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In patients with significant valvular heart disease (VHD) undergoing non-cardiac surgery (NCS), perioperative adverse cardiac events are a relevant issue. Although postoperative outcomes can be adversely affected by valve-related haemodynamic instability, recommended perioperative risk scores prioritise the risk of the surgical procedure and the presence of cardiovascular risk factors, neglecting the presence or extent of VHD. Perioperative management and anaesthetic approach should focus on the underlying type and severity of VHD, the compensatory mechanisms deployed by left ventricle and right ventricle and the type and risk of NCS. Due to the lack of randomised trials investigating different therapeutic approaches of valvular intervention prior to NCS, recommendations mainly rely on consensus opinion and inference based on large observational registries. As a general rule, valvular intervention is recommended prior to NCS in symptomatic patients or in those who meet standard criteria for cardiac intervention. In the absence of such conditions, it is reasonable to perform NCS with tailored anaesthetic management and close invasive perioperative haemodynamic monitoring. However, patient-specific management strategies should be discussed with the heart team preoperatively. Symptomatic patients with severe VHD or those undergoing high-risk NCS should ideally be treated at a high-volume medical centre that is equipped to manage haemodynamically complex patients during the perioperative period.

Although in heart failure (HF) there is a strict correlation between heart and kidney, no data are available on the potential relationship in HF between renal dysfunction (RD) and the impaired sympathetic innervation. Aim of the present study was to assess the relationship between RD and cardiac sympathetic innervation in HF patients with reduced ejection fraction. Two hundred and sixty-three patients with mild-to-severe HF underwent iodine-123 meta-iodobenzylguanidine myocardial scintigraphy to assess sympathetic innervation, evaluating early and late heart-to-mediastinum (H/M) ratios and washout rate. In all patients, glomerular filtration rate (eGFR) by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula was assessed. A direct association was found between EPI-eGFR and late H/M (r = .215; P

The model used to explain the pathophysiologic substrate and progressive worsening in chronic heart failure (CHF) is based on the hyperactivity of renin-angiotensin-aldosterone system and adrenergic pathway. Although the neurohormonal medical approach has many advantages, it has several pitfalls, as demonstrated by high rates of CHF mortality and hospitalization. A growing body of evidence has led to the hypothesis that CHF is a multiple hormone deficiency syndrome, characterized by a reduced anabolic drive that has relevant functional and prognostic implications. The aim of this review is to summarize the evidence of reduced drive of main anabolic axes in CHF.

The end-stage cardiomyopathy is an increasing worldwide problem. Cardiac transplantation lacks sufficient donors to treat all patients, and there is thus debate about alternative strategies. The use of left ventricular assist devices for long-term support is increasing with a positive impact on patient survival. Although there is an ongoing debate regarding the risks and benefits of maintaining pulsatile flow during long-term ventricular assist device support, there has been a significant move towards implantation of continuous flow devices due to the lower surgical morbidity and better long-term reliability of these pumps. The following is a review of the literature on continuous and pulsatile flow for long-term support. Starting from the definition of flow, we analyze the current evidence and consider gastrointestinal complications.

Introduction Coronary artery disease (CAD), along with its main complications such as acute myocardial infarction (AMI) and congestive heart failure (CHF), remains a serious worldwide problem and affects many patients despite the improvement of medical treatment. The possibility of the replacement of the infarcted areas by the re-generation of the myocardial cells has been long discussed and the mobilization of the stem cells from bone marrow (BMCs) to the peripheral blood (PB) induced by cytokines, represents a potential pathway to activate the regenerative process. Patients and Methods We describe BMC mobilization and direct/indirect revascularization in 15 patients operated on for coronary artery bypass grafting (CABG) and/or mitral valve surgery and/or ventricular remodeling combined to multiple trans-myocardial punctures (Sen technique) in ungraftable non-viable fibrotic areas. Results Peak values of circulating BMCs were recorded between day +4 and day +6. We had no in-hospital (0–30 days) mortality. All the patients were discharged from the ICU after a median period of 2 days while the in-hospital length of stay was 10.5+4.2 days (range 7–21) and all patients were discharged in good clinical condition. There were two sudden deaths over the mid-term, at postoperative day (POD) 32 and 45 respectively. Conclusions Our study suggests that the combination of BMC mobilization and CABG may be safely performed. However, considering the small series, final conclusions about the benefit of this procedure must await a larger prospective study comparing the role of cytokines alone, myocardial perforation, and the combination of both.

The scientific literature has pointed out several predictors of negative outcome after surgery such as pain and depression, negatively affecting the postoperative outcome in cardiac surgery. From January 2009 until June 2010, 15 patients scheduled for cardiac surgery were enrolled. The patients were assessed by psychological evaluation either in the hospital stay either in the rehabilitation period with the aim of identifying their emotional condition (sentiments about the onset of the disease, support received from family and friends) even by means of preformed tests for anxiety and depression (tests of Stay and Back). Thus, in our preliminary experience, the psychological evaluation failed to detect the occurrence of postoperative complications. Conversely, the psychological evaluation is very effective in detecting a poor emotional state and the psychological support decreases the degree of anxiety and depression with positive effects on postoperative outcome. In conclusion, a standardize test for anxiety and depression should be used for patients at hospital admission to detect who may benefits by psychological support.

We present the angiograms of a patient aftertransmyocardial laser revascularization (TMR), whichwere performed 10 years before by the application ofholmium laser pulses. Thirteen years before TMRprocedure, the patient underwent coronary artery bypassgraftings complicated by grafts occlusion with no longerpossibility of direct revascularization. Then, refractiveangina required an alternative approach for symptomsrelief as the indirect revascularization by the applicationof the holmium laser pulses. Interestingly, the lateangiograms, taken when the patient suffered from effortdyspnea for ongoing left ventricular dysfunction, showed anetwork of small vessels (absent before TMR procedure)that supplies blood to the heart with no flow through thecoronary arteries because of their complete occlusion.This is a historical presentation of the results of TMR tounderstand the effects of the indirect revascularization onthe blood circulation through the heart over the long-termfollow-up. Coron Artery Dis 00:000–000

Minimally invasive surgery (MIS) for aortic valve replacement (AVR) is going to increase with different techniques described so far. We hereby report the results of AVR through a right minithoracotomy (RM) compared to a median sternotomy (MS).One hundred patients operated for isolated AVR by the same surgeon (chief of the department) were enrolled and allocated to: MS (group A, 50 patients, 26 females, mean age 69.9 ± 12.4 years). RM (group B, 50 patients, 27 females, mean age 71.6 ± 11.2 years). Mean logistic Euroscores were, respectively, 6.5 ± 4.0 and 8.0 ± 5.9 (p=ns).Mean duration of cardiopulmonary by-pass (CPB) was 62.8 ± 18.3 min in group A and 101.4 ± 35.2 min in group B (p0.05); cross-clamp was 44.8 ± 13.4 min in group A and 74.6 ± 26.7 min in group B (p0.05). Thirty-day mortality was 2 (4%) in group A and 0 in group B (p=ns). ICU stay and hospital stay did not significantly differ amongst two groups. The incidence of bleeding was lower in group B, showing a slight reduction of blood transfusions and re-explorations (p=ns).Our experience shows that RM offers a good 30-day survival and a lower incidence of mediastinitis or osteomyelitis. The risk of insufficient vision or sudden complications is safely managed by enlarging the surgical incision through a transverse sternotomy.

Objective Aortic valve replacement (AVR) is nowadays a safe procedure with low rates of mortality and morbidity, but the necessity for a less invasive approach is going to increase. The use of a stentless prosthesis through right mini-thoracotomy has not yet been described and our experience could be useful for other surgeons. Methods From June 2009 until March 2010, seven female patients (mean age 79.9 ± 5.7 years) underwent stentless-AVR for aortic stenosis through a right mini-thoracotomy (RM). The logistic Euroscore was 11.3 ± 6.1, and left ventricular ejection fraction was 60.7 ± 4.5%. In five cases RM was performed through the second intercostal space (ICS); in two cases through the third ICS. The cannulation was in most cases between ascending aorta and femoral vein (5/7). When transverse sternotomy was required (two patients), the right mammary artery was clipped and cut. Results Extracorporeal circulation time (ECC) was 110 ± 41 min and aortic cross clamp was 80 ± 35 min. Two patients required transverse sternotomy. The mean bleeding was 484 ± 469 ml and the duration of mechanical ventilation was 22.0 ± 12.5 h. The ICU stay was 3.3 ± 2.2 days. No in-hospital death was observed. The mean hospital stay was 11.6 ± 5.4 days. Conclusion Right mini-thoracotomy is a safe and applicable approach even in case of AVR using stentless prosthesis. The risk of insufficient surgical exposure or complication may be safely managed, by enlarging the thoracotomy through transverse sternotomy. However, valve implantation could be more difficult than the standard approach and it requires an expert and confident surgeon with a large experience in standard stentless implantation.

Dear Editor,We read with great interest the paper of Maraj et al. [1] dis-cussing about the history of the primary cardiac tumors: we agreewith the Authors that the aim of the clinicians must be precociousdiagnosis even if clinical presentation would be heterogeneous.Moreover, primary cardiac tumors are very rare and in many casespatients may be asymptomatic so that incidental diagnosis is quitecommon.We present the case of a 28-year-old male referred for dyspneaand palpitations that appeared about two months before. Clinicalmanagement by general practitioners was not clear and he un-derwent cardiac assessment only two months later. The trans-thoracic echocardiography revealed the presence of a large cardiacprimitive mass. The magnetic resonance imaging (MRI) studyshowed an 8×6.5×7 cm tumor arising from the free wall of theright atrium, involving the proximal and the medium tract of apatent right coronary artery (Fig. 1A–B). Tricuspid annulus, rightventricle and superior vena cava were compressed (Fig. 1A–B).Ascending aorta was very close to the lesion (Fig. 2A–B) and MRIshowed a 15 mm metastasis in the left lung (Fig. 2A–B). Intravenousadministration of gadolinium enhanced multiple necrosis areassuggestive for a primary cardiac sarcoma. Considering the unfavour-able location and the presence of metastasis, surgical excision wasnot considered and chemotherapy (using bleomicin) was adminis-tered such as palliative therapy. Recurrent pericardial serum-haematic effusion required multiple pericardiocentesis and blood

Abstract 318 Introduction Coronary artery disease (CAD), along with its main complications, acute myocardial infarction (AMI) and congestive heart failure (CHF), remains a serious worldwide problem. Despite advances in medical and surgical treatments, CAD is still associated with a high mortality rate and markedly affects the quality of life of patients. The possibility to replace the scarring by inducing neoangiogenesis and possibly regeneration of injured myocardium is an attractive option to improve the prognosis of CAD patients. For this purpose, cytokine-induced mobilization of bone marrow stem cells (BMCs) into the peripheral blood might represents a potential pathway to activate the regenerative process. Some observations suggest that circulating BMCs may lodge in non-hematopoietic tissues such as muscle, liver and myocardium where the tissue injury or the local inflammation may promote stem cells migration. Thus, the association between cytokine induced BMCs migration and tissue injury, may induce tissue repair since the stem cells are usually attracted from the inflamed tissues. A phase II prospective study was performed combining BMCs migration, obtained by cytokines, and cardiac inflammation, induced by myocardial punctures. Results at early and long-term follow-up are here reported. Patients and methods BMCs mobilization was performed in 15 patients undergoing surgery for coronary artery bypass grafting (CABG) and/or mitral valve surgery and/or ventricular remodeling combined to multiple trans-myocardial punctures (Sen technique) in ungraftable non-viable fibrotic areas. BMC mobilization was induced by granulocyte colony stimulating factor (G-CSF) (Lenogastrim) given at 5 μgr/kg s.c. b.i.d. for 5 to 6 consecutive days, starting on day-3 before surgery along with granulocyte-macrophage colony stimulating factor (GM-CSF) (Molgramostim) at 2.5 μgr/kg s.c./day. Patients entered the study protocol on the basis of the following inclusion criteria: i. severe heart failure with left ventricular ejection fraction (EF) < 35%; ii. ineligibility to cardiac transplantation; iii. widespread myocardial ischemia with at least one area of akinetic and nonviable myocardium, detected by cardiac stress scintigraphy with Thallium; iv. presence of other combined surgical indications, including the requirement of surgery for CABG on areas other than nonviable scars; v. one or more previous myocardial infarction. The study protocol was approved by our local Institutional Review Board and Ethics Committee and all patients signed the informed written consent. Results Cytokine administration induced a variable increase in circulating CD34+ve cells in all patients, with peak values recorded between day +4 and day +6. There were no in hospital (0–30 days) deaths. All 15 patients were discharged from the ICU after a median of 2 days, while the overall in hospital stay was 10.5+4.2 days (range 7–21) and all patients were discharged in good clinical condition. There were two sudden deaths over the mid-term, at postoperative day +32 and +45: both patients had troublesome ECC weaning without other postoperative complications. Presently, at a median follow-up of 48 mos, four patients died, 11 patients are alive, one of them after heart transplantation. Among the 10 non-transplanted long-term survivors, there was a significant improvement of the NYHA class from 2,1±0,8 to 1,3±0,5 (p Disclosures: Off Label Use: G-CSF + GM-CSF in CAD.