Develop of endocavitary suction device for MiECC on minimally invasive mitral valve surgery.

The minimally invasive extracorporeal circulation (MiECC) system was developed to minimize the contact of blood with air and foreign surfaces during conventional cardiopulmonary bypass (CPB). It is also aimed to reduce the inflammatory response by further increasing the biocompatibility of the components that make up the MiECC circuits. The Minithoracotomy (MTH) approach for mitral valve disease remains associated with prolonged operative times, but it is beneficial in terms of reduced postoperative complications (renal failure, atrial fibrillation, blood transfusion, wound infection), length of stay in intensive care unit (ICU) and in hospitalization, with finally a reduction in global cost. Combining the use of the MiECC technique with minimally invasive mitral valve surgery (MIMVS) could open up new research scenarios. Although considerable progress has been made in the standardization of the surgical technique, limitations remain to be filled in the setting of Endo-cavitary aspiration for the association of MiECC with MIMVS. In this paper we introduce invention refers to a device and an air-closed endocavitary aspiration system for cardiac chamber surgery, as well as a method aimed at eliminating gaseous micro-embolic activity, hemolysis and CO2 aspiration and alteration of carbon dioxide production (VCO2) the parameters for goal directed perfusion. The system allows the surgery of the cardiac chambers to be associated with a minimally invasive extra-corporeal circulation circuit.

Robotic-Assisted Epicardial Hybrid Ablation and Left Appendage Closure in Persistent Atrial Fibrillation: First European Experience.

Background: Pulmonary vein isolation is currently considered to be the gold standard for ablating paroxysmal atrial fibrillation. However, its efficacy is limited in patients with persistent atrial fibrillation. The convergent procedure has emerged as a hybrid ablation. This study aims, for the first time in the literature, to introduce a hybrid approach that includes epicardial ablation with cutting-edge robotic technology and subsequent electrophysiological study to verify and an endocardial ablation to complete the ablation lines. Methods: We present 18 cases of robotic-assisted epicardial hybrid ablation performed between April and December 2023 on patients with long-standing persistent atrial fibrillation (mean age: 64 ± 5 years; mean duration: 4 ± 2 years). All of the procedures were performed at "Humanitas Gavazzeni Hospital", Bergamo, Italy. Robot-assisted epicardial ablation performed using the "Epi-Sense AtriCure" device was guided by monitoring electrogram morphology and point-by-point impedance drop. This approach also included left atrial appendage occlusion and the disconnection of the ligament of Marshall. An electrophysiological study and endocardial ablation were planned three months after the procedure. Results: The procedure was successfully executed in all patients with no major complications and a mean operative time of 142 ± 22 min. None of the cases required conversion to full sternotomy or minithoracotomy. The procedure was performed in all cases without extracorporeal circulation and on a beating heart. Fifteen patients (83%) were extubated in the operating room. The length of stay in the intensive care unit was less than 24 h. Acute restoration of sinus rhythm was achieved in 12 out of the 18 patients (67%); the median duration of their hospital stay was two days. In the electrophysiological study, seven pts had sinus rhythm, two had atrial fibrillation, and one patient developed atrial flutter at 3-month follow-up. Patients underwent transcatheter ablation to complete the lesion set and, at the time of discharge, were all in sinus rhythm. Conclusions: In our initial experience, surgical atrial fibrillation ablation consisting of a unilateral thoracoscopic technique facilitated by a robotic platform and continuous EGM monitoring has proven to be safe and feasible. For the electrophysiological study at 3 months, completing the gaps in the surgical ablation lines could improve the clinical results of the technique in terms of sinus rhythm stability. However, mid- and long-term follow-up is required to demonstrate this.

Safety and Efficacy of PCSK9 Inhibitors in Patients with Acute Coronary Syndrome Who Underwent Coronary Artery Bypass Grafts: A Comparative Retrospective Analysis.

Background. The in-hospital reduction in low-density lipoprotein cholesterol (LDL-C) levels following acute coronary syndrome (ACS) is recommended in the current clinical guidelines. However, the efficacy of proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors in those patients undergoing coronary artery bypass graft (CABG) has never been demonstrated. Methods. From January 2022 to July 2023, we retrospectively analyzed 74 ACS patients characterized by higher LDL-C levels than guideline targets and who underwent coronary bypass surgery. In the first period (January 2022-January 2023), the patients increased their statin dosage and/or added Ezetimibe (Group STEZE, 43 patients). At a later time (February 2023-July 2023), the patients received not only statins and Ezetimibe but also Evolocumab 140 mg every 2 weeks starting as early as possible (Group STEVO, 31 patients). After one and three months post-discharge, the patients underwent clinical and laboratory controls with an evaluation of the efficacy lipid measurements and every adverse event. Results. The two groups did not differ in terms of preoperative risk factors and Euroscore II (STEVO: 2.14 ± 0.75 vs. STEZE: 2.05 ± 0.6, p = 0.29). Also, there was no difference between the groups in terms of ACS (ST-, Instable angina, or NSTE) and time of symptoms onset regarding total cholesterol, LDL-C, and HDL-C trends from the preprocedural period to 3-month follow-up, but there was a more significant reduction in LDL-C and total cholesterol in the STEVO group (p = 0.01 and p = 0.04, respectively) and no difference in HDL-C rise (p = 0.12). No deaths were reported. In three STEZE group patients, angina recurrence posed the need for percutaneous re-revascularization. No STEVO patients developed significant adverse events. The statistical difference in these serious events, 7% in STEZE vs. 0% in STEVO, was not significant (p = 0.26). Conclusions. Evolocumab initiated "as soon as possible" in ACS patients submitted to CABG with high-intensity statin therapy and Ezetimibe was well tolerated and resulted in a substantial and significant reduction in LDL-C levels at discharge, 1 month, and 3 months. This result is associated with a reduction but without a statistical difference between groups.

Emergent Conversion to Open Heart Surgery during Transcatheter Aortic Valve Implantation: The Presence of a Rescue Team Improves Outcomes.

OBJECTIVE: Transcatheter aortic valve implant (TAVI) is the gold standard for the high-surgical-risk group of patients with aortic valve disease and it is an alternative to surgery in patients at intermediate risk. Lethal complications can occur, and many of these are manageable only with emergent conversion to open heart surgery. We retrospectively evaluate the outcome of all patients undergoing TAVI in our departments and the impact of a complete cardiac rescue team to reduce 30-day mortality. METHODS: Data from all patients undergoing TAVI between January 2020 and August 2023 in our center were analyzed. An expert complete rescue was present in catheter laboratory. Primary outcomes were in-hospital and at 30-day mortality and evaluation of all cases needed for emergent conversion to open heart surgery. RESULTS: 825 patients were enrolled. The total mortality was 19/825 (2.3%). Eleven of the total patients (1.3%) required emergent conversion to open heart surgery. Among them, eight were alive (73%), with a theoretical decrease of 0.98% in overall mortality. CONCLUSIONS: surgical treatment is rare during TAVI. The presence of an expert complete rescue team as support means an increase in survival. Surgery must be used only to restore circulatory and to treat complication while percutaneous approaches should complete the procedure.

Infective Endocarditis After Percutaneous Device Closure of Atrial Septal Defects: Incidence, Diagnosis, and Treatment. Case Report and Literature Review.

Infective endocarditis (IE) on atrial septal defect (ASD) closure devices, while extremely rare, has been reported to be more frequent early after the procedure. We describe a case of late IE after percutaneous closure of patent foramen ovale (PFO). We also performed a literature review on this subject. We reviewed a total of 42,365 patients who were treated with percutaneous devices: 13,916 for ostium secundum (OS) (32%), 24,726 for PFO (58%) and 3,723 for OS+PFO (8%). Among these patients, we identified 50 cases of IE after atrial septal defect device closure (0.001%). In contrast to previous reports, nearly 66% of IE in this setting occurred late, after at least 6 months from the procedure (33/50 patients). A statistical analysis clearly showed that the mean time from the procedure to IE increased in the last five years, probably associated with a change in antiplatelet therapy after ASD closure. Management of IE on an ASD occluder should always be discussed in the setting of a multidisciplinary heart team that includes a cardiologist, cardiac surgeon, and anesthetist. While surgical strategies gave excellent results, conservative management might be considered in cases of small IE vegetations and for patients in good general condition. However, in these cases, the patient must be closely observed with repeated blood and instrumental tests.

Gaseous Micro-Embolic Activity and Goal-Directed Perfusion Management in a Closed System for Cardiopulmonary Bypass and Minimally Invasive Extracorporeal Circulation during Coronary Artery Bypass Grafting.

BACKGROUND: Cardiopulmonary bypass (CPB) techniques are becoming minimally invasive in clinical practice. The literature describes various extracorporeal techniques which seek to eliminate air-blood contact and reduce both hemodilution and the contact surface such as in Minimally invasive Extracorporeal Circulation (MiECC) and closed systems for CPB. However, the delivery of micro-embolic activity in the circuit and metabolic activity in terms of oxygen delivery for Goal-Directed Perfusion (GDP) management, in relation to the patient's blood volume and central venous pressure, have never been related and correlated. In this report, we present a cohort study that investigated these aspects between the closed SVR2000 System and modular MiECC (both from Eurosets SRL, Medolla, Italy). MATERIALS AND METHODS: Data were collected retrospectively and used to compare 60 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) surgery by two surgeons using an SVR2000 oxygenator in 30 procedures, with a matched cohort of patients from the same period who underwent isolated CABG surgery by two other surgeons using a modular MiECC in 30 procedures. The primary endpoints collected were data on micro-embolic activity, including the number of gaseous micro-emboli in the circuit during the procedure, the mean maintenance value of oxygen delivery (DO2) and data relating to venous return volume and central venous pressure (CVP). RESULTS: During the CPB procedures, the following values were recorded for the closed SVR2000 and MiECC groups, respectively: the average number of gaseous micro-emboli (GME) in the venous line, 833 ± 23 vs 1221 ± 45 (p = 0.028); GME in the outlet of the pump, 375 ± 45 vs 429 ± 76 (p = 0.89; GME in the arterial line, 189 ± 36 vs 205 ± 27 (p = 0.92), and the volume of GME in the arterial line (mL), 0.32± 12 vs 0.49± 17 (p = 0.93). The mean Indexed Oxygen Delivery (DO2i) during cross-clamp (ml/min/m2) was 319 ±12 vs 278 ±9 (p = 0.0019), respectively. The maximum mean volume of venous return in the soft-shell venous reservoir (ml) was 1801 ±128 vs 824 ±192 (p = 0.038). The mean central venous pressure (CVP) during cross-clamp (mmHg) was 0 ± 2 vs 6 ± 2 (p = 0.019). CONCLUSIONS: In this study, the results in the closed SVR2000 group were not statistically inferior to those in the modular MiECC group in terms of gaseous micro-embolic activity during CPB. Our analysis showed an important reduction of GME delivery in both systems. The closed SVR2000 group showed better management for GDP in terms of DO2i, associated with the flexibility of dynamic volume management and the absence of cavitation and regulation of the rate per minute and pump flow, which were reported in the MiECC group. The SVR2000 and modular MiECC systems were both safe and effective in perioperative practice without iatrogenic problems.

Cardiopulmonary Bypass Settings for the Prevention of Early Hypotension During CABG.

BACKGROUND: Vasoplegic syndrome is a form of vasodilatory shock that can occur before, during or after cardiopulmonary bypass (CPB). We introduce a strategy to reduce the incidence of early hypotension phenomena during Coronary Artery Bypass Graft (CABG) procedures. MATERIALS AND METHODS: In this prospective cohort study, 100 patients underwent elective CABG with two perioperative CPB settings. The study group (50 patients) was managed with retrograde autologous priming (RAP), 3-minute stepwise for the institution of CPB, and pulsatile flow (PP). The control group (50 patients) was managed without RAP, with the rapid initiation of CPB, and non-pulsatile (NP) flow. The primary endpoints were MAP (mmHg), number of hypotensive phenomena (MAP < 50 mmHg for > 30 sec), the venous return volume on CPB (ml), the cardiac index (L/min/m2), hemoglobin (g/dL), indexed oxygen delivery (DO2i, ml/min/m2), the systemic vascular resistance index (SVRI, dynes s m2/cm5), number of 1-ml boluses of a vasoactive substance (norepinephrine), the positive fluid balance (ml), and the number of red blood cell units for transfusion. RESULTS: During CPB, the mean values in the study and control groups were as follows: MAP, 68± 7 vs 56 ± 7 (p-value, 0.0019); hypotensive phenomena, 3 ± 1 vs 8 ±2 (p-value, 0.019); venous return volume, 840±79 vs 1129 ±123 (p-value, 0.0017); cardiac index, 2.4 ± 0.4 vs 2.7 ±0.2 (p-value, 0.0023); hemoglobin, 9.13 ± 0.29 vs 7.8± 0.23 (p-value, 0.0001); DO2i, 301± 12 vs 276±23 (p-value, 0.0011); SVRI, 1879 ±280 vs 2210 ±140 (p-value, 0.0017); norepinephrine, 1±2 vs 8 ±3 (p-value, 0.0023); positive fluid balance, 750 ±212 vs 1450 ±220 (p-value, 0.005); and total number of red blood cell units for transfusion, 16 ±4.2 vs 27 ± 5.3 (p-value, 0.008). CONCLUSIONS: In this prospective cohort study, during CPB, the study group showed a better preservation of MAP, SVRI, and DO2i, and a reduction of vasoconstrictor use in a CPB setting with the RAP technique, 3-minute stepwise for the initiation of CPB and pulsatile pump flow, compared to the control group. Further studies are needed to validate this perioperative approach to CPB.

ECMOLIFE intra-hospital transport in life-saving for pulmonary vein obstruction.

BACKGROUND: Transport with extracorporeal membrane oxygenation (ECMO) in the hospital setting can become a challenge as well as in the out-of-hospital setting. In particular, the management of intra-hospital transport with ECMO support of the critically ill patient foresees his shift from the intensive care to the diagnostic areas, from the diagnostic areas to the interventional and surgical areas. CASE PRESENTATION: In this context, we present a life-saving transport case with the veno-venous (VV) configuration of the ECMOLIFE Eurosets system, for right heart and respiratory failure in a 54-year-old woman, due to thrombosed obstruction of the right superior pulmonary vein, following mitral valve repair surgery in minimally invasive approach in a patient already operated on for complex congenital heart disease. After stabilizing the vital parameters with Veno-venous ECMO for 19 h, the patient was transported to hemodynamics for angiography of the pulmonary vessels, where the diagnosis of obstruction of the pulmonary venous return was made. Subsequently, the patient was brought back to the operating room for a procedure of unblocking the right superior pulmonary vein using a minimally invasive approach, passing from the ECMO to the support in extracorporeal circulation. CONCLUSIONS: The transportable ECMOLIFE Eurosets System was safe and effective during transport in maintaining the vital parameters of oxygenation and CO2 reuptake and systemic flow, allowing the patient to be mobilized for diagnostic tests instrumental to diagnosis. The patient was extubated 36 h after the surgical procedures and was discharged 10 days later from the hospital.

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

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

Evaluation of (Wet) and (Dry) Mediastinal Chest Drainage in Minimally Invasive and Conventional Cardiac Surgery.

BACKGROUND: Drainage of fluid and evacuation of air from the pericardial and pleural spaces after cardiothoracic surgery is necessary to prevent effusion, tamponade, and pneumothorax, and also to detect hemorrhage. For this purpose, negative-pressure drains are placed in the mediastinum and pleural cavities. We compared the efficacy and safety of two systems wet and dry drainage for the management and monitoring of negative pressure and anti-reflux valve safety systems, to promote healing of the pleural and pericardial cavities. METHODS: Two devices for mediastinal chest drainage [Venice PAS (Wet) and Rome PAS (Dry); both Eurosets SRL, Medolla, Italy] were evaluated in terms of safety, efficacy and clinical outcomes in a cohort of 60 patients who underwent elective cardiac surgery procedures. The patients were divided into a minimally invasive cardiac surgery (MICS) group [n=30; mitral valve surgery (MVS) by right anterolateral mini-thoracotomy] and a conventional cardiac surgery (CCS) group [n=30; coronary arterial bypass grafting (CABG) in full sternotomy] at a single institution (Anthea Hospital GVM Care & Research, Bari, Italy). RESULTS: Negative pressure was managed with a target value of -20 cmH2O measured in the chest tube and was related to the device: deviation of ± 1 cmH2O for the Venice PAS (Wet) and 0 cmH2O for the Rome PAS (Dry) in the MICS group; deviation of 1 ± 0.8 cmH2O for the Venice PAS (Wet) and 0.8±0.2 cmH2O for the Rome PAS (Dry) in the CCS group. A constant volumetric air leak meter (VALM) value and the absence of air-leak bubbling were correlated with the absence of air in the pleural cavity and complete pulmonary re-expansion to restore normal respiratory dynamics in the MICS group for both models of chest drainage. The maximum total pericardial blood drained was 1104 ± 302 ml with Venice PAS (Wet) and 1530 ± 230 with Rome PAS (Dry) in the CCS group. There were no reports of cardiac tamponade in either group. CONCLUSIONS: The two mediastinal chest drainage devices [Venice PAS (Wet) and Rome PAS (Dry)] in this study were effective, accurate for measuring the applied negative pressure, and safe in their application after cardiac surgery procedures via minimally invasive and conventional approaches for blood and liquid drainage, prevention of cardiac tamponade, and restoration of normal respiratory dynamics after surgical pneumothorax. Both systems are equipped with anti-reflux valves to prevent air and blood from entering the drainage, and no adverse events were reported.

Long-term ECMO, efficiency and performance of EUROSETS adult A.L.ONE ECMO oxygenator.

BACKGROUND: The management of the oxygenator can be prolonged in the long-term procedures especially during extracorporeal membrane oxygenation (ECMO) for bridge to transplant or bridge to recovery. Long-term use often involves an overrun of the time of use with respect to certification of the oxygenating module of 14 days, for the maintenance of performance and efficiency of the oxygenator. The evaluation of the long-term oxygenator efficiency is complex and depends on the: patient pathology, ECMO configuration, the management of coagulation and anticoagulation, materials selection and circuit components, the structure, design and performance of the oxygenator. In this context we investgated the long-term performance of the A.L.ONE Eurosets ECMO oxygenator in relation to the parameters prodromal to replacement. METHODS: We retrospectively collected eight years data from Anthea Hospital GVM Care & Research, Bari, Italy on the long-term use exceeding 14 days of Eurosets A.L.ONE ECMO Adult oxygenator in Polymetylpentene fiber, for ECMO procedures, including the procedures: Veno Arterial (VA) ECMO post-cardiotomy or not, veno-venous (VV) ECMO. The primary end points were the evaluation of Gas Transfer: oxygen partial pressure (PO2) post oxygenator, Carbon dioxide partial pressure (PCO2) post oxygenator, the oxygen transfer across the oxygenator membrane V'O2, differential CO2 content across oxygenator; Pressure monitoring: oxygenator pressure Drop in relation to Blood flow rate (BFR) (ΔP); Hematologic values: Hemoglobin, Fibrinogen, Platelets, aPTT, D-Dimer, LDH. RESULTS: Nine VA ECMO patients who used the oxygenator for 18.5 days and two VV ECMO patients who used the oxygenators for 17.2 days on the seventeenth days reported average values PaO2 (267 ± 29 mmHg); PaCO2 (34 ± 4 mmHg) with gas blender values set to 3.8 ± 0.6 L/min of air and a FiO2 of 78 ± 5%; the transfer across the oxygenator membrane V'O2 was 189 ± 43 (ml/min/m2). The mean peak of partial pressure of carbon dioxide from the gas exhaust of oxygenator (PECO2) was 38 ± 4 mmHg; differential CO2 across the oxygenator "pre-oxygenator PCO2-post-oxygenator PCO2" (18 ± 6 mmHg); the mean blood flow rate (BFR) 4.5 ± 0.6 (L/minute); the pump revolution per minutes mean maximum rate was 4254 ± 345 (RPM); the mean pressure drop (ΔP) was 76 ± 12 mmHg; the mean peak of d-dimers (DDs) was 23.6 ± 0.8 mg / dL; the mean peak of LDH was 230 ± 55 (mg/dl); fibrinogen mean peak 223 ± 40 (mg/dl). CONCLUSIONS: The performance of the Eurosets A.L.ONE ECMO Adult polymethylpentene fiber oxygenator in our experience has proven efficiency in terms of O2 uptake and CO2 removal, blood fluid dynamics, metabolic compensation and heat exchange in the long-term treatment. The device was safe without iatrogenic problems over a period of 14 days in the patients undergoing ECMO VA and in all patients undergoing VV ECMO with continuous administration of anticoagulation therapy.

Negative Pressure Wound Therapy: Comparison of Outpatient and Inpatient Approaches.

BACKGROUND: The results of recent studies regarding the efficacy of Negative Pressure Wound Therapy (NPWT) for the prevention of sternal wound infection (SWI) after adult cardiac surgery are not conclusive. METHODS: Data were collected from patients who were operated upon at the GVM Care & Research group in Italy from 2013 to 2021; all patients who required treatment for sternotomy wound infection with Negative Pressure Wound Therapy (NPWT) through WaterLily™ system (Eurosets, Medolla, MO, Italy) were selected. We compared the preoperative risk characteristics, and particularly those that were most strongly associated with possible dehiscence of the wound. A statistical analysis was performed for comparison of the groups. RESULTS: Out of the total 40,267 patients who underwent cardiac surgery with extracorporeal circulation within this time frame, 1,483 (3.68%) required NPWT, including 690 (46.52%) in the HOME group and 793 (53.47%) in the HOSPITAL group (p =0.76). Thirty-nine (5.65%) patients in the HOME group and 37 (4.66%) in the HOSPITAL group required re-treatment for re-dehiscence after secondary closure (p =0.79). CONCLUSIONS: The use of a WaterLily™ system (Eurosets, Medolla, MO, Italy) was safe and effective for the treatment of sternotomy wounds with superficial and deep infections and was associated with a low rate of dehiscence, even when used with discharged and managed outpatient patients.

'Goal-directed extracorporeal circulation: transferring the knowledge and experience from daily cardiac surgery to extracorporeal membrane oxygenation'.

Metabolism management plays an essential role in extracorporeal technologies. There are different metabolic management devices integrated to extracorporeal devices; the most commonly used and accepted metabolic target in adult patients is indexed oxygen delivery (280 mL/min/m2) and cardiac index (2.4 L/min/m2), which can be managed independently or according to other metabolic parameters. Extracorporeal membrane oxygenation (ECMO) is a temporary form of life support providing a prolonged biventricular circulatory and pulmonary support for patients experiencing both pulmonary and cardiac failure unresponsive to conventional therapy. The goal-directed perfusion initiative during cardiopulmonary bypass (CPB) reduced the incidence of acute kidney injury after cardiac surgery. On the basis of the available literature, the identified goals to achieve during CPB include maintenance of oxygen delivery > 300 mL O2/min/m2 and reduction in vasopressor use. ECMO and CPB are conceptually similar but differ in many aspects and finality; in particular, they differ in the scientific evidence for metabolic management nadirs. As for CPB, predictive target parameters have been found and consolidated, particularly in terms of acute renal injury and the prevention of anaerobic metabolism, while for ECMO management, a blurred path remains. In this context, we review the strategies for optimal goal-directed therapy during CPB and ECMO, trying to transfer the knowledge and experience from daily cardiac surgery to veno-arterial ECMO.

Continuous field flooding versus final one-shot CO2 insufflation in minimally invasive mitral valve repair.

BACKGROUND: Insufflation of carbon dioxide (CO2) into the operative field to prevent cerebral or myocardial damage by air embolism is a well known strategy in open-heart surgery. However, here is no general consensus on the best delivery approach. METHODS: From January 2018 to November 2021, we retrospectively collected data of one hundred consecutive patients undergoing minimally invasive mitral valve repair (MIMVR). Of these, fifty patients were insufflated with continuous CO2 1 min before opening the left atrium and ended after its closure, and fifty patients were insufflated with one shot CO2 10 min before the start of left atrium closure. The primary outcome of the study was the incidence of transient post-operative cognitive disorder, in particular agitation and delirium at discontinuation of anesthesia, mechanical ventilation (MV) duration and intensive care unit (ICU) length of stay. RESULTS: In all patients that received continuous field flooding CO2, correction of ventilation for hypercapnia during cardiopulmonary bypass (CPB) was applied with an increase of mean sweep gas air (2.5 L) and monitoring of VCO2 changes. One patient vs. 9 patients of control group reported agitation at discontinuation of anesthesia (p = 0.022). MV duration was 14 ± 3 h vs. 27 ± 4 h (p = 0.016) and ICU length of stay was 33 ± 4 h vs. 42 ± 5 h (p = 0.029). A significant difference was found in the median number of total micro-emboli recorded from release of cross-clamp until 20 min after end of CPB (154 in the continuous CO2 group vs. 261 in the one-shot CO2 control group; p < 0.001). Total micro-emboli from the first 15 min after the release of cross-clamp was 113 in the continuous CO2 group vs. 310 in the control group (p < 0.001). In the continuous CO2 group, the median number of detectable micro-emboli after CPB fell to zero 9 ± 5 min after CPB vs. 19 ± 3 min in the control group (p = 0.85). CONCLUSION: Continuous field flooding insufflation of CO2 in MIMVR is associated with a lower incidence of micro-emboli and of agitation at discontinuation of anesthesia, along with improved MV duration and ICU length of stay.

The influence of metabolic syndrome in heart valve intervention. A multi-centric study.

BACKGROUND: The effect of metabolic syndrome (MetS), defined as insulin resistance along with two or more of: obesity, atherogenic dyslipidaemia and elevated blood pressure, on postoperative complications after isolated heart valve intervention remains controversial. We hypothesized that MetS may negatively influence the postoperative course in these patients. METHODS: Patients from 10 cardiac units who underwent isolated valve intervention (mitral ± $\pm $ tricuspid repair/replacement (mitral valve surgery [MVS]) or surgical aortic valve replacement (SAVR), or transcatheter aortic valve replacement (TAVR) were included. MetS was defined according to the World Health Organization criteria. Primary outcome was in-hospital mortality and overall postoperative length of stay (LOS). Relevant postoperative complications were also recorded. RESULTS: From 2010 to 2019, 17,283 patients underwent valve intervention. The MVS, SVAR, and TAVR accounted for the 39.4%, 48.2%, and 12.3% respectively of the whole. MetS compared to no-MetS was associated to higher mortality in the MVS group (6.5% vs. 2%, p < .001), but not in the SAVR and TAVR group. In both surgical cohorts, MetS was associated with increased complications including red blood cells transfusion, renal failure, mechanical ventilation time, intensive care and overall postoperative LOS (11 (9) vs. 10 (6), p < .001 and 10 (6) versus 10 (5) days, p = .002, MVS and [SAVR]). No differences were found in the TAVR cohort, with similar mortality and complications. CONCLUSION: MetS was associated to more postoperative complications, with higher mortality in the MVS group. In the TAVR cohort, postoperative complications and mortality rate did not differ between patients with and without MetS, however LOS was longer in the MetS group.

A new technique to adjust the length of artificial chordae during mitral anterior leaflet repair.

BACKGROUND: Length measurement of artificial chordae remains a critical step during mitral valve repair (MVr). The aim of this study is to assess the effectiveness of a new length measuring technique. METHODS: All consecutive patients with anterior leaflet prolapse/flail who underwent MVr using the described method between January 2020 and January 2022 at our institution were included in the analysis. Clinical and transesophageal echocardiography data were collected postoperatively and at 1-year follow-up. The primary outcome was freedom from mitral regurgitation (MR). Secondary outcomes were presentation with New York Heart Association (NYHA) class <2 and leaflet coaptation length ≥10 mm. RESULTS: Of 25 patients, 16 (64%) were males. A total of 15 (60%) had isolated anterior leaflet disease, while 10 (40%) had concomitant posterior involvement. Twenty patients with isolated MR (80%) underwent right anterior mini-thoracotomy, while 5 (20%) with associated valvular or coronary disease underwent sternotomy. The median number of chordae implanted was 2 [1-4]. Postrepair intraoperative MR grade was 0 in 23 patients (92%) and 1 in 2 (8%). Thirty-day mortality was 0%. De novo atrial fibrillation was 20%. At follow-up, mortality was 0%. No patients presented with moderate or severe MR. A total of 22 patients (88%) were in NYHA class I, while 3 (12%) in class II. The coaptation length was 11 ± 1 mm. CONCLUSIONS: The short-term outcomes of the described technique are good with adequate leaflet coaptation in all treated patients. Long-term results are needed to assess the stability and durability of this repair technique.

Hybrid approach for long-standing persistent atrial fibrillation: immediate versus staged treatment.

BACKGROUND: The hybrid approach has become the most effective treatment option for restoring sinus rhythm and reducing the risk of atrial fibrillation (AF) recurrence. However, several issues remain to be clearly defined, including the appropriate timing of the staged procedure and the most effective strategy. METHODS: Over a 12-year period of activity, we performed 609 AF ablation procedures via a right mini-thoracotomy. From this general population, 60 patients underwent a hybrid procedure with catheter ablation performed at least 4 weeks after the surgical procedure to confirm if effective complete electrical isolation of pulmonary veins was achieved. In 20 patients, the second stage procedure was performed during the same hospitalization due to patient's electrical instability. The results obtained in immediate versus staged patients were compared. RESULTS: All patients were discharged after the first stage procedure in sinus rhythm. The 20 immediate patients had a shorter hospital stay compared with the staged patients, in whom the two hospitalizations resulted in a longer hospital stay (immediate 5.5 ± 1.6 days versus staged 8.7 ± 1.4, P < 0.001). A significantly higher number of immediate patients had an associated ablation of the Bachmann's bundle (n = 16 in the immediate group [80%] versus n = 14 in the staged group [45%]; P = 0.001). After a mean follow-up of 74 months, there was no significant difference in the risk of AF relapse between groups (immediate 1/20 [5%] versus staged 7/40 [17.5%]; P = 0.18). CONCLUSION: The hybrid approach for the treatment of AF was safe and effective in immediate restoring sinus rhythm and in its maintenance at follow-up. Our preliminary results show that both immediate and staged procedures show similar efficacy but this result is strongly influenced by the concomitant ablation of the Bachmann's bundle, which appears to be the most important component of the treatment strategy in order to reduce the risk of recurrent AF.