Acute aortic insufficiency due to rupture of an aortic valve commissure.

Myxomatous degeneration generally involves the atrioventricular valves (mitral and tricuspid). Rarely, it may affect the aortic or pulmonary valve. We report a case of an acute severe aortic insufficiency due to a rupture of a commissure of the aortic valve in a patient who had previously undergone mitral valve surgery for myxomatous mitral valve prolapse.

Saphenous vein cannulation in re-redo cardiac surgery.

The widely used peripheral vein site of cannulation (i.e., the femoral vein) cannot always be employed in the setting of re-redo procedures. We propose a safe and simple surgical technique for a femoral vein cannulation using the greater saphenous vein as the inflow tract for the venous drainage in the setting of redo cardiac surgery.

Long-term secondary cardiovascular prevention programme in patients subjected to coronary artery bypass surgery.

AIMS: Patients with coronary heart disease (CHD) are at very high risk of recurrent events. A strategy to reduce excess risk might be to deliver structured secondary prevention programmes, but their efficacy has been mostly evaluated in the short term and in experimental settings. This is a retrospective case-control study aimed at assessing, in the real world, the efficacy of a secondary prevention programme in reducing long-term coronary event recurrences after coronary artery bypass surgery (CABG). METHODS AND RESULTS: Programme participants (henceforth 'cases') were men and women aged <75 years subjected to CABG between 2002 and 2014, living within 100 km of the hospital. Key programme actions included optimization of treatments according to the most updated European preventive guidelines, surveillance of therapy adherence, and customized lifestyle counselling. Controls were analogous patients not involved in the programme because living farther than 100 km away, matched 1:1 with cases for gender, age at CABG, and year of CABG. Both groups (n = 1248) underwent usual periodic cardiology follow-up at our centre. Data on symptomatic or silent CHD recurrences were obtained from the hospital electronic health records. Cox analysis (adjusted for baseline differences between groups) shows that programme participation was associated with a significantly lower incidence throughout 5 years post-CABG of symptomatic [hazard ratio (95% confidence interval): 0.59 (0.38-0.94)] and silent [0.53 (0.31-0.89)] coronary recurrences. CONCLUSION: In a real-world setting, taking part in a structured longstanding secondary prevention programme, in addition to usual cardiology care, meaningfully lowers the risk of coronary recurrences.

Performance of EuroSCORE in CABG and off-pump coronary artery bypass grafting: single institution experience and meta-analysis.

AIMS: To assess EuroSCORE performance in predicting in-hospital mortality in on-pump coronary artery bypass grafting (CABG) and off-pump coronary artery bypass grafting (OPCAB). METHODS AND RESULTS: Additive and logistic EuroSCORE were computed for consecutive patients undergoing CABG (n = 3440, 75%) or OPCAB (n = 1140, 25%) at our hospital from 1999 to September 2007. The areas under the receiver operating characteristic (ROC) curves (AUCs) were used to describe performance and accuracy. No difference in performance between CABG and OPCAB and between additive and logistic EuroSCORE (additive EuroSCORE AUCs of 0.808 and 0.779 for CABG and OPCAB, respectively; logistic EuroSCORE AUCs of 0.813 and of 0.773 for CABG and OPCAB, respectively) was found, although a marked tendency to overpredict mortality by both models was evident. A meta-analysis of previously published data was done, and a total of eight studies representing 19 212 and 5461 patients undergoing CABG and OPCAB, respectively, met inclusion criteria. Meta-analysis confirmed similar performance of EuroSCORE in CABG and OPCAB: estimated AUCs were 0.767 and 0.766 for CABG and OPCAB, respectively, with an estimated difference of 0.001 (95% CI -0.061 to 0.063). CONCLUSION: Additive and logistic EuroSCORE algorithms performed similarly, and cumulative evidence suggests comparable performance in CABG and OPCAB procedures; both risk models, however, significantly overestimated mortality.

Paradoxical Neochords to Treat Systolic Anterior Motion in Hypertrophic Obstructive Cardiomyopathy.

We describe an approach to address the left ventricular outflow tract obstruction in hypertrophic obstructive cardiomyopathy with concomitant systolic anterior motion of mitral valve. The two main purposes of this approach are to enlarge the left ventricular outflow tract through a "moderate" myectomy and to "discipline" the excessive movement of the mitral valve anterior leaflet through paradoxical chords implantation, and similarly, the papillary muscle too, if necessary, by hanging paradoxical chords between the papillary muscle itself and the posterior mitral annulus.

Intraoperative antiaggregant strategy for off-pump coronary artery bypass grafting in a patient with heparin-induced thrombocytopenia.

Immune heparin-induced thrombocytopenia is a rare complication of heparin administration. We describe a patient with a previous diagnosis of heparin-induced thrombocytopenia and related contraindications to anticoagulation who underwent urgent off-pump myocardial revascularization with the administration of only antiaggregant therapy.

Therapeutic hypothermia for comatose survivors after cardiac arrest.

BACKGROUND: Unconscious adults with spontaneous circulation after out-of-hospital cardiac arrest should be cooled to 32-34 degrees C (ILCOR recommendations, 2003) when the initial rhythm is ventricular fibrillation. OBJECTIVES: To assess the technique, safety and efficacy of mild induced hypothermia in patients after OHCA due to VF. METHODS: Patients were cooled using the MTRE CritiCool external cooling system. Cold intravenous fluids were added to achieve faster cooling in 17 patients. Data were collected prospectively and patients were analyzed according to their neurological outcome on discharge, defined by their cerebral performance category. RESULTS: From February 2002 to September 2006, 51 comatose VF patients with OHCA underwent MIH. Treatment was discontinued early in five because of hemodynamic instability; goal temperature was reached in 98% and maintained for an average of 19.5 hours; 61% had a favorable outcome (CPC 1-2) and 37% died. Improved outcome was observed with longer hypothermia time and possibly when time from collapse to return of spontaneous circulation was < 25 minutes. CONCLUSIONS: MIH, using an external cooling system, is simple and feasible, reduces mortality and protects neurological function. Four major factors seem to influence outcome: age, co-morbidities, duration of hypothermia, and possibly the length of time from collapse to return of spontaneous circulation.

The 'respect rather than resect' principle in mitral valve repair: the lateral dislocation of the P2 technique.

BACKGROUND: Leaflet resection represents the reference standard for surgical treatment of mitral valve (MV) regurgitation. New approaches recently proposed place emphasis on respecting, rather than resecting, the leaflet tissue to avoid the drawbacks of the 'resection' approach. OBJECTIVES: The lateral dislocation of mid portion of mitral posterior leaflet (P2) technique for MV repair is a nonresectional technique in which the prolapsed P2 segment is sutured to normal P1 segment. Our study evaluates the effectiveness of this technique. PATIENTS AND METHODS: We performed the procedure on seven patients. Once ring annular sutures were placed, the prolapsed P2 segment was dislocated toward the normal P1 segment with a rotation of 90° and without any resection. If present, residual clefts between P2 and P3 segments were closed. Once the absence of residual mitral regurgitation is confirmed by saline pressure test, ring annuloplasty was completed. The valve was evaluated using transesophageal echocardiography in the operating room and by transthoracic echocardiography before discharge. RESULTS: At the last follow-up visit, transthoracic echocardiography revealed no mitral regurgitation and normal TRANSVALVULAR gradients. CONCLUSION: The lateral dislocation of P2 is an easily fine-tuned technique for isolated P2 prolapse, with the advantage of short aortic cross-clamp and cardiopulmonary bypass times. We think it might be very favorable in older and frail patients. Long-term follow-up is necessary to assess the durability of this technique.

Feasibility of pig and human-derived aortic valve interstitial cells seeding on fixative-free decellularized animal pericardium.

Glutaraldehyde-fixed pericardium of animal origin is the elective material for the fabrication of bio-prosthetic valves for surgical replacement of insufficient/stenotic cardiac valves. However, the pericardial tissue employed to this aim undergoes severe calcification due to chronic inflammation resulting from a non-complete immunological compatibility of the animal-derived pericardial tissue resulting from failure to remove animal-derived xeno-antigens. In the mid/long-term, this leads to structural deterioration, mechanical failure, and prosthesis leaflets rupture, with consequent need for re-intervention. In the search for novel procedures to maximize biological compatibility of the pericardial tissue into immunocompetent background, we have recently devised a procedure to decellularize the human pericardium as an alternative to fixation with aldehydes. In the present contribution, we used this procedure to derive sheets of decellularized pig pericardium. The decellularized tissue was first tested for the presence of 1,3 α-galactose (αGal), one of the main xenoantigens involved in prosthetic valve rejection, as well as for mechanical tensile behavior and distensibility, and finally seeded with pig- and human-derived aortic valve interstitial cells. We demonstrate that the decellularization procedure removed the αGAL antigen, maintained the mechanical characteristics of the native pig pericardium, and ensured an efficient surface colonization of the tissue by animal- and human-derived aortic valve interstitial cells. This establishes, for the first time, the feasibility of fixative-free pericardial tissue seeding with valve competent cells for derivation of tissue engineered heart valve leaflets.

Surgical ablation of atrial fibrillation with a novel bipolar radiofrequency device.

OBJECTIVE: When used for epicardial ablation, unipolar devices do not predictably yield transmural scars. Bipolar radiofrequency proved highly effective on the animal model, but clinical experience is still initial. We describe acute electrophysiologic findings and follow-up results of epicardial ablation with a novel bipolar radiofrequency device. METHODS: A bipolar ablator was used to perform a simplified left atrial lesion set in 90 consecutive patients with atrial fibrillation undergoing open heart surgery. Pacing thresholds were assessed during surgery to validate 24 pulmonary vein encircling lines (12 patients). Follow-up was 100% complete. RESULTS: In 67 of 90 patients (84%), mitral valve disease was the main indication to surgery. Atrial fibrillation was continuous in 74 patients (82%) and intermittent in 16 patients (18%). Pacing threshold assessment showed a complete conduction block in 22 of 24 pulmonary vein couples (92%) after a single ablation and in all patients after doubling of the encircling lines. No complications related to the ablation procedure were recorded. The sinus rhythm restoration rate was 79% at 3 months, 87% at 6 months, and 89% (17/18 patients) at 1 year. Postablation organized arrhythmias consisted in right atrial flutter in 2 patients (2%) and left atrial flutter in 6 patients (7%). CONCLUSIONS: Epicardial ablation with bipolar radiofrequency grants acute transmurality. A simplified lesion set proved highly effective in eliminating atrial fibrillation at 1-year follow-up. Our data suggest that addition of a lesion to the mitral annulus is advisable to prevent left atrial flutter.