External Scaffold for Venous Graft to Treat Chronic Limb-Threatening Ischemia: Results of the FRAME Vascular Support

Background: The surgical treatment of chronic limb-threatening ischemia and optimal conduit choice are extensively debated. The presence of suboptimal autologous material, such as varicosities or venous aneurysms, might impair long-term outcomes. Therefore, kink-resistant external supports have been advocated in the recent literature to improve the conduit quality and outcomes. This study analyzes the FRAME external support in venous ectasic grafts in patients with chronic limb-threatening ischemia. Methods: From September 2017 to September 2023, a total of sixteen patients underwent CLTI surgery with FRAME external support for venous grafts. The inclusion criteria for FRAME applications were varicose or ectasic autologous material with a diameter ≥ 4.5 and ≤ 8 mm in an isolated segment or in the entire vein and a higher risk of bypass extrinsic compression (e.g., extra-anatomical venous bypass course). Results: Technical success and intraoperative patency were achieved in all cases. At 30 days, the limb salvage and survival rates were 100%. The primary bypass patency was 93.7% due to an early graft occlusion. No graft infection was registered. In one case, dehiscence of the surgical wound was treated by surgical debridement and antibiotic therapy. Minor amputation was required in four patients. Over a median follow-up of 32 months, two occlusions were observed; one was treated with reoperation and the other with major amputation. The primary patency was 68.7% and the assisted primary patency was 75%. Limb salvage rates observed during the entire follow-up period were 87.5%. No graft infections or dilatation of the reinforced veins were registered. Conclusions: For patients with CLTI undergoing infrainguinal bypass, satisfactory results in terms of patency and limb salvage rates were achieved using the autologous venous material, even if ectasic or varicose, with the vascular external support FRAME.

Subclavian artery revascularization with subclavian-carotid transposition for TEVAR and non-TEVAR patients

BACKGROUND

Subclavian artery revascularization (SAR) has become an increasingly performed technique in patients undergoing thoracic endovascular aortic aneurysm repair (TEVAR), in order to optimize the proximal landing zone, or in patients with significant atherosclerotic diseases. SAR was usually achieved through carotid-subclavian bypass (CSB) which is daunted by graft and patency-related issues, or through subclavian carotid transposition (SCT) which has recently been reconsidered as a potential solution. Nowadays, multiple endovascular strategies including parallel grafts, chimney graft and branch-fenestrated repair, are available in patients unfit for open SAR. However, there is no consensus on the preferable technique in both TEVAR- and non TEVAR-patients. The purpose of this study was to evaluate our experience with SCT in terms of overall postoperative adverse events and mid-term patency rate.

METHODS

We performed a retrospective cohort study, including all patients who underwent SCT between June 2014 and March 2020 at our Division. Preoperative risk factors, symptoms, intraoperative details, postoperative outcomes and follow-up data were collected.

RESULTS

A total of 27 patients were included in this study. Indications for SCT included aortic arch debranching for TEVAR for thoracic aortic aneurysm and type B dissection and symptomatic subclavian steal syndrome (SSS). There were no major perioperative adverse events or major neurological complications; five minor adverse events occurred (18.5%) (3 Horner' Syndrome, 1 hematoma requiring reoperation,1 pneumothorax). Peripheral nerve injuries and lymphatic lesions were not recorded. On a mean follow-up of 21±16 months, SCT patency was confirmed in all patients and no deaths occurred. Comparison of baseline and operative characteristics and intraoperative details between groups of patients with or without adverse events did not found differences.

CONCLUSIONS

SCT should be considered a feasible, effective and safe technique for SAR, with low perioperative complications and optimal mid-term patency. This surgical technique appears to provide a lower risk of neurological events and mortality, particularly in TEVAR patients, reducing the complications caused by the coverage of the left subclavian artery.

Cardiovascular Effects of Cosmic Radiation and Microgravity

Recent spaceflights involving nonprofessional people have opened the doors to the suborbital space tourism business. However, they have also drawn public attention to the safety and hazards associated with space travel. Unfortunately, space travel involves a myriad of health risks for people, ranging from DNA damage caused by radiation exposure to the hemodynamic changes that occur when living in microgravity. In fact, the primary pathogenetic role is attributed to cosmic radiation, since deep space lacks the protective benefit of Earth's magnetic shielding. The second risk factor for space-induced pathologies is microgravity, which may affect organ function and cause a different distribution of fluid inside the human body. Both cosmic radiation and microgravity may lead to the alteration of cellular homeostasis and molecular changes in cell function. These, in turn, might have a direct impact on heart function and structure. The aim of this review is to draw attention to the fact that spaceflights constitute a novel frontier in biomedical research. We summarize the most important clinical and experimental evidence regarding the cardiovascular effects of cosmic radiation and microgravity. Finally, we highlight that unraveling the mechanisms underlying how space radiation and microgravity affect the cardiovascular system is crucial for identifying potential countermeasures and developing effective therapeutic strategies.

Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery

Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.

Panoramic on Epigenetics in Coronary Artery Disease and the Approach of Personalized Medicine

Epigenetic modifications play a fundamental role in the progression of coronary artery disease (CAD). This panoramic review aims to provide an overview of the current understanding of the epigenetic mechanisms involved in CAD pathogenesis and highlights the potential implications for personalized medicine approaches. Epigenetics is the study of heritable changes that do not influence alterations in the DNA sequence of the genome. It has been shown that epigenetic processes, including DNA/histone methylation, acetylation, and phosphorylation, play an important role. Additionally, miRNAs, lncRNAs, and circRNAs are also involved in epigenetics, regulating gene expression patterns in response to various environmental factors and lifestyle choices. In the context of CAD, epigenetic alterations contribute to the dysregulation of genes involved in inflammation, oxidative stress, lipid metabolism, and vascular function. These epigenetic changes can occur during early developmental stages and persist throughout life, predisposing individuals to an increased risk of CAD. Furthermore, in recent years, the concept of personalized medicine has gained significant attention. Personalized medicine aims to tailor medical interventions based on an individual's unique genetic, epigenetic, environmental, and lifestyle factors. In the context of CAD, understanding the interplay between genetic variants and epigenetic modifications holds promise for the development of more precise diagnostic tools, risk stratification models, and targeted therapies. This review summarizes the current knowledge of epigenetic mechanisms in CAD and discusses the fundamental principles of personalized medicine.

Treatment and Prophylaxis of Post-pericardiotomy Syndrome in Cardiac Surgery Patients: a Systematic Review

PURPOSE

Post-pericardiotomy syndrome (PPS) is a common complication of cardiac surgery. This systematic review aimed to investigate the efficacy of colchicine, indomethacin, and dexamethasone in the treatment and prophylaxis of PPS.

METHODS

Literature research was carried out using PubMed. Studies investigating ≥ 10 patients with clinically PPS treated with colchicine, dexamethasone, and indomethacin and compared with placebo were included. Animal or in vitro experiments, studies on < 10 patients, case reports, congress reports, and review articles were excluded. Cochrane risk-of-bias tool for randomized trials (RoB2) was used for the quality assessment of studies.

RESULTS

Seven studies were included. Among studies with postoperative colchicine treatment, two of them demonstrated a significant reduction of PPS. In the single pre-surgery colchicine administration study, a decrease of PPS cases was registered. Indomethacin pre-surgery administration was linked to a reduction of PPS. No significant result emerged with preoperative dexamethasone intake.

CONCLUSION

Better outcomes have been registered when colchicine and indomethacin were administered as primary prophylactic agents in preventing PPS and PE. Further RCT studies are needed to confirm these results.

Heart Disease and Microgravity: The Dawn of a New Medical Era?: A Narrative Review

After a decline in interest in space missions following the cessation of the Apollo missions, there has been a recent resurgence. Activities on the International Space Station have raised awareness of a positive resumption of space travel to more challenging destinations such as Mars and a possible adaptation of human life on the Moon. The biological and physiological studies conducted on these stations in low Earth orbit are crucial in familiarizing humanity with the potential problems that can arise during long journeys. Cosmic rays and microgravity are the 2 main negative phenomena in space flights. Microgravity in the interplanetary environment plays a special role in altering normal organic processes. These studies are compared to studies conducted on Earth with laboratory technologies that mimic the space environment. To date, the molecular and physiological adaptations of the human body to this unnatural environment are very poor. The aim of this review is therefore to provide an overview of the most important findings on the molecular and physiological anomalies that develop during microgravity in short and long space flights.

Impact of Mitral Regurgitation Recurrence on Mitral Valve Repair for Secondary Ischemic Mitral Regurgitation

OBJECTIVES

The current guidelines still do not include specific recommendations on the use of subvalvular repair (SV-r) for treatment of ischemic mitral regurgitation (IMR). Therefore, the objective of our study was to evaluate the clinical impact of mitral regurgitation (MR) recurrence and ventricular remodeling on long-term outcomes after SV-r combined with restrictive annuloplasty (RA-r).

METHODS

We performed a subanalysis of the papillary muscle approximation trial, studying 96 patients with severe IMR and coronary artery disease undergoing restrictive annuloplasty alongside subvalvular repair (SV-r + RA-r group) or restrictive annuloplasty alone (RA-r group). We analyzed treatment failure differences, the influence of residual MR, left ventricular remodeling, and clinical outcomes. The primary endpoint was treatment failure (composite of death; reoperation; or recurrence of moderate, moderate-to-severe, or severe MR) within 5 years of follow-up after the procedure.

RESULTS

A total of 45 patients showed failure of the treatment within 5 years, of which 16 patients underwent SV-r + RA-r (35.6%) and 29 underwent RA-r (64.4%, p = 0.006). Patients with significant residual MR presented with a higher rate of all-cause mortality at 5 years compared with trivial MR (HR 9.09, 95% CI 2.08-33.33, p = 0.003). MR progression occurred earlier in the RA-r group, as 20 patients in the RA-r group vs. 6 in SV-r + RA-r group had a significant MR 2 years after surgery (p = 0.002).

CONCLUSIONS

RA-r remains a surgical mitral repair technique with an increased risk of failure and mortality at 5 years compared with SV-r. The rates of recurrent MR are higher, and recurrence occurs earlier, with RA-r alone compared to SV-r. The addition of the subvalvular repair increases the durability of the repair, thus extending all of the benefits of preventing MR recurrence.

Cosmic Radiations and the Cardiovascular System: A Narrative Review

In recent times, space flights receive continued interest. Humankind's next two goals are to return to the Moon and, a few years later, to land on the surface of Mars. Although technology will improve enough to enable long voyages, there are still some unresolved questions about the effects of the space environment on human health, including the effects of such long voyages on organs. Specifically, there is no information on the effects of radiation in space on the human cardiovascular system. To better understand the adaptation of the cardiovascular system to radiation exposure, the physical properties of radiation and the cellular and molecular mechanisms underlying tissue changes are essential. To this end, this article aims to provide an overview of the effects of radiation on the cardiovascular system by analyzing the physical properties of radiation and their relationship to cellular and molecular mechanisms and potential changes. Each type of radiation triggers different responses in the cardiovascular system. Radiation plays a relevant role in altering endothelial function and arterial wall stiffness by inducing vascular changes that accelerate atherosclerosis and affect endothelial adhesiveness. Clinical studies have shown that vascular changes due to radiation depend on the delayed manifestations of early radiation damage. To reduce the effects of radiation in space, some pharmacological treatments that seem to be able to counteract oxidative stress during flight are being used. At the same time, new shielding systems that can reduce or eliminate radiation exposure must be developed. Future studies should aim to replicate flights in the deep space environment to study in more detail the harmful effects of radiation on the whole cardiovascular system.

Parasternal Intercostal Nerve Blocks in Patients Undergoing Cardiac Surgery: Evidence Update and Technical Considerations

In the Enhanced Recovery After Surgery era, parasternal intercostal nerve block has been proposed to improve pain control and reduce opioid use in patients undergoing cardiac surgery. However current literature has reported conflicting evidence about the effect of this multimodal pain management, as procedural variations might pose a significant bias on outcomes evaluation. In this setting, the infiltration of the parasternal plane into 2 intercostal spaces, second and fifth, with a local anesthetic spread under or above the costal plane with ultrasound guidance, seem to be standardized in theory, but significant differences might be observed in clinical practice. This narrative review summarizes and defines the optimal techniques for parasternal plane blocks in patients undergoing cardiac surgery with full median sternotomy, considering both pectointercostal fascial block and transversus thoracic plane block. A total of 10 randomized trials have been published, in adjunct to observational studies, which are heterogeneous in terms of techniques, methods, and outcomes. Parasternal block has been shown to reduce perioperative opioid consumption and provide a more favorable analgesic profile, with reduced postoperative opioid-related side effects. A trend toward reduced intensive care unit stay or duration of mechanical ventilation should be confirmed by adequately powered randomized trials or registry studies. Differences in operative technique might impact outcomes and, therefore, standardization of the procedure plays a pivotal role before reporting specific outcomes. Parasternal plane blocks might significantly improve outcomes of cardiac surgery with full median sternotomy, and should be introduced comprehensively in Enhanced Recovery After Surgery protocols.

Patients with Bicuspid Aortopathy and Aortic Dilatation

(1) Background: Bicuspid aortic valve (BAV) is the most frequent congenital cardiac disease. Alteration of ascending aorta diameter is a consequence of shear stress alterations due to haemodynamic abnormalities developed from inadequate valve cusp coaptation. (2) Objective: This narrative review aims to discuss anatomical, pathophysiological, genetical, ultrasound, and radiological aspects of BAV disease, focusing on BAV classification related to imaging patterns and flux models involved in the onset and developing vessel dilatation. (3) Methods: A comprehensive search strategy was implemented in PubMed from January to May 2022. English language articles were selected independently by two authors and screened according to the following criteria. (4) Key Contents and Findings: Ultrasound scan is the primary step in the diagnostic flowchart identifying structural and doppler patterns of the valve. Computed tomography determines aortic vessel dimensions according to the anatomo-pathology of the valve. Magnetic resonance identifies hemodynamic alterations. New classifications and surgical indications derive from these diagnostic features. Currently, indications correlate morphological results, dissection risk factors, and genetic alterations. Surgical options vary from aortic valve and aortic vessel substitution to aortic valve repair according to the morphology of the valve. In selected patients, transcatheter aortic valve replacement has an even more impact on the treatment choice. (5) Conclusions: Different imaging approaches are an essential part of BAV diagnosis. Morphological classifications influence the surgical outcome.

Nosocomial Extracardiac Infections After Cardiac Surgery

Purpose of Review

Nosocomial extracardiac infections after cardiac surgery are a major public health issue affecting 3–8.2% of patients within 30–60 days following the intervention.

Recent Findings

Here, we have considered the most important postoperative infective complications that, in order of frequency, are pneumonia, surgical site infection, urinary tract infection, and bloodstream infection. The overall picture that emerges shows that they cause a greater perioperative morbidity and mortality with a longer hospitalization time and excess costs. Preventive interventions and corrective measures, diminishing the burden of nosocomial extracardiac infections, may reduce the global costs. A multidisciplinary team may assure a more appropriate management of nosocomial extracardiac infections leading to a reduction of hospitalization time and mortality rate.

Summary

The main and most current data on epidemiology, prevention, microbiology, diagnosis, and management for each one of the most important postoperative infective complications are reported. The establishment of an antimicrobial stewardship in each hospital seems to be, at the moment, the more valid strategy to counteract the challenging problems.

The Diagnostic Value of Circulating Biomarkers and Role of Drug-Coated Balloons for In-Stent Restenosis in Patients with Peripheral Arterial Disease

Peripheral arterial disease (PAD) is an increasingly pathological condition that commonly affects the femoropopliteal arteries. The current fashionable treatment is percutaneous transluminal angioplasty (PTA), often with stenting. However, the in-stent restenosis (ISR) rate after the stenting of the femoropopliteal (FP) district remains high. Many techniques have been proposed for the treatment of femoropopliteal ISR, such as intravascular brachytherapy, laser atherectomy, second stenting and drug-coated balloons angioplasty (DCB). DCB showed a significantly lower rate of restenosis and target lesions revascularization (TLR) compared to conventional PTA. However, further studies and multi-center RCTs with dedicated long-term follow-up are needed to verify the true efficiency of this approach. Nowadays, the correlation between PAD and inflammation biomarkers is well known. Multiple studies have shown that proinflammatory markers (such as C-reactive proteins) and the high plasma levels of microRNA could predict the outcomes after stent placement. In particular, circulating microRNA-320a, microRNA-3937, microRNA-642a-3p and microRNA-572 appear to hold promise in diagnosing ISR in patients with PAD, but also as predictors of stent patency. This narrative review intends to summarize the current knowledge on the value of circulating biomarkers as predictors of ISR and to foster the scientific debate on the advantages of using DCB in the treatment of ISR in the FP district.

Efficacy of prophylactic platelet rich plasma (PRP) following open saphenous vein harvesting in cardiac surgery

BACKGROUND

Wound infection represents a frequent trouble following open saphenous vein harvesting in cardiac surgery. Platelets' growth factors are crucial for the healing process. Prophylactic platelet rich plasma (PRP) application on leg wound might reduce the incidence of saphenous vein harvest site infections in patients undergoing coronary artery bypass graft surgery (CABG).

METHODS

Between January 2009 and December 2020, 987 consecutive patients underwent CABG using saphenous vein as conduit graft and were retrospectively divided into two groups. All patients had standard surgical leg wound closure and wound care, but treatment group received adjunctive topical application of PRP (no-PRP and PRP group, respectively). The primary outcome was wound infection.

RESULTS

Saphenous vein harvest site infection rate was similar between PRP (3.5%) and No-PRP (5.2%) group, p = 0.215. The ASEPSIS score was lower for the PRP group (PRP: 3.6 ± 9.1 vs. No-PRP: 5.3 ± 11.2; p = 0.014). Performing a subgroup analysis, the diabetic patients (PRP-DM) group had a lower rate of infection than control group (No-PRP DM) (2.6% vs. 7.7%, p = 0.026). PRP-DM patients had an inferior ASEPSIS score (PRP-DM: 2.7 ± 8.3 vs. No PRP-DM: 7.5 ± 13.2, p < 0.001).

CONCLUSIONS

Topical application of autologous PRP on saphenoug vein harvest site might reduce the rate of surgical site infection, with particular benefit among diabetic patients.

Linezolid Intoxication with Extreme Lactate Blood Levels Successfully Treated with Dialytic Treatment in ICU: A Case Report

INTRODUCTION

Lactic acidosis is a rare but life-threatening complication associated with prolonged linezolid therapy. No specific treatment is suggested, except for antibiotic therapy interruption.

CASE REPORT

A 70-years-old woman faced severe linezolid intoxication after antibiotics therapy initiation for infection of a surgical sternal wound. The patient suffered from a severe increment of blood lactate and thrombocytopenia. She was admitted to ICU twice, and due to dialytic treatment, linezolid and lactate serum levels came back to normality.

CONCLUSION

More studies should be conducted to evaluate the human tissue storage sites of linezolid and the influence of various factors on its clearance and plasma concentrations in critically ill patients.

Outcomes of total arterial revascularization vs conventional revascularization in patients undergoing coronary artery bypass graft surgery: A narrative review of major studies

Coronary artery bypass grafting (CABG) is a widely used surgical procedure which improves clinical outcomes in appropriately selected patients. Conventionally, the greater saphenous vein is often used in CABG. However, due to their higher long-term patency rates, arterial conduits are routinely used, with the left internal thoracic artery (LITA) on left anterior descending (LAD) being the gold standard in CABG. Our aim in the present work was to investigate the outcomes of a total arterial grafting (TAG) on the whole heart, with no use of venous grafts, compared to mixed conduits in real-world data. A literature search was conducted in the bibliographic databases PubMed and Web of Science. Only studies comparing TAG with conventional CABG (at least one venous graft plus one or more arterial grafts), with at least one hundred patients in each group were included in this review. After study selection, a total of 15 relevant studies were evaluated and discussed in the present review. Results indicated that TAG is a highly efficient technique, and multiple arterial grafts can be used to reliably revascularize all coronary artery territories. TAG was more beneficial in terms of both short and long-term outcomes and its use should be encouraged. Large randomized clinical trials are needed to confirm the superiority of total arterial grafting with regard to long-term outcomes.

The Role of Angiogenesis and Arteriogenesisin Myocardial Infarction and Coronary Revascularization

Surgical myocardial revascularization is associated with long-term survival benefit in patients with multivessel coronary artery disease. However, the exact biological mechanisms underlying the clinical benefits of myocardial revascularization have not been elucidated yet. Angiogenesis and arteriogenesis biologically leading to vascular collateralization are considered one of the endogenous mechanisms to preserve myocardial viability during ischemia, and the presence of coronary collateralization has been regarded as one of the predictors of long-term survival in patients with coronary artery disease (CAD). Some experimental studies and indirect clinical evidence on chronic CAD confirmed an angiogenetic response induced by myocardial revascularization and suggested that revascularization procedures could constitute an angiogenetic trigger per se. In this review, the clinical and basic science evidence regarding arteriogenesis and angiogenesis in both CAD and coronary revascularization is analyzed with the aim to better elucidate their significance in the clinical arena and potential therapeutic use.

miRNAs in Cardiac Myxoma: New Pathologic Findings for Potential Therapeutic Opportunities

MicroRNAs (miRNAs) regulate gene expression at the post-transcriptional level, contributing to all major cellular processes. The importance of miRNAs in cardiac development, heart function, and valvular heart disease has been shown in recent years, and aberrant expression of miRNA has been reported in various malignancies, such as gastric cancer and breast cancer. Different from other fields of investigation, the role of miRNAs in cardiac tumors still remains difficult to interpret due to the scarcity publications and a lack of narrative focus on this topic. In this article, we summarize the available evidence on miRNAs and cardiac myxomas and propose new pathways for future research. miRNAs play a part in modifying the expression of cardiac transcription factors (miR-335-5p), increasing cell cycle trigger factors (miR-126-3p), interfering with ceramide synthesis (miR-320a), inducing apoptosis (miR-634 and miR-122), suppressing production of interleukins (miR-217), and reducing cell proliferation (miR-218). As such, they have complex and interconnected roles. At present, the study of the complete mechanistic control of miRNA remains a crucial issue, as proper understanding of signaling pathways is essential for the forecasting of therapeutic implications. Other types of cardiac tumors still lack adequate investigation with regard to miRNA. Further research should aim at investigating the causal relationship between different miRNAs and cell overgrowth, considering both myxoma and other histological types of cardiac tumors. We hope that this review will help in understanding this fascinating molecular approach.

In Stent Neo-Atherosclerosis: Pathophysiology, Clinical Implications, Prevention, and Therapeutic Approaches

Despite the dramatic improvements of revascularization therapies occurring in the past decades, a relevant percentage of patients treated with percutaneous coronary intervention (PCI) still develops stent failure due to neo-atherosclerosis (NA). This histopathological phenomenon following stent implantation represents the substrate for late in-stent restenosis (ISR) and late stent thrombosis (ST), with a significant impact on patient’s long-term clinical outcomes. This appears even more remarkable in the setting of drug-eluting stent implantation, where the substantial delay in vascular healing because of the released anti-proliferative agents might increase the occurrence of this complication. Since the underlying pathophysiological mechanisms of NA diverge from native atherosclerosis and early ISR, intra-coronary imaging techniques are crucial for its early detection, providing a proper in vivo assessment of both neo-intimal plaque composition and peri-strut structures. Furthermore, different strategies for NA prevention and treatment have been proposed, including tailored pharmacological therapies as well as specific invasive tools. Considering the increasing population undergoing PCI with drug-eluting stents (DES), this review aims to provide an updated overview of the most recent evidence regarding NA, discussing pathophysiology, contemporary intravascular imaging techniques, and well-established and experimental invasive and pharmacological treatment strategies.

Biomarkers in EndoVascular Aneurysm Repair (EVAR) and Abdominal Aortic Aneurysm: Pathophysiology and Clinical Implications

Circulating biomarkers have been recently investigated among patients undergoing endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Considering the plethora of small descriptive studies reporting potential associations between biomarkers and clinical outcomes, this review aims to summarize the current literature considering both the treated disease (post EVAR) and the untreated disease (AAA before EVAR). All studies describing outcomes of tissue biomarkers in patients undergoing EVAR and in patients with AAA were included, and references were checked for additional sources. In the EVAR scenario, circulating interleukin-6 (IL-6) is a marker of inflammatory reaction which might predict postoperative morbidity; cystatin C is a promising early marker of post-procedural acute kidney injury; plasma matrix metalloproteinase-9 (MMP-9) concentration after 3 months from EVAR might help in detecting post-procedural endoleak. This review also summarizes the current gaps in knowledge and future direction of this field of research. Among markers used in patients with AAA, galectin and granzyme appear to be promising and should be carefully investigated even in the EVAR setting. Larger prospective trials are required to establish and evaluate prognostic models with highest values with these markers.

Hybrid coronary revascularization in multivessel coronary artery disease: a systematic review

Aim: Hybrid coronary revascularization (HCR) for multivessel coronary artery disease (CAD) integrates coronary artery bypass grafting (CABG) and percutaneous intervention in a planned revascularization strategy. This systematic review summarizes the state of this art of this technique. Methods: Major databases searched until October 2021. Results: The available literature on HCR includes three randomized trials, ten meta-analysis and 27 retrospective studies. The greatest benefits are observed in patients with low-to-intermediate risk and less complex coronary anatomy; highly complex disease and the presence of risk factors favored conventional CABG in terms of adverse events and survival. Conclusion: HCR is an interesting approach for multivessel CAD but should not be considered a 'one-size-fits-all' procedure. Further studies will specify the subset of patients likely to benefit most from this hybrid approach.

Advanced measurements of coronary calcium scores: how does it affect current clinical practice?

Coronary artery calcium (CAC) scoring has emerged as a marker of the burden of atheromatous disease and has been included in scoring systems. The practice of myocardial revascularization, considering percutaneous procedures or surgical strategies, is dramatically changing over years and the prognostic significance of CAC scoring is gradually being conceived. In this interdisciplinary scenario, vessel specific calcium scoring, mapping of coronary calcification and its integration with functional assessment of coronary artery disease might change the future decisions in the catheterization lab and operative theaters. This article summarizes CAC evaluation techniques and its implications in clinical practice.

Perioperative management after elective cardiac surgery: the predictive value of procalcitonin for infective and noninfective complications

Objective: Procalcitonin (PCT) has been associated with adverse outcomes after cardiac surgery. Nevertheless, there is no consensus on thresholds and timing of PCT measurement to predict adverse outcomes. Materials & methods: A total of 960 patients undergoing elective cardiac surgery were retrospectively evaluated. PCT levels were measured from the first to the seventh postoperative day (POD). The onset of complications was recorded. Results: Complications occurred in 421 (44%) patients. PCT on the third POD was associated with the occurrence of any kind of complications (odds ratio: 1.06; p: 0.037), and noninfectious complications (odds ratio: 1.05; p: 0.035), after adjusting. PCT above the median value at the third POD (>0.33 μg/l) predicted postoperative complications (incidence rate ratio: 1.13; p = 0.035). Conclusion: PCT seems to predict postoperative complications in cardiac surgery. The determination at the third POD yields the greatest sensitivity and specificity.

Development and Test of a Portable ECG Device with Dry Capacitive Electrodes and Driven Right Leg Circuit

The use of wearable sensors for health monitoring is rapidly growing. Over the past decade, wearable technology has gained much attention from the tech industry for commercial reasons and the interest of researchers and clinicians for reasons related to its potential benefit on patients' health. Wearable devices use advanced and specialized sensors able to monitor not only activity parameters, such as heart rate or step count, but also physiological parameters, such as heart electrical activity or blood pressure. Electrocardiogram (ECG) monitoring is becoming one of the most attractive health-related features of modern smartwatches, and, because cardiovascular disease (CVD) is one of the leading causes of death globally, the use of a smartwatch to monitor patients could greatly impact the disease outcomes on health care systems. Commercial wearable devices are able to record just single-lead ECG using a couple of metallic contact dry electrodes. This kind of measurement can be used only for arrhythmia diagnosis. For the diagnosis of other cardiac disorders, additional ECG leads are required. In this study, we characterized an electronic interface to be used with multiple contactless capacitive electrodes in order to develop a wearable ECG device able to perform several lead measurements. We verified the ability of the electronic interface to amplify differential biopotentials and to reject common-mode signals produced by electromagnetic interference (EMI). We developed a portable device based on the studied electronic interface that represents a prototype system for further developments. We evaluated the performances of the developed device. The signal-to-noise ratio of the output signal is favorable, and all the features needed for a clinical evaluation (P waves, QRS complexes and T waves) are clearly readable.

Impact of human immunodeficiency virus (HIV) infection in patients undergoing cardiac surgery: a systematic review

The clinical status and prognosis of patients with human immunodeficiency virus (HIV) infection has dramatically changed in the recent years. Cardiovascular diseases can be related to combined antiretroviral therapy and to the aging of HIV-positive population, resulting in significant mortality and morbidity in those patients. It is crucial to understand whether the HIV-status affects the indications and outcomes of cardiac surgery. A literature search was conducted through electronic databases up to 15 May 2020 following PRISMA guidelines. Variables (i.e. patients characteristics) and endpoints (i.e. postoperative complications) were considered as defined in the original publications. All paper describing post-operative outcomes after cardiac surgery were included. Methodological quality of all included studies was assessed using the Newcastle-Ottawa Scale, the Cochrane Risk of Bias tool and the US Preventive Services Task Force grade. A total of eight studies were included in this systematic review; five studies discussed the outcomes of patients with HIV infection, while three studies compared results based on HIV status. All evidences derived from retrospective observational studies with high variability and poor-to-fair quality. Most patients underwent surgical myocardial revascularization. HIV status is not associated with differences in operative mortality (P = 0.32), postoperative mediastinitis (P = 0.30) or pulmonary infective complications (P = 0.67). Cardiac surgery can be considered safe in HIV-positive patients, and HIV status alone should not be considered as a contraindication for cardiac surgery and should not be considered a risk factor for postoperative mortality or perioperative complications. Further studies are required for patients with AIDS.

Sharing of decision-making for infective endocarditis surgery: a narrative review of clinical and ethical implications

Infective endocarditis (IE) is nowadays one of the most challenging disease in cardiac surgery because of its multifaceted clinical and anatomical presentation. Despite the many clinical and surgical advances achieved in the past 60 years, there is a lack of evidence regarding the ideal strategy. The present review aims to investigate and highlight two main novel concepts for the decision-making of the best substitute. Firstly, the concept of an "endocarditis team": a coordinated multidisciplinary effort in the diagnostic work-up, especially in conditions of high risk of embolization or clinical deterioration. A good "endocarditis team" has the role to overcome such problem, in order to ensure a prompt and balanced strategy. Secondly, which ethical considerations are required to drive the choice of valvular substitute. The choice of best valve substitute is a relevant issue of debate, not only with operative but also prognostic and accordingly ethical aftermaths. Many different solutions have been developed to substitute the infected valve. Among these: mechanical prosthesis (MP), biological stented prosthesis (BP), sutureless bioprosthesis and cryopreserved homografts (CHs). Patients need to be informed in detail about the technical issues pertaining the use of these valve substitute. We will discuss the evidences regarding the risk of recurrent infections or future potentially severe calcification of aortic homograft valve and wall (in other words, the failure of the homograft) and the difficulties in managing the reoperation.

Guidelines on prosthetic heart valve management in infective endocarditis: a narrative review comparing American Heart Association/American College of Cardiology and European Society of Cardiology guidelines

Infective endocarditis (IE) represented over the last year a growing medical and surgical concern. The changes in etiology and demographic of the disease, which now includes also a large proportion of iatrogenic conditions, has prompted new studies and updates in the guideline for IE treatment. The increasing use of intravascular and intracardiac devices has introduced new challenges in terms of both antibiotic resistance and surgical treatment of prosthetic endocarditis. Also, patients with complex congenital heart diseases, intravenous drug abusers and patients with chronic renal failure under hemodialysis have been added to the list of high-risk subjects for IE. Important aspects concerning the establishment of the endocarditis team, the clinical management, the optimal medical therapy and the indication and timing for surgery are arguments of debate and controversy across the literature. In particular, the most adequate strategy to be adopted in the context of concomitant neurological complication remains greatly debated. Despite attempts to standardize the practice in IE, the lack of powered randomized clinical evidence prevented the achievement of a univocal consensus in several aspects of the management of IE. This situation reflects in some differences in the recommendation promoted by the European Society of Cardiology and American Heart Association/American College of Cardiology. In this review, we will compare the European Society of Cardiology and the American Heart Association guidelines and discuss important aspects related to clinical management and indications of for treatment.

Systolic Anterior Motion (SAM) Complicating Mitral Valve Repair: Current Concepts of Intraoperative and Postoperative Management

Mitral valve repair is the gold standard for treatment of degenerative mitral regurgitation, such as that caused by leaflet prolapse, flail or annular dilatation. A variety of surgical techniques allow surgeons to achieve a high rate of success with mitral valve repair, even in complex cases, and mitral valve repair is associated with better long-term outcomes than valve replacement. However, in the setting of mitral valve surgical repair, systolic anterior motion (SAM) is a complication that determines the dynamic anterior movement of the mitral valve towards the interventricular septum during systole, and creates a left ventricular outflow tract obstruction associated with residual mitral regurgitation. Awareness of risk factors for SAM influences operative planning for repair. Predictors of SAM are known and can be definitively evaluated with intraoperative transesophageal echocardiography, but SAM still complicates mitral valve repair and, if untreated, negatively impacts short-term and long-term outcomes. A stepwise approach in SAM correction is advocated, consisting of medical therapy with aggressive volume-loading and beta-adrenoceptor blockade, but severe or persistent SAM requires surgical revision with a second cross-clamping or a redo procedure. The correct choice of surgical technique requires a deep understanding of the anatomical substrate of SAM, as SAM can be due to different mechanisms that require tailored surgical correction to avoid ineffective or potentially dangerous procedures. This paper reviews the mechanisms and predictors of SAM and summarizes the current concepts of intraoperative and postoperative SAM management.

Heart Valve Endocarditis

Heart valve replacement is the most common cardiac surgical operation performed worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are the goals of the procedure. However, no detailed guidelines on prosthesis selection and surgical strategies are available, which should be guided by a comprehensive evaluation of the extent of the infection and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence. Conventional mechanical or stented xenografts are the preferred choice for localized heart infection. In cases of complex IE with involvement of the root or the aorto-mitral continuity, the use of homograft is suggested according to the surgeon's and center's experience. The use of homograft needs to be balanced against the risk of structural degeneration. Prosthetic bioroot and prosthetic valved conduit with a mechanical or bioprosthetic valve are also considered acceptable alternatives in patients with aortic valve endocarditis. The further development of preservation techniques to enable the longer durability of allogeneic substitutes is required. We discuss current evidence for the use of valve substitutes in heart valve endocarditis and propose an evidence-based algorithm for the choice of treatment.

Statin treatment and hypertrophic scarring after cardiac surgery

Wound healing process after surgical procedure plays a crucial role to prevent blood loss and infections. Hypertrophic scars might occur after surgery and are generally associated with an inflammatory burden. Cardiac surgery is intrinsically related to a strong systemic inflammatory state that might favor hypertrophic scarring. Besides lipid-lowering effects, statins are known for their pleiotropic and anti-inflammatory activity. The aim of this study was to investigate the impact of statins in the healing process after median sternotomy in patients undergoing cardiac surgery. All patients undergoing major cardiac surgery with median sternotomy and cardiopulmonary bypass, and subsequently evaluated in the outpatient clinic after discharge, were included in this study. A total of 930 Caucasian patients were retrospectively reviewed. At outpatient visit, 276 patients (29.7%) showed the formation of hypertrophic scars. Patients with hypertrophic scars tended to be younger (P = .001) and nonstatin users (P = .001). Logistic regression analysis confirmed the protective role of statins (odds ratio 0.39, 95% confidence interval 0.29-0.53, P = .001), after adjustment for age. A dose-dependent effect was confirmed, showing a more intensive protective effect for higher doses of statins. Statin use might be correlated with reduced hypertrophic scars after cardiac surgery through median sternotomy. A dose-dependent effect has been shown, and statin effect seems to be independent of age in a selected population undergoing surgery with an elevated inflammatory burden. Although further studies are warranted to elucidate the biologic mechanisms, the concept of using statins as anti-scarring agents is novel and should be investigated with tailored studies.

Preventing treatment failures in coronary artery disease: what can we learn from the biology of in-stent restenosis, vein graft failure, and internal thoracic arteries?

Coronary artery disease (CAD) remains one of the most important causes of morbidity and mortality worldwide, and the availability of percutaneous or surgical revascularization procedures significantly improves survival. However, both strategies are daunted by complications which limit long-term effectiveness. In-stent restenosis (ISR) is a major drawback for intracoronary stenting, while graft failure is the limiting factor for coronary artery bypass graft surgery (CABG), especially using veins. Conversely, internal thoracic artery (ITA) is known to maintain long-term patency in CABG. Understanding the biology and pathophysiology of ISR and vein graft failure (VGF) and mechanisms behind ITA resistance to failure is crucial to combat these complications in CAD treatment. This review intends to provide an overview of the biological mechanisms underlying stent and VGF and of the potential therapeutic strategy to prevent these complications. Interestingly, despite being different modalities of revascularization, mechanisms of failure of stent and saphenous vein grafts are very similar from the biological standpoint.

Current diagnostic ECG criteria for left ventricular hypertrophy: is it time to change paradigm in the analysis of data?

BACKGROUND

Twelve-lead ECG represents the most common diagnostic tool in clinical cardiology and allows an immediate screening of left ventricular hypertrophy (LVH), but current criteria might have poor clinical usefulness in everyday clinical practice due to lack of sensitivity.

METHODS

The current study aims to review and compare the clinical performance of known ECG criteria of LVH in a real-life setting; 2134 patients had ECG and echocardiographic exams performed during the same hospitalization. All traces were retrospectively analysed, and the amplitudes of the waves were manually measured. Transthoracic echocardiography was considered as the gold standard to assess LVH.

RESULTS

LVH had a prevalence of 58%. Considering the diagnostic performance of ECG criteria for LVH, the Cornell voltage carried the best area under the receiver operating characteristic curve (0.678), while RaVF (R wave in aVF lead) had the poorer result (0.440). The R5/R6 criterion had the best sensitivity (60%), but with the worst specificity (37.4%). The 'Q or S aVR' had the best specificity (99.9%) but lacks sensitivity (0.80%). The Peguero Lo Presti criterion had a sensitivity of 42.3% and a specificity of 75.8%. The Cornell voltage and the Cornell product had similar area under the receiver operating characteristic curve values which were found to be significantly greater compared with other criteria.

CONCLUSION

Current ECG criteria of LVH have low sensitivity despite an acceptable specificity. Among these, Cornell voltage and Cornell product criteria were equally found to have a more accurate diagnostic performance compared with other criteria. To overcome the intrinsic limitations of the current ECG LVH criteria, a new paradigm in the analysis of electrocardiographic data might be necessary.

Finite Element Analysis Investigate Pulmonary Autograft Root and Leaflet Stresses to Understand Late Durability of Ross Operation

Ross operation might be a valid option for congenital and acquired left ventricular outflow tract disease in selected cases. As the pulmonary autograft is a living substitute for the aortic root that bioinspired the Ross operation, we have created an experimental animal model in which the vital capacity of the pulmonary autograft (PA) has been studied during physiological growth. The present study aims to determine any increased stresses in PA root and leaflet compared to the similar components of the native aorta. An animal model and a mathematical analysis using finite element analysis have been used for the purpose of this manuscript. The results of this study advance our understanding of the relative benefits of pulmonary autograft for the management of severe aortic valve disease. However, it launches a warning about the importance of the choice of the length of the conduits as mechanical deformation, and, therefore, potential failure, increases with the length of the segment subjected to stress. Understanding PA root and leaflet stresses is the first step toward understanding PA durability and the regions prone to dilatation, ultimately to refine the best implant technique.

On-pump beating-heart coronary artery bypass grafting in high-risk patients: A systematic review and meta-analysis

BACKGROUND

Operative technique for surgical myocardial revascularization in high-risk patients remains an argument of debate. On-pump coronary artery bypass graft (CABG) with cardioplegic arrest and off-pump CABG have intrinsic limitations. The hybrid approach of on-pump beating-heart CABG (OPBHC) has been proposed over the years with conflicting results. This systematic review and meta-analysis intends to summarize the contemporary literature.

METHODS

A literature search was conducted through major electronic databases. The systematic review provided a total of 279 articles, of those 17 studies were included in the present study.

RESULTS

Compared with on-pump CABG, OPBHC patients showed a preoperative higher risk profile but had reduced early mortality (risk ratio [RR], 0.59, 95% CI, 0.36-0.97) and reduced postoperative stroke (RR, 0.60, 95% CI, 0.39-0.91). Also, interesting trends towards reduced postoperative intra-aortic balloon pump use (RR, 0.56, 95% CI, 0.31-1.01) and myocardial infarction (RR, 0.48, 95% CI, 0.22-1.07) were observed. Baseline characteristics and postoperative complications were similar between OPBHC and off-pump CABG, but limited data are available. The risk of incomplete revascularization in OPBHC is lower than off-pump CABG (RR, 0.53, 95% CI, 0.33-0.87) but higher than conventional on-pump CABG (RR, 1.71, 95% CI, 1.23-2.39).

CONCLUSION

OPBHC is an effective technique to perform surgical revascularization in high-risk patients as preventing haemodynamic deterioration and guaranteeing adequate end-organ perfusion. OPBHC represents an alternative technique to on-pump and off-pump CABG, in those cases in which complications deriving from cardioplegic arrest or manipulation of the heart are more likely. For these reasons, OPBHC might be useful in patients with recent myocardial infarction or with left ventricular dysfunction.

Antithrombotic treatment in patients with atrial fibrillation undergoing coronary angioplasty: rational convincement and supporting evidence

BACKGROUND

The management of antithrombotic therapy in patients undergoing percutaneous coronary intervention (PCI) with an indication for long-term oral anticoagulant therapy (OAT) is still a matter of debate. We aim to evaluate the safety and the efficacy of dual therapy (DT) compared to triple therapy (TT) in this clinical setting.

METHODS

A study level meta-analysis and a review of randomized trials selected using PubMed, Embase, EBSCO, Cochrane database of systematic reviews, Web of Science, and abstract from major cardiology congresses. Six randomized trials with 12,156 patients evaluating the strategy of DT vs. TT in patients treated with PCI with indication for long-term OAT were included.

RESULTS

Patients treated with DT demonstrated a 45% relative reduction in the risk of TIMI major bleeding (1.71% vs. 2.99%; OR 0.55, 95% CI 0.41-0.71; P<0.0001) and TIMI minor bleeding compared to TT arm (4.67% vs 7.83%, OR 0.55 95% CI 0.39-0.78, P = 0.0007). All-cause mortality was similar in two arms (3.95% vs 3.77%, P = 0.92), as well as cardiovascular mortality (2.21% vs 2.19%, P = 0.97). DT was associated with a borderline increase of ST (1.02% vs 0.67%, P = 0.07). No significant differences were observed in occurrence of MI and stroke.

CONCLUSIONS

Our findings suggest that DT is safer than TT with regard to occurrence of major bleeding. DT with a direct oral anticoagulant plus clopidogrel at discharge could be effective in most patients, maintaining aspirin in periprocedural phase and as longer "tailored" treatment for patients at higher ischemic risk.

A Nomogram for Predicting Long Length of Stay in The Intensive Care Unit in Patients Undergoing CABG: Results From the Multicenter E-CABG Registry

OBJECTIVE

Many papers evaluated predictive factors for prolonged intensive care unit (ICU) stay after cardiac surgery, but efforts in translating those models in practical clinical tools is lacking. The aim of this study was to build a new nomogram score and test its calibration and discrimination power for predicting a long length of stay in the ICU among patients undergoing coronary artery bypass graft surgery (CABG).

DESIGN

Retrospective analysis of an international registry.

SETTING

Multicentric.

PARTICIPANTS

Based on the european multicenter study on coronary artery bypass grafting (E-CABG) registry (NCT02319083), a total of 7,352 consecutive patients who underwent isolated CABG were analyzed.

INTERVENTIONS

A "long length of stay" in the ICU was considered when equal to or more than 3 days. Predictive factors were analyzed through a multivariate logistic regression model that was used for the nomogram.

RESULTS

Long length of ICU stay was observed in 2,665 patients (36.2%). Ten independent variables were included in the final regression model: the SYNTAX score class critical preoperative state, left ventricular ejection fraction class, angina at rest, poor mobility, recent potent antiplatelet use, estimated glomerular filtration rate class, body mass index, sex, and age. Based on this 10-risk factors logistic regression model, a nomogram has been designed.

CONCLUSION

The authors defined a nomogram model that can provide an individual prediction of long length of ICU stay in cardiovascular surgical patients undergoing CABG. This type of model would allow an early recognition of high-risk patients who might receive different preoperative and postoperative treatments to improve outcomes.

Role of autophagy in aneurysm and dissection of the ascending aorta

Maintenance of physiologically balanced levels of autophagy is crucial for cellular homeostasis and in the normal vessel wall, balanced autophagy can be considered a cytoprotective mechanism that preserves endothelial function and prevents cardiovascular disease. Recent studies pointed out the importance of the modulation of the autophagic flux in the pathogenesis of aortic dissection and aneurysms of the ascending aorta. Notably, shear stress (and its receptor p62), IL-6, Rab7 and Atg5/IRE1α pathways of autophagy may be considered the novel super-selective therapeutic target for the preventive and postoperative treatment of aortic aneurysm and aortic dissection. This review intends to summarize current evidences in this field trying to enlighten new avenues for future researches.

Main Risk Factor in Long-Term Postoperative Aortic Root Enlargement After Aortic Valve Surgery Associated with Ascending Aorta Replacement

AIM

Dilatation of the aortic root (AR) after aortic valve surgery associated with ascending aorta replacement (AVS+AAR) is an important concern in long-term follow-up (FU). This study aimed to identify factors that may be associated with this late complication.

MATERIAL AND METHODS

Two-hundred-sixteen consecutive patients (150 males and 66 females) who underwent AVS+AAR from June 2009 to April 2018 at a single center were retrospectively analyzed. The mean trans-thoracic echocardiographic (TTE) FU was 44.9 ± 22.2 months. An increase of 10% in AR size compared to the pre-operative baseline was the outcome variable. The Student t-test or chi-square test was used as appropriate. For a survival analysis, a Kaplan-Meier curve was computed and a log-rank p-value was calculated. Cox's regression model was used to assess the predictive value of variables over time. A p-value < 0.05 was significant.

RESULTS

No significant differences were observed among patients who underwent aortic valve repair and those who underwent aortic valve replacement (log-rank = 0.917). In patients who underwent valve replacement, AR enlargement was associated with the difference between the diameter of the prosthetic valve and the diameter of the straight vascular prosthesis (OR 0.87, P = 0.024). Based on the difference in diameter between vascular and valve prosthesis, we arbitrarily classified the patients into two groups: a small group (S) (n = 52), in which the difference was ≤ 5 mm, and a large group (L) (n = 34), in which the difference was > 5 mm. Significant AR enlargement was observed in 30.8 % of the S group and 14.7 % of the L group (log-rank = 0.026). A difference of more than 5 mm between the aortic valve prosthesis and the vascular prosthesis protected against AR enlargement in the long-term FU (OR 12.31, P = 0.033), even after adjusting for age and sex (OR 00.32, P = 0.043).

CONCLUSION

According to our findings, a difference between the size of the aortic valve prosthesis and the vascular prosthesis of less than or equal to 5 mm was the only factor that increased the risk of AR enlargement after AVS+AAR in long-term FU.

Deep Sternal Wound Infection (DSWI) and Mediastinitis After Cardiac Surgery: Current Approaches and Future Trends in Prevention and Management

Median sternotomy is the most common access for cardiac surgery. Deep surgical wound infection (DSWI) and mediastinitis after median sternotomy remain significant clinical problems after cardiac surgery in terms of mortality, morbidity and healthcare-associated costs. Despite recent advances in medical management and consensus papers, their incidence ranges from 1% to 5%, and the associated mortality ranges from 20% to 50%. Recent studies in this field are providing excellent outcomes with promising results for the near future. The choice of sternal closure technique plays a crucial role in the prevention of DSWI and mediastinitis and should be tailored to the patient's characteristics, as clinical judgement and experience play a pivotal role. Early aggressive surgical debridement, vacuum-assisted closure (VAC) therapy, muscle flap and newer technologies are revolutionizing the paradigm of treatment of DSWI. Also, recent advances in tissue engineering have been refining potential approaches to tissue regeneration or substitution for enhanced wound repair. This editorial aims to briefly summarize the current and future techniques in DSWI prevention and treatment after cardiac surgery.

Inflammatory Response and Endothelial Dysfunction Following Cardiopulmonary Bypass: Pathophysiology and Pharmacological Targets

BACKGROUND

Endothelial injury occurring during cardiopulmonary bypass is a major contributing factor in the development of organ dysfunction, which leads to many of the postoperative complications occurring during cardiac surgery.

OBJECTIVE

This narrative review aims to summarize the main mechanisms of cardiopulmonary bypass - related disease, evaluating the unfavorable events leading to tissue injury, with a description of current pharmacologic and non-pharmacologic mechanisms to reduce CPB-related injury.

METHODS

A Medline/Pubmed/Scopus search was conducted using clinical queries with the key terms "cardiac surgery", "cardiopulmonary bypass", "inflammation" and "endothelial injury", and related MeSH terms, until July 2019. The search strategy included meta-analyses, randomized controlled trials, clinical trials, reviews and pertinent references. Patents were searched using the same key terms from https://patents.google.com/, www.uspto.gov, and www.freepatentsonline.com.

RESULTS

In this review, we discuss the current knowledge of the mechanisms of vascular endothelial cell injury, the acute inflammatory response, and the regulatory factors that control the extent of vascular injury during extracorporeal circulation, summarizing the main target of anti-inflammatory pharmacologic and non-pharmacologic strategies.

CONCLUSION

Inflammatory response and endothelial dysfunction following cardiopulmonary bypass are the prices to pay for the benefits offered during cardiac surgery procedures. Counteracting the detrimental effect of extracorporeal circulation appears to be crucial to improve clinical outcomes in pediatric and adult cardiac surgery. The intrinsic complexity and the tight interplay of the factors involved might require a holistic approach against inflammation and endothelial response.

Mitral regurgitation after transcatheter aortic valve replacement

Patients undergoing transcatheter aortic valve replacement (TAVR) might have an associated significant MR that can potentially lead to left ventricular (LV) failure after procedure. Considering the specific alterations in the mitral valve in TAVR scenario and the widespread use of TAVR in recent years, it appears important to know and understand the anatomical, functional and clinical implications to develop adequate strategies for the future. Patients with severe mitral regurgitation (MR) have been generally excluded from randomized clinical trials, making poor the impact that associated MR can have on clinical outcomes after TAVR. Several factors must be considered whose presence influences the severity of MR. For example, the elevated prevalence of coronary disease with consequent ischemic MR may account for LV dilation observed at the end stage of aortic stenosis. Evidence randomized studies and registries suggests that the rate of concomitant moderate-to-severe MR in patients undergoing TAVR oscillates between 2% and 33%, and patients with moderate to severe MR may have hemodynamic frailty with clinical deterioration during mechanical intervention. Short- and long-term outcomes, including cardiac mortality, appear to be influenced by the existence of preoperative moderate-to-severe MR or by the postprocedural worsening of mild MR, generally due to adverse LV remodeling. The incidence and the prognostic effect of concomitant MR in patients undergoing TAVR requires specific attention as might trigger adjunctive strategy treatment which should be carefully evaluated in clinical trials.

Are the dynamic changes of the aortic root determinant for thrombosis or leaflet degeneration after transcatheter aortic valve replacement?

The role of the aortic root is to convert the accumulated elastic energy during systole into kinetic flow energy during diastole, in order to improve blood distribution in the coronary tree. Therefore, the sinuses of Valsalva of the aortic root are not predisposed to accept any bulky material, especially in case of uncrushed solid calcific agglomerates. This concept underlines the differences between surgical aortic valve replacement, in which decalcification is a main part of the procedure, and transcatheter aortic valve replacement (TAVR). Cyclic changes in shape and size of the aortic root influence blood flow in the Valsalva sinuses. Recent papers have been investigating the dynamic changes of the aortic root and whether those differences might be correlated with clinical effects, and this paper aims to summarize part of this flourishing literature. Post-TAVR aortic root remodeling, dynamic flow and TAVR complications might have a fluidodynamic background, and clinically observed side effects such as thrombosis or leaflet degeneration should be further investigated in basic researches. Also, aortic root changes could impact valve type and size selection, affecting the decision of over-sizing or under-sizing in order to prevent valve embolization or coronary ostia obstruction.

Mitral regurgitation: lessons learned from COAPT and MITRA-Fr

Recent studies about percutaneous treatment of secondary mitral regurgitation (MR) underlined the importance of left ventricular geometry and features of mitral valve as determinants of procedural and long-term success. Guideline-directed medical therapy (GDMT), transcatheter mitral valve treatment (TMVT) and surgical procedures (mitral valve replacement, mitral valve repair at level of the annulus or subvalvular apparatus) have been extensively evaluated but not adequately compared in current clinical studies. A detailed analysis of the results of the study about transcatheter mitral valve repair would allow to evaluate the safety and effectiveness of such procedure and would provide potential indications for improving the quality of percutaneous and surgical repair in patients with moderate-to-severe secondary MR. Patients with proportionate MR (i.e., MR severity is proportional to the amount of left ventricular dilatation) are prone to respond to the optimization of medical therapy, while patients with disproportionate MR (i.e., MR severity is disproportionately higher than predicted by left ventricular dilatation, with high EROA and small left ventricle) are likely to benefit from additional repair. The identification of specific subpopulation of "high responders", based on the anatomic characteristics of the mitral valve and the relative dimensions of the annulus, the regurgitation and the left ventricle, can also apply to medical therapy. However, some pivotal component of MR (such as the symmetry of tethering and the differences in biomechanical features of leaflets) are not adequately investigated in current studies and warrant further evaluation.

Higher preoperative left atrial volume index predicts lack of mitral regurgitation improvement after transcatheter aortic valve replacement

BACKGROUND

Moderate-to-severe mitral regurgitation is present in 20-35% of patients undergoing transcatheter aortic valve replacement (TAVR) and the current literature lacks simple echocardiographic parameters, which can predict post-TAVR changes in mitral regurgitation. The aim of this study is to investigate the echocardiographic predictors of improvement or worsening of mitral regurgitation in patients undergoing TAVR with moderate-to-severe mitral regurgitation.

METHODS

This retrospective study included 113 patients who underwent TAVR with preoperative mitral regurgitation grade at least 2. Patients with concomitant coronary artery disease requiring treatment were excluded. Mitral regurgitation was related to the annular dilatation or tethering mechanism in all patients. Preoperative and postoperative echocardiographies were compared in terms of mitral regurgitation and other commonly measured parameters.

RESULTS

After TAVR, a reduction in mitral regurgitation was observed in 62.8% of cases. On the basis of the difference between postoperative and preoperative echocardiograms, 71 patients had improved mitral regurgitation, whereas 42 patients had stable or worsened mitral regurgitation. After analyzing preoperative echocardiographic parameters with regard to this group difference, left atrial volume index (LAVI) was the only variable that was different between groups (33.4 ± 4.8 ml/m in improved mitral regurgitation vs. 39.8 ± 3.0 ml/m in not improved mitral regurgitation, P < 0.001). In a multivariable logistic regression model, a LAVI increase was associated with lack of an acute reduction in mitral regurgitation (odds ratio = 1.41, P < 0.001) after adjustment for age and preoperative serum creatinine.

CONCLUSION

Higher preoperative LAVI is a determinant predictor of lack of an acute reduction in mitral regurgitation after TAVR, and LAVI could be used as a stratifying tool to tailor the treatment strategy and the timing of the procedures. However, validation of these results and long-term outcomes are warranted to support those conclusions.