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Background: The aim of this study was to investigate the outcome of patients undergoing synchronous carotid endarterectomy and coronary and/or other cardiac surgery. The impact of anesthesia on the outcome was examined., Methods: A retrospective single-center observational study was performed, to investigate the outcome of 127 consecutive adult patients submitted to synchronous surgery from 2011 to 2019. Cooperative patient general anesthesia for carotid endarterectomy followed by standard general anesthesia for cardiac surgery and standard general anesthesia for the whole surgery were compared after a propensity score analysis., Results: Primary outcomes were 30-day mortality (3.1%), incidence of stroke (3.1%), and myocardial infarction (0.8%). Agitation upon awakening, postoperative cardiac troponin I release, the increase of serum creatinine, the occurrence of acute kidney injury and the need for continuous renal replacement therapy were the secondary outcomes. A binary logistic regression revealed that cardiopulmonary bypass use, standard general anesthesia for the whole surgery and the European risk score II, were the strongest predictors of any severe postoperative complications. After propensity score matching, general anesthesia for the whole surgery was significantly correlated with the occurrence of any severe postoperative complication (P=0.038)., Conclusions: Synchronous surgery was performed with acceptable mortality and complication rate even in combination with other than isolated coronary surgery. Cooperative patient general anesthesia during carotid endarterectomy, was not inferior to general anesthesia in this setting.

Objectives: To assess the cost-effectiveness (CE) of transcatheter aortic valve implantation (TAVI) in Italy, considering patient groups with different surgical risk., Methods: A Markov model with a 1-month cycle length, comprising eight different health states, defined by the New York Heart Association functional classes (NYHA I-IV), with and without stroke plus death, was used to estimate the CE of TAVI for intermediate-, high-risk and inoperable patients considering surgical aortic valve replacement or medical treatment as comparators according to the patient group. The Italian National Health System perspective and 15-year time horizon were considered. In the base-case analysis, effectiveness data were retrieved from published efficacy data and total direct costs (euros) were estimated from national tariffs. A scenario analysis considering a micro-costing approach to estimate procedural costs was also considered. The incremental cost-effectiveness ratio (ICER) was expressed both in terms of costs per life years gained (LYG) and costs per quality adjusted life years (QALY). All outcomes and costs were discounted at 3% per annum. Univariate and probabilistic sensitivity analyses (PSA) were performed to assess robustness of results., Results: Over a 15-year time horizon, the higher acquisition costs for TAVI were partially offset in all risk groups because of its effectiveness and safety profile. ICERs were €8338/QALY, €11,209/QALY and €10,133/QALY, respectively, for intermediate-, high-risk and inoperable patients. ICER values were slightly higher in the scenario analysis. PSA suggested consistency of results., Conclusions: TAVI would be considered cost-effective at frequently cited willingness-to-pay thresholds; further studies could clarify the CE of TAVI in real-life scenarios., (© 2021. The Author(s).)

Background: We describe the baseline, operative, and postoperative features of a group of 18 patients who contracted the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection in a rehabilitation facility after cardiac surgery, and present some potential explanations for the surprisingly benign course of the COVID-19 in this cohort., Methods: All patients were operated on an urgent or emergency basis (acute aortic syndrome, 3; refractory heart failure, 12; and endocarditis, 3) during the first lockdown period of the COVID-19 pandemic. The mean age was 70 years, and 12 patients were male. After the diagnosis of COVID-19, patients were treated according to the most recent recommendations. Eleven asymptomatic patients were discharged home or to a COVID-19 hotel and underwent close monitoring. Patients with fever, dyspnea, or a significant rise of the polymerase chain reaction levels were hospitalized, three received antivirals, three azithromicyne, and five hydroxychloroquine. Nasal swabs were repeated on a weekly basis, and all patients were quarantined until the collection of two consecutive negative samples., Results: Diversely from other observations on perioperative COVID-19 reporting mortality rates of 30%-40%, the COVID-19 had a benign course in our cohort: only seven patients required hospitalization, and one required short intensive care unit admission. There were no deaths, and at the latest follow-up, all patients had been discharged home., Comment: Our data show that the SARS-CoV2 infection after cardiac surgery may have a benign course. Further studies are needed to investigate the relationship between the timing of the infection, some potentially protective therapies (e.g., anticoagulants), and the course of the COVID-19., (© 2021 Wiley Periodicals LLC.)

Background: New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed., Methods: Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis., Results: Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups., Conclusions: Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2020 Annals of Cardiothoracic Surgery. All rights reserved.)

Bicuspid aortic valve (BAV) disease is a spectrum of anomalies ranging from mild underdevelopment of a commissure to severe underdevelopment of two interleaflets triangles. Many different classifications of BAV, based on the echocardiographic, surgical or pathological appearance of the valve, and more recently on cardiac CT, have been proposed. We describe a simple technique, based on three-dimensional curved multiplanar reconstruction images, to obtain a pathology-like visualization of the full line of insertion (Hinge) of the aortic valve leaflets and of the interleaflet triangles with cardiac CT. This method could help to obtain a detailed categorization of any specific BAV anatomy based on the degree of underdevelopment (or on the absence) of one interleaflet triangle. Adherence to this concept could help to improve the imaging based analysis of BAV patients undergoing TAVR, and could lead to the adoption of a BAV classification based on the effective pathologic appearance of the valve also for patients undergoing TAVR., (Copyright © 2020 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: Myxomas are the most frequent cardiac tumours. Their diagnosis requires prompt removal. In our centre, for valve surgery we use a minimally invasive approach. Here, we report our experience of cardiac myxoma removal through right lateral mini-thoracotomy (RLMT) with particular focus on its feasibility, efficacy and patient safety., Methods: Between February 2006 and January 2017, 30 consecutive patients (aged 66±12.6years, range 35-83 years) underwent atrial myxoma resection through video-assisted RLMT. Percutaneous venous drainage was performed in all patients and direct cannulation of the ascending aorta was performed in 28 out of 30 (93.3%). The diagnosis of atrial myxoma was confirmed by histology., Results: Complete surgical resection was achieved in all patients. The mean cardiopulmonary bypass (CPB) time was 76.5±40.8minutes and average aortic cross-clamping time was 41.5±29.8minutes. No patient suffered postoperative complications. Five patients (16.7%) received a blood transfusion. Mechanical ventilation ranged from 3 to 51hours (median 6hours), intensive care unit (ICU) stay ranged from 1 to 5days (median 1day). Total hospital length of stay (HLOS) was 5.6±2 days. Home discharge rate was 56.7%. No in-hospital mortality was reported. During follow-up (55.6±32.3 months; range 4-132 months), one tumour recurrence was observed. There were three late non-cardiac deaths. Overall survival was 100%, 85.7% and 85.7% at 1, 5 and 10 years, respectively., Conclusions: The use of video-assisted RLMT is an effective and reproducible strategy in all patients requiring expedited surgery for left atrial myxoma, independently of coexisting morbidity such as systemic embolisation or previous surgery. This technique leads to complete tumour resection, prompt recovery, early home discharge and high freedom from both symptoms and tumour recurrence., (Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objectives: We report an international experience of transfemoral transcatheter aortic valve replacement (TAVR) using the self-expanding Acurate neo valve (Boston Scientific) in aortic regurgitation., Methods: This series comprises 20 patients with pure aortic regurgitation undergoing transfemoral TAVR with the Acurate neo prosthesis at nine centers in Europe and Israel., Results: Mean age was 79 ± 8 years and mean STS score was 8.3 ± 9.3%. Leaflet calcification was none/minimal in 19 patients (95%). Prosthesis size selection was based on perimeter-derived annular diameter, with a tendency to over-size in cases of borderline annuli. One patient required implantation of a second valve. Device success rate was 18/20 (90%). At discharge, aortic regurgitation was none in 14 patients (70%), mild in 5 patients (25%), and moderate in 1 patient (5%). Left ventricular end-diastolic diameter decreased from 58 ± 7 mm at baseline to 53 ± 7 mm before discharge (P<.001). At 30-day follow-up, there was no mortality, no stroke, and 3 patients (15%) had received a permanent pacemaker. New York Heart Association class had improved significantly compared to baseline (85% in class I/II compared to 15% at baseline; P<.001)., Conclusions: In a selected patient population, transfemoral TAVR using the Acurate neo transcatheter heart valve was successful in treating aortic regurgitation, significantly reduced left ventricular dimensions, and improved clinical symptoms.

Background: Significant underexpansion or distortion of valved stents may be associated with altered leaflet function, leading to increased transprosthetic gradients and, possibly, early structural degeneration. We investigated the relationship between a computed tomography measure of the degree of oversizing and the early hemodynamic and clinical outcomes in patients undergoing aortic valve replacement with the Perceval sutureless aortic valve (LivaNova, Saluggia, Italy)., Methods: The degree of oversizing of the implanted prosthesis was calculated as the ratio between the patients' aortic annulus cross-sectional area and the ex vivo cross-sectional area of the implanted prosthesis in 151 Perceval patients who underwent preoperative cardiac computed tomography. This value was then entered in a multivariate analysis to ascertain its role as a predictor of increased postoperative gradient., Results: The operative mortality was 1.3%. Procedural success, defined as having a normally functioning valve in the proper anatomical location, was achieved in 150 patients (99.3%). The mean transprosthetic gradient was 13.4 ± 5.0 mm Hg, and 23 patients (15.2%) showed a gradient of 20 mm Hg or more at discharge or at the 1-month follow-up. The degree of oversizing of the implanted prosthesis was the most important predictor of increased postoperative gradient (odds ratio, 1.264; 95% confidence interval, 1.147 to 1.394; p < 0.0001). Interestingly, other relevant factors (patients' body surface area, prosthesis size) were not associated with increased gradients., Conclusions: Our study demonstrates that excessive oversizing should be avoided in Perceval patients and suggests that a different sizing algorithm, possibly based on cardiac computed tomography, should be developed. Further studies are needed to optimize the sizing strategy for the Perceval sutureless valve., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Massive hemoptysis is a life-threatening condition usually related to a pathology of the bronchial arteries. Pulmonary artery pseudoaneurysms represent a relatively rare cause of severe airway bleeding, but are associated with a mortality rate of over 50%. A case of massive intraoperative hemoptysis treated with temporary occlusion of the right pulmonary artery and delayed endovascular occlusion of the feeding segmental artery is described., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors.

Aims: There are limited data on coronary obstruction following transcatheter valve-in-valve (ViV) implantation inside failed aortic bioprostheses. The objectives of this study were to determine the incidence, predictors, and clinical outcomes of coronary obstruction in transcatheter ViV procedures., Methods and Results: A total of 1612 aortic procedures from the Valve-in-Valve International Data (VIVID) Registry were evaluated. Data were subject to centralized blinded corelab computed tomography (CT) analysis in a subset of patients. The virtual transcatheter valve to coronary ostium distance (VTC) was determined. A total of 37 patients (2.3%) had clinically evident coronary obstruction. Baseline clinical characteristics in the coronary obstruction patients were similar to controls. Coronary obstruction was more common in stented bioprostheses with externally mounted leaflets or stentless bioprostheses than in stented with internally mounted leaflets bioprostheses (6.1% vs. 3.7% vs. 0.8%, respectively; P < 0.001). CT measurements were obtained in 20 (54%) and 90 (5.4%) of patients with and without coronary obstruction, respectively. VTC distance was shorter in coronary obstruction patients in relation to controls (3.24 ± 2.22 vs. 6.30 ± 2.34, respectively; P < 0.001). Using multivariable analysis, the use of a stentless or stented bioprosthesis with externally mounted leaflets [odds ratio (OR): 7.67; 95% confidence interval (CI): 3.14-18.7; P < 0.001] associated with coronary obstruction for the global population. In a second model with CT data, a shorter VTC distance predicted this complication (OR: 0.22 per 1 mm increase; 95% CI: 0.09-0.51; P < 0.001), with an optimal cut-off level of 4 mm (area under the curve: 0.943; P < 0.001). Coronary obstruction was associated with a high 30-day mortality (52.9% vs. 3.9% in the controls, respectively; P < 0.001)., Conclusion: Coronary obstruction following aortic ViV procedures is a life-threatening complication that occurred more frequently in patients with prior stentless or stented bioprostheses with externally mounted leaflets and in those with a short VTC., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.)

Objective: Prediction of operative risk in adults undergoing cardiac surgery remains a challenge. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is one of the most commonly used in clinical settings. Recently, the new EuroSCORE II was published attempting to improve the accuracy of risk prediction. We sought to assess the predictive value of EuroSCORE or EuroSCORE II in selected field of minimally invasive cardiac surgery., Methods: Patients who underwent cardiac surgery operation with minimally invasive approach from 2007 to 2013 identified from prospective cardiac surgical database. Additional variables included in EuroSCORE II, but not in original EuroSCORE, were retrospectively collected via electronic health records reviewing. The C-statistic was calculated for the EuroSCORE (additive and logistic) and EuroSCORE II. The Hosmer-Lemeshow test was used to assess model calibration by comparing observed and expected morality in number of risk strata., Results: There were 39 hospitals deaths (1.6%). A total of 2472 patients were identified from the main database. The mean ± SD logistic EuroSCORE was 7.6 ± 8.3, mean ± SD additive EuroSCORE was 6.1 ± 2.7, and mean ± SD EuroSCORE II was 2.9 ± 4.2. EuroSCORE logistic model performed with substantial accuracy of 0.78, EuroSCORE additive performed with accuracy of 0.78, and EuroSCORE II performed as almost perfect 0.82. Model calibration was poor in EuroSCORE II (χ = 17.57, P = 0.02), calibration for logistic EuroSCORE was also poor (χ = 140.58, P < 0.01), and additive model also (χ = 94.95, P < 0.01). The area under the curve was high in all algorithms; logistic EuroSCORE was 0.78 (95% confidence interval = 0.71-0.85), additive EuroSCORE was 0.79 (95% confidence interval = 0.71-0.86), and EuroSCORE II was 0.82 (95% confidence interval = 0.75-0.89)., Conclusions: In overall settings, original EuroSCORE and EuroSCORE II perform poorly in minimally invasive operation conditions. Data suggest that EuroSCORE could not be used for estimating operative risks correctly. New risk score should be explored, developed, and implemented for selective minimally invasive cohorts.

Objectives: The aim of this study was to compare early outcomes and survival of patients undergoing minimally invasive mitral valve replacement through a right anterior minithoracotomy (MIMVR) versus patients undergoing transcatheter transapical mitral valve-in-valve (M-VIV) implantation for a failed mitral bioprostheses., Methods: From 2005 to 2015, 61 patients with a failed mitral bioprosthesis underwent either MIMVR ( n  = 40 patients, 65.6%) or M-VIV implantation ( n  = 21, 34.4%) at our institution. The groups were compared in terms of early outcomes and survival rates. Treatment selection bias was controlled by a propensity score and was included along with the comparison variable in the multivariable analyses of outcome., Results: Patients with M-VIV implantation were older ( P  = 0.03), had more pulmonary hypertension ( P  = 0.02) and a higher EuroSCORE ( P  = 0.001). In-hospital mortality was 7.5% ( n  = 3) in the MIMVR group and 4.7% ( n  = 1) in the M-VIV group [odds ratio (OR) = 2.46; P  = 0.512]. Incidence of stroke was 12.5% ( n  = 5) in the MIMVR group vs 4.7% ( n  = 1) in the M-VIV group (OR = 0.887; P  = 0.935). No significant differences were noted in postprocedural complications, even after adjusting the results for the propensity score. M-VIV patients had shorter stays in the intensive care unit and in the hospital ( P  = 0.02). In the M-VIV group, 28% ( n  = 7) had less than mild paravalvular leakage, whereas no patients had mild paravalvular leakage in the MIMVR group ( P  < 0.001). Finally, the 2-year survival rates were 86 ± 1% vs 87 ± 1% in patients undergoing MIMVR compared with those undergoing M-VIV implantation, respectively ( P  = 0.1)., Conclusions: In selected patients, M-VIV can be performed safely with results comparable with those of surgical therapy., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of the present study was to evaluate the impact of a retrograde arterial perfusion (RAP) strategy versus an antegrade arterial perfusion (AAP) strategy in a consecutive, large cohort of patients who underwent minimally invasive mitral valve surgery with transthoracic aortic clamping through a right minithoracotomy., Methods: Between 2003 and 2015, 1632 consecutive patients underwent first-time minimally invasive mitral valve surgery with transthoracic aortic clamping at our institution; 141 (8.6%) of these patients received retrograde perfusion with femoral artery cannulation, whereas 1421 (91.4%) received antegrade perfusion with ascending aorta cannulation. Logistic regression was used to evaluate outcomes and risk factors for death and stroke between groups., Results: The overall frequency of 30-day mortality was 0.7% (13/1632) and was similar between groups (retrograde arterial perfusion RAP 0.7% vs AAP 0.8%; P  = 0.903). The overall postoperative stroke rate was 1.3% (22/1632). The stroke rate was significantly higher in patients receiving retrograde perfusion (3.5% vs 1.1%; P  = 0.005). Risk factors for death were advanced age (odds ratio (OR) = 1.3; P  = 0.004), mitral valve replacement (OR = 3.9; P  = 0.05), emergent procedure (OR = 3.4; P  = 0.014) and conversion to sternotomy (OR = 3.7; P  = 0.001). Multivariable regression analysis revealed that retrograde perfusion was an independent risk factor for stroke (OR = 3.3; P  = 0.004). Other risk factors were conversion to sternotomy (OR = 12; P  = 0.001), active endocarditis (OR = 5.8; P  = 0.07) and hypercholesterolaemia (OR = 2.4; P  = 0.048). Interaction modelling revealed that the only significant risk factor for a neurological event was the use of retrograde perfusion in patients older than 70 years with an atherosclerotic burden (OR = 6.4; P  = 0.033)., Conclusions: Minimally invasive mitral valve procedures can be performed with low morbidity and mortality. The use of retrograde perfusion is associated with a higher incidence of neurological complications in older patients with atherosclerotic burden. Central aortic cannulation permits avoidance of complications associated with retrograde perfusion and extends the suitability of minimally invasive mitral procedures to those patients who have an absolute contraindication for femoral artery cannulation., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The study objective was to assess the learning process and quality of care of right minithoracotomy aortic valve replacement with a sutureless bioprosthesis at a single institution., Methods: We performed an analysis of the first 300 consecutive patients (aged 76 ± 6 years; logistic European System for Cardiac Operative Risk Evaluation 9 ± 6) who underwent sutureless valve implantation via a right minithoracotomy by 6 surgeons at the G. Pasquinucci Heart Hospital between 2011 and 2015. The learning curve was analyzed by dividing the study population into tertiles of 100 patients each. Departmental and individual learning curves were calculated using sequential probability cumulative sum failure analysis. Quality indicators were 2 composite end points reflecting the technical success and 30-day complications., Results: The overall mortality was 0.7% (2 patients). No significant differences were noted in terms of mortality and complications between tertiles. The sutureless valve was implanted successfully in 99% of patients (298/300). Cumulative sum analysis failed to identify any significant learning effects for technical success. Nevertheless, surgeons A, B, and C had a small initial learning curve, and surgeons D, E, and F did not, reflecting a trend toward a positive effect of cumulative institutional experience on the individual learning curve. The 30-day complications analysis revealed a cluster of failures at the beginning of the experience. This cluster prompted an internal audit and modification of the patients' selection process. Consecutively, the procedure returned in control., Conclusions: Right minithoracotomy sutureless valve implantation can be performed safely without learning curve effects. Cumulative sum analysis is a valuable tool to describe and monitor the learning process. The analysis can identify periods of less than expected performance and alert the team to react., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Colorectal carcinomas metastatic to the heart are rare. We present a case of colonic carcinoma metastatic to the right atrium and discuss the management and prognosis of these rare lesions., (© 2016 Wiley Periodicals, Inc.)

Background: The recourse to mitral valve-in-valve implantation is expected to rise consistently owing to the increasing use of bioprostheses and to the risks related to redo valve replacement. However, there is concern that the excellent early results of mitral valve-in-valve could be nullified by the development of significant gradients. We report our experience with mitral valve-in-valve implantation, with particular emphasis on the midterm follow-up., Methods: Eighteen patients underwent mitral valve-in-valve implantation at our institution. The mean Society of Thoracic Surgeons score was 10.3. All patients were heavily symptomatic. The mechanisms of bioprosthesis failure were stenosis (3 patients), regurgitation (4 patients) or mixed (11 patients). The mean transprosthetic gradient was 12.8 ± 5.7 mm Hg. All the procedures were transapical. Balloon predilation was never used., Results: In the first patient, the transcatheter valve embolized in the ventricle. The patient died 2 days later of multiorgan failure. There were no other hospital deaths. Four patients died of pneumonia, endocarditis, lung cancer, and stroke at 1, 8, 18, and 46 months, postoperatively. The mean gradient at discharge was 5.1 ± 2.3 mm Hg. At follow-up (median 27 months), all surviving patients were in New York Heart Association functional class II or less. The mean transprosthetic gradient was 7 ± 1.8 mm Hg, and 1 patient had a gradient more than 10 mm Hg., Conclusions: Mitral valve-in-valve implantation allows good clinical and hemodynamic results. In our series, the appearance of a significant gradient at follow-up was not associated with echocardiographic signs of structural deterioration, and was possibly related to the size of the transcatheter and recipient valve., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to compare early outcomes and mid-term survival of high-risk patients undergoing minimally invasive aortic valve replacement through right anterior mini-thoracotomy (RT) with sutureless valves versus patients undergoing transcatheter aortic valve implantation (TAVI) for severe aortic stenosis., Methods: From October 2008 to March 2013, 269 patients with severe aortic stenosis underwent either RT with perceval S sutureless valves (n = 178 patients, 66.2%) or TAVI (n = 91, 33.8%: 44 transapical and 47 trans-femoral). Of these, 37 patients undergoing RT with the perceval S valve were matched to a TAVI group by the propensity score., Results: Baseline characteristics were similar in both groups (mean age 79 ± 6 years) and the median logistic EuroSCORE was 14% (range 9-20%). In the matched group, the in-hospital mortality rate was 8.1% (n = 3) in the TAVI group and 0% in the RT group (P = 0.25). The incidence rate of stroke was 5.4% (n = 2) versus 0% in the TAVI and RT groups (P = 0.3). In the TAVI group, 37.8% (n = 14) had mild paravalvular leakage (PVL) and 27% (n = 10) had moderate PVL, whereas 2.7% (n = 1) had mild PVL in the RT group (P < 0.001). One- and 2-year survival rates were 91.6 vs 78.6% and 91.6 vs 66.2% in patients undergoing RT with the perceval S sutureless valve compared with those undergoing TAVI, respectively (P = 0.1)., Conclusions: Minimally invasive aortic valve replacement with perceval S sutureless valves through an RT is associated with a trend of better early outcomes and mid-term survival compared with TAVI., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: The sutureless prostheses may facilitate minimally invasive aortic valve replacement because of easy and fast deployment. However, correct device sizing remains a crucial step of this procedure, which may be difficult and time consuming in minimal invasive approaches. We sought to analyze the accuracy of contrast-enhanced preoperative multidetector-row computed tomography (MDCT) in predicting the size of the prosthesis to be implanted in patients undergoing aortic valve replacement through a right anterior minithoracotomy (RAMT)., Methods: From January 2011 to September 2013, 235 patients underwent aortic valve surgery as sole procedure with implantation (Sorin Perceval S) in RAMT. Inclusion criterion for this study was presence of preoperative multidetector-row computed tomography (MDCT) with contrast enhancement and Doppler echocardiography. A preoperative MDCT was used to measure the aortic annulus as the diameter derived from either the area (aD) or the circumference (cD) of the virtual basal ring, left ventricular outflow tract (LVOT) diameter derived either from the area (aLVOT) or the circumference (cLVOT). Multidetector-row CT was reviewed by a single operator who was blind to implanted valve size. The operator measured the aortic annulus and LVOT in multiplanar reconstruction modality. Aortic annular diameter and LVOT diameter were retrieved from echocardiographic records. Predictive models were built based on logistic regression; outcome variable was the sutureless valve size, and covariates (annular and LVOT measurements) were used as single and multivariate predictors. A classification tree was built and then pruned with limited nodes to be able to obtain better predictive performance., Results: We identified 54 patients who had preoperative contrast-enhanced MDCT. Seven patients received a size S, 21 received a size M, and 26 received a size L prosthesis. The mean age of the patients at the time of intervention was 76.3 ± 6.8 years, and the mean logistic EuroSCORE was 10.4% ± 8.7%. Echocardiographic measurements showed lower accuracy compared to MDCT measurements. Echocardiographic LVOT measurement was 61.11% to predict the valve size, whereas annulus measurement was 53.7%. The aLVOT from MDCT had an accuracy of approximately 62.96%, and cLVOT had 64.81% predictive accuracy. Aortic annulus perimeter cD had the highest accuracy to predict the valve size [62.96%, under the curve, 0.61] followed by aortic annular surface aD having an accuracy of approximately 70.37% (under the curve, 0.75). Classification tree models, after pruning with 4 nodes, increased their accuracy (83.33%), and it was easy to interpret and possibly to implement for clinical use., Conclusions: Multidetector-row CT-derived estimates seem to have higher predictive value for valve size determination in patients undergoing RAMT with the Perceval S prosthesis, thus facilitating this delicate procedure and preventing the selection of wrong candidates. Possibly for precise aortic annulus measurement, contrast-enhanced MDCT is preferable.

A 78-year-old man was referred for surgical treatment of a 55 x 59 mm abdominal aortic aneurysm (AAA). However, clinical and instrumental data revealed a more complex case than was initially thought, the patient having a large AAA in the setting of severe symptomatic aortic stenosis with multiple comorbidities. Following multidisciplinary discussion, a combined transcatheter aortic valve implantation and endovascular aneurysm repair was performed. The present case represents a good example of the importance of the heart team in the project of tailored operative strategies, and in the optimization of the interventional therapy for the individual patient.

Objectives: The aim of the present study was to monitor performance and learning effects for thoracic aortic surgery. In addition, we evaluated the volume-outcome relationship of patients undergoing surgery of the thoracic aorta, comparing the results of two higher-volume surgeons (HVSs) with six lower volume surgeons., Methods: A total of 867 thoracic aortic procedures (elective cases n = 753 and Type A acute dissection n = 114) were performed from 2003 to 2013 by eight surgeons (range 28-238 procedures) at our institution. Departmental and individual performance was monitored using control charts, with a predetermined acceptable failure rate of 10%. Perioperative death or one or more of four adverse events constituted failure. Moreover, results of two higher-volume operators (n = 460; 53%) were compared with those of six lower-volume operators (n = 407; 47%)., Results: The incidence rate of in-hospital mortality for elective cases was 2% and for Type A dissection repair 9.6%. Institutional control charts revealed that the surgical process was under control for all the study periods apart from small periods of worse than expected performance which were congruent with new surgeons joining the programme. The predominant surgical failure was reoperation for bleeding. There were differences between surgeons with regard to the learning curves and performance. No significant differences were observed between high- and low-volume surgeons in terms of mortality and morbidity for elective cases. However, high-volume surgeons presented a trend suggesting a higher mortality rate in Type A aortic dissection repair (17.1 vs 6.3%; P = 0.09)., Conclusions: Thoracic aortic surgery can be performed with similar results by high- and low-volume surgeon. Control charts can facilitate learning effects and performance monitoring. Implementation of continuous departmental and individual performance monitoring is practicable., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: This study reports the single center experience on minimally invasive aortic valve replacement (MIAVR), performed through a right anterior minithoracotomy or ministernotomy (MS)., Methods: Eight hundred and fifty-three patients, who underwent MIAVR from 2002 to 2014, were retrospectively analyzed. Survival was evaluated using the Kaplan-Meier method. The Cox multivariable proportional hazards regression model was developed to identify independent predictors of follow-up mortality., Results: Median age was 73.8, and 405 (47.5%) of patients were female. The overall 30-day mortality was 1.9%. Four hundred and forty-three (51.9%) and 368 (43.1%) patients received biological and sutureless prostheses, respectively. Median cardiopulmonary bypass time and aortic cross-clamping time were 108 and 75 minutes, respectively. Nineteen (2.2%) cases required conversion to full median sternotomy. Thirty-seven (4.3%) patients required re-exploration for bleeding. Perioperative stroke occurred in 15 (1.8%) patients, while transient ischemic attack occurred postoperative in 11 (1.3%). New onset atrial fibrillation was reported for 243 (28.5%) patients. After a median follow-up of 29.1 months (2,676.0 patient-years), survival rates at 1 and 5 years were 96%±1% and 80%±3%, respectively. Cox multivariable analysis showed that advanced age, history of cardiac arrhythmia, preoperative chronic renal failure, MS approach, prolonged mechanical ventilation and hospital stay as well as wound revision were associated with higher mortality., Conclusions: MIAVR via both approaches is safe and feasible with excellent outcomes, and is associated with low conversion rate and low perioperative morbidity. Long term survival is at least comparable to that reported for conventional sternotomy AVR.

Objective: This study presents a review of our experience with minimally invasive mitral valve surgery (MIMVS) in patients with a previous cardiac procedure performed through a sternotomy over a 10-year period., Methods: From November 2003 to August 2013, 173 patients (age 61.3 ± 12.4 years) underwent reoperative MIMVS through a right minithoracotomy. Previous operations were coronary artery bypass grafting (n = 49; 28.6%), a mitral valve procedure (n = 120; 70.1%), an aortic valve procedure (n = 32; 18.7%), and other operations (n = 14; 8.1%). The mean euroSCORE was 11.2 ± 3.8. The time to redo surgery was 6.9 ± 4.2 years., Results: Procedures were performed with central aortic cannulation in 55 patients (31.7%) and peripheral cannulation in 118 (68.3%). A transthoracic clamp was used in 58 patients (33.5%), an endoaortic balloon in 72 (41.6%), hypothermic ventricular fibrillation in 23 (13.2%), and beating heart in 20 (11.5%). Mean cardiopulmonary bypass and crossclamp times were 160 ± 58 minutes and 82 ± 49 minutes, respectively. Mitral repair was performed in 53 patients (30.6%). Forty-three patients (24.7%) had an additional cardiac procedure. Conversion to sternotomy was necessary in 2 patients (1.1%) and reoperation for bleeding in 11 patients (6.3%). Thirty-day mortality was 4.1% (n = 7). Major morbidities included stroke (n = 11; 6%) and new-onset dialysis requirement (n = 4; 2.3%). The mean blood transfusion requirement was 1.4 ± 1.1 units. Mean follow-up was 3.3 ± 2.6 years. Survival at 1, 5, and 10 years was 93.1% ± 1.9%, 87.5% ± 2.7%, and 79.7% ± 3.8%, respectively., Conclusions: Reoperative mitral valve surgery can be safely performed through a right minithoracotomy with good early and late outcomes. The avoidance of extensive surgical dissection, optimal valve exposure, and low blood transfusion are the main advantages of this technique., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to study the results of minimally invasive mitral valve repair performed by 5 young surgeons who were trained in mitral valve repair directly through a minimally invasive approach, and a senior surgeon who introduced the technique at our institution and was responsible for the training program., Methods: This was a retrospective, observational cohort study of prospectively collected data from 595 consecutive patients who underwent minimally invasive mitral repair performed by 5 trainees (n = 240, 40.3%) and by our lead consultant (n = 355, 59.7%) between 2007 and 2013. Treatment selection bias was controlled by constructing a propensity score from core patient characteristics and it was included along with the comparison variable in the multivariable analyses of outcome., Results: Patients operated on by trainees were more likely to be female (p = 0.04), older (p = 0.001), and with history of atrial fibrillation (p = 0.001). Trainees required a significant longer cardiopulmonary bypass (137 ± 56 vs 123 ± 52 minutes; p = 0.003) and aortic clamp time (97 ± 41 vs 83 ± 40 minutes; p = 0.001). I-hospital mortalities were 1.3% in the trainees group and 0.8% in the senior surgeon group (p = 0.6). The incidence of stroke (1.7% vs 2.5%; p = 0.5), conversion to sternotomy (2.6% vs 3.5%; p = 0.5), and conversion to mitral valve replacement (12.5% vs 10.9%; p = 0.6) were similar between groups. No differences were found regarding other complications. Five-year survival (88.9% vs 89.5%; p = 0.4) and freedom from reoperation (94.5% vs 95.1; p = 0.6) were similar between groups., Conclusions: Minimally invasive mitral valve repair is a safe and reproducible surgical technique that can be taught successfully to cardiac trainees., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Importance: Owing to a considerable shift toward bioprosthesis implantation rather than mechanical valves, it is expected that patients will increasingly present with degenerated bioprostheses in the next few years. Transcatheter aortic valve-in-valve implantation is a less invasive approach for patients with structural valve deterioration; however, a comprehensive evaluation of survival after the procedure has not yet been performed., Objective: To determine the survival of patients after transcatheter valve-in-valve implantation inside failed surgical bioprosthetic valves., Design, Setting, and Participants: Correlates for survival were evaluated using a multinational valve-in-valve registry that included 459 patients with degenerated bioprosthetic valves undergoing valve-in-valve implantation between 2007 and May 2013 in 55 centers (mean age, 77.6 [SD, 9.8] years; 56% men; median Society of Thoracic Surgeons mortality prediction score, 9.8% [interquartile range, 7.7%-16%]). Surgical valves were classified as small (≤21 mm; 29.7%), intermediate (>21 and <25 mm; 39.3%), and large (≥25 mm; 31%). Implanted devices included both balloon- and self-expandable valves., Main Outcomes and Measures: Survival, stroke, and New York Heart Association functional class., Results: Modes of bioprosthesis failure were stenosis (n = 181 [39.4%]), regurgitation (n = 139 [30.3%]), and combined (n = 139 [30.3%]). The stenosis group had a higher percentage of small valves (37% vs 20.9% and 26.6% in the regurgitation and combined groups, respectively; P = .005). Within 1 month following valve-in-valve implantation, 35 (7.6%) patients died, 8 (1.7%) had major stroke, and 313 (92.6%) of surviving patients had good functional status (New York Heart Association class I/II). The overall 1-year Kaplan-Meier survival rate was 83.2% (95% CI, 80.8%-84.7%; 62 death events; 228 survivors). Patients in the stenosis group had worse 1-year survival (76.6%; 95% CI, 68.9%-83.1%; 34 deaths; 86 survivors) in comparison with the regurgitation group (91.2%; 95% CI, 85.7%-96.7%; 10 deaths; 76 survivors) and the combined group (83.9%; 95% CI, 76.8%-91%; 18 deaths; 66 survivors) (P = .01). Similarly, patients with small valves had worse 1-year survival (74.8% [95% CI, 66.2%-83.4%]; 27 deaths; 57 survivors) vs with intermediate-sized valves (81.8%; 95% CI, 75.3%-88.3%; 26 deaths; 92 survivors) and with large valves (93.3%; 95% CI, 85.7%-96.7%; 7 deaths; 73 survivors) (P = .001). Factors associated with mortality within 1 year included having small surgical bioprosthesis (≤21 mm; hazard ratio, 2.04; 95% CI, 1.14-3.67; P = .02) and baseline stenosis (vs regurgitation; hazard ratio, 3.07; 95% CI, 1.33-7.08; P = .008)., Conclusions and Relevance: In this registry of patients who underwent transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic valves, overall 1-year survival was 83.2%. Survival was lower among patients with small bioprostheses and those with predominant surgical valve stenosis.

Background: There is strong clinical and experimental evidence that altered thyroid homeostasis negatively affects survival in cardiac patients, but a negative effect of the low triiodothyronine (T3) syndrome on the outcome of coronary artery bypass grafting (CABG) has not been demonstrated. This study was designed to evaluate the prognostic significance of low T3 syndrome in patients undergoing CABG., Methods: The thyroid profile was evaluated at hospital admission in 806 consecutive CABG patients. Known thyroid disease, severe systemic illness, and use of drugs interfering with thyroid metabolism were considered exclusion criteria. The effect of the baseline free T3 (fT3) concentration and of preoperative low T3 syndrome (fT3 <2.23 pmol/L) on the risk of low cardiac output (CO) and death was analyzed in a logistic regression model., Results: There were 19 (2.3%) deaths, and 64 (7.8%) patients experienced major complications. After univariate analysis, fT3, low T3, New York Heart Association class greater than II, low left ventricular ejection fraction (LVEF), and emergency were associated with low CO and hospital death. History of atrial fibrillation, cardiopulmonary bypass time, and peripheral vascular disease were associated only with low CO. At multivariate analysis, only fT3, low T3, emergency, and LVEF were associated with low CO, and fT3 (odds ratio, 0.172, 95% confidence interval, 0.078 to 0.379; p < 0.0001) and LVEF (odds ratio, 0.934, 95% confidence interval, 0.894 to 0.987; p = 0.03) were the only independent predictors of death., Conclusions: Our study demonstrates that low T3 is a strong predictor of death and low CO in CABG patients. For this reason, the thyroid profile should be evaluated before CABG, and patients with low T3 should be considered at higher risk and treated accordingly., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Transcatheter valve-in-valve implantation is an emerging treatment option for high-risk patients with failing mitral bioprostheses. The presence of a paravalvular leak is considered a contraindication to this procedure that would leave the patient with significant residual regurgitation. The case is described of a patient with a severely degenerated 29 mm Carpentier-Edwards mitral bioprosthesis successfully treated by simultaneous transapical transcatheter valve-in-valve implantation and paraprosthetic leak occlusion. The potential advantages of this approach are discussed.

Background: The study aimed to compare the short-term results of aortic valve replacement through minimally invasive and sternotomy approaches., Methods: This is a retrospective, observational, cohort study of prospectively collected data on 709 patients undergoing isolated primary aortic valve replacement between 2004 and 2011. Of these, 338 were performed through either right anterior minithoracotomy or upper ministernotomy. With propensity score matching, 182 patients (minimally invasive group) were compared with 182 patients in conventional sternotomy (control group)., Results: After propensity matching, the 2 groups were comparable in terms of preoperative characteristics. Cardiopulmonary bypass time (117.5 vs 104.1 min, p<0.0001) and aortic cross-clamping time (83.8 vs 71.3 min, p<0.0001) were longer in the minimally invasive group, with no difference in length of stay (median 6 vs 5 days, p=0.43), but shorter assisted ventilation time (median 8 vs 7 hours, p=0.022). Overall in-hospital mortality was identical between the groups (1.64 vs 1.64%, p=1.0). No difference in the incidence of major and minor postoperative complications and related morbidity was observed. Minimally invasive aortic valve replacement was associated with a lower incidence of new onset postoperative atrial fibrillation (21% vs 31%, p=0.04). Reduction of the complication rate was observed. Median transfusion pack per patient was higher in the control group (2 vs 1 units, p=0.04)., Conclusions: Our experience shows that mini-access isolated aortic valve surgery is a reproducible, safe, and effective procedure and reduces assisted ventilation duration, the need for blood product transfusion, and incidence of post-surgery atrial fibrillation., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Recent studies have suggested an increased risk of stroke in patients undergoing minimally invasive mitral-valve surgery with retrograde perfusion when compared with antegrade perfusion. The aim of the present study was therefore to evaluate the impact on early outcome of retrograde arterial perfusion (RAP) strategy vs antegrade arterial perfusion strategy in a consecutive large cohort of patients who underwent minimally invasive mitral-valve surgery through a right minithoracotomy., Methods: Between 2003 and 2012, 1280 consecutive patients underwent first-time minimally invasive mitral-valve surgery at our institution. A total of 167 (13%) of these patients received a retrograde perfusion, while 1113 (87%) received antegrade perfusion. Logistic analysis was used to evaluate outcomes and risk factors for stroke. Treatment selection bias was controlled by constructing a propensity score from core patient characteristics. The propensity score was the probability of receiving retrograde perfusion and was included along with the comparison variable in the multivariable analyses of outcome., Results: The overall frequency of in-hospital mortality was 1.1% (14/1280) and postoperative stroke was 1.6% (21/1280). After adjusting for the propensity score, RAP was associated with a higher incidence of stroke (5 vs 1%; P = 0.002), postoperative delirium (14 vs 5%, P = 0.001) and aortic dissection (1.7 vs 0%; P = 0.01). Multivariable regression analysis revealed that the use of retrograde perfusion was an independent risk factor for stroke [odds ratio (OR) 4.28; P = 0.02] and postoperative delirium (OR 3.51; P = 0.001)., Conclusions: Minimally invasive mitral valve procedure can be performed with low morbidity and mortality. The use of retrograde perfusion is associated with a higher incidence of neurological complications and aortic dissection when compared with antegrade perfusion. Central aortic cannulation allows the avoidance of complications associated with retrograde perfusion while extending the suitability of minimally invasive mitral procedures also to those patients who have an absolute contraindication to femoral artery cannulation.

Transcatheter valve-in-valve implantation is an emerging treatment option for high-risk patients with failing aortic bioprostheses. The presence of the prosthesis stents is thought to prevent coronary artery obstruction, a known complication of transcatheter aortic valve implantation in the native aortic valve. The Sorin Mitroflow aortic bioprosthesis (Sorin Group, Saluggia, Italy) has a particular design in that the pericardial leaflets are mounted outside the valve stent. As a consequence, the pericardial leaflets of this prosthesis may be displaced well away from the stents during the deployment of transcatheter valves. This might explain why both the cases of coronary occlusion following valve-in-valve implantation reported to date occurred in patients with a malfunctioning Mitroflow bioprosthesis. We describe a patient with a malfunctioning 25 mm Mitroflow bioprosthesis successfully treated by percutaneous transcatheter valve-in-valve implantation, and discuss the role that balloon aortic valvuloplasty plays in the performance of this delicate procedure., (Copyright © 2012 Wiley Periodicals, Inc.)

Objectives: In recent years, there has been an increasing interest in monitoring the quality of cardiac surgical performance. The aim of the present study was to apply control charts (CUSUM curves) to monitor the performance of minimally invasive mitral valve procedures to enhance quality control for that operation., Methods: A total of 936 minimally invasive mitral valve procedures were performed from September 2003 to March 2011 by seven surgeons (range 26-401 procedures) at a single institution. Institutional and individual surgeons' performances were monitored using descriptive statistics and control charts, with a predetermined acceptable failure rate of 10% and calculated 80% alert and 95% alarm lines. Perioperative death or one or more of seven adverse events constituted failure., Results: The incidence of in-hospital mortality was 1.8% (17/936) and compared favourably with the predicted mortality (logistic EuroSCORE 7.3%). Institutional CUSUM analysis revealed an initial learning curve and then the surgical process remained in control for all the study period. There were differences between surgeons with regard to the learning curves and perioperative complications (7.3-11.3%, P = 0.9). Five surgeons crossed the 95% reassurance boundary between operations 23 and 48. One surgeon crossed the 95% reassurance boundary after 116 operations. No surgeon crossed the 95% alarm line, which indicates unacceptably high failure rates., Conclusions: Minimally invasive mitral surgery can be safely performed with low morbidity and mortality. CUSUM curve analysis is a simple statistical method to implement continuous individual and departmental performance monitoring.

Transcatheter aortic valve implantation (TAVI) is a valuable alternative for aortic valve replacement in selected high-risk candidates. Accurate preoperative assessment of the aortic annular dimensions is crucial for the success of TAVI, since choice of an incorrectly sized prosthesis may result in catastrophic complications. These complications include annular rupture and coronary arterial obstruction, if the prosthesis is too big, or prosthesis migration and severe paravalvular leakage, if the prosthesis is too small. According to current recommendations, the choice of prosthesis size is based on transoesophageal echocardiography (TEE) measurements. However, TEE results are dependent on operator experience. Moreover, recent research has shown that TEE can significantly underestimate annular dimensional measurements. Alternative sizing methods based on Multidetector Computed Tomography (MDCT) or manometry during balloon aortic valvuloplasty have therefore been developed. We present a brief overview of the imaging modalities available for preoperative assessment of annular size and discuss their potential advantages and limitations.