Facing the small aortic root in aortic valve replacement: Enlarge or not enlarge?

In patients with severe aortic stenosis, aortic valve replacement (AVR) should aim to implant a prosthesis of adequate size to effectively eliminate left ventricular obstruction and avoid the risk of patient–prosthesis mismatch (PPM). PPM has been demonstrated to be associated with increased mortality, decreased exercise tolerance, and reduced left ventricular mass regression after AVR for aortic stenosis

Left atrial appendage thrombosis and persistent atrial fibrillation: Combined treatment with a totally thoracoscopic approach

Minimally invasive surgical ablation is generally contraindicated in patients with atrial fibrillation and thrombosis of the left atrial appendage. We have treated three of these patients using an innovative technique based on a bilateral video-thoracoscopic approach, performing a continuous encircling lesion at the pulmonary veins outflow with radio-frequency ablation, simultaneously excluding the left atrial appendage. The postoperative course was uneventful, without neurologic events and all patients maintained a stable sinus rhythm at 1-year follow-up. This procedure represents a new mini-invasive method to treat persistent atrial fibrillation when partial thrombosis of the left atrial appendage contraindicates other ablation techniques

An integrated approach for treatment of acute type a aortic dissection

Background and objective: We reviewed a single-institution experience to verify the impact of surgery during different time intervals on early and late results in the treatment of patients with type A acute aortic dissection (A-AAD). Materials and Methods: From 2004 to 2021, a total of 258 patients underwent repair of A-AAD; patients were equally distributed among three periods: 2004–2010 (Era 1, n = 90), 2011–2016 (Era 2, n = 87), and 2017–2021 (Era 3, n = 81). The primary end-point was to assess whether through the years changes in indications, surgical strategies and techniques and increasing experience have influenced early and late outcomes of A-AAD repair. Results: Axillary artery cannulation was almost routinely used in Eras 2 (86%) and 3 (91%) while one femoral artery was mainly cannulated in Era 1 (91%) (p < 0.01). Retrograde cerebral perfusion was predominantly used in Era 1 (60%) while antegrade cerebral perfusion was preferred in Eras 2 (94%,) and 3 (100%); (p < 0.01). There was a significant increase of arch replacement procedures from Era 1 (11%) to Eras 2 (33%) and 3 (48%) (p < 0.01). A frozen elephant trunk was mainly performed in Era 3. Hospital mortality was 13% in Era 1, 11% in Era 2, and 4% in Era 3 (p = 0.07). Actuarial survival at 3 years is 74%, in Era 1, 78% in Era 2, and 89% in Era 3 (p = 0.05). Conclusions: With increasing experience and a more aggressive approach, including total arch replacement, repair of A-AAD can be performed with low operative mortality in many patients. Patient care and treatment by a specific team organization allows a faster diagnosis and referral for surgery allowing to further improve early and late outcomes

Use of sutureless and rapid deployment prostheses in challenging reoperations

Sutureless and rapid-deployment bioprostheses have been introduced as alternatives to traditional prosthetic valves to reduce cardiopulmonary and aortic cross-clamp times during aortic valve replacement. These devices have also been employed in extremely demanding surgical settings, as underlined in the present review. Searches on the PubMed and Medline databases aimed to identify, from the English-language literature, the reported cases where both sutureless and rapid-deployment prostheses were employed in challenging surgical situations, usually complex reoperations sometimes even performed as bailout procedures. We have identified 25 patients for whom a sutureless or rapid-deployment prosthesis was used in complex redo procedures: 17 patients with a failing stentless bioprosthesis, 6 patients with a failing homograft, and 2 patients with the failure of a valve-sparing procedure. All patients survived reoperation and were reported to be alive 3 months to 4 years postoperatively. Sutureless and rapid-deployment bioprostheses have proved effective in replacing degenerated stentless bioprostheses and homografts in challenging redo procedures. In these settings, they should be considered as a valid alternative not only to traditional prostheses but also in selected cases to transcatheter valve-in-valve solutions

Distal Reoperations after Repair of Acute Type A Aortic Dissection—Incidence, Causes and Outcomes

Background and Aim of the Study: In patients with acute type A aortic dissection (A-AAD) whether initial repair should include also aortic arch replacement is still debated. We aimed to assess if extensive aortic repair prevents from reoperations patients with A-AAD. Methods: Outcomes after distal reoperation following repair of A-AAD (n = 285; 1977 to 2018) were analysed in 22 of 226 who underwent ascending aorta/hemiarch replacement (Group 1R) and 7 of 59 who had ascending aorta/arch replacement (Group 2R). Results: Distal reoperation was more common in Group 1R (n = 22) than in Group 2R (n = 0) (p &lt; 0.001) while thoracic endovascular stenting was more frequent in Group 2R (7 vs 3, p &lt; 0.001). Indications for reoperation were pseudoaneurysm at distal anastomosis (n = 4, 18%) and progression of aortic dissection (n = 18, 82%) in Group 1R. Indication for thoracic endovascular stenting was progressive aortic dissection in 3 patients of Group 1R and in 6 of Group 2R. Second reoperation was required in 2 patients from Group 1R (2%) during a mean follow-up of 5 years. Median follow-up was 4 years in Group 1R and 7 years in Group 2R (p = 0.36). Hospital mortality was 14% in Group 1R and 0% in Group 2R (p = 0.3). Actuarial survival is 68 ± 10%, and 62 ± 11% for Group 1R and 100% for Group 2R at 5 and 10 years (p = 0.076). Conclusions: Distal reoperations after A-AAD repair have an acceptable mortality. An extensive initial repair has lower rate of reoperation and better mid-term survival and should be indicated especially for young patients in experienced centers

The Power Manager for the LHCb On-Line Farm

The Power Manager is a tool of the LHCb FMC (Farm Monitoring and Control System) which allows - in an OS-independent manner and without requiring expensive network-controlled power distributors - to switch the farm nodes on and off, and to monitor their physical condition: power status (on/off), temperatures, fan speeds and voltages. The Power Manager can operate on farm nodes whose motherboards and network interface cards implement the IPMI (Intelligent Platform Management Interface) specifications, version 1.5 or subsequent, and copes with several IPMI limitations

The Process Controller for the LHCb On-LIne Farm

The Process Controller is a tool of the LHCb FMC (Farm Monitoring and Control System) in charge of keeping a list of applications up and running on the farm nodes. It tipically runs on a few control PCs each one watching ~200 farm nodes and performs its task by maintaining the list of scheduled applications for each controlled farm node and by interacting with the Task Manager Servers running on the farm nodes to start processes, to obtain the notification of process termination, to re-spawn the terminated processes (if requested) and to stop processes. Processes can be added to or removed from the scheduled application list for one or more nodes by means of DIM commands, while DIM services provide the list of scheduled applications for each controlled farm node together with their properties, the number of re-spawns and the re-spawn times

Surgical Treatment of Annuloaortic Ectasia - Replace or Repair?

Background: Patients with annuloaortic ectasia may be surgically treated with modified Bentall or David I valve-sparing procedures. Here, we compared the long-term results of these procedures. Methods: A total of 181 patients with annuloaortic ectasia underwent modified Bentall (102 patients, Group 1) or David I (79 patients, Group 2) procedures from 1994 to 2015. Mean age was 62 ± 11 years in Group? 1? and 64? ± 16 years in Group 2. Group 1 patients were in poorer health, with a lower ejection fraction and higher functional class. Results: Early mortality was 3% in Group 1 and 2.5% in Group 2. Patients undergoing a modified Bentall procedure had a higher incidence of thromboembolism and hemorrhage, whereas those undergoing a David I procedure had a higher incidence of endocarditis. Actuarial survival was 70 ± 6% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. Actuarial freedom from reoperation was 97 ± 2% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. In Group 2, freedom from procedure-related reoperations was 98 ± 2% at 10 years. At last follow-up, no cases of moderate or severe aortic regurgitation were observed. Conclusions: The modified Bentall and David I procedures showed excellent early and late results. The modified Bentall procedure with a mechanical conduit was associated with thromboembolic and hemorrhagic complications, whereas the David I procedure was associated with unexplained occurrences of endocarditis. Thus, the David I procedure appears to be safe, reproducible, and capable of achieving stable aortic valve repair and is therefore our currently preferred solution for patients with annuloaortic ectasia. However, the much shorter follow-up for David I patients limits the strength of our comparison between the two techniques

Circulating endothelial progenitor cells are actively involved in the reparative mechanisms of stable ischemic myocardium

Background: Myocardial fibrosis (MF) is an adverse correlate of severe aortic valve stenosis (SAVS). microRNA expression modulates different pathophysiological pathways in cardiovascular disease. In particular miRNA­21, has been associated to MF due to pressure overload. Non­invasive estimation of MF, using speckle­tracking echocardiography (2D­STE), could be useful in determining early myocardial damage. Purpose: To analyze the correlation between 2D­STE parameters, MF, plasmatic and tissue miRNA­21 in SAVS. Methods: We evaluated 36 consecutive patients (75.2±8 y.o., 63% F) with SAVS and preserved ejection fraction (EF), undergoing to surgical aortic valve replacement (AVR; Euroscore II 2.28±1.13%; Logistic Euroscore: 6±4.1%). Clinical, ECG, biohumoral evaluation (including plasma miRNA­21) and a complete echocardiography, including 2D­STE, was performed before AVR. 28 patients eventually underwent AVR and, in 23 of them, a basal interventricular septum biopsy was performed. MF and tissue miRNA­21 expression (micro­dissection) were evaluated in each sample. Results: All patients with SAVS (AVAi 0.33±0.1 cm2/m2; V max 4.4±0.4 m/sec; Mean Grad. 50±9 mmHg) showed concentric hypertrophy (LVMi 147±20.7 g/m2, RWT 0.51±0.07), diastolic dysfunction and increased Valvulo­Arterial Impedance (ZVA: 5.9±2.3 mmHg/ml/m2). Despite a preserved EF (66±11%), an altered global and septal deformation (Global longitudinal strain, GLS −13±6.1; Global longitudinal strain rate, GLSr −0.8±0.2 1/sec; Global early diastolic Sr, GLSrE 1±0.35 1/sec; Septal longitudinal strain, SLS −8.6±2.8%; SL­Sr −0,6±0.1 1/sec; SL­SrE 0.6±0.29 1/sec) were observed. We found a significant association between MF and 2D­STE parameters, stroke volume and end­diastolic pressure (all p&lt;0.05). Tissue miRNA­21 was mainly expressed in fibrous tissue than in myocardium (p&lt;0.0001). Myocardial miRNA­21 was associated with AVAi (r=0.46; p=0.043) and cardiac index (r=0.5; p=0.02) while fibrous tissue miRNA­21 was associated to GLS (r=0.8; p=0.0003), GLSrE (r=−0.72; p=0.005), SLS (r=0.6; p=0.01), SL­Sr (r=0.54; p=0.03), SL­SrE (r=0.5; p=0.04) and PAPs (r=0.66; p=0.004). Plasma miRNA­21 was associated to MF (r=0.5; p=0.02) and septal longitudinal strain (r=0.38; p=0.037). Conclusions: In SAVS with preserved EF, MF is associated to impaired myocardial deformation. miRNA­21 has a potential pathophysiological role in fibrogenesis. Non­invasive evaluation of plasmatic miRNA­21 and 2D­STE could be useful in risk stratification, to optimize the timing of surgery in SAVS patients