This sub-study deriving from a multicentre Italian register [Deformation Imaging by Strain in Chronic Heart Failure Over Sacubitril-Valsartan: A Multicenter Echocardiographic Registry (DISCOVER)-ARNI] investigated whether sacubitril/valsartan in addition to optimal medical therapy (OMT) could reduce the rate of implantable cardioverter-defibrillator (ICD) indications for primary prevention in heart failure with reduced ejection fraction (HFrEF) according to European guidelines indications, and its potential predictors.
Ascending aorta (AA) dilatation in patients with bicuspid aortic valve (AV) is related both to genetic and haemodynamic factors. The aim of this study is to compare late progression of AA dilatation in bicuspid AV patients undergoing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve implantation (TAVI).
Introduction: COVID-19 pandemia determined a reduction of healthcare offer to the general population. Hypothesis: COVID-19 pandemia increased the number of emergency operations and in particular of life-saving procedures because of the diagnostic delay due to missed follow-up or unwillingness to present to Emergency Departments for the fear of contracting the coronavirus. Methods: Retrospective analysis of surgical activity in a large Cardiac Surgery Department from 01 March to 31 May 2020 (study period) compared to the same months of 2019 (control period). Results: During the study period there were 191 operations (14% elective and 86% urgent/emergency) versus 225 (44% elective and 56% urgent/emergency) in the control period. Moreover, during the study period four patients presented acutely due to delay of diagnosis: one with ventricular septal defect and free wall rupture due to an evolving acute myocardial infarction (MI) with late presentation; another, who suffered an acute inferior MI several months earlier and did not attend regular follow-up, was operated for a ruptured pseudoaneurysm who was not previously diagnosed; another was operated for aortic and mitral valve endocarditis complicated by cardiogenic shock due to delay caused by a misdiagnosed COVID-19 pneumonia; last patient, previously operated for an acute type A aortic dissection (ATAAD), refused to attend the Emergency Department after the acute onset of back pain and was later diagnosed with severe dilatation (1.4 cm over 6 months) of the thoracic aorta and underwent endovascular stent-grafting. The first patient (who suffered a cardiac arrest after induction of anesthesia) survived with neurological deficit, the second died in the operating room, the third and fourth survived without complications. There were no similar cases in the control period. Finally, two patients were operated for an ATAAD (one COVID-19 positive died of hemorrhagic shock) in the study period versus nine in the control period. Conclusions: COVID-19 pandemia resulted in a significant reduction of cardiac surgical activity, mainly related to decrease of elective surgery and an increased number of surgical procedures for life-threatening conditions caused by delayed presentation of acute patients.
In patients undergoing mitral valve surgery, restrictive suture annuloplasty (De Vega) for less-than-severe functional tricuspid regurgitation has been proven to be safe and effective. The aim of this study is to determine whether the adjunct of the plication of the posterior tricuspid leaflet with the same running suture (bicuspidized De Vega or "De Kay") is equally safe and effective.Single center, retrospective study on patients submitted to suture repair of the tricuspid valve during mitral valve surgery, with either conventional or De Kay, between January 2014 and December 2020. Comparison was based on degree of residual tricuspid valve regurgitation and right ventricular assessment at discharge.Over the course of the study period, 255 patients undergoing mitral valve surgery had a dilated (>40 mm or >20 mm/m2) tricuspid valve annulus, with less-than-severe tricuspid regurgitation. Conventional De Vega was employed in 166 patients (65.1%) and De Kay in the remaining 89 (34.9%). At discharge the adjunct of postero-septal commissure plication has similar outcomes to the classic De Vega repair. It seems to preserve right ventricular function.De Kay repair guarantees the same tricuspidal regurgitation reduction as compared with conventional De Vega early after surgery.
Abstract Background Advances in minimally invasive cardiac surgery require accurate preoperative assessment of the morphology and function of the mitral valve apparatus. The success of mitral valve repair with annuloplasty depends on the correct sizing of the mitral annulus ring (1) (2). Three-dimensional transoesophageal echocardiography (3D-TOE) has been proven to be essential for the anatomo-functional characterization of mitral valve apparatus in patients undergoing surgically mitral valve repair (3). It also allows the measurement of quantitative parameters useful in determining the size of the annuloplasty ring, such as A2 height, intertrigonal distance, intercommissural diameter and total annular perimeter size. Cardiac computed tomography (CCT) plays a key role for device sizing in patients undergoing transcatheter mitral valve replacement (4); it is the gold standard for geometric characterisation of the mitral valve and assessment of the spatial relationship of the mitral valve apparatus to adjacent anatomical structures. Several studies have compared CCT with 3D-TOE in sizing the mitral valve apparatus (6) (7); few studies have compared mitral valve apparatus measurements obtained by 3D-TOE and CCT with those obtained intraoperatively by the surgeon, which is the gold standard. Purpose To compare intra-operatively 3D-TOE assessment of mitral valve apparatus with CCT and to compare 3D-TOE and CCT measures with intraoperative surgeon-measured mitral valve annulus. Methods and results We used a cohort of thirty patients who underwent surgery for severe primary mitral regurgitation with mitral valve repair using the Carpentier technique with annuloplasty, all of whom had undergone CCT prior to surgery to exclude coronary artery disease. We compared measurements of the mitral annulus (intertrigonal distance and intercommissural distance) obtained by 3D-reconstruction of intra-operative TOE and 2D-short axis CCT reconstruction with the ring measured intraoperatively by the surgeon and then implanted, using intraclass correlation. We found that the intertrigonal distance measured by CCT showed good agreement with the surgical ring (ICC 0.89 [CI 0.330-0.985; p < 0.05]); the intercommissural distance obtained by 3D-TOE also showed good agreement with the surgical ring (ICC 0.81 [CI 0.458-0.936; p < 0.05]), while the intertrigonal distance measured by 3D-TOE showed a moderate agreement with the surgical annulus (ICC 0.63 [CI 0.056-0.852; p < 0.05]). We then compared the intraoperative 3D TOE measurements with those obtained by CCT and found excellent agreement when comparing the intertrigonal distance (ICC 0.95 [CI 0.755-0.989; p<0.05]). Conclusions 3D-TOE can be considered as a first-line imaging technique to assess the anatomical features of the mitral valve apparatus, not only in patients undergoing cardiac surgery, but also in those undergoing percutaneous interventions or with contraindications to contrast medium CT. 3D-TOE reconstruction Surgical and CCT
Abstract Background Sacubitril/valsartan changed the treatment of heart failure with reduced ejection fraction (HFrEF), due to the positive effects morbidity and mortality partly mediated by left ventricular reverse remodeling (LVRR). The aim of this multicenter study was to identify echocardiographic predictors of LVRR after sacubitril/valsartan administration. Methods Patients with HFrEF requiring therapy with sacubitril/valsartan from 13 Italian centers were included. Echocardiographic indexes including speckle tracking echocardiography (STE) were used to predict LVRR (defined as LV end-systolic volume reduction and ejection fraction [LVEF] improvement >10% at follow-up) at 6 months follow-up as the primary endpoint. Changes in symptoms (NYHA class) and neurohormonal activations (N-terminal-pro-brain natriuretic peptide [NTproBNP]) were also evaluated as secondary endpoints. Patients with poor acoustic windows and missing data were excluded. Results The final population consisted of 341 patients (mean age: 65±10 years; 18% female, median LVEF 30% [interquartile range:25; 34]. At 6 months follow-up, cardiac dimensions and function, including left heart STE parameters, improved (Table 1). Moreover, 82 (24%) patients showed early complete response (LVRR and LVEF ≥35%), 55 (16%) early incomplete response (LVRR and LVEF <35%), 204 (60%) no response (no LVRR and LVEF <35%) after 6 months of sacubitril/valsartan. Among patients with ischemic etiology, 68% (108) did not develop LV RR. Age, sex, general characteristics, baseline NYHA class and NT-pro BNP did not significantly differ between the groups.Conversely, baseline LV dimensions and LVEF showed significant differences between the groups (p<0.0001). Also, STE parameters were considerably better in group 1 compared to group 2 and 3 both at baseline and follow-up. Non-ischemic etiology, a lower left atrial volume index and a higher global longitudinal strain were all independent predictors of LVRR at multivariable logistic analysis (all p<0.01). With ROC and spline curves, LV GLS >−9.3% showed a good accuracy in predicting LV RR (Figure 1). LA strain was the best predictor of positive changes in NYHA class and NT-proBNP (all p<0.05). Conclusions STE parameters at baseline could be useful to predict LVRR and early clinical response to sacubitril-valsartan, and thus could be used as a guide for treatment in patients with HFrEF. Funding Acknowledgement Type of funding sources: None. Table 1Figure 1
Clinical benefits of minimally invasive cardiac valve surgery (MIVS) have been reported. Improved postoperative mental status was never analyzed with dedicated psychological tests. In the present study we intend to investigate potential benefits of MIVS for patient psychological well-being, with special attention to the relevance of the patient perception of the chest surgical scar, of the self body image and cosmetic aspects.Between 2016 and 2017, 87 eligible patients, age 66.5 ± 14.5 years, operated on for heart valve surgery, underwent either conventional full sternotomy (CS; n = 48) or MIVS by V-shape hemi-sternotomy approach (n = 39). Before selection of the surgical approach, patients had undergone preoperative evaluation of their psychological status using Beck Depression Inventory-II (BDI-II), State-Trait Anxiety Inventory Form Y (STAI-Y), and EuroQol-5D (EQ-5D) psychological tests. Six months postoperatively, patients filled in dedicated questionnaires to assess their psychological status, quality of life, and subjective perception, thus repeating the above-mentioned tests and adding the Body Image Questionnaire (BIQ) and Patient and Observer Scar Assessment Scale (POSAS) v2.0 tests for scar-healing process evaluation.No patient died during the study.The 4 post-test scales of psychological well-being (BDI-II P = 0.04, STAI-Y P = 0.04, 2 indices of EQ-5D P = 0.03, P = 0.01) showed significant differences between the MIVS group and CS group, with MIVS-small incision patients having lower level of depression and anxiety symptoms and better quality of life. Mean score differences of scar perception (BIQ and POSAS v2.0) were significant, with MIVS patients having evaluated the scar quality significantly better than CS patients.MIVS appears associated with significant esthetical and related psychological benefits, as documented by technical tests. These findings should be considered when selecting the most appropriate technique for heart valve surgery.
