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Ex vivo lung perfusion (EVLP) is a relevant procedure to increase the lung donor pool but could potentially increase the airway tree ischemic injury risk.This study aimed to evaluate the direct effect of EVLP on the airway tree by evaluating bronchial cell vitality and tissue signs of injury on a series of 117 bronchial rings collected from 40 conventional and 19 EVLP-treated lung grafts. Bronchial rings and related scraped bronchial epithelial cells were collected before the EVLP procedure and surgical anastomosis.The preimplantation interval was significantly increased in the EVLP graft group (p 0.01). Conventional grafts presented cell viability percentages of 47.07 ± 23.41 and 49.65 ± 21.25 in the first and second grafts which did not differ significantly from the EVLP group (first graft 50.54 ± 25.83 and second graft 50.22 ± 20.90 cell viability percentage). No significant differences in terms of histopathological features (edema, inflammatory infiltrate, and mucosa ulceration) were observed comparing conventional and EVLP samples. A comparison of bronchial cell viability and histopathology of EVLP samples retrieved at different time intervals revealed no significant differences. Accordingly, major bronchial complications after lung transplant were not observed in both groups.Based on these data, we observed that EVLP did not significantly impact bronchial cell vitality and airway tissue preservation nor interfere with bronchial anastomosis healing, further supporting it as a safe and useful procedure.

Chronic postsurgical pain (CPSP) is a relatively common complication after cardio-thoracic operations with well-known consequences in terms of return to normal activities and quality of life. Little is known about the prevalence and severity of CPSP after minimally invasive cardiac surgery. The aim of this study was to measure the rate of CPSP in patients undergoing right minithoracotomy mitral valve (MV) surgery and to compare the effectiveness of different approaches to pain control.A prospective observational study was conducted between March 2019 and September 2020. All patients undergoing right minithoracotomy MV surgery treated with morphine, continuous serratus anterior plane block (SAPB), or continuous erector spinae plane block (ESPB) were included. The Brief Pain Inventory questionnaire was used to evaluate 6-month CPSP and quality of life.A total of 100 patients were enrolled: postoperative pain control was obtained with morphine in 26 cases, with SAPB in 37 cases, and with ESPB in 37 cases. Median intensive care unit and hospital length of stay were 1 day and 6 days, respectively. Pain severity index was lower than 10 in 81 patients, and no differences were recorded between groups (p = .59). No patients reported chronic use of medications for pain management or severe pain interference in daily activities at follow-up.Right minithoracotomy approach is not burdened by a high incidence of CPSP: pain severity index was lower than 10 in more than 90% of patients. Then, in our experience, chronic pain seems not to be related to the type of perioperative analgesia adopted.

Background The relationship between retrograde arterial perfusion and stroke in patients with peripheral vascular disease has been widely documented. Antegrade arterial perfusion has been favoured as an alternative approach in less invasive mitral valve (MV) operations. We aimed to analyse our experience in patients with peripheral arterial disease undergoing MV surgery through a right mini-thoracotomy adopting antegrade arterial perfusion. Method A single-institution retrospective study on prospectively collected data was performed on patients undergoing right mini-thoracotomy MV surgery with antegrade arterial perfusion. Since 2009, indication for the latter was dictated by the severity of atherosclerotic burden. Preoperative screening included computed tomography, angiography, or both for the evaluation of the aorta and ileo-femoral arteries. Results Consecutive patients (n=117) underwent MV surgery through a right mini-thoracotomy with antegrade arterial perfusion, established either by transthoracic central aortic cannulation in 65 (55.6%) cases or by axillary arterial cannulation in 52 (44.4%). Mean logistic EuroSCORE was 11%±2.3%. Twenty-five (25) (21.4%) patients had undergone one or more previous cardiac operations. Operative mortality was 4.3% (n=5). Nonfatal iatrogenic aortic dissection occurred in one case (0.8%). The incidence of stroke was zero. Conclusions Axillary or central aortic cannulation is a promising alternative route to provide excellent arterial perfusion in right mini-thoracotomy MV surgery, with a very low incidence of stroke and other major perioperative complications in patients with severe aortic or peripheral arterial disease.

BACKGROUND: Mean age of patients with valves diseases is significantly increasing, and, in the near future, cardiac surgeons will have to deal with a considerable number of patients aged more than 80 years. The remarkable results gained by the minimally invasive approach have encouraged its application in more complex and fragile patients, such as older people. This study aimed to identify the rate of early mortality and major complications, and independent predictors for mid-term mortality in octogenarians undergoing minimally invasive valve surgery. METHODS: Octogenarian patients undergoing right mini-thoracotomy mitral and/or tricuspid valve surgery between 2006 and 2020 were included. Primary endpoint was to identify independent predictors for mid-term mortality, and secondary endpoints were operative morality, stroke, independent predictors for early composite outcome, and quality of life at follow-up. RESULTS: Analysis was performed on 130 patients. Stroke occurred in one patient (0.8%), while operative mortality was 6% (eight patients). One-year and five-year survival were 86% and 64%, respectively. Logistic regression identified age and creatinine level as independent predictors of mid-term mortality, survival analysis showed that age ≥ 84 years and creatinine level ≥ 1.22 mg/dL were the cut-off points for worst prognosis. Female gender and hypertension were found to be independent predictors of early composite outcome. CONCLUSIONS: Results of the present study show that age alone should not be considered a contraindication for minimally invasive valve surgery. Identifying patients who are most likely to have survival and functional benefits after surgery is decisive to achieve optimal health outcomes and prevent futile procedures.

The role of aortic clamping techniques on the occurrence of neurological complications after right mini-thoracotomy mitral valve surgery is still debated. Brain injuries can occur also as silent cerebral micro-embolizations (SCM), which have been linked to significant deficits in physical and cognitive functions. Aims of this study are to evaluate the overall rate of SCM and to compare endoaortic clamp (EAC) with trans-thoracic clamp (TTC). Patients enrolled underwent a pre-operative, a post-operative, and a follow-up MRI. Forty-three patients were enrolled; EAC was adopted in 21 patients, TTC in 22 patients. Post-operative SCM were reported in 12 cases (27.9%). No differences between the 2 groups were highlighted (23.8% SCM in the EAC group versus 31.8% in the TTC). MRI analysis showed post-operative SCM in nearly 30% of selected patients after right mini-thoracotomy mitral valve surgery. Subgroup analysis on different types of aortic clamping showed comparable results. CLINICAL RELEVANCE: The rate of SCM reported in the present study on patients undergoing minimally invasive MVS and RAP is consistent with data in the literature on patients undergoing cardiac surgery through median sternotomy and antegrade arterial perfusion. Moreover, no differences were reported between EAC and TTC: both the aortic clamping techniques are safe, and the choice of the surgical setting to adopt can be really done according to the patient's characteristics.

Objective Custodiol® and St. Thomas cardioplegia are widely employed in mini-thoracotomy mitral valve (MV) operations. One-dose of the former provides 3 h of myocardial protection. Conversely, St. Thomas solution is usually reinfused every 30 min and safety of single delivery is unknown. We aimed to compare single-shot St. Thomas versus Custodiol® cardioplegia. Methods Primary endpoint of the prospective observational study was cardiac troponin T level at different post-operative time-points. Propensity-weighted treatment served to adjust for confounding factors. Results Thirty-nine patients receiving St. Thomas were compared with 25 patients receiving Custodiol® cardioplegia; cross-clamping always exceeded 45 min. No differences were found in postoperative markers of myocardial injury. Ventricular fibrillation at the resumption of electric activity was more frequent following Custodiol® cardioplegia (P = .01). Conclusion Effective myocardial protection exceeding 1 h of ischemic arrest can be achieved with a single-dose St. Thomas cardioplegia in selected patients undergoing right mini-thoracotomy MV surgery.

Bileaflet Mitral Valve Prolapse (bMVP) has been linked to major arrhythmic events and sudden cardiac death (SCD). Consistent predictors in this field are still lacking. Echocardiography is the best tool for the analysis of the prolapse and its impact on the ventricular mechanics. The aim of this study was to find new echocardiographic predictors of malignant events within an arrhythmic MVP population. We evaluated 22 patients with arrhythmic bMVP with a transthoracic echocardiogram focused on mitral valve anatomy and ventricular contraction. Six of them had major arrhythmic events that required ICD implantation (ICD-MVP group), while sixteen presented with a high arrhythmic burden without major events (A-MVP group). The best predictors of malignant events were the Anterior Mitral Leaflet (AML) greater length and greater Mechanical Dispersion (MD) of basal and mid-ventricular segments, while other significant predictors were the larger mitral valve annulus (MVA) indexed area, lower MVA anteroposterior diameter/AML length ratio, higher inferolateral basal segment S3 velocity.

Minimally invasive cardiac surgery (MICS) has constantly evolved over the past years, and new technologies have been introduced. The aims of this study were to analyze the evolution of our 10-year experience in MICS and to highlight outcomes in different spans of time.Patients undergoing MICS for mitral valve, tricuspid valve, and/or atrial septal defect or atrial masses from November 2005 to November 2015 were retrospectively analyzed. A comparative analysis was performed by identifying 2 groups: the control group (in the first time span of our experience) and the tailored group (patients who underwent surgery after a full preoperative anatomic evaluation with allocation to the proper setting).During the study period 971 patients underwent MICS. MICS procedures increased from 44% in 2006 to 96% in 2015. Subgroup analysis revealed a significant decrease in the rate of procedures performed with retrograde arterial perfusion (99.1% vs 91.7%, P .0001), a significant increase in the rate of complex mitral valve procedures (22.4% vs 7.9%, P.0001), and a significant decrease in the rate of stroke (from 5.2% to 1%, P .001) in the tailored group. The logistic regression analysis showed that the tailored approach was a protective factor against neurologic complications.The present study shows the considerable and attractive results of our decision-making process based on the tailored approach. The 10-year outcome analysis demonstrated a trend toward a progressive decrease in the overall rate of postoperative complications and a significant protective effect of the tailored approach on the occurrence of stroke.

Noteworthy steps forward in diagnosis and management of cardiac and great vessels injuries have been made since Hippocrates stated that all wounds of the heart were deadly (1).

The role of aortic clamping techniques on the occurrence of neurological complications after right mini-thoracotomy mitral valve surgery is still debated. Brain injuries can occur also as silent cerebral micro-embolizations (SCM), which have been linked to significant deficits in physical and cognitive functions. Aims of this study are to evaluate the overall rate of SCM and to compare endoaortic clamp (EAC) with trans-thoracic clamp (TTC). Patients enrolled underwent a pre-operative, a post-operative, and a follow-up MRI. Forty-three patients were enrolled; EAC was adopted in 21 patients, TTC in 22 patients. Post-operative SCM were reported in 12 cases (27.9%). No differences between the 2 groups were highlighted (23.8% SCM in the EAC group versus 31.8% in the TTC). MRI analysis showed post-operative SCM in nearly 30% of selected patients after right mini-thoracotomy mitral valve surgery. Subgroup analysis on different types of aortic clamping showed comparable results. CLINICAL RELEVANCE: The rate of SCM reported in the present study on patients undergoing minimally invasive MVS and RAP is consistent with data in the literature on patients undergoing cardiac surgery through median sternotomy and antegrade arterial perfusion. Moreover, no differences were reported between EAC and TTC: both the aortic clamping techniques are safe, and the choice of the surgical setting to adopt can be really done according to the patient's characteristics.

Background Right mini-thoracotomy cardiac surgery has been recognized as a safe and effective procedure, with remarkable early and long-terms outcomes. However, most of the literature is focused on mitral valve surgery and few studies report on the minimally invasive approach applied to congenital disease. Aim of this study was to review our experience on patients with grown-up congenital heart (GUCH) undergoing right mini-thoracotomy cardiac surgery. Methods Data of patients with GUCH undergoing right mini-thoracotomy cardiac surgery from 2006 to 2019 were retrospectively analyzed. Inclusion criteria were atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, and mitral or tricuspid valve dysfunction in congenital heart diseases. Results During the study period 127 patients with GUCH underwent right mini-thoracotomy cardiac surgery. Mean age was 43.6 years and more than 60% were females; diagnosis was atrial septal defect in 57 cases (44.9%); 24 patients were redo (18.9%). No cases of stroke and major vascular complications were reported. Conversion to sternotomy was required in one case (0.8%). No residual shunts or valves dysfunction were recorded at the postoperative echocardiographic evaluation. Perioperative mortality was 1.6%. Conclusions Right mini-thoracotomy cardiac surgery in selected patients with GUCH allows to avoid the big scar of the sternotomy approach and to accelerate the recovery in a young population. Moreover, in redo cases, it allows the surgeon to reach the heart and the aorta avoiding the well-known risks of a re-sternotomy procedure.

AIM To investigate the incidence and risk factors for vancomycin concentrations less than 10 mg/L during cardiac surgery. METHODS In this prospective study, patients undergoing cardiac surgery received a single dose of 1000 mg of vancomycin. Multiple arterial samples were drawn during surgery. Exclusion criteria were hepatic dysfunction; renal dysfunction; ongoing infectious diseases; solid or hematologic tumors; severe insulin-dependent diabetes; body mass index of < 17 or > 40 kg/m2; pregnancy or lactation; antibiotic, corticosteroid, or other immunosuppressive therapy; vancomycin or nonsteroidal anti-inflammatory drug therapy in the previous 2 wk; chemotherapy or radiation therapy in the previous 6 mo; allergy to vancomycin or cefazolin; drug abuse; cardiac surgery in the previous 6 mo; previous or scheduled organ transplantation; preoperative stay in the intensive care unit for more than 24 h; emergency procedure or lack of adequate preparation for surgery; and participation in another trial. RESULTS Over a 1-year period, 236 patients were enrolled, and a total of 1682 serum vancomycin concentrations (median 7/patient) were measured. No vancomycin levels under 10 mg/L were recorded in 122 out of 236 patients (52%), and 114 out of 236 patients (48%) were found to have at least 1 serum sample with a vancomycin level < 10 mg/L; 54 out of 236 patients (22.9%) had at least 5 serum samples with a vancomycin level lower than 10 mg/L. Vancomycin infusion was administered for 60 min in 97 out of 236 patients (41%). In 47 patients (20%), the duration of infusion was longer than 60 min, and in 92 patients (39%) the duration of infusion was shorter than 60 min. The maximum concentration and area under the concentration-time curve were significantly higher in patients with no vancomycin levels less than 10 mg/L (P < 0.001). The multivariate analysis identified female gender, body mass index (BMI) > 25 kg/m2, and creatinine clearance above 70 mL/min as risk factors for vancomycin levels less than 10 mg/L. CONCLUSION Results of this study identified female gender, BMI > 25 kg/m2, and creatinine clearance above 70 mL/min as risk factors for suboptimal vancomycin serum concentration during cardiac surgery; no relationship was found between infusion duration and vancomycin levels less than 10 mg/L. These findings call attention to the risk of facilitating the emergence of vancomycin-resistant methicillin-resistant Staphylococcus aureus strains.

Objectives Heart transplantation represents the most effective therapy that is currently available for end-stage heart failure. Despite the shortage of organ donors, many donor hearts are not accepted for transplantation due to poor function. Targeted donor management may increase the donor heart utilization rate. The aim of this study is to analyse a 2-year experience of early donor management through the 'scout programme' by a high-volume national cardiothoracic organ retrieval team. Methods A prospective cohort study was carried out between 2013 and 2015 on consecutive donation from brain-dead donors. A member of the cardiothoracic retrieval team travelled to the intensive care unit of the donor hospital to assist with early management. Results One hundred and seventy-eight cardiac donors were enrolled; 106 (59.5%) were 'scouted', and 72 (40.5%) were 'non-scouted'. Donor heart utilization rate in the 'scouted' group was 47.2% (50/106) compared with 30.6% (22/72) in the 'non-scouted' group (P = 0.03). On logistic regression analysis, early donor management by the scouts independently predicted donor heart utilization. The time in the operating theatre from donor arrival to skin incision was significantly reduced in the 'scouted' group. No differences were found in the 30-day graft failure rate or the 30-day, 1-year and 2-year survival rates of the recipients between the 2 groups. Conclusions Early donor management delivered by the cardiothoracic retrieval team significantly increased the donor heart utilization rate from existing donors. Moreover, the time in the operating theatre from donor heart arrival to skin incision was significantly reduced.

Objectives Donor organ utilization and shortage remain the major limitations to the opportunity of a lung transplantation (LTx). Donation after circulatory determined death (DCD) has been adopted as a source of additional organs worldwide. However, concerns about organ quality and ischaemia-reperfusion injury have limited its application. The aim of this study was to retrospectively analyse a single-centre experience in the DCD LTx and compare early and mid-term outcomes with those from a standard donation after brain death (DBD). Methods During the 6-year study period, 186 LTxs were performed: 147 bilateral LTxs (79%) and 39 single LTxs (21%). Of these, 23 recipients received organs retrieved from DCD donors (12.4%). Results No differences were found between the 2 groups of recipients except for age and cystic fibrosis as an underlying disease. No differences in terms of duration of mechanical ventilation, incidence of postoperative extracorporeal membrane oxygenation support, intensive care unit stay, hospital length of stay, airway anastomotic complications, incidence and grade of rejection and freedom from bronchiolitis obliterans syndrome were demonstrated. There was a non-statistically significant trend towards older age in the DCD group. Actuarial survival in the subgroup of bilateral LTx at 1 year and 5 years was 75% and 51% for the DCD group and 82% and 61% for the DBD group, respectively (P = 0.12). Conclusions Short- and medium-term outcomes after the DCD LTx are comparable with those achieved after transplantation from the DBD donors, despite a tendency to use DCD lungs for older recipients. Therefore, the DCD LTx is a clinical option that can be used with favourable results to expand the lung donor pool.

Background Little is known about the coronavirus SARS-CoV-2 disease (COVID-19) in solid organ transplanted patients. We here report a series of heart transplanted patients with COVID-19 from two centers of Italy. Methods All heart transplanted patients of Transplant Centers of Bergamo and Torino with a microbiologically confirmed SARS-CoV-2 infection were enrolled. Data collection included clinical presentation, laboratory and radiological findings, treatment and outcome. Follow-up was performed by visit or phone. Results From February to March 2020 twenty-six heart transplanted patients (age 62±12 years; 77% males; time from transplant 10±10 years; 69% with comorbidities) had a microbiologically confirmed COVID-19. The most frequent symptom was fever, followed by cough. Seventeen patients had a pneumonia, 8 of them severe pneumonia. Seven patients died (27%) and 17 (65%) were hospitalized. Discontinuation of immunosuppression was associated with death (71 vs 21%, p=0.02). Conversely, all patients receiving steroids survived (p The current regimen enabled the prolonged survival and function of orthotopic cardiac xenografts in altogether 6 of 8 baboons, of which 4 were now added. These results exceed the threshold set by the Advisory Board of the International Society for Heart and Lung Transplantation. Conclusions COVID-19 has a significant impact on long term heart transplanted patients. Conversely, SARS-CoV-2 infection seems to have a limited influence on more recent transplants. Our experience may suggest that heart transplantation programs can be maintained even during the pandemic phase if specific and tailored paths to prevent and to limit virus transmission are provided.

Objective: Obesity is becoming a major health problem in the Western world. Results of mitral valve surgery through standard sternotomy in obese patients are controversial especially because of hig...

Background Neurologic injury is still a frequent cause of mortality, morbidity, and long-lasting disability in patients undergoing an aortic arch operation with hypothermic circulatory arrest. The aim of this analysis was to evaluate short- and long-term outcomes in neurologic and cognitive functions in this group of high-risk patients. Methods A total of 333 patients undergoing an aortic arch operation between February 2004 and June 2010 were retrospectively reviewed. Cerebral protection was obtained with deep hypothermic circulatory arrest in 220 patients (66%) or with moderate hypothermic circulatory arrest in 113 cases (34%). Straight deep hypothermic circulatory arrest was adopted in 35 cases (11%), while the association with antegrade cerebral perfusion was adopted in 271 cases (81%) and with retrograde cerebral perfusion in 27 cases (8%). Seventy-eight patients were enrolled in a case control prospective study (mean follow-up time = 42 months) and underwent neuropsychologic evaluations; data were compared with those of a matched-control group of hypertensive patients without history of cardiac operations. Results Forty-one out of 333 patients experienced permanent neurologic dysfunction (12%) and 83 experienced temporary neurologic dysfunctions (25%). Acute aortic dissection and deep hypothermic circulatory arrest were significant predictors of mortality and permanent neurologic dysfunction. Acute aortic dissection and hypothermic circulatory arrest duration >30 minutes were significant predictors of temporary neurologic dysfunction, while antegrade cerebral perfusion was protective on mortality. Neuropsychologic evaluations showed no significant differences between the groups. The operative group showed worse verbal and working memory (P = .003), worse semantic fluency (P = .036), higher degree of alexithymia (P = .004), and a lower quality of life (P = .007). Conclusion Although moderate hypothermic circulatory arrest with antegrade cerebral perfusion demonstrated a lower mortality compared with deep hypothermic arrest, neurocognitive testing demonstrated no difference between the groups. Additionally, patients undergoing an aortic arch operation demonstrated long-term cognitive deficits and psychological dysfunction when compared to a matched cohort of nonoperative patients.

A non-invasive approach to define grafts patency and stenosis in the follow-up of coronary artery bypass graft (CABG) patients may be an interesting alternative to coronary angiography. 64-slice-coronary computed tomography is nowadays a diffused non-invasive method that permits an accurate evaluation of coronary stenosis, due to a high temporal and spatial resolution. However, its sensitivity and specificity in CABG evaluation has to be clearly defined, since published studies used different protocols and scanners. We collected all studies investigating patients with stable symptoms and previous CABG and reporting the comparison between diagnostic performances of invasive coronary angiography and 64-slice-coronary computed tomography. As a result, sensitivity and specificity of 64-slice-coronary computed tomography for CABG occlusion were 0.99 (95% CI 0.97-1.00) and 0.99 (95% CI: 0.99-1.00) with an area under the curve (AUC) of 0.99. 64-slice-coronary computed tomography sensitivity and specificity for the presence of any CABG stenosis >50% were 0.98 (95% CI: 0.97-0.99) and 0.98 (95% CI: 0.96-0.98), while AUC was 0.99. At meta-regression, neither the age nor the time from graft implantation had effect on sensitivity and specificity of 64-slice-coronary computed tomography detection of significant CABG stenosis or occlusion. In conclusion 64-slice-coronary computed tomography confirmed its high sensitivity and specificity in CABG stenosis or occlusion evaluation.

Background: Lung transplantation is the treatment of choice for end-stage pulmonary disease in selected patients. However, severe primary graft dysfunction is a significant complication of transplant and requires the implantation of an extracorporeal support. The aim of the study is to evaluate the impact of extracorporeal membrane oxygenation (ECMO) after transplant in our center. Methods: From January 2008 till June 2018, 195 consecutive unselected patients receiving a lung transplant were considered. Mean age was 49±15 years. Main indications for transplant were idiopathic pulmonary fibrosis in 72 patients, chronic obstructive pulmonary disease in 60 patients, and cystic fibrosis in 40 patients. Prior to transplant, 18 patients were on mechanical ventilation and 14 were on ECMO. Results: Twenty-five patients required venous-venous ECMO after transplant. Vascular disease as cause of transplant [relative risk (RR) 7.8, 95% CI: 1.5–41, P=0.02], donor age (RR 1.6, 95% CI: 1.03–2.3, P=0.03) and need for cardiopulmonary by-pass during transplant (RR 3.1, 95% CI: 1.02–9, P=0.04) were associated with ECMO implantation. Patients requiring post-transplant ECMO received more transfusions (P

With advancements in mechanical circulatory support technology, and limitations in donor supply for heart transplantation, the use of left ventricular assist devices (LVADs) has increased significantly in recent years. Multiple studies have shown that minimally invasive cardiac surgery can improve outcomes, with shorter hospital stays, decreased morbidity, faster recovery and ambulation, and lower total hospital costs. The current generation of centrifugal continuous-flow pumps is miniaturized and makes minimally invasive approaches increasingly practicable. Lateral surgical access to the ventricle allows off-pump implantation with minimal risk of blood loss, reducing the risk of air embolism and difficult de-airing. Off-pump implantation reduces hemodilution, systemic inflammatory response syndrome due to extracorporeal circulation, and the negative effects of pulmonary hypertension and right ventricular dysfunction in the perioperative period. Minimally invasive lateral access is encouraged in cases of bridge-to-transplant to avoid the risks associated with resternotomy. We describe the surgical technique for minimally invasive implantation of the HeartMate 3 (Abbott, USA) left ventricular assist device (LVAD), avoiding sternotomy and cardiopulmonary bypass. Our surgical approach was based on a left minithoracotomy for the LVAD implantation and a right thoracotomy for the outflow graft anastomosis to the ascending aorta.

Less-invasive mitral valve surgery has become a widespread procedure in recent years, although mode of perfusion and aortic clamping are still debated questions. The aim of this study was to compare the results between transthoracic aortic clamping (TTC) and endoaortic clamping (EAC) in a multicenter, retrospective study.Data from 3 centers experienced in both TTC and EAC were retrospectively analyzed. Five hundred consecutive patients undergoing less-invasive mitral valve surgery received either TTC (n = 250) or EAC (n = 250). Age, sex, logistic EuroSCORE, ejection fraction, associated procedures, and mitral valve repair rate were similar. A higher incidence of previous cardiac operations was observed in the EAC group (TTC 8.8% versus EAC 16.8%, p = 0.001).Clamping and cardiopulmonary bypass times were comparable between the 2 groups. Reoperation for bleeding (TTC 11.2% versus EAC 3.2%, p0.001), conversion to full sternotomy (6 cases in the TTC group), and hospital length of stay (TTC 9 days versus EAC 8 days, p = 0.01) were higher in the TTC group. No differences were found in respiratory failure, renal failure, major vascular complication, stroke, and in-hospital mortality rate.Despite recent concerns arising about EAC, this large multicenter study shows equivalence in terms of safety and effectiveness of this technique compared with TTC. Reduction in postoperative bleeding was observed in the EAC group despite the higher rate of complex redo cases.

Purpose Few prospective follow-up studies evaluating the use of peripherally inserted central catheters (PICCs) to deliver chemotherapy and/or home parenteral nutrition (HPN) have focused exclusively on oncology outpatients. The aim of this prospective study was to assess the reliability and the safety of PICCs over a 5-year use in non-hospitalized cancer patients requiring long-term intravenous therapies. Methods Since June 2008, all adult oncology outpatient candidates for PICC insertion were consecutively enrolled and the incidence of catheter-related complications was investigated. The follow-up continued until the PICC removal. Results Two hundred sixty-nine PICCs in 250 patients (98 % with solid malignancies) were studied, for a total of 55,293 catheter days (median dwell time 184 days, range 15–1,384). All patients received HPN and 71 % received chemotherapy during the study period. The incidence of catheter-related bloodstream infections (CRBSIs) was low (0.05 per 1,000 catheter days), PICC-related symptomatic thrombosis was rare (1.1 %; 0.05 per 1,000 catheter days), and mechanical complications were uncommon (13.1 %; 0.63 per 1,000 catheter days). The overall complication rate was 17.5 % (0.85 per 1,000 catheter days) and PICCs were removed because of complications only in 7 % of cases. The main findings of this study were that, if accurately managed, PICCs can be safely used in cancer patients receiving chemotherapy and/or HPN, recording a low incidence of CRBSI, thrombosis, and mechanical complications; a long catheter life span; and a low probability of catheter removal because of complications. Conclusions Our study suggests that PICCs can be successfully utilized as safe and long-lasting venous access devices in non-hospitalized cancer patients.

A 60 year-old female underwent tricuspid valve replacement in 2002. Post-operative recovery was complicated by severe post-pericardiotomy-syndrome. Seven years later she underwent transcatheter valve-in-valve implantation through the right jugular vein because of early prosthesis deterioration. Moreover intra-operative transoesophageal echocardiography showed an important right-to-left shunt through the patent foramen ovale that immediately disappeared after the deployment of a 29-mm Sapien-XT. The patient had an immediate and dramatic improvement in day-by-day activities. This case shows that tricuspid valve deterioration can be safely and successfully treated through this approach.

Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.

Coronary computed tomography (CCT) scans with 64 slices has already shown high sensitivity and specificity in the evaluation of coronary artery bypass grafts (CABG) (1). However, there is still debate in the literature regarding its effectiveness and reliability compared to invasive coronary angiography (CA) in the case of native vessels disease (2).

Background Recent data have highlighted a higher rate of neurological injuries in minimal invasive mitral valve surgery (MIMVS) compared with the standard sternotomy approach; therefore, the role of specific clamping techniques and perfusion strategies on the occurrence of this complication is a matter of discussion in the medical literature. The purpose of this trial is to prospectively evaluate major, minor and silent neurological events in patients undergoing right mini-thoracotomy mitral valve surgery using retrograde perfusion and an endoaortic clamp or a transthoracic clamp. Methods/design A prospective, blinded, randomized controlled study on the rate of neurological embolizations during MIMVS started at the University of Turin in June 2014. Major, minor and silent neurological events are being investigated through standard neurological evaluation and magnetic resonance imaging assessment. The magnetic resonance imaging protocol includes conventional sequences for the morphological and quantitative assessment and nonconventional sequences for the white matter microstructural evaluation. Imaging studies are performed before surgery as baseline assessment and on the third postoperative day and, in patients who develop postoperative ischemic lesions, after 6 months. Discussion Despite recent concerns raised about the endoaortic setting with retrograde perfusion, we expect to show equivalence in terms of neurological events of this technique compared with the transthoracic clamp in a selected cohort of patients. With the first results expected in December 2016 the findings would be of help in confirming the efficacy and safety of MIMVS. Trial registration ClinicalTrials.gov, Identifier: NCT02818166. Registered on 8 February 2016 – trial retrospectively registered. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1821-y) contains supplementary material, which is available to authorized users.