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AIMS Transaortic (TAo) and transapical (TA) implantation can be used in transcatheter aortic valve implantation (TAVI) when the transfemoral (TF) approach is precluded. We compare the safety and efficacy of these alternative techniques. METHODS From October 2007 to February 2016, TAo and TA patients' data were collected. Propensity score inverse probability of treatment weight (IPTW) method was employed to minimize the impact of no-randomization bias. RESULTS From our single-center non-TF-TAVI registry, 282 patients were included: 235 (83.3%) underwent TAo and 47 (16.7%) TA. Differences in baseline characteristics were statistically significant in age, sex, risk profile according to logistic-EuroSCORE, and previous cardiac surgery. No difference in hospital morbidity and mortality, but lower stroke-rate in TAo (1.27% vs. 8.5% p

Objective To analyze Italian Cardiac Surgery experience during the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) identifying risk factors for overall mortality according to coronavirus disease 2019 (COVID‐19) status. Methods From February 20 to May 31, 2020, 1354 consecutive adult patients underwent cardiac surgery at 22 Italian Centers; 589 (43.5%), patients came from the red zone. Based on COVID‐19 status, 1306 (96.5%) were negative to SARS‐CoV‐2 (COVID‐N), and 48 (3.5%) were positive to SARS‐CoV‐2 (COVID‐P); among the COVID‐P 11 (22.9%) and 37 (77.1%) become positive, before and after surgery, respectively. Surgical procedures were as follows: 396 (29.2%) isolated coronary artery bypass grafting (CABG), 714 (52.7%) isolated non‐CABG procedures, 207 (15.3%) two associate procedures, and three or more procedures in 37 (2.7%). Heart failure was significantly predominant in group COVID‐N (10.4% vs. 2.5%, p = .01). Results Overall in‐hospital mortality was 1.6% (22 cases), being significantly higher in COVID‐P group (10 cases, 20.8% vs. 12, 0.9%, p

The impact of the coronavirus disease-2019 (COVID-19) pandemic forced the governments worldwide to deal with an unprecedented health crisis. The aim of this review is to summarize what happened to cardiac surgery worldwide during the first wave of this pandemic. A literature search was performed to extrapolate key concepts regarding guidelines and reorganization of cardiac surgery wards during COVID-19. Supporting literature was also included to discuss the hot topics related to COVID-19 and cardiac surgery. Hence, both official documents from national scientific societies and single- or multiple-center experiences during the pandemics are reviewed and discussed. In Italy, the first western country hit by the pandemic, two different models were proposed to cope with the need for ICU/ward beds and to reallocate cardiac surgical services: Hub-and-Spoke system ('Hubs', dedicated to perform urgent and nondeferrable surgery, and 'Spokes', turned into COVID centers) and/or a progressive reduction in surgical activity. Worldwide, several guidelines/consensus statements were published, suggesting how to deal with the outbreak. Two different approaches for stratifying surgical indications were proposed: dynamic, based on the number of hospitalized COVID-19 patients; static, based only on the severity of the cardiovascular disease. Moreover, the importance of personal protective equipment was stressed. Several measures should have been adopted to deal with an unprecedented need for healthcare resources allocation to care for COVID-19 patients, putting the healthcare systems under serious stress. Cardiac surgery has, as have most surgical activities, been asked to reduce its own activity, giving priority to emergency and nondeferrable cases.

Objectives: The use of transcatheter aortic valve implantation (TAVI) has expanded as an alternative to aortic valve replacement, and more than 500,000 patients have been treated worldwide since April, 2002. The aim of this study was to compare complications and morbidity/mortality associated with different TAVI approaches as alternatives to a surgical-femoral approach. Methods: From January 2007 to January 2015, 2,863 patients underwent TAVI surgery in 36 United Kingdom TAVI centers. Primary outcomes were complications according to VARC-2 criteria. The secondary outcome was long-term survival. Results: The enrolled patients were distributed as follows: 1,150 in the surgical-femoral (SF) group, 1,216 in the trans-apical (TA) group, 207 in the direct-aortic (DA) group, and 290 in the subclavian (SC) group. There were no differences in the rates of acute myocardial infarction, emergency valve-in-valve, cardiac tamponade, or TIA among the groups. The rates of stroke and renal replacement therapy, as well as in-hospital stay, in-hospital death, and 30-day and 12-month mortality in DA and TA were higher than those in SC and SF. The rates of paravalvular leak and balloon post-dilatation in SC and DA were higher than those in TA and SF. The rates of vascular injuries and permanent pacemaker implantation in SC and SF were higher than those in DA and TA. SF provided the best long term-survival (p = 0.008). Conclusions: This was a large study that compared outcomes and long-term survival among different TAVI surgical approaches in a national real-world setting. According to our results, SF provided the best survival. While SC provided worse survival than SF, it was still better than TA and DA, and thus may represent the safest non-femoral access if use of the femoral approach is precluded.

The use of transcatheter aortic valve implantation (TAVI) has expanded as an alternative to aortic valve replacement, and more than 500,000 patients have been treated worldwide since April, 2002. The aim of this study was to compare complications and morbidity/mortality associated with different TAVI approaches as alternatives to a surgical-femoral approach.From January 2007 to January 2015, 2,863 patients underwent TAVI surgery in 36 United Kingdom TAVI centers. Primary outcomes were complications according to VARC-2 criteria. The secondary outcome was long-term survival.The enrolled patients were distributed as follows: 1,150 in the surgical-femoral (SF) group, 1,216 in the trans-apical (TA) group, 207 in the direct-aortic (DA) group, and 290 in the subclavian (SC) group. There were no differences in the rates of acute myocardial infarction, emergency valve-in-valve, cardiac tamponade, or TIA among the groups. The rates of stroke and renal replacement therapy, as well as in-hospital stay, in-hospital death, and 30-day and 12-month mortality in DA and TA were higher than those in SC and SF. The rates of paravalvular leak and balloon post-dilatation in SC and DA were higher than those in TA and SF. The rates of vascular injuries and permanent pacemaker implantation in SC and SF were higher than those in DA and TA. SF provided the best long term-survival (p = 0.008).This was a large study that compared outcomes and long-term survival among different TAVI surgical approaches in a national real-world setting. According to our results, SF provided the best survival. While SC provided worse survival than SF, it was still better than TA and DA, and thus may represent the safest non-femoral access if use of the femoral approach is precluded.

Dilatation of the aortic root (AR) after aortic valve surgery associated with ascending aorta replacement (AVS+AAR) is an important concern in long-term follow-up (FU). This study aimed to identify factors that may be associated with this late complication.Two-hundred-sixteen consecutive patients (150 males and 66 females) who underwent AVS+AAR from June 2009 to April 2018 at a single center were retrospectively analyzed. The mean trans-thoracic echocardiographic (TTE) FU was 44.9 ± 22.2 months. An increase of 10% in AR size compared to the pre-operative baseline was the outcome variable. The Student t-test or chi-square test was used as appropriate. For a survival analysis, a Kaplan-Meier curve was computed and a log-rank p-value was calculated. Cox's regression model was used to assess the predictive value of variables over time. A p-value0.05 was significant.No significant differences were observed among patients who underwent aortic valve repair and those who underwent aortic valve replacement (log-rank = 0.917). In patients who underwent valve replacement, AR enlargement was associated with the difference between the diameter of the prosthetic valve and the diameter of the straight vascular prosthesis (OR 0.87, P = 0.024). Based on the difference in diameter between vascular and valve prosthesis, we arbitrarily classified the patients into two groups: a small group (S) (n = 52), in which the difference was ≤ 5 mm, and a large group (L) (n = 34), in which the difference was5 mm. Significant AR enlargement was observed in 30.8 % of the S group and 14.7 % of the L group (log-rank = 0.026). A difference of more than 5 mm between the aortic valve prosthesis and the vascular prosthesis protected against AR enlargement in the long-term FU (OR 12.31, P = 0.033), even after adjusting for age and sex (OR 00.32, P = 0.043).According to our findings, a difference between the size of the aortic valve prosthesis and the vascular prosthesis of less than or equal to 5 mm was the only factor that increased the risk of AR enlargement after AVS+AAR in long-term FU.

In this study, we review current knowledge regarding molecular pathways activation and their possible mechanisms in the perioperative period of coronary artery bypass surgery (CABG). We also highlight the role of off-pump CABG as a possible way to better understand these biological changes.We show that, after both on-pump and off-pump CABG, there is a marked and protracted activation of several molecular pathways indicating increased inflammatory status, haemostasis activation, as well as increased oxidative stress and unfavourable endothelial milieu. These changes persist for days and even weeks after surgery. Interestingly, a relatively limited number of these pathways show a more pronounced activation in case of cardiopulmonary bypass use, and these markers are mainly associated with oxidative stress activation; on the contrary, the vast majority of the pathways has a similar course both in on and off-pump procedures. Surgical stress accounts for more protracted and marked molecular pathway perturbations overall, being the effect of cardiopulmonary, if any, limited to the very early hours after surgery. The near future of the translational research in coronary bypass surgery is to develop therapeutic strategies aimed at reducing this response, that is largely unrelated to cardiopulmonary bypass use, in order to reduce perioperative complications and to speed up patients' recovery.

We performed a meta-analysis of early and long-term outcomes after tricuspid repair to compare the results of suture-based and prosthetic ring annuloplasty with the employment of an algorithm that derives the original patient time-to-event data. There was an advantage in early but not in long-term survival with the use of the annuloplasty ring. The freedom from moderate tricuspid regurgitation was significantly better in patients with ring annuloplasty (78.9% ± 5.0% at 15 years vs 60.0% ± 4.2%, log-rank p = 0.0107). The ring annuloplasty is associated to better outcomes, being a protective factor for early mortality and long-term recurrence of tricuspid regurgitation after surgery. © 2014 The Society of Thoracic Surgeons.

Atrial fibrillation (AF) is characterized by electrical, contractile, and structural remodeling mediated by interstitial fibrosis. It has been shown that human cardiac mesenchymal progenitor cells (CMPCs) can be differentiated into endothelial, smooth muscle, and fibroblast cells. Here, we have investigated, for the first time, the contribution of CMPCs in the fibrotic process occurring in AF. As expected, right auricolae samples displayed significantly higher fibrosis in AF vs control (CTR) patients. In tissue samples of AF patients only, double staining for c-kit and the myofibroblast marker α-smooth muscle actin (α-SMA) was detected. The number of c-kit-positive CMPC was higher in atrial subepicardial regions of CTR than AF cells. AF-derived CMPC (AF-CMPC) and CTR-derived CMPC (Ctr-CMPC) were phenotypically similar, except for CD90 and c-kit, which were significantly more present in AF and CTR cells, respectively. Moreover, AF showed a lower rate of population doubling and fold enrichment vs Ctr-CMPC. When exogenously challenged with the profibrotic transforming growth factor-β1 (TGF-β1), AF-CMPC showed a significantly higher nuclear translocation of SMAD2 than Ctr-CMPC. In addition, TGF-β1 treatment induced the upregulation of COL1A1 and COL1A2 in AF-CMPC only. Further, both a marked production of soluble collagen and α-SMA upregulation have been observed in AF-CMPC only. Finally, electrophysiological studies showed that the inwardly rectifying potassium current (IK1) was evenly present in AF- and Ctr-CMPC in basal conditions and similarly disappeared after TGF-β1 exposure. All together, these data suggest that AF steers the resident atrial CMPC compartment toward an electrically inert profibrotic phenotype.

Thoracic aortic aneurysms (TAAs) and aortic dissections (ADs) are among the main causes of mortality and morbidity in Western countries. For this reason, the diagnosis, prevention and prediction of TAAs and ADs have become a very active area of research; in fact, it is important to monitor and predict the evolution of these diseases over time. It is also critical, in cases of doubtful diagnosis, to receive some guidance from biochemical assays, particularly in the case of ADs. Although biological testing for disease prediction has already been discussed several times, the role of biomarkers in TAAs and ADs is still under discussion for routine patient screening, periodical follow-up or for prompt diagnosis in emergency conditions. In this review, we update the current knowledge and new trends regarding the role of biomarkers in thoracic aortic diseases, focusing on established and emerging biomarkers in the fields of genetics, inflammation, haemostasis and matrix remodelling as well as on substances released upon cell damage. Other than D-dimer, a sensitive but not a specific marker for the diagnosis of AD that has been widely tested by several authors and currently seems a viable option in ambiguous cases, the remaining markers have been most frequently assessed in limited or mixed patient populations. This currently precludes their widespread adoption as diagnostic or prognostic tools, even if many of these markers are conceptually promising. In years to come, we expect that future studies will further clarify the diagnostic and prognostic features of several established and emerging biomarkers that, to date, are still in the translational limbo separating biological discovery from a practical clinical role. © The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.