Endoscopic Mitral Valve Repair in a Patient With Persistent Left Superior Vena Cava Draining Into the Coronary Sinus - Cannulation Technique and Surgical Management.

Persistence of the left superior vena cava is often an incidental finding during cardiac surgical procedures. In minimally invasive valvular surgery, it may jeopardise venous drainage and myocardial protection. This How-To-Do-It paper describes the cannulation strategy in a case of minimally invasive mitral surgery in a patient with persistence of the left superior vena cava and absence of the anonymous vein detected with preoperative multimodality imaging.

Bioconduit subannular implantation for aortic root endocarditis after previous cardiac surgery: Results from two Italian centers.

OBJECTIVES: Infective endocarditis (IE) with extensive peri-annular abscesses and aortic root involvement is a life-threatening disease. Aortic root replacement with a valved conduit is the most common intervention in this setting and represents a serious challenge for the surgeon. In the present two-center study we analyzed early and midterm outcomes of a high-risk series of IE patients undergoing aortic root reconstruction with a sub-annular implantation of a totally biological valved conduit at our centers. METHODS: The series comprised 29 patients (18 males, mean age: 72.3 ± 10.1 years) operated at "Lancisi Cardiovascular Center" of Ancona and "Pasquinucci Heart Hospital" of Massa, Italy, between May 2016 and October 2019. All patients had undergone a previous cardiac surgery. Median Euroscore-II was 12.6%. Following aggressive debridement, a Bioconduit was implanted using a sub-annular implantation technique in all cases. RESULTS: Thirty-day mortality was 13.8% (n = 4). Multiorgan failure was cause of death in all cases. Respiratory complications occurred in eight patients (27.6%). Renal complications requiring temporary or permanent dialysis occurred in six (20.7%) and two (6.9%) patients, respectively. Mortality and morbidity were not related to the surgical approach. At 1-year follow-up three patients died and no patients underwent reoperation neither reported endocarditis of the biological conduit. CONCLUSION: Considered the high-risk profile of the study cohort, our results suggest safety and efficacy of our approach at 1-year. Indeed, we contend that our subannular implantation of a 100% pericardial valved conduit, allowing an effective abscess exclusion and a conduit anchoring to healthy tissues, can reduce the risk of reinfection and dehiscence.

Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database.

This study provides early results of re-operations after the prior surgical treatment of acute type A aortic dissection (AAD) and identifies risk factors for mortality. Between May 2003 and January 2014, 117 aortic re-operations after an initial operation for AAD (a mean time from the first procedure was 3.98 years, with a range of 0.1-20.87 years) were performed in 110 patients (a mean age of 59.8 ± 12.6 years) in seven European institutions. The re-operation was indicated due to a proximal aortic pathology in ninety cases: twenty aortic root aneurysms, seventeen root re-dissections, twenty-seven aortic valve insufficiencies and twenty-six proximal anastomotic pseudoaneurysms. In fifty-eight cases, repetitive surgical treatment was subscripted because of distal aortic pathology: eighteen arch re-dissections, fifteen arch dilation and twenty-five anastomotic pseudoaneurysms. Surgical procedures comprised a total of seventy-one isolated proximals, thirty-one isolated distals and fifteen combined interventions. In-hospital mortality was 19.6 % (twenty-three patients); 11.1 % in patients with elective/urgent indication and 66.6 % in emergency cases. Mortality rates for isolated proximal, distal and combined operations regardless of the emergency setting were 14.1 % (10 pts.), 25.8 % (8 pts.) and 33.3 % (5 pts.), respectively. The causes of death were cardiac in eight, neurological in three, MOF in five, sepsis in two, bleeding in three and lung failure in two patients. A multivariate logistic regression analysis revealed that risk factors for mortality included previous distal procedure (p = 0.04), new distal procedure (p = 0.018) and emergency operation (p < 0.001). New proximal procedures were not found to be risk factors for early mortality (p = 0.15). This multicenter experience shows that the outcome of REAAD is highly dependent on the localization and extension of aortic pathology and the need for emergency treatment. Surgery in an emergency setting and distal re-do operations after previous AAD remain a surgical challenge, while proximal aortic re-operations show a lower mortality rate. Foresighted decision-making is needed in cases of AAD repair, as the results are essential preconditions for further surgical interventions.

Internal mammary artery atherosclerosis: an ultrastructural study of two cases.

Atherosclerosis of the internal mammary artery (IMA) is generally regarded as a rare (but existent) pathological entity with only a few cases reported in the most recent literature. The only study which to our knowledge has investigated the ultrastructural features of IMA atherosclerosis, demonstrate the presence of endothelial cells loss, defects of internal elastic lamina with no evidence of lipid accumulation. In the present study, we describe two cases of IMA atherosclerosis in which ultrastructural analysis revealed the presence of a typical atherosclerotic plaque morphology with infiltration of inflammatory cells, formation of intraplaque lipid pools, and accumulation of lipid-laden foam cells throughout the thickened intima, never described in this rare lesion before. Microscopically, the lesions were also characterized by intimal thickening, invagination of endothelial cells, migration of smooth muscle cells with splitting, fenestration and/or fragmentation of the elastic sheets. Our observations add new data to the scarce and contradictory literature and to this largely understudied vascular disorder.

Clinical Features and Patient Outcomes in Infective Endocarditis with Surgical Indication: A Single-Centre Experience.

BACKGROUND: Infective endocarditis (IE) is marked by a heightened risk of embolic events (EEs), uncontrolled infection, or heart failure (HF). METHODS: Patients with IE and surgical indication were enrolled from October 2015 to December 2018. The primary endpoint consisted of a composite of major adverse events (MAEs) including all-cause death, hospitalizations, and IE relapses. The secondary endpoint was all-cause death. RESULTS: A total of 102 patients (66 ± 14 years) were enrolled: 50% with IE on prosthesis, 33% with IE-associated heart failure (IE-aHF), and 38.2% with EEs. IE-aHF and EEs were independently associated with MAEs (HR 1.9, 95% CI 1.1-3.4, p = 0.03 and HR 2.1, 95% CI 1.2-3.6, p = 0.01, respectively) and Kaplan-Meier survival curves confirmed a strong difference in MAE-free survival of patients with EEs and IE-aHF (p < 0.01 for both). IE-aHF (HR 4.3, 95% CI 1.4-13, p < 0.01), CRP at admission (HR 5.6, 95% CI 1.4-22.2, p = 0.01), LVEF (HR 0.9, 95% CI 0.9-1, p < 0.05), abscess (HR 3.5, 95% CI 1.2-10.6, p < 0.05), and prosthetic detachment (HR 4.6, 95% CI 1.5-14.1, p < 0.01) were independently associated with the all-cause death endpoint. CONCLUSIONS: IE-aHF and EEs were independently associated with MAEs. IE-aHF was also independently associated with the secondary endpoint.

REDO aortic valve replacement: the sutureless approach.

BACKGROUND AND AIM OF THE STUDY: The study aim was to report the results of a single-center cohort of patients who underwent aortic valve replacement (AVR) with a sutureless prosthesis in case of cardiac reoperation (REDO). METHODS: Between March 2010 and December 2011, a total of 83 patients underwent AVR with the Perceval S sutureless aortic bioprosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy) at the authors' institution. Thirteen of these patients (six males, seven females; mean age 75.2 +/- 5.6 years) had previously undergone cardiac surgery and represented the study population. Preoperative, periprocedural and echocardiographic parameters, as well as clinical outcomes, were analyzed for all patients. RESULTS: The primary procedure was AVR, using a bioprosthesis in six patients (46%) and coronary artery bypass grafting in seven (54%). The logistic EuroSCORE was 19.4 +/- 10.7%. Surgery was always performed via a full sternotomy; the mean implanted valve size was 23.6 +/- 1.3 mm (the previous valve size was 23.2 +/- 3.2 mm; p = 0.66). The mean cross-clamp time was 44 +/- 16 min, and the mean intensive care unit stay was 3.3 +/- 2.3 days. No intraoperative or in-hospital deaths occurred, and all patients were alive at a mean follow up of 8.5 months. Two postoperative events included transient ischemic attack in one patient, and the need for pacemaker implantation in one patient. On echocardiographic evaluation, no patient showed signs of paraprosthetic leak. The mean transvalvular gradient was 10.3 +/- 1.5 mmHg. CONCLUSION: Use of the Perceval S sutureless AVR offers a fast and safe procedure, even in high-risk REDO surgery, providing a good hemodynamic performance with excellent clinical recovery, demonstrated at a follow up of six months. Although the sample size was limited, the results were encouraging and support the use of sutureless valves in the frame of REDO surgery for aortic valve disease.

Advanced age per se should not be an exclusion criterion for minimally invasive aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: The introduction of transcatheter aortic valve implantation (TAVI), coupled with the increasing number of elderly patients requiring cardiac surgery, has given rise to an intense debate on the most appropriate treatment strategy for this high-risk population. The study aim was to compare clinical outcomes in older versus younger patients undergoing minimally invasive aortic valve replacement (AVR). METHODS: Between March 2010 and July 2012, 66 patients undergoing minimally invasive isolated AVR with the sutureless Perceval S bioprosthesis (Sorin Group, Saluggia, Italy) were allocated to two groups according to age > or = 80 years (group A, n = 25) or < 80 years (group B, n = 41). In-hospital and follow up data were collected for all patients, including an evaluation of the patients' quality of life, using the SF-36 questionnaire. RESULTS: Mean age and logistic EuroSCORE were statistically different between groups (p < 0.001 and p = 0.002, respectively). The length of intensive care unit stay was similar in groups A and B (1.9 +/- 0.8 and 2.5 +/- 1.4 days, respectively; p = 0.061). In-hospital mortality occurred in only one patient of group A (1.5%). Postoperative transient cerebral ischemic events occurred with similar frequency in both groups (two in group A and four in group B; p = 0.59). One patient in group A and two patients in group B required pacemaker implantation (1.5 versus 3%; p = 0.68). The mean follow up was 13.9 +/- 7.4 months, during which time three patients died (two in group A, one in group B). All enrolled patients answered the SF-36 questionnaire, and there were no significant differences between groups in all eight domains of the test. CONCLUSION: Within the setting of minimally invasive isolated AVR, the study results showed that the clinical outcomes and quality of life in patients aged > or = 80 years were comparable to those of younger patients. Therefore, advanced age per se does not preclude successful AVR through a minimally invasive approach.

Short-term follow up with the 3f Enable aortic bioprosthesis: clinical and echocardiographic results.

BACKGROUND AND AIM OF THE STUDY: High-risk patients referred for aortic valve replacement (AVR) may benefit from sutureless technology in order to reduce mortality and morbidity. Herein is described the authors' initial experience and short-term results of the sutureless 3f Enable aortic bioprosthesis. METHODS: A total of 28 patients (19 females, nine males; mean age 76.8 +/- 5.1 years; range: 66 to 86 years) with symptomatic aortic valve disease underwent AVR with the 3f Enable bioprosthesis between May 2010 and May 2011. Preoperatively, the mean logistic EuroSCORE was 13.7 +/- 10.8%. Concomitant procedures included mitral valve replacement (n = 1), tricuspid valve repair (n = 3) and coronary artery bypass grafting (n = 5). Echocardiography was performed preoperatively, at postoperative day 1, at discharge, and at follow up. RESULTS: The in-hospital mortality was 3.5% (1/28). Seventeen patients underwent minimally invasive AVR via an upper partial ministernotomy (n = 13) or a right anterior minithoracotomy (n = 4) approach. The cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times were 99.4 +/- 22.9 and 65.9 +/- 18.0 min, respectively, for isolated AVR, and 138.8 +/- 62.2 and 100.5 +/- 52.2 min, respectively, for combined procedures. One patient underwent aortic root replacement for an intimal aortic lesion after sutureless implantation. At a median follow up of four months (range: 2-10 months), survival was 96.5%, freedom from reoperation was 96.5%, and the mean transvalvular pressure gradient was 11.1 +/- 5.4 mmHg. CONCLUSION: AVR with the 3f Enable bioprosthesis in high-risk patients is a safe and feasible procedure that is associated with a low mortality and excellent hemodynamic performance.

Aortic valve replacement with smaller prostheses in elderly patients: does patient prosthetic mismatch affect outcomes?

BACKGROUND AND AIM OF THE STUDY: To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size. METHODS: Between 2005 and 2010, 142 patients older than 65 years were discharged from the hospital after AVR with 19 or 21 mm prosthesis for aortic stenosis. Their median age was 79 years (range 66 to 91). Prosthesis effective orifice area (EOA) was derived from the continuity equation and PPM was defined as an indexed EOA (IEOA) < 0.85 cm(2)/m(2). Patients having IEOA < 0.75 cm(2)/m(2) and IEOA < 0.60 cm(2)/m(2) were also investigated. Mean follow-up was 23 months (range 1 to 58) and was 98% complete. RESULTS: PPM was found in 86 patients, 63 had an IEOA ≤ 0.75 cm(2) /m(2), and 23 had an IEOA ≤ 0.60 cm(2) /m(2). The groups were similar except for older age (p = 0.0364), larger body surface area (p = 0.0068), more male gender (p = 0.0186), and more EF < 40% in patients with PPM. Survival at 58 months was 81 ± 6.4% and was not influenced by PPM (p = 0.9845). At Cox analysis only preoperative NYHA class (p = 0.0064) was identified as an independent risk factor for late death. The SF12 test was used to analyze the QOL of patients and it did not reveal differences between groups. CONCLUSIONS: PPM does not affect survival in this series of elderly patients. We believe that more aggressive surgical procedures are not justified in these patients.

Clinical and hemodynamic outcomes of the Perceval sutureless aortic valve from a real-world registry.

OBJECTIVES: Perceval sutureless valve has been in clinical use for >15 years. The aim of this study is to report the real-word clinical and haemodynamic performance from the SURE-aortic valve replacement international prospective registry in patients who underwent aortic valve replacement with Perceval valve. METHODS: From 2011 to 2021, patients from 55 institutions received a Perceval valve. Postoperative, follow-up, and echocardiographic outcomes were analysed. RESULTS: A total of 1652 patients were included; mean age was 75.3 ± 7.0 years (53.9% female); mean EuroSCORE II was 4.1 ± 6.3. Minimally invasive approach was performed in 45.3% of patients; concomitant procedures were done in 35.9% of cases. Within 30 days, 0.3 and 0.7% valve-related reinterventions were reported. Transient ischaemic attack, disabling and non-disabling strokes were limited (0.4%, 0.4% and 0.7%, respectively). Pacemaker implant was required in 5.7% of patients. Intra-prosthetic regurgitation ≥2 was present in 0.2% of cases, while paravalvular leak ≥2 in only 0.1%. At a maximum follow-up of 8 years, 1.9% of cardiovascular deaths and 0.8% of valve-related reintervention occurred. Among the 10 cases of structural valve deterioration (mean 5.6 ± 1.4 years after implant; range: 2.6-7.3 years), 9 were treated with a transcatheter vale-in-valve implantation and 1 with explant. Mean pressure gradient decreased from 45.8 ± 16.5 mmHg preoperatively to 13.3 ± 5.2 mmHg at discharge and remained stable during follow-up. CONCLUSIONS: This experience represents the largest prospective real-world cohort of patients treated with Perceval showing that Perceval is a safe and effective alternative to conventional surgical aortic valve replacement, providing favourable clinical and haemodynamic results also at mid-term follow-up.

Ten-year experience with sutureless Perceval bioprosthesis: single-centre analysis in 1157 implants.

AIMS: We describe long-term clinical and echocardiographic outcomes in the largest single-centre cohort of patients who underwent aortic valve replacement (AVR) with sutureless Perceval (CorCym, Italy) bioprosthesis. METHODS: Between March 2011 and March 2021, 1157 patients underwent AVR with Perceval bioprosthesis implantation. Mean age was 77 ±â€Š6 years (range: 46-89 years) and mean EuroSCORE II was 6.7 ±â€Š3.2% (range: 1.7-14.2%). Concomitant procedures were performed in 266 patients (23%). RESULTS: Thirty-day mortality was 1.38% (16/1157). Eight hundred and twenty of 891 (92%) isolated AVRs underwent minimally invasive surgery with a ministernotomy ( n  = 196) or right minithoracotomy ( n  = 624) approach. Cardiopulmonary bypass and aortic cross-clamp times were 81.1 ±â€Š24.3 and 50.6 ±â€Š11.7 min for isolated AVR and 144.5 ±â€Š34.7 and 96.4 ±â€Š21.6 min for combined procedures. At mean follow-up of 53.08 ±â€Š6.7 months (range: 1-120.5 months), survival was 96.5% and mean transvalvular pressure gradient was 13.7 ±â€Š5.8 mmHg. Left ventricular mass decreased from 152.8 to 116.1 g/m 2 ( P  < 0.001) and moderate paravalvular leakage occurred in three patients without haemolysis not requiring any treatment. Freedom from reoperation was 97.6%. Eight patients required surgical reintervention and 19 patients transcatheter valve-in-valve procedure for structural prosthesis degeneration at a mean of 5.6 years after first operation (range: 2-9 years). CONCLUSION: AVR with a Perceval bioprosthesis is associated with good clinical results and excellent haemodynamic performance in our 10-year experience. Structural degeneration rate of Perceval is comparable with other bioprosthetic aortic valves. Sutureless technology may reduce operative time especially in combined procedures and enable minimally invasive AVR.

Transcatheter Aortic Valve Replacement in Degenerated Perceval Bioprosthesis: Clinical and Technical Aspects in 32 Cases.

BACKGROUND: Sutureless aortic bioprostheses are increasingly being used to provide shorter cross-clamp time and facilitate minimally invasive aortic valve replacement. As the use of sutureless valves has increased over the past decade, we begin to encounter their degeneration. We describe clinical outcomes and technical aspects in patients with degenerated sutureless Perceval (CorCym, Italy) aortic bioprosthesis treated with valve-in-valve transcatheter aortic valve replacement (VIV-TAVR). METHODS: Between March 2011 and March 2023, 1310 patients underwent aortic valve replacement (AVR) with Perceval bioprosthesis implantation. Severe bioprosthesis degeneration treated with VIV-TAVR occurred in 32 patients with a mean of 6.4 ± 1.9 years (range: 2-10 years) after first implantation. Mean EuroSCORE II was 9.5 ± 6.4% (range: 1.9-35.1%). RESULTS: Thirty of thirty-two (94%) VIV-TAVR were performed via transfemoral and two (6%) via transapical approach. Vascular complications occurred in two patients (6%), and mean hospital stay was 4.6 ± 2.4 days. At mean follow-up of 16.7 ± 15.2 months (range: 1-50 months), survival was 100%, and mean transvalvular pressure gradient was 18.7 ± 5.3 mmHg. CONCLUSION: VIV-TAVR is a useful option for degenerated Perceval and appears safe and effective. This procedure is associated with good clinical results and excellent hemodynamic performance in our largest single-center experience.

Sutureless aortic valve replacement through a right minithoracotomy.

During the past decade, interest in the development of less-invasive cardiac valve surgery has undergone a steady increase, with many surgeons having supplanted full sternotomy with minimal-access incisions. While the minimally invasive approaches for the treatment of mitral disease have been standardized, the preferred route for aortic valve replacement (AVR) remains a matter of debate. Although AVR through a right minithoracotomy avoids opening the sternum, it does require a greater surgical ability and may be a challenging procedure, even for expert surgeons. By simplifying the valve implantation, the availability of sutureless prostheses might provide an important incentive for the diffusion of this approach. Herein are reported the details of three patients who received a 3f-Enable sutureless aortic bioprosthesis via a right minithoracotomy. The advantages and possible improvements of this procedure are also discussed.

Outcomes of Emergent Isolated Coronary Bypass Grafting in Heart Failure Patients.

Patients with previously diagnosed HF are at greater risk for subsequent morbidity and mortality when hospitalized for an Acute Myocardial Infarction (AMI). The purpose of our study was to describe the time trend of the incidence of emergent CABG in patients with and without HF, the clinical characteristics, outcomes, and the risk factors for mortality of surgical revascularization in the short and medium term. This was a single-center retrospective observational study of patients who underwent isolated emergency CABG from January 2009 to January 2020. A propensity-score matching analysis yielded two comparable groups (n = 430) of patients without (n = 215) and with (n = 215) heart failure. In-hospital mortality did not differ in the two groups (2.8%; p > 0.9); the patients with heart failure presented more frequently with cardiogenic shock, and there was an association with mortality and mechanical circulatory support (OR 16.7−95% CI 3.31−140; p = 0.002) and postoperative acute renal failure (OR 15.9−95% CI 0.66−203; p = 0.036). In the early- and mid-term, heart failure and NSTEMI were associated with mortality (HR 3.47−95% CI 1.15−10.5; p = 0.028), along with age (HR 1.28−95% CI 1.21−1.36; p < 0.001). Surgical revascularization offers an excellent solution for patients with acute coronary syndrome, leading to a good immediate prognosis even in those with chronic heart failure.

Sutureless and rapid deployment versus sutured aortic valve replacement: a propensity-matched comparison from the Sutureless and Rapid Deployment International Registry.

OBJECTIVES: To compare procedural and in-hospital outcomes of patients undergoing sutureless (Perceval, Livanova PLC, London, UK) and rapid deployment (Intuity Elite, Edwards Lifesciences, Irvine, CA, USA) aortic valve replacement (group 1) versus sutured aortic valve replacement (group 2). METHODS: Patients receiving isolated aortic valve replacement between 2014 and 2020 were analysed using data from the Sutureless and Rapid Deployment International Registry. Patients in group 1 and group 2 were propensity-score matched in a 1:1 ratio. RESULTS: A total of 7708 patients were included in the study. After matching, 2 groups of 2643 each were created. Patients in group 1 were more likely to undergo minimally invasive approaches and were associated with shorter operative times when compared with group 2. Overall in-hospital mortality was similar between groups. While an increased risk of stroke was observed in group 1 in the first study period (2014-2016; relative risk 3.76, P < 0.001), no difference was found in more recent year period (relative risk 1.66, P = 0.08; P for heterogeneity 0.003). Group 1 was associated with reduced rates of postoperative low cardiac output syndrome, atrial fibrillation and mild aortic regurgitation. New pacemaker implant was three-fold higher in group 1. CONCLUSIONS: Our findings showed significant differences in procedural and clinical outcomes between the study groups. These results suggest that sutureless and rapid deployment aortic valve replacement should be considered as part of a comprehensive valve programme. The knowledge of the respective post-aortic valve replacement benefits for different valve technologies may result in patient-tailored valve selection with improved clinical outcomes.

Sutureless aortic valves in elderly patients with aortic stenosis and intermediate-risk profile.

AIMS: Sutureless valves became an alternative to standard bioprostheses, allowing surgeons to significantly reduce cross-clamping and extracorporeal circulation times, with a potential positive impact on major postoperative complications. The aim of this European multicentre study was to evaluate the safety and efficacy of sutureless valves in patients with an intermediate-risk profile undergoing aortic valve replacement (AVR). METHODS: We investigated early and mid-term outcomes of 518 elderly patients with aortic stenosis at intermediate-risk profile (mean STS Score 6.1 ±â€Š2%) undergoing AVR with sutureless aortic valve. Primary endpoints were 30-day mortality and freedom from all-cause death at follow-up. The secondary endpoint was survival freedom from MACCEs [all-cause death, stroke/transitory ischemic attack (TIA), bleeding, myocardial infarction, aortic regurgitation Grade II, endocarditis, reintervention and pacemaker implant; VARC 1--2 criteria]. RESULTS: Sutureless valve implantation was successfully performed in 508 patients, with a procedural success rate of 98.1% (508/518) as per VARC criteria. Concomitant myocardial revascularization [coronary artery bypass grafting (CABG)] was performed in 74 out of 518 patients (14.3%). In-hospital mortality was 1.9% (10/518). Postoperative complications included revision for bleeding (23/518; 4.4%), prolonged intubation more than 48h (4/518; 0.7%), acute renal failure (14/518; 2.7%), stroke/TIA (11/518; 2.1%), pacemaker implantation (26/518; 5.1%) and aortic regurgitation more than Grade II (7/518; 1.4%). At 48-month follow-up, Kaplan-Meier overall survival and freedom from MACCEs in patients receiving isolated AVR were 83.7% [95% confidence interval (95% CI): 81.1-86.3] and 78.4% (95% CI: 75.5-81.4), respectively, while in patients with concomitant CABG, Kaplan-Meier overall survival and freedom from MACCEs were 82.3% (95% CI: 73.3-91.3) and 79.1% (95% CI: 69.9-88.3), respectively. CONCLUSION: The use of sutureless aortic valves in elderly patients with an intermediate-risk profile provided excellent early and mid-term outcomes, providing a reliable tool in patients undergoing surgical AVR in this specific subset of population. These preliminary data need to be investigated with a TAVI control-group in further studies.

Correlation between micro and macrostructural biaxial behavior of ascending thoracic aneurysm: a novel experimental technique.

Mechanical properties and microstructural modifications of vessel tissues are strongly linked, as established in the state of the art of cardiovascular diseases. Techniques to obtain both mechanical and structural information are reported, but the possibility to obtain real-time microstructural and macrostructural data correlated is still lacking. An experimental approach to characterize the aortic tissue is presented. A setup integrating biaxial traction and Small Angle Light Scattering (SALS) analysis is described. The system was adopted to test ex-vivo aorta specimens from healthy and aneusymatic (aTAA) cases. A significant variation of the fiber dispersion with respect to the unloaded state was encountered during the material traction. The corresponding microstructural and mechanical data were successfully used to fit a given anisotropic constitutive model, with satisfactory R2 values (0.97±0.11 and 0.96±0.17, for aTAA and healthy population, respectively) and fiber dispersion parameters variations between the aTAA and healthy populations (0.39±0.23 and 0.15±0.10). The method integrating the biaxial/SALS technique was validated, allowing for real-time synchronization between mechanical and microstructural analysis of anisotropic biological tissues.

Right anterior mini-thoracotomy and sutureless valves: the perfect marriage.

BACKGROUND: A minimally invasive approach (MIA) reduces mortality and morbidity in patients referred for aortic valve replacement (AVR). Sutureless technology facilitates a MIA. We describe our experience with the sutureless Perceval (LivaNova, Italy) aortic bioprosthesis through a right anterior mini-thoracotomy (RAMT) approach. METHODS: Between March 2011 and October 2019, 1,049 patients underwent AVR with Perceval bioprosthesis. Five hundred and three patients (48%) were operated through a RAMT approach in the second intercostal space. Considering only isolated AVR (881), 98% of patients were operated with MIA, and Perceval in RAMT approach was performed in 57% of these patients. Eight patients (1.6%) had previously undergone cardiac surgery. The prosthesis sizes implanted were: S (n=91), M (n=154), L (n=218) and XL (n=40). Concomitant procedures were mitral valve surgery (n=6), tricuspid valve repair (n=1), mitral valve repair and tricuspid valve repair (n=1) and miectomy (n=2). Mean age was 78±4 years (range, 65-89 years), 317 patients were female (63%) and EuroSCORE II was 5.9%±8.4%. RESULTS: The 30-day mortality was 0.8% (4/503). Cardiopulmonary bypass (CPB) and aortic cross-clamp times were 81.6±30.8 and 50.3±24.5 minutes respectively for stand-alone procedures. In two patients, early moderate paravalvular leakage appeared as a result of incomplete expansion of the sutureless valve due to oversizing of the bioprosthesis, requiring reoperations at two and nine postoperative days with sutured aortic bioprosthesis implantation. Permanent pacemaker implantation within the first thirty days was necessary in 26 (5.2%) patients. At the mean follow-up of 4.6 years (range, 1 month to 8.6 years), survival was 96%, freedom from reoperation was 99.2%, and mean transvalvular pressure gradient was 11.9±4.3 mmHg. CONCLUSIONS: AVR with the Perceval bioprosthesis in a RAMT approach is a safe and feasible procedure associated with low mortality and excellent hemodynamic performance. Sutureless technology facilitates a RAMT approach.

Fate of the aortic valve after root reconstruction in type A aortic dissection: a 20-year follow up.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the fate of the aortic valve after root reconstruction in acute type A aortic dissection. METHODS: Between 1982 and 2006, a total of 373 consecutive patients underwent emergency surgery for acute type A aortic dissection at the authors' institution. Of these patients, 298 (mean age 63 +/- 11 years; range: 22-85 years) underwent replacement of the supracoronary aorta with root reconstruction. The mean follow up period was 6.9 +/- 5.2 years (range: 2 months to 23 years), and was 98% complete. Aortic valve function was assessed by the incidence of aortic valve reoperation and transthoracic echocardiography. RESULTS: The 30-day mortality was 27% (82/298). Survival was 80%, 57% and 49% at five, 10 and 15 years, respectively. For survivors at the latest follow up, freedom from moderate or severe aortic regurgitation (AR) was 93%, 84% and 72% at five, 10 and 15 years, respectively. Four patients had severe AR but were not reoperated on. Among 200 patients discharged, 13 (6.5%) were reoperated on for severe AR, with an operative mortality of 15% (n = 2). Freedom from aortic valve replacement was 97%, 92% and 84% at five, 10 and 15 years, respectively. Cox regression analysis identified age < or = 59 years (p = 0.0201) and 'low-volume surgeon' (p = 0.0004) as risk factors for recurrent moderate or severe AR. CONCLUSION: The study results showed that, when the aortic dissection involves the aortic root, supracoronary replacement of the ascending aorta with a root reconstruction allows preservation of the aortic valve in the majority of patients, with a satisfactory long-term outcome.

Minimally Invasive Sutureless Aortic Valve Replacement is Associated With Improved Outcomes in Patients With Left Ventricular Dysfunction.

OBJECTIVE: Patients with severe aortic stenosis and reduced left ventricular ejection fraction (LVEF) have a poor prognosis compared with patients with preserved LVEF. To evaluate the impact of sutureless Perceval (LivaNova, Italy) aortic bioprosthesis on LVEF and clinical outcomes in patients with baseline left ventricular (LV) dysfunction who underwent isolated aortic valve replacement (AVR). METHODS: Between March 2011 and August 2017, 803 patients underwent AVR with Perceval bioprosthesis implantation. Fifty-two isolated AVR had preoperative LVEF ≤45%. Mean age of these patients was 77 ± 6 years, 24 patients were female (46%), and mean EuroSCORE II was 9.4% ± 4.8%. Perceval bioprosthesis was implanted in 9 REDO operations. In 43 patients (83%), AVR was performed in minimally invasive surgery with an upper ministernotomy (n = 13) or right anterior minithoracotomy (n = 30). RESULTS: One patient died in hospital. Cardiopulmonary bypass and aortic cross-clamp times were 85.5 ± 26 minutes and 55.5 ± 19 minutes, respectively. At mean follow-up of 33 ± 20 months (range: 1 to 75 months), survival was 90%, freedom from reoperation was 100%, and mean transvalvular pressure gradient was 11 ± 5 mmHg. LVEF improved from 37% ± 7% preoperatively to 43% ± 8% at discharge (P < 0.01) and further increased to 47% ± 9% at follow-up (P = 0.06), LV mass decreased from 149.8 ± 16.9 g/m2 preoperatively to 115.3 ± 11.6 g/m2 at follow-up (P < 0.001), and moderate paravalvular leakage occurred in 1 patient without hemolysis not requiring any treatment. CONCLUSIONS: AVR with sutureless aortic bioprosthesis implantation in patients with preoperative LV dysfunction demonstrated a significant immediate and early improvement in LVEF.