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Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. A multi-center retrospective study was designed to assess pacemaker dependency (PMD) and long-term mortality after cardiac surgery procedures. Between 2004 and 2016, PPI-patients from 18 centers were followed. Time-to-event data were evaluated with semiparametric regression Cox models and semiparametric Fine and Gray model for competing risk framework. Of 859 (0.90%) PPI-patients, 30% were pacemaker independent (PMI) at 6 months. PMD showed higher mortality compared with PMI (10-year survival 80.1% +/- 2.6% and 92.2% +2.4%, respectively, log-rank p-value < 0.001) with an unadjusted hazard ratio for death of 0.36 (95% CI 0.20 to 0.65, p< 0.001 favoring PMI) and an adjusted hazard ratio of 0.19 (95% CI 0.08 to 0.45, p< 0.001 with PMD as reference). Crude cumulative incidence function of restored PMI rhythm at follow-up at 6 months, 1 year and 12 years were 30.5% (95% CI 27.3% to 33.7%), 33.7% (95% CI 30.4% to 36.9%) and 37.2% (95% CI 33.8% to 40.6%) respectively. PMI was favored by preoperative sinus rhythm with normal conduction (SR) (HR 2.37, 95% CI 1.65 to 3.40, p< 0.001), whereas coronary artery bypass grafting and aortic valve replacement were independently associated with PMD (HR 0.63, 95% CI 0.45 to 0.88, p = 0.006 and HR 0.807, 95% CI 0.65 to 0.99, p = 0.047 respectively). Time-to-implantation was not associated with increased rate of PMI. Although 30% of PPI-patients are PMI after 6 months, PMD is associated with higher mortality at long term. (C) 2020 The Author(s). Published by Elsevier Inc.

OBJECTIVES Transcatheter aortic valve implantation with a transaortic approach (TAo-TAVI) is an alternative to transapical or femoral access. We studied the procedural and midterm efficacy and safety of TAo-TAVI with Edwards Sapien XT and Medtronic CoreValve devices. METHODS Among 901 patients receiving TAVI since 2006, 265 consecutive patients underwent TAo-TAVI between January 2011 and September 2014. Procedural and midterm results were evaluated according to Valve Academic Research Consortium-2 criteria. RESULTS The mean age was 83 ± 5 years. Sapien XT and CoreValve were used in 191 (72.1%) and 74 (27.9%) patients, respectively. Full sternotomy made elective concomitant off-pump coronary artery bypass grafting possible in 38 patients (14.3%) with severe coronary artery disease unsuitable for percutaneous coronary intervention. The device success rate was 95.5%. Postprocedural paravalvular leak ≥2/4 was observed in 16 patients (6.4%). Emergency open chest surgery was required in 10 patients (3.8%) (3 aortic dissections, 3 valve embolizations, 2 LMCA occlusions, 1 aortic annulus rupture and 1 aortic rupture). Cerebrovascular accidents occurred in 3 patients (1.1%). Transfusions ≥4 units were required in 36 patients (13.6%). New pacemakers were implanted in 26 patients (9.8%). Thirty-day and 1-year mortality were 8.7% and 16.2%, respectively. Mean follow-up duration was 24 ± 6 months. At 3 years, freedom from all-cause death was 80% ± 4%. New York Heart Association class CONCLUSION The TAo-TAVI approach confirms its safety and effectiveness with satisfactory procedural and midterm outcomes with both currently available devices.

Congenital left ventricular aneurysm or diverticulum is very rare. Most congenital left ventricular aneurysms are asymptomatic but some cause systemic embolization, left ventricular free wall rupture, or ventricular arrhythmias causing sudden cardiac death. A 29-year-old woman with congenital left ventricular aneurysm and nonsustained ventricular tachycardia underwent surgical plication of the aneurysm with left ventricular reshaping to improve heart failure symptoms, prevent rupture of the aneurysm wall and the possibility of thrombus formation, and excise the fibrotic tissue of the left ventricular aneurysm, which could be a trigger for left ventricular aneurysm arrhythmias. The postoperative course was unremarkable.

A 49-year-old man was admitted to our department 6 months after emergent surgery for type-A acute aortic dissection. A chest computed tomography-scan revealed a huge aneurysm originating from the proximal aortic arch, strongly adherent to the upper part of the sternum. Extracorporeal circulation was instituted first, and chest was reopened in circulatory arrest. The mass was a giant pseudoaneurysm originating from a laceration at the base of the innominate artery. Due to tissue fragility and complete distortion of the origin of right carotid and subclavian arteries, we performed an extra-anatomic ascending aorta-to-right carotid artery bypass, followed by Teflon-reinforced suture of the proximal artery stumps. The postoperative course was uneventful.

Objective The aim of this study was to describe the clinical course of a consecutive series of patients operated of urgent cardiac surgery during COVID-19 outbreak. Background In Italy, COVID outbreak has mostly occurred in the metropolitan area of Milan, and in the surrounding region of Lombardy, and previously "conventional" hospitals were converted into COVID spokes to increase ICU beds availability, and to allow only urgent CS procedures. Methods Among urgent CS patients (left main stenosis with unstable angina, acute endocarditis, valvular regurgitation with impending heart failure), 10 patients (mean age = 57 ± 9 years), despite a negative admission triage, developed COVID-pneumonia postoperatively, at a median of 7 days after CS. Results Patients showed typical lymphopenia, higher prothrombotic profile, and higher markers of inflammation (ferritin and interleukin-6 values). At the zenith of pulmonary distress, patients presented with severe hypoxia (median PaO2/FIO2 ratio = 116), requiring advanced noninvasive ventilation (Venturi mask and continuous positive airway pressure) in the majority of cases. All patients were treated with hydroxychloroquine, azithromycin, and low-molecular-weight heparin at anticoagulant dose. Overall in-hospital mortality was 10% (1/10), peaking 25% in patients who developed COVID pneumonia immediately after CS. The remaining patients, with late infection, were all discharged home without oxygen support, at a median of 25 days after symptom onset. Conclusions As postoperative mortality in case of COVID pneumonia is not negligible, meticulous rules (precise triage, safe hospital path, high level of protection for health-care teams, prompt diagnosis of suspicious symptoms) should be strictly followed in patients undergoing CS during COVID pandemic. The role of therapies alternative to CS should be further assessed.

BACKGROUND: Patients with liver cirrhosis (LC) undergoing cardiac surgery (CS) face perioperative high mortality and morbidity, but extensive studies on this topic are lacking.METHODS: All adult patients with LC undergoing a CS procedure between 2000 and 2017 at 10 Italian Institutions were included in this retrospective cohort study. LC was classified according to preoperative Child-Turcotte-Pugh (CTP) score and Model for End-Stage Liver Disease (MELD) score. Early-term and medium-term outcomes analysis was performed in the overall population and according to CTP classes.RESULTS: The study population included 144 patients (mean age 66 ± 9 years, 69% male). Ninety-eight, 20, and 26 patients were in CTP class A, in early CTP class B (MELD score 12), respectively. The main LC etiologies were viral (43%) and alcoholic (36%). Liver-related clinical presentation (ascites, esophageal varices, and encephalopathy) and laboratory values (estimated glomerular filtration rate, serum albumin, and bilirubin, platelet count) significantly worsened across the CTP classes (P= .001). Coronary artery bypass grafting or valve surgery (87% bioprosthesis) were performed in 36% and 50%, respectively. Postoperative complications (especially acute kidney injury, liver complication, and length of stay) significantly worsened in advanced CTP class B (P= .001). Notably, observed mortality was 3-fold or 4-fold higher than the EuroSCORE (European System for Cardiac Operative Risk Evaluation) II-predicted mortality, in the overall population, and in the subgroups. At Kaplan-Meier analysis, 1-year and 5-year cumulative survival in the overall population was 82% ± 3% and 77% ± 4%, respectively. The 5-year survival in CTP class A, early CTP class B, and advanced CTP class B was 72% ± 5%, 68% ± 11%, and 61% ± 10%, respectively (P= .238).CONCLUSIONS: CS outcomes in patients with LC are significantly affected in relation to the extent of preoperative liver dysfunction, but in early CTP classes, medium-term survival is acceptable. Further analysis are needed to better estimate the preoperative risk stratification of these patients.

Coronary artery aneurysms (CAAs) are rare lesions in which the optimal management is poorly defined. We present a series of three patients with diffuse symptomatic coronary artery disease and giant CAAs, on the circumflex branch (6 × 5 cm - Patient 1), on the proximal right coronary artery (5 × 6 cm - Patient 2) and on the proximal left anterior descending (LAD) (4 × 5 cm - Patient 3). Standard coronary artery bypass grafting (LIMA-on-LAD plus sequential saphenous vein) and associated CAA exclusion by proximal and distal ligation was performed according to the coronary anatomy. Six month follow-up computed tomography scan control showed complete exclusion of the CAA in all three patients.

OBJECTIVES Our goal was to analyse a consecutive series of patients with solid organ tumours undergoing coronary artery bypass grafting (CABG) by defining the risk factors for early and long-term outcomes. METHODS Between 2005 and 2016, a consecutive series of 4079 patients underwent isolated CABG at our institution. Of 103 patients (2.5%) with active malignancy, we enrolled 82 patients (mean age 71 ± 7 years) with solid organ tumours, divided into 4 subgroups: lung (9 patients—11%), gastroenteric (16 patients—20%), urinary (48 patients—58%) and other solid tumours (9 patients—11%). A deterministic record linkage between the clinical database and the National Hospital Information System allowed identification of long-term survival rates and freedom from major adverse cardiovascular events (acute myocardial infarction, repeated admissions for percutaneous coronary intervention and heart failure). RESULTS The most common forms of cancer were prostate, colon and carcinoma of the lung. Compared to patients without cancer, patients with neoplasms were significantly older and had a higher rate of comorbidities, without significant differences among the cancer subgroups. The 30-day mortality rate was significantly higher in patients with cancer compared to those without cancer (4.9% vs 1.8%). However, on logistic regression analysis, cancer was an independent risk factor for postoperative pulmonary dysfunction but not for in-hospital death. The median follow-up time was 58 ± 12 months. The overall 5-year survival rate was 60% [95% confidence interval (CI) 47–71%], with a dismal 32% (95% CI 5–65%) survival rate among patients who had lung tumours only. The 5-year freedom from major adverse cardiovascular events was 64% (95% CI 52–74%), without significant differences among subgroups, and was comparable to that of the non-cancer population. Resolution of coronary heart disease allowed safe cancer surgical resection in 80% of the population. CONCLUSIONS Based on the results from the present study, CABG should not be denied to patients with solid organ tumours by claiming a worse prognosis or less graft durability. Further studies with larger numbers are warranted.

AIMS Despite several studies reporting a higher mortality rate for women undergoing isolated coronary artery bypass graft (CABG) surgery, this issue has not been completely clarified. The aim of the current study was to determine if sex differences in CABG surgery affect adjusted operative results and operative mortality. METHODS Between January 2005 and December 2012, 3756 consecutive patients (3009 men and 747 women) underwent isolated CABG at our institution. Women presented with older age, smaller BSA and higher rate of preoperative comorbidities. The propensity score methodology was used to obtain risk-adjusted outcome comparisons between the two groups. RESULTS The distribution of preoperative variables among matched pairs (553 patients in both groups) was, on average, equal. Propensity-matched women received a similar number of distal anastomoses (P = 0.56), had similar rate of left internal thoracic artery (LITA) graft (P = 0.73) and comparable extracorporeal circulation (P = 0.61) and aortic cross-clamp (P = 0.39) time as men. Postoperative complications were comparable in the two study groups with the exception of postoperative transfusion rate which was significantly higher in women (P = 0.01). However, operative mortality (3.8 vs. 2.7%; P = 0.20), perioperative acute myocardial infarction (P = 0.50) and stroke (P = 0.75) were not significantly different between the two groups. Interestingly, after adjustment for the other baseline characteristics, female patients with diabetes (P = 0.03), preoperative renal dysfunction (P = 0.07) and obesity (P = 0.07) exhibited a greater operative mortality rate compared with men with the same comorbidities. CONCLUSION After adjustment for preoperative variables, female sex seems not to be an independent risk factor for early mortality in isolated CABG surgery. However, renal impairment, diabetes and obesity seem to play an important role in the operative risk profile of women undergoing isolated CABG.

Background Malignant cardiac tumors are rare and have an extremely poor prognosis even when complete resection is attempted. The aim of this study was to review the experience of primary malignant cardiac tumors in 2 Italian academic hospitals. Methods The hospital records were searched to identify patients with primary malignant cardiac tumors who underwent surgery between January 1979 and December 2012. Secondary cardiac tumors, whether metastatic or invasive, were excluded as were primary sarcomas of the great arteries. Fourteen patients selected from our institution’s surgical series were identified. Eleven (78.6%) were men and 3 (21.4%) were women, and the mean age at surgery was 47.4 years. Results The most common histological type was angiosarcoma (28.6%). The mean survival was 28.8 ± 28 months and it was better in men than in women (30.5 ± 8.7 vs. 21.1 ± 3.2 months). Patients with a radical resection at the first surgery had a longer survival compared to patients with a partial resection (39.9 ± 23.2 vs. 24 ± 4 months). Conclusions The treatment outcome for patients affected by primary malignant heart tumors remains poor. Aggressive surgery alone does not provide good results in terms of survival rate. A new multidisciplinary approach is mandatory to improve long-term survival.

Introduction: A 43-year-old man developed a mediastinal abscess after a redo aortic valve along with an ascending aorta replacement and also a sub-aortic membrane resection. He was surgically revised: as there were no signs of involvement of the valve and vascular prosthesis, a pedunculated tract of the greater omentum was mobilized and positioned around the aortic prosthesis. During a 10-month follow-up, it has been revealed that the patient is doing well and has no recurrence of the infection. Use of the great omentum could be considered in the selected mediastinitis cases. Case Presentation: A 43-year-old man was referred to our institution for a severe aortic regurgitation and an ascending aorta enlargement associated with a relapsing sub-aortic membrane, which had been treated in his childhood. He underwent a redo ascending aorta replacement and an aortic valve replacement (mechanical prosthesis) along with a resection of the relapsing sub-valvular membrane. Some weeks after he was admitted to another hospital for fever, arthromyalgias and chest pain. After a few days, he developed an inflammatory jugular swelling and underwent a chest CT scan showing a bulky anterior mediastinal abscess in the direct continuity with the sternum. A further chest CT scan showed a mediastinal para-aortic capsulated mass, 135 × 85 × 90 mm in dimension, well delimited over the surrounding plans. At the top of the lesion, a further fluid collection was appreciated, extending through the sternum over the subcutaneous tissues, 30 × 20 mm in dimension. Re-sternotomy was performed and the mediastinal mass was opened and drained. After an extension of the median sternotomy through the epigastrium, a pedunculated tract of the greater omentum was mobilized and positioned around the vascular prosthesis to fill the empty space left by the abscess. Conclusions: The greater omentum is well known in cardiothoracic surgery for its valuable features such as plasticity, immune competence, good blood supply and neovascularization-potential. Dead space can be obliterated by omental flap because of its plasticity qualities. It contains a large number of immunologically active cells likely to be responsible for its anti-infective properties. We can affirm that use of the great omentum could be considered in selected post-operative mediastinitis cases after cardiac surgery.

1 Introduction: Cerebral haemorrhage could complicate post operative course after cardiac surgery, especially after multiple mechanical valves replacement needing for anticoagulation. The interruption of vitamin K antagonists in this cases, to avoid the enhancement of the cerebral haemorrhage, can be performed with reasonable safety. Case Presentation: We report the case of a patient who underwent mitro-aortic valve replacement with mechanical valves. Postoperative course was uneventful until the 6th day when he developed paresthesias on the left side and left arm paresis; CT scan showed a sub-cortical cerebral haemorrhage. in the right temporo-parietal area. At that time, he was receiving Enoxaparin (4000 IU/day) and Acenocoumarol (1 mg/day) which were started on the 2nd postoperative day without a loading dose. The patient was then transferred to another hospital where neurosurgery intensive care unit was available; he was conservatively treated without surgery. During his stay at this hospital he did not receive vitamin K antagonists until February, 7th for a total of 117 days receiving only 4000 IU Enoxaparin daily. He was then re- evaluated at our hospital on April 2nd 2008 with transthoracic echocardiography and fluoroscopy: both valves were well functioning with no major problems. Discussion: Withholding anticoagulant therapy after mechanical heart valve replacement due to the severe haemorrhage is a complex problem that can occur after heart valve surgery. Although it has been shown that interruption of vitamin K antagonists can be performed in patients with mechanical valves with reasonable safety for a short-term period. As the patient transferred to another hospital after the occurrence of cerebral haemorrhage, he was treated only with low doses of enoxaparin for 117 days. In less than two months after the coumarols resumption, the subsequent reassessment of the valves performed using echocardiography and fluoroscopy confirmed the normal performance of both mitral and aortic valves. In this case, a very long suspension of standard anticoagulant therapy did not affect the performance of mechanical bi-leaflet mitral-aortic prostheses.

We present the case of a 49-year-old man with an abnormal aortic valve formed by four cusps (three equal large cusps and one smaller cusp; type 1 according to Hurwits and Roberts classification) with a marked lack of coaptation that caused a severe aortic valve insufficiency. The patient underwent a repair of the defect with a tricuspidalization of the aortic valve, restoring the normal coaptation of the cusps and the normal function of the aortic valve. Postoperative course was unremarkable. The early follow-up showed a mild aortic valve insufficiency.

Context Postoperative atrial fibrillation or flutter (AF) is one of the most common complications of cardiac surgery and significantly increases morbidity and health care utilization. A few small trials have evaluated whether long-chain n-3-polyunsaturated fatty acids (PUFAs) reduce postoperative AF, with mixed results. Objective To determine whether perioperative n-3-PUFA supplementation reduces postoperative AF. Design, Setting, and Patients The Omega-3 Fatty Acids for Prevention of Post-operative Atrial Fibrillation (OPERA) double-blind, placebo-controlled, randomized clinical trial. A total of 1516 patients scheduled for cardiac surgery in 28 centers in the United States, Italy, and Argentina were enrolled between August 2010 and June 2012. Inclusion criteria were broad; the main exclusions were regular use of fish oil or absence of sinus rhythm at enrollment. Intervention Patients were randomized to receive fish oil (1-g capsules containing ≥840 mg n-3-PUFAs as ethyl esters) or placebo, with preoperative loading of 10 g over 3 to 5 days (or 8 g over 2 days) followed postoperatively by 2 g/d until hospital discharge or postoperative day 10, whichever came first. Main Outcome Measure Occurrence of postoperative AF lasting longer than 30 seconds. Secondary end points were postoperative AF lasting longer than 1 hour, resulting in symptoms, or treated with cardioversion; postoperative AF excluding atrial flutter; time to first postoperative AF; number of AF episodes per patient; hospital utilization; and major adverse cardiovascular events, 30-day mortality, bleeding, and other adverse events. Results At enrollment, mean age was 64 (SD, 13) years; 72.2% of patients were men, and 51.8% had planned valvular surgery. The primary end point occurred in 233 (30.7%) patients assigned to placebo and 227 (30.0%) assigned to n-3-PUFAs (odds ratio, 0.96 [95% CI, 0.77-1.20]; P = .74). None of the secondary end points were significantly different between the placebo and fish oil groups, including postoperative AF that was sustained, symptomatic, or treated (231 [30.5%] vs 224 [29.6%], P = .70) or number of postoperative AF episodes per patient (1 episode: 156 [20.6%] vs 157 [20.7%]; 2 episodes: 59 [7.8%] vs 49 [6.5%]; ≥3 episodes: 18 [2.4%] vs 21 [2.8%]) (P = .73). Supplementation with n-3-PUFAs was generally well tolerated, with no evidence for increased risk of bleeding or serious adverse events. Conclusion In this large multinational trial among patients undergoing cardiac surgery, perioperative supplementation with n-3-PUFAs, compared with placebo, did not reduce the risk of postoperative AF. Trial Registration clinicaltrials.gov Identifier: NCT00970489