Filippo Benassi

The Evolution of Cardiovascular Surgery in Elderly Patient: A Review of Current Options and Outcomes

Due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients present for cardiac surgery nowadays. Advances in pre- and postoperative care have led to the possibility that an increasing number of elderly patients can be operated on safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is only acceptable in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.

A predictive model for early mortality after surgical treatment of heart valve or prosthesis infective endocarditis. The EndoSCORE

BACKGROUNDnThe aim of this large retrospective study was to provide a logistic risk model along an additive score to predict early mortality after surgical treatment of patients with heart valve or prosthesis infective endocarditis (IE).nnnMETHODSnFrom 2000 to 2015, 2715 patients with native valve endocarditis (NVE) or prosthesis valve endocarditis (PVE) were operated on in 26 Italian Cardiac Surgery Centers. The relationship between early mortality and covariates was evaluated with logistic mixed effect models. Fixed effects are parameters associated with the entire population or with certain repeatable levels of experimental factors, while random effects are associated with individual experimental units (centers).nnnRESULTSnEarly mortality was 11.0% (298/2715); At mixed effect logistic regression the following variables were found associated with early mortality: age class, female gender, LVEF, preoperative shock, COPD, creatinine value above 2mg/dl, presence of abscess, number of treated valve/prosthesis (with respect to one treated valve/prosthesis) and the isolation of Staphylococcus aureus, Fungus spp., Pseudomonas Aeruginosa and other micro-organisms, while Streptococcus spp., Enterococcus spp. and other Staphylococci did not affect early mortality, as well as no micro-organisms isolation. LVEF was found linearly associated with outcomes while non-linear association between mortality and age was tested and the best model was found with a categorization into four classes (AUC=0.851).nnnCONCLUSIONSnThe following study provides a logistic risk model to predict early mortality in patients with heart valve or prosthesis infective endocarditis undergoing surgical treatment, called The EndoSCORE.

ECMO for pulmonary rescue in an adult with amiodarone-induced toxicity.

Amiodarone is a highly effective antiarrhythmic agent. Unfortunately amiodarone-induced pulmonary toxicity is described for medium-long term therapy. We describe a case of a 65-year-old man admitted to our department for breathlessness and with a history of recurrent episodes of atrial fibrillation for which he had been receiving amiodarone (200xa0mg/day) since 2008. Despite diuretic therapy, along with aspirin, statins and antibiotics the patient continued to complain of severe dyspnea and had a moderate fever. Thus, diagnostic hypotheses different from acute cardiac failure were considered, in particular non-cardiogenic causes of pulmonary infiltrates. Following suspicion of amiodarone-induced pulmonary toxicity, the drug was discontinued and corticosteroid therapy was initiated. Due to the deterioration of the clinical picture, we proceeded to intubation. After few hours from intubation we were forced to institute a veno-venous extracorporeal membrane oxygenation due to the worsening of pulmonary function. The patient’s clinical condition improved which allowed us to remove the ECMO after 15xa0days of treatment. Indications for use of ECMO have expanded considerably. To our knowledge this is the first successful, reported article of a veno-venous ECMO used to treat amiodarone-induced toxicity in an adult. In patients with severe but potentially reversible pulmonary toxicity caused by amiodarone, extracorporeal life support can maintain pulmonary function and vital organ perfusion at the expense of low morbidity, while allowing time for drug clearance.

Surgery for prosthetic valve endocarditis: a retrospective study of a national registry

OBJECTIVESnWe described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design.nnnMETHODSnData regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study.nnnRESULTSnOverall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P u2009=u20090.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P u2009<u20090.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P u2009<u20090.001) and median logistic EuroSCORE (14%, 21%, 23%, P u2009=u20090.025). Older age, female sex, preoperative serum creatinineu2009>-2u2009mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (ORu2009=u20091.02; P u2009=u20090.03), renal insufficiency (ORu2009=u20092.1; P u2009=u20090.05), triple valve surgery (ORu2009=u20096.9; P u2009=u20090.004) and shock (ORu2009=u20094.5; P u2009<u20090.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (ORu2009=u20093; P u2009<u20090.001), Enterococcus (ORu2009=u20092.3; P u2009=u20090.01) and female sex (ORu2009=u20091.5; P u2009=u20090.03) independently predicted complications, whereas ejection fraction was protective.nnnCONCLUSIONSnPVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patients haemodynamic status and microbiological factors.

Parma tracheostomy technique: a hybrid approach to tracheostomy between classical surgical and percutaneous tracheostomies

BACKGROUNDnThe aim of our study is to compare the classical surgical tracheostomy (TT) technique with a modified surgical technique designed and created by the cardiothoracic surgery staff of our department to reduce surgical trauma and postoperative complications. This modified technique combines features of percutaneous TT and surgical TT avoiding the use of specialized tools, which are required in percutaneous TT.nnnMETHODSnFrom October 2008 to March 2014 we performed 67 tracheostomies using this New Modified Surgical Technique (NMST) and 56 TT with the Classical Surgical Technique (CST). We collected data about the early clinical complications, deaths TT-related, deaths due to other complications and the presence of late TTs complications were performed by a telephone follow-up. SPSS software (IMB version 21) was used for the statistical analysis. Categorical data were treated with chi-square test and continuous data were treated with t-test for independent samples.nnnRESULTSnNMST group had a significant lower number of early complications (P=0.005) compared to CST group (5 vs. 15). In-hospital mortality was significantly higher in CST group (18 deaths vs. 4 in NMST group, P=0.001) but we registered only one case of TT-related mortality in CST group (P=0.280). We did not note other differences between the two groups regarding short or mid-long term complications.nnnCONCLUSIONSnIn our experience the NMST demonstrated to be easily safe and reproducible with an amount of early, mid- and long-term complications similar to the CST; furthermore the aesthetic results of the procedure appear similar to those of percutaneous TT.

Renal Doppler Resistive Index as a Marker of Oxygen Supply and Demand Mismatch in Postoperative Cardiac Surgery Patients.

Background and Objective. Renal Doppler resistive index (RDRI) is a noninvasive index considered to reflect renal vascular perfusion. The aim of this study was to identify the independent hemodynamic determinants of RDRI in mechanically ventilated patients after cardiac surgery. Methods. RDRI was determined in 61 patients by color and pulse Doppler ultrasonography of the interlobar renal arteries. Intermittent thermodilution cardiac output measurements were obtained and blood samples taken from the tip of pulmonary artery catheter to measure hemodynamics and mixed venous oxygen saturation (SvO2). Results. By univariate analysis, RDRI was significantly correlated with SvO2, oxygen extraction ratio, left ventricular stroke work index, and cardiac index, but not heart rate, central venous pressure, mean artery pressure, pulmonary capillary wedge pressure, systemic vascular resistance index, oxygen delivery index, oxygen consumption index, arterial lactate concentration, and age. However, by multivariate analysis RDRI was significantly correlated with SvO2 only. Conclusions. The present data suggests that, in mechanically ventilated patients after cardiac surgery, RDRI increases proportionally to the decrease in SvO2, thus reflecting an early vascular response to tissue hypoxia.

Aims and expectations of a prospective multicenter study on aortic valve surgery: (E-AVR registry)

Background: Treatment of severe aortic valve stenosis (SAVS) is a hot topic due to improved life expectancy of general population, improvement of diagnostic tools, and consequent increased number of patients requiring aortic valve surgery. Traditional aortic valve replacement and recent transcatheter aortic prosthesis implantation have reported comparable or non-inferior mortality in randomised controlled trials (RCTs). However, RCTs have the limitation of the predefined inclusion/exclusion criteria, and cannot completely reflect the ‘real clinical world’. Recently sutureless prostheses, often implanted via minimally invasive approaches, have been reported as an alternative strategy. However, their definitive impact on clinical results is not yet completely evaluated because of the limited sample size of patients population of most of published studies, based on monocentric patients series. n Methods: The aim of this prospective multicentre registry including all patients referred for aortic valve surgery and treated with all available techniques is to obtain a ‘real-world’ scenario of the clinical results arising from current surgical options. n Results: The research protocol enrollment phase is ongoing. Therefore we have not yet results to publish. When available, the research findings deriving from E-AVR registry will be presented in the scientific community in international congresses and published in peer review international journals in the fields of cardiac surgery and cardiology. n Conclusions: This multicenter, prospective, European registry has been designed with the aim to cast light on a lot of controversial issues, particularly those regarding the impact of patient baseline risk factors as well as treatment methods for SAVR, with or without coronary artery bypass grafting (CABG), on the prognosis after treatment. We believe that the information derived from this registry can provide deep knowledge on the causes that lead to adverse outcomes after SAVR, to avoid them, and finally to identify the best treatment option for SAVS for each patient.

Corrigendum to “A predictive model for early mortality after surgical treatment of heart valve or prosthesis infective endocarditis. The EndoSCORE”. [Int. J. Cardiol. Aug 15 2017;241:97-102.]

Michele Di Mauro ⁎, Guglielmo Mario Actis Dato , Fabio Barili , Sandro Gelsomino , Pasquale Santè , Alessandro Della Corte , Antonio Carrozza , Ester Della Ratta , Diego Cugola , Lorenzo Galletti , Roger Devotini , Riccardo Casabona , Francesco Santini , Antonio Salsano , Roberto Scrofani , Carlo Antona , Luca Botta , Claudio Russo , Samuel Mancuso , Mauro Rinaldi , Carlo De Vincentiis , Andrea Biondi , Cesare Beghi , Giangiuseppe Cappabianca , Vincenzo Tarzia , Gino Gerosa , Michele De Bonis , Alberto Pozzoli , Francesco Nicolini , Filippo Benassi , Francesco Rosato , Elena Grasso , Ugolino Livi , Sandro Sponga , Davide Pacini , Roberto Di Bartolomeo , Andrea DeMartino , Uberto Bortolotti , Francesco Onorati , Giuseppe Faggian , Roberto Lorusso , Enrico Vizzardi , Gabriele Di Giammarco , Daniele Marinelli , Emmanuel Villa , Giovanni Troise , Marco Picichè , Francesco Musumeci , Domenico Paparella , Vito Margari , Francesco Tritto , Girolamo Damiani , Giuseppe Scrascia , Salvatore Zaccaria , Attilio Renzulli , Giuseppe Serraino , Giovanni Mariscalco , Daniele Maselli , Massimiliano Foschi , Alessandro Parolari , Giannantonio Nappi ,

Gender differences in outcomes after aortic aneurysm surgery should foster further research to improve screening and prevention programmes

Background Gender-related biases in outcomes after thoracic aortic surgery are an important factor to consider in the prevention of potential complications related to aortic diseases and in the analysis of surgical results. Methods The aim of this study is to provide an up-to-date review of gender-related differences in the epidemiology, specific risk factors, outcome, and screening and prevention programmes in aortic aneurysms. Results Female patients affected by aortic disease still have worse outcomes and higher early and late mortality than men. It is difficult to plan new specific strategies to improve outcomes in women undergoing major aortic surgery, given that the true explanations for their poorer outcomes are as yet not clearly identified. Some authors recommend further investigation of hormonal or molecular explanations for the sex differences in aortic disease. Others stress the need for quality improvement projects to quantify the preoperative risk in high-risk populations using non-invasive tests such as cardiopulmonary exercise testing. Conclusions The treatment of patients classified as high risk could thus be optimised before surgery becomes necessary by means of numerous strategies, such as the administration of high-dose statin therapy, antiplatelet treatment, optimal control of hypertension, lifestyle improvement with smoking cessation, weight loss and careful control of diabetes. Future efforts are needed to understand better the gender differences in the diagnosis, management and outcome of aortic aneurysm disease, and for appropriate and modern management of female patients.

The role of genetic testing in the prevention of acute aortic dissection

Although much has been learned about disease of the thoracic aorta, most diagnosis of thoracic aortic aneurysm (TAA) is still incidental. The importance of the genetic aspects in thoracic aortic disease is overwhelming, and today different mutations which cause TAA or alter its natural history have been discovered. Technological advance has made available testing which detects genetic mutations linked to TAA. This article analyses the genetic aspects of TAA and describes the possible role of genetic tests in the clinical setting in preventing devastating complications of TAA.