Guglielmo Mario Actis Dato

The Italian study of the Mitroflow postoperative results (ISTHMUS): a 20-year, multicenter evaluation of Mitroflow pericardial bioprosthesis

OBJECTIVE A multicentre experience with the Mitroflow pericardial bioprosthesis has been evaluated longitudinally over a 20-year period. METHODS From 1988 through 2008, 1591 patients (mean age, 75.3±6.8 years, and 60.1% female) from 12 centres had a Mitroflow in the aortic position. Concomitant coronary artery bypass was performed in 41.9% (n=666) of patients, urgency/emergency surgery in 9.5% (n=152) and replacement of degenerated prosthesis in 2.3% (n=36). Follow-up (7.447 patient-years) was 99.2% complete. Median follow-up was 61.9 months (interquartile range (IQR) 30.8-90.9 months). The study was carried out following American Association for Thoracic Surgery/Society for Thoracic Surgeons/European Association for Cardio-Thoracic Surgery (AATS/STS/EACTS) Guidelines for reporting valve morbidity and mortality. RESULTS The early (30-day) mortality was 6.5% (n=104). Actuarial survival rates at 10, 15 and 18 years were 53%, 34% and 27%, respectively (2.2 patient/year). Re-operation was required in 96 patients (5.9%), of whom 59 patients (3.7%) for structural valve degeneration. Actuarial freedom from prosthetic valve degeneration at 18 years was 65.5% (78% in patients>70 years) with a linearised rate of 1.4 patient/year (0.8 patient/year in patients>70 years). At 18 years, freedom from embolism was 82% (0.9 patient/year), freedom from valve endocarditis was 89% (0.6 patient/year) and freedom from bleeding episodes was 95% (0.2 patient/year), respectively. CONCLUSIONS This independent multicentre study indicates that the Mitroflow pericardial bioprosthesis provides favourable long-term postoperative results with a low rate of valve-related events and need of re-intervention, particularly in patients older than 70 years.

Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: A 5-year multi-institutional experience

BACKGROUND Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. METHOD From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. RESULTS Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. CONCLUSIONS Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.

Pulsed or continuous flow in long-term assist devices: a debated topic.

The end-stage cardiomyopathy is an increasing worldwide problem. Cardiac transplantation lacks sufficient donors to treat all patients, and there is thus debate about alternative strategies. The use of left ventricular assist devices for long-term support is increasing with a positive impact on patient survival. Although there is an ongoing debate regarding the risks and benefits of maintaining pulsatile flow during long-term ventricular assist device support, there has been a significant move towards implantation of continuous flow devices due to the lower surgical morbidity and better long-term reliability of these pumps. The following is a review of the literature on continuous and pulsatile flow for long-term support. Starting from the definition of flow, we analyze the current evidence and consider gastrointestinal complications.

Aortic valve replacement using a stentless bioprosthesis through right minithoracotomy: An initial experience

OBJECTIVE Aortic valve replacement (AVR) is nowadays a safe procedure with low rates of mortality and morbidity, but the necessity for a less invasive approach is going to increase. The use of a stentless prosthesis through right mini-thoracotomy has not yet been described and our experience could be useful for other surgeons. METHODS From June 2009 until March 2010, seven female patients (mean age 79.9 ± 5.7 years) underwent stentless-AVR for aortic stenosis through a right mini-thoracotomy (RM). The logistic Euroscore was 11.3 ± 6.1, and left ventricular ejection fraction was 60.7 ± 4.5%. In five cases RM was performed through the second intercostal space (ICS); in two cases through the third ICS. The cannulation was in most cases between ascending aorta and femoral vein (5/7). When transverse sternotomy was required (two patients), the right mammary artery was clipped and cut. RESULTS Extracorporeal circulation time (ECC) was 110 ± 41min and aortic cross clamp was 80 ± 35min. Two patients required transverse sternotomy. The mean bleeding was 484 ± 469ml and the duration of mechanical ventilation was 22.0 ± 12.5h. The ICU stay was 3.3 ± 2.2 days. No in-hospital death was observed. The mean hospital stay was 11.6 ± 5.4 days. CONCLUSION Right mini-thoracotomy is a safe and applicable approach even in case of AVR using stentless prosthesis. The risk of insufficient surgical exposure or complication may be safely managed, by enlarging the thoracotomy through transverse sternotomy. However, valve implantation could be more difficult than the standard approach and it requires an expert and confident surgeon with a large experience in standard stentless implantation.

Complex pectus excavatum in adults: which is the best solution?

We read with great interest the paper of Puma et al. [1], in which they propose an external longitudinal titanium support after sternochondroplasty for severe asymmetric pectus excavatum repair. Pectus excavatum has probably been the chest deformity with the largest number of proposed techniques for its correction over the years. The very interesting solution proposed by Dr Puma gives rise to a few considerations:

Nuss procedure for all? But all are not equal!

We read with great interest the very well-written review of Kresopoulos and Goldstraw [1] and the interesting editorial comment of Robicsek [2] regarding the Nuss procedure. Our experience in this field began in 1956 with the classical Ravich procedure modified over the years by using a steel strut bar seagull wings-like shaped [3]. In the last 5 years, we appreciated the thoracoscopic approach of a steel strut bar insertion in selected cases of young patients (from 15 to 21 years-old) with pectus excavatum. We believe that some aspect of the choice between a so-called ‘minimally invasive’ and an ‘open’ procedure must be pointed out:

Late angiograms ten years after transmyocardial laser revascularization.

We present the angiograms of a patient after transmyocardial laser revascularization (TMR), which were performed 10 years before by the application of holmium laser pulses. Thirteen years before the TMR procedure, the patient underwent coronary artery bypass graftings complicated by graft occlusion with no longer possibility of direct revascularization. Then, refractive angina required an alternative approach for symptom relief as the indirect revascularization by the application of the holmium laser pulses. Interestingly, the late angiograms, taken when the patient suffered from effort dyspnea for ongoing left ventricular dysfunction, showed a network of small vessels (absent before the TMR procedure) that supplies blood to the heart with no flow through the coronary arteries because of their complete occlusion. This is a historical presentation of the results of TMR to understand the effects of the indirect revascularization on the blood circulation through the heart over the long-term follow-up.

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

OBJECTIVES We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design. METHODS Data 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. RESULTS Overall 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  = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P  < 0.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P  < 0.001) and median logistic EuroSCORE (14%, 21%, 23%, P  = 0.025). Older age, female sex, preoperative serum creatinine >-2 mg/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 (OR = 1.02; P  = 0.03), renal insufficiency (OR = 2.1; P  = 0.05), triple valve surgery (OR = 6.9; P  = 0.004) and shock (OR = 4.5; P  < 0.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (OR = 3; P  < 0.001), Enterococcus (OR = 2.3; P  = 0.01) and female sex (OR = 1.5; P  = 0.03) independently predicted complications, whereas ejection fraction was protective. CONCLUSIONS PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patients haemodynamic status and microbiological factors.

Long-term follow-up of stentless prosthesis

BACKGROUND Stentless prostheses have an interesting hemodynamic performance when compared to stented prostheses and are recommended in cases of small aortic annulus. MATERIALS AND METHODS From January 1996 to January 2004, 138 patients suffering from aortic disease, underwent aortic valve replacement. • Group A: 93 patients underwent stentless aortic valve implantation [stentless Biocor (Biocor Industria e Pesguisa Ltda, Belo Horizonte, Brazil) and stentless Sorin (Sorin Group, Saluggia, Italy)]. • Group B: 45 patients underwent stented aortic valve implantation (stented Biocor). Patients were assessed by clinical evaluation and echocardiography after a mean follow up of 124.5 ± 58.2 months. RESULTS There was a significant difference in terms of time of extracorporeal circulation and aortic cross clamp. The actuarial survival at 4, 8, 12, and 15 years is 77%, 50%, 21%, and 18%, respectively. Freedom from reoperation at 4, 8, 12, and 14 years was 92%, 83%, 73%, and 63%, respectively. Freedom from all events, death, and reoperation at 4, 8, 12, and 14 years was 70%, 39%, 13%, and 8%, respectively. There is no statistical difference among the two groups in terms of actuarial survival, freedom from reoperation, and freedom from re-hospitalization for prosthesis-related causes. DISCUSSION There was a significantly higher incidence of pacemaker implantation in Group A and the causes are not known. The rate of freedom from reoperation is high in both groups for the patients who remained alive. There was no statistical difference about prosthesis dysfunction between the two groups. The higher incidence of death in Group A cannot be explained by causes related to the prosthesis because there is no difference in terms of causes of death. Rates of reoperation did not differ between the two groups. CONCLUSIONS The results obtained with stentless prostheses are encouraging even in long-term follow-up.

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 ,