Single-Center Real-World Experience with Sutureless Aortic Valve Prosthesis in Isolated and Combined Procedures.

INTRODUCTION: Due to their favourable hemodynamic performance and the ability to enable minimally invasive access procedures, sutureless aortic valve prostheses have found their place in the armamentarium of cardiothoracic surgeons. In this study, we sought to review our institutional experience of sutureless aortic valve replacement (SU-AVR). METHODS: We carried out a retrospective analysis of 200 consecutive patients who underwent an SU-AVR with a Perceval valve between December 2019 and February 2023. RESULTS: The mean age of patients was 69.3 ± 8.1 years, and patients showed a moderate-risk profile with a mean logistic EuroSCORE-II of 5.2 ± 8.1%. An isolated SU-AVR was performed in 85 (42.5%) patients, concomitant CABG was performed in 75 (37.5%) and 40 patients (20%) underwent a multivalve procedure involving SU-AVR. The cardiopulmonary bypass (CPB) and cross-clamp (CC) times were 82.1 ± 35.1 and 55.5 ± 27.8 min, respectively. In-hospital, 30-day, 6-month and 1-year mortality rates were 4.5%, 6.5%, 7.5% and 8.2%, respectively. The postoperative transvalvular mean pressure gradient was 6.3 ± 1.6 mmHg and stayed stable over the follow-up time. We reported no cases of paravalvular leakage, and the incidence of stroke was 0.5%. CONCLUSIONS: With their favourable hemodynamic performance and shorter CC and CPB times, sutureless aortic valve prostheses facilitate minimally invasive access surgery, being a safe and durable promising approach for the surgical AVR.

Sutureless Aortic Valve Prosthesis in Redo Procedures: Single-Center Experience.

Background and Objectives: Sutureless aortic valve prostheses have presented favorable hemodynamic performance while facilitating minimally invasive access approaches. As the population ages, the number of patients at risk for aortic valve reoperation constantly increases. The aim of the present study is to present our single-center experience in sutureless aortic valve replacement (SU-AVR) in reoperations. Materials and Methods: The data of 18 consecutive patients who underwent SU-AVR in a reoperation between May 2020 and January 2023 were retrospectively analyzed. Results: The mean age of the patients was 67.9 ± 11.1 years; patients showed a moderate-risk profile with a median logistic EuroSCORE II of 7.8 (IQR of 3.8-32.0) %. The implantation of the Perceval S prosthesis was technically successful in all patients. The mean cardiopulmonary bypass time was 103.3 ± 50.0 min, and the cross-clamp time was 69.1 ± 38.8 min. No patients required a permanent pacemaker implantation. The postoperative gradient was 7.3 ± 2.4 mmHg, and no cases of paravalvular leakage were observed. There was one case of intraprocedural death, while the thirty-day mortality was 11%. Conclusions: Sutureless bioprosthetic valves tend to simplify the surgical procedure of a redo AVR. By maximizing the effective orifice area, sutureless valves may present an important advantage, being a safe and effective alternative not only to traditional surgical prostheses but also to transcatheter valve-in-valve approaches in select cases.

Conventional Biological versus Sutureless Aortic Valve Prostheses in Combined Aortic and Mitral Valve Replacement.

BACKGROUND: Sutureless aortic valve prostheses have proven to provide a significant decrease in procedural, cardiopulmonary bypass and cross-clamp time, leading to a significant reduction in mortality risk in elderly high-risk cohorts. In this study, we sought to review our institutional experience on the sutureless aortic valve replacement (SU-AVR) and the concomitant mitral valve replacement (SMVR), comparing the combined conventional surgical aortic valve replacement (SAVR) with SMVR. METHODS AND MATERIAL: Between March 2018 and July 2022, 114 consecutive patients underwent a combined aortic and mitral valve replacement at our institution. We stratified the patients according to the operative procedures into two groups and matched them 1:2: Group 1 underwent a combined conventional SAVR and SMVR (n = 46), and Group 2 included combined SU-AVR with Perceval prosthesis and SMVR (n = 23). RESULTS: No significant differences in the preoperative characteristics were present. SU-AVR combined with SMVR demonstrated excellent haemodynamic performance, comparable to that of SAVR plus SMVR, with median postoperative gradients over the aortic valve of 4 mmHg (IQR 3.0-4.0) in Group 1 and 4 mmHg (IQR 3.0-4.0) in Group 2 (p = 0.67). There was no significant difference in the occurrence of postoperative major adverse events such as death, stroke, myocardial infarction and kidney failure between the groups. There was also no significant difference in the permanent pacemaker implantation rate, paravalvular leakage or valve dislocation. We also could not detect any significant difference in postoperative mortality between the groups. CONCLUSIONS: SU-AVR has proven to be a reliable alternative to conventional valve prostheses in patients with multivalve disease undergoing combined aortic and mitral valve replacement, offering shorter procedural time and outstanding hemodynamic performance compared to the conventional surgical method.

Five-year follow-up of mitral valve repair versus replacement: a propensity score analysis.

BACKGROUND: Mitral valve repair (MVRe) is considered to have a superior outcome compared to replacement (MVRp) in patients with mitral valve regurgitation (MVR). It was the aim of the study to analyse the clinical results and identify risk factors for short and long-term mortality. METHODS: In a retrospective single-center analysis, patients undergoing an isolated mitral valve procedure from June 2010 to December 2016 were identified. These were subsequently homogenized using 10 baseline characteristics for propensity-score matching. Comparative analyses were performed for early and long-term results, using adequate statistical tools, and identifying risk factors for the investigated endpoints, primary end-point: all-cause mortality within 5 years and secondary end-points: recurrent MVR, reoperation, endocarditis and/or mortality with 30 days, 1, 3 and 5 years. RESULTS: 241 patients were identified in the entire patient cohort. After matching, patients were divided into 2 groups of 64 each respectively. The median age was similar in the two groups. There was a significant interaction between early mortality risk of MV in patients with coronary artery disease (CAD) (OR 11.94, 95% CI 1.49-285.92, p = 0.04) and late mortality in patients with higher EuroSCORE II (HR 1.14, 95% CI 1.06-1.23, p < 0.001). The primary end-point showed 5-year survival rate was significantly higher in MVRe versus MVRp (90.06% vs. 79.54% respectively, p = 0.04). The secondary end-point demonstrated recurrent MVR not to be statistically significant between the 2 groups (p = 0.09) as well as reoperation (p = 0.28). Endocarditis was observed in one patient after MVRp. CONCLUSIONS: We concluded MVRe to be associated with lower operative and 5-year mortality and good postoperative outcomes compared to patients undergoing MVRp. Concomitant CAD was identified as one of the risk factors for increasing the in-hospital mortality rate. There was no significant difference in rehospitalisation over the follow-up period. MVRe should be the treatment of choice for severe MVR and should remain a central aspect in valve centers' treatment algorithms and quality measures.

Sutureless aortic valve replacement in high-risk patients with active infective endocarditis.

Background: Surgical aortic valve replacement remains the gold standard of treatment in patients with active infective endocarditis. Such procedures tend to carry a significantly higher operative risk when compared to the conventional aortic valve replacement for a non-infective aortic valve disease. Sutureless aortic valve replacement (SU-AVR) has been introduced into cardiac surgery to allow for a simpler implementation of minimally invasive procedures. Although SU-AVR in several extended indications has proven to be successful, the data on the implementation of SU-AVR in patients with infective aortic valve endocarditis remain scarce. The aim of the study was to examine the feasibility of SU-AVR in high-risk patients with active infective aortic valve endocarditis. Methods: Between December 2019 and March 2022, a total of 151 consecutive patients underwent a SU-AVR for various indications at our institution. Of those, in 13 consecutive high-risk patients SU-AVR was indicated because of infective aortic valve endocarditis. In all cases Perceval S aortic valve prosthesis (Corcym, Saluggia, Italy) was used and the implantation has been performed with Snugger-method. Results: The mean age of the patients at operation was 74.05±11.6 years. Eight of the patients suffered from prosthesis endocarditis while the other five patients presented with the endocarditis of the native aortic valve. All patients suffered from multiple comorbidities, as reflected by a mean logistic EuroSCORE of 47.9%±23.1% and EuroSCORE II of 28.7%±22.0%. In 8 patients (61.5%) a concomitant procedure was necessary. Also 8 patients (61.5%) underwent a redo procedure. Bypass- and cross-clamp (CC) times were 89.8±33.6 and 59.1±27.8 minutes, respectively. We observed no paravalvular leakage and no cases of left-ventricular outflow tract obstruction. Postoperative mean gradients after SU-AVR implantation were 8.1±4.8 mmHg. Conclusions: SU-AVR in patients presenting with active infective endocarditis is a safe and feasible surgical alternative to the conventional operation. Clearly, this operative approach should be considered particularly for high-risk patients in whom successful operative outcomes are determined by a reduction in bypass and CC time. SU-AVR provides excellent hemodynamic performance with a low risk of paravalvular leakage and low transvalvular gradients, whilst simplifying the surgical procedure.

Sutureless aortic valve replacement in pure aortic regurgitation: expanding the indications.

BACKGROUND: In the era of transcatheter methods, patients presenting with a pure aortic regurgitation (AR) are not considered eligible for transcatheter treatment and therefore require another less invasive surgical option. We sought to review our experience with sutureless aortic valve replacement (SU-AVR) in patients presenting with symptomatic pure AR, which until now is a contraindication for implementation of sutureless valve prostheses in Europe. METHODS: Between April 2018 and June 2021, 80 consecutive patients underwent a SU-AVR for various indications at our institution. We analyzed the outcomes and postoperative complications of 12 patients presenting with a pure severe AR undergoing SU-AVR using Perceval (Corcym). RESULTS: The mean age of the patients was 67 ± 9.1 years old. All patients presented with symptomatic pure AR. Patients presented with multiple comorbidities as reflected by the mean EuroSCORE-II of 3.6 ± 2.6%. Six patients (50%) underwent a concomitant CABG procedure. The mean operating- and cross clamp time was 127.25 ± 45.9 and 40.33 ± 17.3 min respectively. All isolated SU-AVR were performed via J-sternotomy or right anterolateral thoracotomy. There were no cases of device dislocation. No patients presented with a paravalvular leakage. We observed excellent mean postoperative pressure gradient at follow-up 5.7 ± 1.5 mmHg. CONCLUSIONS: Our experience with SU-AVR shows the feasibility of sutureless technologies in the aortic valve surgery due to pure AR. Besides the great technical success and excellent hemodynamics, SU-AVR in severe AR offers a great opportunity of reducing the invasivity of the surgical procedure and potentially reducing hospital cost without compromising the postoperative outcomes and in-hospital length of stay.

Non-Inferiority of Sutureless Aortic Valve Replacement in the TAVR Era: David versus Goliath.

BACKGROUND: The rapid development of transcatheter treatment methods has made transcatheter aortic valve replacement (TAVR) a feasible alternative to conventional surgical aortic valve replacement (SAVR). Recently, indications for TAVR have been expanded to intermediate- and low-risk patients, although there still remains a portion of ineligible patients. We sought to evaluate and compare our experience with sutureless SAVR and transapical TAVR in the "grey-area" of patients unsuitable for transfemoral access. METHODS: Between April 2018 and June 2021, 248 consecutive patients underwent a sutureless SAVR (SU-SAVR) or TA-TAVR at our institution. We performed a pair-matched analysis and identified 56 patient pairs based on the EuroSCORE II. All transcatheter procedures were performed using SAPIEN XT/3™ prostheses, while all surgical procedures deployed the Perceval (LivaNova) aortic valve. RESULTS: All patients presented with multiple comorbidities as reflected by the median EuroSCORE-II of 3.1% (IQR 1.9-5.3). Thirty-four patients from the surgical group (60.7%) underwent a concomitant myocardial revascularization. There was no significant difference in major adverse events, pacemaker implantation or postoperative mortality during follow-up. Both interventions demonstrated technical success with similar mean postoperative pressure gradients at follow-up and no cases of paravalvular leakage. CONCLUSIONS: Sutureless aortic valve replacement constitutes a feasible treatment alternative for patients with aortic valve disease who are ineligible for transfemoral access route and/or require concomitant coronary revascularization. With its excellent hemodynamic performance, similar survival compared to TA-TAVR, and high cost-efficiency without compromising the postoperative outcomes and in-hospital length of stay SU-AVR might be considered for patients in the "grey-area" between TAVR and SAVR.

Early experience with the Impella pump: Single-center registry.

BACKGROUND: With the rapid development of mechanical circulatory support technologies, patients presenting with cardiogenic shock have gained access to various treatment opportunities which were not until recently available. The Impella® pump (Abiomed, Danvers, USA) is a minimally invasive device which provides excellent left ventricular unloading and full circulatory support. The aim of the study was to review our center's experience with Impella® and to analyze the major adverse events associated with the device. METHODS: From January 2020 to January 2022, a total of 32 patients underwent Impella® implantation at our center for various indications. RESULTS: The mean age at surgery was 60.3 ± 12.4 years and 9.4% were female. All patients presented with acute cardiogenic shock in INTERMACS Class I (53.1%) and INTERMACS Class II (46.9%). Twenty-six patients (81.25%) out of the whole cohort have been mobilized on Impella® support. Seventeen patients (53.1%) have been weaned from the Impella® support and 10 patients (31.3%) have been bridged to durable LVAD. The median time on Impella® was 7 days (IQR 5.0-11.0). 30-day mortality was 37.5%, with 56.25% survival until hospital discharge. Only one patient developed vascular complications consisting of arm hypoperfusion. There were no cases of stroke on Impella® support. CONCLUSION: The Impella® axial-flow pump seems an appropriate therapeutic option for patients with acute cardiogenic shock requiring partial or full hemodynamic support. It also provides sufficient left ventricular unloading to allow full mobilization and neurological assessment of the patients. Furthermore, Impella® offers a high rate of myocardial recovery.

Articulation is essential: First in cardiovascular surgery implementation of 360° surgeon-powered robotic instruments.

Since the development of endoscopic vision in the late 1970s, the implementation of minimally invasive surgical methods has been rapidly progressing throughout a wide range of surgical disciplines, including cardiovascular surgery. The benefits of minimally invasive procedures including a reduction in operative trauma and postoperative morbidity, have been well-documented and compared to open-heart procedures, eventually becoming the preferred modality of treatment by many centers. Due to the cost ineffectiveness of the robotic systems for numerous institutions, new technologies have been developed to provide the advantages of robotic surgical systems at a lower price, thus making them more widely available. In this paper, we aimed to share our first experiences with Artisential® surgeon-powered robotic instruments and review their general advantages compared to conventional and robotic devices.

Impact of severe mitral regurgitation on postoperative outcome after durable left-ventricular assist device implantation.

BACKGROUND: Mitral valve regurgitation (MR) is a common finding in patients with end-stage heart failure. The aim of the study was to analyze the impact of preoperative moderate-to-severe MR on postoperative outcomes and survival after durable left-ventricular assist device (LVAD) implantation. METHODS: From August 2010 to May 2021, 246 patients underwent a durable LVAD implantation. We stratified the patients into two groups: Group A (n = 109) presented with MR 0-I°, and Group B presented with MR II-III° (n = 137). MR II-III° was defined according to the current recommendations (i.e., vena contracta ≥ 7 mm, regurgitation volume ≥ 30 ml or effective regurgitation orifice area ≥ 20 mm2 ). RESULTS: Significantly more patients in Group B suffered from pulmonary hypertension and presented with chronic obstructive lung disease. We observed significantly higher rates of tricuspid regurgitation (TR) II-III° in Group B (76.1%) versus Group A (14.8%) (p < 0.001) and TR III° in Group B (30.4%) versus Group A (3.7%) (p < 0.001). There was no difference in the incidence of right heart failure between the groups. Within our cohort, the in-hospital, 1-year, 3-year, and 5-year mortality was 22.4%, 32.1%, 50.7%, and 64.4%, respectively. Group B showed significantly worse overall survival (p = 0.05). Patients with preoperative TR II-III° had a significantly worse survival than those with TR 0-I° (p = 0.048). In patients presenting with MR II-III°, we discovered that TR III° seems to predict both in-hospital and mid-term mortality. CONCLUSION: MR II-III° negatively affects the outcomes in patients requiring LVAD implantation. Persisting MR II-III° is an independent predictor of mortality. Patients with concomitant preoperative TR II-III° are at increased risk of developing postoperative major adverse events. Addressing the MR might be considered for these patients.

Alternative access in high-risk patients in the era of transfemoral aortic valve replacement.

BACKGROUND: We aimed to evaluate the outcomes of transapical and transaortic transcatheter aortic valve replacement (TAVR) in high-risk patients who were not suitable for transfemoral access and had a logistic EuroSCORE-I ≥ 25% and Society of Thoracic Surgeons (STS) score >6%. 'STS/ACC TAVR In-Hospital Mortality Risk App' was evaluated. MATERIAL AND METHODS: Between January 2016 and May 2020, 126 patients at very high risk for aortic valve replacement underwent transapical (n = 121) or transaortic (n = 5) transcatheter aortic valve replacement. TAVR was performed using SAPIEN 3™ or ACURATE TA™ prosthesis. RESULTS: The logistic EuroSCORE-I was 40.6 ± 14.0%, the STS-score 7.9 ± 4.6%, and STS/ACC-score 8.4 ± 3.4%. Valve implantation was successful in all patients. Operative, in-hospital and 30-days mortality, were 0, 7.9, and 13.5%, respectively. Survival was 72% at one year and 48% at four years. Expected/observed in-hospital mortality was 1.0 for the STS-score and 1.06 for the STS/ACC-score. Renal failure, low ejection fraction, and postoperative acute kidney injury, hemorrhage, and vascular complications were identified as independent predictors for 30-day mortality. CONCLUSIONS: Transapical and transaortic TAVR in high-risk patients unsuitable for transfemoral access is still a reasonable alternative in these patients. STS and STS/ACC-score appear to be highly accurate in predicting in-hospital mortality in high-risk patients undergoing TAVR.

Rescue extracorporeal life support as a bridge to durable left ventricular assist device.

BACKGROUND: The ideal timing of a durable assist device implantation in patients with end-stage heart failure presenting with INTERMACS profile I is still controversial. The data on extracorporeal life support (ECLS) bridge to durable left ventricular assist device (LVAD) in these patients is limited. MATERIALS AND METHODS: We retrospectively analyzed the outcomes of 35 patients in acute cardiogenic shock (CS) who, between December 2013 and September 2020, were bridged with ECLS to durable LVAD. The mean age was 52.3 ± 12.0 years. The primary endpoints of this study were in-hospital, 30-day, 6-month, and 1-year mortality. The secondary endpoint was the development of any postoperative adverse events and other characteristics during the follow-up period. We also assessed the impact of the rescue ECLS on the recovery of the end-organ function. RESULTS: In-hospital, 30-day, 6-month, and 1-year survival was 65.6%, 75.9%, 69.2%, and 62.7% respectively. The median time on ECLS was 7 days (IQR 5.0-13.0). We observed a high incidence of a severe right heart failure (22.9%), acute kidney injury on dialysis (68.6%), and respiratory failure (77.1%). Bridge with ECLS provided a significant recovery of liver and kidney function prior to durable LVAD implantation. CONCLUSION: The concept of bridging patients presenting in end-stage heart failure and cardiogenic shock with ECLS prior to durable LVAD implantation is a feasible method to ensure acceptable survival rates and significant recovery of the end-organ function.

Transapical transcatheter mitral valve implantation in patients with degenerated mitral bioprostheses or failed ring annuloplasty.

BACKGROUND: We sought to evaluate the outcomes of transapical transcatheter mitral valve replacement in patients with degenerated mitral bioprostheses or failed mitral ring annuloplasty and high surgical risk for redo mitral valve procedure. METHODS: Between August 2012 and December 2020, 41 consecutive high-risk patients underwent transcatheter mitral 'valve-in-valve' (TM-ViV, n=25) or 'valve-in-ring' (TM-ViR, n=16) implantation at our institution. All procedures were performed in a hybrid operating theater using the SAPIEN XT/3™ or the DIRECT FLOW MEDICAL™ prostheses. Data was collected prospectively according to MVARC criteria. RESULTS: The logistic EuroSCORE-I was 42.3%±20.5% (mean ± SD), the Society of Thoracic Surgeons (STS) score was 11.9%±10.8%, and the STS/ACC-score was 7.6%±4.2%. Transcatheter mitral valve implantations were successful in all patients (100%). Early echocardiographic examinations showed no obstruction of the left ventricular outflow tract (LVOT), no paravalvular leakage, and only trace transvalvular leakage in eight patients. There was no operative mortality; thirty-day mortality was 9.8%. Survival was 72% at one year and 63% at three years. At two-year follow-up, transvalvular mean pressure gradients were 4.6±1.4 mmHg. CONCLUSIONS: Transapical transcatheter mitral valve-in-valve or valve-in-ring implantation represents a true minimally invasive alternative to surgical redo procedures, especially in high-risk patients with failed bioprosthetic mitral valves or annuloplasty and favorable anatomy.

Aortic Root Replacement for Destructive Endocarditis - Clinic and Microbiology

Abstract Introduction: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. Methods: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. Results: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. Conclusion: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

Mitral surgical redo versus transapical transcatheter mitral valve implantation.

BACKGROUND: Transcatheter methods have been rapidly evolving to provide an alternative less invasive therapeutic option, mainly because redo patients often present with multiple comorbidities and high operative risk. We sought to evaluate and compare our experience with transapical transcatheter mitral valve replacement (TA-TMVR) to conventional redo mitral valve replacement in patients presenting with degenerated biological mitral valve prostheses or failed valve annuloplasty. METHODS AND MATERIAL: Between March 2012 and November 2020, 74 consecutive high-risk patients underwent surgical redo mitral valve replacement (n = 33) or TA-TMVR (n = 41) at our institution. All patients presented with a history of a surgical mitral valve procedure. All transcatheter procedures were performed using the SAPIEN XT/3™ prostheses. Data collection was prospectively according to MVARC criteria. RESULTS: The mean logistic EuroSCORE-II of the whole cohort was 19.9±16.7%, and the median STS-score was 11.1±12.5%. The mean age in the SMVR group was 63.7±12.8 years and in the TMVR group 73.6±9.7 years. Patients undergoing TA-TMVR presented with significantly higher risk scores. Echocardiography at follow up showed no obstruction of the left ventricular outflow tract, no paravalvular leakage and excellent transvalvular gradients in both groups (3.9±1.2 mmHg and 4.2±0.8 mmHg in the surgical and transcatheter arm respectively). There was no difference in postoperative major adverse events between the groups with no strokes in the whole cohort. Both methods showed similar survival rates at one year and a 30-day mortality of 15.2% and 9.8% in SAVR and TMVR group, respectively. Despite using contrast dye in the transcatheter group, the rate of postoperative acute kidney failure was similar between the groups. CONCLUSION: Despite several contraindications for surgery, we showed the non-inferiority of TA-TMVR compared to conventional surgical redo procedures in high-risk patients. With its excellent hemodynamic and similar survival rate, TA-TMVR offers a feasible alternative to the conventional surgical redo procedure in selected patients.

Surgical redo mitral valve replacement in high-risk patients: The real-world experience.

INTRODUCTION: Redo surgical mitral valve replacement (SMVR) remains the gold standard treatment in patients with a history of mitral valve surgery presenting with recurrent mitral valve pathologies. Whilst this procedure is demanding, it is an inevitable intervention for some indications, such as infective endocarditis, thrombosis, or multivalve procedures. In this study, we aim to evaluate our institutional experience with SMVR on a real-life cohort, identifying the factors that contribute to poor surgical outcomes whilst avoiding selection bias. METHODS: Between March 2012 and November 2020, 58 consecutive high-risk patients underwent a redo SMVR at our institution. The primary endpoints of this study were 30-day and 1-year mortality. The secondary endpoint was the development of any postoperative adverse events. We analyzed and compared the survival in patients undergoing an isolated SMVR and in those that required at least one concomitant procedure. RESULTS: The overall operative, 30-day, and 1-year mortality were 3.4%, 22.4%, and 25.9%, respectively. The mortality in patients undergoing isolated SMVR was significantly lower than in patients requiring concomitant procedures. The multivariable regression model showed that NYHA Class IV, infective endocarditis, and postoperative dialysis were significantly associated with 30-day mortality. Society of Thoracic Surgeons Score, infective endocarditis, concomitant procedures, and mechanical valve implantation appeared to predict long-term mortality. CONCLUSION: This study illustrates that SMVR after prior mitral valve surgery presents a demanding procedure with high operative risk, significant mortality, and morbidity. Whilst this procedure is inevitable for some indications, a careful patient selection and risk stratification provides acceptable surgical results in this cohort.

Sutureless aortic valve replacement in multivalve procedures.

BACKGROUND: Despite the rapid expansion of transcatheter approaches for aortic valve implantation, surgical aortic valve replacement remains the treatment of choice in patients presenting with multiple valvular heart disease. We sought to review our clinical experience with sutureless aortic valve replacement (SU-AVR) in the setting of multivalve procedures, addressing the postoperative outcomes and technical challenges. METHODS: Between December 2019 and December 2020, 20 consecutive high-risk patients at our institution underwent SU-AVR and concomitant mitral valve procedure for various indications. RESULTS: The mean age of the patients at operation was 72.6±9.3 years. Fifty five percent of the patients (n=11) presented with moderate to severe symptomatic aortic valve stenosis, while 35% (n=7) suffered from severe aortic regurgitation. All patients had concomitant moderate to severe mitral valve disease, including regurgitation in 95% (n=19) and stenosis in 25% (n=5). Mean logistic EuroSCORE was 34.3%±24.7%. Cardiopulmonary bypass and cross-clamp times were 101 (88.0-123) minutes and 67.5 (51.7-85.2) minutes, respectively. Optimal sutureless aortic valve prosthesis device success was achieved in 20 patients (100%). One patient (5%) required permanent pacemaker implantation. Thirty-day mortality was 10% and no strokes were detected. CONCLUSIONS: SU-AVR is a safe and feasible surgical alternative to conventional procedures in patients presenting with multiple valvular heart disease. It provides excellent hemodynamic performance with low risk of paravalvular leakage and low transvalvular gradients, whilst simplifying the surgical procedure. Precise sizing and positioning of the valve prostheses is crucial to ensure optimal postoperative outcome.

Aortic Root Replacement for Destructive Endocarditis - Clinic and Microbiology.

INTRODUCTION: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. METHODS: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. RESULTS: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. CONCLUSION: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

Surgical and multimodality treatment of cardiac sarcomas: A systematic review and meta-analysis.

INTRODUCTION: Primary cardiac sarcomas (PCSs) are an extremely rare and aggressive type of malignancies that have been described only by a limited number of observational studies. This study aimed to evaluate the currently existing evidence comparing surgical to multimodality treatment of PCS. METHODS: We systematically reviewed Embase, MEDLINE, Cochrane Database, and Google Scholar, from inception to December 2020, for original articles about surgical and multimodality treatment of PCS. The outcomes included were mortality at various time points, resection margin status, and mean estimated survival. The pooled treatment effects were calculated using a random-effects model. RESULTS: Ten studies including a total of 1570 patients met our inclusion criteria. Surgery was associated with significantly lower mortality when compared to conservative treatment at 1, 2, and 3 years, whereas no significant difference was found at 5 years. Furthermore, multimodality treatment showed significantly lower mortality at 1 year when compared to surgery alone, but not at 2 and 5 years. We found no difference in mortality between angiosarcomas and other PCS subtypes. CONCLUSION: Overall, surgery was found to provide a significant mortality advantage to PCS patients up to 3 years following treatment. Multimodality treatment might be of additional benefit, although only within the first year. Prospective randomized studies are needed to further explore these differences in the treatment of PCS.

Surgical treatment of infective endocarditis in intravenous drug abusers.

BACKGROUND: Despite current progress in antibiotic therapy and medical management, infective endocarditis remains a serious condition presenting with high mortality rates. It also is a life-threatening complication in patients with a history of chronic intravenous drug abuse. In this study, we analyzed our institutional experience on the surgical therapy of infective endocarditis in patients with active intravenous drug abuse. The aim of the study is to identify the predictive factors of mortality and morbidity in this subgroup of patients. METHODS: Between 2007 and 2020, a total of 24 patients (7 female, mean age 38.5 ± 8.7) presenting with active intravenous drug abuse underwent a surgical treatment for the infective endocarditis at out center. The primary endpoint was survival at 30th day after the surgery. The secondary composite endpoint included freedom from death, recurrent endocarditis, re-do surgery, and postoperative stroke during the follow-up period. Mean follow-up was 4.2 ± 4.3 years. RESULTS: Staphylococcus species was the most common pathogen detected in the preoperative blood cultures. Infection caused by Enterococcus species as well as liver function impairment were identified as mortality predictor factors. Logistic EuroSCORE and EusoSCORE-II were also predictive factors for mortality in univariate analysis. Survival at 1 and 3 years was 78 and 72% respectively. Thirty-day survival was 88%. 30-day freedom from combined endpoint was 83% and after 1 and 3 years, 69 and 58% of the patients respectively were free from combined endpoint. Five patients (20.8%) were readmitted with recurrent infective endocarditis. CONCLUSION: In patients presenting with active intravenous drug abuse, treatment of infective endocarditis should be performed as aggressively as possible and should be followed by antibiotic therapy to avoid high mortality rates and recurrent endocarditis. Early intervention is advisable in patients with an infective endocarditis and enterococcus species in the preoperative blood cultures, liver function deterioration as well as cardiac function impairment. Attention should be also payed to addiction treatment, due to the elevated relapse rate in patients who actively inject drugs. However, larger prospective studies are necessary to support our results. As septic shock is the most frequent cause of death, new treatment options, e.g. blood purification should be evaluated.