bluuebunny/crossref_metadata_2025 huggingface dataset:
THORACIC ENDOVASCULAR SURGERY FOR SURGICAL MANAGEMENT OF T4 LUNG TUMOR WITH THORACIC AORTIC INVOLVEMENT
Authors: Lonardo E. , Mileo E. , Calanni Macchio C. , Pisapia G. , Damiano A. , Di Tommaso L.
Published: December 2024

Objective:

Surgical treatment of primary lung T4 tumors is controversial especially when the cancer involves the descending thoracic aorta. We aimed to assess perioperative and midterm aortic related outcome of patients undergone aortic stent-graft implantation, followed by en- bloc surgical treatment of the involved aorta and lung cancer resection.

Methods:

From July 2017 to May 2020, we treated 5 patients, diagnosed with T4 lung cancer by the involvement of the descending thoracic aorta. When only the descending thoracic aorta is involved, a two stage procedure was considered, with aortic stent-graft implantation performed before tumor resection. One stage strategy, with stent-graft implantation carried out before thoracotomy, was preferred for patients with involvement of cardiac and/or other vascular mediastinal structures.

Results:

The mean age was 58.4 ± 6.2 years. All patients were affected by NSCLC. All five patients to completely cover the involved segment of aorta required a single stent-graft. Four patients underwent a two stages procedure. One patient, with involvement of the left inferior pulmonary vein, required a one stage en-bloc resection of the left lower lobe, aortic wall adventitia, left inferior pulmonary vein and reconstruction of the left atrial wall. Primary procedural success was achieved in all. At follow-up no patient developed aortic related complications. One patient died 2 years after surgery, due to local recurrence of the tumor.

Conclusions:

T4 lung resection combined with aortic stent-graft implantation can be safely performed. Postoperative and long-term outcome of these patients is related to the pulmonary disease, not to the aortic treatment.
ISTITUTIONAL MULTIDISCIPLINARY AORTIC TEAM: EARLY REPORT OF 18-MONTHS ACTIVITY
Authors: Totaro P. ,   O. B. O. Multidisciplinary Aortic Team
Published: December 2024

Introduction:

The growing complexity of cases of aortic pathology referred to the cardiac surgeon is making necessary to carry out increasingly accurate preoperative assessment to optimize operative management and postoperative outcomes. This has been recognized by guidelines that have expressly indicated the need for a multidisciplinary “Aortic Team”. Here we report the preliminary results of “Aortic Team” set up at our Hospital 18-months ago.

Materials and Methods:

Following the introduction of the outpatient clinic dedicated to thoracic aortic pathology we decided to discuss complex cases in a dedicated multidisciplinary meeting including figures from surgical, clinical and diagnostic medical fields. The peculiarity of our “Aortic Team” is, the participation of different specialties from the engineering-biomedical field. The planning of the meeting was finalized 1-2 week in advance in order to give all participants the opportunity to evaluate all the available documentation.

Results:

Since April 2023, when the “Aortic Team” was officially inaugurated, 15 meetings have been held on a monthly basis with discussion between 3-5 patients. Forty-four patients were discussed (for a total of 50 consultations). 7 patients received cardiac surgery indication, 4 hybrid indication, 11 a contraindication, 4 a vascular surgery indication, 14 indication to further follow up and 10 no indications. In 34 cases the key factor for final decision was the radiological interpretation and in 10 the anesthetist evaluation.

Conclusions:

The preliminary results of our study confirm the need for multidisciplinary consultation to optimize decision-making progress in complex cases of aortic pathology. The impact of new technologies in medical practice should no longer be ignored and the complete discussion of particularly complex cases must necessarily also include professionals from a field other than healthcare.
TOTAL ENDOVASCULAR AORTIC ARCH REPAIR WITH BRANCHED DEVICES: 7-YEAR EXPERIENCE
Authors: Andreis M. , Cibin G. , D’Onofrio A. , Piazza M. , Antonello M. , Caraffa R. , Gerosa G.
Published: December 2024

Purpose:

Endovascular aortic arch stent grafting (Ar-TEVAR) with branched devices offers a less invasive alternative with promising early results. This study aims to evaluate early and long-term outcomes of Ar-TEVAR in high-risk patients.

Methods:

Between 2017 and 2024, 16 consecutive patients underwent Ar-TEVAR at our institution using the Nexus aortic-arch system and RelayBranch devices. Data were prospectively collected and retrospectively analyzed. The primary endpoint was overall survival; secondary endpoints included procedure-related reinterventions, stroke, paraplegia, and endoleaks. Patients were followed-up with clinical examinations and computed tomography angiography (CTA) at discharge, 6 months, and annually for up to 7 years.

Results:

The mean patient age was 74.1 ± 6.8 years, with a mean Euroscore II of 8.4 ± 2.3. Ten patients (62%) had a history of previous open repair for type A aortic dissection. The overall 30-day mortality rate was 12% (2 patients). At 30 days, secondary procedures were performed in 2 patients (12%). No major strokes or paraplegia were observed, while minor strokes occurred in 5 patients (30%). One patient (6%) experienced a type III endoleak. The median follow-up duration was 24 months (IQR 4-60). Overall survival rates were 73.4% at 12 months, 65.3% at 24-60 months, and 43.5% at 72 months.

Conclusions:

Ar-TEVAR with branched devices demonstrates good outcomes up to 7 years in a high-risk cohort, with no major strokes, no paraplegia, and a low incidence of endoleaks. This procedure is a viable option for patients, especially those with previous open ascending repair for type-A dissection.
OUTCOMES OF A MODIFIED FROZEN ELEPHANT TRUNK TECHNIQUE WITH DEBRANCH FIRST IN ACUTE AND CHRONIC AORTIC ARCH DISEASE
Authors: Montella A. P. , Mastrogiovanni G. , Masiello P. , Rubino A. S. , D’Oria V. , De Santo L. S. , De Feo M. , Iesu S.
Published: December 2024

Backround and Aim:

Although Frozen Elephant Trunk has emerged as a valuable technique in aortic arch pathology it is still burdened by a high mortality and morbidity rate due to the technical complexity and clinical and anatomical substrates. We evaluated early hard outcomes in a surgical approach encompassing the following: 1) central cannulation of the right subclavian artery or the right axillary artery; 2) debranch-first approach (selective cannulation of left common carotid artery with single 8-mm dacron graft and the left subclavian artery for cerebral perfusion with single 10-mm dacron graft); 3) central venous cannulation of right atrium; 4) use of a home-made 4-branched perfusion circuit for extracorporeal circulation; 5) brachiocephalic artery clamping at 26–28°C and beginning of selective antegrade perfusion.

Methods:

Retrospective analysis of a prospectively collected database including 167 patients referred for FET (55%acute aortic dissections, 14.5% chronic aortic dissections, and 30.5% extended aneurysms, 67% males, 9.2% diabetes mellitus, 72% arterial hypertension, 8.2% chronic renal failure, 12% peripheral vasculopathy, 3% bicuspid aortic valve, 11.9% redo)

Results:

The average cardio-pulmonary bypass time, cross clamp time, cerebral and visceral perfusion time is 192, 102, 29 and 12 minutes, respectively. In-hospital mortality occurred in 16% (44% due to respiratory failure), spinal cord injury in 2.8% and stroke in 3.5% of patients.

Conclusion:

Debranch-first technique and cerebral protection through the trivascular perfusion strategy appear safe and effective in the treatment of complex arch pathology.
CRYSTALLOID VERSUS BLOOD CARDIOPLEGIA FOR SURGICAL REPAIR OF TYPE A AORTIC DISSECTION: EARLY AND LONG-TERM OUTCOMES
Authors: Pollari F. , Seven U. , Hitzl W. , Weber L. , Ledwon M. , Sirch J. , Bagaev E. , Fittkau M. , Fischlein T.
Published: December 2024

Background:

Myocardial injury following surgery repair for type A aortic dissection (TAAD) is one of the most feared perioperative complications. The question of which is the most appropriate cardioplegic solution in this scenario remains debated. We aimed to compare the outcomes of patients who underwent surgery for TAAD according to the cardioplegic strategy.

Methods:

A retrospective observational study of all consecutive patients (n=393) who underwent surgery for TAAD in our institution between 2003 and 2020 was conducted. The type of cardioplegia (crystalloid histidine-tryptophan-ketoglutarate, “HTK” or blood cardioplegia, “Calafiore”) was at discretion of the surgeon. New onset of postoperative myocardial injury (defined as a 20-fold increase in Troponin T, “cTnT”, from baseline value), and all-cause 30-days and 1-year mortality were the outcomes. Continuous variables were compared using a generalized linear model (lognormal), while categorical variables were compared using two-tailed Chi-squared tests.

Results:

251 patients were eligible for the study: 230 received Calafiore, while 21 patients received HTK. Age (59.97 vs 63.14 years; p=0.26) and GERAADA-score (18.12 vs 15.53; p=0.3) were comparable between groups. Postoperative ICU- stay was significantly longer in Calafiore than HTK-group (10.98 days±11.76, vs 6.9 days ±7.99; p=0.041). Mortality differences were not statistically significant (30- days=18.7% vs 9.5%, p=0.385; 1-year=22.6% vs 9.5%, p=0.265). Mean peak postoperative cTnT level was slightly higher in HTK-group, but not statistically different (p=0.87). Incidence of new myocardial injury was 12% (n=28) in Calafiore and 9.5% (n=2) in the HTK group (p=1.0).

Conclusions:

No differences were found in patients undergoing surgery for TAAD according to cardioplegia solution. HTK cardioplegia may be a safe alternative to blood cardioplegia in these patients.
DETERMINANTS OF POSTOPERATIVE INFECTIONS AND IMPACT ON PERIOPERATIVE HEART TRANSPLANTATION OUTCOMES
Authors: Londi F. , Santamaria V. , Snaidero S. , Castagnini S. , Bellomare M. , Leone A. , Pagliaro M. , Martin-Suarez S. , Pacini D.
Published: December 2024

Background and Aim:

Outcome of patients undergoing heart transplantation (HTX) can be severely affected by post- operative infections. The present study is aimed at identifying their determinants and at analyse short-term outcomes.

Methods:

Through a retrospective analysis, adults undergoing HTX at Bologna University Hospital from January 2013 to December 2023 (n=231) were either assigned to group 1 (n=63) or group 2 (n=168), according to a positive or negative postoperative infection history, respectively.

Results:

Among preoperative recipient characteristics, no significant difference regarding sex, obesity (defined as BMI >30 kg/m2), history of diabetes mellitus and of device or drive-line infection (in patients implanted with VAD) was found. Instead, incidence of postoperative infections was significantly higher in patients undergoing HTX on IABP (p=0.012), ECMO (p=0.036), mechanical ventilation (p=0.041) or with a history of cardiac surgery (p=0.002).

Furthermore, a significant difference in postoperative infection rates was observed among patients requiring postoperative early CRRT (p<0.001), ECMO (p=0.001) or surgical revision (p<0.001).

Moreover, patients developing postoperative infections had significantly longer ICU stay (p<0.001) and hospital stays (p<0.001).

Lastly, 30-day mortality was significantly higher among patients developing postoperative infections (p=0.037); 1-year mortality was, instead, not affected, with Kaplan-Meier survival analysis showing no significant difference (p=0.323 log-rank).

Conclusions:

A critical perioperative state appears linked to a higher rate of postoperative infections, which significantly affect short-term outcomes and length of hospitalization. No significant impact of postoperative infections on 1-year survival was identified.
HEART PRESERVATION WITH EX-SITU NORMOTHERMIC PERFUSION VERSUS COLD STORAGE: A PROPENSITY SCORE MATCHED ANALYSIS
Authors: Gliozzi G. , Sponga S. , Lechiancole A. , Copetti S. , Livi U. , Vendramin I.
Published: December 2024

Background and Aim:

Heart preservation with normothermic perfusion (NP) is recommended in expected ischemic time longer than 4 hours, in complex redo recipient or in case of marginal donors. The aim of the retrospective review of our institutional heart transplantation (HTx) registry is the comparison of early outcomes of NP versus cold storage (CS).

Methods:

From January 2010 to July 2024, 335 consecutive HTx have been performed. Heart preservation was carried out with NP in 22.7% of cases (76/335), while with CS in 77.3% (259/335).After propensity score matching, 54 pairs with no significant residual imbalance were identified. Main early outcomes were compared between groups (NPmatched e CSmatched, respectively).

Results:

Mean age (57±10 years versus 57±11) and male gender (81.3% vs 80.8%) were similar between groups. Considering unmatched patients, NP showed higher rate of reintervention (50% vs 38%) and mechanical circulatory support (MCS)(23% vs 12%), but similar retransplantation (8% vs 6%); after matching these features resulted well-balanced. Considering matched cohort, graft ischemia time [129(110-149) min vs 248(212-268) min, p<0.05] and cardio-pulmonary bypass time [194(150-235) min vs 207(185-254) min] were significantly lower in NPmatched group (p<0.05). Severe primary graft dysfunction (7% vs 7%), dialysis (19% vs 15%), short-term MCS (11% vs 9%) and 30-day mortality (9% vs 7%) were similar (p>0.05). No differences emerged in terms of 1-year survival (75% vs 82%, log-rank 0.359).

Conclusions:

Heart preservation with NP allows a significative reduction in ischemic and cardiopulmonary bypass times. Inhospital outcomes are similar to CS, especially in high risk recipients and marginal donors, offering several logistical, technical and educational advantages.
OCCURRENCE AND SEVERITY OF PARAVALVULAR LEAK (PVL) IN ELDERLY PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) OR SURGICAL AORTIC VALVE REPLACEMENT (SAVR)
Authors: Matteucci M. , Garis S. , Ferrarese S. , Corazzari C. , Cappabianca G. , Masiglat J. , Dossi F. , Tamborini C. , Castiglioni B. , Musazzi A.
Published: December 2024

Background:

TAVI is a rapidly evolving technology that has been shown to be a valuable alternative to SAVR in elderly patients. However, despite the progress made, there remain several potential TAVI limitations that need not to be minimized before implementing this approach. The current analysis aimed to examine the major outcomes of elderly patients treated with TAVI or SAVR focusing on PVL occurrence.

Methods:

We conducted a retrospective observational study of elderly patients (> 70 years) undergoing isolated TAVI or SAVR between January 2019 and December 2023 at our Institution. The incidence of PVL was the primary endpoint. 30-day mortality and in-hospital length of stay (HLOS) were the secondary outcomes.

Results:

271 patients were enrolled (mean age: 79 ± 5 years); the TAVI group included 140 subjects (mean age: 82 ± 4 years), whereas the SAVR group 131 patients (mean age: 82 ± 4 years). The EuroSCORE II was higher in the TAVI group than in the SAVR population (5.1% vs 2.7%, p<0.001). PVL occurrence (of any degree) was significantly lower after SAVR than after TAVI (15.3% vs 78.6%, p<0.001). The majority of PVL were mild in severity (75% and 71% respectively). 30-day mortality rate was numerically lower in the SAVR group than in TAVI (0.8% vs 3.6%, p=0.252). HLOS was comparable between the two groups (8.5 days for SAVR vs 8.2 days for TAVI).

Conclusions:

TAVI was associated with a higher occurrence of PVL compared with SAVR. Moderate PVL was also more prevalent among the TAVI group.
TIME-TO-EVENT ANALYSIS OF MORTALITY AND STROKE IN TRIALS COMPARING TRANS-CATHETER AND SURGICAL AORTIC VALVE IMPLANTATION WITH DIFFERENT RISK PROFILES.
Authors: Gastino E. , Scarpanti M. , Anselmi A. , Brophy J. , Boden W. , De Caterina R. , Sousa Uva M. , Almeida R. M. S. , Verhoye J. , Mandrola J. , Kaul S. , Barili F. , Parolari A.
Published: December 2024

Background:

We compared the effectiveness of TAVI versus SAVR on a composite of death or stroke at 5-year follow-up within high, intermediate and low-risk profiles.

Methods:

From January 2007 to January 2024, we performed a systematic review of literature including randomized control trials (RCTs) comparing TAVI or SAVR with a minimum 1-year follow-up and reporting Kaplan-Meier analysis. The primary endpoint was the composite of all-cause mortality or stroke. Hazard ratios (HRs) and restricted mean survival time (RMST) differences within high, intermediate and low-risk profiles were estimated by reconstructing time-to-event data.

Results:

Seven trials were included (8418 participants). The incidence of composite endpoints increased with higher baseline risk profiles for both treatments. A time-variant effect was present with an early superiority of TAVI, as supported by a cumulative additional time-to-event of 0.73 months at 4 years driven by the high-risk group. The benefit of TAVI increased over time up to 5 years in high-risk patients (RMST difference 2.495. 95%CI: -0.019; 5.01. P-value 0.05). In intermediate and low-risk patients it showed a quadratic association with a smaller increase and attenuation of the observed benefit after 60 months (Low risk 0.813, 95%CI -0.177 1.802; p-value 0.107.

Intermediate risk 0.076, 95%CI -1.131 1.282, p-value 0.902).

Conclusions:

In RCTs comparing TAVI vs SAVR, the benefits of TAVI differ according to the patient’s risk category. The advantage of TAVI over surgery progressively increases up to 5 years in high-risk patients. At 5 years in low and intermediate-risk there are no significant observed benefits.
THE PROGNOSTIC IMPACT OF HEART FAILURE WITH PRESERVED EJECTION FRACTION IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING
Authors: Scarpanti M. , Garatti A. , Gastino E. , Buttiglione G. , D’Ovidio M. , Canziani A. , Daprati A. , de Vincentiis C. , Parolari A. , Menicanti L.
Published: December 2024

Background and Aim:

Despite hard evidence in favour of surgical myocardial revascularization (CABG) in patients with ischemic heart failure (HF) and reduced ejection fraction (HFrEF), data in patients with HF and preserved EF (HFpEF) are scarce. We aim to determine the prognostic role of preserved versus reduced EF on the outcomes of patients with ischemic HF undergoing CABG.

Methods:

Between 2005 and 2018, 4079 consecutive patients with multivessel CAD underwent isolated, on-pump CABG at a single institution. Preoperative HF was ascertained according to clinical data. Preserved LV function was defined as EF ≥ 50%. Accordingly, our population was divided into 4 groups: Group I (noHFpEF, 65%), Group II (HFpEF, 5%), Group III (noHFrEF, 24%), and Group IV (HFrEF, 6%).

Results:

HFpEF and noHFpEF presented with a similar preoperative clinical profile, while the incidence of comorbidities increased in rEF patients. Perioperative morbidity was similar between HFpEF and noHF patients, but postoperative complications increased with rEF. 30-day mortality was comparable between group I and II, but significantly increased in Group III and IV (from 1.2% up to 5%). Finally, HFpEF showed a 10-years survival comparable to Group III, but significantly reduced when compared to Group I. 10-year freedom from MACE was comparable between Group I and II, and significantly higher than Group III and IV.

Conclusions:

In our experience, HFpEF patients undergoing CABG showed excellent perioperative results while proving a similar risk profile, moreover their long- term outcomes are, as expected, worse than noHFpEF patients and yet significantly better compared to HFrEF patients.
EARLY AND MID-TERM RESULTS OF MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS (MIDCAB) SURGERY
Authors: Margari V. , Squiccimarro E. , Visicchio G. , Kounakis G. , Pascarella C. , Carbone C. , Paparella D.
Published: December 2024

Background and Aim:

This study aimed to evaluate the early and mid-term outcomes of minimally invasive direct coronary artery bypass (MIDCAB) surgery for isolated left anterior descending artery (LAD) disease, with a primary focus on revascularization-free survival.

Methods:

A retrospective analysis was conducted on 155 consecutive patients who underwent MIDCAB at Santa Maria Hospital, Bari, Italy, between May 2017 and December 2023. All patients received a direct anastomosis of the left internal thoracic artery (LITA) to the LAD, with sequential grafting performed for those with concurrent diagonal artery disease. The primary endpoint was revascularization-free survival, while secondary endpoints included early postoperative outcomes and mortality. Kaplan-Meier survival curves, log-rank tests, and Cox proportional hazards models were employed for statistical analysis.

Results:

The median follow-up duration was 36 months [12-48]. No 30-day postoperative deaths occurred. The 5-year revascularization-free survival rate was 87.6% [81.3-94.7], and the overall 5-year survival rate was 90.5% [85.1-96.2]. Predictors of the primary endpoint were preoperative New York Heart Association (NYHA) class III (HR 5.898, p=0.030) and postoperative atrial fibrillation (HR 3.405, p=0.018). The incidence of complications was low, with no cerebrovascular events reported.

Conclusion:

MIDCAB for isolated LAD disease is safe, with satisfactory postoperative outcomes and excellent mid-term survival. These findings align with existing literature, underscoring the procedure’s reproducibility. Further multicenter studies are needed to validate these results and compare MIDCAB with other revascularization strategies.
EARLY RESULTS OF MULTIVESSEL MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING
Authors: Margari V. , Squiccimarro E. , Visicchio G. , Kounakis G. , Pascarella C. , Carbone C. , Paparella D.
Published: December 2024

Background:

Minimally Invasive coronary artery bypass grafting (MICS CABG) and Hybrid Revascularization (HR) are alternatives to sternotomy to reduce the procedure’s invasiveness. We aimed to assess the early and mid-term outcomes of MICS CABG.

Methods:

We retrospectively reviewed multivessel MICS CABG patients at Santa Maria Hospital, Bari, from 2017-2024. The primary outcome was 30-day and follow-up mortality.

Results:

Sixty-one patients underwent MICS CABG via left mini-thoracotomy, with mean 2.3±0.5 distal anastomoses using the left internal thoracic artery (LITA), right ITA (RITA), radial artery, or saphenous vein. Five MICS CABG patients (8.2%) had HR. More than half of MICS CABG cases were performed with planned peripheral cardiopulmonary bypass (CPB), without cross-clamping the Aorta. Of the total cohort, 26 patients (42.6%) received endoscopic MICS CABG, using 3D thoracoscopy for ITAs harvesting via bilateral ports in the 2nd, 3rd, and 4th IS, employing peripheral CPB and aortic clamping by Chitwood clamp at the second IS, with cardioplegia delivery via a 4 cm right anterior mini-thoracotomy. Distal anastomoses were performed via left anterior mini-thoracotomy, with subxiphoid manipulation of the emptied heart. Transit time flowmetry was used in all cases. No conversion to sternotomy was needed. No thirty-day mortality occurred, median ventilation was 4 [2-5] hours, and Intensive Care Unit-stay was 1 [1-2] days. All patients received graft evaluation via computerized tomography before hospital discharge. Mean follow-up was 2.9±1.9 years (max 5 years), with no deaths and 4 (1.9%) follow-up PCI.

Conclusion:

MICS CABG is safe and provides excellent early and mid-term outcomes.
VENOUS EXTERNAL SUPPORT (VEST) ENHANCED CABG: MID TERM CLINICAL FOLLOW UP OF A MULTICENTRIC STUDY
Authors: Weltert L. P. , Sandner S. , Centofanti P. , Fusca S. , Plijakova M. , Lodo V.
Published: December 2024

Objectives:

The main objective of this multicentric study is to evaluate the mid-term clinical outcome in coronary artery bypass grafting (CABG) patients, and specifically need for repeat revascularizations associated with VEST supported saphenous vein graft (SVG), compared with unsupported SVG.

Methods and results:

397 patients underwent CABG in a multicentric real-world setting, with or without concomitant procedures, with at least one SVG supported with an external stent. Patients were followed for major adverse cardiac and cerebral events (MACCE) for a mean duration of 30(1-101) months. Overall, 469 external stents were implanted accounting for 71.7% of all 654 vein grafts. Revascularization rates in territories which were grafted with non- stented SVGs were significantly higher (4.32%) than the rates in territories grafted with an externally stented SVG (1.28%) during the index procedure (p=0.015). Freedom from MACCE at 1,3 and 5 years was 95.1% (SE 0.011), 85.4% (SE 0.021), and 82.4% (SE 0.030) respectively.

Conclusions:

VEST-enhanced CABG is safe and feasible in real world routine practice which includes on and off pump CABG, sequential grafting, and concomitant valve surgery. Mid term clinical follow up suggests that VEST enhanced CABG is associated with low revascularization rates, and these interventional procedures are mostly to non-VESted SVG territories.
ASSOCIATION OF SYSTEMIC INFLAMMATORY REACTION AFTER CARDIAC SURGERY WITH INCREASED 30-DAY MORTALITY: A MACHINE LEARNING APPROACH FOR RISK PREDICTION
Authors: Squiccimarro E. , Lorusso R. , Consiglio A. , Margari V. , Piancone F. , Haumann R. G. , Rociola R. , Whitlock R. P. , Paparella D.
Published: December 2024

Background and Aim:

Systemic inflammation (SIRS) characterizes the postoperative course of cardiac surgery, worsening patient outcomes in its most relevant form. We investigated the impact of SIRS on 30-day mortality and developed a machine-learning model for SIRS prediction.

Methods:

A retrospective evaluation of patients who underwent cardiac surgery from 2016- 2020 in a single hospital was performed. SIRS was assessed 12 hours post-surgery using the ACCP/SCCM criteria. A multivariate logistic model identified SIRS predictors. SIRS-positive patients were matched 1:1 with SIRS-negative ones. The effect of SIRS on mortality was investigated within the propensity-matched cohort. Baseline Risk (BRM) and Procedure- adjusted Risk (PARM) Random Forest Models were trained, optimized, and calibrated. Models’ performance was assessed via cross-validation (CV), using the AUC as a benchmark metric.

Results:

A total of 1908 patients were included. SIRS incidence was 28.7%, and 30-day mortality was 4.6%. Propensity scoring matched 483 patient pairs. SIRS was significantly associated with mortality (OR 2.77; 95%CI 1.40-5.47, p=0.003). SIRS mediated a proportion of its intraoperative predictors’ impact on mortality: 24.3% for anemia, 9.9% for vasopressors, 4.0% for hyperlactatemia (p<0.001). The BRM produced an AUC 0.77±0.04 in the 5-fold CV and an AUC 0.73 (95%CI 0.70-0.85) on the test set, whereas the PRM culminated in an AUC 0.81±0.02 in the CV and 0.82 (95%CI 0.76-0.85) on the test-set (DeLong p<0.001).

Conclusion:

Clinically-defined SIRS after cardiac surgery is associated with 30-day mortality. Machine learning allows to predict SIRS effectively, and paves the way for research exploring targeted interventions to prevent/mitigate its negative effects.
FIVE-YEAR REAL-WORLD EUROPEAN RESULTS WITH A NOVEL AORTIC BIOPROSHESIS IN PATIENTS WITH OR WITHOUT CHRONIC KIDNEY DYSFUNCTION
Authors: Onorati F. , Francica A. , Perrone F. , Theron A. , Grabenwoger M. , Lucchese G. , Pacini D. , Fiore A. , Klein P. , Luciani G. B.
Published: December 2024

Background and Aim:

The durability of bioprostheses in patients with advanced stage of chronic kidney disease (CKD) is not well established. Early bioprosthetic degeneration in these patients is strictly linked to secondary hyperparathyroidism with dystrophic calcification, which is demonstrated to start since CKD stage 3. The INSPIRIS Resilia (IR) valve was designed to improve durability through innovative tissue preservation technology, but in patients with CKD has not been evaluated yet.

This study reports 5-year clinical outcomes and bioprosthetic performance (focusing on SVD staged according to VARC-3) in young patients with CKD undergoing SAVR in a multicenter real-world Registry.

Methods:

From 2017 to 2023, clinical and echocardiographic data of patients receiving IR prostheses for isolated or combined AVR were prospectively collected at 7 European Cardiac Centers. 498 patients were included: 421 with CKD stage 1 or 2, 68 with CKD stage 3 or 4, and 9 on dialysis.

Results:

Patients with CKD ≥3 had multiple comorbidities, higher incidence of preoperative endocarditis and more frequent reoperation after previous AVR.

They exhibit a significantly higher 5-year all-cause mortality (p=0.003) and tend to have higher cardiovascular mortality (p=0.056). In a real-world setting, IR valve shows stable haemodynamics with no signs of progression of intra-prosthetic regurgitation up to 5-year follow up. Outcomes were comparable between CKD groups, with non statistical differences in terms of SVD 2 and 3, prosthetic valve endocarditis throughout the follow up.

Conclusions:

In young patients undergoing SAVR with an advanced stage CKD, IR showed good outcomes over a five-year follow-up period.
EARLY EXPERIENCE IN AORTIC VALVE REPAIR WITH GEOMETRIC RING
Authors: Maraschioni G. , La Torre M. W. , Abbà P. , Ferrante L. , Spitaleri A. , Loforte A. , Boffini M. , Rinaldi M.
Published: December 2024

Introduction:

Aortic valve repair (AVr) with geometric ring aims to restore proper valve function by preserving native leaflets and providing stability to dilated annulus.

Methods:

We analysed retrospectively all AVr procedures for aortic regurgitation (AR) with geometric ring annuloplasty at our division between January 2022 and August 2024.

Results:

During the study period, 59 patients underwent AVr using a geometric ring, among them 51 were male and the mean age was 49,3 years (± 17,4). The aortic valve was tricuspid in 28 patients and bicuspid in 31 (52,5%). The bicuspid cohort was younger, with more dilated annulus and left ventricle. 54 patients (91,5%) needed additional cusp repair with either plication of the cusps (79,6%) or shaving (55,9%). In few cases fenestrations closure or cusps reconstruction were necessary. Concomitant surgical procedures were performed in 30 patients (57,6%), including ascending aorta replacement (28,8%) and mitral valve surgery (20,3%). Aortic valve replacement was required in two patients at the time of AVr because of significant residual AR; one was a prior AVr with suture annuloplasty. Mean length–of–stay in ICU and in hospital were 1 and 6.7 days. No significant complications were reported, nor intra–operative and in–hospital mortality. At an average follow-up of 8 months (max 30 months), 86% of the patients had no significant AR, mean aortic gradient was 12.7 mmHg (± 5,6). Only three patients (5,1%) required subsequent aortic valve replacement.

Conclusion:

Considering our initial learning curve, geometric ring annuloplasty for AR is a safe and reproducible procedure with promising short-term results.
PERCUTANEOUS BALLOON OCCLUSION OF LVAD OUTFLOW CANNULA TO EVALUATE MYOCARDIAL FUNCTION RECOVERY
Authors: Loforte A. , Spitaleri A. , Monteleone G. , Parrella B. , Abbà P. , Galanti G. A. , Sandoval A. , Gallone G. , Conrotto F. , Pidello S. , Trompeo A. C. , Boffini M. , Rinaldi M.
Published: December 2024

Off-pump trials to evaluate myocardial recovery in patients with idiopathic dilated cardiomyopathy (DCMP) supported by continuous-flow pumps might be more challenging than with pulsatile-flow devices because of retrograde flow through the left ventricular assist device (LVAD). The estimated recovery rate is about 5% within five years.

We present the case of a young girl suffering with chemotoxic cardiomyopathy. She developed cardiogenic shock and was initially bridged from extracorporeal life support (ECLS) to a durable LVAD. After two years of LVAD support, echocardiography at low RPMs showed evidence of reverse remodeling. However, significant regurgitation through the pump during right heart catheterization (RHC) would have prevented an optimal assessment of myocardial function, therefore an off-pump trial and percutaneous balloon occlusion of LVAD outflow cannula was conducted in a hybrid operating room to evaluate the chance of pump explant.
SIX-YEAR RESULTS OF THE NEWEST GENERATION PERICARDIAL VALVES IN PATIENTS YOUNGER THAN 65 YEARS OLD: REAL-WORLD DATA FROM A MULTICENTER REGISTRY
Authors: Onorati F. , Francica A. , Perrone F. , Porto A. , Geisler D. , Caruso V. , Mariani C. , Pacini D. , Lucchese G. , Grabenwöger M. , Theron A. , Luciani G. B.
Published: December 2024

Background and Aim:

Structural valve degeneration (SVD) remains the «Achille heel» of biological prostheses and younger age at implantation has been shown to accelerate this process. Current ESC/EACTS guidelines recommend biological prostheses in patients over 65 for aortic valve replacement. This study analyse the six-year results in ≤65 years old patients receiving new generation of bovine pericardial valve Inspiris Resilia prosthesis in the aortic position.

Methods:

From 2017 to 2023, clinical and echocardiographic data of patients receving IR prosthesis for isolated or combined AVR were prospectively collected at 7 European Cardiac Surgery Centers. 1871 patients were included: 1257 (67.2%) aged ≤65 years, 614 (32.8%) aged >65 years.

Primary endopint was six- year freedom from structural valve deterioration «SVD» (staged according to VARC-3 criteria). Secondary endpoints were prosthetic haemodynamics at various time point, freedom from prosthesis explant for SVD, non-SVD issues, infective endocarditis and cardiovascular mortality.

Results:

Patients ≤65 years receiving INSPIRIS RESILIA valve in aortic position had higher six-year freedom from any stage of structural valve deterioration, comparable to those of > 65 year old patients. Stable prosthetic haemodynamic values were reported over time in both populations. Only 1.5% of valve were explanted, with endocarditis being the primary cause. Only 4 cases underwent reintervention due to severe SVD, and no difference in six-year freedom from explant for SVD was reported between ≤65 and >65 years old patients.

Conclusions:

This large multicenter registry showed that the INSPIRIS RESILIA valve has good durability in ≤65 years old patients over a six-year follow-up period.
CTSCAN EQUIVALENT OF HARLEQUIN SYNDROME FOLLOWING ECMO IMPLANTATION MIMICKING AORTIC DISSECTION
Authors: Sciacca C. , Musto M. , Degani A. , Pellegrini C. , Pelenghi S. , Totaro P.
Published: December 2024

Introduction:

Extra-corporeal-membrane-oxygenation (ECMO) is a frequent rescue treatment for acute cardiac dysfunction and/or sudden cardiac arrest. CT scan is frequently scheduled following ECMO implant and, unfortunately, flow artifacts could be difficult to discern from severe pathologic conditions such as pulmonary embolism or acute aortic dissection (AAD). Here we reviewed our series of ECMO-patients undergoing acute CTscan in order to evaluate a potential dramatic mistake in CT scan interpretation in patients in ECMO.

Materials and Methods:

Out of 58 ECMO implanted at our Division, in the last 12-month, 6 patients received early CT-scan. We reviewed all ct scan and we analysed potential flow artifacts leading to misdiagnosis during CTscan report. CT scan report were compared to hemodynamical and clinical status.

Results:

Out of 6 patients receiving contrast-CTscan following ECMO implantation, in 2 patients signs of AAD were reported. In case 1 suspicious of AAD from aortic root was diagnosed following ECMO implantation in cath-lab. Following favourable clinical course and ECMO weaning, CTscan showed no-sign of AAD. In case 2 AAD was diagnosed following ECMO implantation due to sudden cardiac arrest but was not confirmed at TE- Echo. Patient died within 48hour without necroscopical assessment.

Conclusion:

Following ECMO implantation, cardiac recovery, can cause ejection of poorly oxygenated blood, leading to selective distal hypoxia. This phenomenon, was named Harlequin syndrome. CTscan equivalent of harlequin syndrome could be a dissection-like image which has to be recognized by experienced radiologist at time of early CT report to avoid potential drastic consequence.
ANALYSIS OF CLINICAL AND ECHOCARDIOGRAPHIC OUTCOMES IN PATIENTS UNDER 70 YEARS OF AGE WHO UNDERWENT BIOLOGICAL AORTIC VALVE REPLACEMENT: INSPIRIS RESILIA VS. PERIMOUNT MAGNA EASE
Authors: Nassar E. , D’Errico Ramirez A. , Saiydoun G. , Alqdeimat I. , Ruggieri V. G.
Published: December 2024

Background:

The INSPIRIS-RESILIA-aortic-prosthesis, made from bovine-pericardial- tissue, features an expandable-stent for easier future TAVI and anti-calcification-properties. Mid-term-outcome reports are still insufficient. This study compares midterm, clinical, and echocardiographic performance between patients implanted with the INSPIRIS-valve and those with the CE-Perimount-MAGNA-EASE-valve.

Methods:

This study is a retrospective-single-centre study. All patients received biological- prostheses, with or without additional procedures, through full-sternotomy, and follow-up included survival, complications, and hospital stay length. The primary outcome was all-cause- mortality one year post-AVR, with secondary-outcomes including gradients, EF, reintervention rates, and postoperative complications. Data were analyzed using descriptive statistics, and PS- matching was used to adjust for baseline differences.

Results:

We included 300 patients, who were implanted with INSPIRIS (n=52), or ME (n=248) between January 2018 and May 2023. After matching each group included 52 patients. The INSPIRIS-group consisted of younger patients with fewer comorbidities compared to the ME-group, which had higher rates of PAD, preoperative AF, and PTCA. Postoperative- outcomes showed the ME-group had higher transfusion rates (INSPIRIS: 46,1% vs ME: 69,2%, P = 0.017), longer CPB-times (INSPIRIS 93 ± 22, ME 109,51 ± 35,05 P=0,004), and a higher, but not statistically significant, reoperation-rate. Mid-term-results showed no significant difference in survival, SVD, or transvalvular-mean-gradient at 1 year (INSPIRIS 11,3 ± 3,56, ME 11,2 ± 4,1, P=0,9), and 3 years (INSPIRIS 12,9 ± 3,7, ME 12,9 ± 3,6, P=0,7).

Conclusion:

Surgical-AVR using the INSPIRIS-valve exhibited comparable safety and satisfactory mid-term-outcomes, with hemodynamic performance similar to the ME-valve. This study demonstrates favorable clinical results and good hemodynamics at 3 years.
INTRODUCING PHASE OF CARE MORTALITY ANALYSIS (POCMA) IN AN ITALIAN CARDIAC SURGERY CENTRE
Authors: Bortolussi G. , Gastino E. , Buttiglione G. , Scarpanti M. , Vitale N. , Porcedda F. , Garatti A. , Menicanti L. , De Vincentiis C.
Published: December 2024

Background and Aim:

Phase of Care Mortality Analysis (POCMA) is a method for analysing deaths following cardiac surgery.

The first aim is to identify the “seminal event” (SE), defined as the most proximal component in the sequence of care, starting a cascade of deterioration culminating in death.

Secondly, the phase (time period in relation to the operation) where SE took place is ascertained.

Last, the SE is classified as avoidable, when protocols/pathways are available to prevent or rescue and the system lacks the resources; unavoidable when there is a >50% likelihood that the SE could not have been prevented.

Methods:

Between January 2023 and September 2024, each case of in-hospital death following cardiac surgery was discussed at a dedicated monthly multi-disciplinary team (MDT) meeting, and classified according to POCMA. All healthcare providers involved in patient’s care were invited to participate.

Results:

Average number of MDT participants was 15 ±4,5, the majority of whom were cardiac surgeons.

Patients: n=72; age 73 ±9 years; female n=33 (46%); EuroScore2 mean 21 ±19, median 11 (IQR 6). Only 26 (36%) of cases consisted of an isolated procedure, while the rest were combined.

POCMA: Preoperatory 23,6% (judgement 70%); Intraoperative 15,3% (surgeon 33%, stroke 25%); Postop ICU 33% (respiratory care 40%, catastrophe 24%, ICU care 20%); Postop Ward 18% (catastrophe 66%). Avoidable SE n=38 (53%).

Conclusions:

This is the first reported experience with POCMA for internal audit in cardiac surgery in Italy. Issues emerged from MDT discussion, particularly avoidable SE, prompted initiatives aimed at quality improvement.
SINGLE-CENTER EXPERIENCE WITH BIOINTEGRAL NO-REACT VALVED CONDUIT FOR THE TREATMENT OF COMPLEX AORTIC ROOT ENDOCARDITIS
Authors: Campanini F. , Leone A. , Castagnini S. , Bianco E. , Guerrini B. , Folesani G. , Murana G. , Pacini D.
Published: December 2024

Objective:

Despite medical and surgical advancements, managing endocarditis involving the aortic root remains challenging for cardiac surgeons due to the anatomical complexity and critical function of the aortic root. This study aims to assess the outcomes of using Biointegral conduit in patients who have undergone aortic root or aortic valve replacement for complex aortic root infective endocarditis at our center.

Methods:

Between February 2011 and December 2023, 46 patients underwent implantation of BioIntegral valved conduit at our institution. The average age of the patients was 67.6 years, with the primary indication for surgery being severe active endocarditis of the aortic root. We analyzed 30-day mortality, overall survival, and freedom from reoperation as outcome measures using various statistical methods such as T-tests, chi-square tests, Cox regression, and Kaplan-Meier analyses.

Results:

Out of the 46 patients, six died during their hospital stay (13.0%), resulting in a 30- day mortality rate of 8.2% (four patients). The Cox regression analysis showed that factors such as EUROSCORE II, older age, and CPB time were associated with increased 30-day mortality. The Kaplan-Meier analysis revealed overall survival rates of 87.0% at 1 year and 74.5% at 5 years, while the freedom from reoperation for graft dysfunction was 100% at 1 year and 96.4% at 5 years.

Conclusion:

Despite the small sample size, our findings suggest positive long-term survival outcomes and low reoperation rates with the use of the BioIntegral conduit. This conduit showed promise even in patients with complex surgical histories and severe aortic root and valve endocarditis.
THE IMPACT OF STRATEGIC CHANGES ON PAEDIATRIC HEART FAILURE PATIENTS RECEIVING BERLIN HEART SUPPORT IN BOLOGNA
Authors: orioli V. , careddu L. , mangerini V. F. , berardi M. , petridis F. D. , agulli M. , ragni L. , hasan T. , gargiulo G. D. , angeli E.
Published: December 2024

Background:

Heart failure in paediatric age represents a significant challenge, and Berlin Heart (BH) ventricular assist device is frequently the only option. We evaluated the effects of recent strategic changes in BH utilization in our centre.

Methods:

From January 2008 to March 2024, 24 patients underwent BH implant. We divided the population in first era (FE, 2008-2016; n=13; Age 5.3 years; weight 17 kg) and second era (SE, 2017-2024; n=11; Age 6.3 years; weight 18.5 kg), (FE, 2008-2016) and second era (SE, 2017-2024), the latter characterized by a more aggressive approach in order to avoid ECMO implantation before BH. Kaplan-Meier curves have been employed to compare mortality.

Results:

In-hospital mortality was 32%. All survived patients underwent orthotopic heart transplantation (OHT), except one still hospitalized in BH. Comparing the two era the need for pre-operative intubation (18.2%, p=0.001) and the use of ECMO (9.1%) were greatly reduced in the SE. No biventricular BH was implanted in the SE. Kaplan-Meier analysis revealed similar survival rates in BH in the two groups. Otherwise, survival after OHT in the FE was 90%, 70% and 70% at 6months, 1year and 4years respectively, in the SE was 100% all over the follow-up period. Overall survival rates at 5 years in patients in whom ECMO wasn’t used before BH implantation was 72%, while in patients with ECMO was 50%, (log- rank=0.307).

Conclusions:

Our analysis may suggest how an earlier and more aggressive approach in the BH implantation in pediatric patients with heart failure avoiding the use of ECMO may improve long-term survival. ECMO could be risk factor of mortality.
TAUSSIG-BING ANOMALY WITH AND WITHOUT AORTIC ARCH PATHOLOGY, SINGLE CENTRE EXPERIENCE WITH ANATOMICAL CORRECTION
Authors: Hoxha S. , Gardellini J. , Parolo M. , De Laurentis E. , Menon T. , Ciuffreda M. , Cristofaletti A. , Luciani G. B.
Published: December 2024

Background:

Taussig-Bing anomaly (TBA) is a rare congenital cardiac anomaly and frequently associated with aortic arch pathology (more than 50% of the patients) such as interrupted aortic arch (IAA), coarctation and arch hypoplasia. The aim of the present report is to describe our results of TBA correction.

Methods:

Between 12/2007 to 08/2023, 12 patients with TBA underwent surgical correction at our Institution. Ten patients (83%) underwent single stage neonatal anatomical correction with ASO, one had staged repair with anatomical correction with ASO performed at 4 months of age and the other one had Kawashima operation.

Results:

There were 7 male and 5 female patients, with a median age of 23 days (7 dys to 12 Yrs) and median body weight of 3.5 kg (2.8-35 kg). Lecompte manoeuvre was performed in 8 patients of 11 who underwent ASO. There were no early deaths. Only 1 late death (8.3%) due to pulmonary hypertension. Median follow-up was 6.3 years (7.8mon-16,4yrs). Overall survival was 100% at 1 year, 91.7% at 2, 5, 10, 16yrs. All patients were in NYHA class I at last FU. Freedom from reintervention was 91.7% (95% CI) and 66.7% (95% CI) at 1 and 5yrs, respectively. The most common reintervention was RVOT patch enlargement a median time of 10 months after ASO.

Conclusions:

Patients with Taussig-Bing anomaly and aortic arch obstruction can undergo neonatal single stage ASO with excellent survival and very low morbidity. In complex coronary anomalies staged repair may represent a safe strategy to manage TBA.
THE MODIFIED KONNO PROCEDURE IN PEDIATRIC OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY
Authors: Abrami G. , Varrica A. , Hafdhullah M. , Reali M. , Lo Rito M. , Torchio F. , Giamberti A. , Tarus A.
Published: December 2024

Background and Aim:

Transaortic septal myectomy is the preferred surgical treatment for hypertrophic cardiomyopathy (HOCM) in children. This study assesses outcomes of modified Konno in children with severe HOCM.

Methods:

This study retrospectively analyzed outcomes in 10 children who underwent modified Konno procedure in our institute between May 2021 and July 2024. The primary outcomes measured included survival rates, early morbidity, and mid-term functional as well as echocardiographic status.

Results:

The median age at the time of the operation was 4.64 years (IQR: 2.5-14.2), and the median weight was 21 kg (IQR: 14-47). One patient had undergone a prior procedure. Mean septal thickness was more than 25 mm. LVOT mean gradient 55 mmHg. Post procedure LVOT mean Gradient was 5 mmHg. There was one early death. One patient needed a permanent pacemaker due to complete heart block.

Conclusions:

The modified Konno procedure effectively relieves obstruction and ensures good survival in children with severe obstructive hypertrophic cardiomyopathy.