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Background To test in vivo a new design prototype for radio frequency (RF) ablation. Methods A prototype based on a concept of endo-epicardial biparietal bipolar RF ablation with the atrial tissue interposed and consisting of two specular endocardial-epicardial catheters was tested in four pigs (80 +/- 5 kg). The endocardial catheter was introduced into the left atrium through the left atrial appendage on the beating heart. The epicardial counterpart was placed manually on the atrial epicardial surface. The coupling of the two catheters was achieved using a neodymium magnet around the gold plate electrode, and RF was applied to the interposed tissue. The hearts were excised, and the lesions were examined using morphometric evaluation. Results The RF application resulted in transmural lesions in all of the four animals tested. In these animals the maximum endocardial width (W-endo) was 6.34 +/- 0.25, 6.54 +/- 0.33, 6.36 +/- 0.57, and 6.49 +/- 0.96 mm. The pericardial width (W-epi) was similar: 6.37 +/- 0.47, 6.58 +/- 0.32, 6.35 +/- 0.56 and 6.53 +/- 0.94 mm. The lesion area was 924.78, 949.25, 944.25, and 926.05 mm(2), and the lesion volume was 92.47, 94.92, 94.42, and 92.60 mm(3), respectively. Conclusions The idea of an endocardial-epicardial bidirectional biparietal bipolar radiofrequency tool such that the atrial tissue is fully interposed between the two RF poles might be promising for future clinical applications. Further research is warranted.

ObjectiveTo evaluate the size and depth of linear lesions by in vitro testing with a custom-made radio frequency biparietal bipolar ablation catheter in a single-stage setting.MethodsA custom-made catheter was created to generate linear lesions around the left atrium and pulmonary veins of an ex vivo pig. Two frames were made, 1 epicardial and 1 endocardial. A continuous copper braid electrode and an alignment system consisting of 2 parallel rows of neodymium magnets were embedded in a flexible plastic support. After 24 hours of formalin conservation, samples of the left atrium of a freshly slaughtered pig were sliced in a cryotome, thus obtaining a sequence of 100-µm thick layers extending from the endocardial to the epicardial side. After being digitized through a scanner, these layers were evaluated using morphometric computer software. For each slice, we evaluated the maximum length of the lesions, the maximum epicardial length, the maximum endocardial length, the total area of the lesion, and the total volume.ResultsForty transmural lesions from 40 specimens were obtained. The results were the following (the number in parenthesis is the interquartile range in mm): lesion maximum length ( LMAX) was 7.297 mm (0.006), epicardial maximum length ( LEPI) was 7.291 mm (0.014), and endocardial maximum length was 7.291 mm (0.018). The total area and total volume were 1018.50 ± 36.51 mm2and 101.85 ± 3.65 mm3, respectively.ConclusionsOur prototype showed very promising results. The next step will be to enhance the design for clinical application.

Background and aim Classical and paradoxical low‐flow, low‐gradient (LFLG) aortic stenosis (AS) are the most challenging subtypes of AS. The current therapeutic options are aortic valve replacement (AVR) and conservative management: AVR promotes long‐term survival but is invasive, while conservative management yields a poor prognosis but is noninvasive since it uses no aortic valve replacement (noAVR). The present meta‐analysis investigated the rate of survival of patients with LFLG AS undergoing either AVR or noAVR interventions. Methods The meta‐analysis compared the outcomes of AVR with those of noAVR in terms of patient survival. In both groups, a meta‐regression was conducted to investigate the impact on patient survival of the left ventricular ejection fraction (LVEF), either preserved (paradoxical LFLG AS) or reduced (classical LFLG AS). Results The relative risk of survival between the AVR and noAVR groups was 1.99 [1.40, 2.82] (p = .0001), suggesting that survival tends to be better in AVR patients than in noAVR patients. The meta‐regression revealed that a reduced LVEF may be related to a higher survival in AVR patients when compared to a preserved LVEF (p = .04). Finally, the analysis indicated that LVEF seems not to be prognostic of survival in noAVR patients (p = .18). Conclusions Patients with LFLG AS have better survival if they undergo AVR. In AVR patients, reduced LVEF rather than preserved LVEF is related to better survival, whereas there seems to be no difference in prognostic value between reduced and preserved LVEF in noAVR patients.

The aim was to use a propensity score-based analysis to determine the impact of peripheral artery disease (PAD) on early outcomes after coronary artery bypass surgery grafting (CABG) in patients with PAD.We conducted a multicentre retrospective analysis of 11,311 consecutive patients who underwent CABG between 1997 and 2017. Patients with previous or concomitant vascular surgery were excluded. The main endpoints were death, stroke, and limb ischaemia requiring percutaneous or surgical revascularisation. Subgroup analyses were performed to test the interaction of PAD with concomitant factors.There was no difference in mortality in patients with and without PAD (p=0.06 and p=0.179, respectively). Patients with PAD had a greater incidence of stroke (p=0.04), acute kidney disease (p=0.003), and limb ischaemia requiring interventions (p0.001) than those without PAD. The use of off-pump or no-touch aortic techniques did not influence the effect of PAD on the outcomes. Early mortality rate increased in patients with PAD when associated with long cardiopulmonary bypass, cross-clamp times (both p0.001), and postoperative low cardiac output (p=0.01).The presence of PAD is associated, independently of other factors, with greater incidence of stroke, acute kidney disease, and limb ischaemia following CABG, irrespective of the technique employed. Operative mortality was greater in patients with PAD only when associated with long cardiopulmonary bypass and aortic cross-clamp times, and low cardiac output.

Purpose To make an in vitro evaluation of the lesion size and depth produced in two different sets of radio frequency energy bipolar delivery: simultaneous biparietal bipolar (SBB) and simultaneous uniparietal bipolar (SUB). Methods Two separate prototypes have been built for our purpose: one to be used in SBB mode and the other to be used SUB mode. Forty left atrium samples were taken from the hearts of freshly slaughtered pigs. They were ablated into a simulator ABLABOX, where blood flow, temperature, and contact force were controlled. After being sliced into a cryotome, the samples were digitalized by a flatbed scanner, and the images were analyzed by a computer morphometric software. Results Transmural lesions were achieved in 18/20 samples (90%) in SBB, while SUB showed transmurality in 9/20 samples (45%). Overall maximum diameter (DMAX) resulted larger in SUB than in SBB (2.43 ± 0.30 mm, 1.62 ± 0.14 mm, respectively; p DEPI and DENDO, respectively) were wider in SUB group than SBB group (2.28 ± 0.30 mm, 2.26 ± 0.40 and 1.60 ± 0.14 mm, 1.59 ± 0.15 mm, respectively; p ATOT and VTOT) were broader in SUB group than in SBB one (581.01 ± 65.38 mm/mm2, 58.10 ± 6.53 mm/mm3 and 521.97 ± 73.05 mm/mm2, 52.19 ± 7.30 mm/mm3. respectively; p Conclusions In contrast with the smaller lesion sizes, the biparietal bipolar group showed a higher transmurality rate. These findings may suggest a better drive of the energy flow when compared with SUB lesions.

Objective To compare lesion size and depth between a 1-step, a sequential, and a delayed radio-frequency ablation in a hybrid setup. Methods Left atrium tissues obtained from fresh porcine hearts were mounted into the ABLABOX simulator. Based on the time differences between the index epicardial (epi) and consequent endocardial (endo) ablation, 3 study groups were compared: a 1-stage (SEQ- 0) group (0-minute delay), an SEQ 1 group (60-minute delay), and an SEQ 2 group (240-minute delay). During the experiment, a constant epicardial (300 gr) and endocardial (30 gr) force were applied. Per group, 20 samples were studied, and the resulting lesion size and depth were quantified with morphometric evaluation. Results Overall, no transmural lesion was obtained. Lesions in SEQ 0 had better maximum and minimum diameters ( P < 0.001), a larger total area ( P < 0.001), and volume ( P < 0.001) than SEQ 1 and SEQ 2. There was no statistical difference in morphometric parameters (all, P > 0.05) between the delayed procedures (SEQ 1 and SEQ 2). Conclusions In our in vitro model, different time sequences of combined epi–endo ablation did not result in transmural lesions. However, simultaneous epi–endo ablation produced broader and deeper lesions. Our findings need to be confirmed by further research.

OBJECTIVES We studied the flow pattern in the superior mesenteric artery (SMA) during intra-aortic balloon pump support, comparing 2 intra-aortic balloons of 2 different lengths. METHODS Sixteen Landrace pigs (mean weight 84.0 kg ± 6.0) were used in this study. The animals were randomly assigned to 2 groups: group 1 received an 8-Fr, 40-ml standard balloon; group 2 received an 8-Fr, 40-ml short balloon. SMA flow was measured during early, mid- and telediastole. RESULTS The standard balloon led to a reduction in SMA flow in early diastole (P CONCLUSIONS Despite better overall mean mesenteric diastolic flow, the short balloon leads to early- and mid-diastolic flow reduction, although to a lesser extent than the standard intra-aortic balloon pump balloon. Our data are a call for improvement in the design of the short balloon.

This study aims to establish the incidence of atrial fibrillation (AF) in breast cancer (BC) patients, focusing on staging and anti-cancer treatment. A meta-analysis was conducted to investigate the incidence of AF in BC patients and compare this incidence to other cancers. Furthermore, we evaluated the occurrence of AF as an adverse effect of biological therapies vs. non-biological therapies vs. biological therapies + non-biological therapies in BC. Finally, we compared the incidence of AF in early BC and metastatic BC. Thirty studies were included. Twenty-two studies focused on BC, encompassing 166,271 patients. In the BC group, 2.7% of patients developed AF, while in the “all cancer” group, 5.8% of patients developed AF. In addition, there was no difference between different types of therapies (p = 0.61) and between early and metastatic BC (p = 0.57). The type of anti-cancer therapy and the staging of BC does not influence AF’s occurrence in this neoplastic disease.

OBJECTIVESThe aim of this study was to evaluate the lesion size and depth of radiofrequency (RF) ablation in a simultaneous biparietal bidirectional bipolar (SBB) approach, compared to a simultaneous and staged unipolar and uniparietal bipolar setup [simultaneous uniparietal bipolar (SiUB) and staged uniparietal bipolar (StUB), respectively].METHODSFresh left atrial porcine tissue was mounted into the ABLA-BOX simulator. Different ablation approaches were tested: (i) SBB: a concept consisting of SBB endo-epicardial ablation, (ii) SiUB: simultaneous epicardial uniparietal bipolar and endocardial unipolar ablation and (iii) StUB: staged epicardial uniparietal bipolar and endocardial unipolar ablation. In the StUB setup, a 1-h interval between the epi-endo ablation was respected.RESULTSTransmural lesions were present in 90% of the bipolar biparietal ablations, yet no full transmurality was observed in the simultaneous nor in the staged unipolar with uniparietal bipolar ablation group. In SBB, the area and volume of the ablation lesions were smaller (523.33 mm2/mm and 52.33 mm3/mm, respectively) than in SiUB (588.17 mm2/mm and 58.81 mm3/mm, respectively) and StUB (583.76 mm2/mm and 58.37 mm3/mm, P = 0.044). Also, in SBB, the overall, epicardial and endocardial maximum diameters of the lesions (1.59, 1.57 and 1.52 mm; respectively) were smaller than in SiUB (2.38, 2.26 and 2.33 mm; respectively) and in StUB (2.36, 2.28 and 2.14 mm; respectively, all P CONCLUSIONSAlthough bipolar biparietal bidirectional RF ablation results in smaller lesions than uniparietal bipolar and unipolar ablation, their capacity to penetrate the tissue is much higher. Moreover, in uniparietal RF applications, the energy spreads in the superficial layers of the tissue but fails to penetrate. Therefore, the degree of transmurality is much higher when using such a ‘truly bipolar’ ablation approach.

Background We carried out a propensity score-based analysis on early outcomes after coronary artery bypass grafting (CABG) in patients with and without peripheral artery disease (PAD). Materials and Methods A total of 11 311 patients undergoing isolated CABG between 1997 and 2017 were included in the study. Patients were divided into two groups based on whether they were affected (n = 1961) or not affected (n = 9350) by PAD. Inverse probability of treatment weighting was employed to reduce confounding preoperative and operative variables. The main endpoints were death, cardiac death, stroke, and limb ischemia requiring percutaneous or surgical revascularization. Results The excellent balance was obtained, and the groups were very similar. For death and cardiac death, there were no differences between patients with and without PAD (P = .06 and P = .179, respectively). In contrast, PAD patients showed a higher incidence of stroke (P = .04), acute kidney disease (AKD) (P = .003) and limb ischemia requiring intervention (P

Background: Extracorporeal membrane oxygenation constitutes a complex support modality, and accurate monitoring is required. An ideal monitoring system should promptly detect ECMO malfunctions and provide real-time information to optimize the patient–machine interactions. We tested a new volumetric capnometer which enables continuous monitoring of membrane lung carbon dioxide removal (V′CO2ML), to help in estimating the oxygenator performance, in terms of CO2 removal and oxygenator dead space (VDsML). Methods: This study was conducted on nine pigs undergoing veno-arterial ECMO due to cardiogenic shock after induced acute myocardial infarction. The accuracy and reliability of the prototype of the volumetric capnometer (CO2RESET™, by Eurosets srl, Medolla, Italy) device was evaluated for V′CO2ML and VDsML measurements by comparing the obtained measurements from the new device to a control capnometer with the sweep gas values. Measurements were taken at five different levels of gas flow/blood flow ratio (0.5-1.5). Agreement between the corresponding measurements was taken with the two methods. We expected that 95% of differences were between d − 1.96s and d + 1.96s. Results: In all, 120 coupled measurements from each device were obtained for the V′CO2ML calculation and 40 for the VDsML. The new capnometer mean percentage bias (95% confidence interval limits of agreement) was 3.86% (12.07-4.35%) for V′CO2ML and 2.62% (8.96-14.20%) for VDsML. A negative proportional bias for V′CO2ML estimation with the new device was observed with a mean of 3.86% (12.07-4.35%). No correlations were found between differences in the coupled V′CO2ML and VDsML measurements and the gas flow/blood flow ratio or temperature. Coupled measurements for V′CO2ML showed strong correlation (rs = 0.991; p = 0.0005), as did VDsML calculations (rs = 0.973; p = 0.0005). Conclusion: The volumetric capnometer is reliable for continuous monitoring of CO2 removal by membrane lung and VDsML calculations. Further studies are necessary to confirm these data.

The connection between atrial fibrillation (AF) and H. pylori (HP) infection is still matter of debate. We performed a systematic review and metanalysis of studies reporting the association between AF and HF. A systematic review of all available reports in literature of the incidence of HP infection in AF and comparing this incidence with subjects without AF were analysed. Risk ratio and 95% confidence interval (CI) and risk difference with standard error (SE) were the main statistics indexes. Six retrospective studies including a total of 2921 were included at the end of the selection process. Nine hundred-fifty-six patients (32.7%) were in AF, whereas 1965 (67.3%) were in normal sinus rhythm (NSR). Overall, 335 of 956 patients with AF were HP positive (35%), whereas 621 were HP negative (65%). In addition, 643 of 1965 NSR patients (32.7%) were HP positive while 1,322 were negative (67.3%; Chi-square 2.15, p = 0.21). The Cumulative Risk Ratio for AF patients for developing an HP infection was 1.19 (95% CI 1.08–1.41). In addition, a small difference risk towards AF was found (0.11 [SE = 0.04]). Moreover, neither RR nor risk difference were influenced by the geographic area at meta-regression analysis. Finally, there was a weak correlation between AF and HP (coefficient = 0.04 [95% CI −0.01–0.08]). We failed to find any significant correlation between H. pylori infection and AF and, based on our data, it seems unlikely than HP can be considered a risk factor for AF. Further larger research is warranted.

What is the central question of this study? Visceral ischaemia is one of the most feared complications during use of an intra-aortic balloon pump. Using an animal model, we measured the flows at the abdominal level directly and examined flow patterns to enable investigation of flow patterns during the use of the intra-aortic balloon pump. What is the main finding and its importance? We show that there is a significant balloon-related reduction in superior mesenteric flow in both early and mid-diastole.A number of previous studies have shown that blood flow in the visceral arteries is altered during intra-aortic balloon pump (IABP) treatment. We used a porcine model to analyse the pattern of blood flow into the visceral arteries during IABP use. For this purpose, we measured the superior mesenteric, right renal and left renal flows before and during IABP support, using surgically placed flowmeters surrounding these visceral arteries. The superior mesenteric flow significantly decreased in early diastole (P 0.001) and in mid-diastole (P = 0.003 versus early diastole), whereas in late diastole it increased again (P 0.001 versus mid-diastole). During systole, the flow was not significantly increased compared with late diastole (P = 0.51), but it was significantly lower than at baseline (both P 0.001). Flows did not differ between right and left kidneys. Perfusion of either kidney did not change significantly in early diastole (P 0.05), whereas it decreased significantly in mid-diastole (P 0.001), rising dramatically in late diastole (P 0.001) and with an additional slight increase in systole (P = 0.054). This study provides important insights into abdominal flows during intra-aortic pump counterpulsation. Furthermore, it supports the need to rethink the balloon design to avoid visceral ischaemia during circulatory assistance.

Atrial fibrillation (AF) is the most common sustained arrhythmia, and it affects around 3% of the population over the age of 20 years worldwide. It is caused by disorganized activation of the atria, causing impairment of atria and ventricular hemodynamic performance and correlating to dramatic consequences as stroke (fivefold increased). People affected by AF experience symptoms that may significantly influence their quality of life as insomnia, palpitations, shortness of breath, tiredness, weakness, and psychological distress. Despite the advanced progress of either pharmacological or surgical treatment in the last decade, there is the need for newer approaches, especially in those chronic AF forms where the current treatments are not satisfactory. The present thesis explores a different possible approach in applying radiofrequency, broadly used in the treatment of AF, aiming to better exploit its physical characteristics to create long stable improvements in patients' quality of life.

Introduction: This study aimed to test a computer-driven cardiovascular model for the evaluation of the visceral flow during intra-aortic balloon pump (IABP) assistance. Methods: The model includes a systemic and pulmonary circulation as well as a heart contraction model. The straight polyurethane tube aorta had a single visceral while four windkessel components mimicked resistance compliance of the brachiocephalic, renal and sub-mesenteric, pulmonary, and systemic circulation. Twelve flow probes were placed in the circuit to measure pressures and flows with the IABP on and off. Results: With the balloon off, the meantime to reach the steady state was 48 ± 16 s; with the balloon on, this figure was 178 ± 20 s. The stability of pressure and flow signals was obtained after 72 ± 11 min. The number of cycles of stability of the system was 93 [86–103]. Measurements were reliable either with samples of 10 or 20 beats. Bland Altman method demonstrated the reliability of measurements. Finally, all measurements were comparable to published in vivo data. Conclusion: The presented mock circulation was reliable and gave values with high accuracy both at baseline and during mechanical assistance. This system allows evaluation of the mesenteric flow during IABP, under different clinical/hemodynamic conditions. Nonetheless, its translational potential needs to be further evaluated

Background and Aims\ud The main pathophysiological factor of chronic ischemic mitral regurgitation (MR) is the outward displacement of the papillary muscles (PMs) leading to leaflet tethering. For this reason, papillary muscle intervention (PMI) in combination with mitral ring annuloplasty (MRA) has recently been introduced into clinical practice to correct this displacement, and to reduce the recurrence of regurgitation.\ud \ud Methods\ud A meta‐analysis was conducted comparing the outcomes of PMI and MRA performed in combination vs MRA performed alone, in terms of MR recurrence and left ventricular reverse remodeling (LVRR). A meta‐regression was carried out to investigate the impact of the type of PMI procedure on the outcomes.\ud \ud Results\ud MR recurrence in patients undergoing both PMI and MRA was lower than in those who only had MRA (log incidence rate ratio, −0.66; lower‐upper limits, −1.13 to 0.20; I2 = 0.0%; p = .44; Egger's test: intercept 0.35 [−0.78 to 1.51]; p = .42).\ud \ud The group with both PMI and MRA and that with only MRA showed a slightly higher reduction in left ventricular diameters (−5.94%; −8.75% to 3.13%,). However, in both groups, LVRR was p = .33).\ud \ud Conclusions\ud Using PMI and MRA together has a lower MR recurrence than using MRA alone. No significant LVRR was observed between the two groups nor between the PMI techniques employed.

Atrial fibrillation (AF) is the most common arrhythmia, increasing with age and comorbidities. Obstructive sleep apnea (OSA) is a chronic sleep disorder more common in older men. It has been shown that OSA is linked to AF. Nonetheless, the prevalence of OSA in patients with AF remains unknown because OSA is significantly underdiagnosed. This review, including 54,271 patients, carried out a meta-analysis to investigate the association between OSA and AF. We also performed a meta-regression to explore cofactors influencing this correlation. A strong link was found between these two disorders. The incidence of AF is 88% higher in patients with OSA. Age and hypertension independently strengthened this association, indicating that OSA treatment could help reduce AF recurrence. Further research is needed to confirm these findings. Atrial Fibrillation (AF) is the most common arrhythmia, increasing with age and comorbidities. Obstructive sleep apnea (OSA) is a regulatory respiratory disorder of partial or complete collapse of the upper airways during sleep leading to recurrent pauses in breathing. OSA is more common in older men. Evidence exists that OSA is linked to AF. Nonetheless, the prevalence of OSA in patients with AF remains unknown because OSA is underdiagnosed. In order to investigate the incidence of AF in OSA patients, we carried out a meta-analysis including 20 scientific studies with a total of 54,271 subjects. AF was present in 4801 patients of whom 2203 (45.9%) had OSA and 2598 (54.1%) did not. Of a total of 21,074 patients with OSA, 2203 (10.5%) had AF and 18,871 (89.5%) did not. The incidence of AF was 88% higher in patients with OSA. We performed a meta-regression to explore interacting factors potentially influencing the occurrence of AF in OSA. Older age and hypertension independently strengthened this association. The clinical significance of our results is that patients with OSA should be referred early to the cardiologist. Further research is needed for the definition of the mechanisms of association between AF and OSA.

Aim: We evaluated the influence of intra-aortic balloon size and volume on mesenteric and renal flows. Methods: Thirty healthy swine underwent 120-minute ligation of the left anterior descending coronary artery followed by 6 hours of reperfusion. Then, they were randomly assigned to the following five groups of animals, with six animals in each group: no intra-aortic balloon pump (IABP), a short 35-mL IABP, a short 40-mL IABP, a long 35-mL IABP and a long 40-mL IABP. Superior mesenteric artery (SMA) and renal flows were measured at baseline (t0), at 2-hour ischemia (t1) and every hour thereafter until 6 hours of reperfusion (from tR1 to tR6). Results: SMA flows increased significantly at tR1 only in the two short IABP groups (p0.05). Renal flows appeared to be influenced by balloon length, but not by volume. Indeed, flows in the renal arteries rose during IABP treatment; the increase was significantly higher in the short balloon groups and throughout the whole reperfusion (all, pConclusions: Changes in visceral perfusion during IABP assistance were significantly related to balloon length, but not to its volume. This could be relevant for the evolution of balloon engineering design in order to reduce the incidence of mesenteric ischemia following IABP. Further research is necessary to confirm these findings.

Background We explore the association between short- and long- term adverse outcomes following coronary artery bypass grafting (CABG) and the degree of preoperative renal dysfunction classified on glomerular fraction estimated with Chronic Kidney Disease-Epidemiology Collaboration equation (eGFR CKD-EPI ). We also try to identify cut-off values of eGFR CKD-EPI able to predict post-CABG unfavorable events and assess whether a reclassification with new thresholds is necessary. Methods One-thousand-one-hundred-eighty-six consecutive patients undergoing CABG between 2005 and 2014 were categorized in 4 groups according to the eGFR CKD-EPI : Group 1 (≥60ml/min/1.73m 2 ; n=1199), Group 2 (45–59ml/min/1.73m 2 ; n=358), Group 3 (30–44ml/min/1.73m 2 ; n=171) and Group 4 (≤29ml/min/1.73m 2 ; n=126). Median follow-up was 66months [IQR 46–84]. Results eGFR CKD-EPI ≤30ml/min/1.73m 2 , ≤41ml/min/1.73m 2 , ≤27ml/min/1.73m 2 and ≤29ml/min/1.73m 2 were strong predictors of early mortality (OR 5.88 [95% CI 2.59–11.25]), stroke (2.59 [1.43–3.71]), prolonged length of stay (3.49 [1.24–5.92]) and postoperative dialysis (3.68 [1.34–4.91]), respectively. In addition, eGFR CKD-EPI ≤26ml/min/1.73m 2 , ≤25ml/min/1.73m 2 , ≤35ml/min/1.73m 2 and ≤29ml/min/1.73m 2 predicted all-cause death (hazard ratio 2.74 [95% CI 2.10–3.92] cardiovascular death (sub-hazard ratio 2.11 [95% CI 1.42–3.90]), myocardial infarction (2.01 [1.32–3.70]) and heart failure (2.24 [1.41–3.93]), respectively. Analyses corrected by age and left ventricular ejection fraction confirmed these findings. Conclusions In our experience, the use of the eGFR CKD-EPI equation led to categorization with a significantly lower number of patients at risk for post-CABG complications. This might have important clinical repercussions on allocation of healthcare resources and more targeted prevention and management of CABG complications.

Objective This meta-analysis investigates MR recurrence and degree of left ventricular reverse remodeling (LVRR) in CIMR patients in mitral annuloplasty employing different ring designs. Background The deeper understanding of complex changes caused by chronic ischemic mitral regurgitation (CIMR) have led to new generations of rings that, by maintaining normal 3D annular geometry are supposed to enhance long-term repair durability. Methods A meta-analysis of all available reports in literature of MV repair through different ring design was conducted. Meta-regression was performed to investigate the impact of mitral ring characteristics related to flexibility, planarity, symmetry and single type utilized. Twenty studies encompassing a total of 1876 patients were included at the end of the selection process. Results At meta-regression recurrence of MR was not influenced by the ring employed. Nonetheless, the event rate of MR recurrence in planar rings was 19%. Vs. 11% observed with non-planar rings. Recurrence rate in patients implanted with symmetric rings was 14% whereas it was 7% in asymmetric rings. The non-planar asymmetric IMR-ETlogix showed the lowest recurrence rate (6%). Furthermore, in planar group the reduction of pre- and post-operative LVEDD was - 4%. In the non-planar group, the LVEDD was reduced by 8.6%. In patients implanted with symmetric rings LVEDD reduction was 10.8%. LVRR in the asymmetric group was −5.8%. Conclusion MR recurrence occurred the least with asymmetric rings with less disproportionate asymmetry. In contrast, LVRR occurred at a greater extent in symmetric rings.

Background and Aims We investigated neurological events, graft patency, major adverse cardiovascular events (MACEs), and mortality at 1 year following coronary artery bypass grafting (CABG) surgery using automated proximal anastomotic devices (APADs) and compared the overall rates with the current literature. Methods A systematic review of all available reports of APADs use in the literature was conducted. Cumulative incidence and 95% confidence interval (CI) were the main statistical indexes. Nine observational studies encompassing a total of 718 patients were included at the end of the selection process. Results The cumulative event rate of neurological complications was 4.8% (lower‐upper limits: 2.8‐8.0, P

Background and Aims: Conventional coronary artery bypass grafting (CCABG) has been associated with high incidence of stroke, especially for the high degree of aortic manipulation. Off-pump CABG (OPCAB) theoretically represents a valid option, since the avoidance of aortic manipulation can prevent the embolization of atherosclerotic debris. There is a lot of controversy about the outcomes of CCABG compared to OPCAB. The aim of this metanalysis is to examine the incidence of stroke within 30 days from the surgical procedure. Methods and Results: A literature search was conducted from 2009 to 2019 using PubMed database. Nine randomized control trials were included in the metanalysis. Results: The odds ratio between the CCABG vs OPCAB was 0.87 (Lower, Upper limits: 0.65, 1.17, p = 0.355; I2 = 0.0%, p = 0.68; Egger’s test: intercept -0.15 [-1.55, 1.25], p = 0.81). Conclusion: Compared to the CCABG, no advantage was detected in the OPCAB group in terms of stroke.

Background: Minimally invasive aortic valve replacement (MIAVR) procedures are starting to be accepted as the standard procedures for aortic valve diseases. However, only a limited number of studies have directly compared mini-thoracotomy (MT) to mini-sternotomy (MS). Therefore, the aim of this review was to summarize the available literature for comparison between the procedures to have a better understanding of the risks and benefits to guide future procedures. Methods: A literature search for MT and MS was carried out using two literature databases. Relevant articles were identified and assessed through the inclusion and exclusion criteria. Results: 15 studies were identified for inclusion in this review. Comparable results were identified between MT and MS in terms of 30-day mortality. In addition, there was no difference in the incidence of stroke, reoperation for bleeding, and wound infection. In contrast, MT showed longer cardiopulmonary bypass (CPB) and cross-clamping durations than MS. Conclusion: Both MT and MS surgical approaches are reliable, efficient, and comparable. These findings have to be confirmed by large randomized trials

This proof-of-concept study examined the haemodynamic performance as well as the coronary and visceral organ perfusion using a new short balloon for intra-aortic counterpulsation (IABP) in a swine model of myocardial ischaemia. Eighteen healthy pigs underwent 120-min ligation of the left anterior descending coronary artery followed by 6 h of reperfusion, and they were randomly assigned into 3 groups undergoing IABP implantation with a 35-ml short balloon (n = 6), a 40-ml short balloon (n = 6) or no IABP implantation (controls, n = 6). Haemodynamics, and visceral and coronary flows were measured at baseline (t(0)), at 2 h of ischaemia (t(1)) and every hour thereafter until 6 h of reperfusion (from t(R1) to t(R6)), respectively. Mesenteric and renal flows increased significantly at t(R1) only in the IABP groups (all, P 0.05). The new short balloon significantly increased visceral flow, enhanced haemodynamics and improved coronary circulation during reperfusion following myocardial ischaemia in our experimental model.

Objective Visceral ischemia can be a potentially life-threatening complication of intra-aortic balloon pump (IABP) support. A shorter IABP catheter might lead to a reduction of visceral complications. In this animal study, we evaluate the effects of a 35-mL short catheter in comparison with a 40-mL standard-sized catheter. Methods Eighteen healthy swine underwent 120-minute ligation of the left anterior descending coronary artery followed by 6 hours of reperfusion being supported by either a short IABP catheter (short group) (n = 6) or a long IABP catheter (long group) (n = 6) or with no assistance (controls) (n = 6). Hemodynamics, visceral and coronary flows, as well as biochemical markers were evaluated throughout the different phases of the protocol. Results Mesenteric flows increased significantly at reperfusion (P < 0.001 both) remaining constant afterward (all, P > 0.05) in the short group, while remaining significantly lower in the long group at the start of reperfusion, remaining constantly lower than the short group and controls (P < 0.001 vs short, P < 0.003 vs controls). In both long and short groups, catheters improved renal flows at reperfusion (P < 0.001 both) without any further variation (P < 0.05). In the short group, the flows were higher during the whole of reperfusion (all, P < 0.05). Intra-aortic balloon pump support improved hemodynamic indices and coronary blood flows during reperfusion to a similar extent in both the small and the long group (P > 0.05). Conclusions The short IABP catheter proved to be as effective as the standard-sized catheter in supporting hemodynamics and coronary circulation. Furthermore, it even improves visceral flows in comparison with conventional IABP catheters.

Objective We present the first testing study on the ABLA-BOX, a new in vitro module of hybrid atrial fibrillation ablation. Methods ABLA-BOX consists of two chambers that mimic the epicardial and endocardial sides of the heart. The septum between chambers provides catheter access on both sites of the cardiac tissue. A circuit, filled with freshly obtained porcine blood, including a pump, an oxygenator, and a heating device, circulate the blood inside the system. Left atrial fresh tissue is mounted on a tissue holder and magnetically fixed. Epicardial and endocardial catheters are fixed on the catheter holders and blocked with the locker knob. The system allows control of ablation force, flow rate, temperature, and flow pattern. Results Epicardial contact force of 100 g and endocardial force of 30 g resulted in larger lesion volumes (P < 0.001), areas (P < 0.001), and lesion diameters (P = 0.03 and P = 0.008), than the combination of 100/20 g. In addition, with a flow rate of 5 L/min, lesion volumes (P = 0.02), areas (P < 0.001), and diameters (both, P < 0.001) were significantly larger in comparison with those of 3 L/min. Furthermore, dimensions (both, P < 0.001), volume (P < 0.001), and area (P < 0.001) of the lesions at a circulating blood temperature of 38.0°C were larger than with a lower blood temperature (36.0°C). Finally, ablations made under stable flow pattern resulted in greater lesion diameters P = 0.04 and P = 0.03) as well as larger volumes (P = 0.02) and areas (P = 0.03) than under turbulent-like flow reproduced with the system rotor set to 400 rpm. Conclusions The ABLA-BOX allowed easy hybrid ablation with different setups, which can provide cardiologists and cardiac surgeons with reliable and more valuable insights.

Patients with pre-existing cardiovascular disease (CVD) might be more susceptible to infection from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and have higher mortality rates. Nevertheless, the risk of mortality has not been previously quantified. The aim of this meta-analysis is to quantify the risk of mortality in coronavirus disease 2019 (COVID-19) patients. A meta-analysis was conducted analyzing the impact of (1) sex, (2) age, (3) CVD with coronary artery disease (CAD), (4) CAD alone, (5) CVD without CAD, (6) hypertension, (7) cerebrovascular diseases, and (8) diabetes on mortality. Relative risk was assessed for dichotomous variables, mean difference for continuous variables. Twenty-six studies were included, encompassing 8497 patients. Males had 16% higher risk of mortality than females (p < 0.05) and elderly patients had higher chance of dying than younger patients (p < 0.0001). Patients with overall CVD have a 1.96-fold higher mortality risk (p < 0.0001). CAD increases risk of mortality by 1.90-fold (p < 0.05). CVD-CAD were found to increase risk up to 2.03-fold (p < 0.05). Hypertension, cerebrovascular disease and diabetes increase the risk of death up to 1.73-fold, 1.76-fold and 1.59-fold, respectively (p < 0.0001, p < 0.0001, p < 0.05, respectively). Sex, age, presence of CAD and/or other types of CVD, hypertension, cerebrovascular diseases and diabetes mellitus increase mortality in patients with COVID-19.

Since around 50 years ago, the academic world is developing knowledge and technology to understand and to control matter at the nanoscale in order to exploit the peculiar mechanical, electrical, optical and magnetic properties emerging when a discrete number of atoms is assembled in structures which must be described according to the weird rules of quantum mechanics. This huge know how, commonly named Nanotechnology, was nucleated according to deployment strategies mainly defined and funded worldwide by governmental institutions in order to create the base for their further industrial exploitation and to provide an expectedly large socioeconomic impact. In the following, we will give a brief overview of the main applications of nanomaterials and an estimate of their value, based on the forecasts provided by some market research companies. In particular, we will briefly disclose the application of nanomaterials in the fields of Electronics & ICT, Energy and Environment, and, in particular, in the highly rewarding field of Nanomedicine. Further, we will highlight some key aspects of the deployment policies undertaken around the world which still are a key prerequisite for a full exploitation of the potential of Nanotechnology.

Objective Our aim was to evaluate a new inflatable lung retractor, the “Spacemaker”, and its efficacy in facilitating minimally invasive cardiothoracic surgery without the need of one lung ventilation or carbon dioxide overpressure insufflation. Methods The device was tested in 12 anesthetized pigs (90–100 kg) placed on standard endotracheal ventilation. The device was introduced into the right or left side of the chest, depending on the intended procedure to be performed, via a 3-cm incision in the fifth intercostal space. A total of seven animals were used to evaluate hemodynamic and respiratory response to the device, whereas another five animals were used to assess the feasibility of a variety of minimally invasive cardiothoracic surgical procedures. Results Introduction was easy and unhindered. The device was inflated up to 0.6 bar, thereby pushing the lung tissue gently away cranially, posteriorly, and caudally without interfering with pulmonary function or resulting in respiratory compromise. In addition, hemodynamics remained stable throughout the experiments. Different closed-chest surgical procedures such as left atrial appendage exclusion, pulmonary vein exposure, pacemaker lead placement, and endoscopic stabilization for coronary surgery, were successfully performed. Removal was quick and complete in all cases, and lung tissue showed no remnant atelectasis. Conclusions The “Spacemaker” may represent a reliable alternative to current conventional techniques to facilitate minimally invasive cardiothoracic surgery. Further research is warranted to confirm the effectiveness and the safety of this device and to optimize the model before its use in humans and its introduction into clinical practice.

We explore the association between short- and long- term adverse outcomes following coronary artery bypass grafting (CABG) and the degree of preoperative renal dysfunction classified on glomerular fraction estimated with Chronic Kidney Disease-Epidemiology Collaboration equation (eGFROne-thousand-one-hundred-eighty-six consecutive patients undergoing CABG between 2005 and 2014 were categorized in 4 groups according to the eGFReGFRIn our experience, the use of the eGFR

OBJECTIVES: We compare a short and a standard-size balloon with same filling volumes to verify the differences in terms of visceral flow, coronary circulation and haemodynamic performance during aortic counterpulsation in an animal model of myocardial ischaemia-reperfusion injury. METHODS: Eighteen healthy pigs underwent 120-min ligation of the left anterior descending coronary artery followed by 6 h of reperfusion, and they were randomly assigned to have intra-aortic balloon counterpulsation (IABP) with a 40-ml short-balloon (n = 6) or a 40-ml standard-length balloon (n = 6), or to undergo no IABP implantation (controls, n = 6). Haemodynamics and visceral and coronary flows were measured at baseline (t(0)), at 2 h of ischaemia (t(1)) and every hour thereafter until 6 h of reperfusion (from t(R1) to t(R6)), respectively. RESULTS: Mesenteric flows increased significantly at tR1 only in the short-balloon group (P 0.05). CONCLUSIONS: The short balloon prevents visceral ischaemia and, compared with the standard-size balloon, it does not lose IABP beneficial cardiac and coronary-related effects. Further studies are warranted to confirm our findings.

Background. Changes in hemodynamics, coronary circulation, visceral flow, and biochemical marker rate reduction or volume deflation for intraaortic balloon pump discontinuation were assessed. Methods. Twelve healthy pigs were randomly assigned to two groups, the rate-based (RB, n = 6) and volume-based weaning groups (VB, n = 6). Hemodynamics and visceral and coronary flows were measured at baseline after 2 hours of intraaortic balloon pump 1:1, during the first 5 hours of weaning (frequency rate reduced to 1:2 in the RB group and volume decreased by 10%/h in the VB group), after 1 hour of frequency rate 1:3 in the RB group or a volume decrease by 75% in the VB group, 2 hours after withdrawal, and 4 hours after withdrawal. Results. The animals weaned by progressive VB deflation showed a greater degree of vasodilation, better cardiac output and stroke volume, fewer negative values of cardiac cycle efficiency, and higher dP/dT(max) compared with those weaned by RB reduction (p < 0.05 for all). The VB group also exhibited increased coronary flow, lower oxygen consumption of the myocardium, and coronary resistance during VB weaning (p < 0.05 for all). The serum lactate level was lower in the VB group at each experimental point (p < 0.05 for all), but visceral flows were scarcely affected by the weaning method. Conclusions. Volume reduction was the most effective weaning method considering that frequency reduction weaning was responsible for significant negative effects on hemodynamics and coronary circulation. (C) 2016 by The Society of Thoracic Surgeons

Aims To assess the results and impact of lesion set and surgical technique on long-term success of surgical ablation during mitral surgery. Methods and results The patient population consisted of 685 subjects with persistent and long-standing persistent atrial fibrillation (AF) undergoing cardiac surgery for mitral valve disease as the primary indication and concomitant ablation between January 2003 and January 2012 at three institutions. One hundred and sixty-six underwent unipolar (24.2%), 371 (54.2%) bipolar, and 148 (21.6%) had combined ablation. Median follow-up was 58.4 months (interquartile range 43.3–67.9). To appropriately account for death, a competing risk model was employed to identify predictors of cumulative incidence of recurrent AF among lesion set and surgical techniques. Eight-year freedom from recurrent arrhythmia without antiarrhythmic drugs was 0.60 ± 0.02. Success rate was higher using bipolar radiofrequency (RF) ( P < 0.001), after performing mitral isthmus line ( P = 0.003) and following the biatrial technique ( P < 0.001). Competing risk regression revealed that use of unipolar RF [sub-hazard ratio (SHR) 2.41 (1.52–3.43), P < 0.001], combined unipolar/bipolar ablation [SHR 1.93 (0.89–2.57), P = 0.003] and the absence of right atrial ablation [SHR 2.79 (1.27–3.48), P < 0.001] were predictors of cumulative incidence of long-term recurrence. Conclusions Our experience suggests that the use of bipolar clamp improves long-term results in surgical treatment of AF and that right-sided ablation should be routinely added. Randomized studies are necessary to confirm our findings.

Background and purpose Oropharyngeal mycosis (OPM) is a complication of radiotherapy (RT) treatments for head and neck (H&N) cancer, worsening mucositis and dysphagia, causing treatment interruptions and increasing overall treatment time. Prophylaxis with antifungals is expensive. Better patient selection through the analysis of prognostic factors should improve treatment efficacy and reduce costs. Materials and methods A multicentre, prospective, controlled longitudinal study, with ethics committee approval, examined H&N cancer patients who were candidates for curative treatments with radio-chemotherapy. Patients were divided in groups according to OPM appearance: before the starting of RT (cases), during RT (new cases) and never (no cases). Results Of 410 evaluable patients, 20 were existing cases, 201 new cases and 189 did not report OPM. In our study OPM appears in 42.4% of people >70years and in 58.2% of younger individuals ( p =0.0042), and in 68.6% of women versus 50.8% of men ( p =0.0069). Mucositis and dysphagia were higher and salivation reduced among people with OPM ( p p =0.0002) and longer (>12days) treatment interruptions ( p =0.0288). Conclusions Patients with OPM had higher toxicity and a greater number of long treatment interruptions. Analyses of prognostic factors can help clinicians understand OPM distribution and select patients with the highest probability of OPM for antifungal prophylaxis.

Background The study was aimed to determine the measurement accuracy of The CDI™ blood parameter monitoring system 500 (Terumo Cardiovascular Systems Corporation, Ann Arbor MI) in the real-time continuous measurement of arterial blood gases under different cardiocirculatory stress conditions Methods Inotropic stimulation (Dobutamine 2.5 and 5 μg/kg/min), vasoconstriction (Arginine-vasopressin 4, 8 and 16 IU/h), hemorrhage (-10%, -20%, -35%, and -50% of the theoretical volemia), and volume resuscitation were induced in ten swine (57.4 ± 10.7 Kg).Intermittent blood gas assessments were carried out using a routine gas analyzer at any experimental phase and compared with values obtained at the same time settings during continuous monitoring with CDI™ 500 system. The Bland-Altman analysis was employed. Results Bias and precision for pO2 were - 0.06 kPa and 0.22 kPa, respectively (r2 = 0.96); pCO2 - 0.02 kPa and 0.15 kPa, respectively; pH -0.001 and 0.01 units, respectively ( r2 = 0.96). The analysis showed very good agreement for SO2 (bias 0.04,precision 0.33, r2 = 0.95), Base excess (bias 0.04,precision 0.28, r2 = 0.98), HCO3 (bias 0.05,precision 0.62, r2 = 0.92),hemoglobin (bias 0.02,precision 0.23, r2 = 0.96) and K+ (bias 0.02, precision 0.27, r2 = 0.93). The sensor was reliable throughout the experiment during hemodynamic variations. Conclusions Continuous blood gas analysis with the CDI™ 500 system was reliable and it might represent a new useful tool to accurately and timely monitor gas exchange in critically ill patients. Nonetheless, our findings need to be confirmed by larger studies to prove its reliability in the clinical setting.

Cr-doped CaTiSiO5 were synthesized by spray drying of an aqueous solution of precursor salts plus further calcining the resulting powders. The samples were prepared by conventional ceramic method as well for comparison study as ceramic pigments. The evolution of the present crystalline phases with applied thermal treatments has been studied by X-Ray Powder Diffraction (XRPD) and thermal analysis (DTA/TG). The powder morphology and particle size distribution were analyzed by scanning electron microscopy (SEM) and laser diffraction. The color efficiency of pigments was evaluated by colorimetric analysis (CIE Lab system). Results showed clearly efficiency of the spray dried procedure compared with the solid state reaction process. The produced powders consisted spherical particles with brad size distribution (3µm), developing typical brown color. UV-VIS-NIR spectroscopy reveals the existence of Cr(III) as a majority phase occupies basically octahedral sites substituting Ti(IV), which must be responsible for the brown color of this pigment. Furthermore, Cr(IV) ions were found in octahedral coordination substituting Ti(IV) and small amount of tetravalent chromium substitutes for tetrahedral Si(IV).

In the present work, the effects of TV and PC cathodic tube and screen glasses additions (5 and 10 wt.%) to a porcelain stoneware body, in replacement of feldspar, were evaluated simulating the tilemaking process. The presence of glass allows to preserve good technological and mechanical properties, complying with the latest requirements of the industrial practice. The sintering pattern of the glass-added bodies, evaluated by hot stage microscopy, is modified according to the different glass amount and typology; in particular, cathodic tube glass when present at 5 wt.% brings about a lowering of the maximum densification temperature and of the activation energy.

Rutile is widely used as ceramic pigment for its excellent optical properties, high melting point and intense coloration when doped with transition elements. Industrial ceramic pigments are manufactured from anatase plus chromophore elements (Cr, Mn, Ni or V) and counterions (Nb, Sb or W). Several solid state reactions occur during the synthesis, involving both the anatase-to-rutile transformation (A->R) and the formation of accessory phases. The A->R transition is heavily affected by chromophores with a lowering of the onset temperature: V < Cr < Ni < Mn; the effect of counterions is almost completely hidden by that of chromophores, even if the sequence Mo < Sb < W < Nb may be inferred. The crystal structure of rutile pigments is modified by chromophores and counterions doping; in fact, the doping varies the cell parameters, implies a progressive distortion of the octahedral site and a peculiar variation of the mean Ti-O bond length, with longer basal Ti-O distances and a shorter apical Ti-O distance. The pigment co-doped with V and W is different for its minimum Ti-O bond length distortion (BLD), an almost regular TiO6 octahedron, and the occurrence of Ti3+ within the accessory compound Ti5O9.

In the latest years, several mechanical and tribological data have been published about ceramic tiles, including 3-point and 4-point modulus of rupture, fracture toughness, elastic moduli, Poisson coefficient, critical defect size, Weibull modulus, impact strength, creep, microhardness, and wear rates. Literature and unpublished data of both porous (e.g. monoporosa) and vitrified (i.e. porcelain stoneware) ceramic tiles are shortly reviewed, together with the available phase composition and microstructural characteristics. The applicability of general mechanical and tribological models to design ceramic tiles with enhanced strength and wear performances is appraised and the major technological problems are outlined and discussed.

Purpose Data on epicardial contact force efficacy in dual epicardial–endocardial atrial fibrillation ablation procedures are lacking. We present an in vitro study on the importance of epicardial and endocardial contact forces during this procedure. Methods The in vitro setup consists of two separate chambers, mimicking the endocardial and epicardial sides of the heart. A circuit, including a pump and a heat exchanger, circulates porcine blood through the endocardial chamber. A septum, with a cut out, allows the placement of a magnetically fixed tissue holder, securing porcine atrial tissue, in the middle of both chambers. Two trocars provide access to the epicardium and endocardium. Force transducers mounted on both catheter holders allow real-time contact force monitoring, while a railing system allows controlled contact force adjustment. We histologically assessed different combinations of epi-endocardial radiofrequency ablation contact forces using porcine atria, evaluating the ablation’s diameters, area, and volume. Results An epicardial ablation with forces of 100 or 300 g, followed by an endocardial ablation with a force of 20 g did not achieve transmurality. Increasing endocardial forces to 30 and 40 g combined with an epicardial force ranging from 100 to 300 and 500 g led to transmurality with significant increases in lesion’s diameters, area, and volumes. Conclusions Increased endocardial contact forces led to larger ablation lesions regardless of standard epicardial pressure forces. In order to gain transmurality in a model of a combined epicardial–endocardial procedure, a minimal endocardial force of 30 g combined with an epicardial force of 100 g is necessary.