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New Perspectives in Cardiovascular Surgery
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New Perspectives in Cardiovascular Surgery

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (31 December 2021) | Viewed by 49185

Special Issue Editors

Prof. Dr. Francesco Onorati

E-Mail Website
Guest Editor
Division of Cardiac Surgery, University of Verona, Verona, Italy
Interests: cardiac surgery; infective endocarditis; cardiac reconstruction
Special Issues, Collections and Topics in MDPI journals
Prof. Dr. Francesco Nicolini

E-Mail Website
Guest Editor
University Hospital in Parma, University of Parma Medical School, Viale Gramsci 14, 43126 Parma, Italy
Interests: cardiopulmonary bypass; myocardial protection; aortic and mitral valve disease; coronary surgery; aortic vessel disease
Prof. Dr. Eduard Quintana

E-Mail Website
Guest Editor
Division of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona Medical School, Barcelona, Spain
Interests: hypertrophic cardiomyopathy; infective endocarditis; aorta disease

Special Issue Information

Dear Colleagues,

Despite the first conception that any surgical attempts to treat heart disease were unethical, the specialty of cardiovascular surgery impressively developed during the past century, reaching unexpected results in terms of safety and efficacy. Impressive developments in technology, surgical instruments, medical research, pharmacology, immunobiology, and human factors all contributed to these achievements, so that current cardiovascular surgical practice is not the same as that provided to patients only few years ago.

For example, several improvements have been made in antibiotic therapy and biological tissue materials for surgical use in endocarditis or vascular graft infections. Similarly, the development of miniaturized instruments has led to the rapid growth of this practice with minimal access. Again, the development of transcatheter technologies has completely revolutionized the endovascular treatment of valve diseases, as well as thoracic and/or abdominal aortic diseases. On the same side, the development of more biocompatible materials together with the miniaturization of equipment have significantly attenuated inflammatory reaction following cardiopulmonary bypass as well as the safety and efficacy of mechanical assisting devices. Finally, several pharmacological developments have dramatically ameliorated anaesthetic management, as well as the postoperative care of heart transplants.

It is therefore the aim of this Special Issue to focus on the most relevant innovations developed in cardiac surgery, vascular surgery, and cardiovascular anaesthesia during the last two decades, and to provide readers with the current state-of-the-art in these fields of surgery.

We therefore welcome the submission of original articles or review articles focused on the novel findings and last developments dealing with:

  1. Anaesthesia in cardiac and vascular surgery;
  2. Cardiopulmonary bypass management;
  3. Minimally invasive cardiac or vascular surgery;
  4. Transcatheter valve therapies;
  5. Endovascular surgery;
  6. Cardiovascular prostheses and biomaterials;
  7. Surgical management for:
    1. Endocarditis;
    2. Vascular graft infections;
    3. Mechanical assisting devices;
    4. Heart transplant.

Authors are encouraged to focus or underscore the impact of novel findings/innovations on the surgical management of cardiovascular diseases.

Prof. Dr. Francesco Onorati
Prof. Dr. Francesco Nicolini
Prof. Dr. Eduard Quintana
Guest Editors

Manuscript Submission Information

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • cardiac surgery
  • vascular surgery
  • cardiovascular anesthesia
  • cardiopulmonary bypass
  • biomaterials
  • cardiovascular prostheses
  • endovascular therapies
  • transcatheter therapies
  • minimally invasive surgery
  • immunobiology

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Published Papers (15 papers)

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Editorial

Jump to: Research, Review

2 pages, 179 KiB  
Editorial
Special Issue “New Perspectives in Cardiovascular Surgery”
by Annalisa Bernabei, Francesco Nicolini, Eduard Quintana, Alessandra Francica and Francesco Onorati
J. Clin. Med. 2022, 11(15), 4535; https://doi.org/10.3390/jcm11154535 - 3 Aug 2022
Viewed by 1245
Abstract
In recent decades, cardiovascular surgery has been making great strides in the field of medicine [...] Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)

Research

Jump to: Editorial, Review

13 pages, 659 KiB  
Article
Hemiarch Versus Arch Replacement in Acute Type A Aortic Dissection: Is the Occam’s Razor Principle Applicable?
by Igor Vendramin, Daniela Piani, Andrea Lechiancole, Sandro Sponga, Concetta Di Nora, Francesco Londero, Daniele Muser, Francesco Onorati, Uberto Bortolotti and Ugolino Livi
J. Clin. Med. 2022, 11(1), 114; https://doi.org/10.3390/jcm11010114 - 26 Dec 2021
Cited by 10 | Viewed by 2720
Abstract
Background and aim of the study: In patients with acute Type A aortic dissection (A-AAD) whether repair should be limited to ascending aorta/hemiarch replacement or extended to include the aortic arch is still debated. We have analyzed our experience to compare outcomes of [...] Read more.
Background and aim of the study: In patients with acute Type A aortic dissection (A-AAD) whether repair should be limited to ascending aorta/hemiarch replacement or extended to include the aortic arch is still debated. We have analyzed our experience to compare outcomes of patients with A-AAD treated with these 2 different surgical strategies. Methods: From 2006 to 2020, a total of 213 patients have undergone repair of A-AAD at our Center; in 163 of them ascending aorta/hemiarch replacement (Group 1) and in 75 ascending aorta and arch replacement (Group 2) were performed. The primary endpoint was early survival and secondary endpoints late survival, freedom from late complications and reoperations. Patients were compared according to era of operation: 2006 to 2013 (Era 1) and 2014 to 2020 (Era 2). Results: Overall hospital mortality was 12% and 5% in Group 1 and 2; mortality remained stable in Era 1 and 2 for Group 1 (15%), while it decreased from 8% to 1% in Group 2 patients (p = 0.24). Actuarial survival at 5 and 10 years is 72 ± 4% and 49 ± 5% in Group 1 and 77 ± 6% and 66 ± 9% in Group 2 (p = 0.073). Actuarial freedom from reoperation in the entire series is 94 ± 2% and 92 ± 3% at 5 and 10 years. Freedom from reoperation at 5 and 10 years is 92 ± 2% and 89 ± 3% in Group 1 and 98 ± 1% at all intervals in Group 2 (p = 0.068). Conclusions: An aggressive approach to A-AAD provides superior long-term results without increasing mortality. Furthermore, arch replacement during A-AAD repair represents a more stable solution with lower incidence of late aortic-related complications. Immediate aortic arch replacement should be considered in the treatment of A-AAD especially in experienced centers. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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16 pages, 2232 KiB  
Article
Efficacy of Pulsatile Flow Perfusion in Adult Cardiac Surgery: Hemodynamic Energy and Vascular Reactivity
by Mikhail Dodonov, Francesco Onorati, Giovanni Battista Luciani, Alessandra Francica, Maddalena Tessari, Tiziano Menon, Leonardo Gottin, Aldo Domenico Milano and Giuseppe Faggian
J. Clin. Med. 2021, 10(24), 5934; https://doi.org/10.3390/jcm10245934 - 17 Dec 2021
Cited by 11 | Viewed by 3501
Abstract
Background: The role of pulsatile (PP) versus non-pulsatile (NP) flow during a cardiopulmonary bypass (CPB) is still debated. This study’s aim was to analyze hemodynamic effects, endothelial reactivity and erythrocytes response during a CPB with PP or NP. Methods: Fifty-two patients undergoing an [...] Read more.
Background: The role of pulsatile (PP) versus non-pulsatile (NP) flow during a cardiopulmonary bypass (CPB) is still debated. This study’s aim was to analyze hemodynamic effects, endothelial reactivity and erythrocytes response during a CPB with PP or NP. Methods: Fifty-two patients undergoing an aortic valve replacement were prospectively randomized for surgery with either PP or NP flow. Pulsatility was evaluated in terms of energy equivalent pressure (EEP) and surplus hemodynamic energy (SHE). Systemic (SVRi) and pulmonary (PVRi) vascular resistances, endothelial markers levels and erythrocyte nitric-oxide synthase (eNOS) activity were collected at different perioperative time-points. Results: In the PP group, the resultant EEP was 7.3% higher than the mean arterial pressure (MAP), which corresponded to 5150 ± 2291 ergs/cm3 of SHE. In the NP group, the EEP and MAP were equal; no SHE was produced. The PP group showed lower SVRi during clamp-time (p = 0.06) and lower PVRi after protamine administration and during first postoperative hours (p = 0.02). Lower SVRi required a higher dosage of norepinephrine in the PP group (p = 0.02). Erythrocyte eNOS activity results were higher in the PP patients (p = 0.04). Renal function was better preserved in the PP group (p = 0.001), whereas other perioperative variables were comparable between the groups. Conclusions: A PP flow during a CPB results in significantly lower SVRi, PVRi and increased eNOS production. The clinical impact of increased perioperative vasopressor requirements in the PP group deserves further evaluation. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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13 pages, 2044 KiB  
Article
Artificial Intelligence Supports Decision Making during Open-Chest Surgery of Rare Congenital Heart Defects
by Francesco Paolo Lo Muzio, Giacomo Rozzi, Stefano Rossi, Giovanni Battista Luciani, Ruben Foresti, Aderville Cabassi, Lorenzo Fassina and Michele Miragoli
J. Clin. Med. 2021, 10(22), 5330; https://doi.org/10.3390/jcm10225330 - 16 Nov 2021
Cited by 13 | Viewed by 3173
Abstract
The human right ventricle is barely monitored during open-chest surgery due to the absence of intraoperative imaging techniques capable of elaborating its complex function. Accordingly, artificial intelligence could not be adopted for this specific task. We recently proposed a video-based approach for the [...] Read more.
The human right ventricle is barely monitored during open-chest surgery due to the absence of intraoperative imaging techniques capable of elaborating its complex function. Accordingly, artificial intelligence could not be adopted for this specific task. We recently proposed a video-based approach for the real-time evaluation of the epicardial kinematics to support medical decisions. Here, we employed two supervised machine learning algorithms based on our technique to predict the patients’ outcomes before chest closure. Videos of the beating hearts were acquired before and after pulmonary valve replacement in twelve Tetralogy of Fallot patients and recordings were properly labeled as the “unhealthy” and “healthy” classes. We extracted frequency-domain-related features to train different supervised machine learning models and selected their best characteristics via 10-fold cross-validation and optimization processes. Decision surfaces were built to classify two additional patients having good and unfavorable clinical outcomes. The k-nearest neighbors and support vector machine showed the highest prediction accuracy; the patients’ class was identified with a true positive rate ≥95% and the decision surfaces correctly classified the additional patients in the “healthy” (good outcome) or “unhealthy” (unfavorable outcome) classes. We demonstrated that classifiers employed with our video-based technique may aid cardiac surgeons in decision making before chest closure. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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Graphical abstract

12 pages, 410 KiB  
Article
Impact of Bedside Re-Explorations in a Cardiovascular Surgery Intensive Care Unit Led by Surgeons
by Alessandro Affronti, Elena Sandoval, Anna Muro, Jose Hernández-Campo, Eduard Quintana, Daniel Pereda, Jorge Alcocer, Robert Pruna-Guillen and Manuel Castellà
J. Clin. Med. 2021, 10(19), 4288; https://doi.org/10.3390/jcm10194288 - 22 Sep 2021
Viewed by 2478
Abstract
Surgical re-explorations represent 3–5% of all cardiac surgery. Concerns regarding mortality and major morbidity of re-explorations in the intensive care unit (ICU) setting exist. We sought to investigate whether they may have different outcomes compared with those performed in the operating room (OR). [...] Read more.
Surgical re-explorations represent 3–5% of all cardiac surgery. Concerns regarding mortality and major morbidity of re-explorations in the intensive care unit (ICU) setting exist. We sought to investigate whether they may have different outcomes compared with those performed in the operating room (OR). Single center retrospective review of patients who underwent mediastinal re-exploration in the ICU or in the OR after cardiac surgery. Mediastinal re-explorations were also classified as: “planned” and “unplanned”. Primary outcome was 30-day mortality, secondary outcomes include deep sternal wound infection (DSWI), sepsis, ICU and hospital length of stay, prolonged intubation (>72 h), tracheostomy, pneumonia, acute kidney injury requiring dialysis and stroke. Between 2010 and 2019, 195 of 7263 patients (2.7%) underwent mediastinal re-exploration after cardiac surgery. More patients in the ICU group experienced two or more re-explorations (30.3% vs. 2.3%, p < 0.001), a higher incidence of postoperative pneumonia (22% vs. 7%, p = 0.004), prolonged intubation (46.8% vs. 19.8%, p < 0.001) and longer hospital stay (30.3 ± 34.2 vs. 20.8 ± 18.3 days, p = 0.014). There were no differences in mortality between ICU and OR (16.5% vs. 13.9%, p = 0.24) nor in sepsis (14.7% vs. 7%, p = 0.91) and DSWI rates (1.8% vs. 1.2%, p = 0.14). Re-explorations in the ICU were not associated with increased mortality, sepsis and mediastinitis rate. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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14 pages, 3357 KiB  
Article
Biological Characterization of Human Autologous Pericardium Treated with the Ozaki Procedure for Aortic Valve Reconstruction
by Chiara Gardin, Giampaolo Morciano, Letizia Ferroni, Elisa Mikus, Alberto Tripodi, Maurizio Pin, Elena Tremoli, Alberto Albertini and Barbara Zavan
J. Clin. Med. 2021, 10(17), 3954; https://doi.org/10.3390/jcm10173954 - 31 Aug 2021
Cited by 9 | Viewed by 2797
Abstract
Background: The Ozaki procedure is an innovative surgical technique aiming at reconstructing aortic valves with human autologous pericardium. Even if this procedure is widely used, a comprehensive biological characterization of the glutaraldehyde (GA)-fixed pericardial tissue is still missing. Methods: Morphological analysis was performed [...] Read more.
Background: The Ozaki procedure is an innovative surgical technique aiming at reconstructing aortic valves with human autologous pericardium. Even if this procedure is widely used, a comprehensive biological characterization of the glutaraldehyde (GA)-fixed pericardial tissue is still missing. Methods: Morphological analysis was performed to assess the general organization of pericardium subjected to the Ozaki procedure (post-Ozaki) in comparison to native tissue (pre-Ozaki). The effect of GA treatment on cell viability and nuclear morphology was then investigated in whole biopsies and a cytotoxicity assay was executed to assess the biocompatibility of pericardium. Finally, human umbilical vein endothelial cells were seeded on post-Ozaki samples to evaluate the influence of GA in modulating the endothelialization ability in vitro and the production of pro-inflammatory mediators. Results: The Ozaki procedure alters the arrangement of collagen and elastic fibers in the extracellular matrix and results in a significant reduction in cell viability compared to native tissue. GA treatment, however, is not cytotoxic to murine fibroblasts as compared to a commercially available bovine pericardium membrane. In addition, in in vitro experiments of endothelial cell adhesion, no difference in the inflammatory mediators with respect to the commercial patch was found. Conclusions: The Ozaki procedure, despite alteration of ECM organization and cell devitalization, allows for the establishment of a noncytotoxic environment in which endothelial cell repopulation occurs. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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14 pages, 1018 KiB  
Article
Adverse Events of Percutaneous Microaxial Left Ventricular Assist Devices—A Retrospective, Single-Centre Cohort Study
by Anna S. Zaiser, Gregor Fahrni, Alexa Hollinger, Demian T. Knobel, Yann Bovey, Núria M. Zellweger, Andreas Buser, David Santer, Hans Pargger, Caroline E. Gebhard and Martin Siegemund
J. Clin. Med. 2021, 10(16), 3710; https://doi.org/10.3390/jcm10163710 - 20 Aug 2021
Cited by 7 | Viewed by 2209
Abstract
Worldwide, the left ventricular assist device Impella® (Abiomed, Danvers, MA, USA) is increasingly implanted in patients with acute cardiogenic shock or undergoing high-risk cardiac interventions. Despite its long history of use, few studies have assessed its safety and possible complications associated with [...] Read more.
Worldwide, the left ventricular assist device Impella® (Abiomed, Danvers, MA, USA) is increasingly implanted in patients with acute cardiogenic shock or undergoing high-risk cardiac interventions. Despite its long history of use, few studies have assessed its safety and possible complications associated with its use. All patients treated with a left-sided Impella® device at the University Hospital of Basel from 1 January 2011 to 31 December 2019 were enrolled. The primary endpoint was the composite rate of mortality and adverse events (bleeding, acute kidney injury, and limb ischemia). Out of 281 included patients, at least one adverse event was present in 262 patients (93%). Rates of in-hospital, 90-day, and one-year mortality were 48%, 47%, and 50%, respectively. BARC type 3 bleeding (62%) and hemolysis (41.6%) were the most common complications. AKI was observed in 50% of all patients. Renal replacement therapy was required in 97 (35%) of all patients. Limb ischemia occurred in 13% of cases. Bleeding and hemolysis are common Impella®-associated complications. Additionally, we found a high rate of AKI. A careful selection of patients receiving microaxial LV support and defining the indication for its use are essential measures to be taken for the benefits to outweigh potential complications. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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12 pages, 635 KiB  
Article
Outcomes of Septal Myectomy beyond 65 Years, with and without Concomitant Procedures
by Robert Pruna-Guillen, Daniel Pereda, Manuel Castellà, Elena Sandoval, Alessandro Affronti, Ana García-Álvarez, Juan Perdomo, Cristina Ibáñez, Paloma Jordà, Susanna Prat-González, Jorge Alcocer, Clemente Barriuso, Jaume Llopis and Eduard Quintana
J. Clin. Med. 2021, 10(16), 3499; https://doi.org/10.3390/jcm10163499 - 8 Aug 2021
Cited by 8 | Viewed by 2802
Abstract
Introduction and objectives: Septal myectomy remains the first septal reduction therapy for hypertrophic obstructive cardiomyopathy in young patients and those requiring concomitant procedures. Its role in advanced ages is questioned due to perceived increased risk. We assess the outcomes of surgical relief of [...] Read more.
Introduction and objectives: Septal myectomy remains the first septal reduction therapy for hypertrophic obstructive cardiomyopathy in young patients and those requiring concomitant procedures. Its role in advanced ages is questioned due to perceived increased risk. We assess the outcomes of surgical relief of obstruction in patients beyond 65 years old. Methods: A single-center retrospective review of patients ≥ 65 years old undergoing septal myectomy through median sternotomy between April 2015 and February 2020. Results: We identified 52 patients. Mean age was 71.8 ± 4.9 years; 36 (69.2%) were females. All were symptomatic. Mean highest LVOT gradient was 90 ± 39 mmHg. All patients had systolic anterior motion (SAM) of the mitral valve and 36 (69.2%) ≥ moderate mitral regurgitation. Additional LVOT interventions beyond myectomy were performed in 34 (65.4%). At least one other cardiac concomitant procedure was performed 44 (84.6%). No perioperative mortality in elective surgery occurred. One patient (1.9%) developed atrio-ventricular block. Postoperative mean gradient was 4.3 ± 1.9 mmHg, with 46 (88.4%) achieving complete resolution of obstruction. Mitral regurgitation was reduced to grade ≤ I in 46 (88.5%). Mean follow-up time was 2.3 ± 1.2 years and 82% of patients were in NYHA I. Survival at 2 years was 98%. Conclusion: Septal myectomy in the elderly is a safe and effective operation despite the need for concomitant procedures. LVOT interventions beyond septal myectomy to relieve obstruction are common in this advanced cohort of hypertrophic cardiomyopathy patients. This operation carried at experienced centers seems an unmatched therapeutic option. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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11 pages, 1882 KiB  
Article
Postoperative Changes in Pulmonary Function after Valve Surgery: Oxygenation Index Early after Cardiopulmonary Is a Predictor of Postoperative Course
by Tomohiro Murata, Motohiro Maeda, Ryosuke Amitani, Atsushi Hiromoto, Makoto Shirakawa, Masaru Kambe, Yuji Maruyama and Hajime Imura
J. Clin. Med. 2021, 10(15), 3262; https://doi.org/10.3390/jcm10153262 - 23 Jul 2021
Cited by 4 | Viewed by 2298
Abstract
Objective: To determine pulmonary functional changes that predict early clinical outcomes in valve surgery requiring long cardiopulmonary bypass (CPB). Methods: This retrospective study included 225 consecutive non-emergency valve surgeries with fast-track cardiac anesthesia between January 2014 and March 2020. Blood gas analyses before [...] Read more.
Objective: To determine pulmonary functional changes that predict early clinical outcomes in valve surgery requiring long cardiopulmonary bypass (CPB). Methods: This retrospective study included 225 consecutive non-emergency valve surgeries with fast-track cardiac anesthesia between January 2014 and March 2020. Blood gas analyses before and 0, 2, 4, 8, and 14 h after CPB were investigated. Results: Median age and EuroSCORE II were 71.0 years (25–75 percentile: 59.5–77.0) and 2.46 (1.44–5.01). Patients underwent 96 aortic, 106 mitral, and 23 combined valve surgeries. The median CPB time was 151 min (122–193). PaO2/FiO2 and AaDO2/PaO2 significantly deteriorated two hours, but not immediately, after CPB (both p < 0.0001). Decreased PaO2/FiO2 and AaDO2/PaO2 were correlated with ventilation time (r2 = 0.318 and 0.435) and intensive care unit (ICU) (r2 = 0.172 and 0.267) and hospital stays (r2 = 0.164 and 0.209). Early and delayed extubations (<6 and >24 h) were predicted by PaO2/FiO2 (377.2 and 213.1) and AaDO2/PaO2 (0.683 and 1.680), measured two hours after CPB with acceptable sensitivity and specificity (0.700–0.911 and 0.677–0.859). Conclusions: PaO2/FiO2 and AaDO2/PaO2 two hours after CPB were correlated with ventilation time and lengths of ICU and hospital stays. These parameters suitably predicted early and delayed extubations. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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12 pages, 784 KiB  
Article
Hemoadsorption during Cardiopulmonary Bypass in Patients with Endocarditis Undergoing Valve Surgery: A Retrospective Single-Center Study
by David Santer, Jules Miazza, Luca Koechlin, Brigitta Gahl, Bejtush Rrahmani, Alexa Hollinger, Friedrich S. Eckstein, Martin Siegemund and Oliver T. Reuthebuch
J. Clin. Med. 2021, 10(4), 564; https://doi.org/10.3390/jcm10040564 - 3 Feb 2021
Cited by 17 | Viewed by 3301
Abstract
Background: Aim of this study was to evaluate the outcomes of endocarditis patients undergoing valve surgery with the Cytosorb® hemoadsorption (HA) device during cardiopulmonary bypass. Methods: From 2009 until 2019, 241 patients had undergone valve surgery due to endocarditis at the Department [...] Read more.
Background: Aim of this study was to evaluate the outcomes of endocarditis patients undergoing valve surgery with the Cytosorb® hemoadsorption (HA) device during cardiopulmonary bypass. Methods: From 2009 until 2019, 241 patients had undergone valve surgery due to endocarditis at the Department of Cardiac Surgery, University Hospital of Basel. We compared patients who received HA during surgery (n = 41) versus patients without HA (n = 200), after applying inverse probability of treatment weighting. Results: In-hospital mortality, major adverse cardiac and cerebrovascular events and postoperative renal failure were similar in both groups. Demand for norepinephrine (88.4 vs. 52.8%; p = 0.001), milrinone (42.2 vs. 17.2%; p = 0.046), red blood cell concentrates (65.2 vs. 30.6%; p = 0.003), and platelets (HA vs. Control: 36.7 vs. 9.8%; p = 0.013) were higher in the HA group. In addition, a higher incidence of reoperation for bleeding (34.0 vs. 7.7 %; p = 0.011), and a prolonged length of in-hospital stay (15.2 (11.8 to 19.6) vs. 9.0 (7.1 to 11.3) days; p = 0.017) were observed in the HA group. Conclusions: No benefits of HA-therapy were observed in patients with infective endocarditis undergoing valve surgery. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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Graphical abstract

12 pages, 7787 KiB  
Article
Value of Perioperative Chest X-ray for the Prediction of Sternal Wound Complications after Cardiac Surgery in High-Risk Patients: A “Work in Progress” Analysis
by Andrea Ardigò, Alessandra Francica, Gian Franco Veraldi, Ilaria Tropea, Filippo Tonelli, Cecilia Rossetti, Francesco Onorati and Giuseppe Faggian
J. Clin. Med. 2021, 10(2), 207; https://doi.org/10.3390/jcm10020207 - 8 Jan 2021
Cited by 1 | Viewed by 4635
Abstract
Background. Sternal wound complications are serious events that occur after cardiac surgery. Few studies have investigated the predictive value of chest X-ray radiological measurements for sternal complications. Methods. Several perioperative radiological measurements at chest X-ray and clinical characteristics were computed in 849 patients [...] Read more.
Background. Sternal wound complications are serious events that occur after cardiac surgery. Few studies have investigated the predictive value of chest X-ray radiological measurements for sternal complications. Methods. Several perioperative radiological measurements at chest X-ray and clinical characteristics were computed in 849 patients deemed at high risk for sternal dehiscence (SD) or More than Grade 1 Surgical Site Infection (MG1-SSI). Multivariable analysis identified independent predictors, whilst receiver operating characteristics (ROC) curve analyses highlighted cut-off values of radiological measurements for the prediction of both complications. Results. SD occurred in 8.8% of the patients, MG1-SSI in 6.8%. Chronic obstructive pulmonary disease (COPD) was the only independent predictor for SD (Odds Ratio, O.R. 12.1; p < 0.001); proximal sternal height (PSH) was the only independent protective factor (O.R. 0.58; p < 0.001), with a cut-off value of 11.7 mm (sensitivity 70.5%, specificity 71.0%; ROC area under the curve (AUC) = 0.768, p < 0.001). Diabetes mellitus (O.R. 3.5; p < 0.001) and COPD (O.R. 21.3; p < 0.001) were independent predictors for MG1-SSI; indexed proximal sternal height (iPSH) was as a protective factor (O.R. 0.26; p < 0.001) with a cut-off of 5.97 mm (sensitivity 70.2%, specificity 69.0%; ROC AUC = 0.739, p < 0.001). No other radiological measurements were independently correlated with SD or MG1-SS (p = N.S.). Conclusion. PSH and iPSH at preoperative chest X-ray may act as indicators of high risk for sternal wound complications, allowing for early preventative measures. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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Review

Jump to: Editorial, Research

13 pages, 964 KiB  
Review
Cardioplegia between Evolution and Revolution: From Depolarized to Polarized Cardiac Arrest in Adult Cardiac Surgery
by Alessandra Francica, Filippo Tonelli, Cecilia Rossetti, Ilaria Tropea, Giovanni Battista Luciani, Giuseppe Faggian, Geoffrey Phillip Dobson and Francesco Onorati
J. Clin. Med. 2021, 10(19), 4485; https://doi.org/10.3390/jcm10194485 - 29 Sep 2021
Cited by 11 | Viewed by 7635
Abstract
Despite current advances in perioperative care, intraoperative myocardial protection during cardiac surgery has not kept the same pace. High potassium cardioplegic solutions were introduced in the 1950s, and in the early 1960s they were soon recognized as harmful. Since that time, surgeons have [...] Read more.
Despite current advances in perioperative care, intraoperative myocardial protection during cardiac surgery has not kept the same pace. High potassium cardioplegic solutions were introduced in the 1950s, and in the early 1960s they were soon recognized as harmful. Since that time, surgeons have minimized many of the adverse effects by lowering the temperature of the heart, lowering K+ concentration, reducing contact K+ time, changing the vehicle from a crystalloid solution to whole-blood, adding many pharmacological protectants and modifying reperfusion conditions. Despite these attempts, high potassium remains a suboptimalway to arrest the heart. We briefly review the historical advances and failures of finding alternatives to high potassium, the drawbacks of a prolonged depolarized membrane, altered Ca2+ intracellular circuits and heterogeneity in atrial-ventricular K+ repolarization during reanimation. Many of these untoward effects may be alleviated by a polarized membrane, and we will discuss the basic science and clinical experience from a number of institutions trialling different alternatives, and our institution with a non-depolarizing adenosine, lidocaine and magnesium (ALM) cardioplegia. The future of polarized arrest is an exciting one and may play an important role in treating the next generation of patients who are older, and sicker with multiple comorbidities and require more complex operations with prolonged cross-clamping times. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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13 pages, 3649 KiB  
Review
Surgery for Hypertrophic Obstructive Cardiomyopathy: Comprehensive LVOT Management beyond Septal Myectomy
by Alessandro Affronti, Robert Pruna-Guillen, Elena Sandoval, Daniel Pereda, Jorge Alcocer, Manuel Castellà and Eduard Quintana
J. Clin. Med. 2021, 10(19), 4397; https://doi.org/10.3390/jcm10194397 - 26 Sep 2021
Cited by 14 | Viewed by 4591
Abstract
Hypertrophic cardiomyopathy (HCM) is a complex, underestimated, multifaceted disease frequently associated with left ventricular outflow tract (LVOT) obstruction. It is clearly demonstrated that this is due not only to septal hypertrophy but also to systolic anterior motion (SAM) of mitral valve leaflets secondary [...] Read more.
Hypertrophic cardiomyopathy (HCM) is a complex, underestimated, multifaceted disease frequently associated with left ventricular outflow tract (LVOT) obstruction. It is clearly demonstrated that this is due not only to septal hypertrophy but also to systolic anterior motion (SAM) of mitral valve leaflets secondary to mitral valve/subvalvular apparatus abnormalities. Surgical treatment involves performing an extended septal myectomy, eventually followed by ancillary procedures to those structures responsible for maintaining LVOT obstruction, if necessary. In this review, we describe the spectrum of possible surgical techniques beyond septal myectomy and their pathophysiologic rationale. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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16 pages, 20613 KiB  
Review
Long-Term Outcome of Mechanical and Biological Prostheses in Patients with Left-Side Infective Endocarditis: A Systematic Review and Meta-Analysis
by Francesco Formica, Francesco Maestri, Florida Gripshi, Alan Gallingani, Silvia Grossi and Francesco Nicolini
J. Clin. Med. 2021, 10(19), 4356; https://doi.org/10.3390/jcm10194356 - 24 Sep 2021
Cited by 3 | Viewed by 1599
Abstract
Background. Long-term outcomes of patients with infective endocarditis (IE) who received either a mechanical (MP) or biological prosthesis (BP) are conflicting. A meta-analysis of observational studies comparing the long-term outcomes of left-side IE with the use of MP versus BP was performed. Methods. [...] Read more.
Background. Long-term outcomes of patients with infective endocarditis (IE) who received either a mechanical (MP) or biological prosthesis (BP) are conflicting. A meta-analysis of observational studies comparing the long-term outcomes of left-side IE with the use of MP versus BP was performed. Methods. Electronic databases from January 2000 to June 2021 were screened. Studies reporting long-term mortality were analyzed. The primary endpoint was long-term overall mortality. Secondary endpoints were in-hospital/.30-day mortality and freedom from both prosthesis reinfection and reintervention. The pooled hazard ratio (HR) with 95% confidence interval (CI) was calculated for survival according to the random effect model. Results. Thirteen retrospective observational studies reporting on 8645 patients (MP: 4688; BP: 4137) were included for comparison. Twelve studies reported data of long-term survival for a total of 8285 patients (MP: 4517; BP: 3768). The pooled analysis revealed that the use of MP was statistically associated with longer benefits compared to BP (HR 0.74; 95% CI 0.63–0.86; p < 0.0001). The median follow-up time ranged from 1 to 15.3 years. The pooled analysis of five studies reporting data on prosthesis reinfection in 4491 patients (MP: 2433; BP: 2058) did not reveal significant differences (HR 0.60; 95% CI 0.30–1.21; p = 0.15). Five studies reported data on prosthesis reintervention in 4401 patients (MP: 2307; BP: 2094). The meta-analysis revealed a significant difference in favor of MP (HR 0.40; 95% CI 0.29–0.55; p < 0.0001). Meta-regression reported no effect of male gender (p = 0.09) and age (p = 0.77) on long-term survival. Conclusions. In a meta-analysis of retrospective observational studies comparing the long-term outcome of patients who underwent surgery for left-sided IE, the use of MP compared to BP is associated with a significant longer-term survival and with a reduced incidence of late reoperation. The incidence of late reinfection is comparable between the two prostheses. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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11 pages, 1182 KiB  
Review
Left Ventricular Apex: A “Minimally Invasive Motorway” for Safe Cardiovascular Procedures
by Andrea Agostinelli, Alan Gallingani, Francesco Maestri, Silvia Grossi, Florida Gripshi, Luca De Donno and Francesco Nicolini
J. Clin. Med. 2021, 10(17), 3857; https://doi.org/10.3390/jcm10173857 - 27 Aug 2021
Cited by 4 | Viewed by 2234
Abstract
Since the advent of TAVR (transcatheter aortic valve replacement), the transapical surgical approach has been affirmed as a safe and effective alternative access for patients with unsuitable peripheral arteries. With the improvement of devices for transfemoral approach and the development of other alternative [...] Read more.
Since the advent of TAVR (transcatheter aortic valve replacement), the transapical surgical approach has been affirmed as a safe and effective alternative access for patients with unsuitable peripheral arteries. With the improvement of devices for transfemoral approach and the development of other alternative accesses, the number of transapical procedures has decreased significantly worldwide. The left ventricular apex, however, has proved to be a safe and valid alternative access for various other structural heart procedures such as mitral valve repair, mitral valve-in-valve or valve-in-ring replacement, transcatheter mitral valve replacement (TMVR), transcatheter mitral paravalvular leak repair, and thoracic aorta endovascular repair (TEVAR). We review the literature and our experience of various hybrid transcatheter structural heart procedures using the transapical surgical approach and discuss pros and cons. Full article
(This article belongs to the Special Issue New Perspectives in Cardiovascular Surgery)
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