survival was 94 ± 6% in the Bentall group, and 100% in the David group (p = 0.32). Freedom from reintervention for aortic valve dysfunction was 100% in the Bentall group, and 75 ± 13% in the David group (p = 0.04). This inter-group difference became relevant after the first eight-year period of follow-up, and was mainly associated with a particular familiar genetic phenotype involving three out of four reoperated patients. Freedom from all-cause death, myocardial infarction, stroke, prosthetic valve-related complications, and reintervention on any aortic segment was 69 ± 12% in the Bentall group, and 67 ± 14% in the David group (p = 0.33). CONCLUSIONS: The Bentall and David operations are both associated with satisfactory long-term results in MFS patients. The low rate of valve prosthesis-related complications suggested that the Bentall operation would continue to be a standard surgical treatment. The reimplantation technique, adopted for less-dilated aortas, provides satisfactory freedom from reoperation. Careful attention should be paid to the reimplantation technique in patients affected by a serious familiar genetic phenotype.

Single versus double antiplatelet therapy in patients undergoing coronary artery bypass grafting with coronary endarterectomy: mid-term results and clinical implications.

Objectives: Coronary endarterectomy (CE) represents a useful adjunctive technique to coronary artery bypass grafting (CABG) in the presence of diffuse coronary artery disease. Nevertheless, the long-term patency of the graft remains unclear, and no standard anticoagulation and antiplatelet protocols exist for use after CE. The aim of this retrospective study was to evaluate and possibly to clarify the role of single (SAT) versus dual antiplatelet therapy (DAT) at mid-term follow-up. Methods: Between January 2006 and December 2013, CE was performed in 90 patients (mean age 67 ± 8.2 years) who also underwent isolated CABG. After surgery, 20 patients received aspirin 100 mg daily (SAT group), and 52 patients received aspirin plus clopidogrel 75 mg daily (DAT group). Clopidogrel was discontinued in the DAT group 12 months after the operation. Results: The overall in-hospital mortality rate was 2.7% (SAT 0% vs DAT 3.8%; P = ns). Perioperative myocardial infarction was 12.3% (SAT 15.0% vs DAT 11.5%; P = ns), and major bleeding requiring surgical re-exploration was 4.1% (SAT 10.0% vs DAT 1.9%; P = ns). Mean follow-up duration was 71.3 ± 32.7 months (median 79 months), and was 100% complete (5208/5208 pt-months). At 7 years of follow-up, freedom from cardiac death was 84 ± 9% in group SAT versus 85 ± 5% in group DAT (P = ns); freedom from new percutaneous coronary intervention was 93 ± 6% versus 100% (P = ns), and freedom from major adverse cardiac and cerebrovascular events was 73 ± 10% versus 75 ± 6% (P = ns). Conclusions: In patients with diffuse coronary disease, CE is a safe and feasible technique with acceptable mid-term results. No differences were observed in terms of major clinical outcomes between patients treated with single versus dual antiplatelet therapy at least in a mid-term period of follow-up.

Valve Replacement with a Sutureless Aortic Prosthesis in a Patient with Concomitant Mitral Valve Disease and Severe Aortic Root Calcification.

Aortic valve replacement with concomitant mitral valve surgery in the presence of severe aortic root calcification is technically difficult, with long cardiopulmonary bypass and aortic cross-clamp times. We performed sutureless aortic valve replacement and mitral valve annuloplasty in a 68-year-old man who had severe aortic stenosis and moderate-to-severe mitral regurgitation. Intraoperatively, we found severe calcification of the aortic root. We approached the aortic valve through a transverse aortotomy, performed in a higher position than usual, and we replaced the valve with a Sorin Perceval S sutureless prosthesis. In addition, we performed mitral annuloplasty with use of an open rigid ring. The aortic cross-clamp time was 63 minutes, and the cardiopulmonary bypass time was 83 minutes. No paravalvular leakage of the aortic prosthesis was detected 30 days postoperatively. Our case shows that the Perceval S sutureless bioprosthesis can be safely implanted in patients with aortic root calcification, even when mitral valve disease needs surgical correction.

Total Arch versus Hemiarch Replacement for Type A Acute Aortic Dissection: A Single-Center Experience.

We retrospectively evaluated early and intermediate outcomes of aortic arch surgery in patients with type A acute aortic dissection (AAD), investigating the effect of arch surgery extension on postoperative results. From January 2006 through July 2013, 201 patients with type A AAD underwent urgent corrective surgery at our institution. Of the 92 patients chosen for this study, 59 underwent hemiarch replacement (hemiarch group), and 33 underwent total arch replacement (total arch group) in conjunction with ascending aorta replacement. The operative mortality rate was 22%. Total arch replacement was associated with a 33% risk of operative death, versus 15% for hemiarch (P=0.044). Multivariable analysis found these independent predictors of operative death: age (odds ratio [OR]=1.13/yr; 95% confidence interval [CI], 1.04-1.23; P=0.002), body mass index >30 kg/m2 (OR=9.9; 95% CI, 1.28-19; P=0.028), postoperative low cardiac output (OR=10.6; 95% CI, 1.18-25; P=0.035), and total arch replacement (OR=8.8; 95% CI, 1.39-15; P=0.021) The mean overall 5-year survival rate was 59.3% ± 5.5%, and mean 5-year freedom from distal reintervention was 95.4% ± 3.2% (P=NS). In type A AAD, aortic arch surgery is still associated with high operative mortality rates; hemiarch replacement can be performed more safely than total arch replacement. Rates of distal aortic reoperation were not different between the 2 surgical strategies.

A Ternary Zn-Al-Ir Hydrotalcite-Like Compound Exhibiting High Efficiency and Recyclability as a Water Oxidation Catalyst.

Herein it is shown that hydrotalcite-like compounds (HTlcs), doped with a suitably reactive metal, can efficiently act as water oxidation catalysts. As a case study, a ternary HTlc of formula [Zn0.667 Al0.306 Ir0.027 (OH)2 ]Cl0.333 ⋅0.6 H2 O, in which iridium is homogeneously distributed into the octahedral sites of brucite-type sheets, was prepared and tested as a heterogeneous water oxidation catalyst, using NaIO4 as a sacrificial oxidant. This HTlc showed excellent performance in terms of turnover frequency (up to 113 min-1 ), turnover number (>11 900), stability and recyclability.

A structural and (1)H NMR relaxometric study on novel layered carboxyalkylaminophosphonate nanocrystals with Gd(III) ions located in the framework.

Novel Gd(III) carboxyalkylphosphonate nanocrystals were synthesized under mild hydrothermal conditions. Structural properties and (1)H NMR relaxometric behaviour in aqueous solution as a function of the magnetic field strength were investigated, aiming to evaluate the local chemical environment of the paramagnetic centres and their interaction and affinity with water molecules.

Surgical treatment of aortic valve regurgitation secondary to ascending aorta aneurysm: is adjunctive subcommissural annuloplasty necessary?

BACKGROUND: Subcommissural aortic annuloplasty (SCA) has been recommended for treatment of functional aortic regurgitation (AR), but its association with sinotubular junction adjustment is still controversial. METHODS: Sixty patients with moderate or severe functional AR secondary to proximal ascending aorta aneurysm operated on between May 2004 and December 2010 were reviewed. Forty patients underwent SCA and ascending aorta repair (SCA group; mean age, 65 ± 9 years) and 20 underwent ascending aorta repair alone (non-SCA group; mean age, 69 ± 8 years). Preoperative AR grades were comparable between groups (p = 0.9). Echocardiographic data at discharge and during follow-up (SCA group, 41 ± 13 months; non-SCA group, 46 ± 13 months) were analyzed. RESULTS: Improvement of mean AR grade was better in the SCA group than in the non-SCA group at discharge (0.78 ± 0.9 vs 1.8 ± 0.1/4+, p = 0.0001) and at follow-up (0.44 ± 0.8 vs 2.4 ± 0.7/4+, p = 0.0001). Cox-regression analysis (odds ratio [95% confidence interval]) identified a higher residual AR at discharge (0.14 [0.012-0.37], p = 0.02) and the surgical technique, SCA or not (0.5 [0.03-0.899], p = 0.04), as predictors of more than grade 2/4+ AR at follow-up. Five-year freedom from more than grade 2/4+ AR was 94.4% ± 5.4% vs 58% ± 16% in SCA vs non-SCA (p = 0.02), respectively, and the survival rate was 95% ± 5% vs 89% ± 7.5% (p = 0.7). No valve stenosis was observed in the SCA group. CONCLUSIONS: SCA is effective for treatment of functional AR, providing stable results even for significant AR. Our results suggest that it should be possibly associated to sinotubular junction adjustment. SCA seems to not impair normal aortic valve opening.

Left atrial radiofrequency ablation associated with valve surgery: midterm outcomes.

BACKGROUND: Left atrial ablation is a surgical standard technique for the treatment of persistent or chronic atrial fibrillation (p-AF and c-AF, respectively).Objective The aim of the study is to evaluate midterm results of left atrial ablation according to modified Maze procedure in patients affected by p-AF or c-AF and concomitant mitral or aortic valve disease requiring surgical treatment. METHODS: A total of 108 patients (age, mean ± standard deviation [SD]: 66 ± 8.5 years) underwent left atrial ablation by means of unipolar (n = 62) or bipolar (n = 66) radiofrequency for p-AF (n = 28) or c-AF (n = 100) in association with mitral (n = 93) or mitral and aortic valve (n = 35) surgery. RESULTS: In-hospital mortality was 0.8%. Patients with preoperative c-AF had preoperative greater value of left atrial diameter (56.7 ± 7.4 vs. 52 ± 9 mm, p = 0.05) than those with p-AF. At 9 years after Maze procedure, 86% (n = 24/28) of patients with preoperative p-AF were in sinus rhythm versus 28% (n = 27/95) with c-AF (p < 0.0001). Preoperative c-AF and left atrial diameter of 75 mm or more predicted atrial fibrillation recurrence. In patients in sinus rhythm compared with those in residual atrial fibrillation, survival was 100 versus 86% ± 6.4%, New York Heart Association class was 1.3 ± 0.5 versus 1.7 ± 0.6, and need of lifelong anticoagulation therapy was 43 versus 91% (p < 0.05, for all comparisons). CONCLUSIONS: Left atrial Maze procedure for p-AF offers better chances to conversion in sinus rhythm as compared with long-standing c-AF. Survival, functional status, and quality of life are superior in patients who benefit from sinus rhythm.