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OBJECTIVES Endocarditis after the Bentall procedure is a severe disease often complicated by a pseudoaneurysm or mediastinitis. Reoperation is challenging but conservative therapy is not effective. The aim of this study was to assess short- and midterm outcomes of patients reoperated on for Bentall-related endocarditis. METHODS Seventy-three patients with Bentall procedure-related endocarditis were recorded in the Italian registry. The mean age was 57 ± 14 years and 92% were men; preoperative comorbidities included hypertension (45%), diabetes (12%) and renal failure (11%). The logistic EuroSCORE was 25%; the EuroSCORE II was 8%. RESULTS Preoperatively, 12% of the patients were in septic shock; left ventricular-aortic discontinuity was present in 63% and mitral valve involvement occurred in 12%. The most common pathogens were Staphylococcus aureus (22%) and Streptococci (14%). Reoperations after a median interval of 30 months (1–221 months) included a repeat Bentall with a bioconduit (41%), a composite mechanical (33%) or biological valved conduit (19%) and a homograft (6%). In 1 patient, a heart transplant was required (1%); in 12%, a mitral valve procedure was needed. The hospital mortality rate was 15%. The postoperative course was complicated by renal failure (19%), major bleeding (14%), pulmonary failure (14%), sepsis (11%) and multiorgan failure (8%). At multivariate analysis, urgent surgery was a risk factor for early death [hazard ratio 20.5 (1.9–219)]. Survival at 5 and 8 years was 75 ± 6% and 71 ± 7%, with 3 cases of endocarditis relapse. CONCLUSIONS Surgery is effective in treating endocarditis following the Bentall procedure although it is associated with high perioperative mortality and morbidity rates. Endocarditis relapse seems to be uncommon.

Background: Although sutureless and rapid deployment aortic valve replacement (SURD-AVR) has been associated with an increased rate of permanent pacemaker (PPM) implantation compared to conventional AVR (c-AVR), the predictors of new conduction abnormalities remain to be clarified. This study aimed to identify risk factors for conduction disorders in patients undergoing AVR surgery. Methods: Data from 243 patients receiving minimally invasive AVR were prospectively collected. SURD-AVR was performed in 103 (42.4%) patients and c-AVR in 140 (57.6%). The primary endpoint was the occurrence of new-onset conduction disorders, defined as first degree atrioventricular (AV) block, advanced AV block requiring PPM implantation, left anterior fascicular block (LAFB), left bundle branch block (LBBB) and right bundle branch block (RBBB). Results: The unadjusted comparison revealed that SURD-AVR was associated with a higher rate of advanced AV block requiring PPM when compared with c-AVR (10.5% vs. 2.1%, P=0.01). After adjusting for other measured covariates (OR: 1.6, P=0.58) and for the estimated propensity of SURD-AVR (OR: 5.1, P=0.1), no significant relationship between type of AVR and PPM implantation emerged. On multivariable analysis, preoperative first-degree AV block (OR: 6.9, P=0.04) and RBBB (OR: 6.9, P=0.03) were independent risk factors for PPM. Subgroup analysis of patients with normal preoperative conduction revealed similar incidence of PPM between SURD-AVR and c-AVR (1.3% vs. 1.9%, P=0.6). When compared with c-AVR, SURD-AVR was associated with a greater incidence of postoperative new onset LBBB (18.1% vs. 3.2%, P

Infective endocarditis (IE) with extensive annular disruption and aortic root involvement carries an ominous prognosis (1,2). The broad and severe impairment of the peri-annular tissues at the level of the interventricular septum and mitro-aortic continuity may hamper a successful surgical reconstruction, with dehiscence and retraction of the anterior mitral leaflet (AML) being a possible dreadful complication (3,4). Here we present our technique for root replacement (Bentall) that involves a sub-annular implantation of a 100% pericardial valved conduit (BioconduitTM, Biointegral Surgical, Inc., Ontario, Canada).

Background. Over the years, with the introduction of minimally invasive techniques and technologies aimed at reducing surgical trauma, aortic valve surgery has considerably developed and improved. Our approach includes: reduced incisions (upper “J” ministernomy or anterior right minithoracotomy), “ultra fast-track” anesthesia protocols, sutureless and rapid deployment valve prostheses and miniaturized circuits of extracorporeal circulation. The aim of this study was to evaluate the clinical outcomes associated with this multidisciplinary approach. Methods. Between October 2016 and November 2018, 429 patients underwent isolated aortic valve replacement at the Cardiac Surgery Unit of the “Ospedali Riuniti” of Ancona, Italy. Overall, 91 patients (21.2%) were operated according to our minimally invasive approach. A severe aortic valve stenosis was the indication for surgery in 90.1% of patients, aortic valve insufficiency in the remaining 18.7%. Results. There were neither in-hospital deaths nor major or minor neurological events. Atrial fibrillation was the main postoperative complications (n=26, 28.6%). Four patients (4.4%) underwent permanent pacemaker implantation due to third-degree atrioventricular block, and a surgical bleeding revision was performed in 3.3%. No episodes of respiratory failure were reported. The median length of hospital stay was 6 days (5-8 days). Conclusions. Our initial experience with a 360° minimally invasive approach for the treatment of patients undergoing aortic valve replacement shows encouraging clinical outcomes; this approach may lead to an improved perception of surgery both by patients and their families. However, further clinical studies are needed to evaluate the long-term results.