(1) Background: Leadless pacemakers (LPs) have been proposed as a reimplantation strategy in pacing-dependent patients undergoing cardiac implantable electronic device (CIED) extraction for infection. In this study, we analysed the risk of LP infection when this device is implanted before lead extraction. (2) Methods: This was a retrospective study including patients who underwent LP implantation between 2017 and 2022. Patients were divided in two groups according to whether LP was implanted following CIED extraction for infection (Group 1) or other indications (Group 2). The primary aim was to describe the risk of LP infection. (3) Results: We included in this study 49 patients with a median age of 81 [20-94] years, mostly males (36, 73%). In Group 1 patients, 17 cases (85%) showed systemic CIED infections, and 11 (55%) had positive lead cultures. Most Group 1 cases (n = 14, 70%) underwent one stage of LP implantation and CIED extraction. Mortality rate during follow-up was 20% (nine patients). Patients were followed up for a median of 927 [41-1925], days and no cases of definite or suspected LP infections were identified. (4) Conclusions: The risk of LP infection was extremely low. LP appears as a potential option for reimplantation in this setting and should be considered in pacing-dependent patients at a high risk of CIED infection recurrence.

INTRODUCTION:Dual antiplatelet therapy reduces the risk of cardiovascular death, myocardial infarction and recurrence of adverse ischemic events in patients affected by acute coronary syndromes, but in patients urgently needing coronary artery surgery it can increase the risk of severe perioperative bleeding complications. AIM:We evaluated the impact of dual antiplatelet therapy (DAPT) based on acetylsalicylic acid plus clopidogrel or ticagrelor in patients undergoing coronary artery bypass grafting (CABG). MATERIAL AND METHODS:Three hundred and thirty-three patients underwent coronary artery bypass grafting with DAPT discontinuation > 72 hours or 3-4 days (group A, n = 159), 48-72 hours or 2-3 days (group B, n = 126), < 24 hours or 0-1 day (group C, n = 24) prior to CABG. RESULTS:Operative mortality was 1.87% (group A), 0.79% (group B), absent (group C). The incidence of mediastinal re-exploration was 1.25% or 2 patients (group A), 1.59% or 2 patients (group B), 8.33% or 4 patients (group C) (p = 0.01). Group C showed postoperatively a greater incidence of a blood loss greater than 500 ml at 6 hours and a blood loss from chest tube drainages significantly higher at 6 and 24 hours (p < 0.01). Multivariate analysis showed that ongoing ticagrelor intake in group C (HR = 42.4; p = 0.02) and group C (HR = 6.9; p = 0.04) were the only independent predictors of surgical re-exploration. In group C, surgical re-exploration was 2.56% or 1/39 patients taking clopidogrel, 33.3% or 3/9 patients taking ticagrelor (p = 0.002). CONCLUSIONS:Dual antiplatelet therapy ongoing until 1 day or 24 hours before CABG showed a significantly increased risk of bleeding complications in comparison with its discontinuation at 2-3 and > 3-4 days before, respectively. Major blood loss and surgical re-exploration were not associated with increased risk of operative all-cause or bleeding-related mortality. As expected, taking ticagrelor compared with clopidogrel in the short interval confers a higher risk of bleeding complications.

INTRODUCTION:Elephant trunk repair of the aortic arch cannot be performed with a branched prosthesis.AIM:We conceived two different modifications of the original technique to perform an arch replacement with a branched graft, while arranging an adequate landing zone for a subsequent thoracic endovascular aortic repair, without the need of dedicated material.MATERIAL AND METHODS:Eight consecutive patients underwent arch replacement with one of our techniques. Five were emergency patients with acute aortic dissection, and 3 suffered chronic expansive disease. The "modified elephant trunk" includes a separate anastomosis of an endo-luminal prosthetic segment in the descending aorta. Subsequently, the branched arch prosthesis is anastomosed to the distal aortic stump with the attached trunk. In the "prophylactic debranching", a tail is left on the distal end of the arch prosthesis, so that the branches for the supra-aortic vessels will remain displaced proximally, allowing a "zone 1" available for landing.RESULTS:Three patients experienced transient cerebral deficits (1 transient ischemic attack and post-operative delirium in 2 cases), 1 required re-operation for bleeding and 2 needed prolonged intubation. One died of multi-organ failure.CONCLUSIONS:Both techniques proved to be easily reproducible, and allow an adequate landing zone for a subsequent endovascular procedure, while retaining the advantages of using a tetra-furcated prosthesis. They are a viable alternative when a hybrid prosthesis cannot be implanted.

BACKGROUND:Despite improvements in operative techniques, open thoracoabdominal aortic aneurysm (TAAA) repair is complex and characterized by high mortality and morbidity rate. Less invasive techniques have been developed since 2005 for the treatment of TAAA. Unfortunately, many of these devices require custom fabrication, resulting in delay of many weeks until treatment can be delivered but crucial in critical emergency cases. We present a novel hybrid endovascular and surgical prosthesis, which was tested on five pigs, with the aim of reducing the barrier issues of endovascular therapy in such particular cases.METHODS:The principal characteristic of the proposed hybrid endovascular prosthesis is to combine a proximal and distal stented zones and, in between, a classical surgical blood tied Dacron prosthesis. The device was tested in five pigs where feasibility of implantation and acute postoperative outcomes were evaluated, including bleeding, bowel ischemia, renal function, and peripheral blood perfusion.RESULTS:In all cases, following laparotomy, the endoprosthesis was successfully implanted under fluoroscopy and the surgical prosthesis zone could be easily detected by the radio-opaque markers. No major bleeding or cardiac events occurred throughout preparation and implantation. One hour after prosthesis implantation and surgical anastomoses of all vessels were completed, normal urine output was registered, and no acidosis was detected.CONCLUSIONS:This novel graft has shown ease of endoprosthesis and visceral vessels implantation without the need of thoracotomy or extracorporeal circulation and may be useful in an emergency setting or high risk and complex anatomy TAAA unsuitable for traditional endovascular aneurysm repair, or to avoid an excess waiting time for a "custom made" prosthesis. The great adaptability of this "hybrid" prosthesis in complex anatomy for the majority of TAAA could be important in high-risk patients and in some difficult situations, such as a high risk of imminent rupture.

Aim: To evaluate retrospectively the impact of ticagrelor or clopidogrel in patients taking dual antiplatelet aggregation therapy (DAPT, ASA + clopidogrel or ticagrelor) undergoing coronary artery bypass grafting (CABG) on postoperative bleeding complications and need for mediastinal surgical re-exploration, focusing on the interval of discontinuation of DAPT. Material and methods: From January 2017 to January 2018, 190 patients underwent coronary artery bypass grafting with DAPT discontinuation 5 days (group 1, n = 82), 2–4 days (group 2, n = 84), or 0–1 days (group 3, n = 24) prior to CABG. Results: As compared to group 1, blood loss from chest tube drainages at 24 hours was significantly higher in groups 2 and 3 (480 ±238 vs. 512 ±209 vs. 640 ±253 ml; p = 0.007 and p = 0.016). Incidence of surgical re-exploration for bleeding was 1.2% in group 1, 2.4% in group 2, 12.5% in group 3 (p = 0.014). Independent predictors of surgical re-exploration were group 3 (p = 0.05; HR = 9.2) and preoperative increased value of creatinine serum level (p = 0.02; HR = 1.3). In group 3, the incidence of re-exploration was 5.6% (1/18) in patients taking ASA + clopidogrel, 33.3% (2/6) in those taking ASA + ticagrelor (HR-32), respectively (p < 0.001). Operative mortality was 1.2% in group 1, 1.2% in group 2, absent in group 3 (p = not significant). Conclusions: Continued DAPT intake until CABG shows a clear trend towards more bleeding complications when compared with its discontinuation. Major blood loss and surgical reexploration were not associated with an increased risk of operative mortality. Ticagrelor intake confers a higher risk of bleeding in comparison with clopidogrel; by stopping its intake at least 2 days prior to surgery, an increased risk of bleeding complications is not observed.

To determine whether body mass index ≥30 kg/m2 affects morbidity and mortality rates in patients undergoing surgery for type A acute aortic dissection, we conducted a retrospective study of 201 patients with type A dissection. Patients were divided into 2 groups according to body mass index (BMI): nonobese (BMI, <30 kg/m2; 158 patients) and obese (BMI, ≥30 kg/m2; 43 patients). Propensity score matching was used to reduce selection bias. The overall mortality rate was 19% (38/201 patients). The perioperative mortality rate was higher in the obese group, both in the overall cohort (33% vs 15%; P=0.01) and in the propensity-matched cohort (32% vs 12%; P=0.039). In the propensity-matched cohort, patients with obesity had higher rates of low cardiac output syndrome (26% vs 6%; P=0.045) and pulmonary complications (32% vs 9%; P=0.033) than those without obesity. The overall 5-year survival rates were 52.5% ± 7.8% in the obese group and 70.3% ± 4.4% in the nonobese group (P=0.036). In the propensity-matched cohort, the 5-year survival rates were 54.3% ± 8.9% in the obese group and 81.6% ± 6.8% in the nonobese group (P=0.018). Patients with obesity (BMI, ≥30 kg/m2) who underwent surgery for type A acute aortic dissection had higher operative mortality rates and an increased risk of low cardiac output syndrome, pulmonary complications, and other postoperative morbidities than did patients without obesity. Additional extensive studies are needed to confirm our findings.

Introduction Minimally invasive approach through a right mini-thoracotomy is a worldwide used procedure for mitral valve surgery. Aortic occlusion is one the most important open discussion in minimal incision valve surgery. Different techniques have been described during the last years and all have shown benefits and drawbacks. In this retrospective study we define a standard protocol to improve the safety of aortic clamping using a intra-aortic occlusion device in order to reduce related complications. Methods Fiftytwo patients (26 male and 26 female, mean age 62 ± 5 years) underwent cardiac surgery through a right antero-lateral minithoracotomy in our cardiac surgery department. The following surgical procedures have been performed: 32 mitral valve repairs, 4 atrial mixoma excisions, 16 mitral valve replacements. In 7 cases a combined tricuspid valve repair has been performed. In all cases a intra-aortic occlusion device was used for aortic clamping and cardioplegia. Continuous transesophageal three-dimensional echocardiography was performed to confirm the correct position of the venous cannulas and of the intra-aortic occlusion device. In particular, simultaneous multi-plane three-dimensional echocardiography imaging (dual screen simultaneously displaying two real-time images) was acquired to detect the intra-aortic device location in the ascending aorta, the inflation of the balloon, the complete occlusion of the aorta, the delivery of the cardioplegia and to visualize the origin and the blood flow in the right coronary artery. A bilateral upper extremity invasive arterial pressure monitoring has been detected in all cases. Aortic root pressure was measured by the tip of the intra-aortic occlusion device. Neuromonitoring was performed through bilateral cerebral oximetry and transcranial color Doppler. Results The analysis performed among 52 patients has shown no incidence of aortic dissection, no neurological damage type 1 and no myocardial ischemia. In 3 cases a distal displacement of the intra-aortic occlusion device was promptly detected by the combined use of echocardiographic imaging and by a drop of the right cerebral oximetry saturation and of the right radial artery pressure. Discussion In our opinion, the combined use of transesophageal simultaneous multi-plane three-dimensional echocardiography imaging, bilateral upper extremity invasive arterial pressure monitoring, aortic root pressure and cerebral oximetry may be accepted as a standard protocol in order to reduce adverse events and complications related to the use of the intra-aortic occlusion device.

BackgroundWe retrospectively analysed the short-term outcome of the third-generation St. Jude Trifecta aortic prosthesis.MethodsBetween December 2014 and December 2017, 177 patients (mean age 75.1±6.8 years, 95 males, 82 females) underwent aortic valve replacement with a St. Jude Trifecta aortic prosthesis and were followed up to 27±9 months. Preoperatively 92 patients (52.0%) were in NYHA class III-IV, EuroSCORE II was 3.2%±2.1%.ResultsTrifecta sizes implanted were 19 mm (n=46) (26%), 21 mm (n=69) (39%), 23 mm (n=46) (26%), 25 mm (n=16) (9%). Concomitant coronary artery bypass grafting was performed in 60 patients (34.0%). Operative mortality was 3.4% (1.7% for isolated aortic valve replacement versus 6.7% for combined aortic valve replacement and coronary artery bypass grafting) (P=0.084). The only independent predictor of mortality was the need for the mechanical ventilation greater than 24 hours (P=0.037); recently occurring myocardial infarction was risk factor for mortality at the univariate analysis only (P=0.013). Three-year survival was 84%±6%, freedom from cardiac death 98%±1%, freedom from prosthetic endocarditis 97%±1%. No thromboembolisms or structural valve degeneration were observed. Patient-prosthesis mismatch (PPM) was absent in 126 patients (71.2%), mild-to-moderate in 32 (18.1%), moderate in 19 (10.7%), severe in no any patient. Follow-up echocardiography showed an average mean and peak trans-aortic valve gradients reduction more than 70% in comparison with preoperative value (P<0.0001), and a significant regression of left ventricular hypertrophy (P<0.0001). Moderate PPM did not negatively affect survival. Concomitant severe coronary artery disease was found as an independent predictor of reduced survival (72%±12% versus 86%±6%) (P=0.015).ConclusionsTrifecta aortic prosthesis seems to provide very favourable clinical outcome and hemodynamic performance. At three years, survival was negatively affected by severe coronary artery disease detected at the time of operation. During short-term follow-up, no early structural valve degeneration was been observed. Due to low incidence of PPM and low peak and mean trans-prosthetic aortic valve gradients, third generation Trifecta aortic prosthesis should be considered as one of the best options in the setting of the aortic valve replacement surgery. However, a long-term follow-up is mandatory to confirm the early promising data.

Aim:We retrospectively analyzed early results of coronary artery bypass grafting (CABG) surgery using antegrade intermittent warm blood or St. Thomas cold crystalloid cardioplegia. Material and methods:From January 2015 to May 2018, in 556 patients undergoing isolated CABG, cardiac arrest was obtained using warm blood (WB group, n = 402) or St. Thomas cardioplegia (ST group, n = 154). Myocardial enzymes' release was calculated at the end of CABG (time 0), 24, and 48 hours postoperatively. Results:In-hospital mortality was 1.74% in the WB group, 0.65% in the ST group. As compared with the WB group, in the ST group the number of distal coronary artery anastomoses per patient was significantly higher (2.9 ±0.9 vs. 2.6 ±0.8) (p = 0.003), despite a similar required number of cardioplegia doses per patient (2.2 ±0.9 vs. 2.3 ±0.9). The incidence of perioperative myocardial infarction, low cardiac output syndrome, myocardial enzymes release, rate of CK-MB/CK ratio > 10% was similar. As compared with the WB group, in the ST group the proportion of patients with CK-MB/CK ratio > 5% was lower at each time point of evaluation, with a significant difference at time 0 (30.5% vs. 48%) (p = 0.0005), whereas the need for blood transfusion per patient was higher (1.3 ±2.0 vs. 0.54 ±1.3) (p < 0.0001). Within the WB group, the rate of CK-MB/CK ratio > 5% was significantly reduced when dose administration was repeated within 18 minutes compared to 20-25 minutes (36% vs. 59%) (p < 0.0001). Duration of the extracorporeal circulation and of the aortic cross-clamping, and the mean number of coronary bypasses were not identified as risk factors either for the CK-MB/CK ratio greater than 10% or greater than 5%. Conclusions:Based on a single-center experience, both types of cardioplegia are associated with equivalent clinical results. St. Thomas cardioplegia, despite the greater number of grafts per patient and therefore greater extracorporeal circulation and aortic cross-clamping times, and greater postoperative need for blood transfusion, appears to be associated with a lower rate of CK-MB ratio > 5%. Warm blood cardioplegia allows better protection when administered in an 18-minute re-dosing interval.

Aim: Coronary endarterectomy (CE) may provide a useful adjunctive technique to coronary artery bypass grafting (CABG) in patients with diffuse coronary artery disease. Nevertheless, the incidence of complications still remains high, long-term results remain unclear, and no risk factors for late mortality have been completely described yet. Material and methods: We retrospectively reviewed 90 consecutive patients (67 +/- 8.2 years) undergoing isolated CABG in association with CE between 2006 and 2013. Mean follow-up was 75.1 +/- 36.2 months (median: 84 months) and it was 100% complete (6755/6755 patient-months). Results: Operative mortality was 4.4%, the incidence of perioperative myocardial infarction was 11%. Ten-year survival was 83.3 +/- 4.1%, freedom from cardiac death 92.7 +/- 2.9%, and freedom from major adverse cardiac and cerebrovascular events 58.2 +/- 10.2%. Independent predictors of late mortality were age older than 70 years at time of the surgery (p = 0.018) and chronic obstructive pulmonary disease (p = 0.036). Ten-year freedom from cardiac death was better after CE on the left descending coronary artery (LAD) (93.2 +/- 3.3%) in comparison to CE not on the LAD (74.6 +/- 10.2%), although this difference did not reach statistical significance (p = 0.102). Conclusions: Although the incidence of perioperative myocardial infarction continues to be not negligible, in the presence of diffusely diseased coronary artery vessels CE associated with CABG appears to be a feasible adjunctive surgical tool, conferring satisfactory early and long-term outcomes. Coronary endarterectomy on the LAD confers a high probability of freedom from late cardiac death. Patients older than 70 years and those affected by a primary respiratory disease represent a new challenge on which to focus attention due to the increased risk of late death.

Background and Aim: We retrospectively analyzed the short-term outcome of the third-generation St. Jude Trifecta aortic valve. Methods: Between December 2014 and December 2017, 177 patients (mean age 75 ± 7 years, 95 males, 82 females) underwent aortic valve replacement (AVR) with St. Jude Trifecta aortic valve and were followed up to 27 ± 9 months. Results: Operative mortality was 3.4% (1.7%, isolated AVR). Three-year survival was 84% ± 6%, freedom from cardiac death 98% ± 1%. Echocardiographic variables are reported in Table. Conclusions: Trifecta valve provides favourable clinical outcome and hemodynamic performance. No early structural valve degeneration has been observed. Due to the minimal incidence of severe PPM and to the low value of mean trans-prosthetic gradient, Trifecta valve should be considered as one of the best options among the third generation biological prostheses. Longer follow-up is mandatory. Table. Echocardiographic variables and clinical status

Abstract Background and aim: Surgery of mitral valve is one of the most evolving topic, especially for repair techniques and is often challenging for surgeons. We retrospectively evaluate the results of mitral valve repair (MVRep) or replacement (MVR) in primary MR. Methods: 165 consecutive patients (mean age 65 ± 12.5 years) between January 2014 and December 2018 underwent MVRep (89 pts, 54%) or MVR (76 pts, 46%). Mean EuroSCORE II was 3 ± 2%. 89 pts were severely symptomatic for dyspnea (53.9%). In all cases of MVRep a prosthetic ring was implanted; adjunctive procedure were a triangular (11%) or quadrangular resection (11%) and edge to edge (24%). A mechanical prosthesis were implanted in 60 pts (36%). Mean follow-up (95% complete, 157 patients) was 50.2 ± 17.9 months. Results: Overall in hospital mortality was 4.8%; 1.1% (1pts) and 9.2% (7 pts) for MVRep and MVR respectively. Three of these 8 patients were octogenarian and at high risk surgery with an EuroSCORE II>7%. Follow-up mortality was 6.3% (10 pts), cardiac death was 3.8%. 6 years survival was 90.7 ± 3%. Three patients (MVRep) underwent MVR for MR recurrence with a 6 years freedom from reoperation of 97.9 ± 1.2%. Freedom from symptoms was 89.6 ± 3.2%. No significantly differences was found between MVRep and MVR in terms of survival (logRank test, p = 0.61), reoperation (logRank test, p = 0.138) and symptoms (logRank test, p = 0.264). Conclusioni: MVRep appears to have lower in-hospital mortality than MVR (p = 0.025). Long term results showed excellent survival and comparable outcomes in terms of reintervention and relief of symptoms between MVRep and MVR.

Background: Myocardial protection techniques during cardiac arrest have been extensively investigated in the clinical setting of coronary revascularization. Fewer studies have been carried out of patients affected by left ventricular hypertrophy, where the choice of type and temperature of cardioplegia remain controversial. We have retrospectively investigated myocardial injury and short-term outcome in patients undergoing aortic valve replacement plus or minus coronary artery bypass grafting with using cold crystalloid cardioplegia (CCC) or warm blood cardioplegia (WBC). Methods: From January 2015 to October 2016, 191 consecutive patients underwent aortic valve replacement plus or minus coronary artery bypass grafting in normothermic cardiopulmonary bypass. Cardiac arrest was obtained with use of intermittent antegrade CCC group (n= 32) or WBC group (n= 159), according with the choice of the surgeon. Results: As compared with WBC group, in CCC group creatine-kinase-MB (CK-MB), cardiac troponin I (cTnI), aspartate aminotransferase (AST) release, and their peak levels, were lower during each time points of evaluation, with the greater statistically significant difference at time 0 (P< 0.05, for all comparisons). A time 0, CK-MB/CK ratio > 10% was 5.9% in CCC group versus 7.8% in WBC group (P< 0.0001). At time 0 CK-MB/CK ratio > 10% in patients undergoing isolated aortic valve replacement was 6.0% in CCC group versus 8.0% in WBC group (P< 0.01). No any difference was found in perioperative myocardial infarction (0% versus 3.8%), postoperative (PO) major complications (15.6% versus 16.4%), in-hospital mortality (3.1% versus 1.3%). Conclusions: In aortic valve surgery a significant decrease of myocardial enzymes release is observed in favor of CCC, but this difference does not translate into different clinical outcome. However, this study suggests that in presence of cardiac surgical conditions associated with significant left ventricular hypertrophy, i.e., the aortic valve disease, a better myocardial protection can be achieved with the use of a cold rather than a warm cardioplegia. Therefore, CCC can be still safely used.

Background: Chronic kidney disease (CKD) has been found to be an independent risk factor for cardiovascular diseases onset. We investigated the association between initial renal function and clinical outcomes in patients undergoing cardiac surgery. Methods: This was a single- centre, retrospective cohort study of 284 patients underwent cardiac surgery in Tor Vergata University Hospital between Genuary 2017 and February 2018. Patients with eGFR <60 ml/min (Group 1) were compered with patients with eGFR >60 ml/min. A propensity match score has been applied to investigate the effect of ultrafiltration in patients with eGFR <60 ml/min underwent cardiac surgery Results: No significant differences have been observed in term of cardiac, pulmonary, renal and cerebral complications between the two groups. In hospital mortality was 16% in Group 1 and 5.3% in Group 2 (p-value 0.003). In patients with eGFR < 60 ml/min, the propensity match score analysis did not reveal any significant differences in terms of morbidity between untrafiltered and no ultrafiltered patients. The ultrafiltration increased the risk of mortality (9%vs 2%, p-value 0.045). Conclusions: an initial eGFR< 60 ml/min is associated with an incremental risk of mortality in patients undergoing cardiac surgery. The extracorporeal circulation does not seem have any worsening effect on the renal function after the operation. No benefits have been observed using ultrafiltration in patients with severe renal failure.

BACKGROUND:Ischemic mitral valve regurgitation (IMR) develops in approximately 10% of patients after myocardial infarction. Surgical management of IMR is controversial, as many series have failed to demonstrate the superiority of mitral valve repair (MVRep) over mitral valve replacement (MVR) in IMR. Moreover, in the setting of MVRep, the choice of ring type is the subject of much debate. The study aim was to evaluate the results of MVRep in IMR with the use of a semi-rigid incomplete C-ring. METHODS:Between January 2006 and May 2014, a total of 105 patients (79 males, 26 females; mean age 69 ± 8 years) underwent surgical MVRep using a semi-rigid incomplete ring (median size 30 mm) during coronary artery bypass grafting (CABG) to treat IMR. The patients' mean logistic EuroSCORE was 14 ± 12, and the preoperative left ventricular ejection fraction was 43 ± 11%. The mean duration of follow up was 48 ± 31 months, and was 100% complete. RESULTS:In-hospital mortality was 6.6% (n = 7). The main predictor of in-hospital mortality was cardiopulmonary bypass time (p <0.05). Echocardiography performed at discharge showed moderate mitral regurgitation (MR) in only one patient, and significant reductions in left ventricular end-diastolic diameter (p <0.0001) and MR grade (p <0.0001). After seven years, freedom from all-cause death was 73 ± 9%, while freedoms from recurrence of MR grade ≥2 and NYHA class >II were 95 ± 3% and 89 ± 4%, respectively. Freedom from reintervention was 100%. CONCLUSIONS:Despite the adverse prognosis of IMR, the present study demonstrated the effectiveness and durability of mitral valve repair with the use of a semi-rigid ring, as a concomitant procedure to CABG, showing good results in terms of recurrence of MR and event-free survival at mid-term follow up.

Coronary thromboembolism is a rare cause of acute coronary syndromes (ACS, i.e. STEMI) and the data regarding ACS in patients with prosthetic heart valve are poor and based mainly on case report. The likelihood of this focal coronary problem with normal coronary arteries is between 1% to 5% and several mechanisms have been proposed and reported. We here present the single case of a distal left circumflex artery embolism after Bentall procedure and hemiarch resectionin the setting of an acute type A aortic dissection successfully managed with conservative therapy and a brief comment on the actual literature. Paolo Nardi*, Marco Russo, Monica Greci, Calogera Pisano, Guglielmo Saitto, Giulio Pellegrini, Antonio Pellegrino,Carlo Bassano, Antonio Scafuri and Giovanni Ruvolo Department of Cardiac Surgery, Tor Vergata University Policlinic, Rome, Italy

Abstract Background and Aim: Paroxysmal atrial fibrillation (PAF) is the most frequent complication following cardiac surgery. Despite high incidence, its etiology remains uncler. Aim of our investigation was to analyze retrospectively the pathogenetic role of different types of cardioplegia on the onset of PAF. Methods: Sixty-hundred and sixty patients underwent on-pump cardiac surgery between January 2015 and October 2016. Redo operations and emergency surgery were excluded. The types of cardiolplegic solution administered were warm blood cardioplegia (Calafiore, n = 480), cold crystalloid extracellular cardioplegia (St. Thomas, n = 71), cold crystalloid intracellular cardioplegia (Custodiol, n = 109). The way of admistation was antegrade for all types of cardioplegic solution. Results: The incidence of postoperative PAF was 36.2% (239 patients). Two-hundred patients were initially treated by mens of amiodarone infusion that successfully allowed cardioversion in 167 cases (83.5%); in the other 39 patients were initially administered other drugs (i.e. verapamil e.v./per os, beta-blokers per os). A relation between the type of cardioplegic solution and the onset of postoperative PAF was not found (Calafiore, n = 180, 37.5%; St. Thomas, n = 22, 31%; Custodiol, n = 37, 34%; p = NS). Advanced age at operation (71.3 ± 8.7 vs. 65.7 ± 11 years) was the only independent predictor of PAF (p < 0.001). Non-coronary surgery was found as risk factor for PAF at the univariate analysis only (p < 0.01). Conclusions: The use of different type of cardioplegic solutions, and at different temperatures, does not correlate with the onset of postoperative PAF. Initial treatment strategy with amiodarone infusion allows pharmacological cardioversion of PAF in over 80% of cases.

Background and Aim: To analyse short-term results after the Bentall operation and get clinical considerations. Methods: One hundred and twenty-two patients (mean age 60.4 ± 15.8 years, 99 males,23 females) underwent Bentall operation from January 2015 to December 2017 for treatment of ascending aorta expansive aneurysm (i.e. degenerative aneurysm with tricuspid aortic valve, n = 69; bicuspid valve, n = 37; Marfan syndrome and other genetical disorders, n = 13; redo procedures n = 3). Associate procedures (i.e. coronary artery bypass grafting, mitral valve replacement, other) were performed in 26 patients (21.3%). Euroscore II was 4.7% ± 3.9%. Mean follow-up (99.2% complete) was 20 ± 10 months. Results: In-hospital mortality was 1.6% (1% for isolated Bentall). Three-year survival, freedom from cardiac death, from endocarditis, frome reoperation were 97 ± 1.2%, 99 ± 1.3%, 93 ± 5.1%, 98 ± 1.8%, respectively. No thromboembolism and major bleeding complications were observed. Independent predictors of all-cause death were preoperative higher left ventricular (LV) end-diastolic diameter (71.6 ± 12 vs 53.6 ± 8.6 mm; P = 0.009), LV end-systolic diameter (47.7 ± 9.2 vs 36.8 ± 7.9 mm; P = 0.02), lower LV ejection fraction (43.3 ± 15 vs 56.2 ± 8.7%; P = 0.015). Survival was 98.4 ± 1.6% after isolated Bentall, and 92 ± 5.4% after associated procdures (P = 0.04). As compared to preoperative values, clnical and echocardiography follow-up showed improvement of LV function and NYHA class. Conclusions: Excellent results can be expected after Bentall operation. Low rate of operative mortality and late complications, and significant improvement of clinical status make this operation the gold standard and the reference surgery therapy for the treatment of ascending aorta aneurysms. In presence of dilatation and dysfunction of the left ventricle, adequate medical treatment is necessary to improve survival.

Background and Aim: Surgical management of ischemic mitral regurgitation (IMR) is controversial, and in the setting of mitral valve repair (MVRep) the choice of the ring is still debated. We evaluate the results of MVRep with a semirigid incomplete C-ring in IMR. Methods: Between January 2006 and May 2014, 105 consecutive patients (mean age 69 ± 8 years, 75% males) underwent MVRep using an undersized C-ring during coronary artery bypass grafting to treat IMR. Mean logistic EuroSCORE was 14 ± 12%. Preoperative left ventricular ejection fraction was 43 ± 11%. Mean follow-up was 57 ± 35 months. Results: In-hospital mortality was 6.6% (7 patients). Predictor of in-hospital mortality was the duration of cardiopulmonary bypass (p < 0.05). Echocardiography performed at discharge showed a significant reduction of left ventricle end-diastolic diameter (p < 0.0001) and mitral regurgitation grade (p < 0.0001). Eight-year late death was 26% (26 patients), cardiac death 12%. Eight-year freedom from all-cause and cardiac death was 62 ± 7% and 83 ± 4%, respectively. In 7 patients (7%) recurrence of mitral regurgitation (>2 + ) was found. Freedom from recurrence of mitral regurgitation ≥ 2 and NYHA class > II were 89 ± 5% and 76 ± 9%, respectively. No patients underwent reoperation. Instable angina (p < 0.05), moderate-severe pulmonary hypertension (p < 0.0001) and left ventricle end-systolic diameter (p < 0.001) were independent predictors of long-term mortality. Conclusions: Despite the adverse prognosis of IMR, MVRep with semirigid C-ringassociated with coronary artery bypass showed satisfactory long-term survival, and low recurrence of mitral regurgitation/redo operation.