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Background: A minimally invasive approach (MIA) reduces mortality and morbidity in patients referred for aortic valve replacement (AVR). Sutureless technology facilitates a MIA. We describe our experience with the sutureless Perceval (LivaNova, Italy) aortic bioprosthesis through a right anterior mini-thoracotomy (RAMT) approach. Methods: Between March 2011 and October 2019, 1,049 patients underwent AVR with Perceval bioprosthesis. Five hundred and three patients (48%) were operated through a RAMT approach in the second intercostal space. Considering only isolated AVR (881), 98% of patients were operated with MIA, and Perceval in RAMT approach was performed in 57% of these patients. Eight patients (1.6%) had previously undergone cardiac surgery. The prosthesis sizes implanted were: S (n=91), M (n=154), L (n=218) and XL (n=40). Concomitant procedures were mitral valve surgery (n=6), tricuspid valve repair (n=1), mitral valve repair and tricuspid valve repair (n=1) and miectomy (n=2). Mean age was 78±4 years (range, 65–89 years), 317 patients were female (63%) and EuroSCORE II was 5.9%±8.4%. Results: The 30-day mortality was 0.8% (4/503). Cardiopulmonary bypass (CPB) and aortic cross-clamp times were 81.6±30.8 and 50.3±24.5 minutes respectively for stand-alone procedures. In two patients, early moderate paravalvular leakage appeared as a result of incomplete expansion of the sutureless valve due to oversizing of the bioprosthesis, requiring reoperations at two and nine postoperative days with sutured aortic bioprosthesis implantation. Permanent pacemaker implantation within the first thirty days was necessary in 26 (5.2%) patients. At the mean follow-up of 4.6 years (range, 1 month to 8.6 years), survival was 96%, freedom from reoperation was 99.2%, and mean transvalvular pressure gradient was 11.9±4.3 mmHg. Conclusions: AVR with the Perceval bioprosthesis in a RAMT approach is a safe and feasible procedure associated with low mortality and excellent hemodynamic performance. Sutureless technology facilitates a RAMT approach.

Aims To present the results of a novel technique of aortic valve decalcification (AVD) in a consecutive population of elderly patients with severe aortic valve stenosis (AVS) and small aortic annulus. Methods Between January 2008 and December 2012, a consecutive series of 34 patients (mean age 80 ± 13 years) with severe AVS were operated on using AVD. They were compared with a matched population of 68 patients (mean age 82 ± 7 years) submitted to aortic valve replacement (AVR) with bioprosthesis. The two groups were comparable for cardiac risk factors and admission symptoms. Preoperatively, all patients presented with severe AVS, small aortic annulus (19 mm) and preserved left ventricular function. Results Thirty-day mortality was 8.8 vs. 7.5% in the AVD and AVR groups, respectively (P = 0.88). Actuarial 2 and 5-year survival rates were 80 vs. 82% and 64 vs. 78% in the AVD and AVR groups, respectively (P = 0.27). Long-term valve-related events incidence was significantly higher in the AVD group (12%) compared with that in the AVR group (4%; P = 0.01). However, in the AVD group, patients with no or mild residual AR experienced 2 and 5 years of freedom from valve-related events, which is not significantly different from the patients submitted to the AVR group (P = 0.76). After AVD, a significant increase in the aortic valve area (from 0.8 to 1.9 cm) and a parallel reduction in the mean gradient (from 40 to 12 mmHg) was observed in all patients (P = 0.01). Postoperative aortic valve area (1.9 vs. 1.26 cm), as well as mean gradient (12 vs. 21 mmHg), were significantly better in the AVD group compared with that in the AVR group (P = 0.01). Conclusion In this preliminary experience, AVD seems a good therapeutic option for elderly patients with severe AVS. Further studies with longer follow-up are needed in order to confirm these preliminary results and to ascertain the valve durability over time.

OBJECTIVES: Few studies have examined the use of stentless Freestyle bioprostheses in patients with active valve endocarditis (VE). The aim of this study was to evaluate outcomes of stentless Freestyle bioprostheses in patients undergoing full-root replacement. METHODS: From February 2000 to June 2010, 180 patients with VE underwent cardiac surgery at our institution, of which 71 (39.5%) had prosthetic VE. Eighteen patients underwent full-root replacement with Freestyle bioprostheses: 3 patients (16%) had native aortic VE, 14 (78%) had aortic prosthetic VE and 1 (6%) had mitral and aortic prosthetic VE. Mean age was 66.7±10.1, M/F: 6/12, mean logistic EuroSCORE 36.4±21.6. Eight patients (42%) underwent concomitant procedures (two mitral valve replacements, three ascending aorta replacements, one coronary artery bypass grafting (CABG), one ventricular septal disease (VSD) repair, one CABG+ascending aorta+VSD repair). RESULTS: Two patients (11%) died in-hospital. At the median follow-up of 24 months (range 1–113 months), no death occurred and freedom from reoperation was 87.5% (2 patients for aortic root pseudo-aneurysm at 1 and 23 months). All patients are in NYHA functional class I and have satisfactory echocardiographic data (EF 54.3±8%, peak and mean trans-prosthetic gradients 12±6.7 mmHg and 7.5±3.6 mmHg) with 100% freedom recurrence of VE. CONCLUSIONS: Our experience shows that root replacement with Freestyle stentless bioprostheses in patient with VE, is associated with low rates of early and mid-term mortality, good haemodynamic performance and low rates of valve-related morbidity as well as low recurrence of infection.

Pulmonary hypertension (PH) is a well-known independent risk factor for mortality and morbidity after cardiac surgery. However, no weight is given to PH in the current guidelines for the management of patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). The aim of our study was to evaluate the impact of preoperative PH on early and five-year survival in patients with severe AS undergoing isolated AVR.From January 2005 to July 2010, 422 consecutive patients with severe AS underwent isolated AVR. According to systolic pulmonary artery pressure (sPAP), PH was classified as none (sPAPS35 mmHg, N=224), mild-moderate (35≤sPAP50 mmHg, N=159) and severe (sPAP≥50 mmHg, N=39).Overall in-hospital mortality was 2.8%. Unadjusted mortality was 0.9%, 3.8% and 10.2% for patients with normal, mild-moderate and severe PH (p=0.003). In multivariable analysis, severe PH (OR 4.1, 95 CI 1.1-15.3, p=0.04) and New York Heart Association class III-IV (OR 14.9, 95% CI 1.8-117.8, p=0.01) were independent risk factors of in-hospital mortality. Multivariable predictors of five-year survival were extracardiac arteriopathy (HR 2.8, 95%CI 1.6-4.9, p0.0001), severe PH (HR 2.4, 95%CI 1.2-4.6 p=0.01), NHYA III-IV class (HR 2.3, 95% CI 1.3-4, p=0.003), preoperative serum creatinine (HR 2.2, 95%CI, 1.6-3.1,p0.0001) and age (HR 1.08, 95%CI 1.03-1.13, p=0.01). Five-year survival was 86%±3% with normal sPAP, 81%±4% with mild-moderate PH and 63±10% with severe PH (p0.001).In patients undergoing isolated AVR with severe AS, severe PH is an independent predictor of in-hospital mortality and five-year survival.

In logistics and industrial production managers must deal with the impact of stochastic events to improve performances and reduce costs. In fact, production and logistics systems are generally designed considering some parameters as deterministically distributed. While this assumption is mostly used for preliminary prototyping, it is sometimes also retained during the final design stage, and especially for estimated parameters (i.e. Market Request). The proposed methodology can determine the impact of stochastic events in the system by evaluating the chaotic threshold level. Such an approach, based on the application of a new and innovative methodology, can be implemented to find the condition under which chaos makes the system become uncontrollable. Starting from problem identification and risk assessment, several classification techniques are used to carry out an effect analysis and contingency plan estimation. In this paper the authors illustrate the methodology with respect to a real industrial case: a production problem related to the logistics of distributed chemical processing.