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In the absence of a standardized safe surgical reentry strategy for high-risk patients with large or anterior postoperative aortic false aneurysm (PAFA), we aimed to describe an effective and safe approach for such patients.We prospectively analyzed patients treated for PAFA between 2006 and 2015. According to the preoperative computed tomography scan examination, patients were divided into two groups according to the anatomy and extension of PAFA: in group A, high-risk PAFA (diameter ≥3 cm) developed in the anterior mediastinum; in group B, low-risk PAFA (diameter3 cm) was situated posteriorly. For group A, a safe surgical strategy, including continuous cerebral, visceral, and coronary perfusion was adopted before resternotomy; group B patients underwent conventional surgery.We treated 27 patients (safe reentry, n = 13; standard approach, n = 14). Mean age was 60 years (range, 29 to 80); 17 patients were male. Mean interval between the first operation and the last procedure was 4.3 years. Overall 30-day mortality rate was 7.4% (1 patient in each group). No aorta-related mortality was observed at 1 and 5 years in either group. The Kaplan-Meier overall survival estimates at 1 and 5 years were, respectively, 92.3% ± 7.4% and 73.4% ± 13.4% in group A, and 92.9% ± 6.9% and 72.2% ± 13.9% in group B (log rank test, p = 0.830). Freedom from reoperation for recurrent aortic disease was 100% at 1 year and 88% at 5 years.The safe reentry technique with continuous cerebral, visceral, and coronary perfusion for high-risk patients resulted in early and midterm outcomes similar to those observed for low-risk patients undergoing conventional surgery.

Background. Postoperative outcomes of a third-generation porcine bioprosthesis for mitral valve replacement (MVR) have been poorly addressed. The objective of this study was to perform an independent, retrospective, multicenter study on outcomes of patients undergoing MVR with a Mosaic (Medtronic Inc, Minneapolis, MN) porcine bioprosthesis.Methods. From 1998 to 2011, 805 patients underwent MVR with a Mosaic porcine valve in 11 cardiac centers. There were 465 female patients (58%), and the overall mean age was 73.5 +/- 7 years. Associated procedures included coronary artery bypass grafting (201 patients; 24.9%), aortic valve replacement (152 patients; 18.9%), tricuspid annuloplasty (187 patients; 22.3%), and other cardiac procedures (116 patients; 14.4%).Results. Median follow-up was 44 months (interquartile range, 16 to 63), with a cumulative duration of 2.769 patientyears. Early mortality for isolated elective MVR was 3.8% (12 of 313), and overall early mortality was 7.8% (n = 63). The rate of late mortality was 3.4%/patient-year (95 late deaths). At 10 years, overall survival was 57.4% (95% confidence interval [CI], 48.8% to 67.5%), and cumulative rates of cardiac- and valve-related death were 7.4% (95% CI, 4.8% to 10.1%) and 1.1% (95% CI, 0.2% to 1.9%), respectively. The 10-year cumulative rates of thromboembolic and hemorrhagic events were 6.6% (95% CI, 1.4% to 11.8%) and 3.9% (95% CI, 0.1% to 8%), respectively, and the 10-year cumulative incidence of prosthetic valve endocarditis was 3%(95% CI, 1.2% to 4.9%). Finally, the 10-year cumulative incidences of structuralvalve degeneration andreoperationswere5.8%(95% CI, 0.2% to 11.5%) and 4.8% (95% CI, 0.7% to 10.3%), respectively.Conclusions. This independent, multicenter, retrospective study indicated that the Mosaic porcine bioprosthesis forMVR provides satisfactory results in terms of both early andlong-termoutcomes upto 14 years fromits implantation. (C) 2020 by The Society of Thoracic Surgeons

Background Novel surgical approach to repair degenerative mitral regurgitation such as transapical chordae tendineae replacement and "loop in loop" in loop techniques, need of artificial chordae longer than that used in the older techniques of chordae tendineae replacement. This difference in length has been reported as potential critical point for durability of artificial chordae. In the present paper we have investigated the elastic behavior of different diameter and length politetrafluorene (PTFE) suture threads as substitute of native chordae, to identify their reliability to use as long artificial chordae. Methods PTFE suture threads with different diameters were investigated in their mechanical properties at different length from 2 to 14 cm, by a servo hydraulic testing machine, to test the elastic properties of the sample in their use as mitral chordae substitutes. Results Our study shows that the chordae length is an important parameter that can change the performance of chordae itself. The analysis of elastic/properties of suture threads specimen, reveals that long PTFE chords have an optimal mechanical behavior in which elongation is accompanied by a safe elastic properties that make them well resistance during multiple tractions. Conclusions In conclusion the use of PTFE as an artificial chordae may represent a valid choice in case of insertion of artificial chordae with extra anatomic length.

Background and aim of the study We investigated the dimensional and mechanical properties of polyetetrafluorene (ePTFE) sutures used as artificial chordae during mitral valve repair. Methods Mechanical properties of ePTFE synthetic chordae tendineae were tested with a servo hydraulic testing machine. Several different lengths from 2 to 14 cm were studied under both single and multiple mechanical traction. Results The mechanical behavior of artificial chordae reveals that three centimeters is the length over which we observe a significant increase in stiffness. The chordae stiffness grows further at the length greater than seven centimeters following a low number of traction cycles. Conclusion The increase of the length of artificial ePTFE chordae is accompanied by an increasing stiffness that compromises the long-term resistance of the chordae. ePTFE length can alter the performance of artificial chordae. This suggests that mitral valve repairs which anchor ePTFE neochordae to the ventricular apex may have less durability than when anchored to the tips of the papillary muscles.

Background: Atrial fibrillation (AF) is a common complication of coronary artery bypass grafting (CABG). However, limited information is available about the role of preoperative echocardiographic left atrial evaluation to predict AF occurrence after CABG. Thus, we prospectively compared the ability of echocardiographic measurements of left atrial volume to predict AF in this setting. Methods: From January to December 2009, 220 patients (75% males, 66.8 ± 10.0 years) met the inclusion criteria of our study (isolated and elective CABG, no valve surgery, no permanent AF, or other chronic atrial arrhythmias). The day before CABG a complete echocardiographic evaluation was performed with left atrial volume measurements. The primary endpoint of the study was postoperative AF (POAF) lasting >30 seconds. Results: POAF was observed in 61 patients (27.7%). POAF patients showed increased left atrial M-mode anteroposterior dimension (41.2 ± 6.4 mm vs. 43.6 ± 7.3 mm; p = 0.020) and increased left atrial volume (59.0 ± 18.3 mL vs. 70.6 ± 28.1 mL; p = 0.0004). Left atrial volume was an independent risk factor for POAF (OR 10.03; 95% CI 10.01 to 10.05; p = 0.01), along with postoperative bleeding with hemoglobin levels below 8 g/dL (OR 20.84; 95% CI 10.12 to 70.19; p = 0.03) and preoperative left ventricular ejection fraction below 40% (OR 10.08; 95% CI 10.01 to 10.15; p = 0.02). Conversely, preoperative statin therapy exerted a protective role (OR 0.30; 95% CI 0.12 to 0.74; p = 0.009). Conclusion: Preoperative echocardiographic evaluation of patients with isolated CABG demonstrated that left atrium volume measurements were independently correlated to the occurrence of POAF. Further investigations should focus on the opportunity to target prophylactic antiarrhythmic treatments to patients with large left atrial volumes. (J Card Surg 2012;27:128–135)

Objective:Levosimendanhasbeenreportedtoexertcardioprotection.In thisstudy, wehaveexaminedthecardiaceffectsofdifferentdosesof intracoronary levosimendan on ischemia/reperfusion injuries, and the involvement of KATP channels and nitric oxide (NO). Methods: The experiments were performed in a total of 56 anesthetized pigs. In 21 pigs, 1.5, 5 and 12 mg min � 1 levosimendan was infused over 15 min into the coronary artery at the onset of 1 h reperfusion following 2-h ischemia and the effects on cardiac function, infarcted area, and on apoptosis/ autophagy were examined. In addition, the activation of Akt and extracellular receptor kinase (ERK) was analyzed. The findings were compared withthoseobtainedinafurther14pigswherethehighestdoselevosimendanwasinfusedafterglibenclamideand L-nitro-argininemethylester(LNAME). Results: Intracoronary 1.5, 5 and 12 mg min � 1 levosimendan caused an increase of segmental shortening, dP/dtmax and cardiac output of 7.8%, 22.6%, and 31.6%; 7.6%, 16.9%, and 21.6%; 2.8%, 5.9%, and 6.2%, respectively, from values measured at the end of ischemia. The beneficial effects elicited by levosimendan were still evident at the end of reperfusion when the increase of segmental shortening, dP/dtmax and cardiac output caused by the three doses of levosimendan amounted to 3.7%, 13.3%, and 16.5%; 1.5%, 9.4%, and 11%; 1.4%, 2.7%, and 3.9%, respectively. When doses of 5 and 12 mg min � 1 levosimendan were used, a reduction of infarcted area to about 69% and 67% of area at risk was observed, and was significantly different from that of about 79% measured in control animals. In addition, after intracoronary levosimendan, the inhibition of apoptosis and activation of autophagy and a dose-related increase of the level of phosphorylation of ERK and Akt were observed. These responses were completely prevented by glibenclamide and significantly reduced by L-NAME. Conclusions:The results of this study show that intracoronary levosimendan reduces cell death induced by ischemia/reperfusion in a dose-dependent manner and activates survival signaling through KATP channel opening and NO. These findings support interesting implications for cardioprotection in interventional cardiology and cardiac surgery. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: To evaluate the possible protective effects of fenoldopam on renal function in patients undergoing cardiopulmonary bypass. Design: Prospective, randomized trial. Setting: University teaching hospital. Participants: One hundred sixty consecutive patients with serum creatinine >1.5 mg/dL who underwent uncomplicated moderate hypothermic cardiopulmonary bypass for cardiac surgery. Interventions: A random group of 80 patients was managed conventionally (group A), whereas another random group of 80 patients received continuous intravenous administration of low-dose fenoldopam (0.1–0.3 μg/kg/min) during cardiopulmonary bypass and in the early postoperative period (group B). Measurements and main results: An improvement of postoperative renal parameters were observed only in group B: preoperative serum creatinine 1.82 ± 0.2 versus 1.43 ± 0.73 postoperatively (p Conclusions: In this study, fenoldopam was an effective agent in the prevention of renal dysfunction after cardiopulmonary bypass.

Presentation of the inferior epigastric artery as conduit for coronary artery bypass grafting (CABG): harvesting, use and results.

We present a novel postinfarction ventricular septal defect repair, through a single ventriculotomy, using a biseptal double patch and gelatin-resorcinol-formaldehyde glue. This technique reduces the postoperative recurrence of ventricular septal defects by reducing the tension on the patch sutures and by preventing blood from infiltrating into the suture lines within the ventricular septal defect cavity.

Yersinia enterocolitica is an unusual cause of septicaemia, usually occurring in immunocompromised hosts. Endocardial involvement is rare and generally presents as acute endocarditis. We describe the case of a 73-y-old woman, apparently without risk factors for endocarditis, admitted to hospital for persistent fever of unknown origin, arthralgia, and weight loss. Y. enterocolitica was isolated from blood and urine cultures, and echocardiography showed a pedunculated vegetation attached to the non-coronary cusp of the aortic valve. Symptoms and fever resolved after 3 days of intravenous cefotaxime plus amikacin, which were continued for the 2 weeks of her hospital stay; this treatment was followed by intravenous ceftriaxone after discharge. We hypothesized that a chemotherapy course administered 2 months previously for breast cancer might have been a predisposing factor for the Y. enterocolitica valvular infection and that immune system recovery contributed to mitigate the clinical presentation as subacute endocarditis.

Background The circumference of the aortic annulus adjusts proportionally with changes in left ventricular volume. These dimensional changes in the aortic annulus improve the left ventricular outflow tract (LVOT) hemodynamics and enhance the anterior mitral valve leaflet (AML) movement. In this study, we investigated the impact of circumferential and partial circumference prosthetic mitral rings on aortomitral apparatus function. Methods Forty patients who underwent coronary artery bypass graft surgery and restrictive annuloplasty of the mitral valve annulus through either a partial circumference flexible ring (group A=20 patients) or a circumferential rigid ring (group B=20 patients) were evaluated using cardiac magnetic resonance imaging. Imaging was performed at the end of a 2-year follow-up period. Variations in LVOT diameter, transmitral valve gradient, and effective mitral valve area were measured and compared. Results Mean variation in LVOT diameter was significantly higher in group A compared with group B (12.7% ± 4% versus 3.6% ± 5%, p = 0.0005). Transmitral valve gradient was higher in group B than in group A (6.2 ± 3 mm Hg versus 4.6 ± 2 mm Hg, p = 0.007), whereas effective mitral valve area was larger in group A than group B (3.9 ± 4 cm 2 versus 3.1 ± 6 cm 2 , p = 0.009). The long-axis cardiac magnetic resonance imaging of patients in group B demonstrated that movement at the base of the AML was hindered with the AML pivotal point appearing to shift posteriorly. Conclusions This study demonstrated that the use of circumferential annular rings significantly impairs overall aortomitral apparatus function by reducing outflow diameter and AML movement.

Systemic hypotension limits the intravenous use of levosimendan, particularly in coronary disease. Published reports show that the intracoronary administration of levosimendan in animal models causes an increase of coronary blood flow without systemic hypotension. In this case report, the intracoronary administration of levosimendan bolus in a 74-year-old man with postpericardiotomy heart failure elicited beneficial cardiac effects, increasing both systolic and diastolic functions and blood flow in all of the grafts. No changes of heart rate and systemic arterial blood pressure were observed.

Two patients underwent combined heart and lung surgery performed through a limited left anterior thoracotomy. Good exposure of the left pulmonary hilum and the left anterior descending artery was obtained, allowing left upper lobectomy combined with off-pump coronary bypass grafting. This approach avoids potential complications due to sternotomy, staged operations, and cardiopulmonary bypass. These cases show that a limited thoracotomy allows safe and effective combined lung and cardiac surgery in carefully selected patients.

Objectives Mechanical complications of median sternotomy may cause significant morbidity and mortality in cardiac surgical patients. This study was aimed at assessing the role of Posthorax support vest (Epple, Inc., Vienna, Austria) in the prevention of sternal complications and the improvement of anatomical healing in patients at high risk for mechanical sternal dehiscence after cardiac surgery by mean of median sternotomy. Methods A prospective, randomized, study was performed and 310 patients with predisposing factors for sternal dehiscence after sternotomy for cardiac surgery were included. The patients were divided into two groups: patients who received the Posthorax support vest after surgery, and patients who did not. Primary variables assessed included the incidence of mechanical sternal complications, the quality of sternal healing, the rate of re-operation, the duration of hospitalization, rate and duration of hospital, re-admission for sternal complications. Secondary variables assessed were the post-operative pain, the number of requests for supplemental analgesia and the quality of life measured by means of the EQ-5D format. Results Patients using vest demonstrated a lower incidence of mechanical sternal complications, a better anatomical sternum healing, lower hospital stay, no re-operations for sternal dehiscence before discharge and lower re-admissions for mechanical sternal complication. In addition, patients using a vest reported a better quality of life with better freedom from limitations in mobility, self-care, and pain. Conclusions Our findings demonstrate that the use of the Posthorax vest reduces post-sternotomy mechanical complications and improves the healing of the sternotomy, the clinical course, and the post-operative quality of life.