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Introduction: Paravalvular leak (PVL) is a well-recognized complication after mitral valve replacement (MVR). However, there are only a few studies analyzing leak occurrence and postoperative results after surgical MVR. The aim of this study was to assess the rate and determinants of early mitral PVL and to evaluate the impact on survival., Methods: We performed a retrospective analysis involving patients who underwent MVR from January 2012 to December 2019 at our Institution. Postoperative transthoracic echocardiography evaluation was done for all subjects before hospital discharge. Multivariable analysis was carried out by constructing a logistic regression model to identify predictors for PVL occurrence., Results: Four hundred ninety-four patients were enrolled. Operative mortality was 4.9%. Early mitral PVL was found in 16 patients (3.2%); the majority were mild (75%). Leaks occurred more frequently along the posterior segment of the mitral valve annulus (62.5%). Only one individual with moderate-to-severe PVL underwent reoperation during the same hospital admission. Multivariable analysis revealed that preoperative diagnosis of infective endocarditis was the only factor associated with early leak after MVR (odds ratio: 4.96; 95% confidence interval: 1.45-16.99; p = .011). Overall mortality at follow-up (mean follow-up time: 4.7 [SD: 2.5] years) was 19.6% and favored patients without early mitral PVL., Conclusion: The incidence of early PVL after MVR is low. PVL is usually mild and develop more frequently along the posterior segment of the mitral valve annulus. Preoperative diagnosis of infective endocarditis increases the risk of PVL formation., (© 2022 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals LLC.)

Objectives: Endocarditis after the Bentall procedure is a severe disease often complicated by a pseudoaneurysm or mediastinitis. Reoperation is challenging but conservative therapy is not effective. The aim of this study was to assess short- and midterm outcomes of patients reoperated on for Bentall-related endocarditis., Methods: Seventy-three patients with Bentall procedure-related endocarditis were recorded in the Italian registry. The mean age was 57 ± 14 years and 92% were men; preoperative comorbidities included hypertension (45%), diabetes (12%) and renal failure (11%). The logistic EuroSCORE was 25%; the EuroSCORE II was 8%., Results: Preoperatively, 12% of the patients were in septic shock; left ventricular-aortic discontinuity was present in 63% and mitral valve involvement occurred in 12%. The most common pathogens were Staphylococcus aureus (22%) and Streptococci (14%). Reoperations after a median interval of 30 months (1-221 months) included a repeat Bentall with a bioconduit (41%), a composite mechanical (33%) or biological valved conduit (19%) and a homograft (6%). In 1 patient, a heart transplant was required (1%); in 12%, a mitral valve procedure was needed. The hospital mortality rate was 15%. The postoperative course was complicated by renal failure (19%), major bleeding (14%), pulmonary failure (14%), sepsis (11%) and multiorgan failure (8%). At multivariate analysis, urgent surgery was a risk factor for early death [hazard ratio 20.5 (1.9-219)]. Survival at 5 and 8 years was 75 ± 6% and 71 ± 7%, with 3 cases of endocarditis relapse., Conclusions: Surgery is effective in treating endocarditis following the Bentall procedure although it is associated with high perioperative mortality and morbidity rates. Endocarditis relapse seems to be uncommon., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Paravalvular leak (PVL) is a well-known complication after aortic valve replacement (AVR). Although some studies have described the incidence of postoperative aortic PVL, there are conflicting data about the predictive factors and a paucity of evidence regarding their time course and impact on survival., Methods: Data were collected from patients who underwent surgical AVR at Circolo Hospital in Varese, Italy from January 2014 to December 2017. A transthoracic echocardiogram (TTE) was performed in all patients before hospital discharge. Additionally, a second TTE was obtained during postoperative follow-up in subjects with early aortic PVL., Results: A total of 514 patients were enrolled in the study. At hospital discharge, aortic PVL was present in 60 patients (11.7%); the majority (78.3%) of the PVLs were mild. Multivariate logistic regression analysis identified smaller body surface area, female sex, and operating surgeon as the strongest predictors of early aortic PVL. Follow-up TTE was available for 50 patients (83.3%). Median time from the date of surgery to follow-up TTE was 2.2 years (0.4 to 4 years). Most aortic PVLs remained unchanged (50%) or disappeared (36%) over time. Only 2 patients (4%) had a progression of the leak. Overall, mortality was 8.4% (43 of 514). Survival was negatively affected by the presence of residual, mild to moderate, or moderate aortic PVL., Conclusions: Aortic PVL is not uncommon after standard AVR. Operating surgeon, smaller body surface area, and female sex are risk factors for the development of this complication. These leaks are usually mild and generally have a benign course. However, the presence of mild to moderate or more severe aortic PVL may influence postoperative survival., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aims: The aim of this study was to test the feasibility of transcatheter mitral valve implantation of the NaviGate device in acute and chronic preclinical models., Methods and Results: We evaluated NaviGate valved stent implantation in the mitral position in an acute swine model (n=24, ≤5 days) through three different approaches - transatrial, transapical, and transseptal - and in a chronic swine model (n=12, >10 days) through a transatrial approach. The NaviGate implantation procedures were successful in 83% of the acute model studies (n=20) and 83% of the chronic model studies (n=10). Echocardiographic assessment showed low gradient across the valved stent (mean gradient <3 mmHg) and the left ventricular outflow tract (mean gradient <6 mmHg). Post implantation, there was no mitral regurgitation (MR) in 75% (n=15) of the acute studies and mild MR in 25% (n=5). In the chronic model, there was no MR in 60% (n=6) and mild MR in 40% (n=4). The implantation procedure was aborted in four acute studies due to inferior vena cava injury and in two chronic studies due to prosthesis-annulus mismatch., Conclusions: In preparation for clinical application, transcatheter mitral implantation of the NaviGate valved stent was proved feasible in acute and chronic preclinical models. The three featured delivery approaches are of particular value for high-risk patients with functional MR and challenging vascular access.

Objectives: The prognostic impact of failed mitral valve repair (FMR) on in-hospital outcome after redo mitral valve surgery has not been thoroughly investigated., Methods: Hospital outcomes after redo mitral valve surgery because of an FMR in patients from nine European centres were reported. Logistic regressions identified predictors of mortality in combined or isolated redo mitral valve operations. Hospital outcome was compared between propensity-matched cohorts with FMR and native mitral valves in the context of redo surgery and FMR versus failed prostheses., Results: A total of 246 patients with FMR yielded a 6.5% mortality rate at redo surgery. FMR per se did not impact mortality at multivariable analysis ( P = 0.64). A preoperative Global Initiative for Chronic Obstructive Lung Disease (GOLD) score ≥2 chronic obstructive lung disease (COPD) (OR 15.2, P < 0.01), left ventricular ejection fraction <30% (odds ratio (OR) 21.5, P = 0.005), major injury to cardiovascular structures at re-entry (OR 27.2, P < 0.01) or injury to patent left internal mammary artery-coronary artery bypass graft (OR 7.6, P = 0.03) predicted mortality in the whole FMR population. GOLD ≥ 2 COPD (OR 12.3, P = 0.049), age at surgery (OR 1.15 for each incremental year, P = 0.049) and cardiopulmonary bypass duration (OR 1.02, P = 0.022) predicted mortality in isolated redo mitral valve surgery for FMR. The fourth (> 68 years = 13.8% mortality) and the fifth quintiles of age (≥73.4 years = 14.8%) reported the highest mortality (OR 3.8 and 4.2 respectively, P = 0.002) in this subgroup. Propensity-matched cohorts of FMR and native mitral valves in the context of redo surgery showed no differences in terms of mortality ( P = 0.69) and major morbidity (acute myocardial infarction P = 0.31, stroke P = 0.65, acute kidney injury P  = 1.0), whereas more perioperative dialysis ( P = 0.04) and transfusions ( P = 0.02) were noted in propensity-matched failed prostheses compared to FMR., Conclusions: A failed mitral repair does not impact hospital outcome of redo surgery. Given the role of severe left ventricular dysfunction and advanced age on hospital mortality rates, an early indication for redo surgery may improve outcome., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The improvement of life expectancy created more surgical candidates with severe symptomatic aortic stenosis and age >80. Therefore, the main objective of this observational, retrospective single-centre study is to compare the long-term survival of octogenarians that have undergone surgical aortic valve replacement (AVR) to the survival of the general population of the same age and to establish whether any perioperative characteristics can anticipate a poor long-term result, limiting the prognostic advantage of the procedure at this age. From 2000 to 2014, 264 octogenarians underwent AVR at our institution. Perioperative data were retrieved from our institutional database and patients were followed up by telephonic interviews. The follow-up ranged between 2 months and 14.9 years (mean 4.1 ± 3.1 years) and the completeness was 99.2 %. Logistic multivariate analysis and Cox regression were respectively applied to identify the risk factors of in-hospital mortality and follow-up survival. Our patient population ages ranged between 80 and 88 years. Isolated AVR (I-AVR) was performed in 136 patients (51.5 %) whereas combined AVR (C-AVR) in 128 patients (48.5 %). Elective procedures were 93.1 %. Logistic EuroSCORE was 15.4 ± 10.6. In-hospital mortality was 4.5 %. Predictive factors of in-hospital mortality were the non-elective priority of the procedure (OR 5.7, CI 1.28-25.7, p = 0.02), cardiopulmonary bypass time (OR 1.02, CI 1.01-1.03, p = 0.004) and age (OR 1.36, CI 1.01-1.84, p = 0.04). Follow-up survival at 1, 4, 8 and 12 years was 93.4 % ± 1.6 %, 72.1 % ± 3.3 %, 39.1 % ± 4.8 % and 20.1 % ± 5.7 %, respectively. The long-term survival of these patients was not statistically different from the survival of an age/gender-matched general population living in the same geographic region (p = 0.52). Predictive factors of poor long-term survival were diabetes mellitus (HR 1.55, CI 1.01-2.46, p = 0.05), preoperative creatinine >200 μmol/L (HR 2.07, CI 1.21-3.53, p = 0.007) and preoperative atrial fibrillation (HR 1.79, CI 1.14-2.80, p = 0.01). In our experience, AVR can be safely performed in octogenarians. After a successful operation, the survival of these patients returns similar to the general population. Nevertheless, the preoperative presence of major comorbidities such as diabetes mellitus, renal dysfunction and atrial fibrillation significantly impact on long-term results.

Objectives: Although commonly reported as single-centre experiences, redo aortic valve replacement (RAVR) has overall acceptable results. Nevertheless, trans-catheter aortic valve replacement has recently questioned the efficacy of RAVR., Methods: Early-to-mid-term results and determinants of mortality in 711 cases of RAVR from seven European institutions were assessed in the entire population and in selected high-risk subgroups [elderly >75 years, urgent/emergent procedures, preoperative New York Heart Association (NYHA) functional Class IV and endocarditis]., Results: Hospital mortality was 5.1%, major re-entry cardiovascular complications (MRCVCs) 4.9%, low cardiac output syndrome (LCOS) 15.3%, stroke 6.6%, acute respiratory failure (ARF) 10.6%, acute renal insufficiency (ARI) 19.3% and need for continuous renal replacement therapy (CRRT) 7.2%, transfusions 66.9% and for permanent pacemaker (PMK) 12.7%. Mid-term survival, freedom from acute heart failure (AHF), reinterventions, stroke and thrombo-embolisms were 77.2 ± 2.7, 84.4 ± 2.6, 97.2 ± 0.8, 97.2 ± 0.9 and 96.3 ± 1.2%, respectively; 87.5% of patients were in NYHA functional Class I-II. Preoperative left ventricular ejection fraction of <30% [odds ratio (OR) 8.7, 95% confidence interval (CI) 2.1-35.6], MRCVCs (OR 20.9, 95% CI 5.6-78.3), cardiopulmonary bypass time (OR 1.1, 95% CI 1.0-1.1), perioperative LCOS (OR 17.2, 95% CI 5.1-57.4) and ARI (OR 5.1, 95% CI 1.5-18.1) predicted hospital death. Endocarditis (OR 7.5, 95% CI 2.9-19.1), preoperative NYHA functional Class IV (OR 4.7, 95% CI 1.0-24.0), combined RAVR + mitral surgery (OR 5.1, 95% CI 1.5-17.3) and AHF at follow-up (OR 2.8, 95% CI 1.3-6.0) predicted late death at the Cox proportional hazard regression model. Elderly >75 years had similar hospital mortality (P = 0.06) and major morbidity, except for a higher need for PMK (P = 0.03), as well as comparable mid-term survival (P = 0.89), freedom from AHF (P = 0.81), reinterventions (P = 0.63), stroke (P = 0.21) and thrombo-embolisms (P = 0.09). Urgent/emergent indication resulted in higher hospital death, LCOS, transfusions, MRCVCs, intra-aortic balloon pumping (IABP), stroke, prolonged (>48 h) ventilation, pneumonia, ARI, CRRT, lower mid-term survival and freedom from AHF (P ≤ 0.03). Preoperative NYHA functional Class IV correlated with higher LCOS, IABP, prolonged ventilation, pneumonia, ARF, ARI, CRRT and MRCVCs and lower mid-term survival, freedom from AHF, reinterventions and stroke (P ≤ 0.02). Endocarditis demonstrated higher hospital mortality, MRCVCs, LCOS, IABP, stroke, ARF, prolonged intubation, pneumonia, ARI, CRRT, transfusions and PMK and lower mid-term survival and freedom from AHF and reinterventions (P ≤ 0.04)., Conclusions: RAVR achieves overall satisfactory results. Baseline risk factors and perioperative complications strongly affect outcomes and mandate improvements in perioperative management. New emerging strategies might be considered in selected high-risk cases., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study was to evaluate the impact of red blood cell (RBC) transfusions on the occurrence of stroke and transient ischaemic attack (TIA) after cardiac surgery., Methods: Data on 14 956 patients undergoing coronary artery bypass grafting (CABG) and valve surgery (with or without concomitant CABG) were retrieved at three European University Hospitals. The prognostic impact of RBC transfusion on postoperative stroke and TIA was investigated by logistic regression and multilevel propensity score analysis., Results: Postoperative stroke was observed in 147 (1.0%) patients and combined stroke/TIA in 238 (1.6%). Of the total population, 6439 (43%) patients received RBC transfusion with a median of 2 units (25th-75th percentile, 2-4 units). When adjusted for other significant risk factors, RBC transfusion was an independent predictor of stroke [odds ratio (OR) 1.14; 95% confidence interval (CI) 1.11-1.17 per unit] and stroke/TIA (OR 1.12; 95% CI 1.09-1.15 per unit). Increase in the amount of transfused RBC units was associated with higher rates of stroke (no RBC transfusion: 0.5%, 1-2 RBC units: 1.0%, OR 1.42; >2 RBC units: 2.7%, OR 3.10) and stroke/TIA (no RBC transfusion: 0.8%, 1-2 RBC units: 1.8%, OR 1.49; >2 RBC units: 4.0%, OR 2.72). Multilevel propensity score analysis confirmed these findings and showed a very high risk of stroke (3.9%; OR 3.85; 95% CI 2.30-6.45) and stroke/TIA (5.9%; OR 3.30; 95% CI 2.17-5.02) associated with transfusion of ≥6 units of RBCs., Conclusions: Transfusion of more than 2 units of RBCs after cardiac surgery is associated with a significantly increased risk of postoperative stroke and TIA., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: This multicenter study was undertaken to determine the immediate and long-term outcomes in patients undergoing a primary surgical aortic valve replacement (AVR) who had a previous coronary artery bypass graft surgery with patent grafts., Methods: One hundred and thirteen consecutive patients (mean EuroSCORE II, 10.3 ± 7.7%, median 8.0%) who underwent first-time isolated AVR after coronary artery bypass grafting (CABG) were the subjects of this multicenter study. The procedure was performed through a full sternotomy in 95.7% of cases, a patent internal mammary artery graft was clamped in 76.6% of patients. The temperature of cardioplegia was ≤12 °C in 62.8% of patients and systemic temperature was <32 °C in 23.9% of patients., Results: Thirty-day mortality was 4.4%. Stroke was observed in 8.0% of patients, low cardiac output syndrome in 14.1%, prolonged tracheal intubation in 20.8%, and intensive care unit stay was longer than five days in 19.5% of patients. Among patients with a patent internal mammary graft (91 patients), clamping of this graft (5.7% vs. 0%, p = 0.57) was associated with a nonsignificant trend toward increased 30-day mortality. One-, three- and five-year survival rates were 91.5%, 90.4%, and 88.4%, respectively., Conclusions: Patients undergoing isolated AVR after prior CABG have a good immediate and late survival. A history of prior CABG should not be considered an absolute indication for transcatheter AVR., (© 2014 Wiley Periodicals, Inc.)

Background: Octogenarians undergoing surgical aortic valve replacement (AVR) after prior cardiac surgery are expected to be at high risk of adverse events. This finding has recently popularized transcatheter AVR in this cohort., Methods: This multicenter study includes 744 patients (99 were 80 years or older) who underwent surgical AVR after prior cardiac surgery. The outcome of octogenarians was compared with younger patients in the entire cohort and in a propensity score-matched population., Results: Octogenarians and younger patients had similar immediate outcome (in-hospital mortality, 3.0% versus 5.9%; p=0.34; stroke, 5.1% versus 6.7%; p=0.66; dialysis, 9.1% versus 6.5%; p=0.34), as confirmed also in 84 propensity score-matched pairs. Octogenarians and younger patients had similar late survival (5-year survival, 83.1% versus 78.0%; p=0.68; propensity score-adjusted relative risk [RR], 0.23; 95% confidence interval [CI], 0.59 to 1.88). Octogenarians and younger patients had similar freedom from heart failure episodes (at 5 years, 84.5% versus 89.2%; p=0.311; propensity score-adjusted RR, 1.37; 95% CI, 0.62 to 3.04) and from reoperation (at 5 years, 94.9% versus 97.9%; p=0.51; propensity score-adjusted RR, 1.93; 95% CI, 0.35 to 10.56). However, octogenarians had poorer freedom from late stroke (at 5 years, 89.8% versus 97.5%; p=0.016; propensity score-adjusted RR, 6.137; 95% CI, 1.776 to 21.208) and peripheral thromboembolism (at 5 years, 90.0% versus 98.2%; p=0.003; propensity score-adjusted RR, 4.00; 95% CI, 1.07 to 15.00)., Conclusions: Octogenarians undergoing surgical AVR after prior cardiac surgery have similar immediate postoperative outcome as younger patients, and their 5-year outcome is excellent. These data suggest that indications to undergo transcatheter AVR should not rely only on coexistence of advanced age and history of prior cardiac surgery., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Surgical aortic valve replacement (S-AVR) after previous cardiac surgery is expected to be associated with a high rate of adverse events. The aim of this study was to estimate the rate and identify the determinants of postoperative stroke in these patients. This is a multicenter study including 741 patients who underwent S-AVR after previous cardiac surgery. Forty-eight patients (6.5%; after isolated AVR, 6.0%) suffered stroke and 10 of them died during the in-hospital stay (20.8%). At multivariate analysis, women (10.2% vs 4.4%, odds ratio [OR] 2.57, 95% confidence interval [CI] 1.36 to 4.86), emergency procedure (15.1% vs 4.8%, OR 2.63, 95% CI 1.12 to 5.78), perioperative use of intra-aortic balloon pump (22.9% vs 5.3%, OR 2.67, 95% CI 1.15 to 6.19), cardiopulmonary bypass time of >210 minutes (15.7% vs 5.0%, OR 2.31, 95% CI 1.13 to 4.71), blood products transfusion (9.3% vs 0.8%, OR 7.75, 95% CI 1.83 to 32.93), and reexploration for bleeding (24.0% vs 5.2%, OR 4.84, 95% CI 2.18 to 10.77) were independent predictors of postoperative stroke. These findings were confirmed by a regression model including CHA2DS2-VASc score of ≥2, which itself was predictive of stroke (8.2% vs 1.6%, OR 4.52, 95% CI 1.34 to 15.28). Survival at 3 years in patients with postoperative stroke was 51.9%, whereas it was 85.0% in control patients (adjusted analysis: relative risk 2.97 and 1.86 to 4.72, respectively). In conclusion, the risk of postoperative stroke after S-AVR in patients with previous cardiac surgery is high and has an impact on the immediate and late mortality. Excessive bleeding requiring blood transfusion and/or reexploration, prolonged cardiopulmonary bypass time, and use of intra-aortic balloon pump were associated with an extremely high rate of stroke., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Acute kidney injury (AKI) following cardiac surgery is a continuing source of morbidity and mortality. Although several studies have attempted to determine its etiology and prophylactic measures, limited data exist after thoracic aortic surgery. The aim of this study was to evaluate the incidence and predictors of AKI in patients undergoing aortic root replacement (ARR) with valve conduit for ascending aorta aneurysms. A multi-center observational study of 414 patients undergoing ARR with a valve conduit was conducted, focusing on clinical outcome and AKI defined by consensus RIFLE (risk, injury, failure, loss of function, end-stage renal disease) criteria. Mean age was 62.5 years (range: 21-82 years) with 327 males (79%). Emergent operations were performed in 5% of the cases, while concomitant surgical procedures were performed in 24.9%. Postoperative AKI (all RIFLE classes) occurred in 69 (16.7%) patients, while eight (1.9%) required dialysis. Independent AKI predictors were packed red blood cells (pRBCs) >4 units (OR 2.28; 95% CI 1.20-4.30), cardiopulmonary bypass (CPB) time longer than 180 min (OR, 2.08; 95% CI, 1.16-3.73), and concomitant surgical procedures (OR, 1.85; 95% CI, 1.04-3.29). The severity of RIFLE class was associated with longer ICU stay, hospitalization, and higher hospital mortality (p < 0.001 for each variable). AKI after ARR operations with valve conduit for ascending aorta aneurysms increases utilization of health resources and is associated with adverse events. Concomitant surgical procedures, prolonged CPB-time, and pRBCs >4 units as independent AKI predictors merit further researches enhancing possible preventive strategies.

Objective: It is uncertain whether mitral valve replacement is really inferior to mitral valve repair for the treatment of chronic ischemic mitral regurgitation. This multicenter study aimed at providing a contribution to this issue., Methods: Of 1006 patients with chronic ischemic mitral regurgitation and impaired left ventricular function (ejection fraction < 40%) operated on at 13 Italian institutions between 1996 and 2011, 298 (29.6%) underwent mitral valve replacement whereas 708 (70.4%) received mitral valve repair. Propensity scores were calculated by a nonparsimonious multivariable logistic regression, and 244 pairs of patients were matched successfully using calipers of width 0.2 standard deviation of the logit of the propensity scores. The postmatching median standardized difference was 0.024 (range, 0-0.037) and in none of the covariates did it exceed 10%., Results: Early deaths were 3.3% (n = 8) in mitral valve repair versus 5.3% (n = 13) in mitral valve replacement (P = .32). Eight-year survival was 81.6% ± 2.8% and 79.6% ± 4.8% (P = .42), respectively. Actual freedom from all-cause reoperation and valve-related reoperation were 64.3% ± 4.3% versus 80% ± 4.1%, and 71.3% ± 3.5% versus 85.5% ± 3.9 in mitral valve repair and mitral valve replacement, respectively (P < .001). Actual freedom from all valve-related complications was 68.3% ± 3.1% versus 69.9% ± 3.3% in mitral valve repair and mitral valve replacement, respectively (P = .78). Left ventricular function did not improved significantly, and it was comparable in the 2 groups postoperatively (36.9% vs 38.5%, P = .66). At competing regression analysis, mitral valve repair was a strong predictor of reoperation (hazard ratio, 2.84; P < .001)., Conclusions: Mitral valve replacement is a suitable option for patients with chronic ischemic mitral regurgitation and impaired left ventricular function. It provides better results in terms of freedom from reoperation with comparable valve-related complication rates., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background and Aim of the Study: Cardiac surgery can be performed on elderly patients in good physical and mental health, thus improving their mortality, morbidity, and quality of life. Nevertheless, for some elderly patients aortic valve replacement (AVR) is still denied because of the presence of preoperative characteristics, such as older age and left ventricular dysfunction. The study aim was to review early and long-term results in patients aged > or = 80 years who underwent AVR for severe aortic stenosis, and to identify risk factors for in-hospital and late mortality., Methods: A total of 165 patients (mean age 82 +/- 2.1 years) underwent AVR for severe aortic stenosis, with or without concomitant coronary revascularization, at the authors' institution. The mean aortic valve area was 0.61 +/- 0.2 cm2. Preoperatively, 20 patients (12%) had a left ventricular ejection fraction < 35%. The mean EuroSCORE was 9.45 +/- 1.52., Results: Seven patients (4%) experienced low cardiac output syndrome, and acute renal failure occurred in 24. No perioperative myocardial infarction, stroke or sternal wound infection was detected. In total, 23 patients (14%) required prolonged ventilatory support. The in-hospital mortality was 3%. After a mean follow up of 43 +/- 35.6 months there were 18 late deaths: the cardiac-related mortality was 7%. The mean NYHA class was improved from 2.86 +/- 0.67 to 1.44 +/- 0.57 (p < 0.0001)., Conclusion: Conventional AVR remains the standard of care, and can be performed with satisfactory in-hospital mortality, long-term life expectancy and quality of life in high-risk elderly patients. Although the transcatheter aortic valve technique seems to be a promising option, its long-term value must be established in prospective, randomized trials.

Aims: The aim of our study was to examine the effects of statin therapy (atorvastatin) on post-implant structural changes of bovine pericardial tissue in a subcutaneous animal model., Methods and Results: Sixty male C57BL/6 mice underwent subcutaneous dorsal implantation of bovine pericardial fragments. Animals were randomized to treatment with atorvastatin (50 mg/kg) (statin group - SG) or to vehicle (control group - CG). After 1.5 months, all fragments were explanted and submitted to histopathological assessment (semi-quantitative analysis) to elucidate extent of inflammatory infiltrate, signs of tissue injury, or presence of microcalcification. Calcium determination of the implanted pericardial tissue was also performed by inductively coupled plasma mass spectrometry (ICP-MS) assessment. ICP-MS analysis showed that pericardial fragments in SG had significantly (p<0.01) less calcium content than CG (625+/-142 vs. 962+/-590 microg/g, respectively). Light microscopy showed marked inflammatory infiltrates and tissue injury of pericardial specimens in CG animals, whereas SG animals maintained a better preserved original pericardial structure., Conclusions: Our findings indicate that atorvastatin significantly attenuates the post-implant structural degeneration of artificial valve bovine pericardial tissue in a subcutaneous animal model. Further observations are mandatory to assess the effects of statins on the implanted bioprosthetic valve tissue in the blood circulation., (Copyright (c) 2008. Published by Elsevier Ireland Ltd.)

We present a clinical case of severe aortic stenosis in a 73-year-old patient symptomatic for dispnoea class NYHA III-IV. At the physical examination the patient presented a single sternal metastasis of renal carcinoma involving the sternum. Oncological stability prompted us to perform aortic valve replacement. In order to avoid median sternotomy and its complications due to the presence of sternal metastasis we successfully performed aortic valve replacement through a right minithoracotomy.

The aim of this study was to examine perioperative mortality and morbidity and midterm results in patients undergoing coronary bypass graft and mitral valve annuloplasty with advanced dilated cardiomyopathy. Sixty-one patients with ischemic dilated cardiomyopathy underwent coronary artery bypass grafting and mitral valve annuloplasty between January 1998 and December 2003. Patients eligible for revascularization that presented a mild or more severe mitral valve regurgitation at echocardiography (effective regurgitant orifice > 0.2 cm(2)) were considered for annuloplasty with a Cosgrove ring. New York Heart Association class (NYHA) III/IV was present in 40 patients (66%) and Canadian Cardiovascular Society class III-IV in 19 (31%). A previous acute myocardial infarction was reported in 48 patients (79%). The mean number of graft anastomoses was 2.5 +/- 0.7 and the left internal mammary artery was used in 49 patients (80%). In-hospital mortality was 4.9% (3 patients), due to unsuccessful weaning from cardiopulmonary bypass, multiple organ failure, and stroke, respectively. Left ventricle ejection fraction improved from 28.9% +/- 5.2% preoperatively to 35.4% +/- 8.1% at follow-up (P = 0.0001) and a significant reduction in NYHA III/IV was detected: from 40 patients preoperatively (66%) to 14 (31%) at follow-up (P = 0.031). Midterm cardiac-related mortality rate was 3.4%. In our experience combined coronary artery bypass grafting and ring annuloplasty for ischemic dilated cardiomyopathy can be performed with acceptable risks for in-hospital mortality and morbidity. Midterm results show a good survival rate and a durable functional improvement in this subset of patients.

Background: One of the most frequent causes of reoperation after heart valve replacement is periprosthetic leakage (PPL). Previous studies have failed to determine whether PPL is linked to specific anatomic details. The aim of this study was to examine the location within the aortic annulus where PPL occurs, and to evaluate the postoperative outcome after surgical correction., Methods: Between January 1985 and December 2001, 28 patients underwent reoperation because of PPL after aortic valve replacement. The aortic annulus was analyzed in a clockwise format with hour 1 corresponding to the commissure between the left coronary sinus and the right coronary sinus, hour 5 to the commissure between the right coronary sinus and the noncoronary sinus, and hour 9 to the commissure between the noncoronary sinus and the left coronary sinus., Results: Overall operative mortality was 7.1% (2 patients). Repair of PPL was carried out in 8 patients whereas prosthetic valve replacement was necessary in 20 patients. Urgency or emergency operation (p < 0.0037), preoperative New York Heart Association class IV (p < 0.04), need for prosthetic valve replacement (p = 0.05), and implant of mechanical valve (p = 0.031) were independent determinants of dismal prognosis. Periprosthetic leakage occurred more frequently between hour 4 and hour 8 (19 patients), with the risk of leakage being two times greater than in other annular areas., Conclusions: Our study suggests that PPL occurs more frequently in a specific portion of the peculiar aortic annulus. In case of PPL diagnosis, a timely reoperation might decrease operative risks by avoiding emergency procedures and unfavorable preoperative clinical conditions, and preventing prosthetic valve replacement.