TAVI-in-homograft (TiH): open transcatheter aortic valve replacement in calcified aortic homograft case reports

Background Redo surgery in patient who underwent aortic valve replacement with an aortic homograft can result technically challenging because of the massive calcification of the conduit. Case presentation We present a case of a patient who underwent open surgery on cardiopulmonary bypass assistance to implant a standard transcatheter aortic bioprosthesis through aortotomy in an off-label procedure and we discuss its safety and feasibility. Conclusions The combination of open cardiac surgery and open trans-aortic implant of a transcatheter prosthesis may reduce the surgical risk shrinking the technical difficulties that the implantation of a standard surgical prosthesis would have given

Patch and glue repair for extensive left ventricular laceration

Laceration of the left ventricular wall is a rare but potentially life-threatening complication of electrophysiological studies. We describe emergency surgery on a 64-year-old man who suffered cardiac tamponade after an electrophysiological study, which revealed an extensive laceration in the inferior left ventricular wall, requiring repair by a patch and glue technique, with a good clinical outcome

Reply to Chen et al. Improvements in Outcomes and Expanding Indications for the Commando Procedure. Comment on "Giambuzzi et al. Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results. J. Clin. Med. 2021, 10, 3163"

: We would like to thank Lin Chen et al. [...]

Mitral valve repair with artificial chords: Tips and tricks

Mitral valve regurgitation (MR) is a common valvular disorder occurring in up to 10% of the general population. Mitral valve reconstructive strategies may address any of the components, annulus, leaflets, and chords, involved in the valvular competence. The classical repair technique involves the resection of the prolapsing tissue. Chordal replacement was introduced already in the '60, but in the mid '80, some surgeons started to use expanded polytetrafluoroethylene (ePTFE) Gore-Tex sutures. In the last years, artificial chords have been used also using transcatheter approach such as NeoChord DS 1000 (Neochord) and Harpoon TSD-5. The first step is to achieve a good exposure of the papillary muscles that before approaching the implant of the artificial chords. Then, the chords are attached to the papillary muscle, with or without the use of supportive pledgets. The techniques to correctly implant artificial chords are many and might vary considerably from one center to another, but they can be summarized into three big families of suturing techniques: single, running or loop. Regardless of how to anchor to the mitral leaflet, the real challenge that many surgeons have taken on, giving rise to some very creative solutions, has been to establish an adequate length of the chords. It can be established based on anatomically healthy chords, but it is important to bear in mind that surgeons work on the mitral valve when the heart is arrested in diastole, so this length could fail to replicate the required length in the full, beating heart. Hence, some surgeons suggested techniques to overcome this problem. Herein, we aimed to describe the current use of artificial chords in real-world surgery, summarizing all the tips and tricks

Preliminary Results of Debranch-First Technique in Frozen Elephant Trunk Procedures

Background: To evaluate the outcomes of frozen elephant trunk (FET) procedures performed with a customized graft that allows debranch-first technique with continuous antegrade cerebral perfusion and early distal aortic and myocardial reperfusion. Methods: Between 2016 and 2018 34 patients (30 men; median age, 59.7 years) were enrolled in an ambispective single-center study called FET Optimization (clinicaltrials.gov: NCT03600077). The patients underwent FET procedure using a novel modified E-Vita graft (JOTEC GmbH, Hechingen, Germany) plus graft with 2 dedicated reperfusion branches with debranch-first technique. Mortality and morbidity were primary endpoints. Secondary endpoints were overall duration of cardiopulmonary bypass, debranching, limb ischemia, cardiac ischemia, cerebral perfusion, and amount of aortic coverage. Results: No deaths at 30 days were recorded, and the major adverse event (grade ≥ 2) rate was 33% (11 patients) including 1 (3%) nondisabling stroke and 1 (2.9%) permanent spinal cord ischemic event. Proximal FET collar anastomosis were in zone 0 (68%) or zone 1 (32%). Median cardiopulmonary bypass duration was 165 minutes (range, 144-185), distal aortic ischemic time 38 minutes (range, 32-45), and cardiac ischemic time 74 minutes (range, 62-94). The time of distal aortic ischemia was shorter in nonobese patients (27 vs 49 minutes, P = .043) and in zone 0 (23 cases) vs zone 1 (11 cases) anastomosis (34 vs 42 minutes, P = .043). Conclusions: The FET procedure with debranch-first technique is safe and feasible and resulted in low mortality and morbidity rates. Further investigation is needed to compare it with standard techniques

Long-term Outcomes of Stand-Alone Maze IV for Persistent or Long-standing Persistent Atrial Fibrillation

Background: The study sought to assess the long-term outcomes of the stand-alone Cox-Maze IV procedure in symptomatic patients with refractory, persistent, or long-standing persistent atrial fibrillation (AF). Methods: Fifty-nine consecutive patients (mean age 52 ± 10.5 years, previous catheter ablation 80%, left ventricular ejection fraction 55% ± 3.4%, median left atrial volume index 41 [interquartile range, 34-47] mL/m2) with symptomatic, refractory, persistent (56%), or longstanding persistent (44%) AF, underwent stand-alone Cox-Maze IV procedure. Biatrial ablations were performed with bipolar radiofrequency and cryoenergy. Left atrial appendage was excluded in 56 of 59 (95%) patients. Results: No hospital deaths occurred and 1 (1.7%) patient required postoperative pacemaker implantation. Follow-up was 97% complete (median 5.8 [interquartile range, 3.92-7.11] years). The overall survival at 7 years was 97% ± 2.3%. The 7-year cumulative incidence function of AF recurrence and of AF recurrence off class I or III antiarrhythmic drugs (AADs), with death as competing risk, was 14.2% ± 5.6% (95% confidence interval [CI], 5.5%-26.8%) and 26.5% ± 6.9% (95% CI, 14.2%-40.4%), respectively. Multivariate analysis identified the duration of AF as the only predictor of AF recurrence (hazard ratio, 1.01; 95% CI, 1.01-1.02; P < .001). At 7 years, the proportion of patients in sinus rhythm was 84%, of whom 74% were off class I or III AADs. At the last follow-up, 75% of patients were in European Heart Rhythm Association functional class I, no stroke and thromboembolic events were documented, and 70% of patients were off anticoagulation therapy. Left ventricular ejection fraction improved from 53% ± 3.4% at baseline to 59% ± 3.4% at follow-up (P = .003). Conclusions: This study confirmed the safety and efficacy in the long term (7 years) of the stand-alone Cox-Maze IV surgical procedure for persistent or long-standing persistent AF. Indeed, more than 70% of the patients were in sinus rhythm off class I or III AADs and off oral anticoagulation

A call to action becomes practice: cardiac and vascular surgery during the COVID-19 pandemic based on the Lombardy emergency guidelines

OBJECTIVES: During the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) pandemic, Northern Italy had to completely reorganize its hospital activity. In Lombardy, the hub-and-spoke system was introduced to guarantee emergency and urgent cardiovascular surgery, whereas most hospitals were dedicated to patients with coronavirus disease 2019 (COVID-19). The aim of this study was to analyse the results of the hub-and-spoke organization system. METHODS: Centro Cardiologico Monzino (Monzino) became one of the four hubs for cardiovascular surgery, with a total of eight spokes. SARS-CoV-2 screening became mandatory for all patients. New flow charts were designed to allow separated pathways based on infection status. A reorganization of spaces guaranteed COVID-19-free and COVID-19-dedicated areas. Patients were also classified into groups according to their pathological and clinical status: emergency, urgent and non-deferrable (ND). RESULTS: A total of 70 patients were referred to the Monzino hub-and-spoke network. We performed 41 operations, 28 (68.3%) of which were emergency/urgent and 13 of which were ND. The screening allowed the identification of COVID-19 (three patients, 7.3%) and non-COVID-19 patients (38 patients, 92.7%). The newly designed and shared protocols guaranteed that the cardiac patients would be divided into emergency, urgent and ND groups. The involvement of the telematic management heart team allowed constant updates and clinical discussions. CONCLUSIONS: The hub-and-spoke organization system efficiently safeguards access to heart and vascular surgical services for patients who require ND, urgent and emergency treatment. Further reorganization will be needed at the end of this pandemic when elective cases will again be scheduled, with a daily increase in the number of operations