BackgroundIn cardiac transplantation, high-dose antithymocyte globulin (ATG) induction therapy as short-term rejection prophylaxis has not been used.ObjectiveTo evaluate the efficacy and safety of intraoperative use of single high-dose ATG induction therapy after heart transplantation.Patients and MethodsFourteen patients received single high-dose ATG therapy plus shortened standard therapy (group1), and 16 patients received ATG standard therapy (group2).ResultsNo perioperative deaths were reported. During follow-up, 3 deaths were recorded. Five- year patient survival was 92.8% in groupl vs 85.7% in group2 (P = .34). The mean (SD) number of acute rejection episodes per patient was 2.5 (2.2) in the high-dose ATG group vs 2.7 (2.5) in the standard therapy group (P = .83), with 5-year freedom from acute rejection of 45.5% in group 1 vs 35.6% in group 2 (P = .85). Infections were observed in 6 patients in group1 and in 8 patients in group2 (P = .69). Malignant disease was diagnosed in 1 patient in the high-dose group and 3 patients in the standard therapy group (P = .35). Chronic allograft vasculopathy was recognized in 4 patients (28%) in group1 and 8 (50%) in group2 (P = .05). Five-year actuarial freedom from allograft vasculopathy was 69.2% in the high-dose ATG group vs 50.0%% in the standard therapy group (P = .35).ConclusionsHigh-dose ATG for prevention of rejection episodes is safe and efficacious, with a lower rate of early and late complications, in particular, graft vasculopathy.

This study evaluated the long-term clinical performance of the Mosaic bioprosthesis (Medtronic Inc, Minneapolis, MN) after aortic valve replacement.From 1995 to 2008, 178 patients (48 women; mean age, 74±6 years) had aortic valve replacement. Mean functional class was 2.3±0.5, and 157 patients (88\%) were in sinus rhythm. Prosthetic sizes were 23 mm in 98 patients and 25 mm in 66. Follow-up was completed in December 2009 with a cumulative duration of 1,015 patient/years (mean, 5.7±3.5 years, maximum, 13.7 years).Early mortality was 4\%, none being valve-related; of 38 late deaths 7 were valve-related. Actuarial survival at 13 years was 48\%±8\%. Mean functional class of current survivors was 1.2±0.6. Six embolic episodes occurred and four cases of endocarditis, with respective actuarial freedom of 92\%±5\% for embolism and 97\%±2\% for endocarditis at 13 years. Four patients required reoperations for endocarditis and 2 for structural deterioration. Actuarial freedom from structural deterioration and from reoperation for all causes was 89\%±7\% and 86\%±7\% at 13 years, with an actuarial freedom from prosthesis-related deaths of 86\%±5\%. Results of echocardiographic evaluation at 1 year were mean peak gradient, 20±6 mm Hg and mean effective orifice area index, 1.07±0.21 cm2/m2 for size 23 mm and 22±6 mm Hg and 1.11±0.26 cm2/m2 for size 25 mm; at 10 years, mean peak gradient and mean effective orifice area index were 28±13 mm Hg and 1.01±0.19 cm2/m2 for size 23 mm and 26±8 mm Hg and 1.08±0.18 cm2/m2 for size 25 mm.The Mosaic bioprosthesis showed good overall performance, with low incidence of structural valve deterioration and hemodynamic stability in the long-term. Expected increased durability of this device should be verified at longer follow-up intervals.

Left ventricular assistance with surgically implanted pump devices like the HeartMate may be crucial in selected patient with end-stage heart failure. However, mainly due to its high aortic output, the pump itself may induce severe aortic regurgitation that could result in paradoxycal worsening of the anterograde perfusion after the initiation of the support. Surgical or percutaneous occlusion of the aortic valve has proved useful in these kinds of patients. Here we present a successful case of bail-out CoreValve implantation after HeartMate II positioning complicated by acute severe aortic regurgitation in a patient with a failing homograft and end-stage ventricular dysfunction, ineligible for heart transplanation

Objectives: New-generation oxygenators with integrated arterial-line filters have been marketed to improve the efficacy of cardiopulmonary bypass (CPB). Differences in designs, materials, coating surfaces, pore size of arterial filter and static prime exist between the oxygenators. Despite abundant preclinical data, literature lacks clinical studies. Methods: From September 2010 to March 2011, 80 consecutive patients undergoing aortic valve replacement were randomized to CPB using Terumo- CapioxFX25 (40 patients, Group-T) or Sorin-Synthesis (40 patients, Group-S) oxygenators. Pressure drop and gas-exchange efficacy were registered during CPB. Fluid balance, ACT, INR, aPTT, fibrinogen, platelets, serum-albumin, total proteins, white blood cells (WBC), high-sensitivity C-reactive protein (hsPCR) were measured after anesthetic induction(T0), at CPB-start(T1), before CPB-discontinuation(T2), at ITU-arrival(T3), 3-hours (T4) and 24-hours (T5) postoperatively. The clinical outcome was recorded. Repeated ANOVA measure and non-parametric statistics assessed between-groups and during time differences. Results: The two groups showed similar baseline and intraoperative variables. No differences were recorded in pressure drop, gas-exchange and acid-balance (p=N.S. for all) during CPB. Despite similar fluid balance (between-groups p=.979), Group-T showed lower serum-albumin (between-groups p=.014), total proteins (between-groups p=.0001), fibrinogen (p≤.004 at T4 and T5), platelets (between-groups p=.021), with higher INR (p≤.005 at T4 and T5), aPTT (between-groups p=.0001), hsPCR (between-groups p=.034), WBC (p=.003 at T5). Group-T also showed higher postoperative bleeding (p=.038) and need for transfusions (p=.0001). However, clinical outcome was comparable (p=N.S. for all clinical end-points). Conclusions: Both oxygenators proved to be effective and resulted incomparable clinical outcome. However, Sorin-Synthesis seems to better preserve coagulative cascade and serum proteins, resulting in lower transfusions and post-CPB inflammatory response.

Aortic valve stenosis; Left heart catheterization; Valvulo-arterial impedance

The main goal of aortic valve replacement (AVR) is to obtain relief from the fixed left ventricular (LV) obstruction by replacing the aortic valve with a prosthesis, either mechanical or biological, of adequate size. Most currently available prostheses provide satisfactory hemodynamic performance, but small-sized prostheses may be associated with high transvalvular gradients and suboptimal effective orifice area that result in prosthesis-patient mismatch (PPM), and thus are far from ideal for use in young, active patients. The avoidance of PPM is advisable as it has been repeatedly associated with increased mortality, decreased exercise tolerance and an impaired regression of LV hypertrophy after AVR for severe aortic stenosis. Enlargement of the aortic annulus (EAA) has proved to be a valuable method to prevent PPM in the presence of a diminutive aortic root. This review outlines the various techniques described for EAA, presenting technical details, long-term results and major procedure-related complications, and discussing the current role of EAA in patients requiring AVR.

Functional mitral regurgitation remains one of the most complex and controversial aspect--for both clinicians and surgeons--in the management of mitral valve disease in the context of left ventricular dysfunction. Given the current absence of clear guidelines, as well as of results from randomized trials comparing the outcome of different surgical strategies potentially available for this complex scenario, surgical decision making for these high-risk patients poses a real dilemma in the daily practice. The resulting surgical choices often represent a questionable combination of surgeons' personal feeling, local supplies, patients' life expectancy and risk/benefit ratios, opinions and statements of the experts, and so on. This review provides an overview of the present knowledge about the complex pathophysiology underlying functional mitral regurgitation, the different pathophysiology-guided surgical techniques suggested in the last decades, as well as the current results following these different surgical techniques.

Cardiopulmonary bypass (CPB) has a risk of cerebral injury, with an important role of gaseous micro-emboli (GME) coming from the CPB circuit. Pulsatile perfusion is supposed to perform specific conditions for supplementary GME activity. We aimed to determine whether pulsatile CPB augments production and delivery of GME and evaluate the role of different events in GME activity during either type of perfusion. Twenty-four patients who underwent on-pump coronary artery bypass grafting surgery at the University of Verona were divided equally into two groups-pulsatile perfusion (PP) group and nonpulsatile perfusion (NP) group. The circuit included a JostraHL-20 roller pump set in pulsatile or nonpulsatile mode, an open Sorin Synthesis membrane oxygenator with integrated screen-type arterial filter, and phosphorylcholine-coated tubes. Hemodynamic flow evaluation was performed in terms of energy equivalent pressure and surplus hemodynamic energy (SHE). GME were counted by means of a GAMPT BCC200 bubble counter (GAMPT, Zappendorf, Germany) with two probes placed at postpump and postarterial filter positions. Results were evaluated in terms of GME number, GME volume, number of over-ranged GME from both probes, and series of filtering indexes. In PP mode, the pump produced and delivered along the circuit significantly higher amounts of SHE than in NP mode. At the venous postpump site, GME number was significantly higher during PP but no difference was found in terms of GME volume or number of over-ranged bubbles. No significant difference in GME number, GME volume, or number of over-ranges was found at the postarterial filter site. Filtering indexes were similar between the two groups. Neither type of perfusion was shown to contribute to excessive GME production during the most important perfusionist manipulation. Pulsatility leads to GME increment by splitting and size diminishing of the existing bubbles but not by additional gas production. PP augmented GME number at the venous postpump site, while mean volume remained comparable with NP. Sorin Synthesis oxygenator showed high efficacy in GME removal during either type of perfusion. Supplementary GME production and delivery during typical perfusionist manipulations did not depend on perfusion type.

Objectives: New models of centrifugal pumps are claimed to have better hemodynamic performance in pulsatile perfusion during CPB. Few data are available for hemodynamic evaluation of these pumps in vivo, especially in highrisk groups as elderly patients. The study aims at comparing hemodynamic effects of pulsatile versus non-pulsatile perfusion using MEDOS DeltaStream- DP3 centrifugal pump in patients over 75 years old. Methods: Forty patients with severe aortic stenosis (mean age 80.7±3.3, mean EuroScore 5.8±1.4) undergoing AVR from 1.01.2010 to 31.01.2010 were prospectively randomized into pulsatile (n=20pts) and non-pulsatile groups (n=20pts). Pressure and flow curves were recorded simultaneously from external flow-meters (TransonicHT110) and pressure monitor at 6 time points during CPB (at pre-oxygenator, post-oxygenator, aortic cannula and patients radial artery levels). Pulsatility was quantified in terms of Energy Equivalent Pressure(EEP) and Surplus Hemodynamic Energy(SHE). Hemodynamic indexes and clinical effects were monitored during 24 hours peri-operatively. Results: Groups showed no difference in mean CPB time (p=0.98), cross-clamp time (p=0.95), mean perfusion flow (p=0.32) and pressure (p=0.16) values. In both groups the measured blood flow corresponded to the calculated one. Mean SHE generated at the outlet of the pump was 113.5±21.8 ergs/cm3 with further progressive drop along the circuit until 5.3+1.9 ergs/cm3 calculated in the patient (4.7% from initial level). The pulsatile group showed lower vascular resistance during CPB (p=0.035) and significant difference in SVR (p=0.04) and PVR (p=0.02) just after operation. Levels of SHE delivered to the patient correlated positively with urine output during CPB (R=0.34, p=0.041) and PVR after CPB (R=0.44, p=0.015). No differences between groups were found in pharmacologic support, transfusion rates, creatinine levels, respiratory indexes and intubation time. Longer ICU and hospital stay were related to severity of preoperative co-morbidities. Conclusions: Pulsatile flow produced by MEDOS DeltaStream-DP3 centrifugal pump results in hemodynamic advantages and better tissue perfusion in highrisk patients.

Objectives: To evaluate the best method to wean a patient from intra-aortic balloon pump (IABP) after cardiogenic shock. Methods: Thirty consecutive patients needing intraoperative IABP because of cardiogenic shock were enrolled in the study and randomized in the Intensive-Care Unit (ICU) to 2 different weaning protocols. Fifteen patients were randomized to be weaned by ratio (4 consecutive hours of 1:2 assisting ratio followed by 1 hour of 1:3 ratio; Group-R), 15 by progressive volume deflation (10 cc every hour for 5 consecutive hours; Group-V). Weaning protocol started if cardiac index >2.5 L/min/m2, CVP≤12 mm/Hg, blood lactate <2.5mmol/L, mean arterial pressure >65 mm/Hg with a preserved diuresis of at least 5 consecutive hours. Five hours were “a-priori” set as weaning duration. IABP lasting >5hours was defined “failure”. Pressure recording analytical method(PRAM) collected cardiac index(CI), indexed systemic vascular resistances(SVRI), and cardiac cycle efficiency(CCE) at 8 different time-points (T1 to T5 for the first 5 weaning hours, T6: 2 hours post-withdrawal; T7: 12 hours post-withdrawal; T8: ICUdischarge). Central venous pressure(CVP) at the same time-points, time from IABP-withdrawal to ICU-discharge and weaning failure were also recorded. Perioperative troponin-I and lactate leakage were compared. Repeated measures ANOVA assessed group, time and group*time interactions. Results: All patients were successfully weaned and discharged home. Group-V showed better preserved CI, CCE and CVP (group*time p=.0001 for all). Group-R had worse CCE since T3 to T8 (p≤.001), CVP since T4 to T8 (p≤.0001) and CI since T5 to T8 (p≤.0001). SVRI proved comparable during the entire weaning period (p=NS). Despite no differences were detected in troponin-I leakage, lactate proved lower in V-group since T5 to T8 (p≤.027). Time from IABP-withdrawal to ICU-discharge proved longer in Group-R (p=.0001). Conclusions: Despite the quite similar clinical outcome, weaning the IABP by volume deflation after cardiogenic shock better preserved the hemodynamic parameters.

Redo aortic valve replacement procedures have been reduced by the growing practice of trans-catheter aortic valve-in-valve procedures. We analyzed our long-term results of redo aortic valve replacement procedures during a 10-year period in an effort to define subgroups in which trans-catheter aortic valve-in-valve procedures may be better than surgery.From 2002 to 2010, 131 redo aortic valve replacement procedures with at least 18 months of follow-up were prospectively enrolled. Hospital and follow-up outcome of the entire population and of high-risk subgroups were evaluated.Hospital mortality was 2.3\%, major re-entry complications were seen in 1.5\%, re-exploration for bleeding was seen in 9.2\%, perioperative low cardiac output state (ie, low cardiac output syndrome) was seen in 9.9\%, stroke was seen in 3.1\%, prolonged ventilation was seen in 18.3\%, pneumonia was seen in 4.6\%, acute renal insufficiency was seen in 11.5\%, intra-aortic counterpulsation (intra-aortic balloon pump) was seen in 9.2\%, renal replacement therapy was seen in 4.6\%, need for transfusions was seen in 60.3\%, and permanent pacemaker implantation was seen in 2.3\%. One hundred twenty-month actuarial survival, freedom from acute heart failure, reinterventions, stroke, and thromboembolisms were 61.5\% ± 8.6\%, 62.9\% ± 6.9\%, 97.8\% ± 1.5\%, 93.2\% ± 3.0\%, and 91.2\% ± 3.2\%, respectively. Patients aged >75 years had similar outcome to younger patients (nonsignificant P for all). Endocarditis resulted in higher hospital mortality (P = .034), low cardiac output state (P < .0001), intra-aortic balloon pump (P < .0001), prolonged ventilation (P = .011), pneumonia (P = .049), acute renal insufficiency (P = .004), lower actuarial survival (log-rank P = .0001), freedom from acute heart failure (P = .002), and re-intervention (P = .003). New York Heart Association functional class IV at admission resulted in a higher incidence of low cardiac output state (P < .0001), intra-aortic balloon pump (P = .0001), prolonged ventilation (P < .0001), pneumonia (P = .015), and a lower actuarial freedom from re-intervention (P = .0001). Higher need for permanent pacemaker implantation (P = .015) and lower freedom from acute heart failure (P = .019) emerged after urgencies/emergencies.Redo aortic valve replacement procedures achieves good results, especially in nonendocarditic or elective cases, and young or New York Heart Association functional class I/II patients. Indeed, endocarditis significantly affects outcome. New York Heart Association functional class IV and nonelective procedures might benefit from trans-catheter aortic valve-in-valve procedures.

The aim of this study was to test whether adenosine triphosphate-sensitive K(+) (KATP) channel expression relates to mechanical and hypoxic stress within the left human heart.The KATP channels play a vital role in preserving the metabolic integrity of the stressed heart. However, the mechanisms that govern the expression of their subunits (e.g., potassium inward rectifier [Kir] 6.2) in adult pathologies are mostly unknown.We collected biopsies from the 4 cardiac chambers and 50 clinical parameters from 30 surgical patients with severe mitral dysfunction. Proteins and messenger ribonucleic acids (mRNAs) of KATP pore subunits and mRNAs of their known transcriptional regulators (forkhead box [FOX] F2, FOXO1, FOXO3, and hypoxia inducible factor [HIF]-1α) were measured respectively by Western blotting, immunohistochemistry, and quantitative real-time polymerase chain reaction, and submitted to statistical analysis.In all heart chambers, Kir6.2 mRNA correlated with HIF-1α mRNA. Neither Kir6.1 nor Kir6.2 proteins positively correlated with their respective mRNAs. The HIF-1α mRNA related in the left ventricle to aortic pressure, in the left atrium to left atrial pressure, and in all heart chambers to a decreased Kir6.2 protein/mRNA ratio. Interestingly, in the left heart, Kir6.2 protein and its immunohistochemical detection in myocytes were maximal at low venous PO(2). In the left ventricle, the Kir6.2 protein/mRNA ratio was also significantly higher at low venous PO(2), suggesting that tissue hypoxia might stabilize the Kir6.2 protein.Results suggest that post-transcriptional events determine Kir6.2 protein expression in the left ventricle of patients with severe mitral dysfunction and low venous PO(2). Mechanical stress mainly affects transcription of HIF-1α and Kir6.2. This study implies that new therapies could aim at the proteasome for stabilizing the left ventricular Kir6.2 protein.

Aim: It was the aim of our study to determine whether myocardial fibrosis influences physiologic or non-physiologic left ventricular (LV) hypertrophy in severe aortic stenosis. Methods: Myocardial fibrosis was evaluated using specimens taken from the ventricular septum in 79 patients submitted to aortic valve replacement because of symptomatic aortic stenosis. Patients were considered to have physiologic LV hypertrophy if end-systolic wall stress, evaluated by echocardiography, was <90 kdyn/cm(2), while those with end-systolic wall stress >90 kdyn/cm(2) were considered to have non-physiologic hypertrophy. Results: Fibrosis tissue mass index was significantly inversely related with LV fractional shortening and directly related with LV diastolic and systolic diameter and LV mass index (LVMI). Patients with non-physiologic hypertrophy (n = 24) had a higher LVMI due to larger LV diastolic and systolic diameters with thinner wall, resulting in lower relative wall thickness. These patients had a higher fibrosis tissue mass index and impaired LV systolic and diastolic functions, as suggested by lower LV fractional shortening and higher mean wedge pressure. At follow-up of 7.4 ± 2.1 months, the LVMI and New York Heart Association class remained higher in patients with non-physiologic hypertrophy. Conclusions: Our study suggests a different quality of hypertrophies in patients with aortic stenosis, where myocardial fibrosis seems to be the critical abnormality that differentiates adaptive from maladaptive response to increased afterload.

Transfemoral aortic valve implantation has recently emerged as a therapeutic option for patients with symptomatic, severe aortic stenosis for whom standard surgical aortic valve surgery is not suitable. Aortic valvuloplasty and valve positioning is normally performed under fluoroscopy and requires several injections of contrast medium. In critically ill patients with advanced renal insufficiency, contrast media administration can further increase renal damage; therefore, an echocardiogram and fluoroscopy-guided procedure, using the calcified contours of the stenotic aortic valve as a landmark may be a useful alternative. We report the first successful transfemoral aortic valve implantation procedure performed under fluoroscopy and transesophageal echocardiogram control, without administration of contrast medium injections in a patient with severe renal insufficiency and multiorgan failure.

Mitral valve repair is considered the procedure of choice for correcting mitral regurgitation in myxomatous disease, providing long-term results that are superior to those with valve replacement. The use of artificial chordae to replace elongated or ruptured chordae responsible for mitral valve prolapse and severe mitral regurgitation has been the subject of extensive experimental work to define feasibility, reproducibility, and effectiveness of this procedure. Artificial chordae made of autologous or xenograft pericardium have been replaced by chordae made of expanded polytetrafluoroethylene (PTFE), a material with the unique property of becoming covered by host fibrosa and endothelium. The use of artificial chordae made of PTFE has been validated clinically over the past 2 decades and has been an increasing component of the surgical armamentarium for mitral valve repair. This article reviews the history, details of the relevant surgical techniques, long-term results, and fate of artificial chordae in mitral reconstructive surgery.

Objectives: To determine whether vacuum-assisted venous return has clinical advantages over conventional gravity drainage apart from allowing the use of smaller cannulas, shorter tubing and reduced priming. Methods: A total of 80 CABG operations were performed at our institution between July 1999 to December 2010, using vacuum-assisted venous return with small venous cannulas connected to short tubing. These were randomized with 80 CABG operations using conventional gravity drainage. Priming volume, hematocrit value, red blood cell usage, and total blood product usage were compared by means of multivariate analysis. Results: The priming volume was 780+/-140mL for small-cannula vacuumassisted venous return, 1300+/-88mL for gravity drainage (P <.0001). Smaller priming resulted in higher hematocrit values both at the beginning of cardiopulmonary bypass (26%+/-5% compared with 21%+/-4%, respectively, P <.0001) and at the end (28%+/-4% compared with 24%+/-4%, respectively, P <.0001). Red cell transfusions were used in 12% of the patients having small-cannula vacuum-assisted venous return and 41% of the patients having gravity drainage (P =.001); total blood product usage was 15% and 61%, respectively (P =.001). Despite a postoperative blood loss, length of stay in intensive care unit was similar in both groups; the association of vacuum-assisted venous return with lowered blood product usage was confirmed also in the postoperative period. Conclusions: Modified open circuit and vacuum-assisted venous return result in 1) higher hematocrit values during cardiopulmonary bypass and 2) decreased red cell and total blood product usage.

OBJECTIVE: To evaluate whether myocardial fibrosis influences left ventricular performance in severe aortic stenosis and to assess its effect on long-term survival after aortic valve replacement. METHODS: Myocardial fibrosis was evaluated in biopsy specimens taken from the interventricular septum in 99 patients undergoing aortic valve replacement because of severe or prevalent aortic stenosis. Clinical and echocardiographic evaluations were performed at a mean follow-up of 6.2 ± 3.0 years. The patients were classified according to the myocardial fibrosis severity (none or mild in 28, moderate in 52, and severe in 19). RESULTS: Patients with severe myocardial fibrosis had a dilated left ventricle and positive association between the left ventricular end-diastolic diameter (R = 0.77, P < .001), left ventricular end-systolic diameter (R = 0.78, P < .001), left ventricular end-systolic wall stress (R = 0.74, P < .001) and the degree of myocardial fibrosis. Myocardial fibrosis was inversely related to left ventricular fractional shortening (R = -0.64, P < .001), left ventricular ejection fraction (R = -0.53, P < .001), and left ventricular relative wall thickness (R = -0.70, P < .001). Patients with a higher grade of myocardial fibrosis had a significantly lower freedom from cardiac death at 10 years (42\% ± 19\% vs 89\% ± 6\%, P = .002), with congestive heart failure the most common cause of death. At Cox regression analysis, patient age (P = .012), low preoperative transvalvular gradient less than 40 mm Hg (P = .040), preoperative end-systolic wall stress (P = .046), and preoperative myocardial fibrosis grade (P = .034) emerged as the strongest independent predictors of mortality. CONCLUSIONS: In patients with severe aortic valve stenosis, the amount of myocardial fibrosis appears to have significant effect on clinical status and long-term survival after aortic valve replacement. From these results, we believe that new strategies for the earlier detection of myocardial fibrosis are needed to achieve a better prognostic outcome.

To evaluate if pulsatile cardiopulmonary bypass (CPB) has any protective influence on renal function in elderly patients undergoing aortic valve replacement (AVR).Forty-six patients (≥75 years old) with aortic valve stenosis underwent AVR with either pulsatile perfusion (PP) or non-pulsatile perfusion (NP) during CPB. Haemodynamic efficacy of the blood pump during either type of perfusion was described in terms of the energy equivalent pressure and the surplus haemodynamic energy. Urine samples were collected before surgery, at sternum closure, and at 2 and 18 h of intensive care unit stay to detect acute kidney injury markers. Perioperative urine levels of N-acetyl-β-d-glucosaminidase (NAG), kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin (NGAL) were assessed together with plasma creatinine, creatinine clearance (CCr) and 24-h haemodynamic monitoring. Normally distributed continuous variables were described as mean ± standard deviation and non-normally distributed data were presented as the median [25th-75th percentiles].PP was characterized by a significantly higher amount of surplus haemodynamic energy transferred to the patients (P < 0.001), with lower mean systemic vascular resistance during CPB (P = 0.020) and during 18 h postoperatively (group-P = 0.018). No difference was found between pre- and postoperative CCr in the PP group (71 ± 23 vs 60 ± 35 ml/min, P = 0.27), while its statistically significant perioperative decrement was observed in the NP group (67 ± 24 vs 45 ± 15 ml/min, P < 0.001). The PP group showed significantly lower urinary levels of NAG at 18 h postoperatively (P = 0.008), and NGAL at sternum closure (P = 0.010), 2 h (P < 0.001) and 18 h (P = 0.015) postoperatively.Short-term PP in elderly patients showed higher safety for renal physiology than NP, resulting in better maintenance of glomerular filtration and lower renal tissue injury.

Cardiopulmonary bypass (CPB) has a risk of embolic injury with an important role of gaseous micro-bubbles (GMBs), coming from CPB-circuit. Pulsatile perfusion (PP) can provide specific conditions for supplementary GMB-activity with respect to non-pulsatile (NP). We aimed to test GMB-filtering properties of three modern oxygenators under pulsatile and non-pulsatile conditions.Seventy-eight patients undergoing on-pump myocardial revascularization were randomized prospectively into three equal groups according to the oxygenator model used during CPB. Terumo Capiox-FX25, Sorin Synthesis or Maquet Quadrox-i-Adult membrane oxygenators were tested. Each group was divided equally to undergo PP or NP. GMBs were counted by means of a GAMPT-BCC200 bubble-counter with two probes placed at preoxygenator and arterial post-filter positions. Results were evaluated in terms of GMB-volume, GMB-number, amount of large over-ranged GMBs, a series of filtering indices and major neurological outcomes.PP decreased GMB-filtering properties of the tested oxygenators. Those with integrated filters (CAPIOX-FX25 and SYNTHESIS) did not show significant differences between perfusion groups, while QUADROX-i oxygenator with external arterial filter showed significantly higher GMB-volume (P < 0.001), GMB-number (P < 0.001) and amount of over-ranged bubbles (P < 0.001) detected in arterial line during PP. Despite the differences in filtering capacity of all circuits with both types of perfusion, no important differences in clinical outcomes and major neurological events were observed.Pulsatile flow decreases gaseous micro-bubble filtering properties of oxygenators without integrated arterial filters during CPB. PP requires specially designed circuit components to avoid the risk of additional GMB delivery.

Concerns have recently been raised regarding postoperative decreases in platelet count (PC) after aortic valve replacement (AVR) with the Sorin Freedom Solo (SFS) stentless bioprosthesis. In order to assess the relevance and the clinical impact of this phenomenon, variations in PC were monitored in patients with SFS valves, and compared to changes of PC in patients after AVR with two other bioprostheses, the Medtronic Mosaic (MOS) porcine valve and the Sorin Mitroflow (MIT) pericardial valve.Three groups of patients (25 in each group) who had undergone AVR with a biological prosthesis were compared. The patients were similar in terms of their preoperative characteristics, including mean age, NYHA functional class, risk factors, EuroSCORE, and mean PC. The PC was monitored on postoperative days 1, 3, and 5, and again at discharge. Thrombocytopenia was considered to be 'present' when the PC was < 150,000/microl, and 'severe' when the PC was < 30,000/microl.No significant inter-group differences were observed in the duration of extracorporeal circulation or cross-clamp times. The mean postoperative PCs for MOS valves were 154,000 +/- 56,000/microl, 154,000 +/- 54,000/microl, 161,000 +/- 85,000/microl, and 228,000 +/- 95,000/microl at days 1,3, and 5, and at discharge, respectively. For MIT valves, these values were 126,000 +/- 37,000/microl, 113,000 +/- 38,000/microl, 130,000 +/- 46,000/microl, and 170,000 +/- 50,000/microl, respectively. For SFS valves, the values were 99,000 +/- 27,000/microl, 67,000 +/- 9000/microl, 78,000 +/- 54,000/microl, and 96,000 +/- 32,000/microl, respectively. Severe thrombocytopenia was never observed in any patient. A significant decrease in PC occurred with SFS when compared to MOS valves (on days 1, 3, 5, and at discharge, p < 0.001) and to MIT valves (on days 3, 5, and at discharge, p < 0.005). Multivariate analysis showed older age (p = 0.001) and the SFS valve (p = 0.0002) to be incremental risk factors for developing severe or moderate thrombocytopenia after AVR.A reduction in PC occurred with all bioprostheses on postoperative day 1, while a significant reduction in PC was continued for SFS valves on postoperative days 3 and 5, when compared to MOS and MIT valves. A normalization of PC at discharge was observed only with MOS valves. Thrombocytopenia after AVR with biological prostheses was not associated with any major postoperative complication.

To evaluate the long-term results of aortic valve replacement (AVR) and mitral valve replacement (MVR) with the Sorin Bicarbon prosthesis (SBP).Five hundred seven patients (306 men, 201 women), mean age 62 ± 10 years (range, 21-86 years), received an SBP between 1994 and 2000; AVR was performed in 344 (67\%) and MVR in 163 (33\%). The main concomitant procedure was coronary artery grafting in 79 patients (16\%). Follow-up was 99\% complete; mean follow-up was 12.7 ± 4.0 years with a cumulative duration of follow-up of 6475 patient-years in the entire group (4348 patient-years for AVR and 2124 patient-years for MVR).Hospital mortality was 2.7\% (AVR, 2.03\%; MVR, 4.3\%). There were 169 late deaths (AVR, 128; MVR, 41). Actuarial survival at 17 years is 49.7\% ± 5.3\% for AVR and 62.0\% ± 6.1\% for MVR. At the last follow-up, 310 survivors (199 AVR, 111 MVR) are in New York Heart Association functional class I or II. At 17 years, actuarial freedom from valve-related deaths, embolism, and bleeding is 89.8\% ± 4.8\%, 85.8\% ± 5.4\%, and 96.2\% ± 1.2\% after AVR, and 91.9\% ± 3.9\%, 96.3\% ± 1.8\%, 95.0\% ± 2.9\% after MVR. Reoperation was required in 5 patients with AVR (thrombosis in 4 and perivalvular leak in 1). Actuarial freedom from reoperation is 98.1\% ± 0.8\% after AVR and 100\% after MVR; freedom from endocarditis is 100\% after AVR and 99.2\% ± 0.7\% after MVR. No cases of intrinsic structural valve failure were observed.The SBP has shown excellent results in terms of clinical improvement and freedom from valve-related complications, even up to 17 years after AVR and MVR. It therefore seems to be a safe option whenever a mechanical prosthesis is needed.

Enlargement of the aortic annulus may be required during aortic valve replacement to avoid patient-prosthesis mismatch. We reviewed patients with enlargement of the aortic annulus with the aim of assessing the stability of the procedure by means of echocardiographic and angio-computed tomography studies.A series of 53 consecutive patients underwent aortic valve replacement and enlargement of the aortic annulus from 1994 to 2012. The mean age was 68 ± 11 years (range, 29-84 years), and 85\% (45 patients) were female. The predominant valvular lesion was aortic stenosis. The mean logistic European System for Cardiac Operative Risk Evaluation was 11.2 ± 13.0. Enlargement of the aortic annulus was performed by extending the aortotomy incision to separate the commissure between the left and noncoronary sinuses into the anterior mitral leaflet and closing the resulting defect with an adequately tailored patch of bovine pericardium.Hospital mortality was 2\%, with 20 late deaths mostly due to noncardiac causes. At a maximum follow-up of 18 years (mean, 8.9 ± 5.0 years), actuarial survival is 37\% ± 9\%. No cases of severe patient-prosthesis mismatch were observed, and only 2 patients had moderate patient-prosthesis mismatch. At discharge, the mean aortic root diameter was 30.0 ± 2.3 mm and the mean diameter at the sinotubular junction was 31.5 ± 5.0 mm. At follow-up, the mean aortic root diameter was 31.0 ± 3.4 mm and the mean diameter at the sinotubular junction was 31.7 ± 4.5 mm (P = not significant) with no cases of late aneurysm formation on angio-computed tomography.Enlargement of the aortic annulus is a safe and effective procedure and should be indicated in patients with a small aortic annulus; particularly, it should be considered to prevent patient-prosthesis mismatch and its potential deleterious long-term effects.

Objectives: Trans-catheter aortic valve implantation (TAVI) has emerged as an alternative to aortic valve replacement (AVR) for severe aortic stenosis. The majority of TAVI systems currently available incorporate pericardial stentless bioprostheses, with only short follow-up data available. Therefore information on long-term results of AVR with a stentless pericardial valve, such as the Sorin Freedom (SF), represents a valid benchmark. In this study we report the clinical and hemodynamic performance of SF with a 10-year follow-up. Methods: From January 2000 to December 2004, 78 patients, mean age 5.6±5.8 years, underwent AVR with SF. Sixteen (20.5%) were in NYHA class IV, 18 (23.1%) in III, 44 (56.4%) in class I or II. Mean ejection fraction (LVEF) was 58.11±11.16%. Echocardiographic evaluation was performed at 3, 12 months and yearly thereafter assessing effective orifice area (EOA), gradients (PG) and regression of left ventricular mass index (LVMi). Results: There was 1 operative death (1.2%). A total of 77 patients were discharged and followed for total follow-up of 5602 months (mean 70±25 months). There were 24 late deaths with an actuarial survival of 56±8.8% at 10 years. Three patients were reoperated, with a freedom from reoperation of 95±3% at 10 years, because of structural deterioration, endocarditis and dilatation of sinotubular junction, respectively. At last clinical control 47 patients (90%) were in NYHA class I or II and 5 patients (9%) were in NYHA class III. Mean EOA varied from 1.8±0.8cm2 for valve size21 to 2.3±0.6 cm2 for size27 and mean PG varied from 22±9 mmHg for valve size21 to 13±4 mm Hg for size27. LVMi decreased from 182.9±39.6gm/m2 to 142.1±42.6gm/m2 (p<0.001). Conclusions: SF stentless bioprosthesis has provided good results in terms of valve durability and freedom from valve-related complications with excellent hemodynamic performance at 10-year follow-up. These data represent important reference point against which performance of current TAVI systems must be compared.

Objective: The Sorin Pericarbon Freedom (SPF) is a stentless valve made of pericardium clinically available in 1990. We report the clinical and hemodynamic performance of the SPF at 10 years. Methods: From April 2000 to December 2005, 85 patients with a mean age of 75 ± 6 years (range 57-86), underwent aortic valve replacement (AVR) with an SPF. Mean left ventricular ejection fraction was 58 ± 10\% (range 29-86\%) and mean peak transvalvular gradient (PG) 86 ± 24 mmHg. Clinical evaluation was performed at 3, 6, 12 months, and yearly thereafter. Results: There were 2 operative deaths (2.4\%). Follow-up ranged from 2 to 135 months (mean 78 ± 32 months) and was 99\% complete. There were 35 late deaths, 7 of which were valve-related, with an actuarial survival of 45 ± 8\% at 10 years. Structural SPF deterioration occurred in 2 patients, with an actuarial freedom of 96 ± 3\%. A total of 4 patients were re-operated, 2 because of structural deterioration, 1 because of endocarditis, and 1 because of sinotubular junction dilatation; freedom from reoperation was 93 ± 4\% at 10 years. At last clinical control, 41 patients (89\%) were in NYHA class I or II. Mean SPF effective orifice area varied from 1.55 ± 0.66 cm2 for size 21 mm to 2.33 ± 0.86 cm2 for size 27 mm; PG varied from 19 ± 10 mmHg for size 21 mm to 11 ± 6 mmHg for size 27 mm. Left ventricular mass index decreased from 213 ± 51 gm/m2 to 157 ± 436 gm/m2 (p<0.001). Conclusions: The SPF has demonstrated overall good results in terms of valve durability and freedom from valve-related complications up to 10 years, with excellent hemodynamic performance.

Transcatheter aortic valve implantation (TAVI) has nowadays been introduced as an alternative for surgical aortic valve replacement as a treatment for high risk aortic stenosis patients. This procedure is not free of complications: the SOURCE registry, indeed, showed that vascular complications are more frequent with the transfemoral approach. We present the case of an 82-year-old man with known history of severe aortic stenosis at high-risk for surgery. Pre-TAVI screening shows bilateral severely tortuous iliac arteries and aorto-bi-iliac endoprosthesis. Transapical TAVI as a first choice was rejected due to severe lung disease. The patient was then treated by Transfemoral TAVI using a dedicated interventional technique that is described in this case-report.

We report the long-term follow-up of 34 patients who underwent transmyocardial laser revascularization (TMLR) from 1995 to 1999. At 12 years the actuarial survival is 24\%±8\%, actuarial freedom from cardiac deaths is 36\%±10\% and actuarial freedom from major adverse cardiac events 13\%±8\%. Mean angina class of nine current survivors is 2.7±0.6. Based on these results, the use of TMLR as an isolated procedure remains questionable. TMLR could probably achieve better results when employed in combination with myocardial revascularization or as a vehicle of intramyocardial growth factors.

BACKGROUND: Urgent or emergent cardiac surgery in the elderly is burdened by high operative mortality and unacceptable postoperative quality of life. METHODS: From 1998 to 2007, 251 patients aged 80 years underwent nonelective cardiac surgery for urgent (n = 229) or emergent (n = 22) indications. A logistic regression to identify incremental risk factors for postoperative death was performed. RESULTS: The overall early mortality was of 12%, with 8% in urgent and 45% in emergent cases. The most frequent causes of death were infections, particularly pneumonia (23%), renal failure (20%), CVA (17%), respiratory failure (10%), and multisystem organ failure (10%). Incremental risk factors for early mortality were age, emergent procedure, aortic procedure, cardiopulmonary bypass time, and the presence of a major postoperative complication. Mean follow-up time was 5.4 +/- 3.2 years. CONCLUSIONS: An urgent cardiac surgery can be performed in octogenarians with acceptable operative mortality and good long-term survival.