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In patients with significant valvular heart disease (VHD) undergoing non-cardiac surgery (NCS), perioperative adverse cardiac events are a relevant issue. Although postoperative outcomes can be adversely affected by valve-related haemodynamic instability, recommended perioperative risk scores prioritise the risk of the surgical procedure and the presence of cardiovascular risk factors, neglecting the presence or extent of VHD. Perioperative management and anaesthetic approach should focus on the underlying type and severity of VHD, the compensatory mechanisms deployed by left ventricle and right ventricle and the type and risk of NCS. Due to the lack of randomised trials investigating different therapeutic approaches of valvular intervention prior to NCS, recommendations mainly rely on consensus opinion and inference based on large observational registries. As a general rule, valvular intervention is recommended prior to NCS in symptomatic patients or in those who meet standard criteria for cardiac intervention. In the absence of such conditions, it is reasonable to perform NCS with tailored anaesthetic management and close invasive perioperative haemodynamic monitoring. However, patient-specific management strategies should be discussed with the heart team preoperatively. Symptomatic patients with severe VHD or those undergoing high-risk NCS should ideally be treated at a high-volume medical centre that is equipped to manage haemodynamically complex patients during the perioperative period.

Transcatheter aortic valve implantation (TAVI) is emerging a an appealing management strategy for patients with severe aortic stenosis at intermediate, high or exceedingly high risk, but its risk-benefit profile in younger patients is less certain. We aimed at exploring the outlook of patients aged 70 years or less and undergoing TAVI at 2 high-volume Italian institituions.We retrospectively collected baseline, imaging, procedural and outcome features of patients with age ≤70 years in whom TAVI was attempted at participating centers between 2012 and 2021. Non-parametric tests and bootstrap resampling were used for inferential purposes.A total of 39 patients were included, out of3,000 screened with heart team involvement and1,500 receiving TAVI. Most common or relevant indications for TAVI were reduced life expectancy (eg cardiogenic shock or severe left ventricular systolic dysfunction), chronic obstructive pulmonary disease, morbid obesity, active or recent extra-cardiac cancer, porcelain aorta, neurologic disability, cirrhosis, or prior surgical aortic valve replacement, as well as extreme cachexia, and Hutchinson-Gilford progeria. At least two contemporary high-risk features were present in most cases. Transapical access was used in 5 (12.8%) cases, and a sheathless approach in 15 (38.5%). A variety of devices were used, including both balloon- and selfexpandable devices. Clinical outcomes were satisfactory, despite the high risk profile, at both shortand mid-term, with no in-hospital death, and 5.1% (95% confidence interval 0-12.8%) mortality at a median follow-up of 15 months (minimum 1; maximum 85). Notably, no case of significant valve deterioration requiring reintervention occurred.In carefully selected patients with 70 years or less of age and prohibitive risk for surgery or reduced life expectancy, TAVI represents a safe option with a favorable mid-term survival and low rate of adverse events.

Transcatheter aortic valve implantation (TAVI) has proved beneficial in patients with severe aortic stenosis, especially when second-generation devices are used. We aimed at reporting our experience with Navitor, a third-generation device characterized by intrannular, large cell, and cuffed design, as well as high deliverability and minimization of paravalvular leak. Between June and December 2021, a total of 39 patients underwent TAVI with Navitor, representing 20% of all TAVI cases. Mean age was 80.0 ± 6.7 years, and 14 (36.8%) women were included. Severe aortic stenosis was the most common indication to TAVI (37 [97.4%] cases), whereas 2 (5.3%) individuals were at low surgical risk. Device and procedural success was obtained in all patients, with a total hospital stay of 6.6 ± 4.5 days. One (2.9%) patient required permanent pacemaker implantation, but no other hospital events occurred. At 1-month follow-up, a cardiac death was adjudicated in an 87-year-old man who had been at high surgical risk. Echocardiographic follow-up showed no case of moderate or severe aortic regurgitation, with mild regurgitation in 18 (47%), and none or trace regurgitation in 20 (53%). The Navitor device, thanks to its unique features, is a very promising technology suitable to further expand indications and risk-benefit profile of TAVI.

Although in heart failure (HF) there is a strict correlation between heart and kidney, no data are available on the potential relationship in HF between renal dysfunction (RD) and the impaired sympathetic innervation. Aim of the present study was to assess the relationship between RD and cardiac sympathetic innervation in HF patients with reduced ejection fraction. Two hundred and sixty-three patients with mild-to-severe HF underwent iodine-123 meta-iodobenzylguanidine myocardial scintigraphy to assess sympathetic innervation, evaluating early and late heart-to-mediastinum (H/M) ratios and washout rate. In all patients, glomerular filtration rate (eGFR) by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula was assessed. A direct association was found between EPI-eGFR and late H/M (r = .215; P

Aims Sodium–glucose co-transporter-2 inhibitors (SGLT2i) reduce cardiovascular (CV) events in diabetic patients, with a consistent effect on heart failure (HF) related outcomes. However, the effects on ischaemic CV events appear less certain, in particular in patients with history of HF. The aim of this meta-analysis is to investigate CV benefit of SGLT2i and to assess the effects in patients with and without established atherosclerotic cardiovascular disease (ASCVD), with and without HF, and with estimated glomerular filtration rate < or ≥ 60 mL/min. Methods We searched PubMed, Embase, Cochrane, ISI Web of Science, SCOPUS, and clinicaltrial.gov databases. We performed a systematic review and meta-analysis of randomized, placebo-controlled, cardiovascular outcome trials (CVOT) of SGLT2i in diabetic patients, assessing the effects of SGLT2i on 3-point MACE [CV death, non-fatal myocardial infarction (MI), non-fatal stroke] and composite of HF hospitalization or CV death. Results Of 205 articles, 7 CVOTs were included in the meta-analysis. Compared to placebo, SGLT2i significantly reduced by 10% the risk of 3-point MACE (HR 0.90; P = 0.025) (Figure panel A) and the risk of CV death or HF hospitalization by 24% (HR 0.76; P Conclusions SGLT2i significantly reduce CV outcome in diabetic patients. SGLT2i remarkably and consistently reduce HF hospitalization, in patients with and without HF at baseline and independently on the presence of ASCVD.

Background: Sodium-glucose co-transporter-2 inhibitors (SGLT2i) reduce cardiovascular (CV) events in diabetic patients, with a consistent effect on heart failure (HF) related outcomes. However, the effects on ischemic CV events appear less certain, in particular in patients with history of HF. The aim of this meta-analysis is to investigate CV benefits of SGLT2i and to assess the effects in patients with and without established atherosclerotic cardiovascular disease (ASCVD), with and without HF, and with estimated glomerular filtration rate (eGFR) < or ³60 ml/min.Methods: We searched PubMed, Embase, Cochrane, ISI Web of Science, SCOPUS, and clinicaltrial.gov databases. We performed a systematic review and meta-analysis of randomised, placebo-controlled, cardiovascular outcome trials (CVOT) of SGLT2i in diabetic patients, assessing the effects of SGLT2i on 3-point major adverse cardiac events (MACE) (CV death, non fatal myocardial infarction (MI), non fatal stroke) and composite of HF hospitalization or CV death.Of 205 articles, 7 CVOTs were included in the meta-analysis. Results: Compared to placebo, SGLT2i significantly reduced by 10% the risk of 3-point MACE (HR 0.90; p=0.025) and the risk of CV death or HF hospitalization by 24% (Hazard Ratio (HR) 0.76; pConclusions: SGLT2i significantly reduce CV outcome in diabetic patients. SGLT2i remarkably and consistently reduce HF hospitalization, in patients with and without HF at baseline and independently on the presence of ASCVD.

The model used to explain the pathophysiologic substrate and progressive worsening in chronic heart failure (CHF) is based on the hyperactivity of renin-angiotensin-aldosterone system and adrenergic pathway. Although the neurohormonal medical approach has many advantages, it has several pitfalls, as demonstrated by high rates of CHF mortality and hospitalization. A growing body of evidence has led to the hypothesis that CHF is a multiple hormone deficiency syndrome, characterized by a reduced anabolic drive that has relevant functional and prognostic implications. The aim of this review is to summarize the evidence of reduced drive of main anabolic axes in CHF.

Aim: To verify a possible correlation between cell lipid composition, expression of key genes in lipid metabolism and fermentative behaviour of Saccharomyces cerevisiae wine strains. Methods and Results: The fermentative abilities of two commercial wine strains of S. cerevisiae were tested under stressful conditions. Cell number, glucose and fructose concentrations, expression of ACS1, ACS2, ACC1, OLE1, ERG9, ERG10, ARE1 and ARE2 and lipid content were evaluated. The strain that failed to complete the fermentation had lower amounts of C16:1 and C16:0 fatty acids at the beginning of fermentation (0 h) and late logarithmic phase (72 h). While the amount of C18:1 in this strain was lower than that in the strain that completed the fermentation at 0 h, same levels were observed for both strains at 72 h. The sterol levels were generally higher in the strain that failed to complete the fermentation. Gene expression generally increased from the beginning of the fermentation to the late logarithmic phase in both strains. Conclusion: A positive correlation between good fermentative ability, elevated fatty acid content and ACC1 gene expression has been identified. Significance and Impact of the Study: The cell lipid content at the time of inoculum and expression of ACC1 gene of starter strains should be carefully considered in order to identify the possible stuck/sluggish fermentations.

The end-stage cardiomyopathy is an increasing worldwide problem. Cardiac transplantation lacks sufficient donors to treat all patients, and there is thus debate about alternative strategies. The use of left ventricular assist devices for long-term support is increasing with a positive impact on patient survival. Although there is an ongoing debate regarding the risks and benefits of maintaining pulsatile flow during long-term ventricular assist device support, there has been a significant move towards implantation of continuous flow devices due to the lower surgical morbidity and better long-term reliability of these pumps. The following is a review of the literature on continuous and pulsatile flow for long-term support. Starting from the definition of flow, we analyze the current evidence and consider gastrointestinal complications.

Accidental deep hypothermia with body temperature28 degrees C induces high mortality rates for neurological and cardiac complications. Although several reports described successful treatment of hypothermic arrest by extracorporeal membrane oxygenation (ECMO), the field of warming in the homeless is almost completely unquestioned although the malnutrition and the co-morbidities are usually believed as relevant risk factors for poor outcome. This article describes the experience of successful warming by ECMO in two homeless victims of unwitnessed cardiac arrest, who survived without neurological or cardiac complications. In conclusion, this is an initial experience and further research is required, although our results are appreciable in this high risk subset of population.

Introduction Coronary artery disease (CAD), along with its main complications such as acute myocardial infarction (AMI) and congestive heart failure (CHF), remains a serious worldwide problem and affects many patients despite the improvement of medical treatment. The possibility of the replacement of the infarcted areas by the re-generation of the myocardial cells has been long discussed and the mobilization of the stem cells from bone marrow (BMCs) to the peripheral blood (PB) induced by cytokines, represents a potential pathway to activate the regenerative process. Patients and Methods We describe BMC mobilization and direct/indirect revascularization in 15 patients operated on for coronary artery bypass grafting (CABG) and/or mitral valve surgery and/or ventricular remodeling combined to multiple trans-myocardial punctures (Sen technique) in ungraftable non-viable fibrotic areas. Results Peak values of circulating BMCs were recorded between day +4 and day +6. We had no in-hospital (0–30 days) mortality. All the patients were discharged from the ICU after a median period of 2 days while the in-hospital length of stay was 10.5+4.2 days (range 7–21) and all patients were discharged in good clinical condition. There were two sudden deaths over the mid-term, at postoperative day (POD) 32 and 45 respectively. Conclusions Our study suggests that the combination of BMC mobilization and CABG may be safely performed. However, considering the small series, final conclusions about the benefit of this procedure must await a larger prospective study comparing the role of cytokines alone, myocardial perforation, and the combination of both.

The scientific literature has pointed out several predictors of negative outcome after surgery such as pain and depression, negatively affecting the postoperative outcome in cardiac surgery. From January 2009 until June 2010, 15 patients scheduled for cardiac surgery were enrolled. The patients were assessed by psychological evaluation either in the hospital stay either in the rehabilitation period with the aim of identifying their emotional condition (sentiments about the onset of the disease, support received from family and friends) even by means of preformed tests for anxiety and depression (tests of Stay and Back). Thus, in our preliminary experience, the psychological evaluation failed to detect the occurrence of postoperative complications. Conversely, the psychological evaluation is very effective in detecting a poor emotional state and the psychological support decreases the degree of anxiety and depression with positive effects on postoperative outcome. In conclusion, a standardize test for anxiety and depression should be used for patients at hospital admission to detect who may benefits by psychological support.

We present the angiograms of a patient aftertransmyocardial laser revascularization (TMR), whichwere performed 10 years before by the application ofholmium laser pulses. Thirteen years before TMRprocedure, the patient underwent coronary artery bypassgraftings complicated by grafts occlusion with no longerpossibility of direct revascularization. Then, refractiveangina required an alternative approach for symptomsrelief as the indirect revascularization by the applicationof the holmium laser pulses. Interestingly, the lateangiograms, taken when the patient suffered from effortdyspnea for ongoing left ventricular dysfunction, showed anetwork of small vessels (absent before TMR procedure)that supplies blood to the heart with no flow through thecoronary arteries because of their complete occlusion.This is a historical presentation of the results of TMR tounderstand the effects of the indirect revascularization onthe blood circulation through the heart over the long-termfollow-up. Coron Artery Dis 00:000–000

Minimally invasive surgery (MIS) for aortic valve replacement (AVR) is going to increase with different techniques described so far. We hereby report the results of AVR through a right minithoracotomy (RM) compared to a median sternotomy (MS).One hundred patients operated for isolated AVR by the same surgeon (chief of the department) were enrolled and allocated to: MS (group A, 50 patients, 26 females, mean age 69.9 ± 12.4 years). RM (group B, 50 patients, 27 females, mean age 71.6 ± 11.2 years). Mean logistic Euroscores were, respectively, 6.5 ± 4.0 and 8.0 ± 5.9 (p=ns).Mean duration of cardiopulmonary by-pass (CPB) was 62.8 ± 18.3 min in group A and 101.4 ± 35.2 min in group B (p0.05); cross-clamp was 44.8 ± 13.4 min in group A and 74.6 ± 26.7 min in group B (p0.05). Thirty-day mortality was 2 (4%) in group A and 0 in group B (p=ns). ICU stay and hospital stay did not significantly differ amongst two groups. The incidence of bleeding was lower in group B, showing a slight reduction of blood transfusions and re-explorations (p=ns).Our experience shows that RM offers a good 30-day survival and a lower incidence of mediastinitis or osteomyelitis. The risk of insufficient vision or sudden complications is safely managed by enlarging the surgical incision through a transverse sternotomy.

Objective Aortic valve replacement (AVR) is nowadays a safe procedure with low rates of mortality and morbidity, but the necessity for a less invasive approach is going to increase. The use of a stentless prosthesis through right mini-thoracotomy has not yet been described and our experience could be useful for other surgeons. Methods From June 2009 until March 2010, seven female patients (mean age 79.9 ± 5.7 years) underwent stentless-AVR for aortic stenosis through a right mini-thoracotomy (RM). The logistic Euroscore was 11.3 ± 6.1, and left ventricular ejection fraction was 60.7 ± 4.5%. In five cases RM was performed through the second intercostal space (ICS); in two cases through the third ICS. The cannulation was in most cases between ascending aorta and femoral vein (5/7). When transverse sternotomy was required (two patients), the right mammary artery was clipped and cut. Results Extracorporeal circulation time (ECC) was 110 ± 41 min and aortic cross clamp was 80 ± 35 min. Two patients required transverse sternotomy. The mean bleeding was 484 ± 469 ml and the duration of mechanical ventilation was 22.0 ± 12.5 h. The ICU stay was 3.3 ± 2.2 days. No in-hospital death was observed. The mean hospital stay was 11.6 ± 5.4 days. Conclusion Right mini-thoracotomy is a safe and applicable approach even in case of AVR using stentless prosthesis. The risk of insufficient surgical exposure or complication may be safely managed, by enlarging the thoracotomy through transverse sternotomy. However, valve implantation could be more difficult than the standard approach and it requires an expert and confident surgeon with a large experience in standard stentless implantation.

The photochemical reaction of bibenzyl 1, its 4,4′-dimethoxy derivative 2 and bicumyl 3 with some aromatic nitriles (leading to alkylation of the nitrile) and tetranitromethane (TNM)(leading to ring trinitromethylation or nitration) involve SET fragmentation of the radical cation (either C–H or C–C bond) and, in the case of TNM, also of the radical anion.

Dear Editor,We read with great interest the paper of Maraj et al. [1] dis-cussing about the history of the primary cardiac tumors: we agreewith the Authors that the aim of the clinicians must be precociousdiagnosis even if clinical presentation would be heterogeneous.Moreover, primary cardiac tumors are very rare and in many casespatients may be asymptomatic so that incidental diagnosis is quitecommon.We present the case of a 28-year-old male referred for dyspneaand palpitations that appeared about two months before. Clinicalmanagement by general practitioners was not clear and he un-derwent cardiac assessment only two months later. The trans-thoracic echocardiography revealed the presence of a large cardiacprimitive mass. The magnetic resonance imaging (MRI) studyshowed an 8×6.5×7 cm tumor arising from the free wall of theright atrium, involving the proximal and the medium tract of apatent right coronary artery (Fig. 1A–B). Tricuspid annulus, rightventricle and superior vena cava were compressed (Fig. 1A–B).Ascending aorta was very close to the lesion (Fig. 2A–B) and MRIshowed a 15 mm metastasis in the left lung (Fig. 2A–B). Intravenousadministration of gadolinium enhanced multiple necrosis areassuggestive for a primary cardiac sarcoma. Considering the unfavour-able location and the presence of metastasis, surgical excision wasnot considered and chemotherapy (using bleomicin) was adminis-tered such as palliative therapy. Recurrent pericardial serum-haematic effusion required multiple pericardiocentesis and blood

Abstract 318 Introduction Coronary artery disease (CAD), along with its main complications, acute myocardial infarction (AMI) and congestive heart failure (CHF), remains a serious worldwide problem. Despite advances in medical and surgical treatments, CAD is still associated with a high mortality rate and markedly affects the quality of life of patients. The possibility to replace the scarring by inducing neoangiogenesis and possibly regeneration of injured myocardium is an attractive option to improve the prognosis of CAD patients. For this purpose, cytokine-induced mobilization of bone marrow stem cells (BMCs) into the peripheral blood might represents a potential pathway to activate the regenerative process. Some observations suggest that circulating BMCs may lodge in non-hematopoietic tissues such as muscle, liver and myocardium where the tissue injury or the local inflammation may promote stem cells migration. Thus, the association between cytokine induced BMCs migration and tissue injury, may induce tissue repair since the stem cells are usually attracted from the inflamed tissues. A phase II prospective study was performed combining BMCs migration, obtained by cytokines, and cardiac inflammation, induced by myocardial punctures. Results at early and long-term follow-up are here reported. Patients and methods BMCs mobilization was performed in 15 patients undergoing surgery for coronary artery bypass grafting (CABG) and/or mitral valve surgery and/or ventricular remodeling combined to multiple trans-myocardial punctures (Sen technique) in ungraftable non-viable fibrotic areas. BMC mobilization was induced by granulocyte colony stimulating factor (G-CSF) (Lenogastrim) given at 5 μgr/kg s.c. b.i.d. for 5 to 6 consecutive days, starting on day-3 before surgery along with granulocyte-macrophage colony stimulating factor (GM-CSF) (Molgramostim) at 2.5 μgr/kg s.c./day. Patients entered the study protocol on the basis of the following inclusion criteria: i. severe heart failure with left ventricular ejection fraction (EF) < 35%; ii. ineligibility to cardiac transplantation; iii. widespread myocardial ischemia with at least one area of akinetic and nonviable myocardium, detected by cardiac stress scintigraphy with Thallium; iv. presence of other combined surgical indications, including the requirement of surgery for CABG on areas other than nonviable scars; v. one or more previous myocardial infarction. The study protocol was approved by our local Institutional Review Board and Ethics Committee and all patients signed the informed written consent. Results Cytokine administration induced a variable increase in circulating CD34+ve cells in all patients, with peak values recorded between day +4 and day +6. There were no in hospital (0–30 days) deaths. All 15 patients were discharged from the ICU after a median of 2 days, while the overall in hospital stay was 10.5+4.2 days (range 7–21) and all patients were discharged in good clinical condition. There were two sudden deaths over the mid-term, at postoperative day +32 and +45: both patients had troublesome ECC weaning without other postoperative complications. Presently, at a median follow-up of 48 mos, four patients died, 11 patients are alive, one of them after heart transplantation. Among the 10 non-transplanted long-term survivors, there was a significant improvement of the NYHA class from 2,1±0,8 to 1,3±0,5 (p Disclosures: Off Label Use: G-CSF + GM-CSF in CAD.

The photochemical reaction of bibenzyl 1, its 4,4′-dimethoxy derivative 2 and bicumyl 3 with some aromatic nitriles (leading to alkylation of the nitrile) and tetranitromethane (TNM)(leading to ring trinitromethylation or nitration) involve SET fragmentation of the radical cation (either C–H or C–C bond) and, in the case of TNM, also of the radical anion.