Pacemaker implantation after concomitant tricuspid valve repair in patients undergoing minimally invasive mitral valve surgery: Results from the Mini-Mitral International Registry

Objective

Randomized evidence suggests a high risk of pacemaker implantation for patients undergoing mitral valve (MV) surgery with concomitant tricuspid valve repair (cTVR). We investigated the impact of cTVR on outcomes in the Mini-Mitral International Registry.

Methods

From 2015 to 2021, 7513 patients underwent minimally invasive MV with or without cTVR in 17 international centers (MV: n = 5609, cTVR: n = 1113). Propensity matching generated 1110 well-balanced pairs. Multivariable analysis was applied.

Results

Patients with cTVR were older and had more comorbidities. Propensity matching eliminated most differences except for more TR in patients who underwent cTVR (77.2% vs 22.1% MV, P < .001). Mean matched age was 71 years, and 45% were male. European System for Cardiac Operative Risk Evaluation II was still 2.68% (interquartile range [IQR], 0.80-2.63) vs 1.9% (IQR, 1.12-3.9) in matched MV (P < .001). MV replacement (30%) and atrial fibrillation surgery (32%) were similar in both groups. Cardiopulmonary bypass (161 minutes [IQR, 133-203] vs MV: 130 minutes [IQR, 103-166]; P < .001) and crossclamp times (93 minutes [IQR, 66-123] vs MV: 83 minutes [IQR, 64-107]; P < .001) were longer with cTVR. Although in-hospital mortality was similar (cTVR: 3.3% vs MV: 2.2%; P = .5), postoperative pacemaker implantations (9% vs MV: 5.8%; P = .02), low cardiac output syndrome (7.7% vs MV: 4.4%; P = .02), and acute kidney injury (13.8% vs MV: 10%; P = .01) were more frequent with cTVR. cTVR eliminated relevant TR in most patients (greater-than-moderate TR: 6.8%). Multivariable analysis identified MV replacement, atrial fibrillation, and cTVR as risk factors of postoperative pacemaker implantation.

Conclusions

cTVR in minimally invasive MV surgery is an independent risk factor for pacemaker implantation in this international registry. It is also associated with more bleeding, low output syndrome, and acute kidney injury. It remains unclear whether technical or patient factors (or both) explain these differences.

Effect of Hospital-associated SARS-CoV-2 Infections in Cardiac Surgery: A Multicenter Study

BACKGROUND

The effect of hospital-associated SARS-CoV-2 infections in cardiac surgery patients remains poorly investigated, and current data are limited to small case series with conflicting results.

METHODS

A multicenter European collaboration was organized to analyze the outcomes of patients who tested positive with hospital-associated SARS-CoV-2 infection after cardiac surgery. The study investigators hypothesized that early infection could be associated with worse postoperative outcomes; hence 2 groups were considered: (1) an early hospital-associated SARS-CoV-2 infection group comprising patients who had a positive molecular test result ≤7 days after surgery, with or without symptoms; and (2) a late hospital-associated SARS-CoV-2 infection group comprising patients whose test positivity occurred >7 days after surgery, with or without symptoms. The primary outcome was 30-day mortality. Secondary outcomes included all-cause mortality or morbidity at early follow-up and SARS-CoV-2-related hospital readmission.

RESULTS

A total of 87 patients were included in the study. Of those, 30 were in the early group and 57 in the late group. Overall, 30-day mortality was 8%, and in-hospital mortality was 11.5%. The reintubation rate was 11.4%. Early infection was significantly associated with higher mortality (adjusted OR, 26.6; 95% CI, 2, 352.6; P < .01) when compared with the late group. At 6-month follow-up, survival probability was also significantly higher in the late infection group: 91% (95% CI, 83%, 98%) vs 75% (95% CI, 61%, 93%) in the early infection group (P = .036). Two patients experienced COVID-19-related rehospitalization.

CONCLUSIONS

In this multicenter analysis, hospital-associated SARS-CoV-2 infection resulted in higher than expected postoperative mortality after cardiac surgery, especially in the early infection group.

Neurological outcomes in minimally invasive mitral valve surgery: risk factors analysis from the Mini-Mitral International Registry

OBJECTIVES

The aim of this study was to examine the incidence and predictors of stroke after minimally invasive mitral valve surgery (mini-MVS) and to assess the role of preoperative CT scan on surgical management and neurological outcomes in the large cohort of Mini-Mitral International Registry.

METHODS

Clinical, operative and in-hospital outcomes in patients undergoing mini-MVS between 2015 and 2021 were collected. Univariable and multivariable analyses were used to identify predictors of stroke. Finally, the impact of preoperative CT scan on surgical management and neurological outcomes was assessed.

RESULTS

Data from 7343 patients were collected. The incidence of stroke was 1.3% (n = 95/7343). Stroke was associated with higher in-hospital mortality (11.6% vs 1.5%, P < 0.001) and longer intubation time, ICU and hospital stay (median 26 vs 7 h, 120 vs 24 h and 14 vs 8 days, respectively). On multivariable analysis, age (odds ratio 1.039, 95% confidence interval 1.019-1.060, P < 0.001) and mitral valve replacement (odds ratio 2.167, 95% confidence interval 1.401-3.354, P < 0.001) emerged as independent predictors of stroke. Preoperative CT scan was made in 31.1% of cases. These patients had a higher risk profile and EuroSCORE II (median 1.58 vs 1.1, P < 0.001). CT scan influenced the choice of cannulation site, being ascending aorta (18.5% vs 0.5%, P < 0.001) more frequent in the CT group and femoral artery more frequent in the no CT group (97.8% vs 79.7%, P < 0.001). No difference was found in the incidence of postoperative stroke (CT group 1.5, no CT group 1.4%, P = 0.7).

CONCLUSIONS

Mini-MVS is associated with a low incidence of stroke, but when it occurs it has an ominous impact on mortality. Preoperative CT scan affected surgical cannulation strategy but did not led to improved neurological outcomes.

Durability of bioprosthetic aortic valve replacement in patients under the age of 60 years - 1-year follow-up from the prospective INDURE registry

OBJECTIVES

We report 1-year safety and clinical outcomes in patients <60 years undergoing bioprosthetic surgical aortic valve intervention.

METHODS

The INSPIRIS RESILIA Durability Registry is a prospective, multicentre registry to assess clinical outcomes of patients <60 years. Patients with planned SAVR with or without concomitant replacement of the ascending aorta and/or coronary bypass surgery were included. Time-related valve safety, haemodynamic performance and quality of life (QoL) at 1 year were assessed.

RESULTS

A total of 421 patients were documented with a mean age of 53.5 years, 76.5% being male and 27.2% in NYHA class III/IV. Outcomes within 30 days included cardiovascular-related mortality (0.7%), time-related valve safety (VARC-2; 5.8%), thromboembolic events (1.7%), valve-related life-threatening bleeding (VARC-2; 4.3%) and permanent pacemaker implantation (3.8%). QoL was significantly increased at 6 months and sustained at 1 year. Freedom from all-cause mortality at 1 year was 98.3% (95% confidence interval 97.1; 99.6) and 81.8% were NYHA I versus 21.9% at baseline. No patient developed structural valve deterioration stage 3 (VARC-3). The mean aortic pressure gradient was 12.6 mmHg at 1 year and the effective orifice area was 1.9 cm2.

CONCLUSIONS

The 1-year data from the INSPIRIS RESILIA valve demonstrate good safety and excellent haemodynamic performance as well as an early QoL improvement.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov: NCT03666741.

Aortic Cross-Clamp Time Correlates with Mortality in the Mini-Mitral International Registry

OBJECTIVES

Minimally invasive access has become the preferred choice in mitral and/or tricuspid valve surgery (MVR±TVR). Reported outcomes are at least similar to classic sternotomy although aortic cross-clamp times are usually longer.

METHODS

We analyzed the largest registry of MVR±TVR patients (MMIR) for the relationship between aortic cross-clamp times, mortality and other outcomes. From 2015-2021, 7,513 consecutive patients underwent mini-MVR±TVR in 17 international Heart-Valve-Centres. Data were collected according to MVARC definitions and 6878 patients with one cross-clamp period were analysed. Uni- and multivariable regression analyses were used to assess outcomes in relation to aortic cross-clamp times.

RESULTS

Median age was 65 years (57% male). Median EuroSCORE II was 1.3% (IQR: 0.80-2.63). Minimally invasive access was either by direct vision (28%), video-assisted (41%) or totally endoscopic/robotic (31%). Femoral cannulation was used in 93%. Three quarters were repairs with 17% additional TVR and 19% AF-ablation. Cardiopulmonary bypass and cross-clamp times were 135 min (IQR : 107-173) and 85 min (IQR : 64-111), respectively. Postoperative events were death (1.6%), stroke (1.2%), bleeding requiring revision (6%), low cardiac output syndrome (3.5%) and acute kidney injury (6.2%, mainly stage I). Statistical analyses identified significant associations between cross-clamp time and mortality, low cardiac output syndrome and acute kidney injury (all p < 0.001). Age, low ejection fraction and emergent surgery were risk factors, but variables of "increased complexity" (redo, endocarditis, concomitant procedures) were not.

CONCLUSIONS

Aortic cross-clamp time is associated with mortality as well as postoperatively impaired cardiac and renal function. Thus, implementing measures to reduce cross-clamp time may improve outcomes.

Risk-related clinical outcomes after minimally invasive mitral valve surgery: insights from the mini-mitral international registry (MMIR)

OBJECTIVE

With the popularization of catheter-based mitral valve procedures, evaluating risk-specific differentiated clinical outcomes after contemporary mitral valve surgery is crucial. In this study, we assessed the operative results of minimally invasive mitral valve operations across different patient risk profiles and evaluated the value of EuroSCORE II predicted risk of mortality model for risk prediction, in the large cohort of Mini-Mitral International Registry (MMIR).

METHODS

The MMIR database was used to analyze mini-mitral operations between 2015 and 2021. Patients were categorized as low- (<4%), intermediate- (4% to < 8%), high- (8% to < 12%) and extreme risk (≥12%) according to EuroSCORE II. The observed to expected (O: E) mortality ratio was calculated for each risk group.

RESULTS

A total of 6541 patients were included in the analysis. Of those, 5546 (84.8%) were classified as low risk, 615 (9.4%) as intermediate risk, 191 (2.9%) as high risk and 189 (2.9%) as extreme risk. Overall operative mortality and stroke rates were 1.7% and 1.4%, respectively, and were significantly associated with patient's risk. The observed mortality was significantly lower than expected -according to the EuroSCORE II- in all risk categories (O: E ratio < 1).

CONCLUSIONS

The present study provides an international contemporary benchmark for operative outcomes after minimally invasive mitral surgery. Operative results were excellent in low-, intermediate- and high risk patients, but were less satisfactory in extreme risk. The EuroSCORE II model overestimated the in-hospital mortality. We believe findings from the MMIR may assist surgeons and cardiologists in clinical decision-making and treatment allocation for patients with mitral valve disease.

The first taxonomic and functional characterization of human CAVD-associated microbiota

Introduction

Calcific aortic valve disease (CAVD) is the most common heart valve disorder, defined by a remodeling multistep process: namely, valve fibrosis with its area narrowing, impaired blood flow, and final calcification phase. Nowadays, the only treatment is the surgical valve replacement. As for other cardiovascular diseases, growing evidence suggest an active role of the immune system in the calcification process that could be modulated by the microbiota. To address this point, we aimed to investigate and characterize, for the first time, the presence of a valve microbiota and associated immune response in human CAVD.

Method

Calcified aortic valve (CAV) samples from twenty patients (11 from Germany and 9 from Italy) with diagnosis of severe symptomatic CAVD were used to assess the presence of infiltrating T cells, by cloning approach, and to characterize the valve microbiota, by 16S rRNA gene sequencing (NGS).

Results

We documented the presence of infiltrating T lymphocytes, especially the T helper subset, in CAV samples. Moreover, we found a tissue-associated microbiota in freshly collected CAV samples, which was significantly different in Italian and German patients, suggesting potential correlation with other cardiovascular risk factors.

Conclusion

The presence of microbiota in inflamed CAV samples represents the right trigger point to explain the valve calcification process, encouraging further studies to explore the potential link between bacteria and adaptive immune response and to define the critical role of local microbiota-immunity axis on CAVD development.

569 IMPACT OF FRAILTY ON VERY LONG-TERM OUTCOME IN PATIENTS UNDERGOING PERCUTANEOUS TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) IN A HIGH-FLOW REFERRAL CENTER: A PROSPECTIVE STUDY

Background

Transcatheter strategies for aortic stenosis (AS) are a therapeutic option in older patients not amenable for open heart surgery. Guidelines recommend surgical scores like the Society of Thoracic Surgeons (STS) for risk stratification. However, the long-term predictive power of these scores in older patients is limited.

Purpose

To assess the impact of frailty status on the very long-term mortality in patients with severe AS evaluated for transcatheter aortic valve implantation (TAVI) in a high-flow and high-volume tertiary care center.

Methods

Consecutive patients &gt;80 years referred to TAVI from January to December 2019 at our tertiary care institution were prospectively screened for frailty through a comprehensive geriatric assessment (CGA) based on physical function and the Multidimensional Prognostic Index (MPI).

The MPI is a three-level score used to stratify frailty and risk of mortality (low, intermediate, or high risk) based on eight key domains for frailty assessment (functional and cognitive status, nutrition, mobility, and risk of pressure sores, multimorbidity, polypharmacy and co-habitation).

Frailty was defined by an intermediate-high MPI. Patients were also analyzed by STS score (&lt;4%: low risk; 4-8%: intermediate risk; &gt;8%: high risk). All patients prospectively called at 1, 2 and 3 years from TAVI.

Results

Overall, 134 patients were referred for TAVI (mean age: 84±4 years; &gt;90 years: 12%, women 67%). Average STS score was 4.6 ± 3.0 (low risk: 49%; intermediate: 39%, high risk: 12%). Mean SPPB was 6.3±3.7 (SPPB &lt;6: 32%). Ninety-five (71%) patients belonged to the MPI-low risk group, 30 (22%) to the MPI intermediate risk group and nine (7%) to the MPI high risk group.

After 3 years, 17 (12.7%) patients died, and 40 (29.9%) were hospitalized: 21 (15.7%) for cardiovascular complications (N=11 for acute heart failure, N=6 for major bleeding, N=4 for stroke). Four patients (2.9%) implanted a pacemaker. One patient (0.7%) required a de-novo intervention.

At Cox multivariable analysis, only frailty (MPI intermediate-high) was associated with mortality (HR 5.42, 95% C.I. 1.88-12.11, p=0.002) while a high STS score showed a trend towards higher mortality risk (HR 1.63, 95% C.I. 0.91-2.91, p=0.101). Overall, at Kaplan Meier survival analysis, patients considered fit (non-frail) were characterized by a better prognosis irrespective of STS score (&lt;8 vs &gt;8).

Conclusions

In a prospectively enrolled cohort of old TAVI candidates, frailty status was able to identify patients at higher risk of mortality irrespective of STS risk. Frailty assessment could be a useful tool, coupled with other scores, for early detection of patients at risk of disability, and potentially, for preventing the futility of the TAVI procedure.

Comparison of minimally invasive versus conventional thoracic aortic operations: Early and midterm results in a series of 624 patients

OBJECTIVE

Despite minimally invasive techniques having gained wider application in cardiac surgery, current evidence on minithoracic aortic surgery is still limited. The aim of this study was to compare early and midterm outcomes of patients undergoing operations of the proximal thoracic aorta through ministernotomy (MS) versus full sternotomy (FS).

METHODS

Data from 624 consecutive patients who underwent proximal aortic repair through MS (n = 214, 34.3%) and FS (n = 410, 65.7%) at two aortic centers were analyzed. Treatment selection bias was addressed using propensity score matching (MS vs. FS). After matching, two well-balanced groups of 202 patients each were created.

RESULTS

Median cardiopulmonary bypass and cross-clamp times were 88 and 68 min, respectively, with no difference between groups. Overall, 30-day mortality was 1% (n = 2) in MS and 0.5% (n = 1) in FS (p = .6). No difference was found in the rates of stroke (MS n = 5, 2.5%; FS n = 5, 2.5%), dialysis (MS n = 1, 0.5%; FS n = 4, 2%), bleeding (MS n = 7, 3.5%; FS n = 7, 3.5%), and blood transfusions (MS n = 67, 33.3%; FS n = 57, 28.4%). Patients receiving MS showed a lower incidence of respiratory insufficiency compared with FS (0% vs. 2.5%, p = .04). Intensive care unit and hospital stays were similar between groups. Two-year survival rate was 97.2% in MS and 96.5% in FS (p = .9).

CONCLUSIONS

Mini proximal aortic operations can be performed successfully without compromising the proven efficacy and safety of conventional access. In selected patients, MS was associated with very low mortality and morbidity rates. Additionally, MS demonstrated superior clinical outcomes as regards respiratory adverse events, when compared with FS.

Are severe mitral annular calcification still a contraindication to open surgery?

Background

Mitral annular calcifications are considered a contraindication to open mitral valve repair/replacement, being associated with a significant risk of rupture of the atrioventricular groove or prosthesis detachment/paraprosthetic leak. Recently a scoring system has been proposed, to quantify the severity of MAC and predict the success of transcatheter valve in MAC implantation.

Objective

We present a series of consecutive patients with MAC undergoing sugical mitral valve replacement in recent years.

Patients and methods

82 consecutive patients with MAC underwent open surgical correction from January 2019 at our centre. This was a complex cohort of patients with a high surgical risk profile (STS 5.3±3.2). The degree of MAC was moderate in 60 and severe in 22. Annular decalcification was required in 16 patients, and patch reconstruction of the AV groove in 4. The main predictor of the need for annular decalcification and reconstruction was the depth of calcium infiltration in the ventricular wall at CT. At intraoperative TEE only one patient had a significant paraprosthetic leak, that was repaired during a second short period of aortic cross-clamping. 30 days mortality was 1.2% (one patient), and 87% of patients were alive and well at one year.

Comment

The presence of significant mitral annular calcificaion per se should not be considered a contraindication to open mitral valve surgery. The depth of the calcifications in the ventricular wall, as measured at CT 3D multiplanar reconstructions is the best predictor of the need to decalcify/reconstruct the AV groove. Detailed imaging analysis is crucial for the success of the procedure.

Funding Acknowledgement

Type of funding sources: None.

Modelling and fabrication procedure for a 3D printed cardiac model - surgical planning of Left Ventricular Aneurysm

The present paper describes a procedure for the development and production of a physical model for surgical planning of a Left Ventricular Aneurysm. The method is based on the general approach provided in Otton et al. (2017) and was customized to seek a reliable and fast procedure for the production of a specific type of cardiac model – i.e. chambers of the left side of the heart. The paper covers all the steps: processing of the data, segmentation, modelling and 3D printing; details are provided for all the phases, in order to allow the reproduction of the achieved results. The procedure relies on Computed Tomography - CT imaging as data source for the identification and modelling of the anatomy. Materialise Mimics was used as segmentation software to process the CT data. While its usefulness for the surgical needs was verified on a single clinical case (provided by the Careggi Hospital of Florence, Italy), the modelling procedure was tested twice, to produce a physical replica both ex-ante and ex-post surgical intervention.•

The tools used for segmentation and generation of the printable model were customized to reduce modelling time for the specific type of desired model.

•

Detailed information on the use of modeling tools, not available in the literature, will be provided.

•

The procedure allows fabrication of a physical model representing the heart chambers in a short time.

Outcome analysis of synchronous carotid endarterectomy and cardiac surgery. Comparison of two anesthetic techniques after propensity score-matching

BACKGROUND

The aim of this study was to investigate the outcome of patients undergoing synchronous carotid endarterectomy and coronary and/or other cardiac surgery. The impact of anesthesia on the outcome was examined.

METHODS

A retrospective single-center observational study was performed, to investigate the outcome of 127 consecutive adult patients submitted to synchronous surgery from 2011 to 2019. Cooperative patient general anesthesia for carotid endarterectomy followed by standard general anesthesia for cardiac surgery and standard general anesthesia for the whole surgery were compared after a propensity score analysis.

RESULTS

Primary outcomes were 30-day mortality (3.1%), incidence of stroke (3.1%), and myocardial infarction (0.8%). Agitation upon awakening, postoperative cardiac troponin I release, the increase of serum creatinine, the occurrence of acute kidney injury and the need for continuous renal replacement therapy were the secondary outcomes. A binary logistic regression revealed that cardiopulmonary bypass use, standard general anesthesia for the whole surgery and the European risk score II, were the strongest predictors of any severe postoperative complications. After propensity score matching, general anesthesia for the whole surgery was significantly correlated with the occurrence of any severe postoperative complication (P=0.038).

CONCLUSIONS

Synchronous surgery was performed with acceptable mortality and complication rate even in combination with other than isolated coronary surgery. Cooperative patient general anesthesia during carotid endarterectomy, was not inferior to general anesthesia in this setting.

Evidence for hydrogen-sulfide as a novel modulator of Hyperpolarization-activated Cyclic Nucleotide-gated (HCN) channels in human atrial cardiomyocytes

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): M.I.U.R. PRIN 2017

Evidence for hydrogen-sulfide as a novel modulator of Hyperpolarization-activated Cyclic Nucleotide-gated (HCN) channels in human atrial cardiomyocytes

Background

Hydrogen sulfide (H2S) is an endogenous gasotransmitter that controls several physiological and pathological processes in mammalian organs. H2S is synthesized by endogenous enzymes and directly regulates the function of target proteins by sulfhydration of cysteine residues and/or indirect effects mediated by modification of intracellular cyclic nucleotide (cAMP/cGMP) levels. In the cardiovascular system, H2S activates protective responses aimed to counterbalance pathological processes, such as those involved in glucose dysmetabolism, vasal constriction, oxidative stress and cytotoxicity. In cardiac cells, H2S regulates electrogenesis through the modulation of different ion channels, comprising potassium, calcium and TRP channels. No information is available on the effects of H2S on the funny current (If), which is involved in cardiac pacemaking and working myocyte electrogenesis.

Purpose

The aim of this study was to assess whether H2S modulates the properties of If in human atrial myocytes. If is mediated by Hyperpolarization-activated Cyclic Nucleotide-gated (HCN) channels, which are expressed in human atria and are directly regulated by intracellular cAMP/cGMP levels.

Methods

Human atrial cardiomyocytes were isolated by enzymatic and mechanical digestion from atrial specimens of patients undergoing cardiac surgery. The acute effects of H2S on If were tested by single-cell patch-clamp recordings using increasing concentrations of NaHS as H2S donor.

Results

High NaHS concentrations increased If conductance at all potential tested. At physiological potential (-80 mV), relative If conductance changed from 0.33±0.08 to 0.45±0.11 and 0.60±0.11 at 10 and 100 µM concentrations, respectively (p&lt;0.05, n=5-7), while half-maximal activation potential (V½) was shifted from -92.4±0.9 to -83.9±0.7 and -82.4±0.4 mV, respectively (p&lt;0.05, n=5-7). Conversely, low NaHS concentrations reduced If conductance that at -80 mV changed to 0.23±0.07 and 0.25±0.06 at 1 and 5 µM concentrations, respectively (p&lt;0.05, n=5-7). Accordingly, at low NaHS concentration If V½ showed a trend toward less positive potentials. Both high and low concentrations did not modify If kinetics.

Conclusions

H2S exerts a dual, concentration-dependent effect on If expressed in human atrial cardiomyocytes. This response is similar to that induced by NO, a different gas signaling molecule. The effect of H2S on If properties may be caused by direct S-sulfhydration of HCN proteins and/or to modifications of intracellular cAMP/cGMP levels resulting from phosphodiesterase inhibition by H2S. These findings may open novel perspectives to modulate If function and dysfunction in cardiac pacemaker cells and working myocytes.

C13 COMPARISON OF MINIMALLY INVASIVE VERSUS CONVENTIONAL THORACIC AORTIC OPERATIONS: EARLY AND MID–TERM RESULTS IN A SERIES OF 624 PATIENTS

Objective

Despite minimally invasive techniques have gained wider clinical application in cardiac surgery, current evidence on mini thoracic aortic surgery is still limited. The aim of this study was to compare early and mid–term outcomes of patients undergoing proximal thoracic aortic interventions through mini–sternotomy (MS) versus full sternotomy (FS).

Methods

Data from 624 consecutive patients undergoing proximal aortic operations through MS (n = 214, 34.3%) and FS (n = 410, 65.7%) at 2 aortic centers, were analysed. Patients with prior cardiac operations and active endocarditis, and those who underwent emergency operation and combined procedures were excluded. Treatment selection bias was addressed by the use of propensity score matching (MS vs FS). After matching, 2 well–balanced groups of 202 patients each were created. Surgical procedures involved aortic valve replacement/repair and ascending aorta replacement in 190 patients (47%), aortic root replacement in 110 patients (27.2%) and isolated ascending aorta replacement in 104 patients (25.7%).

Results

The median cardiopulmonary bypass and cross clamp times were 88 and 68 minutes, respectively, with no difference between groups. Overall 30–day mortality was 0.7%, being 1% (n = 2) in patients underwent MS and 0.5% (n = 1) in those underwent FS (p = 0.6). No difference was found in the rates of stroke (MS n = 5, 2.5%; FS n = 5, 2.5%), dialysis (MS n = 1, 0.5%; FS n = 4,2%), bleeding (MS n = 7, 3.5%; FS n = 7, 3.5%), and blood transfusions (MS n = 67, 33.3%; FS n = 57, 28.4%) (Table 1). Patients receiving MS were associated with a lower incidence of respiratory insufficiency compared with those receiving FS (0% vs. 2.5%, p = 0.03). The median intensive care unit length of stay was 24 and 25 hours in MS and FS group, respectively (p = 0.3), and in–hospital stay was 7 days both in MS and FS group (p = 0.9). Three–year survival rate was 96.6% in patients receiving MS and 95.7% in those receiving FS (p = 0.9).

Conclusions

Our findings showed that mini proximal aortic operations can be performed successfully without compromising the proven efficacy and safety of conventional access. In selected patients, MS was associated with very low mortality and morbidity rates. Additionally, MS demonstrated superior clinical outcomes as regards respiratory adverse events, when compared with FS.

Case Report: Lithoplasty-Assisted Trans-Axillary Transcatheter Aortic Valve-in-Valve Implantation

We present the case of a severely symptomatic patient with a malfunctioning aortic bioprosthesis and severe multidistrict atherosclerosis that was addressed to our unit for transcatheter valve-in-valve implantation. The imaging and clinical assessment that led to the selection of the access route is discussed.

ST-segment elevation myocardial infarction due to septic coronary embolism: a case report

Background 

Coronary artery embolism is an infrequent cause of type 2 myocardial infarction which can be due to arterial thromboembolism or septic embolism. While systemic embolization is one of the most acknowledged and threatened complications of infective endocarditis, coronary localization of the emboli causing acute myocardial infarction is exceedingly rare occurring in <1% of cases.

Case summary 

A 52-year-old man with a history of Bentall procedure and redo aortic valve replacement due to prosthetic degeneration (11 years prior to the current presentation) presented to the emergency department with high-grade fever and myalgias. Shortly after his arrival, he experienced typical chest pain and an electrocardiogram demonstrated signs of inferior ST-elevation myocardial infarction: coronary angiography showed a lesion of presumed embolic origin at the level of the mid-distal circumflex coronary artery which was treated with embolectomy. Transthoracic and transoesophageal echocardiography highlighted the presence of a periaortic abscess. The final diagnosis of infective endocarditis as the cause of septic coronary artery embolization was confirmed with a Positron Emission Tomography-Computed Tomography (PET-CT) exam and by the growth of Staphylococcus lugdunensis on repeated blood cultures. The patient underwent successful redo Bentall surgery the good outcome was confirmed at 1-month follow-up.

Discussion 

Type 2 myocardial infarction caused by coronary embolism is a rare presentation of infective endocarditis and requires a high level of suspicion for its diagnosis. Prosthetic heart valves are a predisposing factor for infective endocarditis: aortic root abscess requires surgery as it rarely regresses with antibiotic therapy.

Case report of a peculiar aneurysm of the ascending aorta: when there is much more beyond an incidental finding

Background

Aneurysms of the thoracic aorta are common in male patients around the VI–VII decade of life and most have a degenerative aetiology; otherwise, the occurrence of this disease at a younger age should prompt the search of rarer causes. We report a singular case of ascending aortic aneurysm (AAA) in a young man.

Case summary

A large AAA accompanied by multivessel dilatation and renal failure of unknown onset was incidentally found in a 23-year-old male during the diagnostic work-up after a car accident. A systemic disease was therefore suspected, and a full clinical investigation revealed the uncommon diagnosis of sarcoidosis accompanied by large vessel vasculitis.

Discussion

Only a few reports in the literature describe the concurrence of sarcoidosis and large vessel vasculitis (Takayasu arteritis), which may share non-specific immunoinflammatory abnormalities. This case underlines the importance of a multisystem diagnostic approach even in front of an incidental finding that is inconsistent with patient’s age.

Are body mass index and age independent risk factors for new-onset atrial fibrillation after cardiac surgery regardless of left atrial size and left ventricular ejection fraction value?

Background

Obesity, advanced age and left atrium dimensions have been linked to atrial fibrillation (AF).

Purpose

This study aimed at evidencing if the above mentioned risk factors have a role among the others in conditioning the onset of post operative AF (PoAF) in patients undergoing cardiac surgery without previous AF.

Methods

This study evaluated 249 consecutive patients undergoing coronary artery by-pass surgery either isolated or in combination with aortic or mitral valve repair/replacement, or isolated valve repair/replacement. Prior to surgery, in all patients the following data were collected: age (yrs), body mass index (BMI, kg/m2), left atrium (LA) diameter (cm), LA area (cm2), left ventricular ejection fraction (LVEF, %), the presence/absence of arterial hypertension (AH) and diabetes, creatinine (mg/dL). To detect the presence of PoAF, cardiac rhythm was continouosly recorded during the first seven postoperative days.

Results

PoAF occurred in 127 patients (51%). We compared patients with and without PoAF. Mean values (±1 SD) of continuous variables and the frequency of dicothomic ones are reported in the table. No difference was observed for sex, LA diameter, LA area, LVEF and diabetes. Instead, patients with PoAF had higher values of age, BMI, creatinine and a greater prevalence of AH. According to multivariable binary logistic analysis the independent predictors of PoAF were: age (OR = 1.05, CI 95%: 1.026–1.074, p=0.018) and BMI (OR = 1.09, CI 95%: 1.015–1.171, p=0.0001).

Conclusions

Results suggest that advanced age and a higher value of BMI could be strong risk factors for PoAF in patients who undergo cardiac surgery without previous AF. This considering that in the present population the values of LA diameter, LA area and LVEF showed no statistically significant difference between patients with and without PoAF.

Funding Acknowledgement

Type of funding source: None

Time, magnitude and patterns of left ventricular remodeling after MitraClip implantation: clinical implications

Background

The reverse left ventricular remodeling (LV-R) is well known phenomenon that may occurs in a wide spectrum of heart disease, generally associated with an improvement of prognosis. Recently, conflicting data are reported from two randomized trials assessing prognosis after MitraClip implantation.

Purpose

To assess time, magnitude and pattern of LV-R and its relationship with outcome, and to assess the role of ejection fraction (EF) in selection of patients for MitraClip procedure.

Methods and results

Among 47 patients treated with MitraClip for severe mitral regurgitation (MR), 2 switched to surgical intervention. All patients underwent echo before, at discharge, 1 and 6-month after procedure (age 78.2±8.3 years, NYHA 3.74±0.44, LV EF 36.5±12.8%, logistic EuroSCORE I 22.41±8.4, STS-PROM 4.6±1.9, functional MR 82%). From baseline to 6-month reverse LV-R was defined as a ≥15% decrease in LV end-systolic volume (LVESV) and an adverse LV-R as a increase of ≥10% in LVESV, respectively. At 6-month, sustained reduction of MR ≤2 was observed in all patients, but 2; reverse LV-R occurred in 51% (23), adverse LV-R in 18% (8) and no LV-R in 31% (14) patients. In a multivariate regression model, baseline LVEDV were a strong independent predictor of reverse LV remodeling [β −0.564, 95% CI: −0.363 to −0.074; P=0.004], whereas baseline LVEF was not (P=0.126). Furthermore, an LVEDV ≤130 mL was strongly associated with reverse remodeling with an OR: 0.796 (CI: 0.052–0.792, P=0.022). During follow-up (17.5±9.3 months), in adverse/no LV-R patients mortality for any cause and hospitalization for heart failure (HF) occurred in 50% vs. 95.7% (log-rank, P value= 0.006). By Cox analysis, adverse LV-R was strongly associated with mortality for any cause and hospitalization for HF with adjusted OR of 5.6 (95% CI: 1.65–19.00, P=0.006). Finally, combining adverse/no LV-R together the risk of mortality for any cause and hospitalization for HF increased with adjusted OR of 10.08 (95% CI: 1.29–78.6, P=0.027).

Conclusion

The half of real-world patients undergoing percutaneous mitral valve repair for severe MR showed reverse remodeling. However, there was a half of patients in whom afterload mismatch resulted in early and sustained adverse and no remodeling associated with subsequently high mortality and recurrence of HF. Baseline larger LV volumes rather than EF may help us to refine selection patients for MitraClip procedure, avoiding futility.

Funding Acknowledgement

Type of funding source: None

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

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

Durability of bioprosthetic aortic valves in patients under the age of 60 years - rationale and design of the international INDURE registry

BACKGROUND

There is an ever-growing number of patients requiring aortic valve replacement (AVR). Limited data is available on the long-term outcomes and structural integrity of bioprosthetic valves in younger patients undergoing surgical AVR.

METHODS

The INSPIRIS RESILIA Durability Registry (INDURE) is a prospective, open-label, multicentre, international registry with a follow-up of 5 years to assess clinical outcomes of patients younger than 60 years who undergo surgical AVR using the INSPIRIS RESILIA aortic valve. INDURE will be conducted across 20-22 sites in Europe and Canada and intends to enrol minimum of 400 patients. Patients will be included if they are scheduled to undergo AVR with or without concomitant root replacement and/or coronary bypass surgery. The primary objectives are to 1) determine VARC-2 defined time-related valve safety at one-year (depicted as freedom from events) and 2) determine freedom from stage 3 structural valve degeneration (SVD) presenting as morphological abnormalities and severe haemodynamic valve degeneration at 5 years. Secondary objectives include the assessment of the haemodynamic performance of the valve, all stages of SVD, potential valve-in-valve procedures, clinical outcomes (in terms of New York Heart Association [NYHA] function class and freedom from valve-related rehospitalisation) and change in patient quality-of-life.

DISCUSSION

INDURE is a prospective, multicentre registry in Europe and Canada, which will provide much needed data on the long-term performance of bioprosthetic valves in general and the INSPIRIS RESILIA valve in particular. The data may help to gather a deeper understanding of the longevity of bioprosthetic valves and may expand the use of bioprosthetic valves in patients under the age of 60 years.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03666741 (registration received September, 12th, 2018).

P5983Pre-operative physical performance as an independent predictor of in-hospital outcomes in older patients undergoing elective cardiac surgery

Introduction

Risk stratification of patients candidate to cardiac surgery is usually based on the Society of Thoracic Surgeons (STS) score or on the Euroscore II. However, these risk scores has limited predictive value in elderly patients.

Purpose

We conducted a study to determine whether the Short Physical Performance Battery (SPPB), a tool assessing physical performance, predicts hospital death and major morbidity, beyond STS risk score. The outcome was a composite end-point as defined by STS Major Morbidity or Operative Mortality (STS-MM) in STS Risk Model Outcomes: operative mortality, stroke, renal failure, prolonged mechanical ventilation, deep sternal wound infection, and reoperation.

Methods

In this prospective, single-center, cohort, hospital-based study, conducted at Careggi University Hospital, Florence, Italy, all patients aged 75+ years referred for an elective coronary aortic by-pass grafting, valvular surgery or combined cardiac surgery were evaluated pre-operatively. Assessment included SPPB, cognitive and functional status and evaluation of comorbidity. Patients receiving emergency/urgent cardiac surgery or a procedure not considered in the STS risk score calculator, who reported previous cardiac surgery or were clinically unstable were excluded. Participants were classified according to the STS-Predicted Risk Of Mortality (STS-PROM) as at low (<4%), intermediate (4 to 8%) or high risk (>8%).

Results

Out of 250 participants (females: 48.4%; mean age: 79.9 years), 148 (59.2%) were at low, 73 (29.2%) at intermediate and 29 (11.6%) at high risk, based on the STS-PROM. Mean±SEM SPPB score was 8.8±0.2, 7.1±0.4 and 6.0±0.7 in participants at low, intermediate, and high risk, respectively (p<0.001). The outcome occurred in 67 subjects (26.8%). SPPB score predicted the outcome in the entire study sample, controlling for STS-MM score, CKD, and anaemia (adjusted OR: 0.89, 95% CI 0.81–0.98 per each point increase; p 0.017). When analyses were repeated separately in participants with STS-PROM indicative of low (<4%) and in those at medium-high risk, the predictive value of SPPB was enhanced in the formers (adjusted OR 0.73, 95% CI 0.62–0.86 per each point increase; p<0.001- controlling for STS score), whereas was lost in the latter. An alternative model was subsequently tested, where STS score was not included and peripheral artery disease and creatinine (variables contributing to the STS score) were individually entered: SPPB was confirmed as a significant predictor also in this model, controlling for anaemia, peripheral artery disease, and creatinine. The corresponding AUC was 0.813 (Figure 1).

Figure 1

Conclusions

SPPB predicts mortality and major morbidity in older patients undergoing elective cardiac surgery, in particular in those classified as low-risk with the STS risk score. Use of SPPB should therefore be recommended to improve preoperative risk stratification of older patients.

Histopathological comparison of intramural coronary artery remodeling and myocardial fibrosis in obstructive versus end-stage hypertrophic cardiomyopathy

BACKGROUND

Although imaging techniques have demonstrated the existence of microvascular abnormalities in hypertrophic cardiomyopathy (HCM), a detailed histopathological assessment is lacking as well as a comparison between different phases of the disease. We aimed to compare microvasculopathy and myocardial fibrosis in hypertrophic obstructive cardiomyopathy (HOCM) versus end-stage (ES) HCM.

METHODS

27 myectomy specimens of HOCM patients and 30 ES-HCM explanted hearts were analyzed. Myocardial fibrosis was quantitatively determined with dedicated software and qualitatively classified as scar-like or interstitial. Intramural coronary arteries were evaluated separately according to lumen diameter: 100-500 μ versus <100 μ. Microvasculopathy assessment included the description of medial and intimal abnormalities and stenosis grading. The two subgroups were compared considering only the anterobasal septum of ES explanted hearts.

RESULTS

Median value of fibrosis in the anterobasal septum of explanted hearts was 34.6% as opposed to 10.3% of myectomy specimens (p < 0.001). Scar-like fibrosis was widely found in ES hearts while interstitial fibrosis was distinctive of HOCM (p < 0.001). All slides showed 100-500 μ microvasculopathy without any differences between subgroups in terms of lumen narrowing, extent of the disease and type of parietal involvement. Among ES hearts these lesions were associated with scar-like fibrosis (p = 0.034). <100-μ microvasculopathy was also frequent with no differences between subgroups.

CONCLUSIONS

Microvasculopathy is an intrinsic feature of HCM with similar characteristics across the natural phases of the disease. Conversely, myocardial fibrosis changes over time with ES hearts showing a three-fold greater amount, mainly scar-like. ES showed a closer association between microvasculopathy and replacement fibrosis.

Venous-arterial extracorporeal membrane oxygenation for refractory cardiac arrest: a clinical challenge

Guidelines stated that extracorporeal membrane oxygenation (ECMO) may improve outcomes after refractory cardiac arrest (CA) in cases of cardiogenic shock and witnessed arrest, where there is an underlying circulatory disease amenable to immediate corrective intervention. Due to the lack of randomized trials, available data are supported by small series and observational studies, being therefore characterized by heterogeneity and controversial results. In clinical practice, using ECMO involves quite a challenging medical decision in a setting where the patient is extremely vulnerable and completely dependent on the medical team's judgment. The present review focuses on examining existing evidence concerning inclusion and exclusion criteria, and outcomes (in-hospital and long-term mortality rates and neurological recovery) in studies performed in patients with refractory CA treated with ECMO. Discrepancies can be related to heterogeneity in study population, to differences in local health system organization in respect of the management of patients with CA, as well as to the fact that most investigations are retrospective. In the real world, patient selection occurs individually within each center based on their previous experience and expertise with a specific patient population and disease spectrum. Available evidence strongly suggests that in CA patients, ECMO is a highly costly intervention and optimal utilization requires a dedicated local health-care organization and expertise in the field (both for the technical implementation of the device and for the intensive care management of these patients). A careful selection of patients guarantees optimal utilization of resources and a better outcome.

Coronary embolism following valve surgery

A 55-year-old man experienced chest pain on the seventh day after valve surgery. Coronary angiography showed embolic occlusion of the left anterior descending coronary artery. The lesion was treated successfully with thrombectomy using the angiojet rheolytic thrombectomy system, resulting in rapid mechanical thrombolysis and removal via the effluent lumen of the catheter. Thrombolysis in Myocardial Infarction 3 flow was restored.

[Bivalirudin and cardiac surgery: two case reports]

Immune reactions to heparin and in particular heparin-induced thrombocytopenia are not rare and potentially fatal complications of heparin treatment. These conditions are frequently underdiagnosed in cardiac surgery. Moreover, few data are available in the literature about the use of alternative anticoagulants to heparin in this setting. We describe the successful use of bivalirudin in 2 patients with hypersensitivity to heparin who underwent cardiac surgery.

Acute traumatic rupture of the descending thoracic aorta: endovascular treatment

BACKGROUND

Acute traumatic rupture of the descending thoracic aorta is usually considered a surgical emergency; a conventional surgical approach carries high morbidity and mortality rates in the perioperative period. Endovascular surgery has recently been considered as providing a new therapeutic strategy for these patients. The aim of our study was to evaluate the feasibility along with early and midterm results of this procedure in our experience.

METHODS

Among 59 thoracic stent-graft procedures performed between May 2001 and May 2005 in our Department, 11 male patients (mean age 48+/-7.3 years) underwent endovascular repair for acute traumatic rupture of the descending thoracic aorta caused by motor vehicle accidents. The feasibility of endovascular repair and the size of the endograft were assessed on the basis of urgent spiral computed axial tomography. In all cases, the lesion was limited to the isthmus. Follow-up was performed at discharge, at 3, 6, and 12 months, and yearly thereafter by clinical examination, chest x-ray, and computed axial tomography scan.

RESULTS

Technical success was obtained in all patients, and no conversion to open repair was necessary. No intraoperative deaths or complications occurred, and no patient developed temporary or permanent neurologic deficits in the postoperative period. One patient died 22 days after the procedure from acute respiratory failure; cumulative 30-day mortality rate was 9.1%. The mean follow-up duration was 18.2+/-4.5 months. No death, endoleak, or reintervention occurred during follow-up.

COMMENTS

The treatment of acute traumatic rupture of the descending thoracic aorta with stent graft is a feasible and safe technique; it provides low morbidity and mortality rates in the early postoperative period, and midterm results are encouraging. However, long-term studies are worthwhile to evaluate the effectiveness and the durability of this procedure.

Novel drug development opportunity for relaxin in acute myocardial infarction: evidences from a swine model

The hormone relaxin has been shown to cause coronary vasodilation and to prevent ischemia/reperfusion-induced cardiac injury in rodents. This study provides evidence that relaxin, used as an adjunctive drug to coronary reperfusion, reduces the functional, biochemical, and histopathological signs of myocardial injury in an in vivo swine model of heart ischemia/reperfusion, currently used to test cardiotropic drugs for myocardial infarction. Human recombinant relaxin, given at reperfusion at doses of 1.25, 2.5, and 5 microg/kg b.wt. after a 30-min ischemia, caused a dose-related reduction of key markers of myocardial damage (serum myoglobin, CK-MB, troponin T) and cardiomyocyte apoptosis (caspase 3, TUNEL assay), as well as of cardiomyocyte contractile dysfunction (myofibril hypercontraction). Compared with the controls, relaxin also increased the uptake of the viability tracer 201Thallium and improved ventricular performance (cardiac index). Relaxin likely acts by reducing oxygen free radical-induced myocardial injury (malondialdehyde, tissue calcium overload) and inflammatory leukocyte recruitment (myeloperoxidase). The present findings show that human relaxin, given as a drug to counteract reperfusion-induced cardiac injury, affords a clear-cut protection to the heart of swine with induced myocardial infarction. The findings also provide background to future clinical trials with relaxin as adjunctive therapy to catheter-based coronary angioplasty in patients with acute myocardial infarction.