Multifocal, biatrial, primary cardiac embryonal rhabdomyosarcoma.

Malignant primary cardiac tumors are rare, with atrial myxoma and rhabdomyosarcoma the common types in adult and pediatric populations respectively. Rhabdomyosarcomas are rare and are usually located in the atria; they present with symptomatology dependent on their location. A 63-year-old woman presented with the symptomatology of dyspnea, cough, and palpitations and was diagnosed with biatrial primary cardiac rhabdomyosarcoma, which required excision. The postoperative course was uneventful and the patient was discharged on the 5th postoperative day. Postoperative cardiac functional tests revealed an ejection fraction of 60%, consistent with the preoperative value, and no mitral valve dysfunction. Biatrial rhabdomyosarcomas are extremely rare, with only 3 cases reported, including ours, reported in the literature, to the best of our knowledge. Transthoracic echocardiogram is useful in the diagnosis. They require surgical excision along with chemotherapy or radiotherapy. Their prognosis is poor, with a median survival of almost one year. Primary biatrial rhabdomyosarcoma is an extremely rare diagnosis that can present with symptomatology based on the location, size, and number of masses. There is no consensus on how to manage them due to the scarcity of cases, but they are managed as single rhabdomyosarcomas. The majority require surgical excision, with subsequent chemotherapy or radiotherapy. The prognosis is very poor, with the majority of the patients not surviving longer than one year.

A morphofunctional analysis of the regurgitant mitral valve as a guide to repair: Another point of view.

Based on Carpentier's classification and principles, the techniques for mitral valve repair continue to evolve. We herein report our experience with the morphofunctional echocardiographic analysis of single mitral leaflets, as different anatomic features, even if conflicting, may coexist not only in the two leaflets but in the same leaflet as well. A classification is proposed, based on the length (normal, short, or long) and mobility (normal, restricted, or excessive) of mitral leaflets. The surgical techniques adopted for mitral valve repair are the direct consequence of this analysis.

Wrapping of the moderately dilated ascending aorta by fresh autologous pericardium.

BACKGROUND AND AIM OF THE STUDY: Wrapping of the ascending aorta (AA), isolated or associated with aortoplasty, has never been completely accepted. Some complications, as folding of the aortic wall, compression of the vasa vasorum and changes in the flow pattern, with consequent dilatation of the proximal arch, have been described. We used fresh autologous pericardium (FAP), so far never reported, to wrap the AA, with the aim to stabilize its size when moderately dilated, maintaining the preoperative dimension or limiting the reduction to a few millimeters. MATERIALS AND METHODS: From 2015 to 2019, 10 patients, who were operated on for valve or coronary surgery or both, underwent wrapping of the AA with FAP. Mean age was 69 ± 7 years and EuroSCORE II 3.5 ± 1.7. Four patients had moderately impaired ejection fraction (35%-49%). RESULTS: There was no early or late mortality. One patient was reoperated on after 48 months for severe mitral regurgitation. At a follow-up of 53 ± 14 months, a transthoracic echocardiogram showed that the AA size reduced slightly but significantly, from 45.2 ± 2.0 to 42.5 ± 4.1 mm, p = .03. The diameter of the proximal arch remained unchanged, from 37.1 ± 1.6 to 36.3 ± 2.9 mm, p = .20. CONCLUSIONS: In the presence of moderately dilated AA, wrapping can be a reasonable option. The use of FAP stabilizes the size of the aorta after a follow-up of 53 months. Maintaining a size similar to the preoperative one avoids the complications related to the procedure.

Cutting the second order chords during mitral valve repair.

The chordae tendinae connect the papillary muscles (PMs) to the mitral valve. While the first-order chordae serve to secure the leaflets to maintain valve closure and prevent mitral valve prolapse, the second-order chordae are believed to play a role in maintaining normal left ventricle size and geometry. The PMs, from where the chordae tendinae originate, function as shock absorbers that compensate for the geometric changes of the left ventricular wall. The second-order chordae connect the PMs to both trigons under tension. The tension distributed towards the second-order chordae has been demonstrate to be more than threefold that in their first-order counterpart. Cutting the second-order chordae puts all the tension on the first-order chordae, which are then closer to their rupture point. However, it has been experimentally demonstrated that the tension at which the first-order chordae break is 6.8 newtons (N), by far higher than the maximal tension reached, that is 0.4 N. Even if the clinical reports have been favorable, the importance of cutting the second-order chordae to recover curvature of the anterior leaflet and increase the coaptation length between the mitral valve leaflets has been slowly absorbed by the surgical world. Nevertheless, there are progressive demonstrations that chordal tethering affects the anterior leaflet not only in secondary, but also in primary mitral regurgitation, having a not negligible role in the long-term outcome of mitral repair.

A historical appraisal of the techniques of left ventricular volume reduction in ischemic cardiomyopathy: Who did what?

Resection or exclusion of scars following a myocardial infarction on the left anterior descending artery territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a "revisitation" of what described before. In some case, old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world.

Left ventricular surgical remodeling 2.0.

Left ventricular surgical remodeling has been, for a long time, the procedure applied for large dyskinetic, or akinetic, areas as a consequence of a myocardial infarction, mainly located in the left anterior descending area. Many surgical techniques were developed, aimed to a pure reduction of the volume of the left ventricular (LV) cavity or to add to volume reduction a more physiologic conical shape. The expansion of interventional procedures invaded most of the fields before treated only by cardiac surgeons. In this issue, Pillay describes a hybrid technique, involving both interventional cardiologists and cardiac surgeons, aimed to LV volume reduction after an anterior myocardial infarction. A series of internal (right ventricular septum) and external (anterior wall) anchors are implanted to approximate the LV free wall to the anterior septum, consequently excluding the scarred myocardium. Although some limitations of this study, the authors have to be commended for having revitalized a procedure almost eliminated from the surgical scenario.

The secret life of the mitral valve.

In secondary mitral regurgitation, the concept that the mitral valve (MV) is an innocent bystander, has been challenged by many studies in the last decades. The MV is a living structure with intrinsic plasticity that reacts to changes in stretch or in mechanical stress activating biohumoral mechanisms that have, as purpose, the adaptation of the valve to the new environment. If the adaptation is balanced, the leaflets increase both surface and length and the chordae tendineae lengthen: the result is a valve with different characteristics, but able to avoid or to limit the regurgitation. However, if the adaptation is unbalanced, the leaflets and the chords do not change their size, but become stiffer and rigid, with moderate or severe regurgitation. These changes are mediated mainly by a cytokine, the transforming growth factor-ß (TGF-ß), which is able to promote the changes that the MV needs to adapt to a new hemodynamic environment. In general, mild TGF-ß activation facilitates leaflet growth, excessive TGF-ß activation, as after myocardial infarction, results in profibrotic changes in the leaflets, with increased thickness and stiffness. The MV is then a plastic organism, that reacts to the external stimuli, trying to maintain its physiologic integrity. This review has the goal to unveil the secret life of the MV, to understand which stimuli can trigger its plasticity, and to explain why the equation "large heart = moderate/severe mitral regurgitation" and "small heart = no/mild mitral regurgitation" does not work into the clinical practice.

An observational, prospective study on surgical treatment of secondary mitral regurgitation: The SMR study. Rationale, purposes, and protocol.

The natural history of secondary mitral regurgitation (MR) is unfavorable. Nevertheless, there are no evidence that its correction can improve the outcome. If from one side the original cause of secondary MR can be such to limit the possibilities of improvement, from the other side it is possible that the surgical technique widely applied to repair, restrictive mitral annuloplasty, is not adequate to correct the regurgitation. The addition of valvular and/or subvalvular techniques has been considered a possible technical solution. However, we do not know the prevalence of each technique, how many times mitral replacement is used to correct secondary MR. This aspect is of particular importance, as we know that a successful mitral repair causes a better left ventricular systolic remodeling than a unsuccessful repair or replacement. This study is a prospective, observational registry, conceived to understand what is done in the real world. Any surgeon will use the technique he thinks the most suitable for the patient. Every year, for 5 years, patients will have a clinical and echocardiographic follow-up, to evaluate the risk factors for a worse result (death, rehospitalization for heart failure, reoperation for MR return, moderate, or more MR return). This knowledge will give us the possibility to understand which is the technique, or the strategy, more efficient to treat this disease and the real efficacy of the surgical treatment.

Interrupted inferior vena cava draining into the coronary sinus associated with circumflex artery to coronary sinus fistula.

In an adult patient, coronary artery fistula involving the circumflex artery (CX) connected to the coronary sinus caused aneurysm of the left main and CX associated with ectasia of the intermediate branch. The patient had posterolateral infarction with severe ischemic mitral regurgitation and moderate tricuspid regurgitation. A rare venous return anomaly was also present. The inferior vena cava, which was interrupted at the level of the liver, continued with the hemiazygos to drain into a persistent left superior vena cava, which in turn drained into the coronary sinus. Surgery included CX closure and mitral and tricuspid repair. The strategy had to be adapted to the anatomy. The fistula was dissected and snared for cardioplegia delivery, and venous return was achieved by cannulation of the superior vena cava and femoral vein. The procedure was uneventful, and 4 years later the patient is asymptomatic.

Saphenous vein to the right coronary system from the right thoracic artery or the aorta. Long-term propensity-matched results of 2 groups.

OBJECTIVES: Since 2000, we anastomosed the saphenous vein graft to the right coronary artery system using the stump of the right internal thoracic artery as inflow. The long-term results of patients where the right coronary artery was grafted with the right internal thoracic artery or the ascending aorta as saphenous vein inflow has not been reported. METHODS: From 2000 to 2018, 699 consecutive patients had right internal thoracic artery elongated with saphenous vein (I-graft group, n = 358, 51.2%) or saphenous vein from the aorta (Ao-graft group, n = 341, 48.8%) on right coronary artery system. Inclusion criteria were age ≤75 years, bilateral internal thoracic arteries as a Y graft on the left system (three-vessel disease, n = 603, 86.3%) or as a left internal thoracic artery on left anterior descending and right internal thoracic artery elongated with saphenous vein on the right coronary artery system (two-vessel disease, n = 96, 13.7%), only 1 saphenous vein per patient. Propensity-matching identified 272 patients per group. One-hundred and twenty-two patients underwent coronary computed tomographic angiography to asses grafts patency after a median follow-up of 88 (65-93) months. RESULTS: In the paired samples, there was no difference in the early outcome. Ten-year survival and freedom from death, non-fatal acute myocardial infarction and repeat revascularization were higher in I-graft group: 90.6 [standard error (SE): 2.0] vs 78.2 (SE: 5.3), P = 0.0266, and 85.2 (SE: 2.4) vs 69.9 (SE: 5.3), P = 0.0179. Saphenous vein graft, at a long-time follow-up, showed a higher patency rate (81.6% (SE: 7.0) vs 50.7% (SE: 7.9), P < 0.0001) and a smaller internal lumen diameter (2.7, standard deviation: 0.4 vs 3.4, standard deviation: 0.6 mm, P < 0.0001) when right internal thoracic artery was the inflow. CONCLUSIONS: Grafting the right coronary artery with saphenous vein may entail higher patency rate and better outcome when the inflow is the right internal thoracic artery than when is the ascending aorta. Prospective randomized data are needed to test this hypothesis.

Controversy. On pump or off pump: what will I do when I grow up? A narrative systematic review.

The transition from the second to the third millennium happened to be a turning point in the history of myocardial revascularization on a beating heart, which moved from technical development to critical evaluation. This article describes how the initial acceptance and spread of off-pump coronary artery bypass grafting (OPCABG) was followed by the general perception that the technique could not fulfill the expectations placed in it and provides some insight on what should we do with the know-how of OPCABG in the present and the future of coronary surgical revascularization.

Alterations in biomarkers of endothelial function following on-pump coronary artery revascularization.

BACKGROUND: Cardiopulmonary bypass (CPB) has been associated with activation and injury of endothelial cells, probably responsible for the systemic inflammatory response syndrome (SIRS) taking place in these patients. METHODS: We measured plasma concentrations of soluble P-selectin (sP-s), E-selectin (sE-s), tetranectin (TN), vonWillebrand factor (vWF) levels, and angiotensin-converting enzyme (ACE) activity in 31 adult patients undergoing elective coronary artery bypass grafting, just before and up to three days after surgery, and in 25 healthy volunteers. RESULTS: Patients showed higher plasma sP-s and sE-s and ACE concentrations, just before surgery, but significantly lower TN levels, compared with controls. During the first three postoperative days (PD), the concentration of each of the molecules followed a different and independent pattern, although in the third PD, the levels of sP-s, sE-s and ACE were higher and those of vWF and TN lower, compared with the preoperative ones. However, patients had higher sP-s (P=0.06), sE-s (P=0.07), and vWF (P=0.005), but lower TN concentrations (P=0.02) on the third PD compared with controls. CONCLUSIONS: CPB is characterised by pronounced changes in plasma sP-s, sE-s, TN, vWF levels, and ACE activity, which are associated with significant alteration in the intra- and early postoperative endothelial function observed in open heart surgery.

Xiphoid lower-sternotomy approach for multivessel revascularization of the left internal mammary artery to the left anterior descending artery and right internal mammary artery inflow to the other vessels.

BACKGROUND: We describe the technical details and the preliminary results of a new surgical approach for multivessel disease that involves using a lower T sternotomy, grafting of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) and use of the right internal mammary artery (RIMA) as inflow to the other vessels. OPERATIVE TECHNIQUE: The sternotomy was made from the xiphoid up to the fourth intercostal space and then was continued transversally (T incision). The LIMA was harvested for a length of approximately 8 cm, with preservation of the distal part. The vein was simultaneously taken from the leg. The RIMA was dissected for a length of approximately 5 cm, and the distal part was occluded. Then, 3 mg/kg heparin was given. The anastomosis between the vein and the RIMA was performed. The distal venous anastomoses were done either singly or sequentially. The anterior or posterior route was chosen according to the patient's anatomy. The LIMA was then anastomosed to the LAD. One drain was placed. The sternum was closed with 4 wires, 2 for the T incision and 2 for the sternum. RESULTS: Between September and December 2008, 9 patients underwent their operations with this technique. The mean age was 60 years (range, 55-68 years). The mean number of grafts was 2.8. The mean hospital stay was 5.2 days. Operative mortality was 0%. All patients were reevaluated with 16-slice multislice computed tomography, and all grafts were patent. At the 3-month follow-up, all patients were alive and free of symptoms. CONCLUSION: This minimally invasive technique is a useful alternative for complete revascularization. The sternal mammary supply and the upper part of the sternum are preserved.

Female risk using OPCAB, pi-circuit, and aorta no-touch coronary revascularization.

BACKGROUND: In this study, we evaluated female sex as a risk factor in the off-pump coronary artery bypass (OPCAB), aorta no-touch technique. MATERIALS AND METHODS: From February 2001 to November 2005, 1359 patients in our institution underwent isolated coronary revascularization with the pi-circuit technique, which consists of (1) beating heart surgery, (2) OPCAB, (3) no touching of the aorta, (4) use of composite grafts, and (5) arterial revascularization. There were 1159 men (group A) and 200 women (group B). Both groups were compared with respect to preoperative risk factors, intraoperative parameters, and postoperative morbidity and mortality. Follow-up lasted from 4 to 60 months. Data were analyzed with the chi(2) test, the Fisher exact test, the Kaplan-Meier method, and the Cox model of regression analysis. RESULTS: Female patients were older (P < .0005) and had higher prevalences of obesity (P < .0005), arterial hypertension (P < .0005), and diabetes (P < .0005). Emergency operations were also more frequent in this group (P < .027). There was no difference between the groups in the preoperative use of an intra-aortic balloon pump (IABP). The 2 groups were not significantly different with respect to 30-day mortality (1.1% versus 4%) or 7-day mortality (0.3% versus 0%). The 2 groups had comparable rates of IABP use postoperatively. Cognitive disturbances and strokes were rarely encountered (0.6% in men and 0.2% in women). In the early postoperative phase, women had more pulmonary complications (P < .014), and survival seemed to favor the male group during the follow-up period (P < .001). Further analysis with the Cox regression model with exclusion of confounding preoperative morbidity factors (more prevalent in group B) showed that the 2 groups had similar survival rates. As a group, women were 1.06 times more likely to die from a cardiac cause than men (P < .897). CONCLUSIONS: The use of the pi-circuit, aorta no-touch technique is equally effective and safe for both sexes. Women are more prone to pulmonary complications in the early postoperative phase. The apparent difference in survival favoring men can be attributed to the higher prevalence of preoperative risk factors in women. In general, we consider the off-pump, aorta no-touch technique an effective method for lowering morbidity and mortality in the relatively high-risk female patient group.

Aorta no-touch off-pump coronary artery revascularization in octogenarians: 5 years' experience.

BACKGROUND: Approximately 18% of octogenarians have ischemic heart disease. Increasingly, they are being referred for coronary artery revascularization by surgical and/or percutaneous procedures. These strategies have been questioned, however, because of reports of poor outcomes in the elderly. In this study, we aimed to determine the impact of age on morbidity and mortality in patients undergoing off-pump coronary artery bypass (OPCAB) with the pi-circuit procedure during 5 years of follow-up. MATERIALS AND METHODS: From February 2001 to November 2005, 1359 patients underwent isolated coronary revascularization with the pi-circuit technique, which consists of (1) beating heart surgery, (2) OPCAB, (3) no touching of the aorta, (4) use of composite grafts, and (5) arterial revascularization. Sixty-two patients were > or = 80 years of age (group A), and 1297 were <80 years old (group B). Both groups were compared with respect to preoperative risk factors, intraoperative parameters, and postoperative morbidity and mortality. Follow-up lasted from 4 to 60 months. Data were analyzed with the chi(2) test, the Fisher exact test, the Kaplan-Meier method, and the Cox model of regression analysis. RESULTS: Females predominated among the octogenarians (P < .0005). Octogenarians more frequently underwent emergent operations (P < .031) and had worse ejection fractions (P < .026). Obesity was also less prevalent among these patients (P < .007). There were no differences between the groups in the preoperative and postoperative use of an intraaortic balloon pump. Octogenarians had lower cholesterol levels (P < .0005) and had fewer distal anastomoses (2.24 + or - 0.0.76 versus 2.77 + or - 0.92, P < .0005). The 2 groups were not significantly different with respect to 30-day mortality (3.2% versus 1.5%) and 7-day mortality (1.6% versus 0.2%). Differences were noted in the incidences of pulmonary complications (12.9% versus 5.6%, P < .027), atrial fibrillation (41.9% versus 19%, P < .0005), and cognitive disturbances (6.5% versus 0.3%, P < .0005). During follow-up, survival seemed to favor the younger group (P < .001). Nevertheless, further analysis of the data with the Cox regression model to exclude confounding risk factors, revealed the survival rates of the 2 groups to be similar. CONCLUSIONS: Use of the pi-circuit technique is very effective for octogenarians. Although these older patients have a higher incidence of early postoperative morbidity, overall survival is not affected.

The π-Circuit Technique in Coronary Surgery: Analysis of 1359 Consecutive Cases.

Coronary artery bypass surgery still has its unique role in the treatment of coronary artery disease. It faces, however, the continuous challenge of becoming even less invasive and more effective as cases become more complex. We here present the results of 1359 cases treated with the π-circuit technique which consists of an off-pump total myocardial revascularization using composite arterial grafts. The results demonstrate that it is a safe technique providing low mortality, stroke, renal failure, wound infection, and other complication rates. We suggest the application of this technique, as well as of other similar techniques regarding similar principles, especially in high-risk patients.

Anaortic coronary surgery using the Π-circuit is associated with a low incidence of perioperative neurological complications.

OBJECTIVES: Our goal was to compare the observed and the expected rates of postoperative cerebrovascular accidents (CVA) in a large cohort of consecutive patients undergoing off-pump coronary artery bypass grafting (CABG) using the ∏-circuit as a no-touch technique. METHODS: From January 2001 to May 2016, 3081 patients were consecutively submitted to an off-pump CABG operation using the ∏-circuit. A CVA was defined as a neurological deficit, lasting less (transient ischaemic attack) or more (stroke) than 24 h, diagnosed by a neurologist and confirmed by a computed tomography or magnetic resonance imaging scan of the brain. The primary end point was to compare the observed and the expected rates of CVAs; the latter was obtained using the Society of Thoracic Surgeons' calculator. The secondary end point was to compare the observed and the expected mortality rates using the Society of Thoracic Surgeons' calculator and the prevalence of postoperative complications. Moreover, we identified some subgroups at higher risk. RESULTS: The postoperative rate of CVAs was 0.5% (14 cases): 2 (0.1%) were transient ischaemic attacks and 12 (0.4%) were strokes. The mean expected CVA rate (1.6%) was significantly higher than the observed rate (P < 0.001). None of patients who experienced postoperative CVAs died. The observed mortality was 1.3% (40 patients) vs the expected mortality (2.6%), which was significantly higher (P < 0.001). Multivariable analysis identified age >70 years old, diabetes, extracardiac vasculopathy and chronic renal failure as risk factors for postoperative CVAs. However, in all the subgroups of risk, except for those with chronic renal failure, the use of the ∏-circuit was associated with a low rate of CVAs. CONCLUSIONS: The ∏-circuit should be included as a possible choice among no-touch techniques. The observed rate of CVAs of 75% is lower than the expected rate.