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Objectives: The role of the underlying etiology in isolated tricuspid valve surgery has not been investigated extensively in current literature. Aim of this study was to analyse outcomes of patients undergoing surgery due to endocarditis compared to other pathologies. Methods: The SURTRI study is a multicenter study enrolling adult patients who underwent isolated tricuspid valve surgery (n=406, 55±16 y.o.; 56% female) at 13 international sites. Propensity weighted analysis was performed to compare groups (IE group n=107 vs Not-IE group n=299). Results: No difference was found regarding the 30-day mortality (Group IE: 2.8% vs Group Not-IE=6.8%; OR=0.45) and major adverse events. Weighted cumulative incidence of cardiac death was significantly higher for patients with endocarditis (p=0.01). The composite endpoint of cardiac death and reoperation at 6years was reduced in the Group IE (63.2±6.8% vs 78.9±3.1%; p=0.022). Repair strategy resulted in an increased late survival even in IE cases. Conclusions: Data from SURTRI study report acceptable 30-day results but significantly reduced late survival in the setting of endocarditis of the tricuspid valve. Multi-disciplinary approach, repair strategy and earlier treatment may improve outcomes.

Visual Abstract, Highlights • Because autophagy and Nox2 activation were identified as possible mechanisms for preservation of vessel integrity, they could be useful biomarkers to predict risk of aneurysm rupture by detecting the presence of a subclinical aneurysm or monitoring their growth. • Biomarkers such as molecules involved in autophagic machinery or Nox2 activation may help to explain pathological processes involved in TAA development and expansion, thereby opening up novel potential therapeutic strategies, such as the use of natural activators of autophagy or molecules that inhibit Nox2 activation, in the setting of aneurysmatic pathology. • Formation of aortic aneurysmal disease is multifactorial. Among the mechanisms involved, there is endothelial damage, oxidative stress, as well as an autophagy process, that seem to play a key role in TAA. Therefore, to identify the molecular mechanisms of these processes in TAA patients could lay the groundwork for defining strategies for preventing and slowing the progression of TAA., Summary Thoracic aortic aneurysms (TAA) pathogenesis and progression include many mechanisms. The authors investigated the role of autophagy, oxidative stress, and endothelial dysfunction in 36 TAA patients and 23 control patients. Univariable and multivariable analyses were performed. TAA patients displayed higher oxidative stress and endothelial dysfunction then control patients. Autophagy in the TAA group was reduced. The association of oxidative stress and autophagy with aortic disease supports the role of these processes in TAA. The authors demonstrate a putative role of Nox2 and autophagy dysregulation in human TAA. These findings could pinpoint novel treatment targets to prevent or limit TAA progression.

Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery in conventional extracorporeal circulation (CECC), with an incidence of 15–50%. The POAF pathophysiology is not known, and no blood biomarkers exist. However, an association between increased ferritin levels and increased AF risk, has been demonstrated. Based on such evidence, here, we evaluated the effectiveness of ferritin and other haematological parameters as POAF risk biomarkers in patients subjected to cardiac surgery. We enrolled 105 patients (mean age = 70.1 ± 7.1 years; 70 men and 35 females) with diverse heart pathologies and who were subjected to cardiothoracic surgery. Their blood samples were collected and used to determine hematological parameters. Electrocardiographic and echocardiographic parameters were also evaluated. The data obtained demonstrated significantly higher levels of serum ferritin, red cell distribution width (RDW), and platelets (PLTs) in POAF patients. However, the serum ferritin resulted to be the independent factor associated with the onset POAF risk. Thus, we detected the ferritin cut-off value, which, when ≥148.5 ng/mL, identifies the subjects at the highest POAF risk, and with abnormal ECG atrial parameters, such as PW indices, and altered structural heart disease variables. Serum ferritin, RDW, and PTLs represent predictive biomarkers of POAF after cardiothoracic surgery in CECC; particularly, serum ferritin combined with anormal PW indices and structural heart disease variables can represent an optimal tool for predicting not only POAF, but also the eventual stroke onset.

BACKGROUND: Aim of this study is to analyse the performances of Clinical Risk Score (CRS) and European System for Cardiac Operative Risk Evaluation (EuroSCORE)-II in isolated tricuspid surgery.METHODS: Three hundred and eighty-three patients (54 ± 16 year; 54% female) were enrolled. Receiver operating characteristic analysis was performed to evaluate the relationship between the true positive fraction of test results and the false-positive fraction for a procedure.RESULTS: Considering the 30-day mortality the area under the curve was 0.6 (95% confidence interval [CI] 0.50-0.72) for EuroSCORE II and 0.7 (95% CI 0.56-0.84) for CRS-score. The ratio of expected/observed mortality showed underestimation when considering EuroSCORE-II (min. 0.46-max. 0.6). At multivariate analysis, the CRS score (p = .005) was predictor of late cardiac death.CONCLUSION: We suggest using both scores to obtain a range of expected mortality. CRS to speculate on late survival.

BACKGROUND: Acute type A aortic dissection (AAAD) is a pathological process that implicates the ascending aorta and represents a surgical emergency burdened by high mortality if not promptly treated in the first hours of onset. Despite best efforts, the annual incidence rates of aortic dissection has remained stable over the past decades. We measured aortic dimensions (aortic diameters, area, length and volume) using 3D multiplanar reconstruction imaging with the purpose of refining the risk- morphology for AAAD. METHODS: Computerized tomography angiography studies of three groups were compared retrospectively: patients affected by AAAD (AAAD group; n=71), patients affected by aortic aneurysm and subsequently subjected to ascending aorta replacement (Aneurysm, n=77) and a healthy aorta’s group (Control, n=75). RESULTS: Mean diameters of AAAD (4.9 cm) and Aneurysm (5.1 cm) aortas were significantly larger than those of the control group (3.4 cm). In AAAD patients, an ascending aorta diameter greater than 5.5 cm was observed in 18% of patients. Multiple comparisons showed statistically significant differences among mean of the ratio of aortic root area to height between the three groups (P

Saphenous vein graft aneurysms (SVGAs) following coronary artery bypass grafting (CABG) surgery were first described in 1975. Although rare, in the absence of a prompt diagnosis, SVGAs can be responsible for serious complications and adverse outcomes. The clinical presentation of SVGAs described in the literature can vary from an asymptomatic patient with an incidental radiological finding to a profoundly shocked patient with life-threatening hemorrhage secondary to SVGA rupture. Improvements in diagnostic tools within the last decade, such as multislice computed tomographic scanning, has enabled early detection of SVGAs, and therefore, an expansion of the current management options. In this review, the current data and knowledge about clinical presentation, diagnosis, natural history, and treatment of SVGAs are updated, with a specific emphasis on the evolution of management strategies of this rare complication over the last 45 years. Finally, a clinical algorithm to guide decision-making and management is proposed.

Background: Acute type A aortic dissection (AAD) is a life-threatening emergency in cardiac surgery, with high in-hospital (22%) and long-term morbidity and mortality rates. Methods: Data from 134 patients were collected from anamnesis and computed tomography before and after aortic surgery. Data were analyzed using IBM SPSS v23. Results: We found that male patients had better survival than the female (p 0.05).Among survived patients, we found that an increased pre-operative ascending aorta diameter is associated with the establishment of a chronic partial thrombosis (54.2 ± 4.6 vs 50.5 ± 7.0 mm, p 0,05). Entre los pacientes supervivientes, el diámetro de la aorta ascendente preoperatoria se asocia con la trombosis parcial crónica (54,2 ± 4,6 frente a 50,5 ± 7,0 mm, p < 0,05). Además, el diámetro de la aorta descendente preoperatoria se asocia con un tiempo de trombosis completa más prolongado (29,2 ± 6,1 frente a 37,2 ± 6,9 mm, p < 0,05). Conclusiones: En nuestra experiencia, no existe una diferencia significativa entre los procedimientos quirúrgicos más utilizados. Sin embargo, encontramos que la edad, el sexo, el estado de shock, la permeabilidad de la falsa luz preoperatoria y el tiempo de CEC son importantes predictores de supervivencia. Además, los diámetros aórticos preoperatorios son relevantes para determinar el tiempo para llegar a una trombosis completa de la falsa luz.

Minimally invasive mitral valve surgery (MIMVS) was developed in the 1990s, but a systematic adoption of this procedure has been somewhat limited. The minimally invasive approach to the mitral valve has several advantages: a fewer blood transfusions, less pain, shorter ventilation time, shorter length of intensive care unit and hospital stay, earlier return to normal activities, lower risk of wound infections and cosmetic improvements. Despite the mentioned benefits, MIMVS was largely criticized because it is technically more complex and requires a long learning curve. Within the surgical complexity the most challenging aspect appears to be the possible development of serious complications. Resumen: La cirugía mitral mínimamente invasiva (CMIVMIi) fue desarrollada en los años 90, aunque la adopción sistemática de este procedimiento ha sido ligeramente limitada. El abordaje a la válvula mitral mínimamente invasivo tiene diversas ventajas: menor cantidad de transfusiones de sangre, menor dolor, menor tiempo de ventilación, menor estancia en la unidad de cuidados intensivos, retorno más temprano a las actividades normales, menor riesgo de infección de heridas, y mejoras cosméticas. A pesar de los beneficios mencionados, la CMIVMIi ha sido ampliamente criticada debido a que es técnicamente más compleja y requiere una gran curva de aprendizaje. Dentro de la complejidad quirúrgica, el aspecto más difícil parece ser el posible desarrollo de complicaciones graves.

BACKGROUND Isolated tricuspid valve (TV) surgery is a rare procedure generally considered at high risk for perioperative mortality and poor long-term outcomes. Surgical treatment can be performed with either an arrested heart (AH) or beating heart (BH) technique. The aim of this study was to compare the outcomes of isolated tricuspid surgery with 2 different approaches.METHODS The Surgical-Tricuspid Study is a multicenter international retrospective study enrolling adult patients who un- derwent isolated TV procedures (n = 406; age 56 +/- 16 years; 56% female) at 13 international sites. The AH and BH strategies were performed in 253 and 153 patients, respectively. Propensity score-matched analysis was used to compare groups.RESULTS After matching, 129 pairs were obtained and analyzed. The 30-day mortality rate was 6.2% versus 5.0% in the AH and BH groups, respectively (P = .9). The rates of acute renal failure requiring replacement therapy (10% versus 3%; P = .02) and stroke (1.6% versus 0%; P = .08) were numerically higher in the AH group. The 6-year survival rate was 67% +/- 6% versus 78% +/- 5% in the AH and BH groups, respectively (P = .18), whereas freedom from cardiac death was 75% +/- 5% versus 84% +/- 4% (P = .21). The 6-year composite cardiac end point of cardiac death and reoperation rate was 60% +/- 9% versus 86% +/- 5% (P - .024) comparing AH-TV replacement and BH-TV repair groups.CONCLUSIONS Isolated TV surgery performed with a BH strategy is a safe option and resulted in a trend of increased long-term survival and freedom from reoperation compared with the standard AH technique. Patients undergoing BH valve repair had the best long-term outcome. (C) 2022 by The Society of Thoracic Surgeons

Postoperative thoracic aortic false aneurysm is a challenging complication of aortic surgery. We describe our surgical approach for an 8-cm thoracic aorta false aneurysm in a 59-year-old woman who had previously undergone aortic surgery. Surgery must be planned carefully because massive hemorrhage during resternotomy is a dreadful complication of postoperative false aneurysm surgery. We decided to start cardiopulmonary bypass before resternotomy and use a ventricular vent from the apex, an endo-vent from the pulmonary artery, and an endo-balloon with antegrade blood cardioplegia. We successfully performed the procedure without profound hypothermia and circulatory arrest and with a low risk of hemorrhage.

Bicuspid aortic valve (BAV) is a common congenital heart malformation frequently associated with the development of aortic valve diseases and severe aortopathy, such as aortic dilatation, aneurysm and dissection. To date, different genetic loci have been identified in syndromic and non- syndromic forms of BAV. Among these, genes involved in the regulation of extracellular matrix remodelling, epithelial to mesenchymal transition and nitric oxide metabolism appear to be the main contributors to BAV pathogenesis. However, no- single gene model explains BAV inheritance, suggesting that more factors are simultaneously involved. In this regard, characteristic epigenetic and immunological profiles have been documented to contradistinguish BAV individuals. In this review, we provide a comprehensive overview addressing molecular mechanisms involved in BAV development and progression.

OBJECTIVES Propofol-based sedation may increase hemodynamic instability by decreasing vascular tone and venous return. Incremental exogenous catecholamines doses may be required to counteract such effects, aggravating the deleterious effects of sympathetic overstimulation. α-2 adrenergic agonists have been reported to decrease norepinephrine requirements in experimental septic shock. The aim of the present study is to test the hypothesis that switching from sedation with propofol to the α-2 agonist dexmedetomidine may decrease norepinephrine doses in septic shock. DESIGN Prospective open-label crossover study. SETTINGS University hospital, ICU. PATIENTS Thirty-eight septic shock patients requiring norepinephrine to maintain adequate mean arterial pressure and needing deep sedation with propofol and remifentanil to maintain a Richmond Agitation-Sedation Scale score between -3 and -4. INTERVENTIONS An initial set of measurements including hemodynamics, norepinephrine doses, and depth of sedation were obtained during sedation with propofol. Propofol was then replaced by dexmedetomidine and a second set of data was obtained after 4 hours of dexmedetomidine infusion. Sedation was switched back to propofol, and a final set of measurements was obtained after 8 hours. A Richmond Agitation-Sedation Scale score between -3 and -4 was maintained during the study period. MEASUREMENTS AND MAIN RESULTS Norepinephrine requirements decreased from 0.69 ± 0.72 μg/kg/min before dexmedetomidine to 0.30 ± 0.25 μg/kg/min 4 hours after dexmedetomidine infusion, increasing again to 0.42 ± 0.36 μg/kg/min while on propofol 8 hours after stopping dexmedetomidine (p < 0.005). Dexmedetomidine dosage was 0.7 ± 0.2 μg/kg/hr. Before and after dexmedetomidine infusion, sedative doses remained unchanged (propofol 2.6 ± 1.2 vs 2.6 ± 1.2 mg/kg/hr; p = 0.23 and remifentanil 1.27 ± 0.17 vs 1.27 ± 0.16 μg/kg/hr; p = 0.52, respectively). Richmond Agitation-Sedation Scale was -4 (-4 to -3) before, -4 (-4 to -3) during, and -4 (-4 to -4) after dexmedetomidine (p = 0.07). CONCLUSIONS For a comparable level of sedation, switching from propofol to dexmedetomidine resulted in a reduction of catecholamine requirements in septic shock patients.

Dysfunction of the left ventricle (LV) with impaired contractility following chronic ischemia or acute myocardial infarction (AMI) is the main cause of ischemic mitral regurgitation (IMR), leading to moderate and moderate-to-severe mitral regurgitation (MR). The site of AMI exerts a specific influence determining different patterns of adverse LV remodeling. In general, inferior-posterior AMI is more frequently associated with regional structural changes than the anterolateral one, which is associated with global adverse LV remodeling, ultimately leading to different phenotypes of IMR. In this narrative review, starting from the aforementioned categorization, we proceed to describe current knowledge regarding surgical approaches in the management of IMR.

Streptococcus bovis/Streptococcus equinus complex (SBSEC) is a group of non-enterococcal group D Streptococci that colonizes both humans and animals. Due to gastrointestinal disease, they can switch in opportunistic pathogens passing through intestinal mucosal barrier and may cause bacteremia and distant organs damage. Despite infective endocarditis (IE), extra-cardiac manifestations of organs damage include osteoarticular infections, meningitis, and biliary infections among others; moreover, the association with colonic pathological lesions has been largely described. Streptococcus alactolyticus as a species included in SBSEC may share pathophysiological similarities, although it represents an extremely rare cause of distant organ infections, being reported in literature as causative agent of IE in only two other cases. We describe a case of 69-year-old male admitted to our institution due to mild–moderate dyspnea and fever, affected by cervico-brachialgia for 3 weeks. Streptococcus alactolyticus was identified as causative agent of IE on the mitral valve, causing severe regurgitation.

The mitral valve is without doubt the part of the human body that is most under pressure [...]

Saphenous vein graft aneurysms (SVGAs) following coronary artery bypass grafting (CABG) surgery were first described in 1975. Although rare, in the absence of a prompt diagnosis, SVGAs can be responsible for serious complications and adverse outcomes. The clinical presentation of SVGAs described in the literature can vary from an asymptomatic patient with an incidental radiological finding to a profoundly shocked patient with life-threatening hemorrhage secondary to SVGA rupture. Improvements in diagnostic tools within the last decade, such as multislice computed tomographic scanning, has enabled early detection of SVGAs, and therefore, an expansion of the current management options. In this review, the current data and knowledge about clinical presentation, diagnosis, natural history, and treatment of SVGAs are updated, with a specific emphasis on the evolution of management strategies of this rare complication over the last 45 years. Finally, a clinical algorithm to guide decision-making and management is proposed.

Sars-CoV-2 outbreak represents a public health emergency, affecting different regions of the world. Lung is the organ more damaged due to the high presence of Sars-CoV-2 binding receptor ACE2 on epithelial alveolar cells. Severity of infection vary from absence of symptomatology to be more severe, characterized by acute respiratory distress syndrome (ARDS), multiorgan failure and sepsis requiring treatment in Intensive Care Unit (ICU).It is not still clear why in a small percentage of patients immune system is not able to efficiently suppress viral replication. It has been documented as predictive factors for severity and susceptibility affections of cardiovascular system such as heart failure (HF), coronary heart disease (CHD) and risk factors for atherosclerotic progression, hypertension and diabetes among others.Atherosclerotic progression, as chronic inflammation process, is characterized by immune system dysregulation leading to pro-inflammatory pattern, including (Interleukin 6) IL-6, Tumor Necrosis Factor α (TNF-α) and IL-1β raise. Reviewing immune system and inflammation profiles in atherosclerosis and laboratory results report in severe Sars-CoV-2 infection we have supposed a pathogenetic correlation. Atherosclerosis may be a pathogenetic ideal substrate to high viral replication ability leading to adverse outcomes, how reported in patients with cardiovascular factors. Moreover, level of atherosclerotic progression may impact on a different degree of severe infection and in a vicious circle feeding itself Sars-CoV-2 may exacerbate atherosclerotic progression due to excessive and aberrant plasmatic concentration of cytokines.

Funding Acknowledgements None Aim Different surgical techniques are available for mitral valve (MV) repair in patients with degenerative severe mitral regurgitation (MR). Leaflet resection (LR) and neochordoplasty (NP), both including ring annuloplasty (RA), are the most frequently performed techniques for posterior mitral leaflet prolapse/flail repair. Despite NP technique is supposed to preserve LV physiology more than LR, it is unclear which technique provides the best haemodynamic pattern. In the present study, the results of the two different surgical techniques in terms of left ventricular (LV) dimension and function are investigated. Methods 23 consecutive patients who underwent MV surgical repair were enrolled. All patients underwent, before surgery and after 8 ± 2 months, 2D and 3D echocardiography with automatic (Heart Model, Philips) assessment of LV volumes and ejection fraction (EF), left atrial (LA) volume, right ventricular (RV) dimension and function, pulmonary artery systolic pressure (PASP), MR, tricuspid regurgitation (TR) and MVPG quantification. MR was corrected using 1) NP with polytetrafluoroethylene sutures and 2) triangular LR, both with RA. Patients were divided in 2 groups according to the surgical technique. Results: techniques were able to successfully correct MR. There were no significant differences in baseline echocardiogram and demographic characteristics between the two groups. There were no significant differences in terms of post-surgical MVPG between the two groups. In all patients a trend in reduction in LV dimension at follow-up was observed, but it was statistically significant only in NP patients (pre-surgical EDV 150 ± 41 VS post-surgical EDV 100 ± 27 ml, p = 0.03). Conclusions Both MV repair techniques showed a successful MV repair and an improvement in LV volumes at follow-up, especially in NP group. Further perspective studies are necessary to demonstrate the hypothesis of more physiological haemodynamic pattern associated with NP techniques. Echo parameters pre VS post MV Repair Parameter pre post p value LVEDV RN (ml) 150 ± 41 100 ± 27 0.03 LVESV RN (ml) 58 ± 20 46 ± 14 NS LVEF RN (%) 58 ± 8 55 ± 7 NS LVEDV RR (ml) 160 ± 58 118 ± 31 NS LVESV RR (ml) 62 ±11 51 ±13 NS LVEF RR (%) 59 ± 8 57 ± 4 NS EDV: end-diastolic volume, ESV: end-systolic volume, EF: ejection fraction, RN = Ring + Neochordae; RR= Ring + Resect.

The severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2) outbreak is a public health emergency affecting different regions around the world. The lungs are often damaged due to the presence of Sars-CoV-2 binding receptor ACE2 on epithelial alveolar cells. Severity of infection varies from complete absence of symptomatology to more aggressive symptoms, characterized by sudden acute respiratory distress syndrome (ARDS), multiorgan failure, and sepsis, requiring treatment in intensive care unit (ICU). It is not still clear why the immune system is not able to efficiently suppress viral replication in a small percentage of patients. It has been documented as pathological conditions affecting the cardiovascular system, strongly associated to atherosclerotic progression, such as heart failure (HF), coronary heart disease (CHD), hypertension (HTN) and diabetes mellitus (DM), could serve as predictive factors for severity and susceptibility during Sars-CoV-2 infection. Atherosclerotic progression, as a chronic inflammation process, is characterized by immune system dysregulation leading to pro-inflammatory patterns, including interleukin 6 (IL-6), tumor necrosis factor α (TNF-α), and IL-1β. Reviewing immune system and inflammation profiles in atherosclerosis and laboratory results reported in severe COVID-19 infections, we hypothesized a pathogenetic correlation. Atherosclerosis may be an ideal pathogenetic substrate for high viral replication ability, leading to adverse outcomes, as reported in patients with cardiovascular factors. The level of atherosclerotic progression may affect a different degree of severe infection; in a vicious circle, feeding itself, Sars-CoV-2 may exacerbate atherosclerotic evolution due to excessive and aberrant plasmatic concentration of cytokines.

Massive pulmonary embolism (PE) is a severe condition that can potentially lead to death caused by right ventricular (RV) failure and the consequent cardiogenic shock. Despite the fact thrombolysis is often administrated to critical patients to increase pulmonary perfusion and to reduce RV afterload, surgical treatment represents another valid option in case of failure or contraindications to thrombolytic therapy. Correct risk stratification and multidisciplinary proactive teams are critical factors to dramatically decrease the mortality of this global health burden. In fact, the worldwide incidence of PE is 60-70 per 100,000, with a mortality ranging from 1% for small PE to 65% for massive PE. This review provides an overview of the diagnosis and management of this highly lethal pathology, with a focus on the surgical approaches at the state of the art.

Congenital fibromuscular bands have been described in left ventricle or right atrium and have been diagnosed by echocardiography and CT scan. The first report of anomalous band in the left atrium was described in 1897 by Rollestone (1). We hereby present a case of a patient with an incidental finding of left atrial band during a minimally invasive mitral surgery procedure.

Bicuspid aortic valve (BAV) disease is recognized to be a syndrome with a complex and multifaceted pathophysiology. Its progression is modulated by diverse evolutionary conserved pathways, such as Notch-1 pathway. Emerging evidence is also highlighting the key role of TLR4 signaling pathway in the aortic valve pathologies and their related complications, such as sporadic ascending aorta aneurysms (AAA). Consistent with these observations, we aimed to evaluate the role of TLR4 pathway in both BAV disease and its common complication, such as AAA. To this aim, 70 subjects with BAV (M/F 50/20; mean age: 58.8 ± 14.8 years) and 70 subjects with tricuspid aortic valve (TAV) (M/F 35/35; mean age: 69.1 ± 12.8 years), with and without AAA were enrolled. Plasma assessment, tissue and gene expression evaluations were performed. Consistent with data obtained in the previous study on immune clonotypic T and B altered responses, we found reduced levels of systemic TNF-α, IL-1, IL-6, IL-17 cytokines in BAV cases, either in the presence or absence of AAA, than TAV cases (p

During a percutaneous coronary procedure, the device may become stuck and break in the coronary circulation. This complication occurs in 0.1% of all procedures. Even with technological improvements, this event still happens because percutaneous coronary interventions are frequently used to treat complex lesions. We report a case of a patient undergoing a percutaneous stenting procedure in which the 0.014″ guidewire was caught in the right coronary artery. Removal of the guidewire was impossible, and it broke in the brachiocephalic artery. Emergency coronary artery bypass grafting was performed.

OBJECTIVES Reports ranged from mixed to marginal tubing wear and spallation effects as a complication of roller pumps in cardiopulmonary bypass (CPB). Because the rollers constantly compress part of the tubing, we sought to determine whether circuit materials behave differently under a 3-h simulation of CPB. METHODS Two different tubing materials (silicone and Tygon) were tested with a customized experimental circuit, designed to allow in vitro simulation of CPB with priming volumes, pressures, revolutions per minute and temperatures equivalent to the clinical scenario. Samples were analysed with optical and field-emission scanning electron microscopy. We collected 200-ml fluid samples at 4 different times: before starting the CPB (T0), when the predicted revolutions per minute corresponded to about 2 min of CPB (T1), at 90 min (T2) and at 180 min (T3). At the end of CPB, we harvested 2 samples of tubing. Lastly, optical investigations and field-emission scanning electron microscopy observations were used for qualitative and quantitative analysis of circulating fragments. RESULTS T2 and T3 fluid samples showed more particles than T1 samples. Significant differences in terms of particle numbers were detected: silicone tubing released more fragments per millilitre than Tygon tubing, with both materials releasing particles from 5 to 500 µm. Silicone tubing was associated with a time-dependent increase in small particles released (P = 0.04), whereas this did not apply to large particles or to Tygon tubing. Yet, bootstrap estimates suggested that silicone tubing was associated with the release of more small particles whereas Tygon tubing released more large particles (both P CONCLUSIONS Silicone showed a worse spallation performance than Tygon, thus appearing less safe for more complex surgery of prolonged duration or for patients with a prior cerebral ischaemic event. Additional risk and cost-effectiveness comparisons to determine the potential benefits of one type of tubing material over the other are warranted to further expand our findings.

Background: Degenerative mitral valve (MV) disease causing mitral regurgitation (MR) is the most common organic valve pathology and is classified based on leaflet motion. MV repair is indicated as the preferred technique (Class I indication) when the results are expected to be durable. Therefore, a detailed and systematic evaluation of MV apparatus is pivotal in allowing the proper surgical planning, as well as the screening for trans catheter-based treatment when surgery is not indicated. Aim: The aim of the present review is to describe the crucial role of both Transthoracic Echocardiography (TTE) and Transesophageal Echocardiography (TEE) in the decisional process and the guidance of MV repair procedures. TTE is the main investigation and the first approach used to make diagnosis of MR, to assess the severity and to describe the underlying mechanism, while TEE, especially with 3D echocardiography, has been shown to be useful for clarifying complicated valvular anatomy, assessing the surgical result and detecting complications. The surgical treatment of MR takes advantage of ultrasound evaluation of MV apparatus at any stage of the process, thus making the link between surgery and echocardiography unbreakable throughout the perioperative phase.