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Wound healing process after surgical procedure plays a crucial role to prevent blood loss and infections. Hypertrophic scars might occur after surgery and are generally associated with an inflammatory burden. Cardiac surgery is intrinsically related to a strong systemic inflammatory state that might favor hypertrophic scarring. Besides lipid‐lowering effects, statins are known for their pleiotropic and anti‐inflammatory activity. The aim of this study was to investigate the impact of statins in the healing process after median sternotomy in patients undergoing cardiac surgery. All patients undergoing major cardiac surgery with median sternotomy and cardiopulmonary bypass, and subsequently evaluated in the outpatient clinic after discharge, were included in this study. A total of 930 Caucasian patients were retrospectively reviewed. At outpatient visit, 276 patients (29.7%) showed the formation of hypertrophic scars. Patients with hypertrophic scars tended to be younger (P =.001) and nonstatin users (P =.001). Logistic regression analysis confirmed the protective role of statins (odds ratio 0.39, 95% confidence interval 0.29‐0.53, P =.001), after adjustment for age. A dose‐dependent effect was confirmed, showing a more intensive protective effect for higher doses of statins. Statin use might be correlated with reduced hypertrophic scars after cardiac surgery through median sternotomy. A dose‐dependent effect has been shown, and statin effect seems to be independent of age in a selected population undergoing surgery with an elevated inflammatory burden. Although further studies are warranted to elucidate the biologic mechanisms, the concept of using statins as anti‐scarring agents is novel and should be investigated with tailored studies. [ABSTRACT FROM AUTHOR]

Pressure ulcers (PUs) are a common complication after cardiac surgery, with almost one third of patients suffering from PUs during hospitalisation. Because of the burden that PUs exert on both the patients and the health care system, prevention is of utmost importance. The first step in successful prevention, however, includes the identification of the main features that render patients prone to PU development. Cardiac surgery population is not adequately addressed in current clinical trials and studies. Few studies focused specifically on cardiac surgery patients, but the majority included cardiac surgery patients within a heterogeneous population of acute or critical care patients. Therefore, additional research is warranted to understand the unique risk profile of patients undergoing cardiac surgery. Intraoperative risk factors that affect tissue tolerance have not been thoroughly investigated but are likely to play an important role, which might explain the epidemiology of a PU. Further research is also needed to better comprehend the risk of PUs among cardiac surgery patients and to design effective and tailored preventative measures with the help of newer tools for risk assessment. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The aim of this study was to evaluate a novel insertion technique of the prosthetic ring that would further magnify the degree of annulus narrowing, thereby reducing the potential for a residual leak in ischaemic mitral valve repair. METHODS: Thirty-six patients with ischaemic mitral regurgitation (MR) were randomly assigned into two groups. In 18 patients, the prosthetic ring was inserted in the conventional manner with a single row of sutures (control group). In the remaining 18 patients, the ring was attached using a double row of sutures tied both on the inner and on the outer part of the sewing cuff. Both groups had similar preoperative clinical and echocardiographic characteristics with severe leaflet tethering: mean tenting area >2.5 cm2, mean anterior leaflet angle >25° and posterior leaflet angle >45°. The mean prosthetic ring sizes inserted in both groups were identical (mean: 27.3 mm). RESULTS: At 12 months, there was no clinical event except for 1 rehospitalization in the control group. The mean mitral regurgitation grade was higher in the control group than in the group with the double row of sutures at 1.6 ± 0.9 vs 0.7 ± 0.3 (P = 0.0003). Annulus diameter reduction was less pronounced in the control group when compared with the group with the double row of sutures, both in the parasternal long-axis: 29.3 ± 3 vs 26.3 ± 3 mm (P = 0.0003) and in apical four-chamber views: 31 ± 3 vs 28 ± 2 mm (P = 0.003). Leaflet tethering indices were greater in the control group than in the group with the double row of sutures: tenting area: 1.42 ± 0.3 vs 1.1 ± 0.5 cm2 (P = 0.002), anterior leaflet angle: 33 ± 3° vs 28 ± 5° (P = 0.0009) and posterior leaflet angle: 110 ± 13° vs 80 ± 11° (P = 0.0001). Left ventricular function parameters were not statistically different among the two groups. CONCLUSION: A double row of overlapping sutures for attaching the prosthetic ring in downsizing annuloplasty is more efficient in narrowing the mitral annulus than the conventional technique in ischaemic mitral repair. Even in high-risk patients whose leaflets were severely tethered on echocardiography, it almost eliminated the risk of MR recurrence in this study. [ABSTRACT FROM AUTHOR]

The inflammatory burden intrinsically related to cardiac surgery, therefore, might be an acute disturbing factor in the chronic equilibrium of a patient with psoriasis and might have profound clinical consequences. Considering the pathophysiologic similarity between the psoriasis-mediated inflammation and the irritative responses triggered by cardiac surgery and cardiopulmonary bypass, surgical outcomes might be affected by psoriasis. [Extracted from the article]

Three-dimensional (3D) printing is emerging as an innovative tool for a tailored approach to endovascular or open procedures. The efforts of different specialists and data analysis can be used to fabricate patient-specific implants, which might have significant impact even in life-saving procedures such as aortic dissections or aortic arch aneurysm. 3D printing is gradually changing the traditional pattern of diagnosis and treatment. This innovative approach allows a perfect match between the patient's anatomy and the prosthetic graft, ideally resulting in better hemodynamics and improved long-term patency related to reduced turbulent flow. Future applications of 3D printing in the cardiovascular field combined with tissue engineering will enhance the therapeutic features of bioprinted tissues and scaffolds for regenerative medicine. This review will summarize the clinical significance of 3D printing in cardiovascular disease, exploring current applications, translational outlooks and future perspectives.

Heart rate variability (HRV) refers to the variations between consecutive heartbeats, which depend on the continuous modulation of the sympathetic and parasympathetic branches of the autonomic nervous system. HRV has been shown to be effective as a predictor of risk after myocardial infarction and an early warning sign of diabetic neuropathy, and in the cardiology setting is now recognized to be a useful tool for risk-stratification after hospital admission and after discharge. Recent evidences suggest that HRV analysis might predict complications even in patients undergoing cardiac surgery, and the present review summarizes the importance of HRV analysis in adult cardiac surgery and the perspectives for HRV use in current clinical practice. Although future larger studies are warranted before HRV can be included into daily clinical practice in adult cardiac surgery, HRV is a novel tool which might detect autonomic instability in the early postoperative phase and during hospital stay, thus predicting or prompt-diagnosing many of the post-operative complications.

Optimal revascularization strategy in patients with multi-vessel coronary artery disease remains a matter of debate, with advantages and disadvantages in both surgical and percutaneous procedures. A combined approach to achieve coronary revascularization, termed "hybrid coronary revascularization" (HCR), has been recently introduced in clinical practice. HCR is defined as a scheduled combination of surgical left internal mammary artery to left anterior descending (LIMA-LAD) grafting and percutaneous treatment of at least one non-LAD coronary arteries, with both procedures planned and performed within a defined time limit. HCR is indicated in case of both proximal LAD disease eligible to surgical LIMA-LAD grafting and non-LAD disease amenable to percutaneous procedures. Reviews and metanalysis of the literature showed that HCR is non-inferior to conventional surgical myocardial revascularization, and in case of high-risk patients, HCR can be the ideal option. However, the various technical approaches and time-related steps need to be further evaluated. Present and future research in interventional cardiology and cardiac surgery will turn into parallel improvements in HCR procedures. Surgical revascularization with off-pump techniques and minimally-invasive approaches, scoring systems such as SYNTAX II, tools evaluating the hemodynamic significance of atherosclerotic plaques with physiology-based approaches such as fractional flow reserve and instantaneous wave-free ratio, newer generation drug eluting stents, newer antiplatelet agents, and therapies might improve indications and clinical outcomes after HCR procedures. This article reviews the current literature on HCR and aims to provide an overview about future developments.

Mitral valve prolapse occurs in 33.6% of patients undergoing surgery for ischemic mitral regurgitation (IMR). In the context of IMR, reparative strategy cannot disregard the underlying mechanism of pathogenesis and the progressive geometric alteration affecting left ventricle and papillary muscles. We present a case of extended mitral prolapse of the posteromedial commissure and A3 concomitant to chordal injury after inferior myocardial infarction. We propose a combined sequential approach including papillary muscle approximation and a mitral chordae system replacement.

Diabetes is a major risk factor for cardiovascular disease, and recent advances in research indicate that a detailed understanding of the pathophysiology of its effects is mandatory to reduce diabetes-related mortality and morbidity. Advanced Glycation End Products (AGEs) play a central role in the genesis and progression of complications of both type 1 and type 2 diabetes mellitus, and have been found to be important even in non-diabetic patients as a marker of cardiovascular disease. AGEs have a profound impact on patient's prognosis regardless of the glycemic control, and therefore pharmacologic approaches against AGEs accumulation have been proposed over the years to treat cardiovascular diseases, parallel to a more detailed understanding of AGEs pathophysiology. Compounds with anti-AGEs effects are currently under investigation in both pre-clinical and clinical scenarios, and many of the drugs previously used to treat specific diseases have been found to have AGE-inhibitory effects. Some products are still in "bench evaluation", whereas others have been already investigated in clinical trials with conflicting evidences. This review aims at summarizing the mechanisms of AGEs formation and accumulation, and the most relevant issues in pre-clinical and clinical experiences in anti-AGEs treatment in cardiovascular research.

The long-term outcomes of undersizing annuloplasty for the treatment of ischemic mitral regurgitation (IMR) is affected by the progressive dilation of the annulus, which carries increased risk for ring disinsertion. Reasons underlying this phenomenon might be found in the excess of physical stress on the annuloplasty sutures during the ventricular remodeling process. We report a technique based on the placement of a double row of overlapping sutures aiming at reducing the potential for ring disinsertion. Eleven patients with IMR undergoing mitral valve repair associated with coronary bypass grafting were treated with this technique and echocardiographically followed up at 6 and 12 months. The overall annular dimension decreased significantly with a significant reduction of the tenting area and no recurrence of mitral regurgitation at 1 year. A double row of overlapping sutures allowed firm attachment of the prosthetic ring while downsizing the annulus in IMR, limiting the consequences of changes in subannular ventricular geometry. This technique might therefore be considered a useful aid during mitral valve repair.

The first aortic valve homograft was implanted by Sir Donald Ross in 1962. Since then, over 25,000 aortic homografts have been implanted worldwide. Unfortunately, the current cryopreservation method promotes a degenerative process leading to progressive homograft fibrosis and calcification. Valve durability of fresh allografts appears to be superior to cryopreserved grafts. The main indications of aortic valve replacement with a homograft are endocarditis, rheumatic disease, bicuspid and dystrophic aortopathies. Our experience with 210 aortic homografts implanted over a 10-year period is reported. We describe the different implantation techniques with particular emphasis on the current technique of choice, namely homograft root replacement. Approximately one-fourth of all aortic homografts will experience structural valve deterioration at 12 years. Structural homograft valve deterioration translates predominately into valve insufficiency and less frequently into stenosis. Young recipient age it appears is the major determinant of reoperation. Predictors of early and late mortality are discussed.

Background and Aim of the Study: A congenitally dysfunctioning bicuspid aortic valve may require surgical treatment in children and young adults. This retrospective study evaluated mid-term clinical results obtained with the Ross procedure in this patient group., Methods: Between July 1994 and December 2000, 55 patients (48 males, seven females; mean age 27+/-10 years; range: 7-49 years) underwent replacement of a diseased bicuspid aortic valve (stenosis in six cases (11%); insufficiency in 36 (65%); mixed lesion in 13 (24%)) with a pulmonary autograft. Mean NYHA functional class was 1.7. Five patients (9%) had healed endocarditis and six (11%) had previous cardiac surgery. The autograft was inserted as a subcoronary implant in two cases (4%), as a root in 40 (73%), and as a cylinder in 13 (23%). The right ventricular outflow tract was reconstructed with a cryopreserved pulmonary homograft in all cases. Mean cardiopulmonary bypass and aortic cross-clamp times were 207+/-34 min and 162+/-18 min, respectively., Results: No early or late deaths had occurred at a mean follow up of 31+/-19 months. Two patients (4%) were re-explored for bleeding. Four patients (7%) experienced intraoperative coronary complications which resolved without sequelae. Two-dimensional echocardiographic evaluation of neoaortic valve competence at six months revealed no evidence of aortic valve regurgitation in 46 patients (84%), trivial regurgitation in seven (13%), mild regurgitation in one patient (2%), and moderate regurgitation in one patient. The latter patient (subcoronary implant) required reoperation. At six months, the degree of regression of left ventricular mass compared (versus preoperative) was 34+/-13% (p <0.05). Three patients (5%) showed mild dilatation (>4 cm) of the neoaortic root after two years follow up. All patients are currently asymptomatic, in NYHA class I, and enjoy a normal social lifestyle., Conclusion: The Ross procedure may be offered as a low-risk alternative in adolescents and young adults with a bicuspid aortic valve. Although the inclusion cylinder technique might help to prevent root dilatation, continued patient evaluation with regard to root sizing, evidence of neoaortic valve degeneration and homograft dysfunction is required in the long term.

Background and Aim of the Study: The study aim was to evaluate our clinical experience with the CarboMedics heart valve prosthesis., Methods: Between October 1991 and December 2000, 942 consecutive patients (514 males, 428 females; mean age 58+/-11 years; range: 6-78 years) underwent mechanical valve implantation with the CarboMedics prosthesis. Preoperatively, 47% of patients were in NYHA class III and 22% in class IV; in addition, 134 patients (14.2%) had undergone a previous cardiac operation. Aortic valve replacement (AVR) was performed in 469 patients (49.8%), mitral valve replacement (MVR) in 330 (35.0%), double valve replacement (DVR) in 142 (15.1%), and isolated tricuspid valve replacement (TVR) in one patient. Eighty-eight patients (9.3%) underwent associated myocardial revascularization. Mean cardiopulmonary bypass and aortic cross-clamp times for the entire group were 107+/-39 min and 74+/-24 min, respectively., Results: Overall early mortality was 2.3% (6/469 AVR, 1.2%; 12/330 MVR, 3.6%; 4/142 DVR, 2.8%). Late mortality was 3.1% (n = 29; including 17 cardiac deaths (10 were valve-related). Mean follow up was 66+/-31 months (range: 1-109 months), and was 98% complete yielding a total follow up of 4959 years. Actuarial survival at five years for the entire group was 89.3+/-1.6% (AVR 91.1%, MVR 86.4%, DVR 90.5%). Thromboembolism occurred in 26 patients (2.8%, 0.52%/pt-year) and major hemorrhagic events in 20 (2.1%, 0.4%/pt-year). Nine patients (0.9%) required a reoperation, in three cases (0.3%) after Staphylococcus epidermidis-mediated endocarditis. No structural deterioration occurred. Among 891 survivors, 94% of the patients are currently in NYHA classes I or II (p <0.05)., Conclusion: This study confirmed the safety and reliability of the CarboMedics mechanical valve prosthesis, even in old age groups. This bileaflet prosthesis showed no structural deterioration, and a low incidence of overall complications.