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Objectives: Ascending aorta dilatation in patients with bicuspid aortic valve is related both to genetic and haemodynamic factors. Aim of this study is to compare late progression of ascending aorta dilatation in bicuspid aortic valve patients undergoing surgical aortic valve replacement (SAVR) vs transcatheter aortic valve implantation (TAVI). Methods: Data of 189 consecutive patients who underwent aortic valve replacement for severe bicuspid aortic valve stenosis were prospectively collected. Patients who underwent SAVR were compared to patients who underwent TAVI. Indication to the procedure was validated by the institutional Heart Team. Aortic diameters were evaluated by transthoracic echocardiogram. Differences between preoperative and long-term follow-up ascending aorta diameters were compared in the two groups. Results: Between January 2015 and December 2021, 143(76%) patients underwent SAVR and 46(24%) patients underwent TAVI. At 4.6 (Standard Deviation, SD 1.7) years follow-up, patients in the TAVI group showed significantly lower survival (P = 0.00013) and event-free survival (P < 0.0001). Ascending aorta diameter progression was lower in surgical compared to transcatheter patients, 0.95(0.60,1.30) mm vs 1.65(0.67, 2.63) mm, P = 0.02. Ascending aorta diameter progression indexed for body surface area and height, was lower in the surgical group: 0.72(0.38,1.05) mm/m2 vs 1.05(0.39,1.71) mm/m2 P = 0.02, and 0.59(0.36,0.81) mm/m vs 1.11(0.44,1.78) mm/m, P = 0.001, respectively. At multivariable linear regression analysis transcatheter procedure, baseline aortic diameter, and paravalvular leak were significantly associated with increased postoperative ascending aorta dilatation. Conclusions: Bicuspid aortic valve patients who underwent SAVR, showed significantly less long-term ascending aorta diameter progression than patients who underwent transcatheter procedure.

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Aims: Despite general agreement on the benefits of the Heart Team approach for patients with cardiac diseases, few data are available on its real impact on the decision-making process. The aim of the study is to define the evolution over time of the level of agreement with the systematic discussion of patients in the Heart Team and to evaluate the adherence to the Heart Team recommendations and the impact of the Heart Team on the clinical outcome of the patients. Methods: In 2015--2016, an experienced cardiac surgeon and a cardiologist independently reviewed clinical data of a series of 100 patients (Group 1, G1) and subsequently for each patient recommended treatment (surgical, percutaneous, hybrid or medical therapy) or further diagnostic investigations. The next day, each case was discussed by the Hospital Heart Team. The Heart Team recommendation, the subsequent treatment received by the patient and the in-hospital outcome were recorded. The same study procedure was repeated in 2017 in a second (G2) and in 2018 in a third (G3) group, both of them including 100 patients. Results: Complete agreement in treatment selection by the cardiac surgeon, cardiologist and the Heart Team was observed in 43% of cases in G1 and in 70% and 68% in G2 and G3, respectively (G1 vs. G2: P < 0.001, G1 vs. G3: P = 0.01, G2 vs. G3: P = 0.30). Agreement was less frequent in patients with a higher risk profile and in patients with aortic valve stenosis. The Heart Team decision was implemented in 95% of cases with a 30-day mortality of 0.67%. Conclusion: Agreement in treatment selection among the cardiac surgeon, cardiologist and Heart Team appears to be low in the initial experience. Subsequently, it seems to steadily increase over time up to a limit, when it reaches a plateau of stable results. Heart Team clinical cases discussion, based on both guidelines and multidisciplinary experience, represents a key step in defining the best patient treatment pathway, potentially improving the

BACKGROUND: The increasing use of biological substitutes for surgical aortic valve replacement (AVR), has led to the development of new bioprostheses with improved hemodynamics and expected durability.METHODS: In this observational retrospective two-center cohort study, two innovative bioprostheses, INSPIRIS Resilia and AVALUS were analyzed. We analyzed early and 2.4-year follow-up results in terms of safety, clinical outcome and hemodynamic performance. RESULTS: From November 2017 to February 2021, 148 patients underwent AVR with INSPIRIS Resilia (N.=74) or AVALUS (N.=74) bio-prosthesis. The 30-day and mid-term mortality was comparable (1% vs. 3%, P=0.1 and 7% vs. 4%, P=0.4, respectively). Valve-related mortality was observed in one AVALUS patient. Three (4%) patients of the AVALUS group developed prosthetic endocarditis and two of them died after reoperation. No other cases of prosthetic endocarditis were observed. No cases of structural valve degeneration or significant paravalvular leak were detected at follow-up. Median follow-up peak pressure gradient was 21 vs. 23 mmHg (P=0.4) and the mean pressure gradient was 12 vs. 13 mmHg (P=0.9) for Inspiris and AVALUS, respectively. The effective orifice area (EOA) and indexed EOA were 1.5 cm2 vs. 1.4 cm2 (P=0.4) and 0.8 vs. 0.7 cm2/m2 (P=0.5), respectively. Indexed left ventricular mass regression was-33 vs.-52 g/m2 for the Inspiris and AVALUS groups, respectively, (R2-adjusted =0.14; P<0.01).CONCLUSIONS: INSPIRIS Resilia and AVALUS bioprostheses were reliable with comparable results in safety, clinical outcome and hemo-dynamic performance. After statistical adjustment, AVALUS was associated with better left ventricular mass reduction. Long-term follow-up would provide definitive comparative results.

BACKGROUND: In patients undergoing mitral valve surgery, restrictive suture annuloplasty (De Vega) for less-than-severe functional tricuspid regurgitation has been proven to be safe and effective. The aim of this study is to determine whether the adjunct of the plication of the posterior tricuspid leaflet with the same running suture (bicuspidized De Vega or "De Kay") is equally safe and effective.METHODS: Single center, retrospective study on patients submitted to suture repair of the tricuspid valve during mitral valve surgery, with either conventional or De Kay, between January 2014 and December 2020. Comparison was based on degree of residual tricuspid valve regurgitation and right ventricular assessment at discharge.RESULTS: Over the course of the study period, 255 patients undergoing mitral valve surgery had a dilated (>40 mm or >20 mm/m2) tricuspid valve annulus, with less-than-severe tricuspid regurgitation. Conventional De Vega was employed in 166 patients (65.1%) and De Kay in the remaining 89 (34.9%). At discharge the adjunct of postero-septal commissure plication has similar outcomes to the classic De Vega repair. ItCONCLUSIONS: De Kay repair guarantees the same tricuspidal regurgitation reduction as compared with conventional De Vega early after (Cite this article as: Bruno P, Grandinetti M, Farina P, D'Avino S, Graziani F, Calabrese M, et al. Comparison of De-Kay repair versus De Vega suture for functional tricuspid regurgitation: a preliminary experience. J Cardiovasc Surg 2023;64:437-42. DOI: 10.23736/S0021-9509.23.12565-1)

Objective: Previous studies reported a poor outcome in patients with coronavirus 2019 (COVID-19) undergoing cardiac surgery. Complications most frequently described were respiratory failure, renal failure, and thromboembolic events. In their recent experience, the authors observed a very high incidence of bleeding complications. The purpose of the study was to investigate a possible significant correlation between perioperative COVID-19 infection and hemorrhagic complications compared to non-COVID-19 patients. Design: Single-center, observational, retrospective, matched case-control (1:2) study involving patients who underwent open-heart cardiac surgery from February 2020 and March 2021 with positive perioperative diagnosis of COVID-19 infection, matched with patients without COVID-19 infection. Setting: Cardiac surgery unit and intensive care unit of a university tertiary center in a metropolitan area. Participants: In the study period, 773 patients underwent cardiac surgery on cardiopulmonary bypass (CPB). Among them, 23 consecutive patients had perioperative diagnosis of COVID-19 infection (study group). These patients were compared with 46 corresponding controls (control group) that matched for age, sex, body mass index, and Society of Thoracic Surgeons score. Interventions: Open-heart cardiac surgery on CPB. Measurements and Main Results: In the study group, 2 patients (9%) died in the intensive care unit from severe respiratory failure, shock, and multiple organ failure. In the study group, patients showed a significantly higher incidence of bleeding complications (48% v 2%, p = 0.0001) and cases of surgical reexploration for bleeding (35% v 2%, p = 0.0001), a higher incidence of severe postoperative thrombocytopenia (39% v 6%, p = 0.0007), and a higher need of blood components transfusions (74% v 30%, p = 0.0006). Chest tubes blood loss and surgical hemostasis time were markedly prolonged (p = 0.02 and p = 0.003, respectively). Conclusions: A worrisome increa

Functional tricuspid valve regurgitation in the contest of mitral valve disease is a highly prevalent disease. We describe a ringless technique that combines restrictive annuloplasty (De Vega) with posterior tricuspid leaflet obliteration (Kay) used for patients with less-than-severe functional tricuspid valve regurgitation undergoing mitral valve surgery. The technique has been in use at our center since 2012, showing promising long-term echocardiographic results, with stable reduction of the annulus size and stable reduction of the degree of regurgitation.

Background: Progressive right heart chambers dilatation is frequent in the adult congenital heart disease (ACHD) population. We evaluated the immediate and mid-term response of right heart chambers to surgery performed in adulthood for lesions associated with right heart chambers enlargement. Methods: Thirty-six adult patients with lesions associated with right heart chambers enlargement submitted to surgery were studied. We collected echocardiographic data of right ventricle (RV) mid-diameter, right atrial volume indexed, RV systolic pressure, and tricuspid annular plane systolic excursion (TAPSE) prior to surgery (T0), at 2 to 5 days (T1), and 3 to 6 months (T2) after surgery. Results: At T1, we observed a significant decrease of RV mid-diameter (47.2 +/- 8.4 vs. 39.6 +/- 7.4 mm, P<.001), right atrial volume indexed (45.6 +/- 26.6 vs. 27.2 +/- 11 ml/m2, P<.001), and RV systolic pressure (39 +/- 14.8 vs. 32.8 +/- 11.3 mm Hg, P=.03). At T2, a further significant deviation in the rate of RV diameter (39.6 +/- 7.4 vs. 34.5 +/- 5.1 mm, P<.001), in RV systolic pressure (32.8 +/- 11.3 vs. 25.3 +/- 5 mm Hg, P=.03) and TAPSE (13.9 +/- 3.2 vs. 15.8 +/- 2.6 mm, P<.001) was observed. Conclusions: Positive right heart chambers remodeling occurs as early as in the immediate post-operative period in most ACHD patients operated for lesions associated with right heart chambers enlargement.

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Objective: Aortic valve disease is more and more common in western countries. While percutaneous approaches should be preferred in older adults, previous reports have shown good outcomes after surgery. Moreover, advantages of minimally invasive approaches may be valuable for octogenarians. We sought to compare outcomes of conventional aortic valve replacement (CAVR) versus minimally invasive aortic valve replacement (MIAVR) in octogenarians. Methods: We retrospectively collected data of 75 consecutive octogenarians who underwent primary, elective, isolated aortic valve surgery through conventional approach (41 patients, group CAVR) or partial upper sternotomy (34 patients, group MIAVR). Results: Mean age was 81.9 ± 0.9 and 82.3 ± 1.1 years in CAVR and MIAVR patients, respectively (P = 0.09). MIAVR patients had lower 24-hour chest drain output (353.4 ± 207.1 vs 501.7 ± 229.9 mL, P < 0.01), shorter mechanical ventilation (9.6 ± 2.4 vs 11.3 ± 2.3 hours, P < 0.01), lower need for blood transfusions (35.3% vs 63.4%, P = 0.02), and shorter hospital stay (6.8 ± 1.6 vs 8.3 ± 4.3 days, P < 0.01). Thirty-day mortality was zero in both groups. Survival at 1, 3, and 5 years was 89.9%, 80%, and 47%, respectively, in the CAVR group, and 93.2%, 82.4%, and 61.8% in the MIAVR group, with no statistically significant differences (log-rank test, P = 0.35). Conclusions: Aortic valve surgery in older patients provided excellent results, as long as appropriate candidates were selected. MIAVR was associated with shorter mechanical ventilation, reduced blood transfusions, and reduced hospitalization length, without affecting perioperative complications or mid-term survival.

Objective: Clinical benefits of minimally invasive cardiac valve surgery (MIVS) have been reported. Improved postoperative mental status was never analyzed with dedicated psychological tests. In the present study we intend to investigate potential benefits of MIVS for patient psychological well-being, with special attention to the relevance of the patient perception of the chest surgical scar, of the self body image and cosmetic aspects. Methods: Between 2016 and 2017, 87 eligible patients, age 66.5 ± 14.5 years, operated on for heart valve surgery, underwent either conventional full sternotomy (CS; n = 48) or MIVS by V-shape hemi-sternotomy approach (n = 39). Before selection of the surgical approach, patients had undergone preoperative evaluation of their psychological status using Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory Form Y (STAI-Y), and EuroQol-5D (EQ-5D) psychological tests. Six months postoperatively, patients filled in dedicated questionnaires to assess their psychological status, quality of life, and subjective perception, thus repeating the above-mentioned tests and adding the Body Image Questionnaire (BIQ) and Patient and Observer Scar Assessment Scale (POSAS) v2.0 tests for scar-healing process evaluation. Results: No patient died during the study.The 4 post-test scales of psychological well-being (BDI-II P = 0.04, STAI-Y P = 0.04, 2 indices of EQ-5D P = 0.03, P = 0.01) showed significant differences between the MIVS group and CS group, with MIVS-small incision patients having lower level of depression and anxiety symptoms and better quality of life. Mean score differences of scar perception (BIQ and POSAS v2.0) were significant, with MIVS patients having evaluated the scar quality significantly better than CS patients. Conclusions: MIVS appears associated with significant esthetical and related psychological benefits, as documented by technical tests. These findings should be considered when selecting the most appropriate

OBJECTIVES: To assess the role of fetal magnetic resonance imaging (MRI) in detecting associated anomalies in fetuses presenting with mild and moderate isolated ventriculomegaly (VM) undergoing multiplanar ultrasound (US) evaluation of fetal brain. METHODS: Multicenter, retrospective, cohort study involving 15 referral fetal medicine centers in Italy, United Kingdom, and Spain. Inclusion criteria were fetuses affected by isolated VM on US, defined as VM with normal karyotype and no other additional central nervous system (CNS) and extra-CNS anomalies on US, undergoing detailed assessment of fetal brain via a multiplanar approach as suggested by ISUOG guidelines on fetal neurosonogram. The primary outcome of the study was to report the rate of additional CNS anomalies detected exclusively at prenatal MRI and missed at US, while the secondary aim was to estimate the incidence of additional anomalies detected exclusively after birth and missed at prenatal imaging (US and MRI). Sub-group analyses according to the gestational age at MRI (< vs ≥ 24 weeks of gestation), laterality of VM (unilateral vs bilateral), and severity of dilatation (mild vs moderate VM) were also performed. RESULTS: Five-hundreds and fifty-six fetuses with a prenatal diagnosis of isolated fetal VM on US were included in the analysis. Additional structural anomalies were detected at prenatal MRI and missed at US in 5.4% (95% CI 3.8-7.6) of cases. When considering the type of anomalies, supra-tentorial intra-cranial hemorrhage was detected on MRI in 26.7% of fetuses, while polymicrogyria and lissencephaly in 20.0% and 13.3% of cases, respectively. Hypoplasia of the corpus callosum was detected at MRI in 6.7% of cases, while dysgenesis in 3.3%. Fetuses with an associated anomaly detected only at MRI were more likely to have moderate compared to mild VM (60.0% vs 17.7%, p<0.001), while there was no significant difference between the proportion of cases with bilateral VM between the two groups (p=

Surgical ventricular reconstruction (SVR) is the therapy of choice for patients with left ventricular dilatation, apical and anterolateral transmural scar, and low ejection fraction. STICH trial did not show that SVR led to improved survival but several observational studies did. However, because of the considerable operative risk, open heart surgery is considered risky in debilitated patients and clinical results are controversial. Alternative less invasive strategies for left ventricular aneurysm repair have been proposed. We present a case of a left ventricular aneurysm repair using the less invasive ventricular enhancement technique (LIVE) with the Revivent TC system (BioVentrix Inc., San Ramon, CA) in a totally surgical approach, instead of a hybrid interventional-surgical one, as previously described.

Valvular heart disease (VHD) is frequently diagnosed in old patients with clinical evidence of heart failure. This elderly population typically presents a high prevalence of frailty and comorbidities, which are associated with increased operative risk for surgical and percutaneous procedures. Recently, the Euro Heart Survey reported a clear gap between treatment guidelines and their application in the "real world". A more realistic approach to the treatment of older VHD patients treatment, mostly if associated with heart failure, is advocated. A multidisciplinary approach, as obtained with the Heart Valve Clinic methodology (intended to put the patient in the "center" of the scene and the specialists "around him"), has been applied in a group of 79 patients, aged >70 years, with symptomatic VHD, divided in 2 groups according to their frailty status (58 robust and 21 frail). No in-hospital mortality and no difference in late mortality and complications were observed. Infections were more frequent (14.3 vs. 1.7 %; P = 0.02) in frail patients. In patients with postoperative complications, serum levels of interleukin 6 (67.6 vs. 49.6; P = 0.01) and of CAF (C-terminal agrin fragment) as sarcopenia marker (67.9 vs. 62.0; P = 0.04) were higher than that in uncomplicated patients. This study was designed to determine the outcomes of the multidimensional geriatric assessment in the management of older patients with heart failure eligible for heart valve surgery. Geriatric assessment and measurement of inflammatory and sarcopenia markers may represent valid tools for a more realistic evaluation of elderly patients with VHD.

Objectives Aortic valve replacement (AVR) in patients with small aortic annulus (diameter ≤21 mm) is considered a challenging scenario because of technical aspects and the high risk of patient-prosthesis mismatch (PPM). The choice of the appropriate prosthesis is crucial, and at the moment, an ideal device has yet to be identified. We compare clinical and hemodynamic results after AVR with three bioprostheses with different design and characteristics. Methods We retrospectively evaluated 76 consecutive patients from two cardiac surgery centers who underwent AVR (Trifecta = 24; Edwards INTUITY Elite valve system = 26, and Perceval = 26) for severe aortic stenosis between 2013 and 2017. Patients selected were older than 75 years and with an annulus diameter ≤21 mm at preoperative echocardiogram. Reinterventions and combined procedures were excluded. Minimally invasive AVR was performed in 44 (57.8%) patients. Telephonic interview was obtained at 2.9 ± 0.5 years and echocardiographic follow-up at 2.2 ± 0.8 years. Results Clinical outcome was similar in the three groups. At follow-up, Trifecta patients presented significantly higher peak and mean transprosthetic pressure gradients (P = 0.04 and 0.01). Effective orifice area and left ventricular mass regression were comparable, although an advantage was observed in Perceval patients without reaching the statistical significance. Incidence of moderate (P = 0.2) and severe PPM (P = 0.7) was comparable. Conclusions Despite higher postoperative pressure gradients observed with the Trifecta valve, all three prostheses (Trifecta, Edwards INTUITY Elite, and Perceval) have proven to be reliable when implanted in small aortic annuli, with good clinical outcome and favorable left ventricular mass regression.

Objectives: We aimed to describe a sample of subjects admitted to a psychiatric unit after the intake of psychoactive substances for recreational purposes. Methods: Between June and September 2015, 49 subjects were included. Sociodemographic characteristics and psychopathological aspects were investigated, and urine samples for further analysis were collected. Three subgroups (cannabinoids, stimulants, and depressors users) were identified, according to the structured interview regarding substance use and urinalysis. Results: Level of aggressiveness was found to be significantly higher (p <.05) in the cannabinoids subgroup. Self-reported symptom severity was comparable among groups, but trends could be identified: SCL-90 results showed a prevalence of anxiety symptoms among depressors users, hostility or aggression in the tetrahydrocannabinol subgroup, and psychoticism in the stimulants subgroup. Conclusions: The use of psychoactive substances was be characterised by poly-use of both traditional and novel substances. The presence of aggressiveness emerged as a main feature associated with the use of cannabis and other cannabinoids. Binge drinking and sleep deprivation also represented a relevant component in almost all the evaluated subjects.