Guglielmo Saitto

Midterm Results of Different Surgical Techniques to Replace Dilated Ascending Aorta Associated With Bicuspid Aortic Valve Disease

BACKGROUND This study evaluated effectiveness of three different surgical strategies for treating ascending aorta aneurysm, with or without involvement of the aortic root, associated with bicuspid aortic valve (BAV). METHODS Between 2005 and 2011, 150 consecutive patients underwent a Bentall operation in the presence of ascending aorta and aortic root dilation exceeding 45 mm in diameter and malfunctioning BAV (n = 46, group 1); separate aortic valve and ascending aorta replacement in presence of ascending aorta dilation exceeding 45 mm, aortic root of less than 45 mm, and malfunctioning BAV (n = 77, group 2); or ascending aorta replacement, with or without BAV repair, in the presence of ascending aorta dilation exceeding 45 mm, aortic root of less than 45 mm, and normally functioning or mildly insufficient BAV (n = 27, group 3). RESULTS Compared with groups 2 and 3, group 1 patients were younger and affected by more severe BAV insufficiency and worse left ventricular function. In groups 1, 2, and 3, respectively, operative mortality was 2.1%, 1.3%, and 0%, and 5-year survival was 94% ± 4%, 92% ± 3.4%, and 100%. At 5 years, no patient in any group required reoperation on the ascending aorta or experienced aortic complications. In groups 2 and 3, root dimensions did not increase and were also significantly smaller compared with preoperative measurements (p < 0.05). Aortic regurgitation grade in group 3 (0.5 ± 0.8/4+) did not increase compared with the preoperative grade (0.8 ± 0.9/4+). CONCLUSIONS At midterm follow-up, the Bentall operation remains associated with optimal results for the treatment of BAV, despite a worse preoperative presentation. In presence of a mildly diseased or normal aortic root and normal BAV function at the time of operation, less invasive surgical procedures, BAV-sparing, or repair procedures, appear to offer gratifying results.

Single versus double antiplatelet therapy in patients undergoing coronary artery bypass grafting with coronary endarterectomy: mid-term results and clinical implications

Objectives Coronary endarterectomy (CE) represents a useful adjunctive technique to coronary artery bypass grafting (CABG) in the presence of diffuse coronary artery disease. Nevertheless, the long-term patency of the graft remains unclear, and no standard anticoagulation and antiplatelet protocols exist for use after CE. The aim of this retrospective study was to evaluate and possibly to clarify the role of single (SAT) versus dual antiplatelet therapy (DAT) at mid-term follow-up. Methods Between January 2006 and December 2013, CE was performed in 90 patients (mean age 67 ± 8.2 years) who also underwent isolated CABG. After surgery, 20 patients received aspirin 100 mg daily (SAT group), and 52 patients received aspirin plus clopidogrel 75 mg daily (DAT group). Clopidogrel was discontinued in the DAT group 12 months after the operation. Results The overall in-hospital mortality rate was 2.7% (SAT 0% vs DAT 3.8%; P = ns). Perioperative myocardial infarction was 12.3% (SAT 15.0% vs DAT 11.5%; P = ns), and major bleeding requiring surgical re-exploration was 4.1% (SAT 10.0% vs DAT 1.9%; P = ns). Mean follow-up duration was 71.3 ± 32.7 months (median 79 months), and was 100% complete (5208/5208 pt-months). At 7 years of follow-up, freedom from cardiac death was 84 ± 9% in group SAT versus 85 ± 5% in group DAT (P = ns); freedom from new percutaneous coronary intervention was 93 ± 6% versus 100% (P = ns), and freedom from major adverse cardiac and cerebrovascular events was 73 ± 10% versus 75 ± 6% (P = ns). Conclusions In patients with diffuse coronary disease, CE is a safe and feasible technique with acceptable mid-term results. No differences were observed in terms of major clinical outcomes between patients treated with single versus dual antiplatelet therapy at least in a mid-term period of follow-up.

Bicuspid aortic root spared during ascending aorta surgery: an update of long-term results

BACKGROUND Bicuspid aortic valve (BAV) aortopathy is well known in literature even if only few data exist regarding isolated supra-coronary aneurysm with normally functioning valve and root. Aim of this study is to clarify the long-term fate of bicuspid aortic root spared at the time of ascending aorta surgery. METHODS We identified forty-seven patients (mean age, 57±11 y; range, 35-81 y, 31 males) who were treated by means of supracoronary aortic replacement in presence of normally functioning BAV and not significantly enlarged sinues of Valsalva. Clinical follow-up (mean 93±50 months; range, 21-207) was 98.9% complete. RESULTS Freedom from cardiac death at 5- and 10-year was 95%±5% and 83%±16%. Three surviving patients required reoperation for the development of aortic insufficiency [2 cases treated by aortic valve replacement (AVR)] or for progression of aortic stenosis (AS) [1 case treated by transcatheter aortic valve implantation (TAVI)]. Freedom from new procedure on aortic valve was 100% and 94.4%±5.6% at 5- and 10-year. Composite event-free survival at 5- and 9-year was 82%±18% and 69%±30%. CONCLUSIONS Although in the setting of a BAV, aortic root integrity seems to remain stable during long term follow up with low rate of reoperation and occurrence of new adverse event.

Transcatheter aortic valve replacement for a bicuspid aortic valve following replacement of the ascending aorta

A normally functioning bicuspid aortic valve that is spared during replacement of the ascending aorta may ultimately require replacement due to structural deterioration. We report the use of transcatheter aortic valve replacement to replace a stenotic BAV 17 years following replacement of the ascending aorta.

Paravalvular leak of a mechanical mitral valve prosthesis associated with Burkholderia cepacia subacute endocarditis: a rare case successfully treated by multidisciplinary approach

Prosthetic valve endocarditis (PVE) represents an uncommon and very serious complication after heart valve surgery. Prosthetic valve endocarditis occurs in 1% to 6% of patients with valve prostheses and affects both mechanical and biological valves [1]. Up to 34% of all cases of infective endocarditis involve prosthetic heart valves. Prosthetic valve endocarditis represents a nosographic entity independent from native valve endocarditis (NVE) because of its specific clinical features, epidemiology, and microbiological findings; its management is complex and requires a multidisciplinary approach [2]. Anatomical signs of infective endocarditis in the mitral position include valve dysfunction, paravalvular leaks, and annular abscesses. In particular, the incidence of paravalvular leaks (PVL) is estimated at 2–17%: they can be asymptomatic conditions that do not always require treatment or can cause hemolysis and heart failure [2]. Burkholderia cepacia is a Gram-negative bacillus that represents an important nosocomial pathogen, especially in patients affected by cystic fibrosis and chronic granulomatous diseases [3]. It is rarely responsible for endocarditis in community settings, but sporadic cases have been described among intravenous heroin users and patients with prosthetic valves. According to the clinical data, most patients are treated by administration of trimethoprim-sulfamethoxazole even if the microorganism is actually characterized by multidrug resistance [4]. We present the case of a female patient who was submitted to redo cardiac surgery due to echocardiographic evidence of a paravalvular prosthetic mitral valve leak causing severe regurgitation; intraoperative evaluation revealed anatomical signs of previously undetected endocarditis, while cultures from the prosthetic valve indicated the presence of a very rare microorganism: Burkholderia cepacia. A 75-year-old woman with history of previous mitral valve replacement with a mechanical prosthesis (St. Jude 31-mm valve in 2001) was admitted to our department with the diagnosis of prosthesis dysfunction due to a paravalvular leak and critical stenosis of the left anterior descending coronary artery. The patient was in atrial fibrillation; her medical history featured a previous stroke (2 years before). In May 2016, the patient presented with fever and dyspnea and was admitted to the Internal Medicine Ward of one of our referral hospitals with the diagnosis of bronchopneumonia. After a thoracic computed tomography (CT) scan, an empiric antibiotic therapy with ceftriaxone and clarithromycin was administered. Due to a new onset of systolic murmur, the patient underwent transthoracic and transesophageal echocardiography (TTE and TEE), which demonstrated mitral valve prosthesis dysfunc-

Surgical treatment of the ascending aorta aneurysm associated to bicuspid aortic valve

Surgical treatment of patients affected by bicuspid aortic valve (BAV) and ascending aorta aneurysm still represents a challenge for cardiac surgeons. The best surgical management and the timing of operation remain unclear and many studies report different results. Replacement of the valve and/or the aorta can be performed with very low mortality and morbidity, and in the last 20 years, valve repair has become an additional available option in presence of mild-to-moderate insufficiency of BAV. Patients with BAV disease are usually younger than patients with degenerative disease affecting a tricuspid aortic valve, and for this reason the optimal treatment is aimed to reach the goal of optimal long-term results in terms of freedom from valve reoperation and complications. Indication for surgical treatment of aortic root and ascending aorta in patients with BAV is more aggressive respect to tricuspid aortic valve patients mainly due to a greater incidence of acute aortic complications observed during the follow-up of these patients. Isolated replacement of the aortic root or ascending aorta is recommended for diameters of the aorta at 45–50 mm. According with the general opinion regarding the intrinsic predisposition to dilation of the aortic wall in BAV patients, the cut-off beyond which there is surgical indication is shifted down by 50 mm as compared to patients with tricuspid valve. Need for aortic valve replacement, changes further the cut-off for surgery. If the patients undergoes aortic valve replacement ascending aorta should be treated when diameter is >45 mm. It should be take into account also the opportunity

The Prognostic Significance of Patient-Prosthesis Mismatch after Aortic Valve Replacement

Patient-prosthesis mismatch (PPM) is a controversial issue in current clinical practice. PPM has been reported to have a negative impact on patients’ prognosis after aortic valve replacement in several studies, showing increased all-cause and cardiac mortality. Moreover, a close relationship has recently been described between PPM and structural valve deterioration in biological prostheses. In patients at risk for PPM, several issues should be considered, and in the current era of cardiac surgery, preoperative planning should consider the different types of valves available and the various surgical techniques that can be used to prevent PPM. The present paper analyses the state of the art of the PPM issue.

Warm blood cardioplegia versus cold crystalloid cardioplegia for myocardial protection during coronary artery bypass grafting surgery

We retrospectively analyzed early results of coronary artery bypass grafting (CABG) surgery using two different types of cardioplegia for myocardial protection: antegrade intermittent warm blood or cold crystalloid cardioplegia. From January 2015 to October 2016, 330 consecutive patients underwent isolated on-pump CABG. Cardiac arrest was obtained with use of warm blood cardioplegia (WBC group, n = 297) or cold crystalloid cardioplegia (CCC group, n = 33), according to the choice of the surgeon. Euroscore II and preoperative characteristics were similar in both groups, except for the creatinine clearance, slightly lower in WBC group (77.33 ± 27.86 mL/min versus 88.77 ± 51.02 mL/min) (P < 0.05). Complete revascularization was achieved in both groups. In-hospital mortality was 2.0% (n = 6) in WBC group, absent in CCC group. The required mean number of cardioplegia’s doses per patient was higher in WBC group (2.3 ± 0.8) versus CCC group (2.0 ± 0.7) (P = 0.045), despite a lower number of distal coronary artery anastomoses (2.7 ± 0.8 versus 3.2 ± 0.9) (P = 0.0001). Cardiopulmonary and aortic cross-clamp times were similar in both groups. The incidence of perioperative myocardial infarction (WBC group 3.4% versus CCC group 3.0%) and low cardiac output syndrome (4.4% versus 3.0%) were similar in both groups. As compared with WBC group, in CCC group CK-MB/CK ratio >10% was lower during each time points of evaluation, with a statistical significant difference at time 0 (4% ± 1.6% versus 5% ± 2.5%) (P = 0.021). In presence of complete revascularization, despite the value of CK-MB/CK ratio >10% was less in the CCC group, clinical results were not affected by both types of cardioplegia adopted to myocardial protection. As compared with cold crystalloid, warm blood cardioplegia requires a shorter interval of administration to achieve better myocardial protection.

Focusing on Patient Subcategories: When Could We Expect a Suboptimal Late Result after Coronary Endarterectomy?

We read with very interest the paper from Bitan et al,1 in which they optimally described their experience in the treatment of complex coronary patients by means of coronary artery bypass grafting and adjunctive coronary endarterectomy (CE) on the left anterior descending (LAD) or patch angioplasty. With a detailed follow-up, they have reported a satisfactory 5-year survival and a good freedom from repeated revascularization. These data strongly confirmed our recent published clinical experience.2 Although we did not perform an angiographic follow-up of 72 patients undergoing CE (2006–2013), we focused on the results based on single versus double antiplatelet protocols. At 7 years, freedom from death of any cause, including operative mortality was respectively in the single and dual antiplatelet groups of patients 73 9% versus 81 5%, while freedom from cardiac death was 84 9% versus 85 5%. These results showed that different antiplatelet therapies does not make difference in the early and late outcomes. We were really interested in achieving a complete understanding of which risk factors could influence survival, and at the Cox regression analysis we identified as independent predictors of late survival the age older than 70 years (odds ratio [OR]: 1.29; p 1⁄4 0.003) and the presence of chronic obstructive pulmonary disease (COPD) (OR: 23.8; p 1⁄4 0.033). As far as we are concerned, patients with diffusive coronary artery disease represent a very complex category, in which both cardiac and noncardiac factors can play a crucial role. COPD was already been considered as a detrimental factor for coronary surgical patients.3 We believe that the presence of COPD and older age could be therefore considered as potential risk factors to guide revascularization strategy in a specific direction, that is, avoiding CE in older and COPD patients, and taking into account alternative strategies of revascularization, that is, hybrid or, when feasible, percutaneous. The study by Bitan et al gives us the opportunity to study not only clinical results of CE but also patch angioplasty. We would be really interested in knowing the authors’ opinion regarding the potential role of risk factors, both cardiac and extracardiac, that could influence in their experience the late results. What could we learn more from your excellent follow-up?

In-hospital and mid-term outcomes of patients operated on for type A acute aortic dissection complicated by postoperative malperfusion

Aims: To evaluate the effect of postoperative malperfusion (PM) on operative mortality and on late survival in patients who underwent surgery for acute type A aortic dissection in a referred center for aortic emergency surgery. Patients and Methods: From January 2005 to September 2015, 237 patients were referred for aortic emergency surgery at our center. We examined complete data available on 214 patients (mean age 62.5±12.6 years, 156 males). At presentation, various types of preoperative malperfusion (cerebral, renal, mesenteric) were observed in 119 patients (55.6%). Arterial access for cardiopulmonary bypass was via femoral artery (n = 99), via axillary artery (n = 99), or into the ascending aorta (n = 22). Aortic repair was performed using an open technique in 124 patients (58%). Results: Fifty-five patients (25.7%) presented PM; operative mortality was 29% (62/214): 47.3% in PM patients vs. 22.6% in non-PM patients (P 75 years at the time of operation (OR: 1.1, P = 0.0004) and renal PM (OR: 53.5, P = 0.0027). Five-year survival was 79±7% in PM vs. 94±3% in non-PM patients (P = 0.002). Independent predictors for reduced survival were age >75 years (OR: 375, P = 0.05) and renal PM (OR: 28.6, P = 0.01). All types of PM and the location of intimal tear distal to the ascending aorta were found as risk factors for survival in the univariate analysis only (P < 0.05). Conclusions: Surgery for acute aortic dissection is effective in reducing preoperative malperfusion by about 50%. Renal PM is associated with higher operative mortality, whereas all types of PM, in particular renal PM, negatively affected late survival. Surgical techniques, site of arterial cannulation, and more complex interventions requiring an open technique did not appear to be predictors of increased risk.