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Objective This study sought to identify periprocedural risk predictors that affect long-term prognosis in patients with chronic obstructive pulmonary disease (COPD) undergoing isolated coronary artery bypass grafting (CABG). Methods All consecutive 4,871 patients undergoing isolated CABG between May 2005 and June 2021 were included. Patients with and without COPD were compared for baseline demographics and preoperative characteristics. A propensity-matched analysis was used to compare the 2 groups. The primary outcome was long-term incidence of all-cause death. Results After matching, 767 patients each were included in the COPD and non-COPD groups; mean age was 71.6 and 71.4 years (P = .7), respectively; 29.3% and 32% (P = .2) were women, respectively. Intraoperatively, median (IQR) operating room time was higher in the COPD group than in the non-COPD group (5.9 [5.2-7.0] hours vs 5.8 [5.1-6.7] hours, respectively; P = .01). Postoperatively, intensive care unit stay (P = .03), hospital length of stay (P = .0004), and fresh frozen plasma transfusion units (P = .012) were higher in the COPD group than in the non-COPD group. Thirty-day mortality was not different between groups (1.3% in the COPD group vs 1% in the non-COPD group; P = .4). Median follow-up time was 4.0 years. The rate of all-cause death was higher in the COPD group than in the non-COPD group (138 patients [18.3%] vs 109 patients [14.5%], respectively; P = .042). Periprocedural risk predictors for all-cause death in patients with COPD were atrial fibrillation, diabetes, male sex, dialysis, ejection fraction less than 50%, peripheral vascular disease, and Society of Thoracic Surgeons Predicted Risk of Mortality score greater than 4%. Conclusion Patients with COPD undergoing isolated CABG had a significantly higher incidence of all-cause death than those without COPD. Herein, risk predictors are provided for all-cause death in patients undergoing isolated CABG.

Pulmonary vein isolation (PVI) with catheter ablation (CA) represents an effective therapy for atrial fibrillation (AF). Unfortunately, it is still not exempt from severe complications. The balance of risks and benefits should be assessed, and a patient-tailored approach is desirable. So far, several clinical and cardiac imaging parameters have been evaluated to investigate pre- and post-procedural features that could help clinicians in the selection of patients at high risk of a poor outcome after CA. This clinical and systematic review analyses the potential role of new LA parameters, such as LA reservoir strain, to predict AF recurrence after CA therapy. Notably, LA reservoir strain gains substantial clinical importance in patients with paroxysmal AF and when a low CHADS2-VASc score is retrieved. LA reservoir strain provides data concerning the risk of AF recurrence after PVI and, thus, in the management of long-term medical therapy in this patient’s group.

Objectives: To investigate primary and secondary surgical outcomes following transcaval repair (TCR), modified Warden repair, and transatrial repair techniques for partial anomalous pulmonary venous connections (PAPVCs) and sinus venosus atrial septal defects (ASDs). Methods: This is an observational cohort clinical study. Patients who underwent TCR, modified Warden repair, and transatrial surgical repair for PAPVC and ASD between January 2003 and October 2019 at our institution were included in the study. Patients had one of the surgical procedures based on the anatomy of the defect. Results: Ten patients, seven (70%) males and three (30%) females, were included in the analysis. Seven patients underwent TCR, two patients the modified Warden technique, and one patient underwent transatrial surgical repair. Mean age was 57 years ± 14.7. Mean EuroScore II was 3.4 ± 3.5. The baseline left ventricle ejection fraction was 45 ± 6.5%. No patient had previous stroke, pacemaker (PM) implantation, or myocardial infarction. Total cardiopulmonary bypass and cross-clamping time were 123 ± 72.5 and 100 ± 48.5 min, respectively. Mean mechanical ventilation, mean intensive care unit, and mean hospital length of stay for the transcaval, modified Warden, and transatrial groups were 4.6 ± 10.7, 5.7 ± 8.8, and 10.5 ± 9.2 days, respectively. Superior caval or pulmonary venous obstruction, sinus node dysfunction, and PM implantation were not present at follow-up. The patient who underwent transatrial repair had died at 5.5-year follow-up due to myocardial infarction. Total survival rate at 6 years was 90%. Conclusions: The findings from this study elicit that all three techniques have low postoperative morbidity and are feasible and reliable procedures.

An unroofed coronary sinus is a malformation that leads to a shunt between the coronary sinus and the left atrium. In our case, the shunt led to the formation of a gigantic left atrial aneurysm compressing the left atrium on transesophageal echocardiography. During surgery, a myxoma was incidentally discovered.

BACKGROUND: Outcomes of robotic-assisted coronary artery bypass grafting in pregnant women have not been assessed. OBJECTIVE: This study aimed to understand the importance of minimally invasive robotic-assisted coronary artery bypass grafting in pregnant woman with coronary artery disease. We describe the case of a G3P1011 woman at 19+6 weeks’ gestation presenting with a non-ST myocardial infarction treated with off-pump hybrid robotic-assisted revascularization. STUDY DESIGN: This study describes the surgical approach for a pregnant woman presenting with non-ST myocardial infarction treated with hybrid robotic-assisted revascularization. RESULTS: A coronary angiography demonstrated a culprit lesion of 90% stenosis in the left anterior descending coronary artery and an 80% stenosis in the right coronary artery. Because of the high rate of complications with traditional coronary artery bypass grafting, the heart team opted for hybrid robotic-assisted revascularization and the postoperative recovery was uneventful. CONCLUSION: Robotic coronary artery bypass grafting can be the preferred surgical choice to decrease maternal and fetal mortality in patients undergoing coronary artery bypass grafting, and it is an important tool in the surgical armamentarium.

Background: To investigate the impact of Cryo Nerve Block with cryoICE™ device utilization, on post-operative pain in patients undergoing isolated coronary artery bypass grafting (CABG) through left thoracotomy. Methods: All consecutive patients undergoing isolated CABG through left thoracotomy between July 2021 and July 2022 from a single surgeon were included in the study. Patients using the cryoICE™ device for nerve block were compared for baseline demographics and pre-operative characteristics with those that did not use the cryoICE™ device. A propensity-adjusted analysis was used to compare the two groups. The primary outcome was degree of incisional pain and numbness. Results: A total of 103 patients underwent isolated CABG through left thoracotomy. After matching, the cryoICE™ device was used for nerve block in 60 patients while the control group included 43 patients. Mean follow-up was 5.7 months. The cryoICE™ device group had a mean value of incisional pain at hospital discharge was 1.5 (scale 0–10) while at follow-up was 0.69 (scale 0–10). Mean values of skin numbness at hospital discharge were 1 (scale 0–10) and 0.57 (scale 0–10) at follow-up. After univariate analysis comparison of cryoICE™ device group (60 patients) versus non-cryoICE™ device group (43 patients), the total in-hospital morphine use was 49% lower in the cryoICE™ versus the non-cryoICE™ cohort (73.8 + 79.37 mg vs 144.1 + 118.99 mg). Conclusions: Good clinical outcomes were observed in patients undergoing isolated left thoracotomy CABG with cryoICE™ utilization, including a very low incidence of post-operative pain, numbness, and hypersensitivity for all comers.

The use of a left ventricular assist device (LVAD) as a bridge-to-transplantation or destination therapy to support cardiac function in patients with end-stage heart failure (HF) is increasing in all developed countries. However, the expertise needed to implant and manage patients referred for LVAD treatment is limited to a few reference centers, which are often located far from the patient's home. Although patients undergoing LVAD implantation should be permanently referred to the LVAD center for the management and follow-up of the device also after implantation, they would refer to the local healthcare service for routine assistance and urgent health issues related to the device or generic devices. Therefore, every clinician, from a bigger to a smaller center, should be prepared to manage LVAD carriers and the possible risks associated with LVAD management. Particularly, emergency treatment of patients with LVAD differs slightly from conventional emergency protocols and requires specific knowledge and a multidisciplinary approach to avoid ineffective treatment or dangerous consequences. This review aims to provide a standard protocol for managing emergency and urgency in patients with LVAD, elucidating the role of each healthcare professional and emphasizing the importance of collaboration between the emergency department, in-hospital ward, and LVAD reference center, as well as algorithms designed to ensure timely, adequate, and effective treatment to patients with LVAD.

Chronic mitral regurgitation (MR) is the second valvular heart disease for incidence, which worsening severity gradually affects all cardiac chambers and leads to poor outcome if untreated. The recent development of minimally invasive surgical techniques and percutaneous intervention has reduced the operative risk, allowing a more confident referral of these patients for intervention. Therefore, there is a growing need of reliable markers to select the best therapeutic strategies and to identify the optimal timing for intervention. Myocardial fibrosis (MF) gradually occurs as a result of left atrial and ventricular (LA and LV) remodeling due to MR pressure and volume overload. It has been identified as an index of clinical outcome and arrhythmic risk in patients with MR. Particularly, the assessment of LA fibrosis not only allows to define different MR etiology, but also was associated with prognosis and atrial fibrillation (AF) burden. Nowadays, noninvasive estimation of MF is possible through the use of advanced imaging modalities, particularly cardiac magnetic resonance and speckle tracking echocardiography. This review discusses the role of LA fibrosis as a diagnostic and prognostic marker in patients with MR and its quantification by noninvasive multimodality cardiac imaging.

Objective: The goal of this manuscript is to compare clinical and echocardiographic outcomes of patients undergoing aortic valve replacement (AVR) with Perceval sutureless bioprosthesis (SU-AVR) and sutured bioprosthesis (SB). Methods: Following the PRISMA statement, data were extracted from studies published after August 2022 and found in PubMed/MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, SciELO, LILACS, and Google Scholar. The primary outcome of interest was post-procedural permanent pacemaker implantation, and the secondary outcomes were new left bundle branch block (LBBB), moderate/severe paravalvular leak (PVL), valve dislocation (pop-out), need for a second transcatheter heart valve, 30-day mortality, stroke, and echocardiographic outcomes. Results: Twenty-one studies were included in the analysis. When SU-AVR was compared to other SB, mortality ranged from 0 to 6.4% for Perceval and 0 to 5.9% for SB. Incidence of PVL (Perceval 1–19.4% vs. SB 0–1%), PPI (Perceval 2–10.7% vs. SB 1.8–8.5%), and MI (Perceval 0–7.8% vs. SB 0–4.3%) were comparable. In addition, the stroke rate was lower in the SU-AVR group when compared to SB (Perceval 0–3.7% vs. SB 1.8–7.3%). In patients with a bicuspid aortic valve, the mortality rate was 0–4% and PVL incidence was 0–2.3%. Long-term survival ranged between 96.7 and 98.6%. Valve cost analysis was lower for the Perceval valve and higher for sutured bioprosthesis. Conclusions: Compared to SB valves, Perceval bioprosthesis has proved to be a reliable prosthesis for surgical aortic valve replacement due to its non-inferior hemodynamics, implantation speed, reduced cardiopulmonary bypass time, reduced aortic cross-clamp time, and shorter length of stay.

Objective: To highlight the main target points covered by clinical studies on the Perceval sutureless valve for surgical aortic valve replacement (SAVR) and raise a point of discussion for further expansion of its use when compared with stented bioprostheses (SB) and transcatheter aortic valve replacement (TAVR).Methods: We reviewed clinical trials and retrospective studies published up to date and compared the outcomes in terms of mortality, myocardial infarction (MI) stroke, paravalvular leak (PVL), permanent pacemaker implantation (PPI), bleeding and long-term outcomes.Results: Clinical studies showed that 30-day mortality ranged from 0–4% for Perceval and 2.9–7% for TAVR. The incidence of PVL (Perceval 1.9–19.4 vs. TAVR 9–53.5%), PPI (Perceval 2–11.2 vs. TAVR 4.9–25.5%), stroke (Perceval 0 vs. TAVR 0–2.8%), MI (Perceval 0 vs. TAVR 0–3.5%), were all higher in the TAVR group. Compared to other SB, mortality ranged from 0–6.4% for Perceval and 0–5.9% for SB. The incidence of PVR (Perceval 1–19.4 vs. SB 0–1%), PPI (Perceval 2–10.7 vs. SB 1.8–8.5%), stroke (Perceval 0–3.7 vs. SB 1.8–7.3%) and MI (Perceval 0–7.8 vs. SB 0–4.3%) were comparable among the groups. In patients with a bicuspid aortic valve, mortality rate was (0–4%) and PVL incidence was (0–2.3%). However, there was a high incidence of PPI (0–20%), and stroke (0–8%). Long-term survival ranged between 96.7–98.6%.Conclusions: The Perceval bioprosthesis has proved to be a reliable prosthesis for surgical aortic valve replacement due to its implantation speed, the reduced cardiopulmonary bypass time, the reduced aortic cross-clamp time and the shorter intensive care unit and hospital length of stay.

Background Recent data suggest that systemic inflammation can negatively affect atrioventricular conduction, regardless of acute cardiac injury. Indeed, gap‐junctions containing connexin43 coupling cardiomyocytes and inflammation‐related cells (macrophages) are increasingly recognized as important factors regulating the conduction in the atrioventricular node. The aim of this study was to evaluate the acute impact of systemic inflammatory activation on atrioventricular conduction, and elucidate underlying mechanisms. Methods and Results We analyzed: (1) the PR‐interval in patients with inflammatory diseases of different origins during active phase and recovery, and its association with inflammatory markers; (2) the existing correlation between connexin43 expression in the cardiac tissue and peripheral blood mononuclear cells (PBMC), and the changes occurring in patients with inflammatory diseases over time; (3) the acute effects of interleukin(IL)‐6 on atrioventricular conduction in an in vivo animal model, and on connexin43 expression in vitro. In patients with elevated C‐reactive protein levels, atrioventricular conduction indices are increased, but promptly normalized in association with inflammatory markers reduction, particularly IL‐6. In these subjects, connexin43 expression in PBMC, which is correlative of that measured in the cardiac tissue, inversely associated with IL‐6 changes. Moreover, direct IL‐6 administration increased atrioventricular conduction indices in vivo in a guinea pig model, and IL‐6 incubation in both cardiomyocytes and macrophages in culture, significantly reduced connexin43 proteins expression. Conclusions The data evidence that systemic inflammation can acutely worsen atrioventricular conduction, and that IL‐6‐induced down‐regulation of cardiac connexin43 is a mechanistic pathway putatively involved in the process. Though reversible, these alterations could significantly increase the risk of severe atrioventricular blocks during active inflammatory processes.

Background: Ischemic stroke after coronary artery bypass (CABG) has been often linked to aortic manipulation during surgery.Objectives: The objective of the study was to estimate the rate of postoperative ischemic stroke within 30 days from CABG by surgical risk factors alone or in combination.Methods: The multinomial propensity score for multiple treatments was used to create six models with a total of 16,255 consecutive patients undergoing isolated CABG. For each model, a different classification variable was used to stratify patients.Results: Balance achieved in all models was substantial, enabling unbiased estimation of the treatment estimand. Both off-pump techniques with (0.009; 95% CI 0.006–0.011) or without proximal anastomoses (0.005; 0.005–0.003), and surgery performed on the beating heart using cardiopulmonary bypass with (0.009; 0.006–0.011) or without proximal anastomoses (0.024; 0.021–0.029) showed a mean stroke estimate significantly lower than the other techniques. Off-pump surgery and on-pump surgery without an aortic cross-clamp yielded nearly equal incidences of stroke (0.012; 0.008–0.015 and 0.018; 0.012–0.023, respectively). Using an aortic cross-clamp significantly increased the stroke estimate (0.075; 0.061–0.088), whereas using a side-biting clamp did not (0.039; 0.033–0.044). The number of aortic touches (0.029; 0.026–0.031) and the number of proximal anastomoses (0.044; 0.035–0.047) did not significantly increase the incidence of stroke.Conclusions: Aortic cross-clamping was found to be the primary cause of post-CABG ischemic stroke. Instead, additional aortic manipulation from a side-biting clamp, on-pump surgery, multiple aortic touches, number of proximal anastomoses, and aortic cannulation were found not to increase the estimate of stroke significantly. Further research on this topic is warranted.

Primary mitral regurgitation (MR) is the second most common valvular disease, characterized by a high burden in terms of quality of life, morbidity, and mortality. Surgical treatment is considered the best therapeutic strategy for patients with severe MR, especially if they are symptomatic. However, pre-operative echocardiographic evaluation is an essential step not only for surgical candidate selection but also to avoid post-operative complications. Therefore, a strong collaboration between cardiologists and cardiac surgeons is fundamental in this setting. A meticulous pre-operative echocardiographic exam, both with transthoracic or transesophageal echocardiography, followed by a precise report containing anatomical information and parameters should always be performed to optimize surgical planning. Moreover, intraoperative transesophageal evaluation is often required by cardiac surgeons as it may offer additive important information with different hemodynamic conditions. Three-dimensional echocardiography has recently gained higher consideration and availability for the evaluation of MR, providing more insights into mitral valve geometry and MR mechanism. This review paper aims to realize a practical overview on the main use of basic and advanced echocardiography in MR surgical planning and to provide a precise checklist with reference parameters to follow when performing pre-operative echocardiographic exam, in order to aid cardiologists to provide a complete echocardiographic evaluation for MR operation planning from clinical and surgical point-of-view.

Background Systemic inflammation is a strong predictor of atrial fibrillation. A key role for electrical remodeling is increasingly recognized, and experimental data suggest that inflammatory cytokines can directly affect connexins resulting in gap‐junction dysfunction. We hypothesized that systemic inflammation, regardless of its origin, promotes atrial electric remodeling in vivo, as a result of cytokine‐mediated changes in connexin expression. Methods and Results Fifty‐four patients with different inflammatory diseases and elevated C‐reactive protein were prospectively enrolled, and electrocardiographic P‐wave dispersion indices, cytokine levels (interleukin‐6, tumor necrosis factor‐α, interleukin‐1, interleukin‐10), and connexin expression (connexin 40, connexin 43) were measured during active disease and after reducing C‐reactive protein by >75%. Moreover, peripheral blood mononuclear cells and atrial tissue specimens from an additional sample of 12 patients undergoing cardiac surgery were evaluated for atrial and circulating mRNA levels of connexins. Finally, in vitro effects of interleukin‐6 on connexin expression were studied in HL‐1 mouse atrial myocytes. In patients with active inflammatory diseases, P‐wave dispersion indices were increased but rapidly decreased within days when C‐reactive protein normalizes and interleukin‐6 levels decline. In inflammatory disease patients, both P‐wave dispersion indices and interleukin‐6 changes were inversely associated with circulating connexin levels, and a positive correlation between connexin expression in peripheral blood mononuclear cells and atrial tissue was demonstrated. Moreover, interleukin‐6 significantly reduced connexin expression in HL‐1 cells. Conclusions Our data suggest that regardless of specific etiology and organ localization, systemic inflammation, via interleukin‐6 elevation, rapidly induces atrial electrical remodeling by down‐regulating cardiac connexins. Although transient, these changes may significantly increase the risk for atrial fibrillation and related complications during active inflammatory processes.