Surgical Challenges in Infective Endocarditis: State of the Art.

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.

Right tracheal sleeve pneumonectomy with VV-ECMO assistance for non-small cell lung cancer through anterior thoracotomy: a single centre experience.

For a long time, non-small cell lung cancer (NSCLC) arising less than 2 cm distal to the carina has been usually considered unresectable and incurable with a radical or extended resection because of surgical technical difficulty and airway management. Recently, the introduction of more advanced surgical techniques, often including the use of extracorporeal life support (ECLS), has allowed us to extend the limits of conventional surgery, increasing the rate of complete surgical resection. ECLS also overcomes the limitation of conventional ventilation during complex tracheo-bronchial reconstruction, avoiding the presence of disturbing lines or tubes that obstruct the operative field during a challenging surgery. In this article, we share our experience in performing right tracheal sleeve pneumonectomy with veno-venous extracorporeal membrane oxygenation (VV-ECMO) in three cases by anterior right thoracotomy, reporting our tips and tricks.

Single-center experience with partial support device in destination therapy for end-stage heart failure.

Ventricular assist devices (VADs) are considered the standard of care for end-stage heart failure (HF) patients. Despite increasing confidence in the technology, evidence data, endorsement by scientific societies and guidelines, the number of implants reached a steady state and is not increasing at the expected pace. This is most likely related to complications that are still burdening the technology and consequently excluding the most needy, ill, and fragile population. In this manuscript we are reporting a single-center experience in a very fragile, elderly and end-stage HF population, with a superficial, partial support device: the CircuLite Synergy. The patients were included in the pre-CE mark clinical study and consequently the device underwent technical adjustment during the support, based on the complications recorded. At our institution were implanted 6 patients overall: 3 patients survived to discharge and 2 survived up to 5 years. Most of the complications recorded were due to patients' frailty and overall clinical conditions. The initial experience with the CircuLite Synergy device is proving that a more "superficial" device might be more tolerable in an elderly, frail population. Partial support has proven hemodynamically efficacious and efficient in relieving heart failure symptoms, improving medical therapy tolerability, and improving quality of life. Unfortunately, the technology was not made available due to financial uncertainty and poor management, but we hope that once the concept has been proved someone will collect the legacy.

Coral Reef Aorta: A Rare Occlusive Disease of the Aorta Complicating Decision Making for Severe Aortic Stenosis Treatment.

The incidental finding of a severe occlusive disease of the aorta (coral reef aorta) during the assessment for transcatheter aortic valve replacement in a 75-year-old woman with severe aortic stenosis complicated the process for the Heart Team and led to the consideration of a different access route to find the safest and most appropriate strategy of intervention. A successful transapical transcatheter aortic valve replacement was eventually performed. Coral reef aorta, although rare, is associated with great morbidity and mortality, and it needs to be recognized when planning for intravascular procedures, both for a safer selection of treatment approach and for the prevention of intraprocedural and postprocedural morbidities.

Impact of Cusp Repair on Reoperation Risk After the David Procedure.

BACKGROUND: We assessed whether additional cusp repair during valve-sparing aortic root replacement affects the echocardiographic mid-term results; a subgroup analysis among patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) was performed. METHODS: Between June 2002 and May 2015, 157 consecutive patients underwent valve-sparing aortic root replacement with the David technique. Thirty patients (19%) had BAV. In 19 patients (12%), cusp motion or anatomic abnormalities contributed in determining aortic regurgitation requiring an additional cusp repair. Mean follow-up was 7 ± 3.4 years. RESULTS: The cumulative 1-, 5-, and 12-year survival rates were 98%, 94%, and 90%, respectively. Fourteen patients (9%) required aortic valve replacement during follow-up. In 2 patients the underlying cause was bacterial endocarditis. Freedom from aortic valve reoperation was 96% at 1 year, 92% at 5 years, and 89% at 12 years. Reoperation rate was significantly higher (p < 0.001) in patients who received leaflet repair compared with patients who did not, with a freedom from reoperation at 8 years of 58% versus 94%. Among patients with BAV, those who did not require cusp repair had a freedom from reoperation at 8 years of 94%, with a significant difference compared with patients who received cusp repair (p = 0.04). Cusp repair did not affect reoperation risk in patients with tricuspid aortic valve. CONCLUSIONS: Adjunctive cusp repair seems to affect the mid-term reoperation risk in patients with BAV and not in patients with tricuspid aortic valve. We recommend caution in using this technique in case of asymmetric BAV requiring cusp repair.

Hybrid Versus Conventional Treatment of Acute Type A Aortic Dissection.

BACKGROUND: To determine whether the hybrid approach to acute type A aortic dissection results in improved outcomes in terms of mortality, neurologic complications, need for distal aortic reintervention, and false lumen thrombosis compared with the conventional approach. METHODS: Data from comparative studies of hybrid versus conventional treatment of acute type A aortic dissection were combined through meta-analysis. Pooled odd ratios were calculated using random effects models. RESULTS: Seven comparative studies including 967 patients were identified; of these, 503 underwent conventional proximal aortic repair and 429 extensive distal aortic repair including a stented elephant trunk technique. Between the two groups there was no significant difference in operative mortality (p = 0.96), permanent neurologic deficit (p = 0.95), and late mortality (p = 0.59). Distal aortic repair showed a higher rate of false lumen thrombosis of the thoracic aorta (odd ratio 11.16; p < 0.001) and a reduced risk of distal reintervention (odd ratio 0.37; p = 0.01). In sub-group analysis, frozen elephant trunk procedure showed a lower rate of distal aortic reintervention and a higher rate of false lumen thrombosis than antegrade/retrograde stent deployment techniques (p = 0.008 and <0.001, respectively). CONCLUSIONS: Distal aortic repair may reduce the risk of distal reintervention and increase the rate of false lumen thrombosis without significant increase in operative mortality and permanent neurologic deficit; however, no benefit with respect to late mortality was found. The frozen elephant trunk may reduce the risk of distal aortic reintervention and may increase the false lumen thrombosis of the thoracic aorta in comparison with antegrade/retrograde stent deployment procedures.

Minimally invasive direct coronary artery bypass in the era of percutaneous coronary intervention.

AIM: Minimally invasive coronary artery bypass (MIDCAB) allows revascularization of the left anterior descending coronary (LAD) artery through a less traumatic surgical approach. However, the procedure is technically challenging and concern still exists, mainly based on graft patency. The purpose of this study is to critically evaluate short and long-term benefits of this surgical treatment. METHODS: Between June 1997 and July 2012, 306 patients underwent MIDCAB on LAD. The mean age was 62 ±â€Š10 years (range, 32-87 years) and 264 patients (86.3%) were men. Mean ejection fraction was 54%. Eighty-nine procedures (29.1%) were performed using a hybrid approach by means of MIDCAB and postoperative (60 patients, 67.4%) or preoperative (29 patients, 32.6%) percutaneous interventions on non-LAD vessels. A EuroScore more than 6 was found in 43 (14%) patients. The average follow-up time was 9.5 ±â€Š3.2 years and was 89% complete. RESULTS: Six patients (1.9%) required intraoperative conversion to sternotomy, whereas cardiopulmonary bypass institution after the sternotomy was necessary in one. Postoperative acute myocardial infarction occurring nine patients (2.9%), low output syndrome in four (1.3%). Postoperative mortality was 1.6% (n = 5), and perioperative stroke rate 0.6% (n = 2). Five and 10-year survival were 94.1 and 86.9%, respectively. Freedom from death due to cardiac events and major cardiac and cerebral events at 10 years was, respectively, 97.1 and 92.1%. CONCLUSIONS: The results confirm the favorable short and long-term results of the MIDCAB procedure. MIDCAB, in experienced centers, can represent an alternative treatment option for LAD disease.

Unusable radial artery for severe atherosclerosis in a young patient.

We report a young diabetic patient who was found to have an unusable radial artery (RA) for coronary bypass grafting because of severe and diffuse atherosclerosis. Techniques to diagnose RA conduits, which are not usable for coronary surgery, are reviewed.

Cusp repair during aortic valve-sparing operation: technical aspects and impact on results.

AIMS: Aortic valve-sparing operations are nowadays considered safe and reliable procedures in terms of mid-term and long-term results. Although surgical techniques regarding the modality of grafts' implantation have been properly addressed, the modality of cusp repair, when needed, is still open to debate. We sought to review the literature to try to shed light on when the cusp repair is required and how it should be performed. METHODS: We searched the PubMed database using the keywords aortic valve-sparing operation, aortic valve-sparing reimplantation, valve-sparing aortic root replacement, aortic valve repair, and aortic cusp repair. Only studies that included and described in detail the technique of cusp repairs in adjunct to aortic valve-sparing operation were considered. RESULTS: Bicuspid aortic valve more often requires correction when compared with tricuspid valve. The range of the techniques varies from the 'simple' free margin plication to the more complex triangular resection with patch repair. Results in the literature seem to be encouraging, showing that, in most of the cases, cusp repair does not affect valve competence in the mid-term and long-term. CONCLUSION: Correction of the cusp is a delicate balance between undercorrection that could lead to residual prolapse and overcorrection that could lead to cusp restriction. Although complex repair of the aortic valve in addition to root replacement provided satisfactory results, it should be reserved for experienced centers with a large volume of patients.

[CircuLite Synergy ventricular assist device: a new approach to end-stage congestive heart failure]. / Sistema di assistenza ventricolare CircuLite Synergy: un nuovo approccio all'insufficienza cardiaca terminale.

BACKGROUND: The Synergy system, a miniature partial circulatory support device, is implanted by an off-pump, minimally invasive surgical approach. The system has been optimized to improve performance in an EU clinical trial for chronic ambulatory heart failure. This therefore offers the possibility of treating elderly chronic heart failure patients who might not usually be considered for long-term circulatory support. METHODS: From June 2007 to December 2012, 63 patients were implanted with the Synergy system (12 patients ≥70 years) using four different releases of the device. Briefly, the system draws blood through the inflow cannula from the left atrium into the micro-pump (placed in a right subclavicular pocket) and pumps it through an outflow graft to the right subclavian artery. In this paper, we present an intermediate analysis of the clinical trial as performed on April 30, 2013, leading to the placing of the CE mark. RESULTS: Mean duration of support is ongoing at 230 days (range 23-1387). Follow-up showed improved hemodynamic response, with additional improvements in 6-min walk distance (299 ± 144 to 420 ± 119 m) and Minnesota Living with Heart Failure Questionnaire (69.5 ± 20.4 to 49.2 ± 24.3). Older patients had longer mean durations of support (337 vs 188 days). On average, elderly and younger patients showed similar improvements in hemodynamics and 6-min walk distance (107 ± 120 vs 130 ± 121 m). Major adverse cardiac events included bleeding (n=4) with one bleeding related to renal failure resulting in death. CONCLUSIONS: Clinical use of the Synergy device was associated with a significant functional improvement. Very low adverse event rates were reported with the latest device release. Older patients had smaller body sizes and worse renal function than younger patients. Both groups experienced similar hemodynamic benefits and functional improvements. The risk of bleeding and renal dysfunction appears to be increased in the elderly, though still within acceptable ranges compared to other full support devices. Minimally invasive long-term circulatory support devices, like Synergy, offer a new treatment option that might be available even for the elderly chronic heart failure population.

Analysis of postsurgical aortic false aneurysm in 27 patients.

Aortic false aneurysm is a rare complication after cardiac surgery. In recent years, improved results have been reported in regard to the surgical management of these high-risk lesions. We retrospectively examined 28 consecutive cases (in 27 patients) of postsurgical aortic false aneurysm diagnosed at our institution from May 1999 through December 2011. Twenty-four patients underwent reoperation. Cardiopulmonary bypass was instituted before sternotomy in 15 patients (63%). Isolated repair of the aortic false aneurysm was performed in 15 patients. Four patients (including one who had already undergone repeat false-aneurysm repair) declined surgery in favor of clinical monitoring. Eleven patients were asymptomatic at the time of diagnosis. In the other 16, the main cause was infection in 7, and previous operation for acute aortic dissection in 9. The in-hospital mortality rate was 16.6% (4 patients, 3 of whom had infective false aneurysms). Relevant postoperative sequelae were noted in 7 patients (29%). The cumulative 1-year and 5-year survival rates were 83% and 62%, respectively. The 4 patients who did not undergo reoperation were alive at a median interval of 23 months (range, 9-37 mo). Two underwent imaging evaluations; in one, computed tomography revealed an 8-mm increase of the false aneurysm's maximal diameter at 34 months. Aortic false aneurysm can develop silently. Surgical procedures should be proposed even to asymptomatic patients because of the unpredictable evolution of the condition. Radical aortic-graft replacement should be chosen rather than simple repair, because recurrent false aneurysm is possible.

Mitral and aortic valve prosthetic endocarditis after percutaneous closure of mitral paravalvular leak.

A 67-year-old man presented to our hospital with massive mitral and aortic valve prosthetic endocarditis 2 months after transcatheter percutaneous closure of a mitral paravalvular leak with an Amplatzer duct occluder device (AGA Medical Corp, Plymouth MN). He underwent successful reoperation for valve prosthesis replacement and reconstruction of the anterior fibrous trigone. Although transcatheter treatment of periprosthetic valve defects has been shown to be feasible, follow-up data are still limited. This procedure should be reserved only for patients who are not eligible for open surgical procedures and those with small periprosthetic defects.

Bicuspidy does not affect reoperation risk following aortic valve reimplantation.

Aortic valve reimplantation has been shown to be a safe procedure. However, evidences of durability in bicuspid aortic valves (BAVs) are limited in the literature. Between 2002 and 2011, 132 patients (mean age 61 ± 12 years) underwent aortic valve reimplantation. In 24 patients (18%), aortic valve was bicuspid. Mean follow-up was 50 ± 26 months (range 1-102 months) and was 99% complete. In-hospital mortality was 0.8% (1 patient). Survival at 1 and 5 years was 99 and 94%, respectively. Overall freedom from aortic valve reoperation at 1 and 5 years was 96 and 90%, respectively, without significant difference between patients with bicuspid and tricuspid aortic valve. Freedom from aortic valve regurgitation >2+/4+, excluding patients reoperated, was at 1 and 5 years of 100 and 99%, respectively. Patients with valve cusp repair showed a higher rate of aortic valve reoperation; however, only postoperative aortic regurgitation >2+/4+ was significant risk factor for redo procedure at multivariate analysis. Aortic valve reimplantation in BAV without cusp repair provides excellent mid-term results. Further observations and longer follow-up are necessary to determine if BAV sparing, even in the presence of cusps alterations, could allow satisfying durability.

6 months of "temporary" support by Levitronix left ventricular assist device.

An otherwise healthy 47-year-old man presented to the emergency department in cardiogenic shock after suffering a massive myocardial infarction due to left main occlusion. He was initially supported by extracorporeal membrane oxygenation and subsequently was converted to paracorporeal support with a Levitronix left ventricular assist device. He experienced multiple postoperative complications including renal failure, respiratory failure, retroperitoneal hematoma requiring suspension of anticoagulation, and fungal bloodstream infection precluding transition to an implantable device. He was reconditioned and successfully underwent orthotopic heart transplant 183 days after presentation. A discussion of the relevant issues is included.

Compliance of the Valsalva graft's pseudosinuses at midterm follow-up with cardiovascular magnetic resonance.

BACKGROUND: In previous studies, the Valsalva graft's compliance at the level of the Dacron pseudosinuses was found similar to that of normal sinuses shortly (2±1 months) after the operation. We sought to investigate with cardiac magnetic resonance the compliance of the Valsalva graft pseudosinuses at midterm follow-up. METHODS: Seven patients (group A) and 7 age-matched controls (group B) were studied with steady-state free precession and phase-contrast cardiac magnetic resonance for aortic root and ascending aorta evaluation. Blood pressure was measured during phase-contrast acquisition to derive the following mechanical properties of the vascular prosthesis: pulsatility, compliance, distensibility, and elastic modulus. RESULTS: Mean postoperative follow-up was 55±9.84 months. Mean age was 69.2±4.98 years in group A, and 65.7±7.16 years in group B. All the studied variables were coherent in showing a significant difference between the two groups, and between aortic root (skirt portion of the graft) and ascending aorta (tubular part of the graft) in group A. The presence of periaortic fibrosis did not show any correlation with the ascending aorta's mechanical properties. CONCLUSIONS: At midterm follow-up, the pseudosinuses compliance of the Valsalva graft is still appreciable and significantly greater than the tubular portion.

Reimplantation valve-sparing aortic root replacement for aortic root aneurysm in the elderly: are we pushing the limits?

OBJECTIVES: Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and midterm results. However, extending the age criterion in patient selection remains a debate. This study reviews the results of reimplantation valve-sparing aortic replacement in patients greater than 60 years of age. METHODS: During a 51-month period, 63 patients with aortic root aneurysms underwent reimplantation valve-sparing aortic root replacement. The Gelweave Valsalva prosthesis (TERUMO CardioVascular Systems Corp., Ann Arbor, MI, USA) was used in all but one case. The patients were predominantly male, and the mean age was 67 years (range, 61-83 years). Four patients had congenital bicuspid aortic valves, and cusp repair was required in one patient. The mean follow-up was 25 months (range, 1-51 months). RESULTS: There were one hospital and two late deaths. Overall survival at 51 months was 84 +/- 9.9%. During follow-up, one patient developed severe aortic incompetence (AI) requiring an aortic valve replacement (AVR). Freedom from reoperation at 51 months was 92.8 +/- 6.8%. Moderate AI was present at latest echocardiogram in one patient. Freedom from moderate or severe AI at 51 months was 90 +/- 9.4%. There was no episode of endocarditis on follow-up. Univariate analysis demonstrated that no preoperative or intraoperative factor was a predictor for late reimplantation failure. CONCLUSIONS: Reimplantation valve-sparing aortic root replacement in patients greater than 60 years old can be performed with satisfactory perioperative and midterm results. Long-term results are needed to define the durability of this technique and its role in this subset of patients.

Reimplantation valve-sparing aortic root replacement with the Valsalva graft: what have we learnt after 100 cases?

OBJECTIVES: Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and mid-term results. The success of this operation primarily depends on preserving the highly sophisticated dynamic function of the aortic valve by recreating an anatomical three-dimensional configuration similar to the normal aortic root, thus minimizing the mechanical stress and strain on the cusps. Over the years several techniques have been proposed to reproduce the sinuses of Valsalva. We reviewed our experience with aortic valve reimplantation by means of a modified Dacron graft that incorporates sinuses of Valsalva, in a series of 100 consecutive patients. METHODS: During a 60-month period, 100 patients with aortic root aneurysm underwent aortic valve reimplantation using the Gelweave Valsalva prosthesis. There were 74 males and the mean age was 60+/-12 years (range 28-83 years). Five patients had the Marfan's syndrome, 15 had a bicuspid aortic valve. Cusp repair was performed in five patients. The mean follow-up time was 28.6 months (range 1-60). Transesophageal echocardiogram was performed at the end of each procedure to assess the aortic valve in terms of competence, dynamic motion and level of coaptation within the graft. RESULTS: There was one hospital death and two late deaths. Overall survival at 60 months was 91.7+/-5.1%. Five patients developed severe aortic incompetence (AI) during follow-up requiring aortic valve replacement (AVR). The 60 months freedom from re-operation due to AI was 90.9+/-4.4%. One patient had moderate AI at latest echocardiographic study. The 60 months freedom from AI>2+ was 91.6+/-7.9%. Cox regression identified cusp's repair as independent risk factor (P=0.001) for late reimplantation failure (AVR or AI>2+). There were no episodes of endocarditis and the majority of the patients (88%) were in New York Heart Association functional class I. CONCLUSIONS: The aortic valve reimplantation with the Gelweave Valsalva prosthesis provided satisfactory mid-term results. An accurate assessment of the level of coaptation of the aortic cusps in respect to the lower rim of the Dacron graft by means of intraoperative transesophageal echocardiogram at the end of each procedure is mandatory in order to avoid early reimplantation failure. Cusp's repair may play an important role in the development of late AI. However, long-term results are needed in order to define the durability of this technique.

Reoperation for aortic false aneurysms: our experience and strategy for safe resternotomy.

BACKGROUND AND AIM OF THE STUDY: To review our experience with reoperation for aortic false aneurysms (FA) and to present an analysis of the relevant surgical approaches and risks. METHODS: From May 1999 to June 2006, 11 patients underwent a total of 13 reoperations due to aortic false aneurysms, with an incidence of 3% of all thoracic aortic cases. Cardiopulmonary bypass (CPB) and cooling were started before sternotomy in all cases. Three different strategies were adopted for patients depending on the position of the FA in the mediastinum as indicated by a preoperative CT scan. These included: deep hypothermic circulatory arrest (18 degrees C), moderate hypothermia (28 degrees C), and mild hypothermia (32 degrees C). In two patients, the sternotomy ruptured the FA causing profuse hemorrhaging. In all the other cases sternotomy was performed without complication. The repair consisted in simple repair by direct suture (10 cases) or extensive repair by refashioning the anastomosis (three cases). RESULTS: Two hospital deaths occurred with a hospital mortality rate of 16.7%. Permanent neurological deficit developed in one patient. Transient neurological deficit in the form of left lower limb weakness was observed in one patient. False aneurysm recurrence developed in two cases. Among patients present at follow-up (nine survivors), four are in NYHA class I and five in class II. CONCLUSIONS: Aortic false aneurysms carry a high mortality and morbidity rate. Nevertheless, we believe that selecting the right strategy according to the position of the FA in the chest can reduce surgical risk, thus permitting relatively safe resternotomy.

Aortic valve-sparing operations in patients with aneurysms of the aortic root or ascending aorta: preliminary results.

OBJECTIVE: Aortic valve-sparing operations were developed to preserve the native aortic valve in patients with aneurysms of the aortic root or ascending aorta and normal aortic valve leaflets. This paper describes our initial experience with valve-sparing operations and early clinical and echocardiographic results obtained. METHODS: From October 2002 to March 2004, 32 consecutive patients underwent aortic valve-sparing operations at the Istituto Clinico Humanitas, Rozzano, Italy. Preoperative transesophageal echocardiography showed moderate or severe aortic incompetence (AI) in 15 patients (47%). Twenty-nine patients underwent reimplantation of the aortic valve and 3 patients remodeling of one sinus. In 2 cases prolapsing cusp repair was carried out. RESULTS: There were no intraoperative deaths. At discharge, two-dimensional echocardiogram showed no or trivial aortic incompetence (AI) in 17 (52%) patients and mild AI in 13 (42%); 2 (6%) patients had severe AI requiring reoperation, respectively 4 and 6 weeks later. CONCLUSIONS: The valve-sparing procedures showed good preliminary results, thus encouraging further use of this type of repair. However, further larger studies and long-term results are needed in order to define the durability of these techniques.