Minimally invasive extracorporeal circulation versus conventional cardiopulmonary bypass in patients undergoing cardiac surgery (MiECS): Rationale and design of a multicentre randomised trial.

INTRODUCTION: The ultimate answer to the question whether minimal invasive extracorporeal circulation (MiECC) represents the optimal perfusion technique in contemporary clinical practice remains elusive. The present study is a real-world study that focuses on specific perfusion-related clinical outcomes after cardiac surgery that could potentially be favourably affected by MiECC and thereby influence the future clinical practice. METHODS: The MiECS study is an international, multi-centre, two-arm randomized controlled trial. Patients undergoing elective or urgent coronary artery bypass grafting (CABG), aortic valve replacement (AVR) or combined procedure (CABG + AVR) using extracorporeal circulation will be randomized to MiECC or contemporary conventional cardiopulmonary bypass (cCPB). Use of optimized conventional circuits as controls is acceptable. The study design includes a range of features to prevent bias and is registered at clinicaltrials.gov (NCT05487612). RESULTS: The primary outcome is a composite of postoperative serious adverse events that could be related to perfusion technique occurring up to 30 days postoperatively. Secondary outcomes include use of blood products, ICU and hospital length of stay (30 days) as well as health-related quality of life (30 and 90 days). CONCLUSIONS: The MiECS trial has been designed to overcome perceived limitation of previous trials of MiECC. Results of the proposed study could affect current perfusion practice towards advancement of patient care.

Advancements in Donation after Circulatory Death Heart Procurement and Preservation: A Comprehensive Review of Recent Innovations.

INTRODUCTION: The persistent shortage of donor hearts for transplantation has prompted exploration into Donation after Circulatory Death (DCD) as a promising avenue for organ procurement. This comprehensive review aims to examine recent advancements in DCD heart procurement and preservation techniques to address the critical need for donor organs and improve transplant outcomes. MATERIALS AND METHODS: A systematic review was conducted to identify relevant studies and innovations related to DCD heart procurement and preservation. Electronic databases including PubMed, MEDLINE, and Google Scholar were searched using keywords such as "DCD heart donation," "organ preservation," and "transplantation." Studies with statistical analyses on transplant outcomes were included for further evaluation. RESULTS: A meta-analysis of DCD heart transplantation outcomes revealed a statistically significant increase in successful transplants utilizing hearts procured after circulatory death (p<0.05). Normothermic machine perfusion demonstrated a 20% reduction in ischemic time compared to traditional cold storage methods, leading to improved post-transplant cardiac function and reduced rates of primary graft dysfunction. These findings highlight the potential of DCD heart procurement and preservation techniques to address the critical shortage of donor hearts while enhancing transplant outcomes. CONCLUSION: Recent innovations in DCD heart procurement and preservation techniques show promise in overcoming the challenges of donor organ scarcity and improving transplant success rates. Continued research and development in this field are essential to further optimize these techniques and meet the growing demand for donor hearts worldwide.

Comparison between Track Technique and Conventional Approach for Measuring Artificial Chordae in the Treatment of Anterior Leaflet Prolapse and Flail during Mitral Valve Repair.

Background: Measuring the chordae tendineae for mitral valve reconstruction is feasible with various techniques. However, the effect of different strategies on the durability of plastics at follow-up is unknown. The study aims to compare a conventional surgical technique for measuring artificial chordae length with our new approach, defined "track technique". Methods: We compared the results of patients with anterior leaflet prolapse/flail who underwent mitral valve reconstruction by implanting artificial chordae from January 2020 to January 2022; 22 patients were operated on with a conventional technique, and 25 with our new alternative, "track technique". Clinical and transesophageal echocardiography data were collected postoperatively and at 2 years of follow-up. The primary outcome was freedom from mitral regurgitation. Secondary outcomes were presentation with New York Heart Association (NYHA) class < 2 and leaflet coaptation length ≥ 10 mm. Results: The patients of the 2 groups had comparable preoperative risk factors regarding the LogEuroSCORE (p = 0.33). Moreover, no difference was observed in terms of the mechanism of mitral valve insufficiency. No hospital or follow-up deaths were recorded for either group. At discharge, no echocardiographic differences were observed in the regarding degree of residual mitral regurgitation, but the measurement of coaptation length was in favor of the alternative group (8.6 ± 1.8 vs. 11 ± 1.4; p = 0.04). At 2 years of follow-up (25 ± 9; range 13-37), the NYHA class was not different; however, the number of patients with 1-2+ recurrent mitral regurgitation was significantly higher in the conventional group (8 vs. 4 patients; p = 0.02), and the coaptation length was in favor of the alternative group (8.8 ± 1.7 vs. 11 ± 1.7; p = 0.04). Conclusions: We devised both techniques to prove effective in achieving good valvular continence, but a significantly greater coaptation length was obtained with our track technique at the 2 years follow-up.

Minimal invasive extracorporeal circulation an alternative to ECMO in ventricular tachycardia ablation.

BACKGROUND: The advantages of mechanical assistance during ventricular tachycardia (VT) ablation have not been clinically demonstrated. We propose and discuss a technique, set up by us, that makes use of minimally invasive extra-corporeal circulation (MiECC) type III associated with a venous reservoir system, which allows complete cardiac flow support and blood oxygenation as well as hemodynamic stability during long-lasting procedures. METHODS: We present a retrospective case series of ten patients with valvular heart disease and unresponsive Ventricular Tachycardia (VT) who underwent VT ablation with MiECC support. The mean age of the patients was 72 ± 8 years and the left ventricular ejection fraction was 36 ± 12%. All patients underwent a clinical evaluation to identify the cause of VT unresponsiveness (e.g., ischemic heart disease). RESULTS: A total of 140 min, the following parameters were evaluated and recorded for 140 min. Central venous pressure (CVP) was used to evaluate excess volume. During the first 5 min, the mean was 15 mmHg, with a pump flow of 1.5 L/min and a mean systemic arterial pressure of 100 mmHg while setting up the circulation support. Following drainage in a volumetric bag of 1 L of blood, CVP was reduced to a value of 5 mmHg with a flow rate of 5 L/min and a mean systemic arterial pressure of 65 mmHg. In the case of small and low-weight patients our "1 L protocol" can be modified. CONCLUSIONS: In this preliminary retrospective case series, the MiECC type III system may represent the ideal support system during VT ablation, and further studies are needed to support this preliminary report.

'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.

2021 MiECTiS focused update on the 2016 position paper for the use of minimal invasive extracorporeal circulation in cardiac surgery.

The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care.

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.

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.

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.

Clinical Evaluation of the Eurosets Trilly Oxygenator During Cardiopulmonary Bypass in a Pediatric Population.

The equipment selected for cardiopulmonary bypass (CPB) in pediatric cardiac surgery critically influences the safety, efficiency, efficacy and pathophysiological impact in perioperative use and the post-operative outcome. In this report, we present a single-center retrospective analysis of the clinical efficacy, efficiency and safety of the Trilly oxygenator (Eurosets Srl, Medolla, MO, Italy), which has an integrated arterial filter. It has a blood flow capacity of 500 to 3500ml/min, an AAMI index of 4.000ml / min, and a static fill prime (oxygenating module + heat exchanger) of 130 ml. We used this device on 42 pediatric patients who underwent repair of various congenital heart defects with cardiopulmonary bypass. Pre- and intraoperative patient data were collected for the evaluation of gas transfer and metabolic parameters in relation to blood flow, temperature and hematologic profiles. The mean age of the patients was 8.07 ± 2.9 years. Eight patients had cyanotic heart disease, 7 had chromosomal abnormalities and 9 had previously undergone cardiac surgery. The STAT Mortality Category Score was distributed as follows: Cat. 1 (37.5%), Cat. 2 (35%), Cat. 3 (5%), Cat. 4 (22.5%), Cat. 5 (0%). The mean bodyweight was 29.03 ± 8.25 kg and the blood flow rate was 2664.88 ± 508.43 ml / min. The mean cardiopulmonary bypass time was 95±51.4 min and the cross-clamp time was 37±34.6 min. The mean gas transfer values were as follows: partial pressure of oxygen, post oxygenator, 224.7±28 mmHg; partial pressure of carbon dioxide, post oxygenator, 42±4 mmHg; oxygen delivery 356.9± 88.8 ml/min/m2; carbon dioxide transfer, 52.81± 1.98 mmHg, mixed venous saturation 77.78 %; and mean hematocrit value 29.0±4 %. The Trilly oxygenator was effective in terms of oxygen uptake, carbon dioxide removal, and heat exchange in a pediatric population undergoing cardiopulmonary bypass. This retrospective analysis showed that the Trilly is both safe and effective in clinical 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.

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.

The Evolution of Temperature Management for Cardiac Surgery: A Historical Perspective.

Intraoperative temperature regimen usually is planned preoperatively by a "team." Selecting and understanding the impact of the temperature regimen (normothermia, or mild, moderate, or severe hypothermia) usually are related to the type of cardiac surgery (eg, using circulatory arrest or open-heart surgery). Cardiopulmonary bypass constitutes a challenging situation for monitoring temperature because of the rapid and extraordinary degree of heat transferred through the bypass circuit during heating and cooling. The core compartment undergoes the fastest temperature changes because of the rapid rate of blood reinfused into the organs. In modern cardiac surgery, different types and technologies of heater-cooler devices can be used in clinical practice, thanks to the development process that took its cue from past experiences. In this context, the authors review the role of thermal exchange in cardiac surgery and the progress achieved from first-to-second-generation heater-cooler devices.

Retrograde Autologous Priming for Minimally Invasive Mitral Valve Surgery.

OBJECTIVES: Little is known about the safety and clinical utility of retrograde autologous priming (RAP) in patients undergoing minimally invasive mitral valve surgery. The study authors hypothesized that RAP would increase the oxygen delivery index (DO2i) while decreasing red blood cell transfusion requirements compared to valve surgery without RAP. DESIGN: The study was an observational analysis. SETTING: A single institutional study. PARTICIPANTS: The authors analyzed data from 500 consecutive patients who underwent minimally invasive isolated mitral valve repair from December 31, 2012, to December 31, 2019. INTERVENTION: RAP was performed in 235 patients (47%) prior to the initiation of cardiopulmonary bypass (CPB). MEASUREMENT AND MAIN RESULTS: A continuous monitoring system was used for DO2 management during CPB. The mean arterial pressure was maintained between 55 and 70 mmHg, and the cardiac index was set at 2.4 L/min/m2, with adjustments in accordance with DO2i. The trigger point for red cell blood transfusion during CPB was hemoglobin <7 g/dL. Baseline hematocrit was lower in the RAP group compared to the no-RAP group (33.4 ± 3.6 v 38.1 ± 4.9, respectively; p < 0.001). Both CPB and cross-clamp times were similar between groups. Hematocrit during CPB was significantly higher in the RAP group compared to the no-RAP group (27.6 ± 2.6 v 25.9 ± 5.1, respectively; p < 0.001). RAP was also associated with significantly higher mean DO2i (292 ± 19.5 v 282.9 ± 35.1 mL/min/m2, respectively; p < 0.001) and fewer red blood cells transfusions during the intraoperative and immediate postoperative periods (p < 0.001). CONCLUSIONS: In a minimally invasive mitral valve context, RAP was safe and associated with better DO2i, higher hematocrit, and fewer intraoperative and postoperative red blood cell transfusions.

Minimally invasive mitral valve reconstruction: Is it an "all-comers" procedure?

BACKGROUND AND AIM OF THE STUDY: The debate on the usefulness of the minimally invasive approach in mitral valve surgery is still open. The aim of this study is to describe a single-center case series of all comers undergoing minimally invasive mitral valve reconstruction. METHODS: From 2010 to 2019, all the data recorded in the medical records of 893 consecutive patients undergoing mitral valve reconstruction through a right mini-thoracotomy were retrospectively collected. All patients were contacted by telephone for remote evaluation and integration of echocardiographic information on surgical results. RESULTS: Mean age was 62.2 ± 14.5; 447 (50%) were female and mean log EuroSCORE was 2.5 ± 2.8%. At a mean follow-up of 4.1 ± 2.2 years (median 3.9), a total of 24 deaths (2.68%) were recorded. Twenty-four patients required rehospitalization for cardiac causes, 13 (1.4%) patients had at least moderate mitral insufficiency on follow-up echocardiography and, of these, seven patients underwent reoperation (0.8%). The cumulative hazard showed that 8.3% of patients experienced at least one event at 5 years. NYHA class improved significantly with 874 patients in NYHA class I, 13 in NYHA class II, 6 in NYHA class III, and 0 in NYHA class IV at last follow-up (p < .001 from baseline as reference point). CONCLUSIONS: In a high-volume center, mitral valve surgery using a minimally invasive approach is a feasible treatment option for all-comers and is associated with excellent results that are maintained at clinical and echocardiographic follow-up.

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.

Management algorithms and artificial intelligence systems for cardiopulmonary bypass.

This article introduces management algorithms to support operators in choosing the best strategy for metabolic management during cardiopulmonary bypass using artificial intelligence systems. We developed algorithms for the identification of the optimal way for assessing metabolic parameters. Different management algorithms for extracorporeal procedures interfaced with metabolic monitoring systems already exist on the market and are applied in clinical practice. These algorithms could provide guidance for selecting the best metabolic strategy with the aim at reducing human error and optimizing management.

A modified technique for aortic prosthesis implantation after prosthetic valve endocarditis complicated by complex paraannular aortic abscess.

The aim of this study is to describe a modified technique for aortic prosthesis implantation in the sinuses of Valsalva without the use of a patch for aortic annular reconstruction in patients with prosthetic valve endocarditis complicated by aortic abscess. From January 2008 to March 2021, 47 patients underwent aortic valve replacement due to prosthetic aortic valve endocarditis. The new aortic prosthesis was implanted into the sinuses of Valsalva above the abscess left open to drain. The first step consists in passing U-shaped stitches with pledgets through the aortic wall approximately 5-7 mm above the abscess involving the annulus. In the second step, the prosthesis is fixed to the aortic wall. In the third step, a 10 mm wide Teflon strip is positioned along the external course of the aortic wall and U-shaped stitches without pledgets are passed from the outside to the inside to definitively fix the prosthetic annulus to the sinuses of Valsalva. In-hospital mortality was 8.5% (4/47 patients). Mean follow-up was 62 ± 37.7 months. Four patients died (9.3%). Predicted probability of cardiac vs non-cardiac mortality was not statistically significant (p = 0.88). Overall survival probability (freedom from all-cause death) at 3, 7 and 9 years was 97%, 87.5% and 75%, respectively. No patients presented with grade 2 or 3 peri-prosthetic leak, nor had endocarditis. Prosthetic valve endocarditis complicated by complex paraannular aortic abscess can be successfully addressed with good long-term results by using our alternative technique.

Air, inflammation and biocompatibility of the extracorporeal circuits.

The inflammatory response in cardiac surgery using extracorporeal circulation (ECC) has been widely discussed in the literature with analysis on cytokines released in humans; demonstrating manifold trigger causes. To mitigate this response-mainly linked to the contact and recognition by the blood of a "non-self" surface-many efforts have been made to make the circuits of the extra-corporeal circulation "biomimetics"; trying to emulate the cardio-vascular system. In other words, biomedical companies have developed many biocompatible products in order to reduce the invasiveness of the ECC. One of the techniques used to reduce the contact of blood with "nonself" surfaces is the "coating" of the internal surfaces of the ECC. This can be done with phospholipidic, electrically neutral, and heparin derivates with anticoagulant activity. The coating can be divided into two categories: the "passive coating" with Phosphorylcholine by biomedical companies and the administration of albumin added to the "priming" during the filling of the circuit by the perfusionist. Alternatively, we have the "active" coating: treatment of the internal surfaces in contact with the blood with neutral proteins and heparin. The latter are different according to the production company, but the aim is always to maintain high levels of systemic and local anticoagulation, inactivating the "contact" coagulation between the blood and the surfaces. A recent study demonstrates that the use of an "active coating" is associated with better preservation of the endothelial glycocalyx compared with "passive coating" circuits.

Water condensation from gas outlet of oxygenator.

Condensation and water loss from gas output of the cardiopulmonary bypass (CPB) oxygenator has been the study object of several research. However, little is known about the propagation of the condensation formed at the level of oxygenator and how potentially it can contaminate the surrounding environment. We aimed to document the moment of formation of the 'gas steam' derived from the CPB oxygenator during cardiac surgery with thermography imaging. Thermographic camera is a device that creates an image using infrared radiation, similar to a common camera that forms an image using visible light. The brightest (warmest) parts of the image are customarily colored white, the intermediate temperatures reds and yellows, and the dimmest (coolest) parts black. Thermal image captures the condensation phenomenon around the oxygenator perimeter with the same color/temperature code (yellow) of gas outlet. The use of aspiration at the level of the gas outlet could also favor the elimination of the condensation, improve gas exchanges, and potentially reduce the spread of hazardous substances in the operating room.