The Use of Intraoperative Transit Time Flow Measurement for Coronary Artery Bypass Surgery: Systematic Review of the Evidence and Expert Opinion Statements.

Transit time flow measurement (TTFM) allows quality control in coronary artery bypass grafting but remains largely underused, probably because of limited information and the lack of standardization. We performed a systematic review of the evidence on TTFM and other methods for quality control in coronary artery bypass grafting following PRISMA standards and elaborated expert recommendations by using a structured process. A panel of 19 experts took part in the consensus process using a 3-step modified Delphi method that consisted of 2 rounds of electronic voting and a final face-to-face virtual meeting. Eighty percent agreement was required for acceptance of the statements. A 2-level scale (strong, moderate) was used to grade the statements based on the perceived likelihood of a clinical benefit. The existing evidence supports an association between TTFM readings and graft patency and postoperative clinical outcomes, although there is high methodological heterogeneity among the published series. The evidence is more robust for arterial, rather than venous, grafts and for grafts to the left anterior descending artery. Although TTFM use increases the duration and the cost of surgery, there are no data to quantify this effect. Based on the systematic review, 10 expert statements for TTFM use in clinical practice were formulated. Six were approved at the first round of voting, 3 at the second round, and 1 at the virtual meeting. In conclusion, although TTFM use may increase the costs and duration of the procedure and requires a learning curve, its cost/benefit ratio seems largely favorable, in view of the potential clinical consequences of graft dysfunction. These consensus statements will help to standardize the use of TTFM in clinical practice and provide guidance in clinical decision-making.

From bench to bedside: Impact of left ventricular assist device outflow conduit anastomosis position on outcome.

Continuous flow left ventricular assist devices (LVADs) have become a valuable therapy for end-stage heart failure. In vitro research highlighted a role of outflow cannula position on the pattern of blood flow in the aorta. However, the clinical effects of the alterations of flow remain unclear. We investigate short- and long-term outcomes of patients implanted with Jarvik 2000 LVAD, according to the ascending (Group 1) versus descending (Group 2) outflow graft connection to the aorta in a multicenter study. From May 2008 to October 2014, 140 consecutive end-stage heart failure patients underwent Jarvik 2000 LVAD implantation in 17 Italian centers. According with a preliminary multivariate analysis, we selected the 90 patients implanted in the four high-volume centers to avoid bias (Group 1 n = 39, Group 2 n = 51). Among the groups, no differences were recorded in the hospital mortality and the main complications occurring after LVAD implantation were similar. In multivariable analysis, the ascending aorta outflow cannula position and higher creatinine at discharge were significant predictors for long-term survival. Postimplant hemolysis was more pronounced in descending aorta outflow graft anastomosis. Outflow graft anastomosis to the ascending aorta is associated with better long-term survival, independent of age and perfusion techniques, reflecting the previous in vitro results.

Mechanisms, Consequences, and Prevention of Coronary Graft Failure.

Graft failure occurs in a sizeable proportion of coronary artery bypass conduits. We herein review relevant current evidence to give an overview of the incidence, pathophysiology, and clinical consequences of this multifactorial phenomenon. Thrombosis, endothelial dysfunction, vasospasm, and oxidative stress are different mechanisms associated with graft failure. Intrinsic morphological and functional features of the bypass conduits play a role in determining failure. Similarly, characteristics of the target coronary vessel, such as the severity of stenosis, the diameter, the extent of atherosclerotic burden, and previous endovascular interventions, are important determinants of graft outcome and must be taken into consideration at the time of surgery. Technical factors, such as the method used to harvest the conduits, the vasodilatory protocol, the storage solution, and the anastomotic technique, also play a major role in determining graft success. Furthermore, systemic atherosclerotic risk factors, such as age, sex, diabetes mellitus, hypertension, and dyslipidemia, have been variably associated with graft failure. The failure of a coronary graft is not always correlated with adverse clinical events, which vary according to the type, location, and reason for failed graft. Intraoperative flow verification and secondary prevention using antiplatelet and lipid-lowering agents can help reducing the incidence of graft failure.

Grading of aortic stenosis severity: a head-to-head comparison between cardiac magnetic resonance imaging and echocardiography.

AIM: To prospectively evaluate the accuracy of cardiac magnetic resonance (cMR) imaging for the assessment of aortic valve effective orifice area (EOA) by continuity equation and anatomical aortic valve area (AVA) by direct planimetry, as compared with transthoracic (TTE) and transesophageal (TEE) two-dimensional (2D) echocardiography, respectively. METHODS AND RESULTS: A total of 31 patients (21 men, 10 women, mean age 69 ± 10 years) with moderate-to-severe aortic stenosis (AS) diagnosed by TTE and scheduled for elective aortic valve replacement, underwent both cMR and TEE. AVA by cMR was obtained from balanced steady-state free-precession cine-images. EOA was computed from phase-contrast MR flow analysis. AVA at cMR (0.93 ± 0.42 cm2) was highly correlated with TEE-derived planimetry (0.92 ± 0.32 cm2) (concordance correlation coefficient, CCC = 0.85). By excluding 11 patients with extensively thickened and heavily calcified cusps, the CCC increased to 0.93. EOA at cMR (0.86 ± 0.30 cm2) showed a strong correlation with TTE-derived EOA (0.78 ± 0.25 cm2) (CCC = 0.82). CONCLUSIONS: cMR imaging is an accurate alternative for the grading of AS severity. Its use may be recommended especially in patients with poor transthoracic acoustic windows and/or in case of discordance between 2D echocardiographic parameters.

Stroke after Cardiac Surgery: A Risk Factor Analysis of 580,117 Patients from UK National Adult Cardiac Surgical Audit Cohort.

Cerebrovascular accident is the most ominous complication observed after cardiac surgery, carrying an increased risk of morbidity and mortality. Analysis of the problem shows its multidimensional nature. In this study, we aimed to identify major determinants among classic variables, either demographic, clinical or type of surgical procedure, based on the analysis of a large dataset of 580,117 patients from the UK National Adult Cardiac Surgical Audit (NACSA). For this purpose, univariate and multivariate logistic regression models were utilized to determine associations between predictors and dependent variable (Stroke after cardiac surgery). Odds ratios (ORs) and 95% confidence intervals (CIs) were constructed for each independent variable. Statistical analysis allows us to confirm with greater certainty the predictive value of some variables such as age, gender, diabetes mellitus (diabetes treated with insulin OR = 1.37, 95%CI = 1.23-1.53), and systemic arterial hypertension (OR = 1.11, 95%CI = 1.05-1.16);, to emphasize the role of preoperative atrial fibrillation (OR = 1.10, 95%CI = 1.03-1.16) extracardiac arteriopathy (OR = 1.70, 95%CI = 1.58-1.82), and previous cerebral vascular accident (OR 1.71, 95%CI = 1.6-1.9), and to reappraise others like smoking status (crude OR = 1.00, 95%CI = 0.93-1.07 for current smokers) or BMI (OR = 0.98, 95%CI = 0.97-0.98). This could allow for better preoperative risk stratification. In addition, identifying those surgical procedures (for example thoracic aortic surgery associated with a crude OR of 3.72 and 95%CI = 3.53-3.93) burdened by a high risk of neurological complications may help broaden the field of preventive and protective techniques.

Minimally Invasive Strategy to Repair Mitral Valve after Repeated Coronary Revascularization: A Case Report and Literature Review.

Redo cardiac surgery after Coronary Artery Bypass Grafting (CABG) is burdened by high morbidity and mortality, either intraoperatively and postoperatively, with the repeated sternotomy playing a crucial role as risk factor. The right minithoracotomy approach guarantees a safer control on conduits integrity and the right ventricular wall and a low impact on the respiratory mechanics. Herein, we report a patient who previously underwent two CABG (coronary artery bypass grafting) procedures and who was admitted to the hospital with a picture of heart failure caused by a severe mitral regurgitation. He was successfully submitted to a mitral valve repair on a beating heart via the right minithoracotomy approach.

Graft flow evaluation with intraoperative transit-time flow measurement in off-pump versus on-pump coronary artery bypass grafting.

Objective: We aimed to compare transit-time flow measurement (TTFM) parameters for on-pump (ONCAB) and off-pump (OPCAB) coronary artery bypass procedures. Methods: The database of the Registry for Quality AssESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery (REQUEST) study was retrospectively reviewed. Only single grafts were included (ie, no sequential or Y/T grafts). Primary end points were mean graft flow (MGF), pulsatility index (PI), diastolic fraction (DF), and backflow (BF). Unadjusted and propensity score-matching comparisons were performed. Results: Of 1016 patients in the REQUEST registry, 846 had at least 1 graft for which TTFM was performed. Of these, 512 patients (60.6%) underwent ONCAB and 334 (39.4%) OPCAB procedures. Mean arterial pressure (MAP) during measurements was higher in the OPCAB group. After propensity score-matching, 312 well balanced pairs were left. In these matched patients, MGF was higher for the ONCAB versus the OPCAB group (32 vs 28 mL/min, respectively, for all grafts [P < .001]; 30 vs 27 mL/min for arterial grafts [P = .002]; and 35 vs 31 mL/min for venous grafts [P = .006], respectively). PI was lower in the ONCAB group (2.1 vs 2.3, for all grafts; P < .001). Diastolic fraction was slightly lower in the ONCAB group (65% vs 67.5%; P < .001). The backflow was also lower in the ONCAB group (0.6 vs 1.3; P < .001) with trends similar to MGF and PI for venous and arterial grafts. There were 21 (3.3%) revisions in the OPCAB group and 14 (2.1%) in the ONCAB group (P = .198). Conclusions: ONCAB surgery was associated with higher MGF and lower PI values, especially in venous grafts. Different TTFM cutoff values for ONCAB versus OPCAB surgery might be considered.

Intraoperative transit-time flow measurement and high-frequency ultrasound assessment in coronary artery bypass grafting.

OBJECTIVES: We evaluated the influence of transit-time flow measurement with epicardial and epiaortic high-frequency ultrasound in patients undergoing coronary artery bypass grafting procedure. METHODS: The Registry for Quality Assessment with Ultrasound Imaging and Transit-time Flow Measurement in Cardiac Bypass Surgery study is a multicenter, prospective study among 7 international centers performing coronary artery bypass grafting procedures. The primary end point was any change in the planned surgical procedure. Major secondary end points consisted of the rate and reason for surgical changes related to the aorta, in situ conduits, coronary targets, and completed grafts, and the rate of in-hospital mortality and major morbidity. RESULTS: Between April 2015 and December 2017, 1046 patients were enrolled. Of those, 1016 were included in the final analyses. Mean age was 65.9 years, 14.0% were women, and diabetes was present in 39.6%. Off-pump procedures were performed in 39.6% and bilateral internal thoracic arteries in 30.5%. The primary end point occurred in 25.2% of patients (n = 256) and in 77% (197 out of 256) this was based on transit-time flow measurement and/or high-frequency ultrasound. Surgical changes were related to the aorta in 9.9%, to in situ conduits in 2.7%, and the coronary targets in 22.6%. Graft revision occurred in 7.8%, including revisions of the proximal and/or distal anastomosis in 6.6%. In-hospital adverse event rates were 0.6% for mortality, 1.0% for cerebrovascular events, and 0.3% for myocardial infarction. CONCLUSIONS: Surgical changes related to the aorta, conduits, coronary targets, and anastomosis were made in 25% of patients. This was associated with low operative mortality and low major morbidity. Transit-time flow measurement and high-frequency ultrasound may improve the quality, safety, and efficacy of coronary artery bypass grafting procedures and should be considered as a routine procedural aspect.

Improving coronary artery bypass grafting: a systematic review and meta-analysis on the impact of adopting transit-time flow measurement.

Despite there being numerous studies of intraoperative graft flow assessment by transit-time flow measurement (TTFM) on outcomes after coronary artery bypass grafting (CABG), the adoption of contemporary TTFM is low. Therefore, on 31 January 2018, a systematic literature search was performed to identify articles that reported (i) the amount of grafts classified as abnormal or which were revised or (ii) an association between TTFM and outcomes during follow-up. Random-effects models were used to create pooled estimates with 95% confidence intervals (CI) of (i) the rate of graft revision per patient, (ii) the rate of graft revision per graft and (iii) the rate of graft revision among grafts deemed abnormal based on TTFM parameters. The search yielded 242 articles, and 66 original articles were included in the systematic review. Of those articles, 35 studies reported on abnormal grafts or graft revisions (8943 patients, 15 673 grafts) and were included in the meta-analysis. In 4.3% of patients (95% CI 3.3-5.7%, I2 = 73.9) a revision was required and 2.0% of grafts (95% CI 1.5-2.5%; I2 = 66.0) were revised. The pooled rate of graft revisions among abnormal grafts was 25.1% (95% CI 15.5-37.9%; I2 = 80.2). Studies reported sensitivity ranging from 0.250 to 0.457 and the specificity from 0.939 to 0.984. Reported negative predictive values ranged from 0.719 to 0.980 and reported positive predictive values ranged from 0.100 to 0.840. This systematic review and meta-analysis showed that TTFM could improve CABG procedures. However, due to heterogeneous data, drawing uniform conclusions appeared challenging. Future studies should focus on determining the optimal use of TTFM and assessing its diagnostic accuracy.

Intraoperative graft assessment and imaging of native coronary arteries.

The evaluation of native coronary arteries in cardiac surgery represents a useful tool to detect coronary artery stenosis, identify the target artery, and choose the best anastomotic site. Intraoperative graft assessment is a fundamental step of coronary artery bypass grafting. It is able to reduce graft failure related to technical error, improving both short- and long-term outcome of patients submitted to surgical myocardial revascularization. Herein procedures of graft assessment are described, reporting their strengths and limitations.

Aortic valve bypass surgery in severe aortic valve stenosis: Insights from cardiac and brain magnetic resonance imaging.

OBJECTIVE: To investigate and describe the distribution of aortic and cerebral blood flow (CBF) in patients with severe valvular aortic stenosis (AS) before and after aortic valve bypass (AVB) surgery. METHODS: We enrolled 10 consecutive patients who underwent AVB surgery for severe AS. Cardiovascular magnetic resonance imaging (CMR) and brain magnetic resonance imaging were performed as baseline before surgery and twice after surgery. Quantitative flow measurements were obtained using 1.5-T magnetic resonance imaging (MRI) scanner phase-contrast images of the ascending aorta, descending thoracic aorta (3 cm proximally and distally from the conduit-to-aorta anastomosis), and ventricular outflow portion of the conduit. The evaluation of CBF was performed using 3.0-T MRI scanner arterial spin labeling (ASL) through sequences acquired at the gray matter, dorsal default-mode network, and sensorimotor levels. RESULTS: Conduit flow, expressed as the percentage of total antegrade flow through the conduit, was 63.5 ± 8% and 67.8 ± 7% on early and mid-term postoperative CMR, respectively (P < .05). Retrograde perfusion from the level of the conduit insertion in the descending thoracic aorta toward the aortic arch accounted for 6.9% of total cardiac output and 11% of total conduit flow. We did not observe any significant reduction in left ventricular stroke volume at postoperative evaluation compared with preoperative evaluation (P = .435). No differences were observed between preoperative and postoperative CBF at the gray matter, dorsal default-mode network, and sensorimotor levels (P = .394). CONCLUSIONS: After AVB surgery in patients with severe AS, cardiac output is split between the native left ventricular outflow tract and the apico-aortic bypass, with two-thirds of the total antegrade flow passing through the latter and one-third passing through the former. In our experience, CBF assessment confirms that the flow redistribution does not jeopardize cerebral blood supply.

Surgical bleeding after pre-operative unfractionated heparin and low molecular weight heparin for coronary bypass surgery.

BACKGROUND AND OBJECTIVES: Since the impairment of platelet function may cause excess peri-operative bleeding, pre-operative discontinuation of aspirin and heparin bridging are common for cardiac surgery. We evaluated the impact of pre-operative administration of enoxaparin and unfractionated heparin (UFH) on coagulation parameters and peri-operative bleeding in patients undergoing elective coronary artery bypass grafting (CABG) surgery after discontinuation of aspirin. DESIGN AND METHODS: Forty-three patients with three-vessel coronary artery disease undergoing elective CABG surgery discontinued aspirin and were randomized to receive either UFH 180 UI/Kg x 2/day s.c. or enoxaparin 100 UI/Kg x 2/day s.c. until 12 h before surgery (median pre-operative treatment 8 days, range 6-12 days). Surgery was performed as usual with UFH. Neither UFH nor any low molecular weight heparin was given in the immediate post-operative period. The effects of UFH and enoxaparin were monitored by the activated partial thromboplastin time (aPTT) and the Enox-test (sensitive to factor Xa inhibition) using a Rapidpoint Coagulation Analyzer. aPTT and factor Xa activity were also measured by standard methods. Peri-operative bleeding and the nadirs of hemoglobin concentration, hematocrit and platelet count were monitored post-operatively. RESULTS: Patients in the two groups were similar for number of bypasses, on-pump time, total surgery time, and time from the last heparin administration. Coagulation parameters increased significantly and similarly at 30 min and 6 h with both treatments, but returned within the normal range at 12 h. Hemoglobin, hematocrit and platelet counts significantly decreased to the same extent after CABG and re-normalized at the same time. Transfusional requirements of blood and plasma units were similar in the two groups. INTERPRETATION AND CONCLUSIONS: From the kinetics of coagulation parameters and the evaluation of bleeding, enoxaparin is a safe alternative to UFH as a bridging therapy to CABG after discontinuation of aspirin.

Intraoperative graft verification in coronary surgery.

Transit-time flow measurement (TTFM) is a reliable method to check the graft function intraoperatively in coronary surgery. The given parameters are: Mean Graft Flow (MGF); Pulsatility Index (PI) and Insufficiency Ratio (%BF). Some cutoffs of these parameters have been identified as predictors for unfair 1-y clinical outcome: mean graft flow (MGF) less than 20 ml/min and high pulsatility index greater than 5. Other cutoffs have been found as related to postoperative angiography: MGF 15 ml/min or less and pulsatility index at least 3 (sensitivity 94%; specificity 61%); MGF less than 15 ml/min and pulsatility index greater than 3 for left coronary artery or pulsatility index greater than 5 for right coronary artery (sensitivity 96%; specificity 77%); MGF 15 ml/min or less and pulsatility index at least 5.1 left coronary artery (sensitivity 98%; specificity 26%). Hence, with the need to improve the diagnostic accuracy of TTFM, high-resolution epicardic coronary ultrasound module has been added to graft flow evaluation providing 2D ultrasound imaging (either in short-axis or long-axis) and color-flow mapping, allowing an accurate morphological evaluation of body graft and anastomosis. An intraoperative method aimed to verify coronary grafts should be easy to handle, not time consuming, minimally invasive, easily meaningful and relatively cheap; in addition, it should offer objective parameters more than qualitative criteria. We herein report the results of our experience with intraoperative graft verification with TTFM and high-resolution imaging along with a systematic review of the literature in this field with the aim to provide a road map to be followed.

Intraoperative imaging to detect coronary stenosis in no-angiography patients.

Sometimes, patients scheduled for cardiac operations other than coronary artery bypass may be unsuitable for preoperative coronary angiography. We routinely use intraoperative high-resolution epicardial ultrasound to select the proper target for the graft and to check graft anastomosis integrity. We describe 3 patients who could not undergo preoperative coronary angiography for different reasons. In all cases, we discovered significant stenosis in the left anterior descending coronary artery, which required bypass grafting. Intraoperative verification by transit-time flow measurements confirmed the significant stenosis detected by imaging.

Techniques for intraoperative graft assessment in coronary artery bypass surgery.

Early graft patency is a major determinant of morbidity and mortality following coronary artery bypass surgery. Long-term graft failure is caused by intimal hyperplasia and atherosclerosis, while early failure, especially in the first year, has been attributed, in part, to surgical error. The need for intraoperative graft evaluation is paramount to determine need for revision and ensure future functioning grafts. Transit time flowmetry (TTFM) is the most commonly used intraoperative modality, however, only about 20% of cardiac surgeons in North America use TTFM. When combined with high resolution epicardial ultrasonography, TTFM provides high diagnostic yield. Fluorescence imaging can provide excellent visualization of the coronary and graft vasculature; however, data on this subject is limited. We herein examine the literature and discuss the available techniques for graft assessment along with their limitations.

Surgery for prosthetic valve endocarditis: a retrospective study of a national registry.

OBJECTIVES: We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design. METHODS: Data regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study. RESULTS: Overall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P < 0.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P < 0.001) and median logistic EuroSCORE (14%, 21%, 23%, P = 0.025). Older age, female sex, preoperative serum creatinine >-2 mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (OR = 1.02; P = 0.03), renal insufficiency (OR = 2.1; P = 0.05), triple valve surgery (OR = 6.9; P = 0.004) and shock (OR = 4.5; P < 0.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (OR = 3; P < 0.001), Enterococcus (OR = 2.3; P = 0.01) and female sex (OR = 1.5; P = 0.03) independently predicted complications, whereas ejection fraction was protective. CONCLUSIONS: PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patient's haemodynamic status and microbiological factors.

A predictive model for early mortality after surgical treatment of heart valve or prosthesis infective endocarditis. The EndoSCORE.

BACKGROUND: The aim of this large retrospective study was to provide a logistic risk model along an additive score to predict early mortality after surgical treatment of patients with heart valve or prosthesis infective endocarditis (IE). METHODS: From 2000 to 2015, 2715 patients with native valve endocarditis (NVE) or prosthesis valve endocarditis (PVE) were operated on in 26 Italian Cardiac Surgery Centers. The relationship between early mortality and covariates was evaluated with logistic mixed effect models. Fixed effects are parameters associated with the entire population or with certain repeatable levels of experimental factors, while random effects are associated with individual experimental units (centers). RESULTS: Early mortality was 11.0% (298/2715); At mixed effect logistic regression the following variables were found associated with early mortality: age class, female gender, LVEF, preoperative shock, COPD, creatinine value above 2mg/dl, presence of abscess, number of treated valve/prosthesis (with respect to one treated valve/prosthesis) and the isolation of Staphylococcus aureus, Fungus spp., Pseudomonas Aeruginosa and other micro-organisms, while Streptococcus spp., Enterococcus spp. and other Staphylococci did not affect early mortality, as well as no micro-organisms isolation. LVEF was found linearly associated with outcomes while non-linear association between mortality and age was tested and the best model was found with a categorization into four classes (AUC=0.851). CONCLUSIONS: The following study provides a logistic risk model to predict early mortality in patients with heart valve or prosthesis infective endocarditis undergoing surgical treatment, called "The EndoSCORE".

A Novel Technique to Reconstruct Tricuspid Valve Anterior Leaflet in Massive Endocarditis.

Tricuspid valve (TV) endocarditis is a common complication in intravenous drug addicts. In case of TV replacement, the main issue is the high risk of new endocarditis on TV prosthesis. On November 2014, a 44 year-old male patient with a history of intravenous drug addiction was referred for TV endocarditis owing to Staphylococcus aureus and severe regurgitation complicated by pulmonary embolism and heart failure. Preoperative echocardiography showed a large vegetation of the anterior leaflet (1.95 × 0.92 cm) covering a huge hole in the leaflet itself. Herein, a novel technique for the treatment of massive endocarditis of the TV is described. Complete anterior leaflet reconstruction was achieved with a huge equine pericardium patch along with native chordae tendinae reimplantation onto the free edge of the patch. Finally, a ring annuloplasty was performed to stabilize the valve reconstruction. The postoperative course was uneventful with evidence of trivial tricuspid regurgitation and no signs of IE recurrence. Complete reconstruction of the anterior leaflet with a patch of xenopericardium and native chordae tendinae reimplantation might be an alternative technique to TV replacement.

Corticosteroid prophylaxis for fetal immaturity in a pregnant patient with atrial myxoma.

We report a case of a woman at 32nd gestational week, admitted for resting dyspnea, showing left atrial (LA) myxoma. Cardiac myxomas are the most common primary benign tumors of the heart. The incidence of cardiac myxomas diagnosed in pregnancy is extremely low. In the present case, cesarean delivery and concomitant surgical resection of LA myxoma were both delayed after corticosteroid prophylaxis in order to reduce neonatal cerebral, intestinal, and pulmonary complications. .

From bench to bedside: Can the improvements in left ventricular assist device design mitigate adverse events and increase survival?

OBJECTIVE: In vitro tests demonstrated that the new cone-bearing configuration of the Jarvik 2000 (Jarvik Heart Inc, New York, NY) left ventricular assist device exhibits better hydraulic efficiency than the previous pin-bearing design. We investigated the long-term outcomes of patients who received the Jarvik 2000 left ventricular assist device, depending on bearing design. METHODS: A retrospective review of prospectively collected data from 18 centers included in the Italian Registry was performed. From May 2008 to September 2013, 99 patients with end-stage heart failure were enrolled. Patients were divided into 2 groups according to their Jarvik 2000 suspending mechanism: Group pin included patients with pin bearings (May 2008 to June 2010), and group cone included patients with newer cone bearings (July 2010 to September 2013). The 2 groups did not differ significantly in terms of baseline characteristics. RESULTS: A total of 30 of 39 patients (group pin) and 46 of 60 patients (group cone) were discharged. During follow-up, 6 patients underwent transplantation, and in 1 patient the left ventricular assist device was explanted. The cumulative incidence competing risk of the entire cohort for noncardiovascular-related death was 28% (20%-40%); the cumulative incidence competing risk for cardiovascular-related death was 56% (42%-73%): 71% in group pin versus 26% in group cone (P = .034). The multivariate analyses confirmed that the pin-bearing design was a risk factor for cardiovascular death, along with Interagency Registry for Mechanically Assisted Circulatory Support class. Right ventricular failures and ischemic and hemorrhagic strokes were significantly higher in group pin. CONCLUSIONS: Patients with the new pump configuration showed a better freedom from cardiovascular death and lower incidence of fatal stroke and right ventricular failure. Further studies are needed to prove the favorable impact of pump-enhanced fluid dynamics on long-term results.